The week in review - medical segment.

I have decided to have a nonmedical and medical post this weekend, which gives you some flexibility in how much you want to read about the nitty-gritty of the hospital.  Most people seem to like the medical aspect, though,  and I will try to explain things in "regular English" too.  :)

The ward is busy right now (15-18 patients each day this week), and I think the type of patients are fairly typical of an average week.  I continue to be impressed with the high level of medical care that is provided to these kids with debilitating illnesses and conditions, but the reality is that we cannot always provide everything they need. 

Joseph is a 17 month old boy who came in with tuberculosis and congestive heart failure.  He was found to have an elevated left hemidiaphragm on his first chest xray, but the stomach bubble looked normal and it was unclear why the left hemidiaphragm was elevated.  That xray was not good quality and only PA (straight on, as opposed to from the side).  Lateral chest xrays are very difficult to get here, even if you order them.  

Joseph hanging out on his bed, doing much better than when he arrived.

A subsequent xray showed actual loops of bowel in his chest.

So, this little boy had a previously undiagnosed congenital (born with) diaphragmatic hernia!  (His stomach/intestines and spleen were in his chest cavity instead of his abdomen.)  When he was stable enough to go to the OR (called theatre here - even the spelling is British), he was repaired by our incredible pediatric surgeon, Erik Hansen.  Below is his immediate post-op xray, and he was doing beautifully!

Post-op...looking good!

Another little boy, named Philemon, also came in with a diagnosis of tuberculosis.  He had been on appropriate medications for 6 weeks but had continued to worsen.   Unfortunately, he was too sick already and there was not much we could do for him.  He acutely decompensated on the floor and was taken to the ICU, but died shortly after arrival.   He was our one death on the ward this week.

Notice the large pneumatocele on his right, not to mention the diseased lung tissue.

After the pneumatocele burst, his right lung totally collapsed.

Victory is a little boy who has one of the most patient, gentle mothers that I have met here.  She doesn't speak much English and my Kiswahili is still very rudimentary, so we can't have a conversation, but I love to watch her with him.  I thought he was going to die 3 or 4 weeks ago before we got a handle on his infection - and he needed blood but it took 3 days to find blood that matched his type!  She waited patiently with him, sharing his bed, and has never questioned what we are doing.  They have been here such a long time, but they may be ready to go home on Tuesday!  I asked mom how far away they live - 12 hours by matatu (a little Kenyan minibus packed with people)!!  Imagine being in a hospital with your very sick little boy for weeks, and then having to get into a crowded minibus and travel 12 hours home.  We have to plan to have his discharge ready early so they can catch an early matatu.  Please pray that he gets to leave and makes it home safely - I am going to miss them.

As I have mentioned, Rick and I are covering the pediatric ward during the week right now, but when we take call we cover kids in the ICU and nursery too.  A couple of weeks ago, I went to the delivery of a 27 weeker - she was 970 grams....that is 2.1 pounds!   She did not even need to be intubated, but breathed on her own with the help of CPAP (continuous positive airway pressure).  What a champ! :)

Baby M right after stabilization.

Baby M a couple of weeks later - not even on oxygen! :)

On my most recent call night, I was called to the resuscitation of a 37 weeker, who actually looked more like a 34 weeker.  She was only 1.45 kg, or 3.1 pounds, so she had not had a very healthy intraunterine life.  She looked like such a serious old woman who had already had a hard 8 months or so!  She needed oxygen, but I think she will do well.

Back to the ward, this little baby was admitted for severe malnutrition and rickets, but she is otherwise a totally healthy and developmentally normal 5 month old......only she weighs 2.7kg.  That is about 6 pounds.  She is only crying here because she didn't want to be undressed - she was a cute little thing often playing with a couple of small toys her mom had.  If you look closely, you may be able to see the knobs on each rib that one gets with severe rickets - in medical slang, it is called a rachetic rosary.  I had never felt one before coming to Kenya, but now I have felt many.

