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.

safe in kenya, praying for boston

The last twenty-four hours have had much of the surreality that traveling across several time zones often does for me, this time including strange napping schedules, train malfunctions at Heathrow and weirdly empty airport terminals. But the journey was incredibly smooth, and I settled into bed last night in Nairobi looking forward to finishing off the last leg of the trip this morning. My driver picked me up promptly after breakfast, and he wanted only to stop for some supplies quickly before getting on the road. While he ran to get coffee at Java House, he offered me the two Kenyan papers he'd purchased at the grocery store, and I thought, why not? I didn't at all expect to see the headline about the Boston explosions.

Of course. Who would? I had just flown from my comfortable, idyllic, safe New England home to Kenya. Where my family still worries about me a little all the time. And two bombs exploded four miles from where I live.

I thank God that so far as I have been able to tell (thank you, facebook and gchat) everyone I know is safe. But my heart is completely broken for my city. It's a powerful reminder that nothing about this life or this world is certain.

So while I pray for Boston today, I have plenty else to do as well: I'm on call tonight, and I haven't unpacked anything in my apartment but my computer. And then I should probably touch base with someone on the pediatrics service, so I know where to run to resuscitate the babies tonight.

More to come.

reflections on readiness

Seven days. One hundred sixty eight hours. Almost eighty of which will be spent at work, and about fifty of which - hopefully! - will be spent sleeping. Which leaves me not quite forty more to get ready to be carted to Logan Airport next Sunday night with a few awkwardly enormous bags and get on a plane with everything I'll need for four weeks in Kenya. But what's "ready"? I've been asked several times over the last week if I'm ready to go. I kind of wonder if I look confused when I try to answer. It wouldn't be surprising, because the internal dialogue usually goes something like this:

"Well, I bought that skirt the other day. I think I have enough clothes now."

"On the other hand, I'm still waiting for a bunch of stuff to come in the mail. And I need to buy pepperoni. Wait... is it bad that I'm bringing pepperoni and Parmesan cheese and haven't managed to find medical supplies?"

"What if I realize I need to buy something halfway through this week and I can't find time? Worse, what if I don't realize I need to buy something halfway through this week? Also, I would really feel a lot better if I knew what kind of electrical outlets I was going to be dealing with, because I've totally forgotten the adapter situation..."

(pause)

"Would answers to all of that make me ready?"

And I realize that in trying to be ready, put together, well-packed, it's tempting to become distracted from the main thing, which is that I am going to Tenwek to serve, and to be poured out for the sake of the sick and the hungry. Poured out. Being ready for that doesn't require skirts or supplies or compatible electrical adapters. It requires being filled up by the living God, because only by resting in Him will my heart find the readiness that it needs.

He leads me beside still waters. He restores my soul.

So that's the kind of readiness I'll be pursuing this week, between days in the ICU and evenings of one-last-hangout-before-I-leave. Amidst the chaos, quiet and deep rest.

So now it's one hundred sixty-seven. I pray I really will be ready, and I hope you'll pray that, too.