beth is here!

Beth arrived safely yesterday morning, and it's been lovely to have her. Last evening, she and Agneta and I took a quick walk down to the dam under ominous skies and were made subject to a rather breezy drizzle but were ultimately rewarded by this:
It was actually a double rainbow, but the picture of the double isn't quite as nice. Just thought I'd share. :)

weekend bits

I'm up a little earlier than usual this morning, courtesy of a call around 6:15 to make me aware of a little preterm baby that had just been brought to the nursery. And I haven't blogged since Friday evening, so I thought I'd make myself a tall mug of coffee, enjoy some leftover cornbread, and take advantage of what will likely be one of my last chances to update. (Patti, if for some reason you are reading this, it was actually a good thing to get up fifteen minutes early, and I don't want you to feel bad.) But it appears that I'm down to my last two days at the compound, which is a very sad feeling. Last night I had horrible dreams about having to say goodbye, and it seemed like I could never find everyone to whom I wanted to say farewell, and there was a lot of crying. I suspect it's not that far off what will actually happen. :) But anyway, my last weekend on call is over, and as there wasn't one cohesive theme that emerged from the two days, I'll resort to the bits-and-pieces approach.

Around 3:00 on Friday afternoon, I was summoned to casualty to see a five-month-old baby named Kibet who had been brought in with gastroenteritis. By the time I saw him, he had received 60 ml/kg of fluid (in layman's terms, a lot), still looked somewhat lethargic, and hadn't had any urine output yet. Joshua Nderitu, the FP registrar who was working in casualty, told me that he had also obtained a history of herbal administration from the mother, and my heart sank a little as I remembered the little baby we lost two weeks ago with the same story. An hour later when the creatinine came back at 2.2 mg/dL, it sank a little further, and we cleared out an ICU bed for him as soon as we could. (It's the only place in the hospital where you can really get reliable ins and outs and be on a continuous monitor.) I think I must have bemoaned the lack of ability to get urine electrolytes about a dozen times that evening (in conjunction with bemoaning the widespread use of herbals) and second- and third- and fourth-guessed my decisions on fluid management. You have perhaps heard me say you have to be smarter to be a good doctor here since you can't just order tests for everything? This was one of those times. But I did the best I could and prayed for God to bring him through the rest of the way.

On Saturday, Mercy and I set a land-speed record for rounding on peds and finished up with both the ward and the nursery by 11:30, which was a particularly fortunate thing since I had woken up feeling a little green around the gills and had to sit down about every five minutes in order to think properly during most of rounds. God was definitely looking out for me. But Kibet's creatinine was up a little from admission, which lent credence to my suspicion that this was not just dehydration, but wasn't terribly reassuring, and I began to wonder when I should talk to the parents about transfer to Nairobi (while he was still stable on room air)...

Sadly, the green-ness of the gills prevented me from enjoying the two Kipagenges on Saturday, at least from a culinary perspective - by dinner, all the appetite I could muster was for a bottle of Sprite. But I did have fun getting to hang out with everyone, I think particularly since I hadn't been already stuck in meetings with the whole crew all day. And John and Krista offered me their supply of Pepto Bismol after dinner, which I took, in spite of the fact that I really detest Pepto. But it did result in some improvement, enough that I wanted to be awake, but not to think much, and so Laura and I borrowed Love Comes Softly (fine, laugh if you must!) from Krista and watched it before calling it bedtime. A last-minute call to the ICU for Kibet's evening creatinine results resulted in being told that the creatinine machine was currently out of order. Oops. But he had had a little bit of urine, maybe even not in response to Lasix, and so I was slightly encouraged.

Yesterday, Laura - who has been unable to sleep past 6:00 am for more than a week now - came up to the nursery with me to start rounding at 7:00. I was pleasantly surprised to discover that my nausea had really abated almost completely, and rounds were conducted in the usual upright position. Also, it turned out that the creatinine machine had been fixed, and Kibet's numbers were actually down! We weren't quite as fast as the day before (but did get mostly done prior to church at 9:00) and still had about three babies left in nursery by the time we had to get down to Mercy Rop's for lunch.

One of the small miracles of yesterday was that I discovered in the course of casual lunchtime conversation that Linner had been unexpectedly assigned to go to a week-long seminar on infant nutrition in Nakuru this week. I think I must have looked absolutely stricken when Mercy told me this, and she made several phone calls until she found Linner up at her office at the hospital. Which is where I immediately ran (as much as one can run up the hill to the hospital on a full stomach) to find her. There were at least five or six things I'd been saving up since Thursday to ask her - on Monday, I thought - and it would have been horrible not to be able to say goodbye. (I have a thing about goodbyes, if you haven't noticed.) She gave me advice, some keys, a few assignments, and a big hug. There are a lot of times when I think I would come back to Tenwek just for her...

