Doctor Strike Day Two

Scott and I both opt to begin the day around 7:30, checking on critical patients before rounds. Which is a good thing, because we're almost immediately called about a transfer from Naivasha. A strike-effect, a very sick baby lands our way. Throughout the day the combination of an increase in patient volume (one man went to ICU after 36 hours of bouncing from one non-functional hospital to another after his road traffic accident) and the considerable decrease in functioning work-power.

This cheerful little girl spent over three weeks on our service, as the TB therapy finally kicked in and she began to come back to life. This was her first day without an oxygen mask on her face, and I just had to take her photo. Though the endless stream of malnourished, dwindling, gasping, struggling little people can get depressing, the wonder of watching most of them move from lethargy to life makes it worthwhile.

My team is down to Lillian, the Clinical Officer who works full-time week-days in Paeds, and me. The strike is harder on people like Lillian than anyone else. Our 20-ish patient service used to be shared between her, a medical officer ntern (doctor) and one or two clinical officer interns, who would all review some of the patients and present them, or follow up labs, or write up new admissions. Now she tries to come in early, too, to see as many patients as she can, and we review all of them and then finish up together. Lillian is bright, caring, cheerful, competent, willing . . everything you would want in the person you spend most of your days with. So one of the blessings of this strike is working with her. After rounds we go to the Maternal and Child Health clinic where we see patient after patient again. And keep checking in with ICU, casualty (emergency), nursery, the floor. I'm called to private clinic to see a sick missionary baby, and to the neurosurgical ward to help with a deteriorating four year old. It's non-stop.

In the late afternoon I find out that one of the preemies in nursery has dangerous levels of jaundice and needs an exchange transfusion. This baby temporarily dies while we are putting a line in her umbilical vein, requiring CPR. I try and explain what's happened to her anxious parents. Then the charge nurse and I begin the tedious process of removing her blood volume and replacing it twice over, a teaspoonful (5 ml) at a time. After a short time the line fails to work and I am rescued by the ever-patient paeds surgery resident, who helps me replace it. At first I am relaxed and chatting with my nurse about Christmas but the baby once again begins to have a falling heart rate, and it takes all our care to keep her alive through the procedure. My advent devotions pointed out that if Jesus could come to Bethlehem, God can show up anywhere, so we should expect him in the hard places. Once again the exchange transfusion reminds me of a crucifixion, a small innocent person spread out and pinned down, lots of blood, what looks like murder and turns out to be life-saving.

I hand the baby over to the nursery nurses several hours later, because at the last minutes of the exchange the OB nurses want me in the operating theatre, where Scott has gone to do a C-section. It's about 8 pm. A small perk of shared OB/Paeds call is we keep meeting over babies. This time the mom has failed to push the baby out and the baby's heart rate is falling. Scott extracts her surgically, untangles the umbilical cord from around her neck, and hands her over to me.

Another perk of no interns: the happy moments are mine alone, a healthy baby who could have died and is now squalling and strong. But no time to linger, the preemie in the nursery needs more support post-transfusion, and another baby keeps forgetting to breathe. Then I remember that hours ago I'd been called to go to an admission in casualty.

This is our most interesting patient of the night, a six-year-old Maasai boy who was perfectly normal and well until a couple of days ago, when he began to bleed. in his eyes, his gums, his skin, his vomit, his urine, his stool. Being from Bundibugyo my first thought is ebola, and my second was along the lines of the ER docs that he had leukemia. But he just wasn't that sick. His platelet count turned out to be 1000, which is a half a percent of normal. Frightening. But the words ITP popped into my head, hopefully from the Spirit, and I decided to gamble on treating him for an immune disorder. We admitted him for a blood transfusion and steroids and protection from trauma, hoping he can avoid bleeding somewhere critical like his head before his platelet count recovers. Saw a couple more kids there, one in severe heart failure for admission, one who had swallowed a ten shilling coin, which is smaller than a dime and worth about that much.

