the rest of my pictures

(phlebotomy time in the nursery)

It took an overnight call at the hospital during which I woke up at 4:00 am and decided I was done with sleep for the night - three cheers for jet lag! - but I have finally uploaded most of the rest of the pictures from my trip. So if you're interested, they can now be found at http://picasaweb.google.com/castickney/Tenwek2008.

i just couldn't open my blog

Many apologies to those of you who have written wanting to make sure that I’m all right since I haven’t posted in over a week. The truth of the matter is that the Tenwek internet server slowed to a bit of a crawl such that it was actually impossible for me to open either my email or my blog. So rest assured that I am healthy and safe… and actually in Nairobi. I wasn’t supposed to be here just yet – my return trip was planned for tomorrow – but because there was a plane flying Russ White and Carol Spears back out to Olerai today without a planned return cargo, it seemed to make the most sense for me to take the plane back rather than chartering my own tomorrow. Tears were shed over the early departure (though let's be serious: that was going to happen anyway), bags were packed, goodbyes were made, and here I am.

But I can back up a little...

Much happened during the last week, but it thankfully started with a much-needed day off on Sunday. I had been on call Saturday - and had narrowly avoided my second exchange transfusion - and richly savored my first opportunity to sleep in in two weeks. I invited myself over to Julie and Mike's place for lunch following church, but there's always enough time between church and mealtime to make something of it, so I finally made time to go for my first (and only, as it turned out) walk of the trip. The sun was out, the day was beautiful, and the water was falling picturesquely over the falls. In spite of the fact that memory of the roads and paths didn't quite serve as well as I had hoped it would, it was wonderful to get out and finally see the countryside again. Perspective is always helpful.


I went to bed on Sunday grateful for my Sabbath rest and feeling that I was rejuvenated for the next two days (which Chuck would have off). And then Monday happened. I was mentally planning a blog entry that I never got to write about that day; its intended title was simply "whoa". Why, you ask? Well, I think it started when I got signout that a pediatric patient had been admitted to the ICU with meningitis and possible herniation, and that he was hanging out on an oxygen facemask because all of the normal ventilators - plus a few extra hauled over from theater - were in use already in the ICU. I rushed to see that child during morning report, and until noon, things appeared to be going smoothly.

(the Tenwek ICU gone crazy)

But then I stuck my head into nursery, just to make sure that it was safe to go to lunch, and found the nursing staff in the process of starting to bag a baby (meaning his oxygen levels were extremely low). So... so much for lunch. An hour or so later, another nurse walked briskly into the nursery with a small bundle in her arms: a premature baby born ten days ago at home and now not breathing. We started bagging her, too, as we called the chaplain for assistance with the mother.

(the Tenwek nursery gone crazy)

While we were still bagging, I got a call from my intern Charles, who was in casualty and wanting to tell me about a child who had presented in diabetic ketoacidosis with a blood sugar of 1026. (Note: normal is <125, and even diabetics in DKA don't often get above 700.) As an aside, I'm glad we never got a blood gas on that patient, or I think I would have been even more frightened than I already was. Torn as I was between needing to be with the apneic premie and wanting to see the diabetic whom I feared to be on death's door, things only became more complicated when I stopped through the ICU and discovered my meningitic patient with a pulse ox of 58%. We started bagging him, too, and over the next two hours, I ran between the two resuscitations and the mini-ICU we were endeavoring to run in casualty for the poor 11-year-old diabetic, whose teeth began chattering with all of the normal saline we infused, but whose mental status, praise God, remained intact. The chaplain seemingly tailed me as I went from the ICU to the nursery to casualty for the latest blood sugar reading and back to the ICU. One of the saddest parts of the situation was the realization that I was holding the diabetic patient - who had a good prognosis if managed appropriately - in casualty because I knew that the patient with meningitis would die soon and open up a precious ICU bed. Exhausted and anxious, I prayed for peace for myself at the same time that I prayed for peace for the dying children's parents.

Around 8:30 - after discovering a Triatix-overdose patient in the corner of casualty who was gurgling and unarousable and then suctioning and bagging him up to a barely-reasonable pulse ox before wheeling him briskly over to the ICU - I dashed down the hill to my apartment, where I threw on my scrubs, wolfed down leftover meatloaf and potatoes (yes, probably faster than I should have), and ran back up to the hospital just in time to be called to yet another ICU code on a medicine patient with pneumonia. We were actually successful in resuscitating this patient, once we realized his ET tube was plugged with secretions and I reintubated him, but then I couldn't figure out how to work the anesthesia machine/ventilator that he had been attached to, so we manually bagged him until the anesthetist on call arrived to rescue us from our quandry. It was 11:30 before I stumbled back out of the lower hospital gate, but in what amounted to almost a miracle, I slept after that until 6:00 am. I woke up incredulous and rejoicing in God's amazing mercy. And then I realized I was so exhausted I'd left my door unlocked and the curtains open! Go figure.

