heading home

The last few days have flown by quickly, and suddenly (it seems) I find myself sitting on the porch of the same room at the Mennonite Guesthouse in which I stayed almost four weeks ago. This time, however, I've got company: Agneta and Lisette and I came into Nairobi yesterday afternoon for some time in the city (i.e. pedicures and restaurants) prior to my flight out tonight. Bringing friends with me made it easier to leave Tenwek, and I remain hopeful that God will continue to provide opportunities for me to return on a regular basis. On a random note, we passed some unusual roadkill on the drive here: an elephant, thankfully on the side of the road, but clearly attracting a lot of attention. (Note the Kenyan man on the far right also taking a picture with his camera phone.)

As it happened, I got to do a little bit of critical care in my last couple of days at the hospital. Wednesday night was my final call, and I had dropped by casualty just before 5:00 to talk about a couple of patients that my intern was admitting when a small boy was carried in by his father and laid, gasping, on a stretcher. He had been seen at a dispensary (clinic) earlier in the day before going to a district hospital about half an hour down the road from Tenwek. There they placed an IV - I'm not sure they actually gave him anything through it - and referred him to us. He'd had two days of cough, high fevers, and respiratory distress since earlier in the day; by the time he got to Tenwek, he was completely obtunded and retracting more than any four-year-old ought to be able, so we prepared to intubate him. I have to say, it was easily the best-coordinated intubation I have been a part of in casualty, no doubt because one of the casualty consultants was there to help orchestrate. But when I put the tube in, he immediately started coughing thick, purulent secretions out of the tube. We suctioned and suctioned, and then suctioned some more before we were finally able to keep his oxygen saturation reliably in a safe zone.

ICU was out of ventilators for the night, but HDU had one available, so we took our little guy down to get him settled. As a side note, the transport of a critically ill patient down the hill from casualty to HDU never fails to amuse and frighten me simultaneously: I was on the downhill side of the stretcher, and it seemed terribly precarious as we tried to navigate the bed and maintain the patient's airway down the hill and through the cluttered, narrow hallway to HDU. Happily, the transport went smoothly, and when we hooked up the pulse ox in the unit, he was fully saturated and looked comfortable, so after spending more time than I want to admit figuring out the ventilator setup with the nurses - I am NOT a vent technician, unfortunately - I felt comfortable leaving him for the night.

Thursday morning on rounds, our patient was looking significantly better: we were able to minimize his ventilator support, and the nurses were eager to get him extubated. I stopped his sedation and asked them to call me when he had woken up (see right), and we could pull the tube. I was really happy to see him looking so appropriate - he'd looked half-dead when I met him in casualty - but when we took the tube out, he went from comfortably sitting up in bed to incredibly distressed, with biphasic stridor that didn't respond to nebulized epinephrine. The nurse found his family and managed to get a history of stridor in the early phase of his illness as well, and I started to wonder if he had bacterial tracheitis (high fevers, stridor, gosh-awful disgusting endotracheal secretions, unimpressive CXR...). Regardless of his diagnosis, his level of distress meant I didn't really have a choice, and one of the HDU nurses helped me reintubate him while the other nurse on duty assisted the medicine consultant with a resuscitation at the other end of the room. Just another day in the HDU. At any rate, I was sad to have to leave before he got better - and before we could determine his diagnosis with certainty - but I really think he should recover fully.

On a less clinical note, I was also reminded powerfully of the other part of my role as a physician at Tenwek Wednesday evening. I was walking by the peds ward when I saw one of our patients, Faith, being wheeled out after her discharge home. She's a particularly sad case, a teenage girl newly-diagnosed with HIV and a non-existent CD4 count who came in with worsening mental status and a fairly acute-onset paralysis of half her body. All of our investigations - we were able to be pretty thorough since her care is funded through PEPFAR - didn't turn up any reversible causes of her illness, and we began to talk to her mother about hospice care. She wasn't able to eat by mouth safely, so we arranged to send her home with a feeding tube in her nose, and we spent time counseling mom about her prognosis. Her mother very much wanted to take her daughter home and care for her there, a brave act in such a resource-limited setting, and she planned to bring Faith weekly to a local dispensary where she could be seen by the hospice team. Seeing her leave, surrounded by more family than I'd seen during her week-long hospitalization, I felt a wave of hope for her. Her earthly life isn't likely to be long, but she is clearly cared for immensely, and by a family who knows God and the true nature of hope. After I wished her mom well, she suddenly ran back to me and grabbed my arm. "Please pray, daktari!" So we did, in the middle of the hospital courtyard, with dusk falling and her family circled around her. We treat the physical body - sometimes well, sometimes not well enough - but Jesus is our comforter, our hope, and - ultimately - our healer. And so we can praise God, even in situations like Faith's.

As a final note of reflection, I've been reading I Corinthians 13 all month - my church back home has been studying it this fall - and it's been incredibly challenging as I consider what it means to apply the nature of love to what I do every day at the hospital. If I speak in the tongues of men and of angels, but have not love, I am a noisy gong or a clanging cymbal. And if I have prophetic powers, and understand all mysteries and all knowledge, and if I have all faith, so as to remove mountains, but have not love, I am nothing. If I give away all I have, and if I deliver up my body to be burned, but have not love, I gain nothing. I come to Tenwek to practice medicine, to teach interns, to care for patients, but without love, it's nothing, nothing, nothing. And as it turns out, love is a fairly radical and demanding way of life. I'm grateful that I serve a God who patiently works that out in me, gently convicting and correcting even as He loves, and who allows me to be part of His work in such amazing circumstances.

Love bears all things, believes all things, hopes all things, endures all things. Love never ends. 

faces from the month

Chepkemoi and her mother are two of the warmest, most delightful people I have ever had the privilege to care for. I actually met Chepkemoi when I was here earlier this year, during her second admission for cryptococcal meningitis, a complication of her HIV. She was unfortunately admitted with a third episode last month, and in spite of being stuck in the hospital, was said to wake up smiling every morning. During her hospitalization, she made a request for a Swahili Bible, which - after far too long a delay on our part! - we secured for her from the chaplains, and I got to watch her proudly print her name inside the front cover. As it turns out, her preferred name is actually Faith.

