a foot in two worlds

I'm back, and in spite of the fact that I tried everything I could (non-pharmacologically speaking) to avoid it, I woke up at 3:30 Monday morning and spent the whole of the day (except for the hours before dawn, of course) feeling incredibly jet lagged. On the plus side, I'm entirely unpacked and caught up on my mail, so it's not a total loss. And I've managed to sleep until after 5 both of the last two mornings, which is really almost acceptable, so I think progress is being made. 

On the other hand, I've had to dive almost immediately back into the generally-frenetic pace of the hospital, and even as I try to re-engage, I'm cognizant of a desire not to let the last month slip away into the foggy recesses of my brain. Especially with a draining and sleep-deprived 22-hour trip back, re-entry to Boston often feels like I'm stepping out of a hazy dream world, but I'd like there to be a less well-defined separation, somehow. I know when I'm here I need to be fully here, but the relationships and experiences that I have at Tenwek are important enough that they should continue to be relevant and meaningful even this side of the ocean.

Deborah after discharge

With that said, the remainder of my fourth week was relatively calm, medically speaking: although I lost my senior co-attending, Eli, on Thursday to a research training in Nakuru (and technically lost him Tuesday to preparations for leaving), we still made it through rounds in timely fashion. And while we had a few sick kids on the ward, there were no ICU or HDU patients, and with the exception of a wildly hypernatremic two-month-old that I was pretty convinced also had pertussis, none of the patients were routinely giving me palpitations.

Pediatrics team enjoying the morning sunshine post-chai

My biggest praise, medically speaking, of my final week, was for the recovery of a patient who'd been in hospital for the majority of my visit. HIV-positive, he'd come in essentially obtunded and with a spinal tap that was consistent with meningitis. Because of some findings on that study and his HIV status, we were pretty concerned that he had meningitis related to tuberculosis, which has a not-all-that-great prognosis, even when treated. So we treated him for that in addition to run-of-the-mill meningitis, and he was only slowly improving, still dependent upon feeding by a tube in his nose and waking up only minimally. About a week into his hospital stay, he was complaining of significant headaches, and we talked on rounds about getting a head CT and repeating his spinal tap. But his family didn't have funds for the imaging (about 100 USD), and I didn't feel safe repeating the tap without it. I wasn't on call that night, but my intern texted me that evening to let me know that he was fairly acutely decompensating and they were taking emergency measures to try and reverse things. We decided to add in another antibiotic as part of it, but I went to bed fearing that he wouldn't make it. The next morning, however, I heard from Eli that he was not only alive, but somewhat improved.  And over the next several days, he had a turnaround so rapid that he was able to resume eating on his own and get up in a wheelchair to go out and bask in the sun. The most likely explanation is that the bacteria that was causing his meningitis was one that was resistant to the usual antibiotic we use, and the added antibiotic finally began to treat his infection, which had probably been only kept at bay for the preceding week. His grandmother let me take a picture of him on Friday before I left, and when I showed it to him, he giggled. From a boy who came in nearly comatose, I was thrilled to hear such a normal expression of glee and joy.

Baking together for eight years

There were plenty of non-medical highlights from the rest of the week as well, starting on Tuesday, when Julie and I had an all-out cookie-making fiesta. We have an long history of baking together, in several countries on two continents, and it was sweet (haha!) to spend some time together in the kitchen again. I may have discovered the first smitten kitchen recipe I'm not totally over-the-moon about (hint: popcorn in cookies is just as weird as you think it will be), but the brownie roll-out cookies were divine. The next day I took part of the spoils into chai time for the peds team, and we had a small party - complete with a candle in a tiny cookie - in celebration of Eli's birthday; that evening we used the rest in a dinner party to more formally celebrate his birthday and mark? mourn? my impending departure. Friday I was invited to pizza night with the Horn family (minus absent Eli), and Julie made strawberry pancakes for a Saturday morning brunch before my transportation back to Nairobi arrived. In light of my oh-my-goodness-I'm-leaving Countdown Panic, it was particularly lovely to be able to spend some good time in the company of the folks who had made up much of my community for the month.

