Friday, August 17, 2007

Wonderment never stops

Wonderment makes staying up all night worthwhile. The combination of a viral illness and chronic sleep deprivation has created a wall that I hit yesterday at 6pm before my call night. I lay down to take a nap before the enviable sleepless night started. At nine I went into round on the ICU patients I knew to be sick from earlier that day.

The first man that I checked in on was a 28 year old male who was brought in by his neighbor eariler in the day. Our patient had become remorseful about ingesting a bottle of organophosphates in a suicide attempt and had asked for help just before collapsing. In casualty he was unresponsive, had pin point pupils, an unrecordable blood pressure, pulse of 42 and an O2 saturation of 70%. The intern took on the case as if she had seen this before…she had…many times: gastric ravage, activated charcoal, atropine, and a quick trip to the ICU. There he was started on an Atropine drip (by the visiting resident from Idaho, the dose she gathered from a Google search on organophosphate ingestion.) By the time I had seen him, he had been intubated and had received about 6 times as much atropine as he probably should have (based on an article that I found). His pulse was 130, blood pressure 170/120+, urine output decreasing. I turned off the atropine and watched him for several hours in hypertensive crisis. In the mean time, I treated him for possible acute alcohol withdrawal with some valium that seemed to help things a little. I stopped by to check in after my ward rounds to find his pupils fixed and dilated, no tone or reflexes, his respiratory rate matching the vent all night. Meg, the other resident had already been talking about extubating him to free up a bed. His hope for his own life was contagious, I got it that night. Come morning, though, it was time to move the hope onto another patient. This is how it goes.

Watching his blood pressure was actually in the background of the main focus of the night which was an exchange transfusion of a three day old who had sepsis and suspected ABO incompatibility; an indirect hyperbilirubinemia of 27. Before last night, I had yet to use the page in the Children’s handbook regarding exchange transfusions. Exchange transfusions had existed for me only in the form of a fleeting image when I thought about dying babies in someone else’s care. The image was composed of a sterile U.S. ICU with a million people surrounding a fancy dialysis-like machine all knowing what they were doing. That image was about to be destroyed. I called THE pediatrician (the only one available in Kijabe, on call all the time) who gave me a list of supplies to gather: B+ blood, reusable 2cc syringes, a “tiny” NG tube and a minor surgical tray. Dr. Meissner walked us through placing an umbilical catheter. We then began the process of the transfusion that would continue for the next 7 ½ hours. It required withdrawing 5-10cc of blood from the child and replacing it with fresh blood each time over 5 minutes, all the while keeping very close track of the blood pressure, oxygen saturation and giving small fluid boluses as needed. My image is now a half dozen cheerful, sleepy people gathered around the prehistoric incubator shedding a purple bili light into the small ICU to save this tiny patient from kernicterus.

What was soon identified as the “grunt work” of the exchange transfusion was done all night by the tired intern and clinical officer who developed very arm and back, which freed me up to assess and infant born at 34 weeks born with mec and after PPROM. By this time in Kijabe, I was ready for spinabifida, mec aspiration syndrome, congenital abnormalities, or some other dreadful problem… but the baby actually did well weighing in at 2.5kg with APGARS of 8 and 9. A sigh of relief. I went back up to the ICU…

…to a 12 hour infant born vaginally with a double nuchal cord and required 25 minutes of resuscitation earlier in the day with O2 sats that never toped 70%. C-pap was attempted but the baby was judged by the pediatrician to have asphyxic brain death—she was, we were taught, doing the “rowing sign.” They had withdrawn c-pap and discussed with the mother the imminent death of her daughter. That discussion was at 5:30pm. Her mother sat in the room praying for a miracle; she was still sitting in the room at 2AM with a daughter saturating in the mid 40s. Was this a miracle or was it suffering? What would have happened to this baby at Swedish?

There were several other admissions: the inevitable motor vehicle accident brought in a man with several fractured ribs and a flail chest. A man—who shares my birthday—was transferred from an outside facility in hopes of a spine surgery to decompress his T4 tuberculosis mass that had rendered him paraplegic for the past 4 weeks. A 77 year-old Massai gentleman with known hypertension, diabetes and history suggestive of a left CVA…there is usually one per night that I feel comfortable with. Sort of… this Massai man does not exactly fit the diabetic hypertensive stereotype we have in the US. He has been farming all of his life, has no TV or processed foods and weighs 110 pounds.

I slept much of the day today. It has been a wonderful rainy, restful day with Liam by the fire. Tomorrow is Saturday. After round, we are heading to Naivasha for the day to see some more animals with some new friends the Davis’. Rich Davis is a general surgeon who just graduated from residency and is here for at least 5 years. I have such tremendous admiration for him.

Tuesday, August 14, 2007

A daily routine?