Emily was admitted after she nearly passed out while walking 10 km after her vehicle broke down. As it turns out, she has a heart defect that explains this very well (and has actually had surgery to partially correct it in the past)! Since she was here around the same time as the visiting cardiac team, she was able to return to be evaluated for further interventions. Happily, it turns out that she doesn't need surgery right now. But we did counsel her not to do any more 10 km hikes! The other delight of seeing her in echo clinic - and feeling a lot better than when she was admitted - was seeing her personality sparkle... she is a teenager for SURE.

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This is Mathias. He also has a heart problem, but his heart failure is actually because his tonsils and adenoids are too big, and over his short two years of life, they've caused enough obstruction that he has significant pulmonary hypertension. Which is all beside the main point, which is that he is a very sweet little boy whose most frequent facial expression is the same one that he's got in this picture: very attentive and vaguely suspicious. But he never fussed and was always cooperative. His father, a slightly older Kipsigis man, was his caretaker during his entire hospitalization - unusual for this culture - and was incredibly patient with us while he cared dutifully for his son.

What else can I say about Jemima? I know it's not right to have favorites, but aside from Chepkemoi, Jemima was the patient I most looked forward to seeing every day. I've written about her infectious smile and how I tried to coax it out of her for several days after her heart surgery before it finally returned over the weekend. It's only become more consistent since then... two days ago during a rainstorm I found her wheeling around the HDU goofing off with another cardiac kid and grinning like crazy. Today we took our picture together since she's been discharged and will hopefully be leaving the hospital soon once they clear their bill.

And finally, this is Shadrack. He's got some sort of poorly-defined recurrent hemolytic anemia, and he was admitted last week with a low hemoglobin (like, really low) and feeling pretty darn awful. How awful he must have felt became clear after we transfused him a couple units of blood, his fever went away, and he turned into one of the biggest hams I've met. This is him, hamming it up on Saturday. Seeing him like this was pretty good reason to discharge him home.

I love seeing (and photographing) these faces... and these five are just a small sampling of all of the beautiful children I've gotten to love during the last month. Knowing them and caring for them has filled my heart with joy and heartbreak both, and I'm grateful for the imprint each of them has left.

grief and responsibility

There's been a lot going on at Tenwek this week: not only has there been a cardiac group here doing pediatric CT surgery, but Tuesday was the thirtieth anniversary celebration for Tenwek Community Health & Development. Which is amazing. As one of my friends pointed out, how many development organizations make it anywhere near that long? And Tenwek's has been going since I was four years old. I managed to see part of the ceremony around the lunch hour, which included wonderful tributes by choirs from several of the local primary and secondary schools.

However, all of the early hubbub is not, ultimately, what's weighed on my mind for the bulk of this week. Tuesday night I was on call, and it was unusually quiet until my pager went off around 3:00. When I called my intern back, he let me know that one of our ward patients had passed away just a short time before. For reasons that are still not entirely clear to me, though he was paged by the nurses, he was unable to make contact until resuscitation had already been ongoing for some time and they stopped shortly thereafter, before I was even made aware. I was crushed. It was a patient who had been with us for nearly two weeks: he had come in critically ill, had survived a stint in the ICU, and was making real progress. I'd met his father for the first time two days before and he'd given me a real smile for a picture while basking out in the courtyard. That morning his caretaker told us he'd been vomiting - a change - and we'd done a little bit to work him up. But not all of his tests were back and what we did know wasn't diagnostic of anything in particular. So his death that night felt awful. I was sad because I'd gotten to know him and cared about him, but I was also sad because I felt like I had failed him. I had a strong suspicion about why he died, and I felt the weight of feeling like I ought to have been able to prevent it. I couldn't sleep and I couldn't forgive myself.

Just an hour later - still awake - I got another page. A baby born at home had been brought to the hospital because of an umbilical cord accident that had resulted in what sounded like a lot of bleeding on the way. Though my intern assured me the baby looked okay and the hemoglobin level was low but not frightening, I went up to the nursery to evaluate her. Unfortunately, she appeared to be in shock when I got there and didn't yet have access. After numerous valiant attempts by the nursing staff to secure an IV, I asked permission to root around in their supply cupboard and pull together what I'd need to place an umbilical line. Getting everything together took longer than I wanted, but the procedure went smoothly, until I took down the drapes and found that the baby was only gasping for breath irregularly. By some miracle, the blood we'd decided to transfuse had arrived in the nursery, and I pushed several syringes of that as well as IV fluid through her new umbilical line before her breathing became regular again. I knew she needed more blood and more fluid, as well as antibiotics, so I wrote careful orders and pointed them out before heading back to shower quickly and get ready for the day. Three hours later, my co-consultants and I stuck our heads into nursery to check on her and found a nurse assisting her breathing once more. We attempted to resuscitate her again, but unfortunately her heart rate continued to fall and we realized that there was nothing more to be done. But she hadn't gotten any of what I'd ordered, and I felt a huge weight descend on me. I know the system here, and I know how it works and doesn't, and I should have known better: if that baby really needed the extra fluid and blood, I should have stayed and pushed it myself. There's no question.

Deaths are rarely easy, but these two, back-to-back, were a real struggle for me. I didn't want to be reassured that it wasn't my fault, and trying to process it for quality improvement purposes, so to speak, left me with a cold weight in my chest every time I thought about it. My conclusion was always the same: it wasn't a knowledge deficit, either of the system or of the patient, it was a decision not to take control of the case. And even though I know the grace of God is sufficient for my bad decisions and weakness, I desperately wanted the chance to do it over. In spite of how difficult it has been, the last few days have done some to heal the rawness of Wednesday morning's wounds, but I expect that those six hours will remain with me for a long time.

On a lighter note - and one which no doubt contributed to my recovery from those events - one of my very favorite patients from this trip, Jemima, who had unrepaired Tetralogy of Fallot and was admitted with profound hypoxia, had an uneventful trip to theater Wednesday afternoon for her cardiac repair and emerged with pinker lips than she's probably ever had in her life. Her mother was all smiles immediately post-op, but Jemima was another story, and for a couple of days it seemed that not even my silliest antics would coax a grin out of her. But this morning she finally cracked a smile for me down in HDU, and I hope that soon her smile will be constant and infectious once again.

