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.