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!