My weakening sprit was not ignited much this morning on rounds.
I transferred a patient to the ICU with a blood sugar of 20 who was unresponsive when I arrived to round on her and had been that way for some unknown amount of time. No one had noticed on the crowded wards where beds are separated at most by a curtain. I am grateful for the donated glucometer since a “stat lab” is a term as weighty as supercalifragulisticexpialidocious (just watched Merry Poppins this weekend with Liam… good flick, highly recommended.)

I had to tell a 52 year old woman with T2 paraplegia (for 4 weeks) from metastatic thyroid cancer who has been sitting waiting for the arrival of a neurosurgeon from the states. The hope has been that she could regain some function after decompressive surgery and she could go home with her husband and live with palliative care for her cancer. He was promised to come last week and we heard on the day of his expected arrival that he was delayed a week. With a smile and with much gratitude the couple requested that they stay in the hospital. Everyday we talked about Tuesday the 14th of August as the day she would have her surgical evaluation. A small note written in the chart today said his trip had been canceled. Without hope for recovery at all, the couple agreed to leave the hospital. They reiterated their gratitude for my “help.” Simultaneously—I admired their peace and contentment with the outcome but felt bewildered and almost uneasy about their lack of frustration with me… the hospital… the doctor who did not arrive… the cancer…

I had to tell a 67 year old female that she was HIV positive. Her tribe shuns those with HIV. Her eyes welled with tears as she told me that she has never been unfaithful. She told me that she does not know anyone her age that is “positive.” In short, she did not believe me, did not want me to tell her family members and told me that it must be a mistake. She requested politely to be discharged later in the day.

I watched as the ICU doctor extubated a 10month old with an unknown 2 day illness thought to be meningitis or an intracranial bleed of unknown etiology who was rapidly decompensating. His parents stood by to watch him die. The ICU needed the ventilator for another baby.

In the afternoon I worked in the outpatient clinic.

A 50 year old man with a bloody knee effusion from a probable ACL tear (diagnosed clinically of course) came in with a septic joint. He had stopped at a local dispensary on his long journey to Kijabe for some “treatment” there. I tapped the joint to discover thick, bloody puss.

I have worn off as a novelty now. The nurses are not too happy to answer my questions about the functional flow of the clinic. For me, the flow is less than intuitive, perhaps it is because I am American that I can not always understand who goes to the cashier when, how the charts get to the pharmacy, how quickly I can expect the lab results come back to the unlabeled cubby hole, who can help with interpretation, which rooms are empty and available for a patient to be seen in… everyone else understands these things perfectly.

A 73 year old female who was seen last week for a “CHF exacerbation” by one of the clinical officers and told to come back this week for a “therapeutic tap” of her right pleural effusion. He asked me to perform this. In addition to a nodular thyroid and an exam that was not at all convincing for CHF, her pleural fluid was grossly bloody and her son was mortified at the news that his mother may have a malignancy.

The intern class is a group of very smart, talented, gregarious people. They joke around with each other, shake hands and exchange hugs and stories in the hallway. When I see them, I think of my own cohort at Swedish and long for the comradery that we had. I do not expect to have that connection here with this group of people, but it would certainly be nice to feel a little bit more on the inside than I do. I acknowledge this requires time… of which I do not have much left here.

Bill and I discuss coming back here for a longer time. Despite all of the challenges that have marked the past few days, the thought of being an insider here is quite thrilling to me. I have a lot of wisdom to gain before that is a real possibility. We will wait on God’s direction.


