Recent pictures

Peds team during chai break


Masai boy with liver disease

8 month old boy who was in the ICU for over a week, on a ventilator for several days, and coded twice, now doing well and ready to go home - Praise the Lord!

Elise and I getting ready to hike down to the waterfall

Abi and I after she fell - within 10 minutes, she had been examined at home by 2 doctors, a nurse, and had steri-strips placed on the laceration on her forehead - the benefits of living at a mission hospital!

Child with malnutrition and liver disease

Hippo bite while getting water from the river

Girl with tetanus - getting ready to go home

Girl with tetanus now able to walk though still with stiffness of her arms and legs

Heart Surgery

Tenwek offered heart surgery last week to both pediatric and adult patients. A team of surgeons, ICU doctors, cardiologists, nurses, perfusionists, and biomedical technologists arrived from various parts of the U.S. and performed eleven cardiac surgeries. Most of the patients had congenital heart disease or rheumatic heart disease and the surgeries were quite complicated. All eleven patients did very well and most have been discharged home. The few that are left will be discharged soon. These surgeries were truly life-saving for these patients and would not have been possible without this team of volunteers (who come approximately every 6 months). The cardiologists also helped us with over 100 other patients (children and adults) with cardiac disease who were not surgical candidates.

One of the patients who received surgery was a 12 year old girl (pictured below) I had cared for on the pediatric service. She had been in the hospital for several weeks with congestive heart failure of unknown cause. We suspected tuberculosis was the culprit (causing TB pericarditis) but despite 2 weeks of TB medications, she was not improving and required significant amounts of oxygen and medication for heart failure. We were considering discharging the patient with hospice but decided to wait for the cardiac team to evaluate her first. The team decided she was a candidate for a pericardectomy (removing the lining from around the heart). She had surgery last week and has done very well. She is now off oxygen and on very low doses of medications. She likely will be discharged home this week to continue on TB meds as an outpatient.

Thoughts

Tenwek Hospital functions as a tertiary care referral center in Kenya. We provide some of the most specialized medical care in the country including ICU care. This week, a 16 year old girl was admitted in a very critical condition. She had severe pneumonia and ARDS (acute respiratory distress syndrome) and had an oxygen saturation of only 70% (normal is >92%) on the maximum amount of oxygen without a ventilator. We decided to intubate her and place her on a ventilator. She required two medications to keep her blood pressure close to normal (it was very low due to septic shock). She had labs checked frequently and received one blood transfusion. We gave her three different IV antibiotics and IV fluids. Her condition waxed and waned over the course of the week with her oxygen level and blood pressure improving and then worsening. Yesterday her neurologic condition worsened – she no longer needed sedation on the ventilator as she did not wake up or move – we suspected brain death. Today, she died.

I wonder; did we help this girl and her family? If she had not come to us but had stayed at home or in a district hospital, she would have died 5 days ago. Instead she died 5 days later with a huge hospital bill from 5 days of extensive ICU care. Few Kenyans in this area have health insurance. Her parents are subsistence farmers and will likely have to sell some land to pay her bill as almost no one has a savings account here. Just because we can offer this specialized level of care, does that mean we should? I believe God is sovereign and had a purpose for this child and her family but I also want to be a good steward of the resources He has given me – the medical knowledge and the medications, treatments, etc. The ethical issues are a bit different here when people live in significant poverty and must pay out of their own pocket for anything I order as a physician. Anyways, these are just a few thoughts about difficult aspects of practicing medicine in a developing country beyond different medication choices and learning tropical medicine.

Weekend Fun

Some of you might be wondering what there is to do for fun when you live in rural Kenya. Well, we don't have concerts to go to, but we do have the Tenwek Fine Arts Festival put on by the missionary kids. We don't have restaurants, but we enjoy excellent home cooking (even organic) for every meal and often eat with friends. It takes a lot of effort to go anywhere by car, but there are plenty of beautiful hikes in any direction. We can't go to movie theaters, but we get together for DVDs on laptops - or even with a projector on special occasions. We play lots of games - Ultimate Frisbee, racqetball, Settlers, Dutch Blitz, Catch Phrase, etc. We celebrate birthdays and just hang out. I actually have rarely been bored here - it's my kind of fun! And there are always books to read, blogs to update, and emails to respond to if nothing else is going on. :)

Pizza night

Movie night

View of Tenwek (buildings in middle of picture) from Mt. Motigo

Hiking

Tenwek Fine Arts festival

Ballet performance

Birthday parties - Rachel's

Julie's birthday

Maggie's 1st birthday

Anna's 5th birthday

Dinner with some recent short term visitors

Baby D

Despite our best efforts, we lost several children this weekend - not uncommon here given that patients often are sick much longer before they seek medical attention here or they go to a local dispensary first which may or may not know how to best treat them or they try traditional herbal medicine first or they are just too sick for the limited staff and resources we have even at this big mission hospital. But rather than dwell on those difficulties, I'd like to share with you a child that survived miraculously despite all those counts against her - to look on the bright side, as my mom would say.



