Last Call For . . .

Me.  At Kijabe for a while, anyway.

And it was a doozy. 

I had the sense it would be, that I would not slip quietly into the night.  At 8 am Saturday I walked into ICU to sort out three kids, all on ventilators and very sick:  a 7 year-old-girl who just wasn’t waking up as she should have after having a brain tumor removed, a 1-month-old refugee baby who had a second bowel perforation, and a nearly-1-week-old boy whose spectacularly horrible crash into renal failure (on my last call) remains a bit mysterious.  ICU care, is, after all INTENSIVE meaning careful examination, review of labs, detailed notes, considered orders, pausing to draw blood or position tubes or consult surgeons.  Then on to nursery, where another 18 or so neonates need to be monitored for jaundice or infections or prematurity.  We have an 850 –gram 28-week baby, and every size on up.  Then to get my colleague’s report from the floor on another 25 kids with problems ranging from malnutrition, to liver failure, to brain demyelination, to simple bronchiolitis. And then the day just kept getting crazier.  When you’re managing almost 50 sick kids, in a place like Kijabe, you basically just keep moving from Casualty to OPD to ICU to the delivery room to Nursery to the Neurosurgery Annex to the Paeds floor to lab to xray to the whole circuit again.  A lumbar puncture here, a consult there, referring back to the list of labs to check, popping in to make sure someone’s labored breathing improved, or talk to a parent. 

About 4 I got a call from our CO intern who had just seen a 2-day-old born-at-home baby.  Mom brought him because he was not feeding.  He was scrawny and jaundiced bloated in the stomach, and his umbilical cord, tied with string, stank.  We sprang to action to keep him from becoming another septic kidney-failure ICU case, with tests and fluids and antibiotics.  In the process he vomited green stuff, which is always bad.  Xrays looked like a possible bowel obstruction, and within a few hours he was heading into surgery (turned out to just be a very bad sludging paralysis of the gut from his shock, not an anatomical defect).  I had taken my first nutritional break of the day and after munching a few nachos was trying to catch the beginning of the Student Council talent show, but literally within 30 seconds of arriving at RVA the dreaded code-page occurred.  Running down the hill, trying to imagine who was dying, please not that one.  This time it was a 7-kg (15-lb) almost-2 year old former preemie F. with severe malnutrition, shunted hydrocephalus, wacked-out blood chemistries, a scalp abscess, and very anemic.  The excellent nurses had her breathing as I huffed in, but her efforts were so shallow and weak, and she was so cold, and sleepy.  We called the neurosurgery resident to remove some fluid from her shunt to see if that would help (it seemed to, but not enough).  I knew I was missing Jack’s performance by then.  We did this and that, and I tried to get a feel from her very agitated mother and from the file whether this was a kid we should consider taking to ICU.  Maybe because it was my last call, maybe because I didn’t know the family and situation well enough and wanted to buy time, maybe because I could see at least 3 fixable problems that 48 hours in ICU might be enough to turn around, I wanted to intubate her.  Long story (3 hours of bagging her myself while directing my team and liaising with others to get a bed) short, I did.  At various points I had both medicine attendings on call coming by to discuss the bed shortage, and I agreed that this child’s prognosis fell in line behind the 17-year-old girl with the new tracheostomy  . . but it was reasonable to move an adult out to make space for little F., and they did.  Then the paeds surgeon wandered in to tell me about the baby he had taken to theatre, and in his kindness said “is there anything I can do for you?” and was probably surprised when I said, sure, can you incise and drain the abscess on this kid’s scalp while I keep her alive right here?  Done.  At one point I handed the bag and tube to a nurse to keep squeezing while I ran to resuscitate an infant born floppy through meconium, but after a quick intubation and suctioning and stimulation, that cone-headed little being turned pink and cried, wide-eyed and ready to live.  Back to the ward.  After many delays we got little F. to the ICU, a transfusion started, new labs and medications, on the ventilator, copious notes written.  More patients in casualty, who had been waiting quite a while.  Another stressed baby who turned out OK.  More labs to search out.  Finally at 1:30 am, I walked home.

