follow up

Rejoice with those who rejoice; mourn with those who mourn. - Romans 12

As I was walking up to morning report today, I ran into Eric Miller, who was on call for peds last night and told me that the twin Kiprono had developed pulmonary hemorrhage and died during the night. This morning, his brother did the same and stopped breathing just before lunchtime. It's made me think a lot this morning about hope. So often here I brace for the worst and attempt to protect my own heart from grief by remaining doubtful. But after the first day and the first night, I had allowed myself unabashed hope for the lives of these two boys. So in some ways, the pain of their deaths is more intense, and my confusion at the purposes of God even deeper.

But in mulling over all these things, I am also trying to remember what real hope is. That it is not a hope in happiness or health, or even earthly life, but in a God who loves us and knows our deepest pain, even this pain of watching a son die. This hope I hold tightly to, whether I am laughing with the mother whose baby is recovering from orbital cellulitis and now smiles constantly or whether I am weeping in prayer with the mother of Kiprono and Kiprotich...

Thank God He is deserving of our hope.

nursery news

I told Laura that it was my goal to be in bed by 8:30 tonight, so this is either going to be the quickest, least-edited blog post I've written yet, or I'm not really going to be in bed at 8:30. It remains to be seen.

I've spent a lot of time in the nursery this week, where God has been moving in some mysterious and miraculous ways. On Monday, we had a three-month-old addition in the form of an HIV-exposed baby girl. She was abandoned by her mom and brought to the hospital by her psychotic father, where we have proceeded to love her and spoil her rather rotten (she has disposable diapers and a baby doll - what more could a three-month-old want?). She has been christened Abigail after a couple of us thought of the name simultaneously, and she is adorable and healthy and has served as a ridiculous distraction for the last several days. We hope to find her a place at a baby home soon. This is a picture of me with Abigail, one of a series in the Abigail Photo Shoots that seem to take place on a daily basis.

On Tuesday, Linner put a PICC line into the gastroschisis baby, so we pulled the TPN stock out of the pharmacy refrigerator, put the whole page of scrawled calculations I'd come up with over the weekend to use, concocted our solution, and started giving the baby a few more calories. Carol has been working hard to reduce the silo this week and is hoping to close tomorrow, so pray for her and the baby both if you get a chance. It would still be a while until the baby could start to eat, but it would be a huge step in that direction. Yesterday, Mom asked me to take a picture of her and the baby...

Yesterday started out somewhat slowly, but turned quickly into one of those emotional-ringer days in the nursery. I had had two consecutive resuscitations go badly - one in the evening hours of Tuesday, a baby of a young first-time mother who was rather unexpectedly asphyxiated, and one Wednesday mid-morning, a baby whose mother had been pushing for five hours at home before she came to the hospital. We gave PPV in the delivery room longer than I want to admit to the second baby, who refused to do more than gasp for air, then brought him to the nursery for nasal CPAP and to die, but then he started to breathe and cry. He's actually doing reasonably well now, but I don't know what his outcome will be in the end (I'm thinking more about this because of a 6-year-old child with severe cerebral palsy we had on the ward for a couple of days this week). But it's hard to stop in the delivery room... it's a huge struggle, because you want the baby to have every chance possible, and I just haven't figured that one out yet. After placing that baby on CPAP, we were summoned soon after to another resuscitation, and after waiting with an anxious and heavy heart, I burst into tears of relief and thanked God when I heard the baby crying vigorously across the delivery room.

