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. :)