The phone numbers in Kijabe are three digits. At 10pm my pager displayed “438 999” which means nursery—run! I had been home for a couple of cherished hours to have dinner with Bill and Liam during my Friday night call prior to this page. I slipped on my rubber shoes and ran down the dark dirt road holding my weakening flashlight trying to avoid an ankle sprain on my way to the hospital. I arrived to a grey infant, limp, being bagged by Julius. Lisa was standin’g by watching intensely. Lisa, who had admitted this three day old earlier in the day is the Clinical Officer on “first call” and Julius is the fantastic intern on “second call.” They called me to help them through this resuscitation. “See one--do one--teach one” has proved to be a reliable pattern for me here with only several exceptions of skipping either the first or second part. Our dying patient was the first born daughter of a young woman who sat nearby watching with glazed eyes reflecting the vast disparity between two possible outcomes. She had delivered at home with much joy and no reported problems. “It is cold these days and babies just can’t stay warm during these home deliveries” Julius says quietly. This little one came in with respiratory symptoms and a fever today and was started on antibiotics for presumed pneumonia—no CXR, LP or labs were done.
There is no way to know if anything would have changed if I had been called during the admission earlier in the day. Lisa told me the baby “did not look too bad.” Intubated, epinephrine, and 10 minutes of bagging generated a heart rate over 130 and shallow respirations that lighted the air in the room for several minutes. Placement of an NG tube revealed frank blood and that made the dried blood around the nares and ETT more notable. After 25minutes I decided to check the pupils which were fixed and dilated. We withdrew support and her daughter died less than a minute later.
Julius and Lisa left the nursery while the three nurses were speaking in Swahili in a hushed tone. I felt the urge to respond to these hushed tones—which I interpreted initially as grief. What followed was an experience I will never forget. Those nurses started at me, at the ground, at each other in silence. In a quiet, polite, respectful manner I asked for their thoughts--wanting to allow a moment to debrief the difficult experience just gone by. Their stare was not one of grief, not one of sadness, not one of surprise or of routine; I did not get it. It was the first time that I was painfully aware of a cultural divide the extent of which I now feel I do not appreciate most of the time.
I spoke with the mother through Lisa’s Swahili interpretation. Through most of my condolences and explanations, she looked at the ground without a tear until I put my hand on her shoulder. Then her weeping leaped from her body like a spirit that was emerging from her.
I had heard that death was common here. I pulled this advanced warning out of my frontal lobe to try to balance the emotions that were welling up in me. There were so many emotions that night as I walked back in the dark toward home with my flashlight and my spirit weakening.
Why was I not called for that admission? Is that protocol here—I don’t even really know my role as an attending for these very self sufficient interns. Maybe they just don’t respect me, maybe something I said or did was inappropriate? Why were those nurses staring at me?
I am a “mazugu”! (The word for white person in Swahili, literally means “strange one”.) Why did this precious daughter have to die? How would I have coped with Liam dying at three days of age and listening to an explanation of his death in Swahili? Why do I have to think about the fact that the mother asked what would happen to her baby if she couldn’t pay for the short hospital stay? Perhaps it was good after all that a chest x-ray and LP were deferred—this would have made it even less likely that she could take her dead child away from the hospital.
Where have I come? What good am I doing here?
There were two more infant deaths that night.
It is really almost too much to bear.

Tuesday, August 7, 2007

A shade of red

August 6th 2007
Tonight feels a little cooler than usual. I lit candles for dinner. Being together as a family feels deeply satisfying tonight after spending the weekend apart—Bill and Liam on Safari and I mostly at the hospital on call between Saturday morning and Monday at one after rounds. An hour of video captures an experience for Liam that he will likely never forget: seeing lions, rhinos, giraffe, gazelle, buffalo at Lake Nakurru which was a shade of pink from the thousands of flamingo that live on the shores. My last 55 hours was exhausting and full of experiences that I will never forget in this hospital that was a shade of red with two traumas and several memorable deliveries. The coolness of this evening may be from the lack of cloud cover, but Mike’s departure this afternoon is already felt. His time of service here certainly brought warmth to this place. One of the most skilled, wise and caring doctors was somewhere between a foot and a page away—teaching me intensely for most hours occupying the past two weeks. At a rate that is unprecedented for me, I have learned to do new procedures, about conditions I had never before thought of, and more about what kind of physician I want to be. His presence epitomizes appropriateness of a “short term-er” in this very different medical culture. He is strong and confident with his treatment plans, warm and gentle with his greetings and treatment of the staff, decisive, patient, and compassionate with patients and more than willing to work very hard.

Beginning tomorrow morning, there are a few things I am concerned about.
As a young female I am nervous about the lack of respect and confidence that the staff will have in me without Mike beside me. There are not many female physicians here. The nurses are “Sista” the doctors are “Doctor”. Half the time I have been “Sista” and half the time I have been “Doctora”. I am still in training after all, I hold on to my status like a safety blanket; even if I strove to be confident with my treatment plans, I can’t be. My voice is quiet and English speaking. It would better to be either quiet and Swahili speaking or louder and English speaking. Being kindly mocked for being over-relational with my patients at the R3 roast seems a long way of. Using any relational skills seems not to be an advantage here at this point.

The sound of screaming interrupted the impending downtime and lunch that I expected after finishing up two admissions in casualty Saturday afternoon. I left the elderly woman—with possible HSV encephalitis spitting blood from her macerated mouth and irrationally fidgeting with her blankets—to go to the entrance of causality. The car door swung open, out tumbled a blood drenched woman, one of three adults sitting packed in the back seat of a Mazda in its final days. Her voice came from behind a face covered in blood from the open wound on her right forehead. Her shirt was torn, her legs were not moving. I froze. A few nurses hauled her onto a stretcher in a manner so routine it calmed me enough to take charge with the second passenger who was slouched over in the middle seat. His face was also drenched in blood but there was no voice coming from behind it. His grimace was terrifying to me. I am not sure that I have ever seen someone in so much pain. I had a rational conversation with myself that moving him on to the stretcher was absolutely necessary even though it hurt him so.

