Respite

8/2/07

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

7/31/07
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…

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.

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.

Mike

Hitting the ground running

7/26/07
First day on service picking up the new load of patients from David Welch, MD – a Canadian family physician who has been here for nearly a month. He had a census of 31 patients on Monday but has weaned it down a bit since that time – now it’s only 13 plus a consult. Here is the short list:
41 y.o. F with tremor, clonus, hyperreflexia, fever, weight loss – probable TB meningitis
29 y.o. HIV positive F with 3 month hx of ascending peripheral neuropathy now with profound weakness.
26 y.o. F with fever, mediastinal mass the size of a grapefruit
19 y.o. F with who had a 7.5 liter pus filled mass (Mary Weirusz started her care, and Elizabeth and I will finish it…)
55. y.o. F with HTN and out of control DM.
77. Y.o. F with end stage cor pulmonale, COPD – palliative care
26 y.o. F with HIV, malaria, Pulmonary TB, and confusion.
82 y.o. F with CHF
35 y.o. F with HIV, with an aggressively growing set of masses- breast, RUQ and R inguinal masses – 6-25 cm in size. Looks bad – bx pending
73 y.o. M with lytic bony lesions – we have no idea what they are yet – no myeloma though.
19 y.o. M with severe kyphoscoliosis – immobile, bed sores, on palliative care.
30 y.o. M with HIV, wasting, TB in lungs and candidal esophagitis
70 y.o. with huge liver with mets – biopsy pending
28 y.o. with TB, HIV – the usual


This call day I have had 5 admissions (possible 28 y.o. with malaria, and another 32 y.o female with HIV, diffuse TB in her lungs, 55 y.o. with cord compression, and 53 y.o. MVA victim with contusions, and an 88 y.o. with pneumonia), 2 other ED evals going to Ortho – acute cord compression, and an MVA victim that had occurred 5 days ago.
I hope this gets interesting…
Daniel and Jordan started working today in the supply section, getting acquainted with one of the employee's 8 year old boy who was following them all around. I am on call tonight for admissions and the ICU (which is fairly quiet). Things are running more smoothly here than in the past, more patients in the ED, in clinic and on the wards but the chaos feels less. I think the old ways of doing things are getting supplanted by newer ideas – a good thing in this environment.

Mike

Flight of Ideas

It feels a little like standing on a beach, waiting for the typhoon to come rolling in. This year, I have more anxious moments about my trip to Kenya than the last time. I can’t put my finger on it but I sense more mixed emotions than the last two times there. Perhaps it is knowing that you have no idea really what to expect in the work that lies ahead in the next two weeks. I only want to be useful to the patients there and to be able to contribute to the staff who arduously labor there at the Kijabe Hospital. I am looking forward to working with Elizabeth and seeing her grow by the experience as she finishes her residency.

Well, we’ll be boarding soon to a long butt-rotting flight/layover/flight combo that tests our sleep centers ability to function. I only hope Jordan, Daniel and I do get some sleep. The guys are calm but excited about the trip ahead. I know the work they will be doing may be less-than-exciting but hopefully they will appreciate that service of any kind is what matters, not the adreneline level of an experience.