pecc doings, part two

As a warning, this is a fairly heavy post, but it’s what I’ve found myself pondering the last several days, and it’s also important to me to be able to share even the hard parts of what I see and do. But it may not be for everyone. 

I’m back in Boston. I managed to sit in a pollen-covered chair on my porch about five minutes after arriving home, which made the hour afterward a little miserable. But a double dose of Zyrtec and half a dozen spritzes of nasal steroid later I seem to be returning to baseline…

Interestingly, the thing that may have made the biggest impression on me over the last two weeks at KNH was an exposure to the paediatric wards that I haven’t had before. What I realized was that as sad and challenging as the PICU can be, I have been – in some ways – very sheltered within its walls. I see the patients in front of me. It can feel bleak when it’s clear a child has a terrible prognosis, but the PICU has ventilators, and it has pressors, and we can do the Critical Care Things, mostly. But out on the wards – at least in the acute rooms, where the team gets called to do PICU reviews – all they can do is put a child on oxygen, keep giving them medications, and hope for the best. And kids die. Some of them would eventually, even in a PICU, but some are dying simply because there’s no room in the inn. 

Heading in for a PICU review

Each day after PICU rounds are complete, we walk the wards and see any children who have been requested for PICU review. On Thursday, I was standing at the bedside of an infant while the ward resident told us about her, and as I was unwrapping layers of the baby’s clothing, I watched as she began breathing irregularly and then began to gasp. What then? I knew there were no PICU beds, and what I had heard of the story hadn’t given me much reason for hope. But we did some ventilation with a bag and mask and gave a dose of epi for weak pulses, and the resident spoke to the parents before we talked ourselves into stopping. We walked away with her pulse fading as a nurse was pushing a bolus of fluid into her IV. When did she die? I don’t know. I’m not sure anyone actually did, and somehow that feels even sadder.

Diarrhea, septic shock, acute kidney injury, acidosis, respiratory failure: it’s the terminal spiral of too many infants on the KNH wards. Far too many simply present much later than they should. An infant we heard about on Friday in ward 3A had been at home without passing urine for a week before being brought to a district hospital. There she spent another week without any urine before being transferred to KNH for the only remaining option, peritoneal dialysis. She was still breathing, but hypoxic and clearly uremic, and I could only hope that the plan to get the PD catheter in urgently that day was executed in time.

But the baby that really broke my heart was a beautiful three-week-old who had presented with a mild version of the usual story, until the night before we saw her when she had suddenly developed respiratory distress, needing a lot of oxygen. Did she aspirate? Maybe. She was certainly uremic and could have. But I think she wasn’t beyond hope. We didn’t have any PICU beds, so we had them call around. Main ICU? Full. NICU? Full. Could the newborn unit at least do CPAP? Full. Was there a CPAP machine somewhere, anywhere, that we could hook up and attach to the baby? Maybe. They’d work on it. Her mother was quietly wiping tears from her eyes as we talked about options, and I suggested they put the baby on a cannula and turn the flow up as high as they could in the meantime, just in case it effected some positive pressure, but the next day the ICU residents told me that she had died while they were trying to organize the CPAP.

In my US life, I hear a lot about hospital capacity alerts and lack of ICU beds, but in contrast to KNH, it feels like a joke. Here we always, as a matter of protocol, have a bed reserved for emergencies. There are three other PICUs within five miles of my hospital. I can only guess that a large number of the children admitted to the KNH wards – there are four, and they are not small – would make floor nurses at my hospital absolutely faint. And yet the KNH ward nurses and residents keep going. How? Whatever the answer is, it inspires me to engage the difficult consults and to try to teach however I can, even in the absence of any good answer for the child in front of us.

How do you tell these stories? I often pass myself off as a regular old pediatrician during casual interactions in my everyday life because the idea of critically ill children, even in a highly controlled environment, is a lot for some people to contemplate. But even my colleagues’ eyes widen when I talk about some of the children I’ve met and cared for in Kenya... 

More medical resources and better infrastructure are one answer to the challenges that places like KNH face. But I believe that smart, well-trained health care providers who are able to think critically and make hard decisions well are ultimately just as important. I don’t claim to be the smartest doctor (goodness knows) or the best teacher (hardly), but God has wired me to be resilient (usually) and continues to grow the place in my heart that loves trainees and being a part of their training, especially in challenging places like KNH. Even at the end of sad and exhausting days, I’m grateful for that.

pecc doings

I’m not sure if it’s a function of getting older and given periods of time feeling relatively shorter than they used to, but arriving back in Nairobi last weekend, it hardly felt that I’d been gone at all. In fairness, it’s only been two and a half months since I left Tenwek, and I’m not sure I’ve had two Kenya trips in such rapid succession before. And I’ve also remained tethered more tightly, being in contact with people on this side of the ocean a lot more frequently than I usually am.