Mercy, after surgery for RHD

Shadrack, whose blood was FINALLY thin enough

I've continued to get updates on the patients over the last few days from Norah, the Kenyan MO who is currently running the peds service, and while it's good to feel involved there still, I know that will taper off as well as I become more immersed in life at home. Technology makes the world a lot smaller these days, but just as much as staying in touch, I want to remain faithful in prayer for the people who are pouring themselves out on a long-term basis at Tenwek. And, Lord willing, make it back next year myself to help continue the amazing ongoing work there. 

warfarin, weddings, and other tales

The problem with committing to regular updates is this: the longer you wait, the more there is that happens and the harder it is to convince yourself to take the time to write. But if I don’t do it now, I think it’s unlikely to happen before I find myself in the Nairobi airport on Saturday, so here goes.

I. Follow-up

My little guy in ICU who unexpectedly developed seizures died last Wednesday. For a while I thought he might make it through extubation, but by Wednesday morning it was clear that he wasn’t even trying to breathe on his own anymore, and the extent of his brain damage was severe enough that he couldn’t survive. I had grieved for the three days leading up to his death, but that morning was particularly poignant for me: not only did his father ask to be present while we took him off the ventilator – an incredibly uncommon request in our setting – but he also began to tear up as we did it. It was gut-wrenching to watch an otherwise-stoic Masai man come to tears as he watched his son slip away, and in the face of his grief, I felt mine renewed.

Deborah

The joy of last week, however, was Deborah, who bounced back miraculously well from her subdural hemorrhage and very real brush with death. Seeing her smile in the ward every morning lifted my heart, and after better defining her heart disease and coming up with a reasonable plan to manage it, we discharged her on Friday – though like many patients, she continues to wander the ward and bask in the courtyard while her family gathers the funds to pay her hospital bill. God brought her through that, without question, and I am so incredibly grateful.

II. Warfarin woes

Shadrack

The blood thinner that Deborah was on, warfarin, has become my nemesis over the past three weeks. Not only did she nearly die because of the consequences of a supratherapeutic level, but we had another rheumatic heart disease patient come in with over-thin blood who came close to losing an arm (from compartment syndrome) as well! And don’t get me started on the two patients we’re trying to get into the right range of blood-thinness: in spite of a rational approach to titrating their doses, we can’t seem to get lab results which make any sort of realistic, or consistent, sense. One of these warfarin prisoners, Shadrack, has now been hospitalized ONLY for this purpose for the last week. Or more. Normally we might have them come back as an outpatient and follow up, but Shadrack’s care is primarily at a hospital some distance from Tenwek, and without knowing how much we can rely on their clinic to make dose adjustments as necessary, we feel compelled to keep him until we’ve got it right. Especially having so recently seen the consequences of getting it wrong. The good news is that Shadrack has an incredibly joyful personality and doesn't seem the least bit discouraged about the situation: he always has a handshake or high five for me when I walk by, as well as an irrepressible grin.

III. Eldoret adventures

This past weekend, I was invited to the wedding of one of my interns. I had the days off already, and I loved the idea of being able to celebrate with him and his fiancée (also an intern at Tenwek). Annette, the respiratory therapist here, was driving and had an extra seat in her car, so with fairly uncharacteristic spontaneity, I decided to join the road trip. We left Saturday morning at 6:00 am for the four-hour drive to Eldoret, because the wedding was advertised as starting at 10. We arrived just a few minutes after 10 and found... a nearly-deserted church. (Bonus: we got a great parking space.) I had learned quite a bit about Kenyan weddings en route, so the eventual 11:30 start seemed very reasonable. It was a joyous and beautiful day, with a throng of friends and family so large that the wedding photographers had very smartly elected to use – among other strategies – a drone, which effectively bypassed the hordes of well-wishers who crowded the bride and groom most of the afternoon.

Though some of the Tenwek staff made the sprint back to Bomet Saturday evening, our car stayed the night in town. We’re essentially prohibited from driving after dark, and the wedding didn’t wind down until after 5, so we found hotel rooms and had dinner. I found our hotel restaurant to be very comfortingly Kenyan, insofar as it boasted an extensive menu, most of which, it seemed, they did not have available. In the end, it was a good excuse to eat sausages and eggs for dinner, and I went to bed quite happy. The following morning was notable mainly for a rather unexpected tour of a large swath of Eldoret. The city was hosting a half-marathon that morning, and in spite of the fact that the races had largely concluded by the time we checked out of the hotel, it was an hour-long proposition involving multiple u-turns, main road closures, unexpected dead ends, and eventually a Google-maps-led tour of what we referred to as some “suburban estates” to get to our end goal (Nakumatt).

