Thursday, December 13, 2007

Other Blogs from the Summer of 2007 - Kijabe

To get other perspectives on working at Kijabe from Swedish Family Medicine Residents, go to: - Mary Wierusz's blog - Elizabeth Hutchinson's blog


Sunday, August 5, 2007

One down, one to go...

It’s Sunday afternoon and Elizabeth and I are on our 2nd day of call for the weekend. Yesterday (Saturday) we were handed the OB, ICU and Medicine services to cover after all of the doctors on site came in for rounds in the morning. That consists of about 55 patients, not including post partum patients. We don’t have to see all of the patients but we are responsible to cross-cover for them.
The morning started out slow, we rounded leisurely on our 7 patients we had on our service before starting call. Within an hour of finishing rounds we were summoned to see a 26 y.o. woman with AIDS who was being cared for by another family physician here. She was puffy with excess fluid (anasarca), short of breath and very hypoxic. I scanned her old X-ray from the day before and saw the large pleural effusion compressing her right lung. We ordered a STAT XR of her chest and in less than an hour we saw that her right chest was nearly obliterated. Elizabeth did the pleural tap and we started to drain fluid. At 500cc’s of fluid running into our collection bag, the ER paged us, and at 1000cc’s Elizabeth went down to start consulting on the ER patients. At 1500cc’s, I was paged to the ICU, but wanted to get off all the fluid we could for this very sick lady with AIDS. Finally at 2000cc’s I pulled the catheter and headed off to the ICU. The patient was breathing much easier the rest of the day and evening, but was still terribly sick. She died early this morning.
The 3 day old lay in the ICU bed looking jaundiced and limp. Dr. Messner, our outstanding German neonatologist, signed him out to me as “I don’t think we can save this one but we try, yes?”. I hooked up the infected baby to a old German-made CPAP machine with labels that read “Luft” und “Heitzung”, etc.. We were able to get the baby saturating reasonably well but he was pausing his breathing intermittently – a sign he was seriously compromised. His white blood cell count was sky high and his platelets were dropping. Then there was bleeding from inside his stomach and lungs and we were backed into a corner. He needed O-positive blood and at his size, it wouldn’t take much to make up the loss but the infection was taking over. At the same time another ICU patient also needed fresh O-positive blood. Guess who is O-positive? Despite all of the antibiotics, respiratory support, and blood transfusions, he died this morning at 2:20 AM. I sat with the mother and the chaplain and we prayed together shortly before he died. This baby was to be her second child and she had waited 5 years to have this one and was worried she may not carry another baby.
Around this whole story was the car accident with 4 victims, 5 admissions to our service and more ICU care. Dinner break came at 11:30PM, so much better than lunch at 1:30AM like last time. Elizabeth did a great job of triaging her patients and evaluating the trauma victims, sewing up a foot that had a good portion of the sole filleted open, and stepping in on a delivery where she saved the patient from C-section by good insight and management of the labor in culturally challenging circumstances.

Sunday 10 PM
We have enjoyed a completely reasonable call day, the ER was empty a few minutes ago, no one in the waiting area, no one in active labor right now. Elizabeth stepped in to help in a resuscitation and the baby ended up having a large meningomyelocele about 8 cm long. Fortunately, one of the top surgeons in the world who started the Bethany Hospital for children lives here and will begin to repair it tomorrow.
At dinner time, we did a C-section for a term footling breech baby which came out great. It took an hour for the husband of the patient to consent for the C-section. Elizabeth did a beautiful job with the C-section.
Daniel, Jordan and I then raced off to Mama Chiku’s restaurant to get our last dinner in Kenya at the finest dining in Kijabe. It was great to see Mama Chiku and her now adult kids, Kimami and Ruth. Daniel and Jordan have had quite the adventures this past week with Kim and his other friend, John.

