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.