Fortunately, we had left plenty of time, and we did, in the end, get to see quite a bit of the city, including Moi Teaching & Referral Hospital, where I’ve sent lots of patients over the years. The drive back was beautiful – through the Nandi Hills and the tea country around Kericho – and I arrived at Tenwek exhausted but glad for the chance to see more of the country and celebrate the beginning of a marriage.

Tea fields outside of Kericho

IV. Last week

One of my least favorite things about coming to Tenwek is that I usually feel like I’ve hit my stride right around the third week, and so by the time the fourth week rolls around, I’m in a mild panic about leaving too soon. I was starting to feel a little undone by that this morning, but once the afternoon hit, I hardly had time to think about it. I had just finished lunch back in my apartment when I got a 999 (code blue) page for only the second time this entire trip. I ran as much as I could (uphill at 6500 feet) up to casualty to find a day-old full term baby getting CPR. No IV access, and not much of a story. I wound up intubating him and giving a couple of rounds of epinephrine down the tube (after having some mild internal panic about the endotracheal dose of epi that I couldn’t comfortably sort through while also trying to ventilate the baby and run the code). When we finally got the monitor leads hooked up, the rate couldn’t have been more than about 15 or 20 beats per minute, and the complexes, if they were there at all, were wide. And I called it.

Five minutes later I found out this was the third infant son this mother has lost – she has one living daughter – and suddenly I felt the weight of the world crash down on my shoulders for having stopped when I did. We didn’t even check for hypoglycemia! I didn’t consider all the Hs & Ts! And did I underdose the epinephrine? But it turned out, when I got as much of the story as there was to get, that the baby was seen at a clinic earlier in the morning, was recognized as being quite sick even there, and was warm but pulseless when he showed up in casualty. And I did dose the epi appropriately after all. But I still wanted to scream and cry for the unfairness of it all and was trying not to do so when I got another 999 from the ward.

This time it was Vicky, a girl who was brought in last Friday after multiple seizures in the setting of new left-sided weakness. She had a completely normal spinal tap, an EEG(!) consistent with generalized encephalopathy, and a weirdly-abnormal CT scan that didn’t really help us toward any sort of definitive diagnosis. Just for good measure, her HIV testing was indeterminate, so that opened up a whole world of even weirder diagnostic possibilities – probably a lot of which weren’t treatable with our resources, anyway. She limped through the weekend without any seizures but had never regained consciousness. I was starting to have a fairly ominous feeling about her, so in many ways, it was merciful that it ended quickly. It was a bit of a messy code – sometimes they just are – and it was a reminder to me that death really is a messy thing, though back home we can often make it feel fairly sterile and controlled. 

But after all of that, there was a Kipagenge potluck tonight to celebrate Canadian Thanksgiving. It was incredibly good for my extroverted soul, and it filled me up enough that I feel as though I have plenty to give in the next few days, whether I am ready for them to be my last days or not.

blood, sweat and tears

It’s been a rough weekend call thus far. Among other things, it feels as though having an ICU doctor here has created a magnetic attraction for critically ill patients – mostly Triatix poisonings – and has kept me quite busy. 

But there was also Deborah, a rheumatic heart disease patient with three days of headache whom I told my intern Tess to accept when she got the referral call from another facility - mostly because I didn’t think there was a good reason to decline. But I kind of didn’t know what we were going to do for her. She didn’t look WELL, exactly, when I saw her in casualty, but she was answering our questions when we got her attention, her neurologic exam seemed non-focal, she wasn’t having fevers and she didn’t seem to be decompensated from a cardiac perspective. And her labs, other than showing that her blood was thinner than we’d want it (she’s on blood thinners because of her heart), were not particularly exciting. It crossed my mind to do a head CT, but it’s an expensive proposition, families rarely have the funds immediately available, and it didn’t seem urgently indicated, so I put a pin in it, mentally. And we admitted her, planning to observe closely.