I learn so much here and am blessed by the staff and patients here. This morning walking into the hospital, I heard some nurses singing in beautiful harmony from the ward above the entrance. Funny we don’t hear that at home in Seattle. There is much sadness and sickness here but there is also tremendous faith, peace and contentment. I wonder what this place will be like when I return. Will the advances in economics change the people and the medical care so profoundly that we lose the compassion that should drive us? Or will the faith and service of those who are hear act as a catalyst that will bring the best of both worlds – greater medical expertise and compassion- to the same place. I believe the latter will be true. Where God is at work, there is nothing that will overcome his purpose.

Friday, August 3, 2007


Our medicine team has dwindled as we head toward our call weekend where we anticipate that we’ll double the size of our inpatient team to over twenty again. We have had several deaths on our service this past two days. The first was our 53 y.o. with a massive tumor load in his liver who died about 10 hours after we told him the pathology report that showed he had adenocarcinoma, and the second was one woman with AIDS and PCP pneumonia. Fortunately, we were able to send some people home who have recovered from their acute illnesses rapidly. Two patients with congestive heart failure went home this week – one young but with severe mitral regurgitation, and one who was older with cardiomyopathy due to hypertension. On rounds today we went to see a diabetic patient who was having cardiac ischemia just laying there in her bed who had pain for several hours already. Off to the ICU for her, as we treated what looked like an acute infarct when we first got her on a cardiac monitor. On arrival, she became lethargic from a low blood sugar since she had received her insulin but was too ill to eat from her chest pain. The pace of these crises is handled quite differently here – a bit like herding cats.
One great moment this past week was when I gave one of our AIDS patients (M.) a toothbrush that was donated by one of my patients back home to hand out here. She is wasted and quite ill, on treatment for TB and PCP pneumonia and not eating well at all. She had teeth that have been stained by her iron supplementation and had no toothbrush to clean them. She lay gaunt in bed with sunken eyes as we started on examination of her. When we were done, I asked her if she would like a toothbrush and toothpaste to clean her teeth. I gave her the package and had to open the brush packet as she was too weak to do so herself. She looked at our team with a huge smile. Now for the past two days, her smile has graced us each day on rounds as her teeth are getting whiter by the day. Thanks, Mr. and Mrs. Walker, for the gift you gave to M. and many others here. I am not sure if she will survive but she has known compassion and caring from strangers in a far away land. If she can pull through and get on HIV treatment, she may live a long life, but we must get her through this critical illness first. Only God knows if that will happen but we are determined to give it our best effort.

Tuesday, July 31, 2007



Daniel, Jordan and I made a foray into a game park last Saturday to get out into the countryside of central Kenya. Lake Naivasha with its Crescent Island Park are only 45 minutes away so we hired Elisha to take us there for the day. We left after Saturday morning rounds were completed and drove along the Rift Valley escarpment (at close to 8900 ft elevation) then down to Naivasha. Signs of new development were all around and the road was in great shape.

The great thing about Crescent Island Park - which started after they filmed Out of Africa there - is that you can stroll around the park freely. There are no predators in the park so you don't have to stay in a vehicle. We took a small canoe with outboard motor passing several disinterested hippos to the small dock on the island. We strolled around a 2-3 mile circuit walking among the animal heards - giraffes, wildebeests, antelopes, gazelles, water bucks, and dik-diks.

The sun was out when we started then the afternoon clouds moved in about an hour before the boat was due to pick us up. We finished out walk at about 3PM amidst a dramatic thunderstorm that was surrounding the Lake on three sides. Sure enough the rain moved in and when our boat arrived, we were in the midst of a tropical downpour. As we motored across the lake, it felt like scene from an old Bogey movie "African Queen"- sheets of rain splattering the green lake water infested with hippos the size of a truck. Completely soaked, we returned to Kijabe with fun but damp memories.

The guys are working in the surgery prep room to help get bandages and instrument packs put together for surgery. It's a hopping place as the OR's are quite busy here - 2nd busiest OR's in Kenya which is amazing considering how huge the hospitals in Nairobi are.

Our inpatient team is slimming down as we discharge patients from our last call night, and one died yesterday from her anaplastic carcinoma of the breast. We got the tissue diagnosis only 24 hours before she died. The 33 week newborn is doing fine and mom is up and around after the c-section. One more day then we are on call again for the weekend. Hopefully it will be managable and not a crazy weekend of admissions.