I went home for lunch in hopes of taking a power nap but felt my pager go off after only five minutes - a pair of 27-week twins (an estimate which is probably not more than a week off) had just been delivered rather precipitously. The first was distressed but breathing when I got there, but the other was getting PPV and looked grim. I wound up intubating the second one and giving him a dose of epi before I was convinced that he had an acceptable heart rate. Like only a few hours before, I thought we'd be taking the second baby to the nursery to die, and my heart broke for their mother, who had delivered and lost a set of preterm twins before. But when we finally bothered to put the pulse ox probe on the second (intubated) twin, it read 94%. And though I had to intubate the other by the end of the afternoon as well, they are both still alive, comfortable on their ETT tubes, pulse ox-ing now in the high 90's and - after this afternoon - also under bili lights. They each weigh a kilo and change. Their names are Kiprono (left) and Kiprotich (right). I have spent the whole day shaking my head in wonder at God... I hit the limit pretty early on of what I could do for these babies, and He has very clearly done the rest. I can't tell you how much I would appreciate your prayers for these two babies and their mother. They have a very long road ahead of them, but that God has sustained them even this far is a miracle.

I'm on call tomorrow night but have the entire weekend off afterward to look forward to... Laura and I have plans finally to go for a walk on Sunday in that after-church-before-lunch slot, which will mark my first venture off the compound of the trip, and only her second, I believe. Lord willing and it don't rain, there will be pictures to show for it.

Okay, the bedtime deadline didn't work out: it's 8:52. But I'm going to publish, find my jammies, and crawl under my covers now.

how i know the developing world is developing

This evening as I approached the nursing station on the medical ward, the nurse on duty seemed very attentive to her computer screen. As there's not yet much of a medical nature on the hospital computer system, I became curious and looked back at her screen as I walked past... her attention, it turns out, was focused on a game of solitaire.

neonatal resuscitation

Before I get to the strictly medical portion of this blog entry, a few things:

1) I mused about finding a picture of the hospital surroundings. And yesterday on my way to lunch, I decided to take one. Here it is. It's pretty green these days, but the general chill of the late afternoons (and the percentage of time on call) has discouraged me from taking a walk off the compound. Maybe this weekend...

2) Little Kimutai, for whom I had asked prayers, unfortunately died late Saturday night after a failed resuscitation. And today I lost a little baby in the nursery who had been pretty seriously ill ever since she was admitted about two weeks ago. Her mother, Mercy, actually wanted to hold her while she died, and it was one of those times when I didn't even try to hide my tears... as often as I've seen it happen, it just never gets easier.

3) Last night, my med student friend Laura invited me to have "tea" with her. As she is from England, it turned out that this was code for a light supper. She proposed having "eggs and soldiers" for our meal, so I got to learn what that was, too. (It is toast cut in strips - per her internet research, optimal width 22 mm - and dipped in soft boiled eggs.) Of course, since I'm a little leery of eggs that are wet enough to dip anything in, I hardboiled mine and made them into an egg-and-tomato sandwich instead. But still with toast. Yum!

4) Tonight there was a Kipagenge (yummy outdoor potluck for the whole compound). Sadly, I didn't know about it until about half an hour beforehand, and so I had already eaten a large lunch, too. (Yes, "too".) Also, it was cold outside. No kidding. Adam White (one of the MKs) had some parka-type outerwear on, and though I teased him about looking as though it were below freezing, he was probably a lot warmer than me by the end.

5) I'm not on call tonight!! Even though I slept a reasonable amount this weekend, it's still very (wonderfully) different lying down in bed, turning out the light, and being certain that your phone isn't going to ring in five minutes.

6) I started to develop a sore-throat-type feeling earlier today. Please pray it doesn't blossom into anything.

Okay, I think I'm finally going to get around to discussing the heading... back in the States, neonatal "resuscitations" hardly merit the term. I distinctly remember the apprehension I had prior to my first night of solo Mac House call as a PGY-2 and being told confidently by the chiefs,"Don't worry - just dry the baby off." And really, most of the time, that's all it is... there. Here, it's a different story. I think I've been summoned to at least one or two resuscitations each day. When I arrive, I always feel a sense of trepidation asking the OB nurse why I'm there. What will it be this time? Or what combination of things? A huge percentage of the babies I'm called to resuscitate have meconium-stained fluid, and many also have fetal distress, because many of their mothers have been in second stage labor (pushing) for many hours at home before they come to the hospital. Not to mention that I've had two cord prolapses in the last three days! (Only one of them had mec on top of that.)