Not normal.

Several hours later, Tess was called because she was becoming quite agitated. It’s often difficult for me to assess these things here, even with an interpreter, but she was clearly deteriorating. So we decided to do an emergent head CT, for which I had to sign as a “long term doctor” (which I am not) on a voucher to have it done without funds. Anxious of what we might find, I sat next to the tech while the images came through. Very often here we don’t find anything abnormal on head CT, even though there is something obviously amiss. But this time it was clear: she had a large bleed on the left side of her brain causing marked compression. After assuring the CT tech that no, we did not need contrasted images as well, I asked Tess to call the surgical resident and then called the surgical consultant directly. She obviously needed the neurosurgeon to drain the blood emergently, but with her blood as thin as it was – not to mention her heart disease and the anesthesia risk it conferred – it was a high risk proposition. In the States, we would fix the thin blood problem by giving fresh frozen plasma, a component of the blood that concentrates the clotting factors. Here, there is no such thing. The best we can do is administer vitamin K, which helps reverse blood thinners, and fresh whole blood, which contains clotting factors as part of it. Deborah has one of the most common blood types, but the freshest blood the blood bank had was almost two weeks old, and the clotting factors from blood that old would be ineffective.

But it turns out that Deborah and I have the same blood type (thank you, first year med school lab experiment), which is how I found myself lying on a bench in the lab at midnight with an enormous 12-gauge needle hanging out of my arm while the surgeons wheeled Deborah off to the theater. I’ve never donated blood before: I tend to blame being rejected because of a stunningly low blood pressure the time I tried to donate in high school, coupled with frequent trips to Kenya, but the truth is that I’m a bit of a ninny about it. As a result, I’m grateful for the adrenaline of last night’s situation and the fact that I didn’t really have time to think about it. There’s very much a culture on the part of the staff here of doing what’s needed in terms of blood donation, so it just seemed logical, since there was nothing else I could personally do for her other than pray.

I was advised by the phlebotomist to rest afterward, but I had barely made it back to my apartment (and eaten the last three chocolate chip cookies in the guesthouse kitchen) before I was called back to ICU, where one of my Triatix overdose patients had had what sounded like a near-arrest. It broke my heart, because he had been recovering well and was smiling at me earlier in the afternoon. I’ll never be certain what the sequence of events was last night, but four hours after that event he started having seizures, and in spite of multiple doses of medications, I had to put him back on a ventilator this morning before rounds. He’s quieted down today, but I am deeply fearful that he's had a bad brain injury as the result of whatever happened. It feels horribly unfair because this was a critically ill child who should have recovered without complications, and now he may not even survive.

I spent a good amount of time in my apartment this morning crying to God about the unfairness of it all. The Psalm reading in this morning’s lectionary was Psalm 47 and 48; the former starts “Clap your hands, all peoples! Shout to God with loud songs of joy!” Which is so not where I was, emotionally, and brought me tears all the more. But further on the psalmist reflects, “God reigns over the nations; God sits on his holy throne.” And it’s true, whether children like Deborah manage to defy bad odds, or children like my overdose patient unexpectedly do poorly. Up there on his holy throne, God sees it all – and cares about it all. I have to recognize and trust that even as I endeavor to do the best work I can.

I passed by peds ward this evening to check on Deborah, who wound up there instead of ICU because of a bed crunch. She was sharing a bed with her sleeping grandmother, a woman of not-inconsiderable size, but she saw me coming in the door and raised a hand to wave at me. When I got to her bedside, she was smiling, and said, “I am happy.” I told her I was too. Please pray with me for a smooth recovery for her, as she is certainly not out of the woods.

I managed to nap for about three hours this afternoon, but I've still got twelve hours left of call, and I'm praying for respite and a safe night for the children. But I need also to trust that God will give me alertness and wisdom should I need it, and that He sees it all and loves my patients more than I possibly ever could.

seasonal confusion

I've made it safely to Tenwek and through my first two days at the hospital, so instead of working too too diligently on those presentations I need to finish for next week's critical care conference (I've still got the whole weekend, right?) I thought I'd squeeze in an update.

