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.

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