Then back to the operating theatres, where Scott was doing another C-section. This mom had had a previous c-section, and now was carrying twins. She was supposed to deliver at the district hospital, but due to the strike was sent here, which likely saved all three lives. She had massively dilated blood vessels covering her uterus and could have bled to death.

Instead she had two identical boys. Lovely.

Earlier in the day I passed a visiting prayer warrior, Jeanne B, in the hall. We first met umpteen years ago when we were working at Kijabe temporarily, because she comes with her retired pathologist husband for 3 months every year. She said, "How can I pray for you today" and I said "pray for my attidtude". So this photo is for Jeanne, I snapped it in the theatre dressing room on the way out, because I know her prayers were with me.

One admission to ICU, and back to see the sickest patients in ICU, Nursery, ward, last check-in at Casualty and then, just after midnight, I came home. Scott had been able to help the kids with dinner hours ago, but not eaten, so they left us each a nice plate of spaghetti and green beans and salad, and we sat down to eat our first meal since breakfast.

Jack graciously waited up for us and watched football on TV.

By 1 am we're both about to sleep, for a short while. I get paged to nursery, but the competent charge nurse tells me the xray I ordered earlier can wait for review in the morning. I want to hug her. We sleep. At 2:30 Scott gets called back for a couple of middle-of-the-night hours to care for the mother of twins whom he ends up admitting to ICU, and I spend from 5 to 7 am trying to keep the baby from Naivasha, and my two ICU patients, alive.

When I realize it is 7 am, I opt for a quick trip home to shower and have tea. And as I walk out of maternity, this is the sky I see. It's still raining most of every day, but glimpses of sun and sky are appearing.

And so Day 3 begins, back before 8, for the usual chapel, rounds, C-sections, admissions, babies, consults. I do appreciate the medical officer interns, it is NO PICNIC to take call without them. I remember being in med school and residency 20 years ago, when days like this one would be common and constant, and no excuse for not working full-out the day after. Only this time I have kids whom I miss, and whose feeding and care I have to still ensure through phone calls. Oh, and I'm a few years older I suppose. But thanks to the attitude prayers, I found a lot to enjoy in those intense 24 hours. Because the public medical system serves the poor, they are the ones who truly suffer from this strike. I'm just missing a little food and sleep, but not my life.

Dec 4th

Four years ago on this day, Dr. Jonah Kule died of ebola.  We were in Bundibugyo, and he had admitted himself to Mulago Hospital in the capital, where he had gone to pick up his daughter from boarding school before he fell ill.  He died alone, in a tent pitched on the hospital grounds for isolation, with his last words being that no one else should die of this terrible disease, and that he was now going.   That is a long story for another time, but suffice it to say that that night when we got the call from the MSF team that night, in the darkness of pre-electricity Bundibugyo, we were stunned, grieved, frightened, bewildered, numb, disbelieving, crying, despairing, praying, a gamut of emotions.  Standing outside to maximize the weak cell phone signal, talking to the doctors, then being the ones to call and tell his wife, all of us in tears, Scott and Scott Will and later our neighbor Tibererwa, recounting how this happened.  And wondering, what was God doing.  How could He allow such injustice and suffering.

Tonight we sit in cold soggy Kenya, just below the equator, with unseasonable rains drenching us, waiting to hear if the Kenyan doctors will all go on strike at midnight.  There are issues of justice and corruption here as well, though a strike seems like a far cry from a doctor who laid down his life to serve the sick.  We hope that the government will negotiate and avert the collapse of the public hospital system.  If they do not, we will find ourselves being the only functioning hospital in the district, working without any of our interns and some of our consultants, and adding onto our already-stretched capacity the overflow of patients who can not find care in their usual places.  

Two thousand years ago, God chose to show up in the darkest time of the year, in obscurity, and in danger.  One of my advent meditations pointed out that He did this to show that if He can be present there, in Bethlehem, He can come anywhere.  To Bundibugyo during ebola, to Kijabe during a doctors' strike.  Because our hope is not in God changing our circumstances immediately, but in God Himself.  In His ability to bring light into the darkness, redemption into death.  Unlikely though it is, it is in these places of dense night, of loss, that we find Him choosing to be with us.