Other random facts from yesterday: when I went to return the Pepto to the Fitzwaters (um... and get the next movie in the series), Krista told me that I had missed, by about ten minutes, some major excitement. Evidently a large crane with a mostly-detached wing had landed in the green space, and to put it out of its misery, Eric Miller chopped off its head... with a panga. And then put it in the trash can. Someone is going to get a nasty surprise when they empty the garbage containers today!

Also, because of a child who came to casualty in status epilepticus, I had to move little Kibet out of the ICU last night, at which point it looked like he might honestly, for real, be making some urine on his own and pharmacologically unprompted. Pray for him as he may be turning a corner! The funny part of the status case - if there can really be a funny part - is that I was in the middle of writing my seizure presentation for today when Agneta called me from casualty to tell me about the patient, whom she'd taken care of by virtue of being in the right place at the right time. As she gave me the history and told me what she'd done, I had to stifle a laugh, because it was almost as though she was reading through the slides of my presentation. The child even had the same name - Kiprono - as the child in my case scenario. I told her maybe she should go back to being an intern, as she was obviously very good at it! (I don't think she was all that amused.)

The most exciting news of today, though, is that Beth Stuebing is scheduled to arrive today at lunchtime! She is a good friend from medical school who is now a surgery resident at Brown and was meant to come in March of this year - well after I left from my Jan/Feb trip - but was delayed because of the post-election violence, and so I will actually get to see her for a couple of days, which is tremendously exciting. Getting to share someplace that has become so special with good friends is very cool.

So that turned out to be more of an excessively long narrative than a bits-and-pieces approach, but hopefully you made it through. I will try to write at least once more before my departure from Tenwek (and known internet access) on Wednesday morning. The plan is currently for Agneta, whose birthday it is on Wednesday, and me to go on safari for a couple of days and then head into Nairobi on Friday... I'd appreciate prayers that all the details would be worked out smoothly, because a few things are still a little up in the air.

Time to go talk about seizures!

in half an hour, there's a kipagenge

So I've come to the end of the (work) week, my last complete one of the trip. I'm on call this weekend, so it's really less momentous than it would seem, but I think the most notable thing about this week has been its calm. There have been only a few admissions to peds per day, and other than Kipkoech, the baby with gastroschisis who unfortunately died Monday night, none of the children have even been all that critically ill. It's been something of a blessed respite for me and the rest of the peds team, though I really do get a vaguely unsettled feeling when we finish rounding in nursery before 4:00 and manage to clear out MCH less than an hour after that. It's like I should be working harder. Here's a shot of the peds team (minus Rose, a CO intern who finished last week) that we had time to take after work and before 5:00 pm today. From left to right, it's me, Mercy, Kevin, and Laura. Go team!
The peace and quiet this week has given me some time to mull over some other things (besides neonatal jaundice!), which is nice. During the last couple of days I've been thinking about the tension that I sometimes feel here when things at the hospital don't go as smoothly as I think that they ought to. Obviously, there are constraints, and some tests, or procedures, or therapies just aren't options, but there's also a lot that can be done and sometimes doesn't happen or doesn't happen efficiently. And it's easy to get frustrated, sometimes just with a culture that doesn't always perceive urgency in the same way as we Westerners do, and sometimes even with specific people. The challenge, I think, is to find a way to respond with love but also with expectation that standards can improve. There is clearly a Biblical precedent for an expectation of excellence, and if we're providing care for people in order to give glory to God, is it not right to do that in the best way that we are able? So I'm trying to figure out how I can urge the people around me on to excellence while still maintaining a spirit of gentleness and kindness. No easy answers there.

This weekend there's a WGM Field Meeting at Tenwek, which has brought a number of missionaries from surrounding areas and has provided an excuse to have three (three!) kipagenge potlucks in the next day and a half. The first tonight seems to involve a Whole Lot of Pizza, and there are hints that dessert will include brownies. Mmm, yummy. There's nothing like a good Friday night pizza party to start the weekend off right, even a weekend on call.

One last picture for now, taken during a down moment this week in the PACU where Laura and I had been called a little prematurely for a neonatal resuscitation. That green blur in the foreground is the blanket on the baby warmer, where I perched the camera to get the shot while we were waiting for baby (who was just fine, by the way). We were contemplating setting up a shot from the perspective of a baby on the warmer table with the suction catheter coming straight at it but decided against it. We can't be serious all the time...

easy afternoon

As it turned out, I didn't have time to procrastinate on my jaundice talk last night, so there was no blog. (Presentations always take longer than I think they will!) But yesterday was relatively relaxing overall. There was a long-term doctors' meeting at 8:00 instead of morning report, so the rest of us got to start rounding an hour early. I'm not precisely sure what the combination of circumstances that precipitated this particular outcome was, but by some miracle, we finished rounding both on the peds ward and in the nursery by 1:00. This has never, ever happened to me before. (Okay, it probably had something to do with the really low peds census, the extra hour of rounding in nursery, and the absence of any resuscitations.) At any rate, it meant that I got to head down to lunch at the hospital restaurant with an unusually light load. Wednesday lunch at the restaurant is scheduled to be a weekly occurrence - on other days visitors alternate between the guesthouse and missionaries' homes - but had sort of fallen into disuse of late. But this week, at Shannon's suggestion, we all made a pact to come. So it was curry all around, and I enjoyed a refreshing Stoney Tangawizi. (Try not to be jealous, Jeff Schlaudecker!)

