Thailand fun

Our days at the conference began at 6:30am and continued until 9pm each night with many fascinating lectures on relevant medical topics (translating into 45 hours of CME credit for me!), spiritual renewal sessions with Os Guinness (Christian author), field reports from missionaries in vastly different settings - from a special needs orphanage to a government clinic to a mission hospital, worship time together with the ~500 conference attendees (including families), and sharing struggles and triumphs with each other over meals and in small groups. I thoroughly enjoyed each aspect of the conference, but, as you can imagine, the schedule was exhausting - especially by the end of the second week! So I'm thankful for the fun interludes with friends on the two weekends:

Zip lining through the rain forest

Exploring the city of Chiang Mai

Buddhist temple

Traditional dancers

Feeding elephants

Starbucks at the Chiang Mai wall

I wouldn't believe the elephant painted this landscape if I hadn't seen it with my own eyes!

Or that elephants could play soccer!

We ate lunch at a tiger exhibit

And viewed an orchid farm

I loved so many aspects of this cross cultural experience in Thailand. But it was so much bigger than just Thailand. This year's conference attendees serve in 35 different countries, mostly in Asia, many in very difficult living conditions. Quite a few have served for several decades. I sought out every opportunity to learn from their wisdom and experience as I head down this road in medical missions. I heard excellent advice on transitioning back to the U.S., navigating cross cultural communication, managing conflict, helping third culture kids thrive, caring for those Stateside as well as those in the developing world, cultivating a ministry of listening, dealing with family challenges, etc. I also was so encouraged to share together with friends of mine in the same situation I am as newer medical missionaries looking ahead to an uncertain future. I look forward to crossing paths with these friends and colleagues for years to come.

Though I enjoy traveling, it's also really nice to come back to welcoming friends and routine in my own familiar surroundings. I'm happy to be back at Tenwek!

East or West?

Every year the Christian Medical and Dental Associations provide continuing medical education for missionaries around the world to assist them in keeping their medical licensing current while living overseas. I was unable to attend the conference in Africa last year due to staffing needs at Tenwek, so my colleagues graciously allowed me to come to the conference in Thailand this year. Thus far I have loved my first glimpses of Asia - though I was a bit confused in Bangkok as to whether I had traveled East or West.

Flying into Bangkok, I noticed divided lane freeways with freshly painted lines on the roads, overhead signs, exit ramps, and cars staying in their lanes - things I don't see everyday in Africa. I traveled around the airport on moving walkways and escalators and even saw drinking fountains (couldn't remember what they were called at first - "drinking machines?"). Familiar brand name toiletries and candy was advertised at the various stores. I even found stores selling North Face and Nike gear. And the best part of all was the Starbucks coffee and Dunkin Donuts which I happily consumed in the food court overlooking the nicely groomed grounds and modern architecture of the freeway nearby. I felt a bit backwards being so amazed by such simple things and caught a glimpse of what my re-entry to the States will look like in September.



There were clues, though, that I had indeed traveled East - signs written in Thai, for instance, the many alters to Buddha, being greeted with hands together in a bow rather than a handshake, the beautiful scenery of the rain forest and the delicious Thai food.



I've been absolutely amazed to glimpse the global church through meeting missionaries from so many nations around the world and worshipping together. Some of these missionaries work in mission hospitals similar to Tenwek in Papua New Guinea, Bangladesh, and Nepal. Others work in difficult countries in the Middle East and Asia where they are not able to worship freely. I was speaking to a missionary doctor in my small group from one of these countries and she said to me, "Wow! I could never do what you're doing in Africa." I replied, "I could never work in [her country]!" But the truth is that God has equipped each of us - even those working at Mayo clinic who are at this conference to lecture and instruct us about HIV and congenital heart disease and high blood pressure - for the work He has given each of us to do. He cares about the poor and oppressed, the orphans and the sick around the world and shows His mercy and His justice by calling His children to go to those places and share His love. He gives us His grace for the experiences we have when we have them and strengthens us for the task at hand. And one day every knee will bow and every tongue confess that He is Lord! (Phil 2:10-11)

Internal Medicine service

I know I usually post pictures of children - who can help it when they're so adorable?! And I do work on the pediatric service more often but I also care for adult patients on the internal medicine service regularly - they're just not as photogenic. :) But I enjoy caring for both adults and kids and working with interns on both services. On medicine this month, we've been busy with ICU patients, consults from the OB and orthopedic services, and patients sometimes two to a bed on the male and female medical wards.

Medicine team during chai break and teaching time yesterday

Male medical ward

Top five diagnoses (in no particular order): Bacterial meningitis, esophageal cancer, HIV and associated complications, tuberculosis, pesticide ingestion (suicide attempts)

Other common diagnoses: congestive heart failure, diabetes, hypertension, pneumonia, stroke, kidney failure, anemia

Medical officer Anthony supervises the intern performing a bone marrow biopsy in a young patient with unexplained low blood counts

Being a med/peds doc, even on the medicine service I continue to follow along with peds patients as I often take overnight or weekend call for peds. Please pray for these two quadruplets (only three are remaining, unfortunately) who became ill again Friday night.