So "resuscitation" takes on real meaning in the Tenwek PACU (where the C/S babies are brought), and I get more practice intubating and bagging babies in one week here than I do in a year's worth of Mac House moonlighting. I've made the process into a routine over the past week: 1) Set up equipment. 2) Locate spirit swabs and wipe last baby's dried goop off equipment. 3) Find out from nurse what all the problems are before she rushes off to the theater. 4) Pray continuously for baby until nurse arrives with bundle in towel and places it in front of me. Praise God, the routine has worked out reasonably well so far, and even the first cord prolapse baby, who required about five minutes of PPV before his respirations were truly adequate, is doing well. And even when I have to jump out of bed at 3:00 am, pull on my fleece and walk briskly up to the hospital, it's still a joy to see a baby go from blue and and frighteningly floppy to pink and screaming and crying. It's just one of God's miracles that never gets old...

waiting for my pager to go off

I'm beginning to think that I need to take some pictures outside of the hospital so that I can provide a sense of the landscape, and not just the buildings where I work. But it's been a bit tricky of late to get good pictures outside. August is winter in Kenya, insofar as winter is actually a season here, and it's a very different experience from the weather in January through April, which is my prior frame of reference. For instance, most of this week, it has been sunny in the mornings (thank goodness, since my shower water tank is solar-heated!), but by the end of lunch, it's usually a race back to the hospital against the rain. And it's not the same as rainy season, either: during rainy season, the daily storms are intense but clear out pretty quickly so that the evening is often sunny again. Lately, afternoon storms have variably given way to a kind of cloudy chill. I'd be lost without my fleece. But it did make the fire in the Bemms' fireplace last night very cozy.

So far the weekend has been a bit of a mixed bag. I managed six hours of sleep last night after two neonatal resuscitations which ended happily (though one poor baby had a pretty impressive caput!) and made it up to the nursery shortly after 7 am to start rounding. Carol (one of the surgeons) replaced the silo in the gastroschisis baby on Friday, and his bowel is actually looking fairly viable, so one of my tasks for the weekend is to sort out an appropriate dilution for the TPN that Tenwek has in stock. And none of the babies were misbehaving badly this morning, which is always a relief. But upon arrival to the peds ward, a nurse and I were summoned to see a child whom we had discharged on Friday and hadn't yet left the ward (not an uncommon situation). This child, a six year old boy, had been admitted with what turned out to be profound liver failure and a liver mass which - because of the liver failure - could not be biopsied. As there was nothing we could do, we had explained his diagnosis as best we could to his parents, and I found his mother in tears this morning as she sat next to her gasping child. We took them into a side room, but mom elected to wait outside in the hall while he died. It's one of the interesting cultural contrasts I've often wondered about here, that parents so often don't want to be present for the death of their children. In the States, I feel like I've been trained over and over to do everything possible to have the parents present during all of their children's critical moments, but here, even when I offer, I'm often turned down. It's been a challenge for me to learn how to gracefully honor these parents' grieving process, too, in spite of my Western sensibilities.

Rounds were mostly uneventful otherwise, though I did decide to transfer a four-month-old boy named Kimutai upstairs to the ICU. He was admitted earlier this week with diarrhea and dehydration and has subsequently developed oliguric acute renal failure (=kidneys not working). Because of this, he has been accumulating fluid and has had progressive respiratory distress. Shortly after he arrived in the ICU, I was called to assess him for gasping respirations and I wound up intubating him, in spite of the fact that the two main ventilators were already in use. Thank God, once his oxygen levels improved, he began to breathe a little bit better on his own again. But unless we can support him until his kidneys recover (which could be in just a few days, or never), he will eventually die. Please pray for him and those of us who are caring for him.