A late lunch

Post-call day.

I had yesterday's lunch at 0130 this morning.

Elizabeth, my stellar 3rd year resident, was baptized into the Kijabe medical community by sharing call with me and taking on our new service on her first day. As expected the call day was a challenge – it was Monday so all of the weekend travelers from Somolia, Ethiopia and central Kenya arrive in the ED or the Clinic by midday. We started out the morning getting our service rounding going and in the process of getting our team up to speed on all of last week’s admits from my call day and Dave Welch’s call day on Friday. We found one of our young ladies (the 19 y.o. with a belly full of pus that Mary Weirusz admitted right before she left) was in DIC from sepsis, laying in her bed slowing exanguinating from her abdominal wound. We transferred her to the ICU as fast as we could. We were covering the ICU that evening so we knew we’d be caring for her over night. Another patient with pneumonia had a progressive pulmonary effusion so we tapped it but found it was loculated so couldn’t adequately drain it. We had one “normal” patient, as Elizabeth noted. Our 88 y.o. with lobar pneumonia, dementia and an old stoke made us feel right at home and desirous of a geriatric consult from our Geriatric team back home.

After rounding on 15 patients, somewhat incompletely due to calls to the ED for admissions, we settled into OPD (the outpatient clinic) at about 2 PM. OPD consultations included a man with metastatic cancer in his liver and lungs with no known primary, an Ethiopian with an old CVA, a young man with cord compression from his severe scoliosis, etc. Never had a minute to sit down much less eat.

The ED – seizing patients, heart failure, lumbar fracture from a fall, - all ably handled by Elizabeth and tucked into our service and that of the surgeons.

At about 6 PM, I was in the ICU getting signout on the patients :
55 y.o. with a huge aneurysm who had his sentinel bleed yesterday just when a new volunteer vascular surgeon showed up from Texas and saved his life. Not doing terribly well post op and later in the evening hemorrhaged into his stomach from an ulcer that coincidentally was adjacent to what may have been his aorto-duodenal fistula.
19 y.o. with DIC who we knew well – no fresh blood available and her platelets bottomed out. She died around 10 PM from sepsis and DIC.
96 year old with an upper GI bleed – did well.
41 y.o. “Ruth” from my past call night, still struggling with her respiratory status but survived the night.
65 y.o. with end stage heart failure that spiraled down and succumbed at 0120.

To add to the fun, we were now on OB call. I did a D&C with one of the Kenyan interns at about 7 PM, then we tried to find our patients we admitted to the ward. This may sound silly but the politics of getting work done here is delicate at times, especially if the nurses are signing out (with chai time as well). We finally found our last patient at about 11:30 PM!

At about 8 PM, our 55 y.o. in the ICU started his active bleeding and all of the management that ensued. Then we had a young pregnant girl show up at 33 weeks of gestation with a footling breech at 5 cm dilation. Elizabeth and I took her back for an urgent C/S (which Elizabeth did as primary surgeon- way to go!). It’s only fair that her first case be a preterm breech C-section. Mom and babe did well, though the baby is a bit preterm and will need care in the nursery for a couple weeks.
After the C/S, we regrouped to sort through our patients to tied up loose ends then care for our heart failure patient who died quietly very early in the morning. Elizabeth managed our newborn as it developed transient tachypnea of the newborn (TTN) and required transfer to the ICU for management.

So at 1:30 AM, it was finally time to grab lunch…

Sunday, July 29, 2007

Tribal Fusion

Sunday – and around here that means that most of the people in the area are attending their church. At the AIC church in Kijabe, today was a special event unbeknown to me. Today was “Culture Celebration” Sunday – apparently the first one of its kind. The pastors had invited six of the major tribal groups in the region to send a representative group to perform for the service. They are the Kikuyu, Kamba, Masai, Karinga, Luo and Turkana tribes. Once you have been here a while you can start to visually recognize some of the tribes – not by their dress but by their facial characteristics. I suppose over time the genetic mix will be so diffused that tribal features will be lessened by cross-tribal marriages which are now common. Tribal friction has been an issue here in the past and clearly part of the churches mission here has been to put an end to tribalism. The pastor spoke this morning that each person is to be seen as a child of God and that’s all that matters. So today’s event, with its joyous singing and rhythmic dance, was part of that strategy. After the service, each tribal group had a table out in the warm, sunny grounds around the church where they offered samples of their favorite dishes for anyone to try. The Masai’s grilled goat rib slab was most intriguing…