I talked to Dr. Jonah's wife Melen on the phone today. She is a strong and admirable woman who has endured too much.  Yet the nursery and primary school she founded are thriving.  Her oldest daughter is entering her last year of high school.  Her son, born after his father's death, is a joy to her.  Five young men are now in medical school because of Jonah's death.  Three have written to us in the last week with good news of classes passed, of learning, of eagerness to serve.  Our team in Bundibugyo works hard, too hard, to keep that small light  burning.  But they have moments of beauty too, of connection, of redemption.  Because we are still in the story, we can't fully make sense of today, or of the 4th of December 2007.  But if we look all the way back two millennia, perhaps we begin to see that the light shined in the darkness, and the darkness could not overcome it.

Beanie Babies Batch one

Luke reports that we now have 13 beanie babies--3 from friends in NJ and this box which arrived from CT. THANKS!! Just a reminder that he flies out on the 17th, and he has to figure out his packing, so it would be nice to get any shipments by the 15th, which is 12 days from now. Children in Kenya will be very happy. We're aiming for 50 . . .

Caught in the turbulence

Scott brought back from his meetings a thought provoking book called The Meeting of The Waters, 7 Global Currents that will Propel the Future Church, by Fritz King. In the introductory chapter he describes two classic missionaries meeting at a guest house, two contrasting models of missions. The first is an older lady who has spent her entire life with a remote people group, rarely traveled back to America, had given up everything. We honored two couples and two single women who were just like that this past week at the AIM conference. They were retiring after 30 to 43 years of service in Africa. They had pioneered remote stations, translated books into local languages, established schools, weathered wars. They bore up under whatever life brought their way with very little outside help. They were grey-haired sturdy survivors with practical shoes, quiet and unassuming, faithful servants for the duration. One had come here as a little girl in 1946, a trip which took two months on a boat in those days. After a few years in Tanzania her parents left due to health reasons, but she returned as a young woman in 1968, was married in the RVA chapel, and the rest is history. These are the heroes that drew my heart towards Africa as a girl. They are the generation that laid down their lives and did the right thing, year after year, without fanfare. I didn't even know any of these people, but the standing ovations at their retirement brought tears to my eyes.

The second missionary in King's introductory chapter is a 30-something guy who is multitasking on his cell phone and computer, has left his family in America while he checks out a project run by local leaders that his church supports. He has a career, but is arranging to take two years to spend overseas lending his skills. This is the new generation of missionaries. The break with their formal life is less abrupt, more fluid. They set boundaries and have high expectations of personal development, exercise, protected family time, organizational support and responsibility. Travel and communication lend connectivity, educational levels are high, they are task-oriented generally, outcome-focused, and missions is an important part of their life, but not their whole life. We meet amazing people like this here too. Skilled doctors donating a month, or six, or more to boost services and education. Teachers, engineers, artists, contractors. People with the funds and vision to start and orphanage or foster micro-enterprise, who will leave it within a few years in local hands.

As I finished the introduction and started into the book (I'm only a third of the way through) I had sort of an "aha" moment. When the two rivers flow together to create the Amazon, there is a stretch where their waters flow in parallel, then a period of mixing and turbulence. And we are squarely in that turbulence. With 18 years in Africa behind us, we are a bit past the half-way mark towards the classic old-time missionary life. This is who we expected to be. And this is why over a year out from Bundibugyo, I have to keep remembering the very specific ways God led us, and convincing myself it is right to be here at Kijabe. On the other hand, we carry iphones and text our son in America, we travel, we access grant funding for projects, we connect with the national health system. We're now working at a hospital that was founded upon the classic missionary model, but is largely staffed by more modern types. When I look at the December call schedule, we are 2 of about 5 missionary doctors with more than a decade behind us, the rest of the 30-some names on there are either short-termers or young Kenyans.