Tuesday was decidedly more placid: I was actually early for lunch at the Spriegels' house and managed to escape the nursery around 6:00, though I did have to return in the middle of my signout to Chuck when the new premie I had just admitted decided that CPAP was inadequate for her respiratory needs. But I was invited to dinner at the Bemms' house (again), so it was a pleasant and relaxing end to the day, involving lasagna, cuddling with children, and NCIS on DVD. Fellowship can really erase long days in a flash.

(Lydia Bemm with a Really Large Stack of waffles)

As it turned out, Monday was my last night on call, so for the rest of the week, my evenings were free (and late!). Wednesday I spent time with Agneta in her new apartment, helping to organize her kitchen and marveling at her vast spice collection. And then yesterday I found out I'd be leaving Friday rather than Saturday and suddenly the time was too short... never mind that I was scheduled to be on call Friday night, I hadn't planned on goodbyes for another twenty-four hours! Here's where the tears came in. I really think most everyone on the compound has seen me cry in the last four weeks. For me, it seems to be an occupational hazard. So I had Valentine's Day dinner with Julie (and Mike) and was introduced to the fabulous game of Bananagrams (no goodbyes there, since Julie is all for putting them off, just like me); I stopped by the Osteens to say farewell and then wound up back at my home-away-from-home to watch more NCIS rather than face the big suitcase sitting on the spare bed in my apartment.


I had thought I'd be able to work a regular morning at the hospital today; I realized quickly that I was kidding myself. But after a waffle for breakfast, several hugs goodbye, and a few hasty runs to collect mail and packages for transport to the States, I made my way back up to the peds ward to catch the end of rounds, after which I visited the nursery and saw babies until noon. After that, departure preparations were inevitable, and Julie and Linda Spriegel came to assist me with my bags. My parting gift was a Tenwek patch for my white coat and an encouragement to recall to my friends my time at the hospital that is also a church... or is it a church that is also a hospital?

I arrived safely in Nairobi and am now comfortably situated for the night; so much has happened that I think it's about time to go process a little of it. I'm sure I'll be processing for a while, and I hope to reflect online a little more once I return home. In the meantime, keep praying for Tenwek and everyone there...

mellow

Yesterday was just kind of one of those days. I know I've said that it's a good day here when all of your patients make it to the end alive, and that death is not uncommon, but sometimes it's harder than others. For once I'll be spare with the medical details and just say that we had a new baby (who had been quite sick) die early yesterday morning. And around the same time, the baby who was exchange transfused over the weekend became much, much sicker. Mom, who is the sweetest of women and speaks reasonably good English, and I talked and prayed for her baby Kiplangat, but it came to the point that nursery staff were having to breathe for the baby, and by the time I left for lunch I was certain that he would be dead by the time I returned.

I think I've mentioned before, probably to a lot of you, that at Tenwek you really have to be a smarter physician to practice good medicine, because you have fewer diagnostic resources to fall back upon - and fewer treatment options once you think you've arrived at a diagnosis. So when things go badly, I find that the temptation is to take the blame on my own shoulders. That was certainly my struggle yesterday noon; why would God call me to this if I'm not skilled enough to provide the best care, when someone else could likely do better? I know that too often I'm relying on my own strength, that I'm counting on myself and my own knowledge and my own training and forgetting that I have a heavenly source of strength as well. Not that that means babies won't die and all disease will melt away, but it does mean that I can "run and not grow weary... walk and not be faint".

Kiplangat was still alive when I made my way back to the nursery after lunch... I'm not the only one who has difficulty letting these little ones go. And as I took my turn breathing for him over the course of the afternoon, I still prayed for his life. Late in the day, I was called away to a resuscitation; when I returned, he was maintaining good oxygen levels in spite of the fact that he had been left to take breaths on his own. I don't know what happened overnight, and it would certainly still be a miracle if he lived, but I am confident in the faithfulness of God, whatever comes to be, and know that He is willing to comfort this baby's family... and me.

Drained as the day left me, I decided to invite myself over to the Bemms' house after work and was asked to stay to dinner, and there is always occasion to find joy there. Bible study at the Whites' followed, so the day ended well with worship and with some encouraging words: "I was sick and you looked after me... whatever you did for the least of these brothers of mine, you did for me."

addendum

I meant to post this picture with the rest of the story, but better late than never, right? The reason it is in existence is that I mentioned to Daniel, the nurse who served as my exchange transfusion assistant, that friends at home were going to have a hard time believing I had actually had to do this on my own. He, realizing that I had a camera with me, offered to serve as photographer to document the occasion. I look pretty goofy, but it is proof, I guess.

not to keep you in suspense

The internet has been fairly slow of late, so I honestly haven't been able to access my blog site to finish up my tale.

Where did I leave off? Oh yes, I had forgotten to have Chuck draw me a diagram of how to set up an exchange. And he was in Nairobi. So first I called Ashley McGee, another of the doctors on the compound who is in family medicine, thinking that maybe he would know how. Unfortunately, he hadn't, but he did volunteer to call the Bemms on my behalf. Ultimately - so as not to drag this out longer than it need be - I wound up going down to the McGees' house and waiting for Chuck to call back. And then taking copious notes involving stopcocks and luer-lock syringes on the back of an envelope. And finally trotting back up to the nursery, where I nearly felt as if I were going to pass out since I had just walked clear across the compound and up the hill at top speed. (Note: I did not run.)