I did round today on my sickest patients – our service is at 20 patients with 30% of them with AIDS related illnesses. “Ruth”, who was in my last report, is awake, breathing on her own, moving all extremities, and talking now. She is not yet back to her baseline as she is confused but has made great improvement in the last 24 hours. Tomorrow, Elizabeth joins me on our team and we are on call so are bound to get a slew of new patients. Time for a nap.

Friday, July 27, 2007

Sounds of Life

7/27/07 0550
It’s early morning after my call night. I can’t get back to sleep now after being awakened at 0440 with a STAT page to the ICU and still being on Pacific Standard Time. It has been quite a night, which should come as no surprise to anyone who has read Mary’s blog last month. Didn't I just say that things were quiet in the ICU?

It was the first time I ever really heard it. The sound of a heart coming back to life, that is.

One of my ICU patients, who we’ll call Ruth, was taken urgently to surgery for an exploratory lap by one of our brave surgeons around dinner time last evening. She had been diagnosed with metastatic choriocarcinoma last week when they removed a huge mass from her belly. She was recovering well, started on chemo (a rarity here but her prognosis is relatively good) this past week but was oozing from her wound constantly. She became progressively short of breath and her abdomen distended with blood so she was rushed to the OR to drain the blood and stop any ongoing bleeding. The surgery appeared to be a success and I was called that they would be bringing her, after extubating her, to the ICU for me to care for.
I decided to go down to the “Theater” to meet the patient there and speak with the surgeon to get a report. I met him outside the OR and he reviewed the case. As we were talking, the anesthetist brought the patient out to us. As we stood over the bed and spoke for a few more minutes, we suddenly noticed she had stopped breathing. No respirations, no pulse.
The nurse anesthetist quickly re-intubated the patient and we gave her several breaths. We wheeled her into recovery to hook up our ambu-bag to oxygen and started CPR. The surgeon bagged, I did chest compressions and the RN scrambled to get meds. He agonized “I’ve killed her, ahhh, I’ve killed her.” I reminded him he just took 7 liters of blood out of her belly, so there is nothing he needed to apologize for.
At Kijabe it is said that precious few survive codes – often due to the advanced stage of disease one sees before they come here for help.
I listened to Ruth's chest after 1 minute of compressions and several minutes of ventilation. Good breath sounds on the right, not so great on the left. We pulled the endotracheal tube back 2 cm and the breath sounds were fine. Resumed CPR. Our anesthetist appeared with some syringes.
“What do you want?”
“Epinephrine – 1 mg – IV ” I said.
More chest compressions, bagging the patient for another minute. I listened again – no cardiac activity. We continued compressions for another minute. “More Epi – 1 more milligram, do you have any vasopressin?”. The answer was no.
More chest compressions and bagging for another minute. We paused the bagging so I could listen again – I heard a soft tap – tap - tap. Then Ruth’s left ventricle surged to life. On about the 10th soft beat, it suddenly coordinated its strength and you could feel the pounding of her heart through her thin chest wall. She held her own but I needed to put her on an old Sieman’s ventilator, the only one that is working right now at the hospital. I placed a subclavian line to have better vascular access as we continued to resuscitate her.
A few minutes ago, now about 6 hours after Ruth’s heart stopped, she was laying in her ICU bed. I walked by and listened to her lungs and heart. She is still on a ventilator as I didn’t want to extubate her overnight, but she opened her eyes. I can only pray that she fully recovers and has a chance at life again. She has a long haul ahead of her. As for me, I was stunned by privilege of hearing her heart come back to life. A miracle.