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Tuesday, June 23, 2015

Advice for Young Doctors, Gleaned from Goodbyes

This morning's farewell was a breakfast party (complete with chocolate cake, above, as all breakfasts should be) with our Paeds team, including nursing staff from the BKKH floor, the Family Clinic, the nursery, the ICU . . the many places around the hospital where Paeds patients are seen.  I am grateful for the steady pace of closure, the ebenezer-opportunities to reflect on God's grace, to be thankful for friends, to say goodbyes in the truest sense of "God Be With Ye".

As I reflect on what people say at these events, I realize that the things I tend to think make a great doctor, and the things which truly do, are two different lists.  Not one person in now four parties has mentioned a dramatic story or clever diagnosis.  A certain level of competence is essential, but brilliance is overrated.  I remember the baby who was dead post-exchange transfusion, and nothing brought him to life until I pushed calcium, and he literally resurrected, and a year later I saw him in clinic a normal toddler.  Or the infant born with such severe swelling (hydrops) she looked inhuman, and after a long ICU stay being told "this is the last chest tube we have", and praying, and against extreme odds she survived and mom sent me pictures on her first birthday.  That kind of wonder.  But those are like peaks of mountains, rarely seen, and not commonly traversed; occasionally beautiful, but not where most of us live.

So here are the basic essentials that nurses and trainees and administrators and colleagues notice and remember:

1.  Come when you're called.  It's that simple.  Keep your pager by your bed, keep your phone ringer turned up, and answer.  When someone wants you to see a patient, show up.  Don't make excuses.  Don't complain.  Don't make people feel bad for calling you, even if it was silly.  Just show up.  It's probably the #1 thing I've heard in the last two weeks.  Your nursing colleagues want to know you have their back, you won't leave them to manage alone.

2.  Listen to the nurse.  You might be covering 50 kids on four services scattered all over, she (or he, but mostly she here) is watching 2 or 8 or 10 closely within arm's reach.  She notices when breathing changes, or feeds aren't actually going so well.  If you're thinking of making a change in management, ask her what she thinks, and take her opinion seriously.  She knows if the endotracheal tube is still necessary because lung secretions are too thick.  If she tells you the patient is worse, listen.

3.  Be clear and definitive in a crisis.  When the kid is coding, then everyone needs the confidence of a leader who assigns roles by name, who orders the sequence of treatment, who has a plan and communicates it.  Listen 95% of the time, but when someone is dying, be ready to take action and responsibility.

4.  Stay organized.  Keep up with the details.  Your team wants to know that you're paying attention.

5.  Let your heart shine through.  People are watching, and they take encouragement when you sit and counsel a family, when you pray, when you go an extra step and care.  You can't fix every problem, you can't even fix most of them.  But you can show compassion for every patient.  Be willing to raise funds for those who can't pay.  Be willing to weep sometimes over a poignant sorrow. Invest in relationships around you.

Medical school is fascinating, but most of the above I learned from my parents long before.  Come, and listen.  Take charge in chaos.  Pay attention.  Be kind.

These are the characteristics of a doctor that nurses want to work with, and that is who you want to be.

If any students or trainees are reading this, let me end with the testimony I shared this morning.  There's nothing like goodbyes to make you realize the treasure you've been given.  This was the prayer guide for my mom's prayer group this week:

Give them a strong sense of purpose so that they are led to the right occupation and are always in the job or position that is Your will for their life.  Speak to them about what they were created to do, so that they never wander from job to job without a purpose.  Help them find great purpose in every job they do.

And as I prayed it, I realized how it had been answered for me.  This job, being a missionary doctor, is what I was created to do.  It's impossibly straining and wonderfully fun, both at the same time.  Hang in there, because this is the best job in the world, and so worth it.

Sunday, June 21, 2015

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.