In less mellow news, I discovered a Ziploc bag of chocolate chip cookies on my doorstep when I arrived home this afternoon. Apparently the Hershey's I brought over for the Osteens had already been put to good use, and they wanted to share the spoils. (I ate four right off the bat.) And then when I stopped by to thank them, I was promptly sat down and fed one of Jennifer's enchiladas... and then homemade spicy hummus and pita. So I didn't really have to worry about dinner tonight. And, perhaps selfishly, I've left the remainder of the Ziploc's contents downstairs in the guesthouse with Laura, my new English med student friend (and fellow VeggieTales fan), so hopefully she will succumb to the temptation and spare me from the rest!

Well, despite the eerie quiet of the evening, I should probably call up to the ICU to check on Kimutai. And then it might be appropriate to catch a nap before the inevitable page finally comes...

off the wards

It's hard to believe my first week is almost over... time really does fly. Work up on the wards has taken on the familiar feel again, and what accompanies that is not always joyful. We've had a few deaths in the last two days, including both a beautiful full term baby whose mother had terrible chorioamniotis and a tiny preterm girl who had necrotizing enterocolitis. I'm continually amazed by the faith of some of the people I encounter here. The mother of the tiny baby returned to the nursery yesterday to say goodbye to some of the other mothers whom she'd befriended, and when I told her how sorry I was that her baby had died, she responded,"I loved her, but God loves her even more." What a powerful comfort...

I've been relishing my free evenings this week outside the hospital. On Tuesday, I went to dinner with some of the Bemms at John and Krista Fitzwater's house; John is on leave from his surgical residency program for an MPH and has been doing research (and working!) here since March. For all who know, they're living at the Chupps' house. That homes are often occupied by different families each time I come is one of the more interesting things about visiting here repeatedly. At any rate, we had a delicious regular old American meal: cheeseburgers, potato salad, baked beans, chips, salsa, and strawberry shortcake. I was stuffed silly by the time I followed Amy back home, where I (re?)learned to play Dutch Blitz before we watched a movie. (nb: I no longer fall victim to the common misconception that one will lose weight at Tenwek simply because one is in Africa.)

On Wednesday, I finally found Agneta at home and spent some time catching up with her before Bible study. Agneta, for those of you who don't know her, has been at Tenwek now since 2005, when she did her internship here. She subsequently spent two years as a medical officer here, working primarily in pediatrics, before starting a surgical residency in January. She is absolutely one of the smartest and most gifted people I know, and really has an unbelievable heart for the patients here. She's come to be a dear friend here as well as an example of selflessness and being totally committed to God's call. This is an old (Jan '08) picture of her with one of our favorite surgical patients...

I've been trying to do a little better with sleep the last few nights in order to gear up for the weekend. I'm on call three nights in a row, which has the potential to be tiring, but in some ways the weekend can be relaxing, too... it's often just me seeing the patients, and it allows me to take the time that I want without interruptions. And there's something about being in the nursery early in the morning that's very soothing... unless, of course, there's a baby not doing well. :) But I look forward to telling you about it.

It's time for me to head up to morning report - Debby Mutai, a former CO intern here, who has been serving as a missionary to Sudan, is going to be giving an update on her work there, and I don't want to miss it. Morning report, which is usually a lecture from one of the specialties or grand rounds by one of the interns, is a good educational start to each morning. Yesterday, Rose gave her grand rounds on otitis media, and at the end, we were entertained - and educated - by a live demonstration of the best way to position a fussy child for the ear exam (see below).

More to come later...

intro to the wards

It took me a couple of days, but I finally decided to write a real post... it's probably a poor prognostic sign for the blog that it's taken me this long, but don't worry, it just means that I'm busy and having a good time.

I started work Monday morning on the pediatrics ward, where I'll be for the month I'm here. It took me a little bit of time to get back into the rhythm of the workflow, but fortunately not too much has changed since I was last here six months ago. Moms share beds with their children on the wards, extra nutrition is distributed in the form of milk and special uji (high-calorie porridge), and there's always a willing student nurse to help me translate my conversations. The biggest change is probably the fact that as of Sunday, I'll be the only pediatrician at the hospital and won't be able simply to call Chuck when I have a question about a diagnosis or management. With this in mind, I've spent the last three days furiously scribbling questions into a little notebook so that I can get as many answered before the end of the week as possible!