At any rate, I’m halfway through my annual trip to KNH. Some things are the same - for instance, I can wander blithely around the hospital without any form of ID and no one seems to mind - but in contrast to years past, I’m now being evenly split by the UoN Paediatric Anaesthesia fellowship and the new PECC (Paediatric Emergency and Critical Care) fellowship. This means more fellows and a broader target audience. PECC also has a series of visiting faculty volunteers over the year, which means that it’s less urgent to cover every pertinent topic in critical care during a two-week window. (Whew!) So far I’ve met three of the fellows – the fourth will be back from leave tomorrow – and overall my time has felt a bit more structured than it has on past trips, which is actually a huge relief.

 

Lillian, the PECC fellow assigned to KNH PICU this month

One implication of supervising the PECC fellows is that I’m a bit more formally responsible for supervising patient care in the PICU than I have been before. With the anaesthesia fellows, we came along for morning rounds, and I’d help troubleshoot issues that came up during rounds, but when it was over, we walked away. Now, though, I’m supervising a fellow who is assigned to the PICU, fields calls, and is responsible for the patients: not only do we round in the morning, but we also return in the afternoon to follow up. I’m finding this has made me more aware of the challenges inherent in the KNH system and the way they impact the ability to think in an informed fashion about clinical decision making. Honestly, it can be overwhelming not to get the results of a chemistry panel for 24-36 hours when a toddler has severe acute kidney injury, or to have any idea of whether or not a baby's anion gap is elevated because the lactate is sky-high. And why does EVERYONE seemingly have refractory metabolic acidosis? A couple of patients have already made me acutely aware that my clinical exam skills aren’t always what they could be, and I have a lot of admiration for the folks who work hard to take good care of these sick babies day after day, week after week, month after month.

The bottom line is that I’m only here for two weeks, and I have it easy: I get to go back to a PICU where I’m utterly spoiled for resources, both human and medical. So I pray every morning for a heart that’s willing to jump in, to engage the trainees with whatever knowledge I can communicate and whatever critical thinking I can model. The fellows are incredibly smart without exception, and in spite of whatever anxiety I have every morning climbing the stairs to the PICU, it’s always always a joy to work with them.

an end to ordinary time

I’m currently in the throes of readjusting to life in Boston: still a little jet lagged, thrown wildly by the ten inches of snow we woke up to yesterday morning, and with half my mind and heart still back at Tenwek. But the good news is that Lent starts tomorrow, and it’s an excellent time to start reflecting on what God has done in me over the past month and how that should be part of me moving forward – I appreciate that the liturgical rhythms of my church tradition force me into contemplation and reflection on a regular basis.

My last week was, as usual, all of the things I expected it to be and yet still surprising. I will have equally poignant memories of sitting on the swing in Riverside, relishing beautiful evening hours with friends, and of sitting on the floor in the paeds resuscitation room, holding a weeping mother whose baby had just passed away. There were moments of exhaustion and disbelief and moments of joy and gratitude. I missed my official opportunity to say farewell at Wednesday morning devotions because we were elbows-deep intubating a teenage girl in HDU – though for the record, I’d rather be intubating than making speeches any day. And there was a quiet final round of chai and mandazi (and sausage!) on Friday morning as we calculated TPN for a toddler with an esophageal stricture and the interns surreptitiously circulated a goodbye card while I pretended not to see.

As I told friends there, I’m a terrible leaver, which is perhaps just a euphemism for transitioning poorly. So after doing morning rounds Friday, I insisted on the driver giving me time for lunch with the Ganeys and for a final farewell to the paeds team during their lunch at the Sleeths’. (The simplest route to achieving a later departure? Not showing up until you’re ready to leave.) And then away. I felt the challenge of leaving more intensely this time than I usually do. In part, it’s the busyness and intensity of the service I left behind and a heightened recognition of the challenges of sole responsibility and the scope of the work. Equally, though, is the family I became a part of last month, who welcomed me not as a guest, but as one of their own, and loved me so, so well.

The volume of tears shed on the journey back is best left undiscussed, but the intensity of the embraces in which I was enfolded the next day at church was deeply comforting. And the inevitable question? How was your trip? Well, it was all of the things: wonderful and terrible and heartbreaking and amazing and challenging and exhausting and beautiful.