There is almost never a time that I have met eyes with a Kenyan and not exchanged a greeting. “Habari” people say. “Nzuri” is the response. (What is the news or how are you. Followed by fine.) This was one of those times. We met eyes and exchanged no words. That moment had to establish trust. Everyone else was busy, there was no one else who could care for him

The language barrier felt more painful than ever. He pointed with a grunt and an arched back at his right leg. I did a primary survey. The secondary survey required cutting off his pant leg. He watched me and gave an unexpected moan of disappointment—these may have been his only pair of pants. There were three others involved in the accident. The sound of their care was a roar of urgency around us. For 15 minutes, Alyano and I contributed no sounds to that roar, we exchanged no words at all. I was surprised at how I systematically assessed his body, placed an IV, started fluids, and helped prioritized him for radiological evaluation. Lunch came much later after I sewed up his avulsed heel. Fortunately he had no major fractures and no harm to his vital organs.

The 8 beds in a room the size our bedroom are usually full with laboring mothers. Each time I enter this room I am dumbfounded by the stillness of the room. Labor. Labor? The labor that I know is not still. How do these woman labor silently? I came to evaluate a 28 year old G7P6 at 3 cm for breech presentation. There had been no ultrasound and there is no working ultrasound available now. The weight of an accurate leopold’s and cervical exam was greater than I am used to. This woman had had 6 healthy children by vaginal delivery. Her husband expected nothing different from this one and was reluctant to consent to a surgery proposed by the white doctors. The cost means sacrifice beyond what I could ever comprehend for this family trying to feed eight bodies already.
As the OR was preparing for her section a young mother came in with meconium, ready to delivery. My recent humbling experience (in Seattle) taking the NRP course gave me some pause to jump into try to help with this delivery. The Kenyan intern turned to me and asked “Can you help?” “Of course…”
The baby was delivered within 20 minutes in routine fashion by the nurse and an attendant doing intermittent doppler monitoring. The limp, pale baby was handed to Joy and myself at the warmer draped with clean, stained sheets. I chuckled to myself as I thought about my urgent summarization of NRP onto a palm memo literally just before we left Seattle. …humm not helpful now. Emergencies and palm memos are not really compatible. I do remember no stimulation prior to suctioning the trachea. I need size ??? (dang it) O laryngoscope and ask for the the ??? (dang it) 14 french catheter for orophynx and ??? (dang it) 5 french cathether for the trachea? Do we have epinephrine? There is no need to remember what ET tube size we need as there is no ventilator. The suctioning went well. The child had a voice, a weak cry and respiratory effort, and still very little tone. Drying and stimulating was insufficient. (Palpation of the umbilical artery worked!) her heart rate was okay. My mind was straining to remember the exact flow of the algorhythm this time not for the simulation test but for a tiny life. I was in a some kind of a comfortable pattern of thinking and acting and the infant was heading in the right direction behind the bag and mask. Then, for the first time I made note that the child had a body below her lungs and saw that she had a deformity of her leg. I moved it with one hand just enough to now notice an externalized spinal cord. I had been resuscitating the infant with an enormous spina bifida and had not even noticed.
Parenting Liam I have learned a repetitive pattern: as soon as I begin to feel comfortable with a certain stage of his life, he changes and suddenly I am learning to manage a different child.
An instant of comfort may be all I can expect before the next challenge presents itself here in Kijabe.
There were too many stories to tell, I will highlight a few:
I was so grateful to be able to take the lead—with Mike’s necessary step by step guidance--on my second c-section.
A man dehydrated from diarrhea had a positive “spot” test. With a growing immunity to the prevalence of this situation, I told him of this result. His eyes welled quietly with tears. I tried to explain that there are medicines that can help him and a clinic that will take care of him over time. He looked sincerely at me and started shaking his head. “Hapana” (no) “no one gets taken care of. They all die.” Dr Olieffe’s patients--70 years old HIV positive men whose chief complaint is lipodystrophy—are truly in a different world.
A 24 year old female came into causality and was put into the middle stretcher and waited there for some time before she was seen sometime between the roars of the first and second traumas. “She has a very tender abdomen” began the intern who presented her case to me. Her abdomen was distended and well exemplified an acute abdomen. I called the surgeon who took her to the OR--before her labs returned, in front of the woman with an open forehead--to find military TB peritonitis.
A 65 year old female from Nivasha (a nearby village in the Rift Valley) who had no known medical history presented to the ED with fever, vomiting, myalgias, headache and dizziness for 3 days. Comfort? Nope. Her labs returned: sodium 107, creatitine 4.4, Cl 80, hct 21, glucose 42. Malaria positive.
In recent months, Liam had his three year old well child check weighing in at 35 lbs. A three year old child came in with a febrile illness, he weighed 21 pounds. It was his third admission in 2 months. “Where is his mother from?” Asked one of the “long term” doctors during the next morning? The answer gave him reason to believe she was HIV positive. “They don’t make much money there and there is lots of tourism.” In a nation that is bursting with Christian presence and unabashedly promotes religious morals, there is refreshingly no judgment surrounding HIV that I have yet seen.

