dilemmas

With just days left, this is the part of my Tenwek trip during which I typically feel the time slipping away, sleep less, talk more, and rely on a bit of extra adrenaline. Writing and communication with folks back home fall by the wayside, but a short update on recent adventures is probably in order, to minimize the mental burden involved in trying to write about the second half of my trip all at once later.

Most of the MMR hub-bub has subsided, thanks be to God. I did, however, meet the Bomet County governor on Monday, when she arrived at Tenwek with a not-inconsiderably-sized entourage and made a visit to the pediatric ward to meet the affected babies and their parents. Someone definitely snapped a picture of us doing one of those Official Handshake Things, which makes me giggle every time I think about it, but there seems at least to be no internet-available evidence of it as yet.

Otherwise, this week’s theme has been Dilemmas. Mostly of the diagnostic kind: kids with weird, vague abdominal pain; altered mental status without a compelling explanation; or severe diffuse bone and joint pain seemingly out of nowhere! On Tuesday, though, the dilemma turned out to be management. I got a call from one of my interns on Monday afternoon, who was seeing a 13-year-old girl in clinic who showed up with oxygen levels far below what they should be, and complaints of swelling and shortness of breath. Once she told me more of the story – that the girl had had progressive scoliosis from age 4 and had been lost to follow-up from another facility – it started to come together. But even with the story, I wasn’t prepared for the girl I met. Her scoliosis was so severe that her left cheek rested on her chest, and she clearly had not only bad restrictive lung disease, but now also evidence of pulmonary hypertension on the echocardiogram we quickly got. But she was alert and cheerful, and reportedly still goes to school and does well there. The admission plan seemed relatively straightforward: while recognizing we weren’t going to be able to do much to improve her chronically low oxygen levels, we could probably work on the swelling she had in her feet and trial a medication aimed at the pulmonary hypertension. And we gave her some oxygen, thinking it might make her feel better.

Not normal.

But Wednesday afternoon, it became clear that our best intentions at symptom management had knocked her off the wildly abnormal tightrope of homeostatic equilibrium that her body has adapted to over the years. She was unresponsive and not breathing well, and we moved her quickly to the HDU and started BiPAP. I left for the evening praying fervently for her – everyone knows that the Hippocratic Oath says first, do no harm, and we had unintentionally violated that foremost tenet. Thankfully, the BiPAP reversed the problems we had created, and I’ve spent today reminding myself that probably the less I do for her, the better. That’s hard for an ICU doctor!

I also achieved a major milestone – for me – this week. Especially as I’ve gotten more regular about running for exercise over the years, I’ve always thought that I should try running here. It’s not nothing: the roads are bad, there are boda bodas everywhere, and we’re at altitude. Like, a lot of it. Bomet is 6500 feet above sea level, nearly a quarter of a mile higher than Denver, and it’s something I have always noticed in hurried trips up the hill to the hospital over the years. But on Tuesday evening after signout, I put on my running shoes and went for it. Neither the mileage nor the pace was particularly impressive, but I did it, and it felt good. In the process, I rediscovered a favorite-but-forgotten path from the Njerian Road to the Lower Bridge, which involves a steep descent to the river and a similar ascent on the opposite bank. In case you were wondering – no, I didn’t run that. Inspired by Tuesday’s endorphins, I decided to do it again the next evening. I might have been pushing my luck, however, as about three-quarters of a mile into it, I tripped on a rock and executed a three-stage stagger/fall witnessed by no fewer than four Kenyan ladies. (“Sorry! Sorry! Sorry!”) There was some blood, but not enough that I didn't get up and keep running, although it did make it awkward later when I was walking and bypassers wanted to exchange the traditional handshake and greeting...

Always graceful.