Six pounds at 5 months.

Mom wanted me to take a photo with me too. :)

On Friday, I had to tell one mom that her previously healthy 10 month old will never be normal, presumably because of the recent meningitis she had.  Also that day, I had to tell two different families that their daughters had cancer.  They both have a fairly good prognosis....if they are able to be treated.  One has Non-Hodgkin Lymphoma - that dad was stoic and focused during the entire conversation.  He asked good questions, but I could not get a good feeling for whether he would take the girl (a 5 year old) for treatment.  They live fairly close to a government hospital that offers chemotherapy, but the waiting lists for treatment are long and the costs are prohibitive for some families.  The other girl is still an inpatient in Kijabe - she came in with new onset severe headaches and seizures.  We were able to get an emergent head CT for her which showed a likely low-grade astrocytoma.  I think we will have to use the Needy Children's Fund for her MRI (about $200) to better delineate the tumor to see if she is a surgical candidate.  Kijabe Hospital has a very good neurosurgical department, so she is in the right place here.

During my talks with these families, I have found them to be very open to praying together - whether just with me or with the chaplain too.  The chaplaincy department here is so important - they come visit with the patients, learning about their lives and needs in a deeper way than we can; they come to family meetings that bring bad news to bear; they follow up with patients and families and help us know who needs financial help; they really care about these families and want to model Christ's love to them.  I am so thankful to be on a team with them!

For the most part, the patients have to overcome tremendous obstacles to be treated - transportation, finances, time away from family obligations or work.  Last week on Thursday, a father came to take his daughter and wife home because the wife was in danger of losing her job due to missing too many days.  I talked to the dad about how, if they left, I would need to see her back on Saturday, to which he agreed.  Then, as I have gotten into the habit of asking, I inquired about how far away they live - 5 hours.  So, they were going to leave at 4 or 5pm, ride a matatu 5 hours home so the wife could work on Friday, and then come back and go home again on Saturday.  Life is hard here.


Love,
Sarah
Matthew 11:28   Come to me, all who are weary and heavy-laden, and I will give you rest.

The week in review - nonmedical.

It has been a big week here!  President Mwai Kibaki was supposed to come to dedicate the new wing of the hospital that is scheduled to be built in the next couple of years, the CT scanner that is being installed (donated from the States), and the new Maternal/Child heath clinic.  I heard that the last time he visited a few years ago, they patched the road down from the highway the day or two before he visited.  The afternoon before the festivities this week, people were whitewashing the parking curbs and putting up tents, but the road was still in terrible condition, so I doubted he would come.  

The Deputy Prime Minister arrived to represent President Kibaki.  The top four in command of the Kenyan government are the president, the vice president, the prime minister, and the deputy prime minister, so number four is nothing to sneeze at.  There were speeches and band performances for most of the day.  I was not able to attend, but I am told that the during the speeches the hospital administration asked the DPM for road repair (needed terribly for the road from the highway to Kijabe), a new ambulance, a police vehicle for the local police (not many police stations have cars here, so you have to go pick them up - tricky in an emergency!), as well as government support of the hospital and national doctors.  Government support of a more reliable water supply may have been part of that, also.  I think I mentioned a couple of weeks ago that the water spigots were slow or dry at our house for 1-2 days.  At the hospital yesterday, the water stopped at the sink I was using, and I had to go to 3 sinks to find one that had water to finish washing my hands.  I don't understand how that happened, but water is definitely not to be taken for granted here, as it is in the States.

The Kenyan Police and Military on the morning of the dedication.