It is late now. I need get some sleep.

Sunday, August 5, 2007

Bill's reflections on week 1.

August 2 2007

Elizabeth, Liam and I have now been in Kenya for a week and lot has been going on. We arrived at Kijabe (the site of the hospital Elizabeth is serving in) after a 36 hour journey. Our trip was fairly straight forward- if long- and Liam handled everything with aplomb. We unpacked and got settled in and then packed up for a weekend stay back at Nairobi (about 1.5 hours away) to stay with our good friends the Harbers. We struggled to get adjusted to the time change for the first few days (Liam kept waking up ridiculously early ready to play), but somehow the hospitality of our hosts helped ease our transition. Covering the past 7 years with our conversations took up most of our cherished time with these wonderful friends. We had several adventures, Elizabeth was able to run with them again in a nearby forest and we spent the evenings by their fire sipping port and periodically stopping to acknowledge how funny the American accent is. David and Jenny have a staff of 6 Kenyans that are paid competitively and meet every need ranging from laundry, meal cooking, tea times (at wake up, 10am, and 4pm), yard work, night guarding, horse keeping--they have 4, car washing, daily fire place cleaning and prep--there are 4 places, etc. Given that there is 50% unemployment in Kenya folks are grateful to have work at all. While in Nairobi, we visited the house of our stay from 98' to 2000. We were longing to see our landlord and his family and we weren't even sure he would still be alive. We were greeted at the gate by our good friend, James, who has continued to work for even less than peanuts for the Bharaj family. It was a sweet reunion for Elizabeth and I to see James and to exchange handshakes and hugs. To help supplement Jame's family income, we had employed his wife, Jonas, for a few days each week. We had visited their dirt-floored tin shack in a neighboring slum and witnessed how desperate their lives were. They named their daughter after Elizabeth and James was always a friendly presence around our home as he worked the garden. It was terribly bitter for us, then, to suspect James and Jonas as the ones to have taken more than $800 in the days before we moved back to Seattle. We called the police in to investigate and quickly called them off the case after James was roughed up. James steadfastly claimed his and Jonas' innocence and yet we had nobody else to suspect who could have had access to our home. Anyway, regardless of who took the money, 7 years had softened my heart about the event and I was just glad to see him again. We asked about another of the gardeners, Victor, and James said he was fired years ago for stealing from Bharaj. I didn't suspect Victor could access our house, but now my guess is he found a way. The fact that James is still working for Bharaj, actually, is his best proof of innocence seeing as whoever took that money pocketed almost two years worth of salary for James. We left behind a single malt bottle of scotch whiskey for Bharaj (what speaks love to a Siekh man whose religion supposedly foreswears alcohol) and left some money for James and Jonas.Victor, God bless him if he took the money, needed $800 much more than Elizabeth and I missed it. As we drove around Narobi with the Harbers, Elizabeth and I kept looking at each other with smiles at familiar sites ranging from the ridiculous to the beautiful. The roads seem improved and we were struck at the marked decrease in litter that used to blanket the streets and fields. The actual improvement of the country (economy, crime, corrumption, etc.) really depends on who you ask as we have gotten radically different responses every time we bring the topic up. The Harbers took us to the animal orphanage and Liam got to see, face to trunk, 10 frolicking orphaned baby elephants. Yes, baby elephants frolick. They were hilarious rolling around in the mud and dirt, wrestling, and kicking a soccer ball. After Liam got over his fear (we were separated by only a thin yellow rope...would lawyers EVER let this arrangement happen in the States?) he delighted in them. We also saw a baby rhino before heading the the Giraffe Manor where 10 giraffe will feed out of your hand. Elizabeth gamely fed one with a food nugget from her mouth. Yep, she got a fat, giraffe smooch and all on film. The next day, the Harbers took us to a private game reserve and we had a picnic lunch within site of jumping gazelles and all sorts of birds swooping in to land in our small lake. We were the only other people in the whole ranch and it stretched as far as we could see. The Harbers let me drive their four-wheeler ATV around the lake and Liam and Elizabeth joined me on seperate, slower drives. We got on mountain bikes and proceeded on a two wheel safari. Pretty surreal to be pedaling amidst a wildebeast, ostrich, zebra, a family of 12 giraffe, antelope, warthog. We were assured that there were no cats or other dangerous game. Regardless, Liam stayed in the car. :) On Sunday, we were going to attend Matthew Harbers polo match but it was cancelled. Good thing Jack's cricket match was not! If you've ever wanted to know the rules of cricket, I think I could get pretty close. We finally stopped playing with the Harbers and were driven as per usual in heart-stopping fashion (by Jacqueline, in a van given to her family by my Young Life leader, Scott Hashimoto, so that they could have an income source--long story) back to Kijabe. This week has been a great challenge for Elizabeth as she has jumped right into some incredibly difficult medical cases. Many patients die not for lack of proper care but for lack of blood supplies or access to modern equipment. She has been able to be the lead doctor on a c-section and has done so many other amazing things already. Today, she is "up country" at a remote clinic, together with one other nurse, to see patients. That scenario would scare the crap out of me even if I did know all what Elizabeth knows. She really is an excellent, and brave, doctor. Liam and I have been exploring Kijabe a bit, tracking the monkeys that jump around in the trees just outside our door and playing in the missionary preschool playground. A family has loaned us toys and the all important bat and balls. The past two mornings, Liam and I have volunteered in the surgery prep room. Our job has been to take large rolls of gauze bandaging, unroll, cut and fold into a usable size. It feels pretty insignificant, but someone has to do it. Liam has been a rock star in the hospital with friendly Kenyans trying to pry a handshake or smile from him. He has been game to supervise me and the other Kenyan folders. This is now more journal than letter to you guys, but thanks for indulging. Please pray for me. There is a skin something or other that might be staph that radiates from my left eye lid to the side of my head. Nothing too serious yet, but annoyingly itchy. Liam and I go on a brief safari this weekend at Lake Nakuru National Park. I'm pretty fired up to see him take in his first lion in the wild.