At any rate, it’s my last night on call, and I’ve already had more excitement than I’ve wanted (although, okay, I was going to be sort of disappointed if I didn’t get to intubate somebody this trip), and it’s also later than I wanted to be awake, so I’ll end here, and I promise to work on writing something else (including, perhaps, the tale of this evening’s excitement) during my trip home. Prayers for finishing well would certainly be appreciated, and I look forward to seeing Boston friends and family again soon!

unexpected

Tuesday morning started out reasonably well this week. The pediatrics team has been starting rounds at 7 am, and once I got over the shock of it (what am I, a surgeon?), it has actually given a nice rhythm to my mornings. I round for an hour, go to morning report for an hour, then head back home to have breakfast and devotions while the team finishes pre-rounding. And breakfast is a much better idea at 9 am than 6:45.

Our census was low enough on Tuesday that we finished ward rounds prior to morning report, and we finished the nursery without any intervening emergencies well before 11:30. But as we were seeing the last few babies, I got a call from Lorna, the intern in clinic this week, who was seeing a nine-month-old whose twin had died sometime en route to Tenwek that morning. They had both received a routine vaccine the day before in a local health clinic, and both had developed irritability and swelling around the injection site. The baby she described to me over the phone sounded quite sick, and I asked her to move the child to casualty immediately, and I would meet her there.

Aided by the casualty staff, we worked to resuscitate the baby and to try to figure out what had happened. Her entire arm and part of her adjacent chest wall were swollen; she had a fever, was breathing quickly, and wasn't terribly alert. Fortunately, she appeared to stabilize somewhat after our initial interventions, and we gave her antibiotics for good measure and consulted the surgical team in case there was some type of drainable infection. Meanwhile, the CO in clinic called the county public health authorities, who were reportedly dispatched to the clinic in question.

A few hours later, another nine-month-old turned up in casualty with an eerily similar story, and though this child wasn't as sick as the first, there was enough swelling of the arm to make me nervous. We admitted both to ICU-like settings for the night, and both seemed to be holding steady as I headed back down to the guesthouse after a last check on them late in the evening.

Thankfully, both had calm nights, and in spite of some challenges securing IV access for the sicker baby the next morning, all the signs seemed to be pointing to improvement. While it was an awful and sad situation, I was grateful that both the babies were doing reasonably well, and I started to breathe more normally again. At lunchtime, I walked down the hill to eat at the Ganeys' and, since the service was not too worrisome, took my time getting back up to the hospital. Heading toward the lower staff gate on my return, I ran into Steve Burgert, the medical superintendent at Tenwek; he asked if I had a few minutes. Apparently, the hospital had been set upon that morning by the local media, and while they had been redirected to the Bomet County government, the CEO had told them they could return if they were unable to obtain any information from the county.

I'm intentionally hiding in this picture.

I sat down with Steve and the CEO and gave them a summary of what we had seen in the children thus far - and found out in the process that a third child was now in casualty - and promised to be available if necessary later in the day. I was really hoping that it wouldn't be necessary, especially since it wasn't completely clear what the journalists' spin on the story was going to be. I had seen the third baby, who was relatively well-appearing, and was reading in the library a couple hours later when Steve called, asking me if I could come participate in an interview with a group of journalists. There was an odd photo session involving me wearing a theater gown and examining both babies while the hospital's IT guy took video and still photos (rather than allow the journalists in patient care areas). And then they put us in front of the camera. With a microphone clipped to my shirt, I got asked to comment on the condition of the patients and to speculate as to what had happened. I have seen some of the footage - you're crazy if you think I'm going to tell you where - and in my desperation not to violate patient confidentiality, conjecture wildly, or say anything that would reflect poorly on the hospital, I definitely came across as mildly stunned and possibly hyperventilating. Thankfully Steve was much more composed and managed to convey the relevant information about what parents should be alert to and the fact that immunizations are still highly recommended!