Happenings on the school front:  This week Anna had a band concert and Emily had a reader's theater presentation with her class.  Ted has exams next week as the term draws to a close on Thursday.  (Yes, we have school and work on Thanksgiving Day, which is not celebrated here.)  Most of the kids grade 4 and up have been working on Pinewood Derby cars for the last few weeks, and this morning was the 39th Annual Pinewood Derby.  It was a big event with electronic timing and photo finishes!  Each grade competed among themselves.  Anna's car did very well, and she ended up in 5th place overall.  It was also Senior Store, which is a monthly event for the seniors to raise money for their senior trip.  For us, this translates into powdered sugar donut dots and chocolate covered donuts.  Yum! 

A heat getting ready to run - Anna's car is in Lane D.

Picture of the video screen showing the photo finish - Anna's car is in Lane F this heat!

Anna's band concert

Emily with the neighbor's cat, LP.

Ted brought a couple of buddies from school to dinner last night - one from Nairobi and one from Rwanda.  I wonder if they heard about the feast we put on for Caring Community last weekend!  (Caring Community is a program where the classes are broken up into groups of 6-8 kids and hosted by a family - events about once a month.)  For Caring Community, we grilled chicken and filet (the "t" IS pronounced here and it is less expensive than chicken!), had baked potatoes, fruit salad,, broccoli salad, homemade bread, and several kinds of dessert.  Rick sent them on a photo scavenger hunt in two teams, and they were quite creative!  One of the challenges was to find and photo a monkey, which none of them could, - if they could only have been around the last couple of days, they would have seen many in our yard and on the porch!  They have been climbing on the roof and using the chicken wire "roof" of the shamba (garden) like a trampoline!

Hanging out after dinner at Caring Community

Monkey on the porch railing

Emily found a new friend in the yard. :)

The sunsets were spectacular this week - they always make me think of my parents.  My dad especially loves to watch the sunset over the pond where I grew up. :)  Here are two of my favorite photos from this week - enjoy! :)

As we approach the celebration of Thanksgiving, know how thankful I am for each of you!

Love,
Sarah
Philippians 1:3-6    I thank my God in all my remembrance of you, always offering prayer with joy in my every prayer for you all, in view of your participation in the gospel from the first day until now. For I am confident of this very thing, that He who began a good work in you will perfect it until the day of Christ Jesus.

Philemon 1:4-7    I thank my God always, making mention of you in my prayers, because I hear of your love and of the faith which you have toward the Lord Jesus and toward all the saints; and I pray that the fellowship of your faith may become effective through the knowledge of every good thing which is in you for Christ’s sake. For I have come to have much joy and comfort in your love, because the hearts of the saints have been refreshed through you.

You know you are in Africa when....

*you no longer bother to chase bugs out of the shower.

*the power goes out in the grocery store, your home, or even in the middle of the high school play and no one even flinches or interrupts their conversations.

*the few cars in the "doctor's parking lot" are not from this decade, this century, or even this millenium!

*there are iron bars on all windows and doors.

 



















 *it is not surprising to find patients' parents doing their laundry when you enter the room.

*you have to enclose your shamba (garden) not to protect from deer, squirrels, or birds but from the monkeys.  (ours is the right side of this photo, behind the under-construction chicken coop)

 









 


*"doing laundry" may mean hanging it to dry, taking it down to avoid the rain, then putting it back out again, bringing it back in...  (two times up and down is my personal limit!)

*spa/manicure appointments are out of the question, but "free body massage" is the norm while driving

*"Mom, can we ride on top of the car?" is not an unusual question, and the answer is frequently "Yes!" (in Kijabe, not on the highway!)