Saturday, August 4, 2007

Up Country

August 3, 2007

Yesterday I left Mike to run the service and left on a four-wheel-drive hospital ambulance to cover the weekly trip to a community “dispensary” two of the 5 that Kijabe staff visits on a monthly basis to act as the consult for the nurse or pharmacist that runs the medical clinic.

The medicine was interesting, but the non medical aspects of the journey will probably last in my memory longer. Our driver’s name was Paul. He has been driving this vehicle for the past 10 + years and he was nervous. The past few days it has been raining which means the beautiful rolling hills of red clay covered with brilliant green tea plants of the Kikuyu land turn into slops so slick I mentioned the concept of chains for the tires during one of several stops to push the truck out of the hill. Even though running is something I have unfortunately done none of here yet, I am glad that my body is “fit” as I gained significant respect from my male co-travelers as I pushed the truck in my skirt and wimpy dress shoes while the other “ladies” stayed inside. I had a well thought out plan: when the “consultant” came all the way and had no idea what was going on with the patient, “at least” they would say “she can help us get out of the mud.”

It was still a long time after we arrived at the dispensary before I got to try out my ability to be a consultant. First came the traditional Kenyan breakfast: chai, white bread with Blue Bonnet, and a hard-boiled egg which we shared in a room made of tin walls and a wooden plywood roof with indulgent relaxation and light conversation. From there we went to another room with concrete walls painted white and decorated with evangelistic HIV awareness posters and scripture verses. For the next 20 minutes we had a church service complete with Kikuu praise songs, a short sermon about how Christ came to heal the sick in conjunction with bringing his message of “good news” and how grateful they were that God had brought us (myself, a Kenyan intern, a medical student from Australia and two dental hygienists) to their village, followed by prayer. We were given a tour of the dispensary, the lab, the examination room, a description of the procedures of the dispensary, and all that they had to offer patients. It was only then that I asked quietly and as politely as possible “are there patients for us to see?”
“There are two here and the rest are coming.” Apparently the sight of the ambulance passing through the village is sign that we are available and the patients need time to trave. “The young always come first, the oldest and sickest may not make it today because of the rain.”
“Do you know where the oldest and sickest are? Can we go to them?” My question was somehow hilarious, received with prolonged laughing by the pastor, the driver and the pharmacist.

We saw our two patients, the dental hygienists did a tooth extraction and by 1 pm we were back in the truck to the second of two villages on the schedule for the day.
The second clinic was slightly larger. We were served a large meal, had chatty conversation and then saw our seven or eight patients who had been waiting for us. Again I was struck by disease progression here. We saw a 65 year old female with 3 years of bloody stools, occasionally black, with weight loss and mild abdominal pain. At first it struck me as unfortunate that guiac cards were unavailable and there was no ability to due a hct, but when I felt a 3 cm mass in her right lower abdomen, those tests seemed ridiculously unnecessary. Fortunately she could easily get a colonoscopy at Kijabe if she could find someone to take her there.

