I knew the morning would be difficult, because we had agreed to withdraw baby Malt from the ventilator because she showed no signs of brain activity. Her dad, from a religion and culture that is supposed to be stoic, held onto my hand and wept. (Crying men really get to me, two dads in one week, two decisions to stop aggressive care, is almost too much). Malt had brainstem reflex gasps that kept her heart beating for a full hour and a half after I pulled her tube, which was cruelly agonizing, making me second-guess my decision and giving the family a false glimmer of hope that was dashed. Two beds over we waited for the death of another child, 4 years old, a long and complicated story of malnutrition and a mysterious mass on his back that took weeks to diagnose as a mycobacterial infection. After two months at Kijabe he was discharged back to a refugee camp on the Somali border where he got none of his ongoing care, developed an obstructed bowel that diverted out through the skin on his back, then lost his kidney function, and finally came back to Kijabe past the point of no return. Both these families are from remote areas to the northeast where they would almost certainly never encounter tangible witness to Jesus. If I were planning it, I would have had both their children improbably and miraculously healed. Instead their children slipped away to death. I do think both families could see the extreme effort poured out on their child by strangers; the odd intimacy of being swept into the most crucial hours of someone's life may have more Jesus-witness in the long run than a proud victory. I don't know, and I'm clearly not in control here.
That would have been enough for one day. But the strike goes on, and we're packed. In another one of those timing flukes ... in spite of my fantasies of perhaps a gentler post-weekend-call day, perhaps departing early . . . it turned out one person after another on the Paeds team had some sort of illness or family crisis or tiredness or whatever that took them out of reach for parts of the day. So it was a non-stop day, except for running home to check on Acacia who had had a fever last night and missed school (she does feel better now, but pray for her). At 3:30 I admitted a post-operative neurosurgical patient to the ICU (where I'm not really working but seem to spend a lot of my time). I wonder if Kijabe is the only place in Africa a kid could have two world-leading neuro and craniofacial surgeons work on their skull and brain. By 4 I was starting to think of the evening and rest, and deemed it wise to call the two new family medicine residents who will take call and give them a little sign-over and orientation. We all introduced ourselves, washed hands, and I opened my mouth to tell them about the cozy humid little nursery where everyone was doing fairly well.
Then all hell broke loose. At that moment, a desperate call back up to ICU. The xray I ordered ended with the little post-op patient's breathing tube being dislodged. Only when I walked in I saw it was more than that--the little boy was pulseless and pretty much gone. Mostly dead, but not all dead. Another opportunity to use the PALS course skills from last month, running a full-scale code to get him back. Which we did. And just as that finished, a desperate call back from nursery. Where there was another new admission of a mostly dead baby. He had lost 1/3 of his body weight in his short 5 days of life, was blazing with fever, convulsing, and dry as a prune. For you medical types: Na 180, K 6.4, Cr 3.1. These are very bad numbers. I pushed some fluids in an intra-osseous (in the bone) line until the Paeds surgery fellow who happened to walk in was recruited to get a real IV line. It was one of those admissions where everything was harder than it should have been, no gloves, no lines, no nurses, just that time of day I guess. Another distraught mom. By 6 he was stabilized (though far from OK, he still may die) and I literally had my hand on the door latch to nursery when a nurse burst in with a 1 kg 29 week (very premature) baby in a cloth, just-delivered, dusky and wet and mewing slightly, heart rate falling. Really? This was the baby whose mom was, as per the last hour's report, no where near delivering tonight. Yet here he was. Thankful for Bob our clinical officer who stayed and helped me, we had to scoot one baby over to reach oxygen for this one, intubate and give the magical soapy surfactant mixture for his lungs. It was dark, after 7, when we finally walked out the door.
Monday, to the max. Time for some sleep.