*On any given day, I - a general pediatrician - am likely to be mananging Tb, malaria, pneumonia, HIV, rickets, liver disease, congestive heart failure, asthma, meningitis, congenital heart disease, UTI, severe acute malnutrition, or a variety of syndromes

 *a friend's video makes me laugh until I cry, because I have seen wildebeests in acton (The Dumbest Animals Alive!)  https://www.facebook.com/photo.php?v=10151273861093646    

*your neighbor yells "it's big and it's hairy and IT'S IN MY HOUSE!!" and it isn't her husband, it is this: 



*morning activities may include helping to "herd" your neighbors chickens

Anna made these - Reece's, eat your heart out! ;)

Love,
Sarah

Maintenance

Since I last wrote, Emily turned 9!  :)  She had a fun time having 3 friends sleep over and she heard from some special people in the States. :)  We were going to go to Naivasha, a town about 45 minutes from here, to swim on her actual birthday, but it turned out to be quite cool and rainy.  We decided to make the best of it and go anyway, but the car wouldn't start.  Grrrr.  We have already sent the car back once for repairs.  Maintenance of anything, including vehicles, is an interesting thing here in Kenya.  It is not a straightforward thing to find someone that you can trust to buy the car from or work on the car, and then there is the whole thing about finding/ordering/receiving parts.  Evidently, you can wait weeks to months for parts.  (By the way, if anyone has a desire to look for the weather stripping for the front windshield of a 1996 Toyota Land Cruiser Prado, I would be very grateful for the help!!  The rust from the leak is staining our clothes.)

Other happenings.....we have now weathered our first true stomach bug in Africa.  Not counting the GI problems in Machakos.  Not too bad, all things considered, but I found it quite difficult to manage the laundry when the water stopped coming out of the tap.  What?!!  Why, you ask?  Well, it took me most of a day to find out, but evidently the main water holding tank "failed."  Maintenance again.  So, the tank is old and I don't know all of the issues, but the missionary engineering team here has a plan in place that they are working on to increase both the capacity and the reliability of the water supply.  Hooray!  So, in 4 or 5 months, the water supply should be pretty dependable.

In the hospital, there are some children improving while some children not. Some we are clearly in control of the diagnosis, and some we are still trying to figure out.  Some I am able to pray with, and some I find communication with nearly impossible due to the language barrier.  I am learning that smiles of joy and tears of anguish are universal languages, and in both situations words often add nothing.

 I posted this photo  earlier of a boy with this massively swollen thigh who was wasting away.  Well, Rick took the photo below just before he went home!  Evidently, he had a deep tissue fungal infection that began to improved rapidly when we treated his oral thrush with fluconazole.  I say "evidently" because we never were able to get a tissue diagnosis, culture,  or any kind of confirmation, but he is remarkably better and eating well again.  I saw him in outpatient clinic at the end of this week and he was smiling and looking quite "normal."  The family had run out of the medication, though, so we refilled the prescriptions that he will need to take for 6 months.  Maintenance again....

 Samuel is a little boy that has been here for some time for congestive heart failure, of presumed metabolic or viral cause.  There is a surprising number of small children that come in with heart failure related to the strain of malnutrition.  So avoidable and heart breaking.  Samuel needed to be on a medicine called digoxin to help his heart, but he developed this rash about 5 days after beginning digoxin. 

 So, after a lot of reading, I decided that he may have toxic pustuloderma (a fancy name for a pustular drug reaction).  Do I stop his digoxin and risk worsening heart failure, or keep him on the digoxin but risk the 5% mortality that comes with this reaction? 

 Well, his heart must be improved because he has faired okay off of the digoxin, and his rash is clearing after desquamating.  He is close to being off of oxygen (we think) and will be able to go home.  This is how he looked on rounds this morning. :) (A trial off of oxygen failed.)

We had to talk mom out of leaving with him yesterday.  Actually, I have had several parents this week who wanted to take their children home despite our advice of the need for treatment.  One family still may take their daughter home tomorrow, and I can understand their desperation.  This particular girl has a large thoracolumbar menigomyelocele (a out-pouching of her spinal canal through the skin of her back) which is infected with 2 different bacteria (one of which is Acinetobacter baumannii - yuck!).  She must finish 21 days of antibiotics and then neurosurgery will close this defect.  The estimated bill is 100,000-120,000 Kenyan shillings (around $1200-1400!), if everything goes smoothly.  I think the father is looking at that number and just thinking that it is impossible.  Lots of tears are shed on the ward for fear of not being able to pay.  There is a Needy Children's Fund that is able to help contribute to many patients' bills, but generally they need to contribute what they are able.  The family usually gets an estimate of the bill and then goes out and tries to "find the money," which means that they enlist the help of family and friends.  If you feel led to donate to the Needy Children's Fund, please contact us.  It is a huge help to so many families here that struggle to pay their bills - some of which actually contemplate leaving the hospital when the child would die without treatment.