Perk of time zones:  I could call Caleb at that hour, but as soon as we connected as I walked in the door, I had to hang up.  Another emergency baby.  Only that one turned out fine.

A few hours of sleep, and then the final 999 (code) page at 6:45 this morning.  I sleep in my clothes, so within a few minutes I was running into the casualty to find a good-sized previously normal 1-month-old boy now pale, limp, lifeless.  Another resuscitation, intubation, assuring the lungs were getting oxygen while the clinical officer did CPR, handing the bagging off to the nurse and moving around to put in an intraosseous (into the bone) line, adrenaline and fluids and dextrose and more adrenaline and calcium and half an hour of all-out effort with zero response. This baby had arrived dead, and this time was too long gone to call back.  As soon as I left the curtained emergency cubicle to talk to the parents, the mother collapsed onto the floor wailing.  This was a SIDS death, and in this case from talking to the parents tragically it sounds like the baby may have suffocated in co-sleeping in a situation where some alcohol blunted awareness.  Talking, praying, comforting weakly.  There are no words to make this OK.  An irreplaceable precious life, all that potential, all that love, gone. 

More ICU reviews, and then meeting the Sunday call team and signing over all ?50 kids.  Then it was 9, and I had 45 minutes to make breakfast and prepare Sunday School.  Last call for discipleship.  Chocolate-chip cream scones, chai, and cappuccinos outside, completing a 2-week series on Spiritual Disciplines for college survival, I sent them scattered around the yard for 30 minutes of enforced quiet to read scripture meditatively and listen to God. A wistful Sunday, 10 great guys (12 when the other 2 aren’t teaching younger boys) who are seeking to be men in the best possible way.  Cooking for them and teaching them and praying for them and caring about them has been a highlight of this year.  Then church and tears and relief and sadness, the reality of closure, of turning a corner. 

I asked my team women here to pray for this last call, and they did.  Because being on call at Kijabe is more than a job. Yes, the challenges can be exciting and rewarding, digging deep for ideas, hoping for instinct and inspiration to fill the gaps of knowledge.  I relish being stretched (well, sometimes) and seeing death turn to life; drawing on two decades of experience; consulting with colleagues (thanks Ari!); supervising.  I am energized by the interactions with nurses, their competence and trust.  A highlight of yesterday was a mammoth card signed by maternity and nursery staff.  Completely over-the-top, and lovely. 

But when I think of call here, it is the unseen dimension that I will remember.  Sometimes I go through a day like yesterday acutely aware of the deeper battle.  Evil preys upon the lives of the innocent.  Our job is to stand in the way, and say:  you shall not take this one.  Many times we come to end-of-life mercy and painful acceptance of death, we pray over a child as the soul goes to Heaven.  But most of the time, we struggle to draw the line, to choose life.  When I am running 110% for 19 out of 25 hours, I know that I’m all-in for the cause of the Kingdom.  When both times I tried to take a break to connect with one of my own kids were met with immediate disaster calls, it only makes the spiritual nature of the big picture more clear (thankfully Jack was savvy enough to buy himself three meals via Junior Store yesterday).  We don’t always win.  This morning’s tragedy overshadows the 23-hours before of holding multiple other children back from the brink.  But that is how it is.  Hard work, satisfying victories interspersed with mistakes and sorrows and loss, but always a bit more of the former than the latter, that keeps us going.

So I walked out, my last official morning, into a rare bit of sunshine.  Smiling for my selfie, grateful to be able to rest from this intensity and finish some projects and prepare to go, grateful for my colleagues and friends who will carry on with grace and skill, grateful for the privilege of practicing medicine on the edges where every day and night holds the potential for crisis and for joy.  But not quite believing it is over for now.