We saw an eleven year old for evaluation of murmur who had a history of recurrent pharyngitis, and arthralgias. We suspected rheumatic heart disease requiring her to have monthly penicillin injections for prophylaxis. As I pursued the differential diagnosis and looked up treatment regimen and prognosis for this case that felt quite unusual to me, the Kenyan intern was moving on to the next case… bread and butter for her. We saw physiologic jaundice and probable early HIV neuritis.

Our trip home was uneventful, peaceful, full of more reflection as I watched the rolling hills pass by, the children waving, and the sun come out from behind the clouds. We bounced along to the Kenyan praise music playing on the radio.

I will never have a day like this again.

When I came home, Bill and Liam were playing with the wooden train… besides the big red plastic bat and a fire engine, they are the only toys Liam has. I am not sure if this reality is more difficult for Bill or for Liam.

Bill and Liam have been helping in the OR storage room folding sterile packets and learning Swahili from the “vegetable ladies.” Bill has also been busy planning their upcoming Safari this weekend when I am on call. He has been an incredible support, had maintained a remarkable attitude and actually seemed interested in what I am doing in the hospital. Movie nights with Mike, Jordan, and Daniel have been good. Yesterday Mike implored us to watch one of his favorites about the characters from Star Trek being captured by aliens and taken into space on their ship… he and Daniel have seen it more than five times. Now I have seen it once… the first movie I have seen in about 6 months…humm…prioities?
And the next morning Mike was teaching me about intercranial bleeds, Glasgow Coma Scores, and craniotomies.

Friday, August 3, 2007

First day on call

August 1st

I have learned—over the past three years in this process of medical training—that anticipation of challenging medical situations is worse than actually living through them. For the past three years, fear about being in a situation where I am unsure about what to do at a medical decision tree plagues me. Over the past several months I have sensed a mirage; a chasm between being in the process of being trained and knowing. Each day that I move closer to leaving residency, the hope that I will somehow find my way on the other side of the chasm, that I will know grows more intense.

Literally and figuratively, being in Kijabe this short time has caused the mirage to vanish. Knowing is so far off that I am now convinced that it will never fully come. Knowing more while learning along the way is the constant in medicine; there is no chasm, there is no need to get across. Kijabe is teaching me that being a physician means caring, and doing what you are capable of in the moment.

My first 24 hours of work was full. It is one thing to be in a new hospital. And another to:
work in wards with new names: “casualty” (ED), “OPD” (clinic), the “special ward” (for those who can pay more than the routine cost of being on the men’s or woman’s ward)
work among medical professionals with titles such as “medical officer”, “intern”, “registrar”
care for patients who speak a different language
work with nurses who operate with a different set of cultural norms
identify diseases that I have never seen and prescribe medications that I have never heard of
be called in as a “consultant” for people who are not more than three years my junior and have been trained in this environment… from the ED, clinic and the wards all at once.
I was sweating most of the day, did not have lunch until 9pm and did not urinate the whole day… but felt completely at peace in my soul, knowing that life was so full and experiences so rich.

Just a week earlier, the excellent Dr. Wierusz had admitted and taken care of a young female who had an abdominal mass which was drained in the OR and found to be an abscess; 6L of pus was removed from her abdomen. She improved over the next few days and was nearly discharged--pending “mobilization”. But she was increasingly less willing to move as her left lower extremity grew more edematous with a presumed DVT and her abdominal incision opened with infection. When she started bleeding from her open wound, her hematocrit and platelets dropped. In DIC, we transferred her to the ICU during my day on call. The blood bank had several nearly empty drawers of blood, probably about 7 or 8 units. One unit of O+ was promised to an elderly gentleman in the ICU with a GI bleed who had a better chance of survival. The young woman needed whole blood in lieu of cryo and FFP—which are never available. Both Mike and I would have given her our blood; but the amount that could have saved her at this point was more than either of us could spare. She became hypotenseive, tachycardic, and soaked with her own blood. In the middle of the night, Mike and I watched the haunting progression of tachypnea to agonal breathing. She died peacefully. There was no need for a code because there was nothing to offer on the other side of that code. In the traditional Kenyan way, her nurse watched with quiet distress--another one of her patients was dying. There is no escape from death. After all she is working in the ICU where “advanced medical technology” (cardiopulmonary monitors, one intermittently working ventilator, and more selection of IV medications) is available, where the ratio of nurses to patients allows more personal and attentive care, where more money is spent for presumed aggressive medical care, where patients are saved. But even in the ICU patients are still are malnourished causing diminished immune response, disease burden is advanced because of lack of prevention or early detection, and life saving treatments are in short supply and high demand throughout the nation—even in the ICU.