Here is a very happy mom whose baby has a complicated congenital heart lesion (single ventricle physiology with coarctation of the aorta and patent ductus arteriosus) and who today finished her last day of antibiotics for E. coli meningitis!!   She will be going on Monday for repair of the heart lesion.  Mom was praising God today for her improvement and the chance to have the surgery.  It is wonderful to be able to praise God with the patients who are improving!

Below is a patient in the ICU who is on CPAP.  I won't go into the specifics of his case, but notice the water bottle on the table with the top cut off and the tubing going into it.....that is his CPAP contraption!  If he needs more PEEP (for the medical people), you just push the tube farther under water.  1 cm = 1 unit of PEEP.   I also found out this week that it is common practice to use plastic water or soda bottles as spacers for asthma inhalers.  Pretty ingenious, actually.  If anyone wants to know how to set it up instead of paying $30-50 a piece for spacers in the States (insurance often doesn't cover it), just shoot me an email!

Here is our wonderful Dr. Mardi  in the resuscitation room giving a talk to the nurses about the basics of resuscitating a baby/child.  ABC - airway, breathing, circulation.  I was called to see a baby in the resuscitation room on Friday morning.  Long story short....he had a massive bleed into his head.  The oxygen tank was empty (maintenance....), so they had to go get the one from the peds ward.  So, Mardi has clued me in on the importance of checking for yourself that there is oxygen in the tanks of the 2 resus rooms and supplies in the crash carts - pediatric masks, ambu bags, suction, ETT, laryngoscopes (with batteries!!!), I/O needles, etc. 

Hospital laundry

Beautiful flowers at the "new" house - we move on Tuesday.

A woman cutting hay with a machete on the roadside-presumably gathering for her animals.  It makes my back hurt just looking at this!

We followed this truck for a while on the big highway back from Nairobi - we were a little hesitant to pass on the left!!

Another common site on this highway - to cross the street, they run across 2 lanes of traffic, jump the barrier, and run across the other 2 lanes of traffic!

It appears that some people have knocked down areas of the wall to make it easier to cross.  There are many of these "holes." Reverse maintenance.

A great view of the crater of Mt. Longonot.

I asked the kids at dinner if our medical conversations are different here than in the States (the curse of a two doctor family).  Anna said "yes, you used to talk about injuries and ear infections, and now you talk about whether a child will die or not."  Fairly accurate.  I have been praying for specific kids with the girls when I put them to sleep recently.  I did that some in the US, but not often enough.  Hence, they are fairly aware of how sick the children in the hospital are.  Emily has learned to make these cute little finger puppets lately, and recently asked me to give one to a child in the hospital.  I gave the first one to this little girl with nephrotic syndrome (note the puffy eyelids) - she loved it!  Emily made several more today for me to give out - I can't wait! :)

This bird has caught a nice breakfast!  He flattened it several times with his beak and then swallowed it whole.

 I know I have mentioned a number of things that belie some degree of frustration on my part.  I'll be honest, some things here are incredibly frustrating.  On one particularly frustrating day this past week, Emily was complaining to me about how her memory work was hard - to which I replied that sometimes hard is good because it makes us better.  And then I heard what I was saying....to myself.  Ouch.  James said something similar:

     Blessed is a man who perseveres under trial; for once he has been approved, he will receive     
     the crown of life which the Lord has promised to those who love Him.

In fact, he went a step further by saying that I should by HAPPY about it.