The first thing I'd like to clear up is that, for the record, it is NOT supposed to be rainy season here. We're emerging from the chill of July and August - months during which Kenyans in Bomet wear thick parkas and wrap themselves in scarves, though the temperature doesn't really get much below fifty-five degrees - and the short rains don't start until October. But with the exception of Tuesday, it's apparently been raining pretty consistently here for the past week. Which is not to say that they don't need it - they do - but if I wind up posting a bunch of pictures of mud and stormy skies, I want to make sure I've calibrated everyone to the fact that it's not normal. 

It does, however, give me a good excuse to wear fleece, flannel pajamas, and wool socks. All at the same time. Which I love.

view out my window of the road to the hospital

I'm staying at the guesthouse this trip for the first time in several years, and in spite of that, I've gotten so used to cooking for myself here that I've opted to do the same again. My apartment has an incredible number of windows, I have my own coffee pot, and the showers have been as hot as I could ever want. My only complaint is that my desk is high enough (or my chair is low enough?) that I feel really short sitting at it. Sidenote: can't imagine how short actually short people must feel sitting there. I keep getting invited to the Ganeys' house for dinner, but one of these nights, I'm actually going to give the stove a whirl.

The peds service at the hospital is not too hectic right now, which is nice for reacclimation. I think we may have discharged half of the ward patients home today, although we did also lose a child in the HDU who has essentially been in coma on a ventilator for the last several days without ever having a clear diagnosis. These cases, which I refer to as "encephalopathy NOS", can be particularly challenging, since our ability to arrive at a clear diagnosis, let alone a treatable one, is often rather limited, and it's hard to watch a previously healthy child deteriorate neurologically to the point that you can be certain they won't be able to recover.  In this child's case, I arrived at the end of the story, and so I think I felt the emotional weight of his loss less than the rest of the team, but it's always both sad and frustrating. Please pray for Allan's family as they grieve his death.

Another of my least favorite Tenwek diagnoses is rheumatic heart disease, something we essentially never see in the West because of our aggressive treatment of Strep infections. We had one known RHD patient on our service yesterday (who is actually reasonably stable, albeit chronically quite sick), and today we diagnosed a second, a 15-year-old girl whom we had been treating presumptively for tuberculosis. Except now maybe it turns out it was just her heart (severe mitral stenosis), and not TB at all. As bad as TB sounds, at least it's a diagnosis with a cure. RHD is not. Her heart already has evidence of longstanding disease (her right ventricular pressures are at least systemic), but because her heart function is still preserved, she may be still at a point at which an intervention (likely surgery) might greatly improve her long-term prognosis. We'll need a lot of wisdom as we navigate the next steps in caring for her, so please pray for that as well!

... and one of my interns just called to tell me that she is admitting a third decompensated RHD patient who showed up to casualty (the emergency room) this afternoon. Sigh. May I double my request for prayers? Thanks.

Normally I like to apply a bit more spit-and-polish to my writing, but for the sake of just getting something down, today I'm going to have to come straight to the point: it's been a very busy summer for me here in Boston, with lots of time (probably too much) at the hospital and two big transitions (a new role at work and a new home in JP). And two days from now, I'm departing my lovely new home - which is just now really starting to feel like home - for my next four weeks at Tenwek. 

It's been about sixteen months since I was last there, and I've dragged my feet intentionally, to some extent. I felt the need to be more present here in Boston, and I needed a bit of a break from the pace of work that is mandated by dropping everything and leaving for a month - but I also knew that furlough was approaching for Tenwek's long-term pediatrician and his family, and it felt right to postpone my next trip until they were away. But the feet-dragging is over, and in spite of the chaos in which I currently find my life here immersed, I'm getting on a plane and leaving. I am not ready, in almost any sense of the word, but I also anticipate being grateful for the jarring removal from my patterns of life here. Being at Tenwek is often both incredibly busy and exhausting, but it's exhaustion of a different kind, and I usually have dramatically more time for contemplation while I'm there. Once I get my power point lectures prepared, anyway. (Ugh.)

At any rate, it's my intention to write regularly. It helps me process, but it also helps me feel connected to friends at home. I'd appreciate prayers over the next few days for rest, focus (on the aforementioned lectures), joyful farewells with friends, and safety in travels.

I'll write again from the other side of the ocean.