This morning, to kick off my final weekend on call, I also forced myself out of bed at 5:00 to join a few friends in the traditional sunrise hike to Motigo, the highest point near Tenwek. I hadn't been since 2006, and I was struck by how built up the area was in comparison to seven years ago. But the sunrise was the same, chilly and beautiful, and I came away with numb hands and a few pretty pictures that don't even begin to do it justice. At least with my camera (um, iPhone) you know there's not a chance in the world of really capturing the mist that settles between the hills at dawn and the pink clouds on the horizon, but there's something about the purity of God's creation as seen from the top of that hill that makes you feel like you have to try. Trust me when I say you've just got to be there yourself.

halloween, triatix, and lunch in bomet

I've got to admit something: I've been feeling a pretty spectacular lack of desire to do much writing this trip. And I don't know exactly why that is. Perhaps it's because writing is often how I process, and much of this trip has felt relatively straightforward. Perhaps it's because I haven't felt monumentally challenged or unusually encouraged in my faith by anything that's happened so far. Or perhaps it's just because I haven't taken enough good pictures, and I feel like a blog post ought to have good pictures. So anyway. I'm trying to discipline myself to write in spite of those things.

At any rate, I'm mostly through a weekend off, which I've been quite grateful for, as I spent Friday feeling a little feverish and peaked. Not nauseous, exactly, but completely lacking in any sort of desire to eat or drink. Something was definitely amiss, I just wasn't sure what. I remember writing about this when I was here several years ago, and it felt very similar. “Green around the gills” was what I called it then, and that still seems about the best way to describe it. Fortunately, the day was light, and when we finished up around 3:30, I was pretty happy to head home after purchasing some cold fizziness at the hospital canteen.

Friday evening was the Fall Festival (i.e. Halloween), which I was seriously tempted to forego in favor of continued couch time, but it's a big gathering of the community here, and I'm glad I pulled myself together and got up there. The kids (see picture) were ridiculously cute, and judging the costume contest was a challenge. And we wound up with birthday donuts for Julia's tenth birthday... which I ate. Apparently some things overcome green gills.

One of the other things that overcomes green gills, by the way, is adrenaline. I got to test that one out when my on-call intern paged me around 8:30 (at which point I had settled pretty thoroughly into a corner of the couch and was watching The Blind Side with my housemates). When I called back, Betty's voice had a sense of urgency to it, and she had gotten as far as “a Triatix (poison, usually intentionally ingested) patient who isn’t doing very well…” before I was looking for my shoes. She’d managed to get out “satting 45% on room air” when I cut her off and fled the house for casualty. I’ve worked here enough that what I found shouldn’t have surprised me, but when I arrived, I was pointed to a curtained-off corner of the room, where my unattended patient appeared to have a reasonable heart rate, but was barely breathing, and the pulse ox sensor was beeping noisily but not registering a number. Happily, casualty has made strides in having equipment available, and there was an airway basket nearby, though the masks were entirely too small for the large teenager in front of me. I urgently requested a mask from the nurse we’d called for assistance, as Betty was occupied looking for intubation equipment, but when she finally returned, she came bearing a mask for me. Nope. We finally got that straightened out, and with a laryngoscope blade whose light had seen many better days, a lot of suction, and a dose of Valium to assist, we managed to get him intubated.

Of course as the adrenaline wore off, my body remembered that I hadn’t been feeling particularly well and had eaten so far that day a scone, a small piece of banana bread, and… that donut. Which caused me to put my back to the wall and ask Betty to bag for a minute or two while I focused on breathing. Then came the problem of patient placement. Leaving poor Betty attached to the endotracheal tube, I first went to ICU, where all of the beds were occupied. Next, HDU. Same there. Fortunately, there is a nurse in charge overnight - COPP, anyone? - and she understood the urgency of the situation, which became worse when we found out there weren’t any ventilators available, either. She promised to work on it, and I returned to casualty to relieve Betty. Realizing I was potentially stuck manually ventilating for a while, I requested a chair, which the poor frazzled nurse brought for me quite promptly. And I sat there, thinking... this is not my usual. Sitting in casualty, leaning my elbow on the bed of a patient who just tried to kill himself, and from whom is wafting the odor of every body fluid possible, with stomach contents splashed on the gurney and the floor in front of me. Lord, have mercy. On my patient, who considered his life not worth holding onto. On his family, who had brought him to us and was awaiting the outcome. On me, who in spite of good intentions, still got frustrated with staff who couldn't help me care for my patient as quickly as I wanted. Working here is humbling.

Yesterday was my first opportunity to take a nice long trek through the hills around Tenwek, so when friends invited me to accompany them on a walk to Bomet for lunch (three-plus miles away), I gratefully accepted. There's a main road to Bomet, but Jen has discovered a back way that eliminates cars and boda bodas and features equally pretty scenery. It was a lovely hike to town, and we ran a few errands, like visiting Radiant Supermarket, before sitting down for lunch at the one restaurant in Bomet that boasts wooden tables, apparently. The chicken and chips were perfect after a long walk, but the skies had clouded over by the time we were done, and we opted to take a taxi back. I'm hoping for a few more opportunities to walk in the next couple of weeks. Maybe tomorrow evening after work if the weather cooperates.

In the meantime, my housemates are attempting to recreate the donuts from Friday evening's festivities, and I think I'm going to go see if I can give them a hand.

thursday again

I'm not exactly sure how it's Thursday again already. Time has been flying by, and the hours have been filling up without much effort at all. All week I've been thinking, "I have plenty to write about - maybe I can sit down and do it tonight!" And here we are... at Thursday. A sunny late afternoon Thursday, to be precise, and the fact that I'm at home because I ran out of things to do at the hospital is pretty impressive. Time to catch up on the rest of life.

View from the hospital courtyard this week.

After a relatively quiet Saturday on call, Sunday was actually quite busy. Or at least it felt that way, as I found myself up at the hospital for the bulk of the afternoon trying to fix a toddler with supraventricular tachycardia (really high heart rate). Thankfully he was stable, because I floundered for several hours before finding out about the secret stash of cardiac drugs in theater, which included the adenosine I'd been wishing for all day. Quite naturally, he managed to lose his IV once I'd found the drugs, so we spent another half an hour securing an IV line. We had just taped it in place when I heard the nurse behind me say, "Excuse me, doctor... doctor? The patient... she has stopped." Around here, that's code for "arrested", so my syringe of adenosine fell to the bed, and my little SVT guy had to wait while we attempted to resuscitate the patient in the next bedspace over, a very sad teenage girl with end-stage heart failure who had been admitted only a few hours earlier. In spite of a transient return of circulation, she ultimately didn't survive; my toddler, however, got his adenosine and promptly went back into a sinus rhythm with a much more normal heart rate. Miraculously, the rest of the night was calm.

