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Thursday, October 27, 2016

Thursday by the numbers



80-90:  The number of inpatients on our daily rounds this
 week, at least the couple of days I tried to count.  It's pretty challenging to even see, let alone think carefully about that many, particularly when they are filtered through trainees, or don't have vital signs, or are crowded two to a bed.  About 2/3 are in the Newborn Unit, which is not exactly a NICU, but aspires to be.  It takes a lot of stamina and patience to plow through this many patients, and supernatural intervention to identify the handful who truly need attention to survive.  One thing we're trying to model:  at the end of each section, look back and think, who is the sickest here?  Today's choice had been with us for days and just wasn't better.  We checked a malaria smear. Positive.  Oh.  Prayers appreciated that in the onslaught, we would be alert to potentially crucial diagnoses.

1143 umol/l (13 mg/dl):  a very high creatinine, which means very poor kidney function.  Babies who fail to breast feed well sometimes show up at about 2 weeks of age with dehydration, looking shriveled and yellow and lethargic.  This one got into trouble right under our nose, as his mom stayed admitted for an infected wound after her C-section.  I found baby J convulsing because he was no longer breathing effectively, he was infected, sick, feverish, wasted, hadn't passed any urine in a day or two, and nearly dead, having lost almost a third of his body weight.  A week later we aren't out of the woods, but in spite of trying to treat this ICU-level sickness with limited resources, he's alive.  This is one of the few moms I've been able to pray with, and I'm really pulling for her.



 3 in 3 weeks:  the number of confirmed new TB diagnoses found on Paediatrics.  The first was the girl with the drooping face whose morning headaches and vomiting led us to suspect something more sinister than a Bell's palsy, whose mom overheard me talking about Neurosurgery at Kijabe, checked herself out and went there just as the visiting team was wrapping up, and had emergency surgery to relieve the pressure in her brain caused by a tuberculoma.  The second was a preemie I found here as I started, somehow during the strike the baby's very sick mother was transferred to Kenyatta but the baby stayed with us.  Though the mom's diagnosis was uncertain, she was discharged on TB meds so I decided to put the baby on prophylactic treatment.  Just as baby A was reaching a 2 kg potential for discharge, the nurses noted a suspicious lymph node.  Sure enough, a biopsy proved TB, perhaps congenital which is pretty unusual.  It's tricky to manage medication for someone that small, but we're treating her.  The third was a 12 year old admitted late Sunday night.  I happened to be there for another problem, and heard we had a new patient vomiting blood so I thought I should take a look.  A quick exam revealed her problem was in her lungs, not her stomach (see xray).  She was big enough to cough a sputum for us confirming the diagnosis.  There are many many challenges at Naivasha Sub-County Hospital, but we have a very key piece of laboratory equipment called Gene Expert that detects TB very effectively.  I love it.  This is a fatal disease if untreated, and a curable one if found.  Very satisfying.

19:  number of reported deaths last month on our service.  I feel like I saw a little dead body, or heard about a baby passing away, about 2 days out of 3 so far, so that rings true.  It also explains how hard it is emotionally to respond to that level of loss, and to keep believing we can make a difference, and to care.  But kudos to my partner here, we had a mortality review meeting which was inefficiently long and painful, but productive.  We identified some issues that I've already seen improve.  In the last week I've turned a little corner where I'm suddenly being called more. The up side is that sometimes I can help.  The down side is being actually present for more deaths when I can't.  I miss working in a place with chaplains.

53: number of pages in the 2016 Kenya Paediatric Protocol, that I had printed and laminated and taped up to walls all over this place.  Kenya really is impressive sometimes, and this protocol is one of those places where this country takes a lead.  It is practical, evidence-based, thorough, and gives us a standard of care.










45:  number of moms I counted when I showed up early one morning, and found they have their own singing, devotions, and prayer.  I can't say how encouraging it was to stumble upon the mothers inviting Jesus into the nursery, each praying for her baby.  We may not have any actually functional equipment (except one monitor that works, and one incubator that heats, and a couple of oxygen concentrators whose output is split and shared by a dozen babies, the rest is just a graveyard of junk that is useful as a cupboard or a table), we may only have 1 or 2 nurses per shift for 50-60 babies, we may have demoralised doctors and government squabbles . . . but we have praying moms.  So there's hope.



video

6:12.  The verse in Ephesians that changed my day.  Yesterday I was back at the proverbial end of my rope of frustration.  This morning this verse smacked me right in the face:  our struggle is not against flesh and blood human beings, it is against the system that grinds them down, the corruption, the evil, the dysfunction, the microbes, the despair.  I SO NEED PRAYER to remember this, to not blame a trainee for laziness, to not snap at a lab person when a sample is lost.  Somehow the re-set to my own heart made for a better day, some laughing, some teaching.  Part of my bang-head-against-wall melt down the day before was over the passive-aggressive failure to get some critical blood transfusions done . . and last night the intern managed to swing all three.  So by GRACE alone I went to the lab today to thank them, to fill in the clinical scenarios, to give them a sense of partnership in lives saved.  Much more fun than complaining.  Maybe I should try it more often.  A trusted Kenyan friend reminded me that the way to make change is by making friends.  I believe Jesus would say the same.  Please pray for us to humbly and kindly remember that, for the Spirit to smooth over our failures, and for true relational building to bring about better care.

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