end part three

I’m down to my final hours in Nairobi and facing a car ride of Friday afternoon traffic before I arrive at the airport, so I thought I’d be productive about being stopped in a line of bumper-to-bumper cars and finally explain a little bit of what I’ve been up to for the last two weeks:

Two years ago, the University of Nairobi started a pediatric anesthesia fellowship. While anesthesia training has been available for many years, the fellowship represented the first pediatric-specific curriculum available in East Africa, and the program has support to fund a handful of external lecturers each year for two week blocks of time. I’ve written about how I wound up here last spring, and the program director kindly invited me back this year.

In contrast to last year, I was the only visiting faculty while I was in town. And it was great. The three fellows – two Kenyans and a Zambian – were cleared from theater duties for the two weeks, and I got to hold them captive in the ICU (21 beds for a 2000+ bed hospital!) every morning for pediatric rounds, after which we spent time in didactic sessions. Honestly, not having to compete with the theater for the fellows’ time was a phenomenal improvement, and the fellows themselves were all bright, engaged, and incredibly dedicated. Aside from feeling like it was a tremendous privilege to be charged with a chunk of their learning in pediatric critical care, they were also all just fun to spend time and work with, as were the two pediatric registrars assigned to the ICU this month. Today after rounds and teaching, the whole group took me for nyama choma after they were horrified to discover that I had never had it, let alone had any clear idea of what it was. (Answer: basically, Kenyan barbecue – delicious Kenyan barbecue.)

Having some sense of what to expect – out of Kenyatta and out of Nairobi – based on my prior experience was incredibly helpful, too. I remember how overwhelming last year’s trip felt: being asked unexpectedly to run morning PICU rounds in the random absence of the assigned consultant; being given short notice for major presentations; and the insanely high level of acuity among the pediatric patients. This year, I had some sort of clue. And when I ran rounds (about half the time I was there), I wasn’t completely at sea. I knew the system. I knew the patterns. I knew that almost every patient admitted to ICU winds up on meropenem, no matter their diagnosis. So the whole thing seemed kind of… possible.

I’ve been coming to Kenya for over a decade(!) now, but figuring out Nairobi has been an adaptation to yet a different culture and daily rhythm of life. This year I stayed within walking distance of Kenyatta, which meant that one of the biggest interferences in daily life, traffic, became a source of curiosity rather than chagrin. Crossing Ngong Road twice a day felt like the highest-stakes game of Frogger I'd ever played, but my walk to work - and sometimes home - often also included a stop at the local Java House... a perk which meant I had to add JH to my monthly budget. Monday and Tuesday of this week, I was particularly grateful for my Upper Hill guesthouse: after a fairly minimal amount of rain the week before, we got solid, hours-long downpours which resulted in impressive flooding and impassable roads in several parts of town. One of the fellows didn’t arrive home until 4:30 am Wednesday morning, and several hospital employees still didn’t have power as of Thursday night. Even the hospital power was out for several hours Wednesday morning, and many ICU bedspaces had people assigned to manually ventilate patients until the power was restored. I had fairly little to complain about in comparison, though I had rather stupidly forgotten to pack my umbrella Monday morning and turned up looking like a drowned rat at my guesthouse that evening. I think it took my shoes two days to dry completely.

Manual ventilation

So that's the last two weeks, in brief. And now I'm sitting at a JKIA Java House waiting for a reasonable time to head toward my departure gate. Incidentally, there's a new Nairobi airport terminal, and it's all of the things you would expect a new airport terminal to be: shiny, brightly-lit, and spacious. It's comfortable and pleasant and suddenly I don't mind the idea of showing up three hours before a flight. But there's still a sign just past security reminding travelers to let the check-in staff know - just in case it's slipped their minds - if they are carrying firearms, harpoons, or spear guns in their baggage.

Some things don't change.

matemwe

This past weekend, I got a new stamp in my passport - Tanzania - and spent a lovely two and a half days on Matemwe Beach, on the northeast coast of Zanzibar. It's a quiet part of the island, where hotels are less densely packed along the shoreline, tides can be dramatic and the local economy includes seaweed harvesting at low tide. I was the only guest booked into my B&B, where I got what I referred to as a "rainy season upgrade" to the largest room, and the household cook stuffed me to the gills with curry and fish and many other delicious dishes. Dire weather reports had inspired me to purchase an umbrella before I left, and I mentally prepared myself for gray skies and daily downpours. I repeated "rainy season is my favorite season" like a mantra and believed it.

But I have to confess that I wasn't completely upset when Saturday dawned not entirely cloudy and the proceeded to become so sunny by late morning that, halfway into my walk south along the beach, I started to fear for my poor New England winter skin. (Yes, Mom, I used SPF 30.) Sunday did bring some rain, but - mantras aside - I really do enjoy a beautiful stormy sky, and it was nice to worry less about burning to a crisp.

I've posted a slew of pictures to facebook, and you can click on the one at the end of this post to access them, whether you're on facebook or not. A few reflections:

1) Matemwe is one of the less built-up parts of the island, and during rainy season it seems practically deserted (by tourists), which was perfect. I have an incredibly low tolerance for hassle, and with so few wazungu around, there wasn't much hassle. So peaceful... I would pick it again over the more lively parts of the island in a heartbeat.