Zucchini bat.

Monday was Mashujaa Day, or Heroes' Day, in Kenya, so those of us not on call had the day free. As so often happens on a rare day off, I didn't manage to sleep any later than normal, but I did spend the morning in my pajamas, which always feels like a luxury. Perhaps not surprisingly, I donned an apron and went a little crazy in the kitchen: apple cinnamon scones, zucchini muffins (to use up a ridiculous zucchini bat I bought last week), soda bread, and a new soup from The New England Soup Factory Cookbook, which is my favorite soup cookbook of all time. Oh, and cocoa brownies. Which I really ought to make back home sometime, too, because they are delicious. I also did some laundry and made a trip up to the new grocery store just outside the hospital gates, so I felt pretty domestic by the time all was said and done. We had friends over for dinner and stayed up late (or at least late-ish, by my circadian clock) playing Waterworks, the 1970's-era Parker Brothers game that I really am going to buy this time.

Deep cleaning the peds ward.

The rest of the week has been a bit of a blur since then. Though the ward census and nursery acuity have both continued to be relatively low, there's always plenty to be done in the late afternoon: X-rays to chase down, consults to follow up, patients to see in casualty, lab results to chase. (It's always unnerving to check a baby's bilirubin drawn six hours before and discover it's critically high and no one else has realized...) And yesterday, I got to represent pediatrics (paediatrics) at the Kranium meeting, which was illuminating, if nothing else. The electronic medical record is set to go fully live in the nursery next Monday, and it will be an exercise in creativity and patience to figure out how to navigate the computers on wheels through the maze of babies in boxes and breastfeeding mothers. Pictures to come, I promise. In the meantime, it's been nice to feel a little breathing room this evening to relax and have a little downtime. I think we're planning to watch a movie, if we don't all fall asleep first!

And because this picture has made me giggle every time I've pulled it up, I'm going to leave you with it. A little context: when we see babies in the nursery, we're asked to take off our white coats and put on gowns. (Infection control, I guess.) Usually they come in the form of shapeless, pinafore-type garments, but apparently yesterday Vincent and Kenneth found these jackets and decided they were preferable. I'm not so sure. But they do look adorable in pastel.

Two very masculine pediatric interns.

having a home

To come quickly up to speed:

Hi. I made it to Kenya! Uneventfully and - praise God - without any evidence of jet lag in spite of succumbing to sleep in an empty row of seats during the bulk of my flight from Paris to Nairobi. I arrived Monday afternoon at Tenwek, took the half day to settle, and plunged into work on Tuesday morning. So far the only disaster was the minor stroke I must have had when I decided to leave my ATM card at home, which resulted in me running out of cash before I even made it to Bomet. Fortunately, a friend in Boston graciously retrieved it and had it sent to a doctor due to arrive early next week, so that story should have a happy ending.

Every trip here has a slightly different flavor, and the thing that's been dominating this one so far is the sense of having a home to come to at the end of each day. And housemates with whom I can knock elbows in the kitchen, laugh over dinner, and sit quietly in the living room doing work. The consistent hot showers and cozy bed don't hurt, either. Normally I live in the guesthouse while I'm at Tenwek, where accommodations are lovely but not exactly homey. So when offered the chance to stay at the furlough-ing Bemms' house (thank you, Bemms!) and to be responsible for my own meals, I jumped at it. Getting Lisette and Priya as housemates has been an unexpected bonus for the built-in community it's provided.

Road home (that's home on the right)

I'll admit that while I was excited about coming here, I was simultaneously more than a little loathe to leave Boston this fall. It felt like there was a lot going on, and it's one of my favorite seasons of the year in the city. I was enjoying fall baking, I was enjoying my friends, and I was enjoying life where I was. It can be challenging to detach, to exchange seasons, usual community and rhythms. For those reasons, I think I'm particularly grateful this time around to be where I am. Doing life in a relatively normal way, even if I'm away from Boston, has eased the transition and has allowed me to feel like I'm really living here, which helps me to be fully present. That's a huge gift.

HDU patient. I promise he's sick.

Hospital life has fallen into a comfortable rhythm again as well. After a slightly overwhelming start to the week, many of our ward patients have been sent home and - after having so many patients that we had to board admissions in casualty early in the week - our census is actually quite low. There's the usual assortment of puzzling cases and a handful of critically ill children whose presence makes me a frequent visitor to both the ICU and HDU, but by and large, it feels familiar.

As I just typed that, I realized that for all the familiarity, the system is actually dramatically different since I last visited: Tenwek has gone live recently with an electronic medical record, which has come with the same sort of headaches and growing pains that any sort of EMR change always does. It's been a crash course for me, and when I showed up in the ICU this morning to do rounds by myself and found out they'd - in the preceding 24 hours - transitioned to computerized vital signs, I felt momentarily paralyzed, until a kind nurse showed me how to access the data I needed. Up until today, pretty much all I knew how to do was order labs and review results! Trying to assimilate, I even wrote computerized notes on the HDU patients later. And then I proceeded to eliminate all boundaries that being away from the hospital ought to confer by logging onto the system from home this afternoon. It's convenient to be able to check on patients when I'm on call without huffing and puffing my way up the hill (please note: altitude 7000 ft), but am I going to be able to leave it alone when I'm off duty? Sigh. I'll report back.

In the meantime, I continue to appreciate prayers for wisdom in dealing with complex patients as well as discernment in navigating systems which have shifted in subtle and not-so-subtle ways since I was here in May. And for truly restorative rest during downtime. I'm on call all weekend but looking forward to having Monday off, as it is apparently a national holiday. Maybe there will even be time to write again...

time flies (!)

Let's set aside the fact that I only used the last of my Dorman's coffee a few weeks ago. And the fact that I have a 200 Kenyan shilling note in my wallet because I just haven't gotten around to taking it out yet. Even without these bits of insight, it still seems like this next trip to Tenwek has been approaching at a frightening pace. Some Tenwek visits meander onto my radar, and others I race headlong into; this is definitely one of the latter.