Friday, June 19, 2015

Ever since Cain

The rain mists down from glum skies today, with occasional outbursts of serious force.  Scott is a thousand kilometers away.  The first of three pre-packing projects I had expected to finish last night took me double the time so just finished.  And in spite of my best intentions, I keep checking the news and reading with sorrow about the shootings in the AME church in South Carolina.

The victims were middle-aged church ladies, an elderly janitor, a young college grad, pastors.  The kind of people who spend their mid-week evening in a church.  People like me.  Except, they were hated because of their racial identity, by a 21 year old kid with a gun.  

A thousand people smarter than me will analyze what went wrong. Centuries of injustice of the most horrific sort, kidnapping people, buying them, selling them, trafficking them across oceans, treating them as expendable means of production, as subhuman beings to be exploited.  Centuries of enriching ourselves at the expense of others, and justifying it with indefensible laws.  Centuries of emphasizing difference, building barriers.  Then another century of denying the sins of our fathers and ourselves, thinking we could somehow move on, that it would all go away.  Only it didn't.  Educational and economic gaps still glare; the tension is still ready to boil at any flashpoint.  Baltimore and Ferguson and McKinney and now, Charleston.

Why does someone like Dylann feel justified in walking into a church and shooting people who, but for a bit of melanin in their skin, could be his mother?  I think the bottom line in hate-crimes is fear.  Fear that the other type of person will get something I need, fear that my type of people won't be OK.  Fear based on scarcity, fear that my survival is threatened by the others.  Fear that this is a zero-sum universe, and that the equation may not add up favorably for my group.

In Africa, we call that tribalism.  Kenya's neighbor breeds that fear, sending young men the same age as Dylann (but more lethally armed) into churches and universities to kill.  In Burundi, the decades of mistrust, violence, suspicion between two groups of people are torpedoing efforts to establish democracy.  In South Sudan, the newest country in the world is disintegrating as its diverse groups grab for land and power and wealth, ready to kill their supposed competitors.  In Uganda, a simmering conflict between the two main language-groups of people where we work heats up, last summer triggering numerous deaths.  These are all the places we work, and every single one is as unstable as Charleston.

Ever since Cain, one type of person looks at another and thinks, maybe that one is going to get what I need, let me kill him to save myself.

What can overcome that fear?  Only love. Which is not a vague feeling of benevolence towards the other group.  Love requires interaction.  Understanding.  Living alongside.  Sharing.  Sacrificing for the other.  Listening.  Repenting.  Love brings a change in perspective, from competition in a world of scarcity, to collaboration in a world where grace throws all bets off.  Love means confidence that God has my back, that I don't have to kill or threaten or dominate my neighbors to survive.  Love celebrates the differences that make this world beautiful and interesting; love lets the toe be a toe and the eye be an eye and is thankful we can work together.

As a minority for the last nearly 22 years, I have been privileged to be befriended and accepted by people whose area of the world was devastated by the area in which I was born.  People like the man who wrote a message of forgiveness on Dylann's facebook page.  Perhaps my other-ness has been so extreme as to be non-threatening in a sea of tribal anxiety.  But I am grateful to rub shoulders every day, working and living with people who do not look the same as I do, discovering that we actually are brothers and sisters.  

A church-shooting in Charleston is the predictable outcome of segregation, keeping people afraid of the other, keeping people apart.  And ever since Cain killed Abel, we have longed for a world where fear does not drive hate, and where perfect love casts it out.

Thursday, June 18, 2015

The beginning of the end

Only one more weekend-call, 24 hours of work, and I will be done with my Kijabe Paediatrics career, at least for the foreseeable future.  The jumble of emotions that comes with this is so intense that I am actually left feeling a bit numb:  sadness, the realization that I'll miss this work and these people, weariness, relief, regret for things left undone, amazement for things accomplished by God through this team, knowing I'll feel left out as life moves on.