The sermon text on Sunday was Micah 6:8: He has told you, O man, what is good; and what does the Lord require of you but to do justice, and to love kindness, and to walk humbly with your God. Solidarity with the suffering is a whole-life calling, not a one-month-a-year calling, and not something I can tick off on an annual basis. Tomorrow we will be marked by the sign of the cross in the imposition of ashes as we enter a season of repentance, reflection and renewal. I’ll be praying also for stillness and quiet in the next forty days, and for God to speak clearly into it.

rest and reflection

Julie and I got back this afternoon from a long weekend away in Naivasha. It was a lovely three days, and while the spa treatments were certainly a highlight, I even more appreciated the time with Julie. We've been friends for over a decade, but we've rarely had this much uninterrupted time together, and it was full and encouraging and lifegiving. She is one of My People, and it was a sweet time.

I also spent some time in Naivasha trying to reflect on my time at Tenwek this month and my life and simply attempting to be still. To be perfectly honest, I mostly failed, at least at the latter. I can be physically still without too much difficulty (most of the time), but my mind is another story. I noticed this last weekend - not for the first time - when I was grieving that baby's death. My skull felt like an echo chamber for my thoughts, and one of the hardest parts of the process was feeling as though I couldn't hear anything God might be trying to say to me over the noise of my own thinking.

In our morning prayer liturgy, the confession is followed by this prayer: Grant your faithful people, merciful Lord, pardon and peace; that we may be cleansed from all our sins, and serve you with a quiet mind; through Jesus Christ our Lord. What would it really look like for me to serve with a quiet mind? Increasingly, it seems that I don't know the answer to that. Sometimes it's the weight of sin or other missteps that prevent my mind from being quiet, but it's just as often the concerns of my life or work that I perceive to be priorities taking up that space. I'd like to practice quiet a bit better. Lent is coming up soon: it's an appropriate season for reflection, and it would be good to devote real time to it then.

In the meantime, I'm officially in the last week countdown here that generally makes me sad and slightly panicked and certainly not quiet in mind or spirit. I'd appreciate prayers for peace, good moments at work with the interns and residents, and meaningful time with friends. It's been busy at the hospital, so whatever else it may be, I'm sure the last days will be lively, and I'm grateful to be rested going into them.

Lake Naivasha, home of many many hippos.

last weekend

I was so committed to trying to get an update in on a weekly basis when I first got here, but I’d forgotten how life can get away from me quickly once things start happening…

Clark was off last week, but I still had a family medicine resident and an MO (medical officer) on service and the census wasn’t dramatic, so it felt entirely manageable – and honestly a lot more like what I’m used to when I’m here, responsibility-wise! But Thursday evening I got paged by the on-call attending about a critically ill 7-month-old who had been referred from one of the nearby district hospitals after her twin sister had died there a few hours before, and I headed up to help out. The short version (because the long version is probably better told in person) is that we were able to get her sort of stabilized that night in spite of multiorgan failure, and in spite of myself, I began to hope that she could survive. I’m not sure I’ve ever pleaded with God so intently for a child’s life. But the following evening after a reasonably steady day, her heart unexpectedly stopped beating. By the time I got up to ICU, it had started back up, her status seemed back to what it had been, and I couldn’t figure out what had happened. I left about a half an hour later and didn’t hear any more that night, but the following morning it became evident that she had sustained a non-survivable brain injury. I spent Saturday talking to her relatives, and late in the afternoon, we removed her from the ventilator that was keeping her alive.

Every once in a very great while, I have an Indescribably Hard case, and this was one of them. They are always moments in which I feel ultimate responsibility for a child’s life and have to live with the decisions I made in their care. I think I didn’t really start processing that until Sunday morning, when I spent half an hour literally crying out to God, weeping over her death and my part in it. Have mercy, O Lord, for I am faint; heal me, Lord, for my bones are in agony. My soul is in deep anguish. How long, Lord, how long? But at the end of it, I had no choice but to wash my face, take a deep breath, and hike up the hill to my waiting interns for morning rounds. When I got back home, though, I found Julie and said out loud all of the hardest things that had been playing on repeat in my head all morning. It was an act of love for her to hear me out, and in bringing all of my dark thoughts into the light of day, they started to feel less impossible to live with.

There’s not a terribly satisfying end to this update: I believe God provided comfort for me in the form of friends both here and back home, and I cling to the knowledge that in being a doctor I am responding in obedience to what I believe he has asked me to do with my life. And as one of my friends here has pointed out to me, our fundamental hope is in the resurrection. If it weren’t true, this would all be in vain.

When there’s so much I can’t understand, I often find myself dwelling on this, from Paul: For now we see in a mirror dimly, but then face to face. Now I know in part; then I shall know fully, even as I have been fully known.