I spent quite a bit of time after I got back to the States last spring thinking about the pace at which we lead our lives, and what is healthy, and what is not, and what God sometimes calls us to that would, on the face of it, seem unsustainable but for his grace. Lately, as almost anyone who's talked to me knows, I've felt as though I'm squarely in that last category. Thankfully, the grace of God has been quite evident to me, especially in the last week: providing unexpected encouragement from friends, easing the tempo at work, allowing me enough sleep in spite of being on service. I'm very grateful, but in having the space to reflect, even a little, I've also realized that the one thing I haven't done yet about this trip is get excited. As in really, truly, looking forward to what's coming in just a week.

The push to the finish line (or... departure gate?) slows in intensity as of Wednesday morning. (At which point maybe I'll remember to phone in a prescription for malaria prophylaxis...) I hope that I'll really be able to use the last three or four days to prepare well, and that that process will make me as excited as I ought to be.

You can check back soon to find out. :)

click here for pictures.

For a Saturday afternoon in the MICU, life has been rather slow this afternoon, so I've finally compiled (read: pared down) an album of pictures from my trip. Because I am a more avid consumer of social media than I like to admit, you can find it on facebook via this link, even if you're not a facebook user.

Thanks for being a part of my journey for the last month... tune in again in the fall for more, hopefully!

stateside

I'm back. Boston is in bloom - which means my car is covered with a fine layer of pollen - and spring has sprung. The excitement I felt on realizing that Saturday was enough to propel me into a jog around the neighborhood to take it all in (eye drops and Zyrtec to follow). This morning I dive back into routine at the hospital.

I don't want to get lost in the regular, though, because if I do, I'm afraid that the last month will be relegated to some back-brain part of my memory that makes it feel like an entirely different world. And I really long for consistency between the two spheres in which I work. At church last night, I said that being a physician at Tenwek makes me feel more coherent vocationally than I do anywhere else, which is true. The challenge is to translate that coherence into my practice every day in a way that's honest and loving.

Caleb, on the ventilator

With that said, I also haven't told any stories from my last week at Tenwek, which - in spite of a continued low ward census composed of mostly surgical patients - still contrived to feel quite mentally busy because of a few sick patients and a few busy call nights. The first patient was Caleb, a little month-plus old baby born with tracheoesophageal fistula that was repaired before I met him. In spite of his repair, however, he's been quite slow to grow and gain weight, and he started having lots of reflux and aspiration events which ultimately landed him on the nursery's only ventilator Monday morning. I spent a fair bit of time standing over his bed with Agneta, his surgeon, praying and wondering what on earth we were going to do with him. Late in the afternoon he plugged off his breathing tube with blood and secretions and had to be reintubated, and I left the hospital dreading the next time that would happen. But the urgent call late Monday night actually came from the peds ward, where the charge nurse called me to see Chemutai, a three year old girl with pneumonia that Chuck and Paul had admitted early in the evening. She was breathing quickly and struggling for every breath; back-to-back nebulizer treatments didn't help her at all, and since we didn't have a CPAP mask small enough for a three-year-old, we moved her up to the ICU and I intubated her as well. It was nearly four o'clock in the morning before I made it back to my apartment at the guesthouse, and the dreams in my brief sleep after were riddled with ventilator alarms and phone calls about inadvertent extubations.

Chemutai, off the ventilator

It's illuminating for me to reflect back on both of those cases, over which I agonized quite a bit. Part of it was a sense of responsibility for those two patients: I'm an intensivist, and I should certainly know how to care for children on ventilators. But I was caring for both of them in settings in which I still felt my resources (with regard to diagnostics and staffing) to be somewhat limited, which left me with a rather bad case of the nerves. There's clearly part of me that rebels against the sense of ultimate responsibility that being in that role imparts. I didn't want to deal with the personal failure implied if things had gone poorly, especially since I felt like both kids should have been okay. Really, to some extent, I think I didn't trust myself. I'm not a trainee anymore, but I'm still finding my confidence in many situations, and that's something I will need to grow in. Both Caleb and Chemutai survived their stints on mechanical ventilation: the former underwent a Nissen and G-tube procedure the day before I left, and the latter was discharged home on Friday, smiling and shy, to the care of her attentive father.

Meanwhile, I spent Thursday and Friday morning saying my goodbye-for-nows to friends at the hospital and on the compound. Last mandazi and chai, a final walk around the loop to the dam, and one more evening wrestling three-year-olds and playing Bananagrams at the Bemms'. It helps that they've already penciled me into the visiting staff schedule for October (and this morning I got my block assignment for next year, which should permit that!) and that I have a discrete point in time to look to for coming back. This past month flew, and the next five months likely will as well, so that gave me peace in departing, even if I did shed a few tears more than I had hoped. God has really tied my heart to this place - to the work that is going on there and the people who are faithfully doing it - and I pray that I'll have regular opportunities to be a part of it.

"prayer!"

View from the porch.

Nestled as I am into my last day off before I leave, I don't really have any excuse not to get a good blog update in. I'm "house-sitting" for the Bemms while they're in Nairobi this weekend; it might more accurately be described as getting to use their house and - more importantly, at least to me! - their kitchen in exchange for feeding the Manchesters' dog, Walker, twice a day. I think I'm clearly getting the better end of the bargain on this one. So I'm settled into a seat on the awesome screened-in porch, enjoying a remarkably beautiful day and trying to figure out if I shouldn't really be talking a walk somewhere instead...

The early part of this week was incredibly busy: it started early Monday morning when, as I was putzing around thinking about getting into the shower, I got a page from the ICU, where they had been resuscitating a profoundly dehydrated child for four or five hours. I threw on scrubs and headed up, but very sadly, when we checked a blood gas, the baby's pH was 6.44 and he had barely palpable pulses; given all he'd been through that night, there was really nothing else we could do to save him. His creatinine later came back quite elevated, and it seems likely he had multi-organ failure before he even got to the hospital.

That evening, I was out to dinner at Carol Spears' but - on account of the events of the morning - had decided that I was going to carry my pager with me even when I wasn't on call. Even so, I managed to miss four pages while we were outside eating dessert, and when I finally realized and called up to casualty, Chuck told me that there was a girl with impending respiratory failure who had been diagnosed as an outpatient the day before with acute glomerulonephritis (kidney disease). I stopped by home just long enough to change into scrubs and grab my stethoscope before heading up the hill, where I met Chepkorir, a lovely 15 year old girl who, in spite of the fact that she was quite clearly having the worst and most frightening day of her entire life, smiled and, with a little bit of English, was able to answer a few of my questions. Her oxygen saturations were very low, her blood pressure was high, her heart had a gallop, and she was sitting bolt upright and breathing nearly eighty times a minute; I was shocked that she was as alert and interactive as she was. A chest X-ray showed impressive pulmonary edema - it had apparently been nearly normal the day before - and a blood gas confirmed that she was both truly very hypoxic and quite acidotic, though she was making up for it rather admirably with her respiratory rate.