So we're in an in-between generation, uncomfortable not living up to the heroes of the past generation, but not really fully able to buy into the ethos of the new generation either. I guess that's OK, to be Hebrews 11 pilgrims and strangers. Being securely settled in one group is not our goal. I hope we can be part of the melding, the settling out of the streams to honor what is best in both. Combining longevity with innovation, relationship with technology, perseverance with enabling nationals. Maybe because we're spending our first Christmas in this new place, it's a good time to reflect.

World AIDS Day, Dec 1

This morning our HIV-AIDS team at Kijabe Hospital led chapel. This year's theme, ZERO. Zero new infections by following the ABCs of Abstinence (unmarrieds), Be Faithful (marrieds), and Condoms (those who can't manage A and B). Zero stigma, because stigma hurts people, keeps them from seeking care, drives the epidemic. And Zero preventable deaths, because infected people should have access to medicine. Watch this compelling video and think about it. http://youtu.be/vKdgF7DHTG0

Complicated

It's 9 pm, and we just cleaned up from a pretty delicious dinner whose preparation was interrupted by two trips to the hospital, which makes the whole cooking scene a bit more challenging. The first call was to attend the death of a very sick preemie whom I had left only an hour before, knowing he was dying. After 48 hours of an all-out effort, his vital organs were failing and we knew we were at the end of the road. I had made the always-agonizing decision to accept that he was dying, and tell the parents. Francis was in the ICU right next to his mother, whose life he saved by being born too early. She suffered from a life-threatening complication of pregnancy called "eclampsia", which can only be cured by delivery of the baby. So this doctor had to make the difficult decision of taking the baby out of the mother way too early, or risking the mother dying and leaving behind her other two children and husband. Francis' life was only about 72 hours long. But I think this was the right decision.

The second call was much more fun: the Kenyan lady who runs the "Supa Duka", the one-room everything-you-really-need small store in our village, had just delivered a strapping healthy baby boy. We are always called for C-sections, but this time there was nothing to do other than admire the lovely boy.

And while I was in the nursery, I checked on Dancun, the little boy whom I agonized about a couple of weeks ago, an HIV-exposed 28-week preemie who nearly died that night. He's now a "feeder and grower", a seemingly healthy little speck of a baby, who in spite of starting out similarly to Francis has miraculously lived. And I ran into Scott in the operating theatre, who had just finished his fourth or fifth surgery for the day, a woman whose ectopic pregnancy had ruptured her fallopian tube spilling two litres of blood into her abdomen. Thankfully her life was saved.

Which was a nice end to three solid days of nonstop work. Well, not exactly end, but at least it's in sight tomorrow morning.

Let's see, the last couple of days included a little boy with an rare congenital syndrome called Pierre-Robin, the usual parade of malnourished marginal toddlers and their desperate mothers, another boy with meningitis, preemies, two kids with severe heart lesions, a girl with damaged kidneys after an infection, the amazingly improved and nearly-healed baby born with part of his intestines missing as well as the one who had hemorrhages in both lungs, quick consults for rashes including chicken pox and fungal infections. And most distressingly, an 8 year old deeply jaundiced with a liver mass that turns out to be lymphoma, a cancer that could potentially be treatable. Only we need to get him to a hospital with an oncologist and chemotherapy. Which requires a lot of money. Which his Maasai father thinks he can manage by selling off his cows. Meanwhile we are starting chemotherapy at Kijabe and hoping we can keep him alive long enough for the cow market to come through.

The sheer breadth of pathology on this service always surprises me. One can spend all day, non-stop, from bed to bed, to ICU, to nursery, to the clinic or the emergency room, conferences and meetings, and then back around to all those places again, without a moment of down time. Yet the doctors in Kenya have threatened to strike on Monday, Dec 5. Meaning a barely-survivable day could get lots worse. Kijabe hospital without any functioning Kenyan doctors is unimaginable.

