Weekend patients

Snapshots from my weekend call on pediatrics...

Patient A:
This little 5 year old boy first went to a national hospital in February with abdominal pain and swelling. They did an abdominal ultrasound which did not show a mass but did show left kidney "inflammatory process". They also did an echocardiogram which showed a cystic lesion in the right atrium of the heart, possible hydatid disease.

The cystic lesion is on the left in the above echo. Hydatid disease is caused by a dog tapeworm and results in multiple cysts, usually in the liver or maybe the lung. Evidently they can rarely occur in other random places like the heart. Treatment involves a special variety of aspiration as well as albendazole. Obviously it would be pretty difficult to aspirate a cyst in the heart, so A was discharged in March with 1 month of albendazole.

Unfortunately, A completed his medication but continued to have abdominal pain and swelling and then developed poor appetite and weight loss.

He presented to Tenwek with his father (left) and a translator (he and his father only speak Masai). We repeated the echo and did find the above mass in the right atrium. But it seemed more solid than cystic and it didn't explain his abdominal distension. An abdominal ultrasound revealed a large 15x13cm mass involving the left kidney. Based on our surgeon's recommendations, we then sent the child 4 hours away for a CT scan. He returned today with the results: Nephroblastoma (Wilm's tumor) involving the left kidney and extending up the IVC to the right atrium. Unfortunately too extensive for resection without cardiac bypass, so he was sent home. We may try chemotherapy to hopefully shrink the tumor from the heart and then surgery, but we're still researching the possibilities. If only it had been "simple" hydatid disease.

Patient B:

A four day old baby brought in with "spasms". Mother received no antenatal care (ie no tetanus immunization) and the child was delivered at home. The umbilical cord was cut with a non-sterile kitchen knife. Diagnosis: neonatal tetanus. This child will likely remain in the nursery for a month or more. He is being fed by an NG tube & nursed in a dark isolette in the back of the nursery as any touch or stimulation causes spasms.

Patient C:

One of three patients admitted this weekend with congestive heart failure from rheumatic heart disease. Likely the illness began several years ago with a strep throat that was untreated. The result is valvular heart disease that progresses over time. We have a pediatric cardiothoracic team that comes for a week once a year to perform valve replacements for a few of these patients. The rest we manage with medications to help keep the symptoms under control and hopefully improve the quality of life for these children.

Patient D:

5 year old boy with Burkitt lymphoma, a cancer that for some reason is much more common in Africa than in other places. It is also extremely fast growing. This child received his first chemotherapy here last week and is remaining as an inpatient in hopes of improving his nutritional status. He will have more chemo this week and hopefully we will begin to see the tumor shrinking.

Patients E, F, G, H:

A baby with a scalp wound

One of the interns evaluating another rheumatic heart disease patient in Casualty (ER)

The "greeter" on peds - this boy's been here a while and loves to greet everyone who walks by

An orphan who unfortunately was severely neglected and malnourished but is now doing much better and will hopefully go home with a caring relative soon

Patient I: No picture for this one due to the critical nature of her condition. An 8 year old girl has been sick for some time at home and received herbal treatments. She has had multiple seizures over the last 2 days and is now unresponsive, so the family brought her to the hospital. She is lying in bed sweating in an opisthotonic position (neck hyperextended and back arched) with frequent seizures that don't stop until after the third dose of seizure meds. An HIV test comes back positive. A lumbar puncture (spinal tap) reveals 1536 WBCs in her CSF!!! She also has signs and symptoms strongly suggestive for tuberculous meningitis in addition to the obvious bacterial meningitis. She amazingly makes it through the night but her prognosis is still not good.

Patient J: A 10 month old baby is transferred from a nearby district hospital with a diagnosis of intussusception (where the intestines telescope on each other and cause an obstruction). On further evaluation, it turns out the baby has had bloody stools and bloody vomiting for one day. Prior to this, he had a febrile illness and was treated with herbal medications. Our exam and studies reveal a tender, enlarged liver and florid liver failure with an INR of 7 (normal is 1 meaning the child is not able to clot his blood) and a hemoglobin of 3 (meaning significant blood loss). Our suspicion, though we're unable to prove it, is that the traditional herbal medications caused the liver failure. The baby is receiving blood and Vitamin K and hopefully will stop bleeding soon.