After we slugged her with a hefty dose of diuretic, Chuck mentioned that he had a CPAP machine in his office, so we went to get that and set it up in the HDU (high-dependency unit), where she was going to be admitted. I rarely have pediatric patients with whom I can communicate in English, so before I left her in casualty, I asked her if she wanted to pray. She nodded decisively in the affirmative, so I said a quick prayer for her before I ran off. We eventually got the CPAP set up (though as it appeared to be a home-use machine, it was anyone's guess how much pressure we were dialing in!), brought Chepkorir down to the unit, and got her onto a nasal mask, since it was the only compatible piece we had. Though her distress appeared to ease somewhat, and her Foley catheter was starting to fill with urine, her appearance was still enough to make my heart beat in my throat. We got her settled in as much as possible and, with her mother leading us in a heartfelt prayer in Kipsigis, we asked God to watch over her before leaving her in the hands of the HDU nurses for the rest of the night.

No more oxygen!

The next morning I stopped by HDU first thing on my way to morning report; Chepkorir was still sitting up in bed, breathing quickly, and had not slept at all. I got a butterfly needle from Chuck's secret stash to get another ABG and felt a leap of hope in my chest when I saw the blood pulsate bright red in the tubing instead of the purple it had been the night before. She was still acidotic, and her kidneys hadn't much improved, but her oxygen levels were up, a full face mask had become available, and - knowing that it was out of my hands - I spent the day praying that her renal function would come back, and quickly. I can't imagine what the HDU nurses thought of me that day, as I stopped in countless times just to check on her heart rate, add up her urine output, and size up her respiratory distress. When I stopped in to draw her evening blood gas, we had another of our simple English conversations, with her nodding yes and no behind the mask; as I was saying goodbye for the evening, she began gesturing furiously at her face. Thinking her mask was uncomfortably-situated or she was feeling nauseous again, I unstrapped it and pulled it away to let her speak. Very pointedly, she looked at me and said, "Prayer!" The simple insistence of the request smote me for the steady faith that it conveyed. We prayed and got her back on the mask. Ever smiling, she waved goodnight to me, and when I stopped in after a trip to the delivery room in the middle of the night, she was sleeping curled on her side in bed, breathing more slowly than I'd seen since I met her.

Chepkorir had steady improvement over the next few days; she came off of oxygen Thursday and transferred to the regular ward the next day. Her creatinine returned to normal, we weaned her from diuretic, and last evening she had - praise God - a nearly-normal echocardiogram (to assess heart function). This morning I snuck onto the ward to see her and bid her and her mother goodbye, as I think the team is going to discharge her home today. Honestly, her smile hasn't changed since Monday night when I met her, and she continues to amaze me with her joy, even in the worst of circumstances. She and her story will stay with me, not only because it was a patient outcome far better than I hoped for, but because of how God met both of us through our brief acquaintance.  I trust that God has equipped me by nature and training to be able to care for the sickest of patients, but in situations like this one, I am powerfully reminded of how limited I am and am immeasurably thankful that God is omnipotent.

Friday was a slower pace than the rest of the week, and in spite of a sprint from the guesthouse to the delivery room at 5:00 last night - not optimal on a steady incline at nearly 7000 feet! - to receive a very preterm baby, the evening quieted nicely. I made biscuits this morning: after carefully consulting three different websites about baking at altitude, I hilariously still managed to flub completely by halfing all the ingredients except for the milk. Fortunately, I threw a little more flour and butter in and things seemed to work out fine. I had planned to get off the compound today with Agneta, but our plans were thwarted at the last minute because of weekend staffing issues. But now that I'm done blogging and the sun is still shining as brightly as ever, I might take that walk until Agneta wakes up from her post-call nap... I should check and see how the falls are flowing!

full and busy and encouraging

Well, so far this week the prayers I asked for have been very much answered: life here has been quite full in a lot of really excellent ways. Down side? I don't have quite the energy I'd like tonight to write a full blog! I have at least one good story to tell, and I do promise to tell it at some point, but if I go to bed in the next few minutes, then I might get over eight hours of sleep tonight, which would kind of be a much-needed miracle. So: tomorrow.

I will share a few pictures, though, which might make this brief update worth it...

Wheelchair antics. This guy had periorbital cellulitis. His legs work fine.

We've actually done a bit of house-cleaning on the pediatrics ward in the last several days, sending enough patients home that I looked around one of the two main rooms in the ward today and wondered where everyone had gone! It's a good thing, though, and has kept the days manageable. Here's one of our little ones, feeling a lot better after being treated for pneumonia.

So glad to be discharged home!

And finally, the weather: it's fluctuated from downpours to a few days at a time without rain. Today after lunch I was sizing up the sky, thinking, "Hm, are we really going to make it a fourth day in a row without rain?" Half an hour later, I saw this out of the nursery windows. So... no. Not really. But there is nothing quite like seeing a storm roll in here, with grays crowding out the blue against a backdrop of all of the rainy-season greens. It's just beautiful.

delivering bad news

I'm an intensivist, and that means that an all-too-regular part of my job involves having sad and difficult conversations with parents when their children aren't doing well. Because training has changed a lot in recent years, I've been coached in how to approach these conversations since the first year of medical school. So in spite of the heaviness I still often feel in my chest, it's a familiar scenario for me, and I understand how to navigate the discussion. But a large part of that familiarity, I am realizing, is connected to a familiarity with my own culture and how Americans respond to and process grief.

This past week in the nursery, we had a mother bring in her three-week-old daughter; by history, she'd had a "large head" since birth, but it had been getting worse, and the day before she'd stopped breastfeeding. The baby had the most impressive bulging fontanelle I've ever seen, and when we tapped it for CSF, it seemed likely that the baby had developed hydrocephalus after suffering a bleed either before birth or shortly thereafter. Our visiting neurosurgeon evaluated the baby and because of some test results and some findings on his exam, he thought it unlikely - even with a shunt to relieve the fluid build-up on the brain - that the baby had a good prognosis.

