The Lord is my shepherd, I shall not want

Everyone has days that feel like an emotional roller coaster.  Join me on one of my own recently....

This happened a few weeks ago, while Rift Valley Academy was on it's month-long term break.  The fact that the expat population in Kijabe drops dramatically doesn't affect the patient volume or workings at the hospital, but it feels different here.  Rick and Ted both had birthdays that month, but we had decided to celebrate them together and early this year, since Ted was away for most of the month and over both the birthdays.  (This is sort of relevant.)  So, Tuesday was Rick's ### birthday - gosh, there was some static when I tried to tell you how old he is.  Anyway, Emily had been invited to a birthday party that day at a place in Naivasha (about an hour away) that has a pool.  Well, Tuesday is Rick's usual day to work, but I offered to work so that he could go to Naivasha and swim and hang out with folks on his birthday.  So, that is the background...

The day started off like any other day.  I met a visiting nurse about 8:45 to show her around and let her shadow on ward rounds.  On the ward, I checked in with the visiting US peds resident and was found by one of the chaplains who needed to talk about a patient's bill - this patient had actually been discharged a week prior, but no one on the team knew that he had been moved to a different bed and had stayed because he couldn't pay his bill.  Another patient needed help clearing his bill, so that took a little time to sort out.  I checked in with nursery, which was remarkably calm and less full than I have seen it in almost 2 years of being here...only 20 patients!  I went to round on the patient in the ICU - a very sick 14 month old with continued fevers and terrible lungs, despite adequate TB meds, meropenem, vancomycin, flagyl, and fluconazole.  Nothing had seemed to work for about 3 or 4 weeks, but the baby had finally seemed to turn a corner - it was time to try to extubate him and get him off the ventilator.

His chest xray at its worst.

So, we talked to the mom and got everything ready (including everything needed to RE-intubate him, should it go poorly), and I pulled out the breathing tube.  It felt tight coming out, which worried me that he may have so much swelling in his airway that he wouldn't tolerate breathing on his own...and, even worse, that he would be very difficult to re-intubate.  We hooked him up to CPAP and watched his oxygen saturation slowly fall on the monitor.  He had a good respiratory effort but terrible stridor - another sign of upper airway swelling - and had some wheezing (bronchoconstriction).  Finally, I decided to bag him (breath for him with a bag and mask) and asked for an albuterol neb to help relax the smooth muscle in his airways.  He bagged up immediately to 98% oxygen saturation...a factoid that will come into play later.  After the neb treatment, he looked pretty good.  He remained in good shape on face mask oxygen all day!  What a wonderful step for him; his mom was thrilled!

Then, since it was the visiting peds resident's last day of a 5 week rotation, I went over all of the patients on the ward with her - both so that I would know them for rounding the rest of the week and because I was taking call that night.  There were 3 very fragile patients in the HDU (high dependency unit = step down unit), including one that I had fully expected not to pull through 2 weeks before in the ICU.  The other 2 were new admissions and so sick - one with probable urosepsis and severe malnutrition; the other with Down's syndrome, severe malnutrition, and heart defects/heart failure.  All three patients were on high flow oxygen, either by CPAP or nonrebreather face mask.

 After that, it was off to the Maternal and Child Clinic to see a couple of patients.  One patient with constipation - a blessedly "normal" problem that is not life threatening.  Another with some developmental delay and neurologic findings after a fall a few months ago that the intern wanted me to see.  This patient turned out to have a huge dark patch over her left neck and shoulder and a mass in the left upper lobe of her lung on xray.  It turned out that her mother and maternal grandfather brought her and, when I asked them if anyone else in the family had dark patches like hers, they both started showing me their skin findings.  This little girl has a particularly severe presentation of something called Neurofibromatosis-1 and will be having surgery here in a week or so to debulk some of the neurofibroma that has invaded her spinal column and upper chest.  Please pray for her.

The discolored skin is evidence of a large neurofibroma underneath

 We admitted an infant with respiratory distress who has previously been diagnosed with an interrupted aortic arch vs. tight coarctation of the aorta (usually not repairable in this country, but we are working on getting him signed up with a visiting team of heart surgeons).  We admitted another child a few months old with probable TB - this was his NINTH admission for respiratory issues!