Cow's milk

As you have seen pictures and read about some of our malnourished children, you may wonder where the milk comes from to feed them. After all, there's no grocery store around the corner. I was curious, anyways, so yesterday I took a field trip to the hospital kitchen. The milk itself comes from local cows. Each morning approximately 50 people who live nearby milk their cows and walk to the hospital with 2-5 liters of milk each. They then sell the milk to the kitchen at 24 shillings per liter (approx 30 cents). The hospital buys 250L of milk per day. Two girls walking home after delivering their milk

In the kitchen, the milk is then boiled (it's unpasteurized, after all) and strained. We need high calorie formula to feed our malnourished children. Sometimes we have formula powder to add to boiled water, but when we don't, we make our own. The milk is mixed with sugar, oil, and water in prescribed amounts to make F-75 and F-100 formula (75 and 100 calories per 100mL respectively). Or we make "special ugi" - water, milk, egg, sugar, oil, and millet flour mixed to make a porridge type drink that is also high calorie.

Some kids don't like the formula as it's too sweet but this little one loved it and gained weight quickly.

Yes, L, milk really does come from cows.

Superbowl

Last year we woke up in the middle of the night to watch the Superbowl. This year, we managed to record the game and all watch it together Monday night. (We just had to be careful not to check Facebook on Monday!) Pretty close game and fun event for everyone.

Hospitality & Electricity

There are advantages and disadvantages to living with lots of other Americans - advantages are having people to watch the Superbowl with (post to follow), to celebrate American holidays together, and to generally understand my culture and frame of reference. Disadvantages are that I don't have as many opportunities to experience the local culture, and thus I appreciate it when those situations arise. I'm grateful to one of the long term missionaries for explaining some valuable nuances of Kenyan hospitality which I had noted but not understood before - specifics of welcoming guests, serving food, and closing the time together which are different from what I'm used to. I've enjoyed putting some of these tips into practice through hosting interns and colleagues this month. I recently also appreciated the opportunity to learn firsthand through eating dinner at one of my fellow doctor's home. Drinking chai with the Terrer familyLittle Debora loved helping to welcome the guests and clear the dishes. I enjoyed the Kenyan meal a lot, though I must say, I wasn't sad to see mursik missing from the table - a traditional drink of sour, charcoal milk! Some cultural experiences are ok left to the imagination!

On another note, this blog has been late in coming partly due to busyness at work but also because our electricity has been very unreliable lately. We were without power most of three days last week and it's been off a couple hours each day this week, too. Our power actually comes from a hydroelectric dam. As you can see from this picture, the river is drying up which means lack of power for us! So while those of you in the States are experiencing severe winter weather, we're also without power (but due to good weather, actually). Hopefully rain will come soon! It does serve to make us grateful for things we often take for granted - like candles and cold refrigerators!

Going home

Each of these patients stayed on the peds ward for about one month - not how any of them intended to spend their Christmas! But, thankfully, they were all discharged home in stable condition last week. I always looked forward to greeting them each day and will miss them but am grateful for happy endings.

This little boy survived bacterial and tuberculous meningitis. Unfortunately, though, he lost his vision as a result of the severe infections. We gave the family the contact info for the Kenya Society for the Blind - hopefully they will pursue that further as that organization would be quite helpful in teaching braille and helping this boy learn how to live with blindness. The typical daily activity for a Masai boy his age, though, is to herd goats or cows, which, sadly he will be unable to do. Pray for his adjustment to a difficult life.

This is one of the few patients to learn my name. Though I like my name, I don't think my parents considered whether it would be easily pronounced in other languages or by small children. But little E greeted me "Dr. Alyssa" each day as she endured several skin grafts and other surgeries to treat her scars and contractures from burns.

I blogged about this little one with severe malnutrition earlier this month - 15 months old and 3.7kg, now quite well and discharged home at 5.2kg. She even smiled for me the day before she went home!

Intern Graduation 2011

Tenwek Hospital trains 16 interns per year who then work in district hospitals and outpatient departments around the country. Different from the U.S. system, physicians (medical officers) do not usually begin residency immediately after internship but work a couple years as a generalist at a district hospital and then hopefully find sponsorship for residency. Clinical officers (similar to physician assistants) complete a similar internship and then generally work in outpatient departments and dispensaries though some do eventually specialize as anesthetists, etc . Internship is one year and consists of 3 months each of medicine, peds, surgery, and OB/Gyn - not a lot of time to train independent, qualified doctors! But I think Tenwek does an excellent job and it's amazing to watch the growth in individual interns over the course of a year. It's especially interesting this time of year as we are transitioning from one class completing internship to another class starting. These pictures are from the recent graduation ceremony.