CHF exacerbation, renal insufficiency and hyperkalemia. Familiar--I could have been on 3SW at Swedish and ordered an EKG, started gentle diuresis, and potassium lowering. Unfamiliar--the EKG machine is not working, elevated potassium is often a lab error and can not be trusted, (there is no kayexylate and certainly no dialysis available anyway), and the patient is becoming unstable with tachycardia and hypotension. Stop diuresis and stare at the cardiac monitor above his bed--ST depression, flipped T waves and Q waves develop. He looks unwell. A cath lab does not even exist in the imagination. We watch this man infarct his myocardium. Antithrombotic therapy? Incidentally, his INR is 2.2--not unlike a surprising number of the patients here—possible vitamin K deficiency, or a whole host of other possibilities except of course previous anticoagulation therapy as this is the first time this gentleman has been to the hospital. His death occurs several hours after his young female roommate.

Two of five ICU patients are taken to the morgue, their bodies are released after their poor families pay for the hospital stay.

Six months post partum, a woman with choriocarcinoma is in neutropenic precautions after her course of chemotherapy and in the ICU after her successful resuscitation by Dr. Tuggy two days previously. She has an iatrogenic pleural effusion which is thought to be the cause of her tachypnea. Her breathing however seems to be mimicking the progression seen several hours ago by the 19 year old. None of us mention agonal breathing because her vitals are otherwise holding stable and there is no good reason that she too should die tonight. She, after all has been identified as a lucky one, saved from death two days ago, undergoing aggressive treatment—she is a hopeful recovery. She is a mother.

I left for two hours that night to sleep in my own bed. And hers had emptied in that amount of time. The small African ICU had lost three. The night nurses went home, still quiet. They seemed to be attempting to walk the line between complacency about frequent death and mourning for the young lives that are ending time and time again.

The ICU had another admission that night. A male 3 hours old, born to a 17 year old G1 at about 33 weeks gestation (based on the post partum glance assessment) by LTCS for footling breech and PPROM. He had been in the nursery with increasing grunting, tachypnea 40-50s and tachycardia. Unlike the other patients, I knew this one from the beginning of his time at Kijabe. Under the dim fluorescent lights of an operating room with red-mud-stained tiled floors, in the late hours of my first call day, I did my first c-section thanks to the play by play direction of a family doctor from Seattle who I admire tremendously. The experience of “first” had begun long before I made the skin incision. We found shoe covers that were made of blood stained cloth and heaped together in a bin. We scrubbed with plain ‘ol soap and water followed by squirting some alcohol on our hands. My gown had a cotton exterior and a plastic interior that demonstrated its sterilization process by clinging to itself like a polypropylene shirt with extreme static cling. The anesthetist administered the spinal within 2 minutes in a manner so graceful one might have thought that she was creating some kind of art on the patient’s back. The patient appeared comfortable and I could not tell that she was nervous until she clung to Mike’s gently offered hand and put her head on his shoulder. Her eyes were shinning, scared and young. Her gravid body was the only thing I knew about her. It seemed that she needed a father at this moment, and Mike was filling that role. I hope to God that she has someone other than Mike to hold her hand as she is raising this child. Her shining eyes were hidden behind the cotton sheet curtain while I trembled with anxiety at several points during this surgery--a dystocia of the head for about 2 minutes and a brisk bleed until we closed the placenta. A one and a half pound crying boy was born and handed to an excellent German pediatrician while we closed. It was only after three hours of life that he had begun to look sick accounting to his transfer to the ICU for c-pap… unfortunately the c-pap machine was discovered to be broken… but that is another story.

This was only part of the ICU story that night. I am skipping the patient who was two days post emergent repair of a AAA (who had presented with an upper GI bleed and thought to have an aorto-duodenal fistula) who was now briskly filling his NG drainage bag with bright red blood. He ended up visiting the OR again in the middle of the night for a pyloroplasty and vagotomy to control bleeding from a duodenal ulcer.
The other patient was an 96 year old man with a GI bleed. He was sleeping.

I interpreted the promise of many “procedures” as a carrot for this experience in Kijabe. I was fortunate to get to do a thorecentesis as part of daily rounds on the wards, an LP in the ED (“casualty”) on a seizing 17 year old, a FNA of a 3cm breast mass with associated lymphadenopathy in a patient who traveled from hours away. Procedures here are more than a chance for this resident to develop her skills. They are a necessary piece of delivering medical care to an overwhelming number of patients who almost all have progressed disease and little ability to “follow up.” One does what is needed--now--because there may never be a later. Skill is something I feel a certain desperation to improve for the purpose of being more efficient with my care of sick patients where ever I am delivering medical care. Perhaps someday I will be able to perform an LP as that anesthetist did in the OR the previous night.

Hoping that tonight we will have warm water, I need to bathe Liam. And then will to try to get some sleep around the reflections the percolate when my head hits the pillow. Tomorrow’s morning report followed by chapel comes quickly.