I've experienced all sorts of unusual things during my visits to Tenwek, but this may - in every way - be the strangest. By the grace of God, we've been able to support these kids while they recover, but if I have learned anything from this, it's that I should stick to medicine and not pursue an alternate career in the media! Most importantly, we moved our sickest baby out of HDU this evening, and I haven't heard of any critically ill children presenting anywhere else. I got to sit in on a meeting today with people from the sub-county's ministry of health, which has quarantined all remaining MMR vaccine from the batch which was implicated, and the investigation is ongoing. We continue to pray for these kids and this situation - and in particular, for the parents of the baby who died - and I'd appreciate your prayers, too. And if you're desperate to see what The Daily Nation had to say about the situation (or see me in the news), you can find it here.

You can't say I didn't warn you.

Hello, weekend.

What a week. There’s no question I’ve never had such a rocky transition to Tenwek, and while all’s well that ends well, I was certainly not well in the process…

Having gotten a good snow fix from the “bomb cyclone” in Boston, I was happy to depart the crushing Arctic cold that followed it, and I arrived at the airport last Saturday evening more ready to be on my way than I normally am leaving home. But when my plane still wasn’t at the gate an hour and a half after we were supposed to depart, things started to feel a little ominous, and I ultimately went to the desk to ask about contingency plans should I miss my connection in Paris. The desk agent seemed to be struggling to line up a backup seat on another flight – she kept saying she didn’t understand why the boarding pass wasn’t printing out correctly – and said that I’d have to talk to an Air France agent at CDG if I needed the alternate flights anyway. I very explicitly confirmed that my original ticket and boarding pass for the 11:00 am flight to Nairobi were still valid and resumed pacing the halls of terminal A.

We finally pushed back from the gate three hours late, and despite the captain’s repeated promises to make up as much time as possible in the air, it seemed likely that the two hours and forty-five minutes I originally had in layover time was likely to disappear entirely. My sister figured out my gate assignment and sent it to me while I was in-flight – miraculously, the arrival was in the same building – so when we touched down just after 10:30, I thought there was enough of a chance that I could make it that I had to try. I don’t love running with luggage, or getting sweaty, or any of the assertive-bordering-on-pushy things that go along with trying to make a flight that’s leaving imminently, but the alternative is a potent motivator. I made it off the plane – and to/through security – relatively quickly and sprinted the remaining distance to the gate, arriving 15 minutes before the scheduled departure. So when the desk agent told me that they had already sent the final bus from the gate to the plane and couldn’t do anything about it since it was just me, I put my head down on the desk and started crying.

Oh, and by the way, my boarding pass wasn’t valid because the Boston agent had rebooked me to alternate flights anyway.

The CDG-NBO flight is a once-daily shindig, so Air France rerouted me through Amsterdam to catch the evening AMS-NBO flight on KLM. On a full flight in a middle seat. Sigh. The short version of the next several hours went like this: nap in awkwardly rearranged seating near the airport hotel, overpriced airport dinner including apricot tart (probably the highlight of the whole eight hours), discovery that the AF website was now noting “one or more” of my checked bags to be missing, and another flight delay that left me in tears in front of my second – and third – ticket agents of the day.

This delay really WAS only fifteen minutes, though, and while I didn’t have time to sit down in the Amsterdam airport, I didn’t feel compelled to do any of that running-and-getting-sweaty nonsense I’d done in Paris. I made the connection easily, and eight hours in a middle seat wasn’t actually the worst ordeal of my whole life. But after clearing immigration in Nairobi, I took up my post in baggage claim with a deep conviction that my bags were not coming. They didn’t. The internet, at least when it comes to scanning baggage, apparently doesn’t lie.

The revised plan had been to drive directly to Tenwek from the airport, but after being told my bags were scheduled to arrive that evening, I decided to wait in town rather than risk the additional step of having them couriered out to Bomet. It also meant I could get some rest (my cumulative sleep deprivation at that point was not something to be examined too closely) and do my grocery shopping prior to returning to the airport so that we could leave early the next morning and get out to Bomet before noon. I was scheduled to start ward service on Tuesday, so I had to ask Annette to arrange for someone else to cover the day. But lo and behold, only one of my two bags dropped onto the baggage carousel that evening, and it was, quite naturally, the one containing shoes and food and gifts but absolutely no clothes whatsoever. I said a quick hello to Mike and Julie Ganey, who had arrived on the same flight, and then made my way back to the lost luggage desk, where I was told that the remaining suitcase would arrive the NEXT night on the same flight. The skepticism I felt upon hearing that was… significant. Since it seemed fruitless to delay any longer in Nairobi, I signed my suitcase up for the courier service with a sinking feeling that I would never see my clothes again. I managed to avoid tears until I got back to the guesthouse and started video chatting with my parents, but at that point, I melted into a sobbing mess.