Lunch with one of the interns and his family

The graduating intern class of 2011

Interns pictured with consultants (attending physicians). I had the privilege to work with this class from their first call night a year ago till the end of their internship and so was proud to celebrate with them and their families on this special day.

I truly believe in educating and discipling national physicians to provide excellent medical and spiritual care for their patients wherever they go. I can care for a few patients myself who might otherwise not have received care but now there are 16 new medical and clinical officers to care for patients all over the country of Kenya and even beyond. I was so excited to find out recently that one of our graduates is planning to work exclusively in Southern Sudan. She was born there but has been raised primarily in Kenya. She voted proudly in the referendum last week as a Sudanese citizen and will be moving to Sudan soon as one of the few doctors in the southern region. And we thought we had limited resources here in Kenya! Please pray for Grace as she ministers to her people and for the country of Sudan. So far the referendum (vote to make Southern Sudan a separate country from the north) seems to have gone more peacefully than expected but the results won't be announced till next month. Please also pray for our other interns who are waiting for their postings from the government as to where they will be working next. And they didn't even get to submit a rank list! They're just told, "Report tomorrow (or yesterday) to ____." And then they get out the map to find out where ____ is!

Anyways, thanks for reading to the end of this long post! And thanks to those of you who have supported me so that I can participate in educating these young doctors!

Patient updates

First an update on the quadruplets: They are all four breathing well on their own with no signs of problems from premature lungs. Their mother is recovered from her c-section and has family helping her to feed and care for the quads. But the babies unfortunately are not tolerating their feeds very well. They all four had necrotizing enterocolitis (gastrointestinal infection that preterm infants are prone to) and are slowly recovering. We are trying to advance their feeds via NG tubes daily. Continue to pray that they will tolerate the feeds and begin to grow soon as they are all still quite small at 2 lbs each.

Now on to some other pediatric patients:

This 16 year old girl has a condition called osteogenesis imperfecta which means she is prone to fracture her bones with minimal trauma. She has been here 6 weeks in traction for a hip fracture but has maintained a good attitude throughout that time. She has been diligent in studying for school and always has a friendly smile for visitors and the medical team. Hopefully she'll be able to go home soon.

The little boy on the back of his big sister was diagnosed last week with congenital hypothyroidism. In the States, this is diagnosed with newborn screening and then patients are put on the appropriate medication as infants to prevent further problems. Unfortunately, this little one wasn't diagnosed till he was a toddler which means that even though we have started thyroid medication now, he will continue to be developmentally delayed and will likely have a low IQ.

We thank God for providing miraculous healing for this baby. At birth he was noted to have significant difficulty breathing and a blue color to his whole body. Normal oxygen saturations are above 90% - his oxygen levels were 30%. Through a couple simple tests, we diagnosed him with PPHN - persistent pulmonary hypertension of the newborn. Basically this means that his lungs did not adapt the way they were supposed to to life outside his mother. The first 24 hours, his oxygen saturations were 30-75% despite maximum oxygen support. The second day, his saturations were 24-54%. Finally, the third day, they increased to 72-92%. He was weaned off oxygen after 2 weeks and discharged home breathing well and feeding well with no obvious problems shortly thereafter. Treatment for PPHN in the States involves things like ventilators, inhaled nitric oxide, ECMO, vasopressors - none of which we can really do here. It's quite remarkable that this baby's oxygen levels were so low for so long and yet he never had a seizure and you can see how alert and active he is (another picture below). Praise the Lord!

The next four pictures are of the same child. Little Chepkirui was admitted to the hospital at 15 months old weighing 3.7kg (8lb - less than my one month old niece Emma weighs). She is the 9th child in the family and her mother delivered child #10 shortly after Chepkirui was admitted. On arrival in the emergency department, Chepkirui was cold, gasping, and critically ill. No one thought she would survive the night. But this first picture is her a few days after admission. You can see she's in a special warmer box to help keep her temperature up.

Picture taken one of the first days she could sit up on her own.

Now able to maintain her temperature out of the box and able to feed from a small cup instead of the nasogastric tube. Pictured with the intern who cared for her that first night in Casualty.

Now weighing 4.7kg (10lb), able to eat rice and beans in addition to milk, and getting close to going home. I have yet to see a smile but Chepkirui is now quite alert and interactive and willingly lets me hold her and play pat-a-cake with her. Please pray for the family, the nutritionist, the social worker, and the community health team as they seek to find a solution to prevent her and the other children from getting into this severely malnourished state again.

A teenage girl with Down syndrome recovering from pneumonia

This plant may appear harmless but in actuality we admit several children each month due to poisoning from ingesting its fruit. Datura (Jimson Weed) poisoning causes severe agitation, dilated pupils, and confused behavior - one of the many things I've learned since coming to Kenya!