Monday I worked in our new Developmental Clinic.  For most of my time here it has been an idea only, but Ima managed to put meat behind the idea, and Stephanie Cox the audiologist is actually making it happen.  So many children in Kenya suffer from significant disabilities, often because of inadequate care during pregnancy and delivery.  They bounce from clinic to clinic hoping for a miracle that fixes a damaged brain, and we have wanted to create a welcoming interdisciplinary environment for them to access a solid Paediatric opinion, nutritional monitoring and supplementation, physical therapy, testing and treatment for speech and hearing disorders, and the prayerful ministry of a chaplain.  Once a month we're bringing all these threads together in a one-stop clinic.  I am the least important part of this chain; Sherri with her PT skills can teach the parents and provide the equipment that makes a huge difference in the kids reaching their potential. It's a great group to work with, and very different from our usual hectic, overcrowded, low-support outpatient setting.  Pictured left, we're going through files before the clinic starts, collaborating and forming plans for each kid.

Our Paeds team is pretty large this week: visiting pre-med, pre-nursing, and med students, our usual CO and MO trainees, etc.  I have enjoyed being back in the nursery, teaching a lot of basic but good things about how to help a baby breathe, why breast-feeding is best, what is the differential of respiratory distress, how to recognize a baby who is critically ill, and what research is still needed to answer important questions.  This is Alanna soothing a baby who was very upset that we were busy with rounds and her mom was late for her feeding.

And the Kijabe-classic craziness still continues, unabated.  Admissions and consults in the last couple days include: a child with what looks like TB meningitis, a child with severe gastroenteritis and dehydration, a refugee baby with a perforated bowel, a child from a nearby country whose parents came to Nairobi convinced she had cancer and were overjoyed to find out she merely had a urethral prolapse, an orphan with perforated ear drums, and this cutie-pie pictured left.  Her mom has miliary TB and was in the intensive-care step down when she went into preterm labor at 28 weeks, and delivered this 1300 gram (a little over 2 pounds) baby, who was whisked to NICU.  I took this photo, and probably the highlight of the week was going back up to the very sick mom's bedside and showing her her daughter, and seeing her smile through her oxygen mask.

The second-to-last call night (Monday) was a doozy, with admissions and deliveries and labs and work.  In the middle of the night, this little one started falling apart.  Please pray for him.  He was just a normal baby who looked a bit jaundiced, then turned green then mottled then his kidneys failed and he was getting too tired to breathe.  I intubated him and took him to ICU on life-support, and our team has kept him alive so far this week, but it's touch and go.  We think he has a severe infection, and yesterday we did an exchange transfusion.  If he lives it would be miraculous.

I gave my last teaching conference, on Severe Acute Malnutrition, one of the topics I am most passionate about.  I love getting the interns to THINK about why malnutrition occurs, and the huge complex web of factors from soil conditions and rainfall to marriage dynamics and education.  I love showing them how we can turn someone from death to life, but also admitting how often we fail and how much we still need to learn and understand.

And we had our "Lower-Station" dessert and prayer fellowship farewell, dozens of our neighbors gathering to say goodbye to us and the Hein family as we head out.  These are the people who know how to pray for us, whose hearts are bound up with ours, with whom we have labored for 4 1/2 years now.  They graciously gave up a Friday night to love us.

I'll end with some group shots, one of the perks of a last week is that everyone is game for pictures.
Mary and Rachel, the in-charge nurses for NICU and Maternity.  Calm, competent women, a pleasure to work with.

Nursery team

Kijabe Paeds Consultants (minus Sarah who is still on maternity leave): the friendship and excellence of these women has been the highlight of living and working at Kijabe

Paeds team at morning teaching rounds!  

Our newest consultant, Caren, who has been sharing ICU and nursery with me the last two months.

Sophomore Restaurant last weekend, dressing up for a nice meal with the Massos and Justin.

Acacia and Ali  . . about two hours after he fractured his clavicle playing rugby.  Real men can still dress up and have a dinner date.

Jack and Wianne.

