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Saturday, June 03, 2017

Bloody socks, and other metrics of a week on the edge

Last night, our evening walk was abruptly interrupted by a distress call to help a visiting resident and the interns with a 40-year-old woman on her 11th pregnancy whose uterus ruptured.  Hours later as Scott wearily walked back in the door for a 9:30 pm dinner, and I was starting the laundry (thankful for a washing machine these days) to deal with the usual sweat-soaked scrubs, he sighed "the blood soaked through my socks".  That's what a surgery with 3 liters of blood loss, with a patient who's blood pressure never topped 60 until the end of the case, when you go through 80 sterile sponges, looks like. The baby was dead before the mom made it into the operating theatre, but thankfully the mom (particularly good news for her ten other kids) lived, and today is alert and recovering.  There are not many places in Kenya where that would be true.  Kenya's maternal mortality ratio is 500/100,000 (5/1000); which means given our volume of deliveries (600/month) we would expect 3 deaths/month, or 24 since we started in October.  Instead there have been 2.  That's a good metric, but the bloody socks demonstrate the reality of what it takes to get there.

Neonatal mortality is a bit more difficult for us.  Given the national ratio of 23/1000, we would expect about 14 deaths/ month just from our own labor and delivery but we also get the sickest babies born anywhere in a radius of probably 50 miles around. This year so far we're averaging about 16 deaths/month, with an average of about 150 admissions/month.  That NICU mortality rate hovering just over 10% is good on a national average, but still means we've lost over a hundred patients in the time OB lost 2. It gets pretty hard.  Still, our department is probably the most pro-active in the hospital.  We just started doing exchange transfusions for severe jaundice, the levels that cause brain damage.  Only a few places in the country will attempt this.  This week we had two babies with shockingly horrible levels due to a mismatch between their (paternal inherited) blood groups and their mothers.  Both were successfully drained of their entire blood volume twice over and replaced with donor blood in increments of a tablespoon or two at a time.  Both are doing well today.  On the prevention side, my colleague has a grant to teach "Helping Babies Breathe", the essential first-minute-of-life resuscitation skills every nurse-midwife needs.  This week she presented a quick taste of this at our hospital-wide CME, and began the first of a series of 9 weekly one-day trainings to up-skill select nurse-trainers around our catchment area.

That's how we walk in a world where your socks get bloody--first by attempting to push care boundaries to save individual lives day after day, and secondly by supporting the slow shift of education and attitude and habit and expectation that makes a long-term impact.  And thirdly, by bearing witness to the realities of injustice and brokeness, the stories that don't have such triumphal endings, but are equally important to God.

Little B came into our paeds ward at the beginning of the week, 9 months old, wasted thin limbs, an enlarged liver, a terrible cough, fevers, and a convulsion.  Her cerebral spinal fluid looked clear, but her chest x-ray showed pneumonia, and we suspected TB even before her universal admission HIV testing came back positive.  It turned out that her quiet mom was on treatment for AIDS, and as a baby B's first test after 6 weeks was negative.  But when it came time for her next test at 6 months, the family had traveled to the far western border to bury her 10-year-old brother who had been killed in a bicycle accident.  The dutiful mother had B tested there.  Positive.  Per the current international standards, she should have been started on highly-active anti-retroviral treatment (AIDS drugs) right away.  The mortality in the first year of life for infected babies, untreated, is on the order of 50%.  But the hospital there said, no, go home and get started in Naivasha.  When B's mom returned home with her many weeks later after the terrible ordeal of one child's death, she had no official record of the positive test, so the small health center in a flower-farm settlement insisted on repeating it.  These tests have about a month turn-around time, sadly.  So that meant B was 9 months old and dying and had never been treated by the time she showed up at our hospital.  We started strong antibiotics, and extra nutrition, and tested for TB, then decided to treat even though the test was negative.  But by Friday evening she was dead.  Too little too late, as is so often the case for children with AIDS.  A terrible virus, and a terrible failure of the health care system to find little B and treat her in time.

Which brings me to the end of this post.  This week in a devotion talking about the Franciscans, the author stated "Francis wanted us to live a life on the edge of the inside--not at the center or the top, but not outside throwing rocks either.  This unique position offers structural freedom and hopefully spiritual freedom too."  This phrase resonated, and I hope that's where we are, fully engaged in living and speaking truth, but on the edge willing to take risks.  We're not in a position of power at Naivasha hospital, we're plunging in but our influence is small and slow and hopefully more helpful than harmful but always a mixed bag.

Bearing witness on the edge of the inside, and working in concretely specific as well as globally foundational ways for change, sounds a lot like Micah 6:8, the verse on our prayer card and on my Dad's funeral program.  So here's a couple of examples from the news this week that I found convicting and inspiring.  First, as the NBA finals roll on, a press conference with LeBron James after a hateful person sprayed racist graffiti on his house:

"No matter how much money you have, no matter how famous you are, no matter how many people admire you, you know being black in America is tough," James said. "And we got a long way to go, for us as a society and for us as African-Americans, until we feel equal in America."

And lastly an interview with the author of Just Mercy, Bryan Stevenson, about growing up in America and the current controversies over Confederate monuments.  He makes good points about truth leading to reconciliation (though I would argue that true repentance is healthier than shame).  This book is on my list to read in the next few months.  Here's a quote from the interview:

"For me, it's important to redefine what it is we are dealing with when we deal with poverty, and that definition begins with recognizing that the opposite of poverty isn't wealth. The opposite of poverty is justice. If we actually had been just to those communities that we removed from the land, if we had been just to the formally enslaved, if we'd been just to immigrants who came and gave great wealth, we would actually be in a very different place when it comes to dealing with structural poverty."

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