Thursday, November 7, 2013

God of Wonders

Look around you and you will see the fingerprints of God everywhere!  It's pretty exciting.  :)

On Sunday, I experienced my first solar eclipse, and it was amazing.  Thanks to a friend at RVA and some donations of leftover solar eclipse viewing glasses from the Australian eclipse in 2012, we and our neighbors were treated to an amazing view of the eclipse over the Rift Valley in the late afternoon.  We served "eclipse food" - sort of.  In Kijabe, the moon eclipsed about 90-95% of the sun...which fit right in with my off-center deviled eggs.  Why were all of the yolks at the ends of the eggs??  Must be the way the eggs are stored.  In Northern Kenya, the eclipse was total - but they unfortunately did not experience the best weather for viewing.

Not-quite-total-eclipse deviled egg

Two cool dudes ;)  They look like they are at some sort of 1960's scifi drive-in!

Um...

Our neighbors made a pinhole projector to watch the eclipse safely.
This is what it looked like through the "projector."
Emily and her friend Sallie even painted their faces for the occasion. :)

We borrowed a welder's helmet from another friend at RVA, so that we could take photos without frying our cameras.  I didn't know your camera could be damaged from photographing the sun, but it makes sense.  The protective glass made all my photos turn out green, but no matter. 

Early on

Near maximum eclipse

I love events like this that show off the majesty of God in this giant universe - to see the moon cross in front of the sun in real time like that is almost breath-taking to me.  I mean, the moon and sun are both mind-boggling enormous and so far away,  and I watched them cross in front of each other.  Wow.  Our God is a big, mind-boggling amazing God!

At the time of maximal eclipse, an eerie dusk settled over the area.  It was noticeably darker...but not a normal change in light as during a storm or evening.  And it became cold.  Our dog, Mak, who is terrified of our steep stairs (because he can't get back down them), appeared on the upstairs porch.  I don't know if he sensed something strange, or if he just wanted to join the party, but he really wasn't himself the rest of the night.  Very subdued and quiet.  This change in light only lasted about 5 or 10 minutes, and then the sun began to become stronger and warmer again as the moon moved past the sun. 
Mak watching the sun descend in the sky after the eclipse ended.

I'll share another photo of the full moon that I took while up near Mount Kenya last June.  Amazing that it turned out so well, since I know almost nothing about photography.  It doesn't do it justice, of course, but look at all the detail on the surface of the moon even so.  I wish I could photograph the night sky here in Kijabe - one of the perks of getting called into the hospital in the middle of the night is walking back and seeing a bajillion stars and the Milky Way stretched across the sky.  Truly more than my mind can comprehend!  I can identify with the words of the David in Psalm 8: 3-4 "When I look at your heavens, the work of your fingers, the moon and the stars, which you have set in place, what is man that you are mindful of him, and the son of man that you care for him?"
Yet, He loves us like a father loves his child.


Sunset over Mt. Longonot on another night.  God is certainly a God of Wonders!

Lord of all creation
Of water, earth, and sky
The heavens are Your tabernacle
Glory to the Lord on High

God of wonders, beyond our galaxy
You are holy, holy
The universe declares Your majesty
You are holy, holy

Lord of heaven and earth

Early in the morning
I will celebrate the light
And as I stumble through the darkness
I will call Your name by night

God of wonders, beyond our galaxy
You are holy, holy                           
The universe declares Your majesty
You are holy, holy

Lord of heaven and earth

Hallelujah to the Lord of heaven and earth

God of wonders, beyond our galaxy
You are holy, holy
Precious Lord, reveal Your heart to me
Father holy, holy
The universe declares Your majesty
You are holy, holy, holy, holy

Hallelujah to the Lord of heaven and earth
(Lyrics by S. Hildalong and M. Byrd)


Lots of love,
Sarah

Isaiah 40:11-13
He tends his flock like a shepherd:
He gathers the lambs in his arms
and carries them close to his heart;
he gently leads those that have young.
Who has measured the waters in the hollow of his hand,
or with the breadth of his hand marked off the heavens?
Who has held the dust of the earth in a basket,
or weighed the mountains on the scales
and the hills in a balance?
Who can fathom the Spirit of the Lord,
or instruct the Lord as his counselor?





Tuesday, November 5, 2013

Hateful Tb

Tuberculosis.  Even the word sounds bad. 

I remember reading in Time magazine a few years ago about the resurgence of tuberculosis and the development of resistance to the medications that we have to treat it.  In the developing world and the HIV population, it is a very real problem - and those two worlds intersect here in Kenya.  Our HIV population is smaller than you might imagine - about 6 percent of our pediatric inpatient population.  Many of them have tuberculosis or have been treated for it in the past.  But, it is not just a problem of HIV infected patients - many of our patients come in with chronic coughs which make us suspect Tb.  I say suspect, because it is actually difficult to confirm Tb in children here.  All children get the BCG vaccine for tuberculosis as infants, and that can muddy the waters when interpreting the skin test that you are all probably familiar with.  That skin test is not even available to us here in Kijabe.  Chest xrays are standard in the work-up of cough/shortness of breath/oxygen requirement, but CXRs are only shadows and cannot confirm the diagnosis of Tb.  Sputums are difficult to obtain on infants and young children.  Gastric aspirates are possible here, but they end up being difficult in practice and are often not confirmatory.  We can occasionally pursue other testing in Nairobi, but those sources are not routine. 