It fell to me to communicate this to the baby's mother. Accompanied by one of the nurses who spoke Kipsigis, I led the mother to a small office down the hall from the nursery. I tried to start from the beginning, explaining what we thought had happened to baby Faith, and then tried to ask a little more about their family - were they a well-resourced family who would want to pay for a shunt in spite of the grim prognosis? But no, neither the mother nor her husband were employed. Faith was the fifth child in their family, and they owned only a small piece of land on which they farmed enough to feed their household. Her husband, in fact, was an amputee, and she had no one with her in the hospital as she cared for the baby. During the conversation, I watched the mother slowly turning further and further away from me in her chair, until finally her back was to me, and she asked in a broken voice through the interpreter what she should do next and if she could go home.

Looking at her, I realized that I didn't have any idea how to comfort her; I didn't know how to engage the grieving process in her culture. Quite honestly, it made me feel rather helpless, and I wasn't getting any cues from my nurse-interpreter. In the end, I offered her the only thing I could: prayer. Which is probably the most powerful comfort, in that situation, we could hope to hold out to her anyway. But her grief and her tears were heartfelt for her little girl, and my heart ached for not knowing how to care for her.

In spite of a somewhat-weighty ending to the week, I've had a wonderful weekend off. On Saturday I went to the interns' graduation - or rather, part of it. It was supposed to start "promptly" at 11, and in spite of the fact that Chuck had told the Kenyans to be there at 10:30, there was still one graduating straggler that we had to wait for, until he showed up at 11:15! I slipped out during the middle to do some rounding on peds so that Dino, the family medicine doc covering peds this weekend, could come perform his part in the graduation ceremony. So I missed the "meat" of it, but got to participate in the actual meat as I was back in time for the incredibly lavish luncheon. In the end, I think it turns out I kind of invited myself to the celebration (I had made an apparently erroneous assumption that it was open to everyone), but honestly, I just wanted to be able to celebrate with Charles and Dennis, the two interns who had been on peds, so I felt like the purity of my motives mostly made up for it.

Graduating interns! Soooo happy.

Much of yesterday was surprisingly dark and rainy, so when today dawned bright and sunny, Laura and Mike (two med students in the guesthouse) and I resolved to take a nice long walk after church. After I threw my laundry in the washer and changed into slightly-less-inappropriate sandals, we gathered Agneta from her apartment and headed for the site of the old rickety bridge below the dam, which for the last five years has just been an actual (new-and-improved) bridge.

The old bridge was rickety. This one is not.

It's always a walk that tests my agility and fitness level: the slope down to the bridge is steep and, especially during rainy season, rather treacherously muddy. (Why did I wear sandals instead of sneakers? I had just put all of my socks in the washer, sigh.) But we all reached the bottom without incident, crossed over, and headed back up the opposite bank, which is only slightly less steep, but offers gorgeous views of the surrounding hillsides. After reaching the top of the path, which is routinely traversed by donkeys and cattle as well, we followed the road for a bit and then took a muddy turn-off suggested by Agneta, who also shortly thereafter confessed to having a ridiculously poor sense of direction. Our turn-off led us to a hillside that gently sloped down to a narrow brook, which we had some fun crossing (skirts, sandals, mud and all) before heading back up to the main road.

Before: so graceful.

After: hanging onto Agneta for dear life.

We eventually made our way back to the dam, which was built many years ago across the river and powers the hydroelectric plant that supplies electricity for the entire hospital compound. Every time I'm here the river seems to have a different character, and I'm relatively convinced that I've never seen so much water coming over the falls as there is right now. There is no other word to describe the sound than thunderous, and it's a clear reflection of the heavy rains we've been getting.

We've been hearing in the last few days about Kijabe, another mission hospital just outside of Nairobi, and also the site of Rift Valley Academy, where there's in fact been so much torrential rain that there were mudslides Friday evening and several of their access roads have been cut off. As much as we are grateful for the rain, it's a double-edged sword, and we're praying for respite from the rains for the folks east of us.

The rest of today has been relaxing: after lunch I tried to make brown butter shortbread cookies with the assistance of Hannah Smiley-Jones and Lydia Bemm, and while they certainly tasted fine in the end, between the altitude and the fact that apparently I don't know how to adjust the temperature on the guesthouse oven, they were decidedly less beautiful than usual. I guess I'll just have to try again! I played chicken with the late-afternoon stormclouds by leaving my laundry on the line as long as I possibly dared and settled for scattering half-dry socks around my room to dry overnight.

It's been a busy weekend, but a wonderful rest nonetheless, and I look forward to heading back up to the hospital tomorrow morning, where I get to take care of great kids like this one, who saw me pull me camera out last week and demanded to have her picture taken with me.

Me in a white coat: you're never going to see that in the States!

Hard to believe there's only two work-weeks left. Please pray that they're full and busy and encouraging!

full moon call night

Shortly after dinner this evening, I was summoned up to casualty to see a patient by Mercy, my on-call intern, and incidentally discovered a beautiful full moon. I'm a person who finds the full moon to be enchanting and would happily sit underneath it for hours just appreciating its beauty (well, I would until the mosquitoes start to get friendly, anyway). So upon my return from the hospital, I zipped up my fleece, perched on the balcony steps, and spent some time watching the moonlight silhouette the trees and listening to the thunder of the river flowing over the dam down the hill. It hasn't rained in almost two days and the skies are fairly clear tonight, though in the bright moonlight, the stars are fading into the background. Peaceful.

My camera can't quite capture the magic.

Fully twenty four hours have  passed since I started thinking about writing another post, but the honest truth is that I feel like I don't have all that much of import to relate. I mulled it over this morning, wondering if the comfortable routine of the last few days is somehow wrong. As if I'm not paying enough attention - to the work at the hospital? to God? - and I'm going to find myself back on a plane for the States having missed out on... something. But needing to feel something profound every day can be a trap, too, and can get in the way of obedience to a simple call to serve. I've been going through the Psalms in the mornings and made it to Psalm 121 today: I lift my eyes to the hills. From where does my help come? Especially here, where I'm surrounded by hills, I love that verse, and I'm trying to remember it every time I look out the window at the hospital, just to stay grounded.

The hills.