2) I've never seen such white sand in my life. The truth is that Matemwe Beach is scattered with both seaweed and half-buried pieces of litter, but somehow the vast smoothness of the sand contrived to render the latter mostly invisible, and the seaweed, in particular, often looked as if it had been découpaged elegantly onto the high tide line by the receding waves.

3) I'd heard a lot about how the low tides on the east coast of the island can be disappointing for swimming, but I realized that I'm actually not all that enthusiastic an ocean swimmer. I have a bit of a thing about the ocean when I can't see what's going on underwater, and especially by myself on a fairly deserted beach... well, the stillness and clarity of low tide was just about right. Wading around in the afternoon was like exploring a giant tide pool (starfish! crabs! sea urchins!), and the only thing that kept me from walking all the way out to the reef was a lack of appropriate footwear (see above re: sea urchins) and the fear that I'd wind up dunking my camera in the water. No, it didn't occur to me to leave my camera on dry land... why?

4) Tanzania grants multi-entry visas, so I've got a little less than a year to get my next visit planned and executed. Who's in?

end part two

I am long overdue an update: I’m well into the third (and final!) portion of my trip and don’t have much of an excuse. My only defense is that I was too busy being part of my adopted family for the last two weeks to sequester myself for the time it would take me to write a post. But in my lonely little guesthouse in Nairobi, I’ve got unreliable wifi, but plenty of time.

Not a beverage.

I’m happy to report that our high pediatric mortality rate of the first two weeks decreased markedly for the second half of my time at Tenwek, and our patient list seemed to become shorter and less sick by the day. At one point, there were only ten (ten!) babies in the nursery, which is almost unheard of, as the census there is often in excess of twenty. I did have one fairly impressive scare in a five-year-old boy who was admitted with severe malaria. Especially for a malaria patient he wasn’t markedly anemic when he was admitted – they often are because the parasites can cause the red blood cells to burst – but I was summoned emergently to the pediatric ward on his fourth hospital night when he was discovered tachypneic, unresponsive, and pale (“pale-plus-plus”, as they say) and his hemoglobin level was found to be 0.9 g/dL. (Reference for non-medical types: normal is more than about 12 or 13 g/dL, and in the States, you would typically get a blood transfusion if it drops below 7 g/dL.) And let me tell you, it was real. By the grace of God, and in spite of the fact that it was 4:30 am, we were able to get emergency blood and a decent IV line, and we transfused him a bulging unit of blood in less than an hour. After which he regained consciousness, asked for his mother, and was transferred to the HDU before receiving a second, properly cross-matched, unit. It was an incredibly humbling experience, as in retrospect (at 6 am, lying in bed and unable to sleep) I realized that there had been warning signs this was happening, even though in many ways he looked clinically stable. Though by some further miracle he didn’t develop renal failure, this is probably as close to classic blackwater fever as I will ever see, and I spent the next couple of days thanking God profusely for being merciful in sparing his life.

The rest of Kenya, part two was characterized mainly by life at home, where for the first week – before Abby and David returned to RVA – I made a tenth in the Bemm household. When I wasn’t at the hospital, there were epic games of Bananagrams, raucous and joyful meals around the table, and geriatric evenings with Amy during which we knit/crocheted, yawned at 8:30, and went to bed at 9:00. More than the fun of having companionship and small, squeezable children (and bunnies) underfoot, being able to be part of a family for those two weeks was an incredible blessing to me. I’m an extrovert, and I’d always rather be around people than not, but being loved and accepted without question (even with bedhead in my pajamas or when my pager going off in the middle of the night woke other people up) is more than just having people around: it was both a wonderful gift and a wonderful reflection of the love of Christ. And it’s the kind of hospitality I want to be able to show people in my life back home, even when it gets messy.

I also managed a few good walks during the last couple of weeks. I realized, as the time grew short, that my walking had been hindered not just by my own end-of-the-day exhaustion, but also by the fact that it was just raining an awful lot of the time! The rainy season has been much rainier than average in that part of the country – Narok, about an hour away, has had quite a bit of flooding – and quite often the skies let loose all evening long. But I love the look of a stormy sky, particularly in contrast to the vast swaths of green on the hillsides, and so I risked the rain (what’s going to happen besides getting wet, anyway?) and enjoyed (i.e. photographed) the beauty, at the cost of only some very muddy shoes. On my final walk, I was gleefully mocked by more than one passerby as I took pictures of a tea field (“You’re taking pictures of chai?”), which was probably merited, as tea is hardly a novelty in the highlands of Kenya, but I ignored it. I was already an oddity as a mzungu, so being a mzungu taking pictures of tea could hardly have been all that much weirder.

And now I’m in Nairobi. Kenya 2015, part three. I’ve been two days at Kenyatta National Hospital now, but I’ll save my stories about it for the next time. And this weekend I’m planning to cross another location off of my lifetime Places To Visit list, so hopefully there will be some pictures to share after that adventure as well…

They mocked me, but then they insisted on having a picture.