Then, I headed over to check on the patient in the ICU and the ones in HDU - 2 of which were needing somewhat higher oxygen flows.  They didn't look great, and I expected it to be a long call night.  I made some adjustments to their medications with the intern and headed home to make dinner. 

At home, Rick and the girls had returned from a fun day at the pool.  :)  We got dinner ready and ate a very casual birthday dinner, since we had already celebrated and I never know how much time I'll have on call....a casual completed dinner is more satisfying than an interrupted elaborate dinner.  It was turning into one of those nights where the pager is going off at the same time as the house phone is ringing, and the intern is calling on your cell phone while you are on the phone with the ICU or casualty.  While I was answering a call from casualty, the pager went off and then the intern called my cell phone - one of the children in HDU had arrested.  I ran up to the hospital and jumped in after the first dose of epi - the nurses and one of the outgoing medical interns (the new ones had recently arrived) were doing a fabulous job.  About 25 minutes into that resuscitation (that wasn't going well), I was called emergently to ICU because the baby up there had suddenly crashed. Really wishing that I could clone myself, I gave quick instructions to the intern and ran upstairs.  Why was that baby suddenly crashing after such a stable day??  When I arrived, the sats were in the 60s, so I started bagging the baby (breathing with a bag and mask).  The sats continued to fall - but, this baby had responded so quickly to bagging earlier in the day.  As I asked for the equipment and medications that I needed to reintubate this baby, I looked around at the 3 adult  patients in the big, open room.  I realized with a pit in my stomach that all of their monitors had red numbers for their oxygen saturations, and it suddenly struck me what was happening - the oxygen had failed.  The nurses ran to the patients' bedsides and began to bag them, while I sent one nurse on a hunt for any available oxygen cylinders.  I knew this baby would respond to oxygen and didn't need intubation.  He found one amazingly quickly in casualty, hooked it up, and the baby's oxygen saturations immediately rose to the 90s.

Running back down to HDU, I found all 3 infants being resuscitated at the same time.  This is one of those times where you know you are woefully inadequate and cannot handle everything that needs to happen at the same time, but you jump in and take one step at a time.  The nurses and available interns did a wonderful job, and they deserved a lot of commendation.  Keeping your wits about yourself in that sort of a situation is not something that comes naturally, but panic causes a spiral.  I won't go into the remaining details, but order and function was restored in under an hour...an eternity plus some.  Talking and praying with parents that night, discussing the events with the medical director, teaching the interns so they could learn from what they had seen and done.....it was draining, and on the walk home in the dark, I couldn't keep back the flood of tears.  I was so thankful that the kids were already asleep when I returned home. 

The rest of the night was mercifully light, with only a few phone calls.  God kept bringing Psalm 23 to my mind, and I prayed it each time I was awakened.  I prayed it for the children and families in the hospital, and for myself.  In the morning, I went in the talk to the chaplain of the children's ward to fill her in and met some visitors that were with her.

 
We ended up praying for the children affected by the events, and the visitors each spontaneously prayed parts of Psalm 23.  I feel like God was, once again, sending reassurance that he can and will be my/our Comforter...He will comfort his children, even in the deepest, darkest valley.  I am learning how to be comforted in the midst of sadness and even grief.  It is not the same kind of comfort as when all things are made right again - it is a comfort that comes despite the sadness, despite the wrongs, despite the loss....and it is real and good.

Psalm 23

The Lord is my shepherd,
I shall not want.

He makes me lie down in green pastures;
He leads me beside quiet waters.

He restores my soul;
He guides me in the paths of righteousness
For His name’s sake.

Even though I walk through the valley of the shadow of death,
I fear no evil, for You are with me;
Your rod and Your staff, they comfort me.

You prepare a table before me in the presence of my enemies;
You have anointed my head with oil;
My cup overflows.

Surely goodness and lovingkindness will follow me all the days of my life,
And I will dwell in the house of the Lord forever.

We all will experience various hardships in this fallen world, but I am learning more about the comfort that can only come from God in difficult situations that we must still walk through.  No taking another path, no running away - we just have to walk straight through it, but we are not alone.  I hope this will be an encouragement to some of you in those difficult situations right now.

Love,

Sarah