When a patient dies, the nurses use their own creative verb, saying "he complicated". It's an interesting take on death, as a complication of life, or of their disease. Or does it mean that the patient has made our life or our job more complicated? Difficult, confusing, complex, interrelated, entangled. Not the ending we all planned. Life as a doctor here is just that, complicated. The clues to a disease are often obscure, the labs unreliable, the history vague. Understanding the thoughts of the parents who come looking for an easy fix adds another layer of complication. And sorting through all of those layers with the pressure of time and people waiting complicates things further.

Hoping that no more patients complicate tonight.

Light shines in darkness

Here is one more Advent site, thanks to counselor Susan S here at RVA.  A daily devotion is posted, including scripture, prayers and a meditation.  The site is:

http://www.d365.org/followingthestar/

Below the short thought on Mark 13:24-27

Many of us carry the false assumption that the goal in life is to be happy. That is why so many people around us mask their struggles and claim a false sense of happiness. Doesn't God want us to be happy? God cannot intend for us to be in darkness, depression, despair.  

Mark tells this story so we would not forget that darkness cannot stop God. Mark calls us to be honest. Yes, there is darkness. It hurts when someone close to us dies. Our hearts break when a friend abandons us. The pressure to succeed smothers us at times and we don't know if we will ever see the light of day. The one who comes may come right in the midst of that darkness. Darkness does not stop him from making all things new. True, the one who comes may not bring simple happiness. The one who comes will bring meaning.

Michelle Thomas-Bush

Advent

Today begins Advent, a season of preparation, repentance, anticipation, and party. I've been looking for some resources to celebrate with our family, and here are a few I've found.

1. Advent Conspiracy: Worship fully, Spend less, Give more, Love all. http://ac.wcrossing.org/default.aspx?page=3684

And here is their 2011 short video on youtube: http://youtu.be/9IN0W3gjnNE

2. Daily Scripture readings from the Anglican Book of Church Order: http://www.crivoice.org/advent2.html

3. A booklet of Advent readings and meditations from my friend Bethany's church: http://fairmount.liberti.org/advent/

If these don't come up as links, then copy and paste into the browser (sorry!!).

Unexpected Cost

6:30 a.m., a light rain in the chill of the early morning, and a dozen bleary-eyed students balancing stuffed duffels into the back of a van, heading home.  Yesterday they did the traditional end-of-term countdown, and were released to clean up and pack.  By this morning the bustling boarding school was nearly empty, eerily quiet and damp.  I help Acacia load her suitcase, checked her passport, her money, her phone.  Then a big hug, and I'm standing back by my car holding in tears that rise and surprise me.  

When we agreed to bring our friends' daughter into our home, I thought about a lot of things.  Whether she would be too homesick.  How she would find the volume and pace of our family in comparison to hers.  Whether she would find friends, or regret not living in the dorm.  Whether we would thrive together.  How the sibling relationships would work out.  It is an awesome responsibility to parent someone else's child, and I expected some sense of relief if we made it through our first three months relatively intact.

Instead, I felt only grief.  Another precious person to hold and release.  Another important relationship that has huge gaps of space and time.  Another piece of my heart sent away.  Four kids were going to leave our home eventually, and now we have to survive five.  

Be careful whom you love, or just let the cost sink in and hurt?  

stuffed-animal-love

As Thanksgiving turns to Christmas Consumption, and we read of people flocking to Walmart and the Malls .. . here's an idea for de-cluttering. Would you like to pass on some of your small stuffed animals, beanie babies or about that size? The sophomore class at RVA (which we help sponsor) does an annual Valentine sale to raise money for the class. We're in charge of creating gift baskets which parents can purchase for their children as a reminder of their love while separated far away at boarding school. I know my kids have been very attached to stuffed animals, particularly in stressful times of life. So along with candy, we thought it would be fun to include a little stuffed animal in the baskets.

If you want to donate some of your slightly used but still lovable animals for this cause, mail them by Dec 10 to Luke who will fill his luggage with as many as he can to transport them here:

Luke Myhre

PO Box 201510

New Haven, CT 06520-1510

If we get more than 50, we will pass them on to the children at the hospital. Thanks so much. No doubt the suite of guys at Yale will get a kick out of this influx into their dorm too.