What is the bottom line? The baby got his exchange transfusion. And - miraculously, or so I felt - it was successful. I nearly cried with relief when the lab finally called me back with the bilirubin results from after the procedure. So that was the major excitement for the weekend. What else has happened that has not been medical? (You don't have trouble believing that my skin is still almost Cleveland-winter-white, do you?)

Saturday evening post-exchange I trundled down to the Bemms, where I so often find myself when I'm disinclined to go back to my own room, and spent some time relaxing with Amy and Agneta. Sunday lunch was barbecue out on the Whites' back porch, and as it was good food and great company, I can hardly be blamed for dragging my feet returning to the hospital to finish rounds afterward... on Sunday evening, we had a send-off reception for the McGees, who actually left today to go back to the States. Things have been relatively quiet since. I'm back on med/peds call tonight, though, so anything can happen.

I've been realizing lately how different my time at Tenwek has been this year than it has in the past. In some ways I wish I had more time to relax and hang out, because I love the people here so much, but in others, it's actually been encouraging to be so busy, because I know that it means I'm providing some relief to people like John Spriegel and Chuck Bemm. And I can always forward my phone calls if I want to try to hang out and be on call at the same time. I'm starting to feel a little sleepy right now, though, so I think it's time for me to call up to nursery, find out the new weight of the baby who appears to be in renal failure, and then try to get some sleep.

well-rested

It's a funny thing. It seems that the more careful I am about going to bed early when I'm on call, the fewer calls - and more sleep! - I am likely to get. So having gone to bed at 9:30 last night, I am pretty well-rested this morning, which is a lovely thing. Part of me almost regrets not having a resuscitation sometime last night, since I had promised the Whites to stop by their wee-hours-of-the-dawn Super Bowl party if I was awake. I'm not that sad, though. Sleep is lovely.

It was a busy weekend on call, but a good one, and it certainly could have been more busy, so I was fortunate in that as well. Rounds went smoothly both days - in some ways, when you're the only one rounding, it's easier to find a single nurse who will stick with you for the whole thing - and there were very few admissions. Undoubtedly the most interesting occurrence was in nursery on Saturday. I had been watching a small near-termish baby for a couple of days whose bilirubin (jaundice) levels were rising in spite of phototherapy, and Friday's level was high enough that I was particularly anxious to see the result on Saturday morning. I think I must have called the lab three or four times myself about it before I finally found out that it had continued to skyrocket, and I was really going to need to do an exchange transfusion. For those not in medicine: this is a (time-consuming) procedure whose end goal is essentially to replace the infant's entire blood volume with donor blood - twice, usually - by serially removing small amounts of blood from the baby and replacing it with equal amounts of donor blood. And let me tell you, in 2008, in Western neonatology, it doesn't come to that all that often. I've spent four months in the NICU back home and hung out there even more, and I've never even seen one. The true irony is that I had mentioned to Chuck on Wednesday that I was interested in having him show me how to set one up... and then I didn't follow through before he left for Nairobi.

*** The life of an on-call pediatrician never ends ***

I just got called to a baby resuscitation in the middle of breakfast, and it took long enough that now I'm late for morning report, so the end of my intriguing tale will have to wait until later! Be well, and thanks for praying.

taking a deep breath

For those wondering, in spite of a few moments during which I was decidedly not of good courage, and several more moments of medical uncertainty, by God's grace I did survive my encounter with HIV clinic yesterday. My efficiency was... lacking, though, and I was grateful to have Rop, a C.O., around to see some of the backlog that my inexperience simply wasn't going to allow me to make it through before closing time. Many things amaze me here: how much there can be to do, the fact that it's completely acceptable for me to leave abruptly and without explanation in the middle of an outpatient visit to assess a sick child in casualty... as I was trying to plow through a sheaf of unfinished charts yesterday around 4:45, I received yet another call: "Doctor Carolyn, please come to ICU!" Hearing the urgency in the nurse's voice, I ran from MCH as quickly as my long skirt would allow me, knowing exactly what must be happening to the child I had admitted there only an hour before. Three rounds of epi later, we had to admit that there was nothing further we could do for the child, and I was left only with the task of finding the mother, sitting with a chaplain outside the ICU, and telling her of the death of her baby.

I've begun to realize (again) that it's a pretty good day here when all of your patients survive until the end of it. But there are limits, often frustrating limits, to what we can do for the physical body, so it's a good thing that we still have a message of hope, even for a person without a chance for medical recovery.

Today was relatively run-of-the-mill, insofar as one can actually say that here. And so I took a few hours to relax and read this evening. I'm making my way right now through Miracle at Tenwek, the story of Ernie Steury, Tenwek's first physician, and I have such admiration for what he (and his family) perservered through during their many years here... he was one doctor, on call every day, serving 300,000 people, for so long. It gives me courage when I'm feeling tired and/or facing a weekend on call (like this one!) to know that I serve a God that can sustain us through even so much as that.

On a decidedly more cheerful note, I took this picture in nursery today... what, Kiptoo, you don't like the paparazzi?