Below, you'll see one of the other things that hasn't changed: having to split two oxygen ports between four (or more!) patients.


In addition to being my first day of work, Monday was also my first night on call. While I spent the hours between 9 and 1 walking back and forth between my apartment (and the Bemms' house, where I was getting my day's questions answered) and the hospital, things were quiet later on, and the baby resuscitation which ended my night ultimately resulted in a squalling, healthy baby.

Though it has resulted in some of my biggest heartbreaks, I have loved working in the nursery at Tenwek over the years. Linner, the charge nurse, is a gifted nurse and ministers overtime to the babies and their mothers here. Right now there are definitely a few babies (and families) who need prayer... One baby born three weeks ago has choanal atresia (blockage of the nasal passages, which babies use to breathe) and appears to have other anomalies as well, including congenital heart disease, though because our echo machine is currently nonoperational, we don't know what kind. While nasal stents are allowing her to breathe, she has continued to require oxygen for reasons that we can't determine with any certainty. Ultimately, I don't know whether she will live, and we as doctors need prayers for wisdom as we try to care for her. One other baby, pictured below, has gastroschisis, a severe anomaly that is difficult to repair successfully with limited resources. In addition, we can't allow the baby to feed normally, and so his nutrition is suffering. Without the intervention of God, quite honestly, this child is unlikely to survive.


Such are some of the challenges facing me for the next month... and I hope to be more timely about updating you for the rest of the trip than I have so far! Thanks for praying.

late entry for 8/17

(nb: the following was composed yesterday before I actually had unlimited internet access...)

I'm here at Tenwek Hospital, where I arrived safely last night. If you're scratching your head right now and thinking, "Wait... Carolyn's in Kenya already?" don't worry. I feel the same way - time flies.

My trip was pretty uneventful, although I think I really did one of the worst jobs of trying to time out my naps that I've ever done and consequently found myself pretty wide awake at 2:00 Saturday morning. Conveniently, Chuck Bemm (the pediatrician at Tenwek) had to bring their youngest daughter, Hannah, into Nairobi on Saturday morning for a doctor's appointment, so I was able to get a ride back to Tenwek with them yesterday afternoon. I spent the morning drinking Dormans coffee and finally finishing off Blue Like Jazz, which I've been meaning to read for over a year now. The drive back through the Rift Valley was pleasant, if somewhat treacherously dusty on occasion, and it was a good chance to catch up on what's been going on at the hospital with Chuck. Among a few surprises when I arrived at Tenwek was the fact that I'd been assigned a pager! I think some of the long-term doctors are less excited about the advent of the paging system, but to me it means not being so tightly leashed to the phone on call nights, which is exciting. I had dinner with the Whites and managed to stay up until about 10 before hitting the hay. I think I got the best sleep last night that I've had in at least a few weeks, which - for the second night in a dramatically different time zone - is a pretty sad commentary on my recent sleep patterns. But it felt nice. :)

Church was this morning, and it was great to see many of my friends from last time again. I found it a bit ominous, though, when Carol Spears (one of the surgeons) greeted me with a huge hug and said,"Welcome back! I'm so sorry... we're going to just about kill you while you're here!" So after lunch, I made my way up to the hospital to take a look at the attending call schedule, but really, it's not so bad. I'm going to be on the peds wards for the four weeks, and I'm only on call twice this week, including tomorrow, before being on both days next weekend. (That said, it doesn't mean that I won't appreciate prayers for strength!) And in spite of the fact that the peds ward looks pretty crammed, Russ White assures me that more than thirty of the patients are primarily surgical... as I walked by, I saw a rather unfortunate child who appeared to have both legs in vertical traction! Poor thing. I popped my head into nursery, too, which has acquired several gorgeous new warmer beds since February, one of which was occupied by a two-day-old baby with gastroschisis, which is not an easy thing to deal with here. I know that all the staff - particularly the med/peds people - are feeling stretched right now, so definitely pray for endurance.