I am just setting the stage for you about how difficult it can be to actually diagnose this common and potentially devastating infection.  Is it treatable?  Yes, very often.  Is it a simple treatment?  No, definitely not.  The standard regimen is to begin on 4 drug therapy (plus pyridoxine, to prevent some side effects of the medications).  This must be taken daily for 2 months, and then you can back down to 2 medications.  Tuberculosis is a tricky germ and, if you use only 1 or 2 or even 3 drugs, it can easily develop resistance.  If the children are infected, often you need to test the parents to see if they need to be treated also.  Taking medications for this long can be difficult for a family (it is difficult for us to remember medications in our family!), and these medications are hard on one's body.  So, you don't want to start someone on the medications, if you don't really think they have Tb....but it is difficult to confirm and you don't want to miss it and have it spread in the body and worsen.

Students learn in medical school that Tb can be anywhere in the body.  Here, we have most often seen it in the lungs, meninges around the brain, and bone.  We use the abbreviations PTb (pulmonary Tb) and TbM (Tb Meningitis) commonly.  We admitted an 8 month old child last week with a 5 month history of cough and a suspicious chest xray.  Mom denied any exposures to people with known Tb/chronic cough, but you have to take that with a grain of salt.  After 2-3 days of "regular" antibiotics for a possible bacterial pneumonia, I started him on the 4 drug Tb regimen (RHZE) because everything about him pointed to Tb.  That one was a pretty easy decision, and I am hopeful that he will do well.





Two other boys with Tb (or probable Tb) have been heavy on my heart this week.  One is a little boy named Jonah, who has Pott's Disease or Tb of the spine.  He is about 8 years old and was brought here from northern Kenya.  He is from the Samburu tribe and does not speak English or Kiswahili, so verbal communication is difficult.  However, he is a sweet little boy who would smile and wave through the window of his hospital room when he saw me and many others coming down the hall.  Tb of the spine will eat away the bones and cause collapse of the vertebrae, resulting in a gibbus formation and "hunchback."  Jonah's condition was advanced and he could not walk.  I have learned, though, that once the infection is treated and the spine is stabilized, these kids often heal well and the overwhelming majority are neurologically normal - walking!  The goal with him has been to treat with Tb meds, debride the abscess around the spine, and stabilize the spine with rods/bone grafts. 





His surgery was difficult due to hypotension (very low blood pressure) and an episode of circulatory collapse but, after 3 trips to the OR, his infection was drained and the spinal cord fused.  We are all waiting and praying that he will wake up and be neurologically normal - first, his brain after the cardiac arrest that he experienced during his second surgery, and secondly, that his lower extremities will function.  For the full, eloquently written story, see Mike Mara's blog (orthopedic surgeon) at marasafari.org.

The second boy is named Vincent.  There are some things in life that just don't have an explanation.  We see many things here in Kijabe that just "shouldn't happen,"  and this is one of them.  He is a 15 year old boy - about Ted's age - who has been having weakness for a few years, and has not been ambulatory since January.  He is from a large family without resources, and he did not receive proper treatment.  He may have Pott's Disease too - many elements of his presentation are similar to Jonah's:  hunchback on exam, vertebral collapse on MRI, etc.




The big difference is that, because he lay in bed without proper cushioning or rotation, he has developed enormous pressure sores on his buttocks.  I can't post photos of this, because it is just too horrifying.  It is horrifying to me.  I held it together while examining the wounds Saturday morning, but couldn't control my emotions when I got home.  The left ulcer shows the ball of the femur totally exposed and is some 10 inches or more across.  He is depressed, weak, paralyzed, and in pain.  If only I could turn back the clock to before these pressure sores developed and treat him....if only I could stretch new healthy skin and tissue over these gaping wounds....if only Jesus could touch him.  Jesus can heal him - with one touch or slowly over time.  But I feel helpful to care for him - he cannot have spinal surgery until his pressure sores heal, and really that is secondary now.  His wounds are growing a multi-drug-resistant bacteria called Klebsiella, and he is terribly malnourished which prevents wound healing. 

He should be in high school and playing sports with his friends, like my son.  I can offer no logical explanation of his situation, and it grieves me to even think of him.  Please pray that his infections will respond to the many costly medications and that he will eat and gain weight.  Please pray that his pain is tolerable and that he truly has the will to live and cooperate with his wound care and conditioning.  Please pray that he truly knows Jesus.

Love,
Sarah

Matthew 9:36-37
And Jesus went throughout all the cities and villages, teaching in their synagogues and proclaiming the gospel of the kingdom and healing every disease and every affliction. When he saw the crowds, he had compassion for them, because they were harassed and helpless, like sheep without a shepherd.