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.
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| 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
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| 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.
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| 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.
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