Patient K:

14 year old with bacterial meningitis, now well and going home

Almost all of these children are in these conditions due to poverty or due to the fact that they live here. A few of them might have had similar illnesses in other places but wouldn't have taken so long to see a healthcare provider, so the disease wouldn't be so advanced. Lack of education plays a role as does corruption in the traditional healers being quite willing to take people's last shilling without the hope of offering a cure. Many of our patients have been crossing the border to Tanzania lately to see this "miracle healer" on the border who is making money hand over fist (as are the taxi drivers who bring people to see him) and encouraging people to stop taking their HIV meds or diabetes meds or seizure meds. We've had patients die as a result.

It doesn't seem fair. And yet I know I'm not the only one who cares about the injustice of it all. Many are working to fight corruption and injustice and to address poverty around the world. And you can see the hope and joy on these children's and parents' faces just from the limited care we are able to provide. Most of all, God Himself is just and He will bring justice on the earth.

The Lord "executes justice for the oppressed and gives food to the hungry. The Lord sets prisoners free, the Lord gives sight to the blind, he lifts up those who are bowed down, the Lord loves those who live justly. The Lord watches over the immigrant and sustains the fatherless and the widow, but he frustrates the ways of the wicked. The Lord reigns forever." Psalm 146:7-10

Recent weekend fun

So, we have to be a bit more creative with weekend activities here as we live quite far from any restaurants, movie theaters, etc. - but sometimes I think that's more fun, anyways! We do watch movies together regularly and play games, too. And even when there's not much going on, I love to read and have enjoyed reading lots of good books here and then sharing them with friends. Here's some pictures of some recent weekend activities:

The Cropseys planned a murder mystery dinner complete with characters and plot. We had to get a bit creative with costumes (the fringe on my dress is crepe paper). I may or may not have been the murderer. :) We had a great time and discovered some hidden acting talents among our friends, too.

The missionary kids performed at the Fine Arts Festival last week - a great opportunity for them to participate in a school program and display their artwork from the year and fun for us to cheer them on. It's been a long time since I attended a piano recital or middle school band program - probably since back when it was me participating! I much prefer being a proud "aunt" than a performer!

Birthdays are always fun occasions for celebrating. Eric and Heather share the same birthday.

Maggie loved her Veggie Tales cakes!

We enjoyed the second Tenwek Coffeehouse not too long ago. Interns, residents, and consultants all performed and everyone enjoyed chai and cookies.

The audience participated in the singing and dancing.

And one of my favorite weekend activities - Ultimate Frisbee! We actually played twice this weekend - so much fun!

Case presentations

To read about two interesting cases from the past week in Kenya and Burundi, click here.

Burundi

Amahoro! (Peace - Kirundi greeting.) We certainly experienced God's "amahoro" last week as we were affirmed in His leading us to Burundi as a team long term. We pray that "amahoro" will continue to reign in Burundi for many years to come. As you can see from the map, we didn't travel too far from Kenya - a short 90 minute flight from Nairobi to the capital of Bujumbura. We certainly noticed some similarities in another East African country but a lot of differences, too, culturally, linguistically, and materially.

Our host, Bishop Buconyori, and his daughter and her husband greeted us warmly at the airport and prayed with us prior to our 2 hour drive up country to Kibuye Hospital. Our team currently includes 8 adults and 6.5 children but only three of us traveled to Burundi this time around.

Kibuye Hospital, new maternity building

Sunday afternoon we enjoyed hiking near the hospital

Behind me down the hill is the hospital

Ariel view of Kibuye

I enjoyed rounding with the medical students each day on the various services (pediatrics, internal medicine, obstetrics). Dr. Marx in the above picture is Hope Africa University faculty and we look forward to working with him in the years to come.

Women and children waiting for immunizations

Medical students Blaise and Isaac with me and a malnourished 2 year old

This child fractured her femur one week ago in a bicycle accident but her mother wasn't able to bring her to the hospital until now. Bicycles are a very common mode of transportation in Burundi.

Busoma for breakfast - a type of nutritious porridge

I so appreciated the opportunity to teach such eager medical students. They desperately need more teachers and thus are forced to learn a lot from outdated textbooks. I found them to be bright, enthusiastic learners who asked insightful questions and learned quickly. It's so much fun to teach students who really want to learn!