So. While the day-to-day hasn't been highly eventful, it has been quite pleasant. And - up until yesterday - periodically monsoon-ish. On Tuesday, I practically swam down the hill after work to have dinner with Jen and Todd Lavery, who are here for two years through the SP Post-Residency Program. Jen and I were introduced via email by a mutual friend, and this was our first opportunity to meet. Dinner was falafel (I think I need the recipe), flatbread, cucumber salad, artichokes, and lots of enjoyable conversation, followed by an introduction to a 1970's-era Parker Brothers game called Waterworks. It's rather mindless fun, and a great way to spend an evening with cool people. I found it on ebay yesterday... I'm a little bit tempted to buy it.

This week the peds ward team has been over-generously staffed, with five interns and a medical student, and rounds have been pleasant and - rather notably - devoid of emergencies. Mercy and I were even reflecting that none of the ever-so-numerous babies in nursery are particularly ill right now, which is a huge blessing. We have had a few challenging cases, including a teenage boy who was referred to us almost a week ago in a coma from which he never awoke and never had a clear diagnosis in spite of our best efforts. Knowing his prognosis, we offered his parents the chance to take him home today, rather than stay in the hospital while the bill increased every day, but they declined. It seemed cruel to hope that he would die quickly rather than linger and increase the expense to his family. But when Mercy was urgently paged to the ward just a few minutes ago while we were on the phone, and I called ahead to find out why, they told me that he had stopped breathing. I can't help thinking that it's merciful that he's no longer suffering and that his family is no longer living in uncertainty. The interns and one of the chaplains had spent quite a bit of time with his relatives, and they understood his prognosis, but I always fear that grieving without a clear answer as to what happened is very hard for families. Pray for them.

On a lighter note, today was the last day for one of our MO interns, as he's graduating on Saturday with his classmates, and we lingered in the nursery after rounds, taking team pictures. Notably absent from the team picture is Chuck Bemm, the long-term pediatrician who also oversees the all of the interns and seems to be pulled in about five or six different directions every minute of every day. Perhaps we'll get one with him at graduation...

Joram, Benta, Paul, Dennis, Mike, Mercy, and me.

I won't deny that while I've enjoyed the rhythm of this week at the hospital, I am a little bit looking forward to having the weekend off. Okay... more than a little bit. I'll try to write more then and will hopefully have more of substance to report, but if it doesn't happen, just know that I'm having fun and loving being here. I'm going to try closing my eyes for a bit, as there are apparently four vomiting siblings in casualty that I'm sure I'm going to hear more about later, and I'd love to get some rest before then. It sounds like they drank some bad fermented milk - I wish I was being redundant by saying that, but I'm not - and I'm just crossing my fingers they'll keep down their ORS. I'll leave you with a picture of a little guy I watched wheeling around outside the ward for most of the day before I asked him if I could take his picture. He seemed really attached to this chair, and would careen around, crashing into walls and posts without seeming fazed in the least.

Not sure I'd let him drive me anywhere...

Hysterical.

rainy sunday

It's the end of the weekend - and nearing the end of my four nights-out-of-six-on-call sprint - and it's been rainier here today than it's been since I arrived. Consequently, though it's only 8:00, I think I could pretty happily tuck myself into bed, read a chapter of North and South, pray that the night stays quiet, and turn out the lights before 8:30. But I also recognize that I've hit the end of my first week without a real Tenwek update, and lest I get horrifically backlogged, I really ought to do a little documentation.

Ah, rainy season... beautiful.

The week has been a challenging one, as I felt somewhat torn between a desire to be back home while my city was going through tumult and a desire to really focus on being here. But I've found myself slipping day by day back into the routine of being at Tenwek, in spite of the several things that have changed. Mornings start with the sunrise, my showers are tepid (but efficient!), and I linger over the Psalms with a mug of Dorman's coffee before heading up for morning report. And there's a great community of visitors right now as well, which has been an exciting discovery, especially as the missionaries have been only slowly filtering back home after retreat and holiday. There have been phenomenal conversations and stories nightly around the guesthouse dinner table, and Livingstone and Helen are still cooking feasts - and an overabundance of desserts - for every meal.

Encounters with old friends have been incredibly encouraging as well... the joy of discovering that Agneta will be here the entire time I'm visiting... an invitation to the Bemms' Pizza Friday and getting to meet the "midgets"... people like these are much of what make Tenwek feel like a home to me.

Up at the hospital, neither the peds ward nor the nursery have been terribly busy (though there's still babies in wooden crates at every turn in the latter), and the interns pre-round entirely by themselves, which means that rounds feel more efficient. There's bedside ultrasound, and the X-rays are now computerized. It's been slowly dawning on me just how much more I know now than I did during my last visit, and how much more comfortable I am teaching. Which is not to say that my interns don't hear me ask "So... what do we do for that here?" at least twice a day. And it doesn't have a lot to do with being at Tenwek, per se, except that I think being here and recognizing the difference between me now and me four and a half years ago has been really illuminating.

Much of what I've spent time thinking about this week is just how many examples of humility, dedication and a servant's heart I have opportunity to witness in this place, and how that can challenge me. I know my attitude is often less than perfect, and momentary weariness or plain old laziness can tempt me to cut corners, but I want to be pricked by those moments, prodded by God out of my selfishness and sloth. Having that kind of sensitivity is certainly not a comfortable thing, but I pray that it will serve to refine me.

This weekend has been a relaxed one, in spite of being on call, and I realized this morning that peds call here is actually - on most occasions - much more straightforward and restful than my call on 11S back in Boston. This morning I sent both the interns to the ward to pre-round before church, and I assigned myself to the nursery, where early mornings can be quiet and peaceful before feeding time at 9:00, when green gingham-clad mothers descend upon the nursery en masse to feed their little ones.

The littlest guy I'm caring for is sunbathing under the blue lights.

We finished rounds after lunch, and after a quick run back up to the hospital for a delivery, I spent much of the afternoon meandering around my apartment and the guesthouse, watching the rain pound down. At one point, I accidentally woke Agneta out of a dead sleep by calling her apartment and was rewarded by seeing her appear in the guesthouse not long after, which provided a lovely opportunity to catch up on life. Taco dinner with chapatis (a complete and utter weakness of mine) followed, and now I really do think I might be excused for trying to get to sleep. I asked Mercy, my intern, to get a stat creatinine measurement on a patient on the ward, and that was a couple of hours ago, but "stat" here is relative, and I can probably sleep a while yet before the results are out.

My prayer this week is relatively simple: to be fully present here and to serve with humility and joy, much as Micah 6:8 exhorts. "... and what does the Lord require of you but to do justice, and to love kindness, and to walk humbly with your God?"

Lala salama.