Lower station ladies, courageous women who are quietly changing the world.

My newest mug for tea, thanks to Jack's pottery class.  He's turning out some amazing work.

That's a lot of end, probably beyond the beginning of it.  Pray for our hearts to trust God in this major time of transition, to end well, to love and support those around us, to discern the priorities of the day.  Scott is now arriving in Bundibugyo for a week in Uganda to focus on Christ School planning and progress; I am holding on through one more weekend of work, the last Senior boys Sunday School, and a list a mile long of what must be done in the next three weeks.  Thanks.

Thursday, June 11, 2015

Dry Run for Dying

Or, packing up a life.

Somehow a few mornings ago, out of nowhere, I saw the parallel between this time in my life (6 weeks until departure) and my Dad's death 9 years ago.  He knew he was going to die of ALS, and he had a year of warning to both celebrate and bring closure, to assure everyone was cared for, and say goodbye.

Which is where we are now.  We came to Kijabe thinking we would stay for two years, and now it's been 4 1/2. Jack is graduating, we're due for a furlough, our parents would like to see us, it is time to reconnect with supporters, all our kids will be in the US, we have worked towards this point . . . in short it is time to close this chapter.  We will come back to East Africa, Lord willing, in a year, but not to Kijabe.

Why?  When we came to Kijabe there was no paeds department, and now we have four excellent paediatricians (3 Kenyan and 1 American) with a fifth moving into our house after we leave.  Two more missionaries are in the wings thinking they'd like to move here in the next couple of years if a spot opens.  And one of our Kenyan colleagues said she'd had 20 phone calls from Kenyan doctors newly graduating from residency, who would like to work in this environment.  Our neonatal survival numbers are the best in the country.  We are moving forward in patient care and research and teaching.  Everyone I work with is smarter and younger than me, and I've handed over the leadership to one of the best doctors I've ever worked with (and I mean that on a medical, spiritual and personal level).  In short, it is OK to go.

But that does not make it easy.  My Dad walked through that process with dignity and faith and grace.  At this moment, I am acutely aware that it must not have been easy for him, either.

So please pray for us to be like him.  We are trying to tie up loose ends, to advocate, to hand over well, to anticipate, to leave all our work in the best possible condition.  We are thinking about the needs of kids and team mates, and making plans.  We are cleaning up and out (in theory that is, we actually haven't started), paring down, planning to set aside essentials for living somewhere new when we return, thinking about what to take to the States, what to leave for others, what to throw away.  We are feeling the crunch of projects not quite done.  We are making preliminary plans for travel, buying tickets.  We are savoring time with Jack, with kids at school, with friends and team.

The first call schedule without my name on it was circulated this week, for July.  There are dozens of small deaths, the realization that I won't be part of the plans for new programs, that my colleagues will be called, not me.  There is the healthy tension of letting go.  And there are the moments of joy as well, when we get to celebrate.  So I'll end on that note.  Today the Maternity Department called us to a 7:30 am meeting (not unusual, we sometimes have those on Thursdays to work out schedules or discuss issues.  This time, though, the entire department of consultants, nurses, clinical officers, trainees gathered to say farewell.  We felt very loved and appreciated by their kind words.  One nurse had told her supervisor she wanted to go in our suitcase because she knew that we always responded promptly to calls, so she felt secure when she had a night on call with us.  Others appreciated mentoring and teaching and high standards of excellence.  We all laughed as one doctor thanked Scott for being the only other Man U fan in a sea of Arsenal supporters.

We love working with this group, who have become our friends, and that's what makes the goodbye so much like dying.  As believers we know that death is not the end, that reunions will occur, that good awaits, that tears will be dried.  But the parting is still painful.  Truth.

Scott thanking the team.

Charge nurses Rachel and Beatrice present us with a gift.

The gathered department.

The gift:  a reminder that "In every desert of calamity, God has an oasis of comfort".  Good words in this time of sorrow.