Past midnight I finally hung up with my parents, who had been on the phone with Air France trying, unsuccessfully, to get more information about my luggage than I had been able to and slept for only a couple of hours before finding myself awake again. At some point it crystallized for me: I was not going to be able to pull myself out of this of my own accord, and I didn’t feel like God was anywhere nearby or listening. But I had the wherewithal to write an email asking friends to pray, which was probably the wisest thing I did the whole day.

Eventually it was time to face the morning, and after a shower and breakfast, my driver took me back to the shopping mall, where I'd seen a Woolworth's and several other stores likely to sell a few essentials. Business completed, we headed finally for Tenwek, an uneventful trip other than a slightly unnerving phone call from the airport, aiming to confirm that I wanted my bag to be delivered to Kijabe Hospital (what?! no!), and arrived mid-afternoon. Adrenaline got me through the rest of the day, and after several offers from women here to let me raid their closets and a lovely welcome dinner with friends, I passed out in bed. Wednesday morning, I was able to confirm that my suitcase had actually arrived in-country (amazing!) and was being handed over to the courier service (fingers crossed). The following afternoon, I received this text:

Mildly incredulous is probably the best way to describe my response, but the visiting staff coordinator arranged a driver to transport me into town before the office closed that evening. My bag and I were reunited in a duka whose appearance made me feel slightly justified about the skepticism I'd felt (see below).

It was really quite a day. Hospital events aside - which would extend this post from merely Too Long to Seriously, Nobody's Going to Read This - Mike and Julie and the kids arrived from town, I got to laugh myself silly over dinner with them and the Horns, and I had my stuff back. 

I've spent a fair bit of time reflecting on the events of those several days this week, and I've come to a number of conclusions, at least one of which should have been obvious. Some of the others, though, fall more into a category of Things I Wish Weren't True About Me, and are ultimately areas in which I want God to work and grow me rather than just convict (see Hebrews 12:12-13). 

1. Sleep deprivation is the worst. It reveals every weakness of character you could ever imagine, and then some. It stinks, but it's worthwhile paying attention to what those are.
2. Seriously... it was Just Clothes. I tend not to think of myself as a materialistic person (to be perfectly transparent, probably to a point of unhealthy pride at times), but it was crazy how the absence of my material things had the power to undo me. One friend reminded me of Matthew 6:28-30, which was humbling and encouraging - and also true, as evidenced by the generosity I encountered when I arrived at Tenwek! It's clear there are many material comforts I take for granted, and I want both to be more aware of those and to learn to hold them more loosely.
3. Maybe I don't trust God in the day-to-day as much as I think I do. Unlike this week, I'm fortunate to have a lot of agency in the daily events of my life under usual circumstances, and that makes it easy to believe that I trust God to provide for me, when in fact I may actually be trusting myself to navigate life and make reasonable choices that will keep me pretty happy. 
4. God is still nearby, even when I can't tell. Monday night was not a good night, and I felt incredibly alone. I certainly wish I had been able to feel God's presence then, but I'm very grateful that I have friends who are willing to remind me of True Things and pray for me when I don't feel coherent enough to do it myself. One more reason that living this life in community is so essential.

It's almost time for lunch at the Manchesters' (not to be missed!), and if anyone has actually read all of this, I'll be shocked, but I promise to keep the rest of my updates shorter. I work the remaining twelve days of my trip without a day off, so prayers for endurance and good rest when I can are appreciated.