     Consider it all joy, my brethren, when you encounter various trials, knowing that the testing of      
     your faith produces endurance. And let endurance have its perfect result, so that you may be    
     perfect and complete, lacking in nothing.

And Paul said in Romans that I should even be EXCITED about it!
 
     And not only this, but we also exult in our tribulations, knowing that tribulation brings about 
     perseverance; and perseverance, proven character; and proven character, hope; and hope does not
     disappoint, because the love of God has been poured out within our hearts through the Holy Spirit 
     who was given to us.

So, joyful endurance and perseverance = crown of life, perfect and lacking in nothing, HOPE.
And, hope does not disappoint.  

Please pray that I keep the hope ever before me and do not get bogged down in the frustrations.

Love,
Sarah
James 1: 2-4, 12
Romans 5:3-5

 

Mashujaa Day

Today we'll have a history lesson. :)

Friday was Multicultural Day at RVA - a day that has grown out of respect for Kenyan history and the people among whom we live and serve.  Kenyatta Day (which was Saturday) is a national holiday that honors the first Kenyan president (Jomo Kenyatta) after Kenya gained independence in 1963.   Last year, the new constitution changed the name to Mashujaa Day, or Heroes Day, to recognize that there were many heroes involved in helping Kenya gain its independence.  In Kenya, there is no school on Kenyatta/Mashujaa Day, so a few years ago RVA began a new tradition of celebrating Multicultural Day - fitting because there are students from 28 or 29 countries this year!  It is a day that the students can both celebrate their heritage AND learn about and appreciate so many others.  There is a flag ceremony at the end of the assembly during which 1 or 2 students carry their country's flag and say something in their language at the microphone, while the national anthem of that country plays.  Many of them were dressed in the traditional clothes of their country.  It had a very Olympic feel and was quite touching.  During Olympic opening ceremonies - and during this flag ceremony - I always like to imagine how all the peoples of the earth will one day worship God together and what that will actually be like.  Mind boggling, inspiring, exciting!  Enjoy a sampling of countries (and please forgive my lack of cropping!).

Madagascar

New Zealand

Norway

Republic of South Sudan - as you can imagine, there was a lot of cheering for him!  His life at home must be quite different than his life at RVA, but you can't distinguish any difference as he interacts with his peers from all over the world.

Uganda

Singapore

United Kingdom

United States-I was surprised by the emotions I felt when these kids started down the aisle amid raucous cheering.  It is hard to be a cultural minority and to be so far from home and everything you are used to.

Kenya - I really shouldn't have been surprised that Kenya was saved for last.  After all, we are all here in this country to serve and work among these people!  The sound in the auditorium was, in a word, deafening when they started down the aisle!

After the assembly, there was an event called the One World Run which is an international 5K race to raise money for AIDS orphans.  Rick, Ted, and Anna ran, I walked and photographed, and Emily cheered us all on!

Ted sprinting for the finish line!

A silly photo after finishing 25th at 7500 feet. :)

Rick actually smiling as he finishes!  He has not been running here, but still finished in under 30 minutes!

Here comes Anna!

Emily with Julia, one of her favorite friends from our time in Machakos. :)

That evening there was a pickup "American football" game (you have to distinguish it from football/soccer here) followed by fireworks on the field.  There was also a perfectly stunning sunset!  The mushroom cloud on the left is a rainstorm in the valley....

The next day was the school carnival, which is not unlike our Fall Festival back home.  The girls each dressed up with their "Big Sisters," while Ted dressed up as Pajama Heroes with our friend Julia. :)

Macaroni and Cheese

Hawaiian Hula Dancers

Pajama Heroes or Pajama Mashujaa!

This is our first full week in the hospital and we begin taking night call.  We are still trying to wrap our mind around the sorrows and the joys here at Kijabe Hospital....but will save that for another post.

Love,
Sarah
Ecclesiastes 3:1-13