After lunch, I admitted a pretty stable preterm baby to the nursery and wandered over to the library to work on my presentation. Laura found me soon afterward to tell me that Kevin had just left clinic for lunch and there were no patients to be found anywhere. We gave it about forty-five minutes, and then I called over to MCH again, but they denied needing any help. (A lack of pediatric clinic patients at 3:00 in the afternoon is fairly shocking.) After another forty-five minutes, I made an excuse and wandered over to investigate at MCH myself, but I found Kevin finishing up with the last patient and really, really there were no other children to be seen. With such a break yesterday, one wonders what God has prepared for today! Heh.

Feeling our freedom and noting that it had actually not rained, Laura and I decided to take advantage of our early day and go for a walk. We headed out around the Freije loop, which is a nice length for a pre-dinner walk, and made it back in plenty of time for me to make an egg-and-tomato sandwich and head upstairs to work on my talk (note a theme for the day?) before Bible study. This week at Bible study we talked about the latter half of Ephesians 6 (the armor of God), and - in contrast to last week - I did not fall asleep on the couch in the middle of the TD Jakes video.

It's about time for me to pack up my laptop and head up the hill for morning report. Today has dawned sunny and breezy again, and I wonder if it portends another rain-less day. I'll let you know later.

breezy morning

I have not much to say this morning, except that I am post call, got plenty of sleep, and am really enjoying the few moments in my apartment before devotions. The coffee is just right, it's sunny outside, and there's a beautiful cool breeze blowing through the trees. If I didn't have to go to work, I'd definitely go for a walk. It's a good day.

I will make an effort to have more of substance to say this evening... no doubt as I procrastinate on finishing my talk on neonatal jaundice.

poised at the beginning of a new week

It's a new week (my third already, can you believe it?) and a new month, and since I didn't manage to eek out a blog post over the weekend, I thought I'd type for a few minutes this morning. Though I have no idea what awaits me up at the hospital - the call schedule for the month hasn't been posted yet, and I haven't been on the wards or in the nursery since Friday - the weekend provided sufficient refreshment that I'm feeling hopeful. (Or should I say Hopeful?)

Not only did I take a walk yesterday with Laura, Shannon (2nd year FP resident) and Merwyn (medical student), but I squeezed one in before the rain on Saturday morning as well. The pictures I took are mostly all included in the slide show that is currently running to the right. It was a gorgeous two days, and though the rain still did come, the weather seems possibly to be changing a little, as the skies have been waiting longer to let loose lately. The countryside around the hospital is really beautiful, and with the rain, the hundreds of shades of green are out in full force. The dam, too, has more water running over it than I've seen since my initial trip in 2004. And in what amounted to quite a bit of personal encouragement, climbing the far bank of the river past the former rickety bridge (those of you who have been here know the trek of which I'm speaking) made me only moderately out-of-breath, rather than pre-syncopal! Perhaps my habit of running has done me good.

On Saturday evening, Agneta orchestrated a girls' movie night, which was much-appreciated. She, Shannon and I all trooped over to the Fitzwater house after Annemarie (age 20 months) had made it to bed, and with Krista made popcorn. Figuring out how to hook up the projector to the TV (for audio) and the DVD player (for video) didn't take too long, and we settled down to watch Cheaper by the Dozen, which I had never seen before, and which caused me to laugh harder than I had in a long time at a movie. Part of me thinks that the intensity of the laughter spilled over from the rest of the emotional intensity I'd experienced over the week, but whatever caused it, it did me more good than a simple movie ought to. Now Agneta's on a search for Cheaper by the Dozen 2...

Geoffrey Musyoka spoke at church yesterday about pride, which is always a convicting topic for me. It's an important distinction to realize that God calls us to excellence, but that - even in achieving excellence - it's nothing we have a right to take credit for. He made that very point in an eloquent way: "On the door of achievement, pride will always come knocking." And humility goes deeper than actions or words... it's an internal posture, and one that all too often I don't take.

Well, it's about time to finish off my mug of coffee (I may have absconded with the guesthouse coffee maker last week... but no one has complained yet), read my devotional, brush my teeth, and head up the hill. Quick update: Kipkoech, the baby with gastroschisis, was closed on Friday (no more silo!) and has hung in there over the weekend, but Eric told me yesterday that he's starting to get quite tachypneic, so I expect his belly is feeling pretty tight with all those bowels in there. Pray for him...

Happy Labor Day!