Jason, Heather, & I identifying the proposed location of our future houses - quite close to the hospital and to the medical student housing. I didn't know surveying building sites would be part of my missionary job description!

Faders and I outside Kibuye Hospital

Teaching medical student Noel how to do a paracentesis

Rounding with medical student Alliance

The students requested teaching on examining a newborn

Elementary school children. There's not enough space for the kids to go to school all day, so 600 kids attend school in the mornings and 600 in the afternoons. As you can see if you look closely, most of the children have no shoes.

Resuscitating a baby born by C-section without oxygen. There's only one small oxygen concentrator for the operating room and no oxygen on any of the wards. Thankfully the baby was ok. The other surprise was the lack of running water in the hospital - the pipes are there and evidently worked in the past, though, so hopefully the solution won't be too difficult. It was so helpful for Jason and I to work in the hospital so we now know how to prepare. For instance, we will begin looking for an oxygen concentrator to bring with us! And for some advice on setting up the lab (currently only hemoglobin, malaria smear, type and cross, and HIV test is available - no WBC, platelets, coagulation studies, creatinine, electrolytes, CSF cell count, etc.). But I was thankful to discover that care for children under five, pregnant women, and people with HIV or TB is provided by the government free of charge, so I think we'll keep quite busy!

We enjoyed a fun game night with the medical students. This class of 16 students is in their 6th out of 7 years of medical school at Hope Africa University. When more teachers are available at Kibuye Hospital (us!), the students will spend most of their 6th and 7th years at Kibuye. After hanging out with the students last week, I'm really excited to work with them more when we return as well as to mentor and disciple them and enjoy more game nights!

Hope Africa University in Bujumbura. We will likely lecture here at times, but most of our teaching will be clinical up at Kibuye.

View from HAU

Children at a deaf school in Bujumbura we visited saying, "I love you"!

We won't need to learn sign language, but we will need to learn both French and Kirundi fluently. We have new motivation for language study after discovering how necessary both languages are for everyday life. Few of the rural patients spoke any French (only Kirundi) but morning report, interactions with hospital staff, and even customs at the airport was all in French. We plan to study French in Albertville, France for 10 months beginning September 2012 and then to study Kirundi on arrival in Burundi in 2013. It's a long road ahead but we are so thankful for this opportunity to live in this beautiful county and to serve these beautiful people with God's "amahoro".

Village living

I enjoy living in community with other missionaries. Because Tenwek is a large mission hospital with a nursing school, two residency programs, and an internship, more than 50 Americans live and work in this area. The church service at the hospital on Sundays is primarily attended by hospital staff and missionaries and thus is mostly in English with a few Swahili songs. I appreciate being able to worship in English and understand the service. My Kenyan friends and colleagues also speak fluent English and, because they are mostly physicians who have lived in Nairobi, they are quite familiar with Western culture and several have even traveled overseas. These facts have made my cross cultural adjustment a bit easier, but they also mean I'm more removed from the average villager than I would be in another rural setting - and than I likely will be in Burundi. I'm grateful for the opportunity this weekend to experience village life a little more intimately.

Janet invited several of us to her church and to her home. The church recently built this beautiful new building but has yet to finish the roof, windows, or floor, so they are raising funds for this project.

View from the church with traditional Kipsigis homes - round mud structures with grass roofs

For the church offering, people brought produce, sugar cane, and even this chicken. These items were then sold and the money was contributed to the building fund.

View from the outhouse :)

Heather and Anna enjoying their meal of beans and rice

Janet's house

Chicken coop

Janet and Richard with their children Mercy and Emmanuel

In intern Bible study last week, we discussed the story of Isaac blessing Jacob and Esau. This story made a lot more sense to people who come from a similar culture where the oldest son is blessed and meal preparation takes a lot longer as you have to kill the animal first and then cook it. It's interesting to note the similarities between the rural culture here in Kenya and that of Bible times. I look forward to learning more about rural living in the years ahead.

The verse I shared with the congregation during our introduction as guests is relevant no matter where you live, though:
"Mungu kwetu sisi ni kimbilio na nguvu, msaada utakaonekana tele wakati wa mateso." Zaburi 46:1
"God is our refuge and strength, a very present help in trouble." Psalms 46:1