Baby D was admitted April 17th with severe respiratory distress from pneumonia - she was 4 weeks old at the time and had been seen at another hospital before being sent to Tenwek. She was admitted and placed on antibiotics. On the night of her admission, though, her respiratory status worsened and she was no longer able to keep the oxygen level in her blood up (O2 sats were 60s - normal is 90s) despite CPAP. We don't have an infant ventilator (breathing machine), but we can intubate (place a breathing tube) and deliver CPAP via the trachea to direct the oxygen in as high a concentration as possible to the lungs. The baby still has to breathe on their own for this to work. So Baby D was intubated but it was a big challenge to keep her intubated. She had a lot of secretions from her infection which weakened the tape holding the tube in place plus she was quite fiesty and kept trying to pull the tube out as best she could even though her oxygen saturations plummeted whenever the tube came out. She was reintubated several times - a task that became more difficult as she developed swelling in the vocal cords from the multiple intubations.



The notes in the chart on the night of April 20th-21st read as follows:

130am"Despite endotracheal tube in place, patient not breathing adequately. Oxygen saturations decreasing. Discussed patient's condition and poor prognosis with mother."

2am"After bagging the infant for 3 hours, reintubating, and placing on tracheal free flow CPAP, patient with no spontaneous respirations [not breathing]. No further medical support to offer at this time."

2am nursing note "Resucitation called off. Baby with heart rate of 140 with prolonged apnea. ETT in place. Baby positioned and observed."

230am nursing note "Oxygen saturation increased to 96%. Given meds and left comfortable. May God continue to perform His miracle of healing!" [By the way, that's not a sentence I've ever seen written in a patient's chart before, but it's true. I'm grateful to work in a place where nurses and doctors alike understand and believe that "We treat. Jesus heals."]



Baby D was reintubated at least four more times after this night. She remained intubated for a total of 9 days until April 26th when she was finally extubated to oxygen via nasal cannula. She was off oxygen May 6th and was discharged yesterday in excellent condition. Even in the States, patients needing intubation and significant respiratory support for such a long period of time often don't do well. I've never seen a child live that long here in such a condition. She is a true miracle and I thank God for her life. This picture is her and her mother the day before going home.

Happy Mother's Day!

"What a heritage falls to them whose surroundings from childhood have been illumined by the Book of God, whose winds have been freighted with the prayer and concern of others for their souls." Jim Elliot

Jim Elliot in his first letter to his parents written en route to Ecuador: "I surely praised God for the valiant way you both took my going. It is true that I know very little about how you feel at seeing me leave. All I understand is that it must be very keen, deep, and closely linked with all that this life involves for you. I pray for you whenever you come to mind, asking the help that is from God for you both. You are as well a constant source of praise for all that you have given of yourselves for my sake. The will of God is always a bigger thing than we bargain for, but we must believe that whatever it involves, it is good, acceptable, and perfect."

"You probably never thought before of the fact that Amy Carmichael had a mother.” My mother

I praise God for my mother today and the sacrifices she has made for me to be here. I look forward to seeing her here in June!

Lake Nakuru

I travelled to Nakuru last week with several other health care workers from Tenwek for a conference on ARVs (medication for AIDS). The conference was quite beneficial in provided further information on the status of AIDS in Kenya and the most recent Kenyan guidelines on how to treat these patients. I especially appreciated the information on pediatric HIV/AIDS and preventing mother to child transmission as I rarely saw children with HIV during residency in the States but am caring for them daily here. I also enjoyed another opportunity for more immersion into the Kenyan culture through interacting with the other conference participants.

Beyond the educational value of the conference, though, was the benefit of the hospitality of missionaries Jim and Alice Vanderhoof. I really enjoyed getting to know them better and hearing their stories of how God has been faithful through the 26 years they have lived as missionaries in Kenya. Jim and Alice are pictured here with myself and Eric McLaughlin - another post resident working with his family at Tenwek (http://www.doctorsmclaughlin.blogspot.com/).

The highlight of the week was a tour of Lake Nakuru - a national park filled with amazing wildlife. We even saw a herd of 22 giraffes!

Lake Nakuru is most famous for the many flamingos which create a pink rim around the lake.

I am thankful to not be driving in Kenya (left side of the road, right side of the car, inexperienced drivers on the road, suboptimal road conditions, etc) even moreso now as in the past week, we had a dead battery at Lake Nakuru and a flat tire on the way home to Tenwek. Thankfully the drivers knew what to do - even without AAA! Praise the Lord for bringing us back home to Tenwek safely.