Interesting Day at Kijabe Hospital - Thursday, September 30

This post was originally written on Thursday, September 30, the day that these events happened.

There is a lot of medical mumbo-jumbo in here, so I will include a little glossary at the end. 

I was awakened today with a "999" page to the nursery.  "999" here means come immediately, do not call first.  I had slept in scrubs since I was on call, so I jumped up, threw on socks and shoes and hurried to the nursery.  I found one of our patients, a child born with encephalocele, had stopped breathing and the nurses were giving bag/mask ventilation.  The child had ventilated easily with the bag and mask, and sats and HR were good with bagging.  The problem was that when you stopped bagging, there was NO respiratory effort at all.  Not a gasp, nothing.  Because the encephalocele implies that there is a good chance of a brain abnormality, it is debatable here whether you would intubate this child or not, because the child might never make an attempt to breathe again.  I checked quickly to see if ICU had a bed and a ventilator available, and they did.  Next I had to talk with one of the main docs here and also the pediatric neurosurgeon.   The opinion was that this child should be given the opportunity to be ventilated, at least for a few hours, to see if he would begin to breathe on his own again.

I returned to the nursery, and with the help of the intern and the nurses, we intubated the baby and transported him to ICU for ventilation.  I received a crash course in the little ventilators we have here shortly after arrival, and have previously had to change ventilators once since I have been here, so I was able to grab the ventilator and get it ready to go for this child (no respiratory therapists here to set eveything up).  We settled him into ICU and ordered a chest x-ray for tube placement.  Side note: the parents later asked if the child could breastfeed while on the ventilator.  This was not the first time I have heard the question asked since I have been here.

I then returned to nursery to grab the things I had left there.  I walked in to find a 3 day old who was just being admitted after driving all night in an ambulance from Somalia.  This child had bilious vomiting and an incredibly distended abdomen.  The child had not stooled once since birth.  Examination turned up a good reason for no poop: no anus.  We ordered some preliminary labs and films and called the pediatric surgeons to come see him.  They came and agreed to operate on him today.  Fortunately, the rectum was very close to the skin surface, so they were able to just open up an exit for him.

No Anus = No Poop and a Really Distended Tummy

After that baby was admitted, I went back up the hill to the apartment and finally showered, changed, and ate breakfast.  I returned to the hospital and went about the usual daily activities, which led to me seeing a 7 year-old boy with significant direct hyperbilirubinemia (total 19, direct 11), fever, and proteinuria.  I was also called to the clinic to see a child with a positive Gower's sign, which suggests Duchenne Muscular Dystrophy.  I am hoping that maybe he has a spinal cord lesion instead, but we found out that there was a family history of DMD, so DMD is the likely diagnosis.

And, earlier this week, we had a girl with carpopedal spasm and a positive Chvostek's sign, which I have never seen before.  She ended up passing away, so please feel free to pray for her family, as they are undoubtedly mourning her loss.

Glossary:

Encephalocele - a "neural tube defect" in which there is an external sac at the base of the skull which may contain membranes and fluid only or may contain brain tissue.  Related to spina bifida.

Gower's sign - when a child uses his arms to help straighten/strengthen the legs as he stands up.

Carpopedal spasm - spasm of the hands and feet associated with low calcium

Chvostek's sign - twitching of the mouth when the facial nerve is tapped or percussed.  Also associated with low calcium.

Reflections on the Safari and Return to Kijabe.

We returned from the safari on Sunday with an awe of what we had just seen of God's creation.   I have had the blessing of seeing many beautiful places on this earth, both near and far.  I think one of the ways God's rewards those who rise early is by allowing them to see terrific sunrises periodically. Here in Oconee County we also have some fantastic sunsets that I get to watch while I drive home (I guess God gives the gift of his beautiful creation to those who don't have to get up early, too).  I have always enjoyed our trips to the mountains and to Lake Rabun because of the great beauty of those places.  Growing up near Clark's Hill Lake, I have fond memories of skiing at sunset on a surface of glass.  I love driving to the Lowcountry of South Carolina and driving under the oaks draped in Spanish moss on the way to the beach.

Madeline jumping from the boat dock at Lake Rabun

Lake Rabun

Despite the natural beauty all around us in the southeast, there are a few places that I have been in this world that are almost overwhelming and are certainly a testimony to the greatness of the Creator. Oahu and Maui, though more than 20 years have passed since our visit, are among these awe-inspiring places. Parts of Bermuda, where Amy and I went for our honeymoon, were fantastic, as well. Much of the Caribbean is similarly spectacular. The coast of central and northern California provides one incredible view after another, and standing at the base of a redwood is an experience encourages humility regarding our own importance.  Our family road trip to Arizona two years ago led us to the Painted Desert, the Petrified Forest, and the Grand Canyon. The varied hues of the Painted Desert were phenomenal, the bizarreness of the Petrified Forest was amazing, and the beauty and absolute vastness of the Grand Canyon was overwhelming and inspired worship of the One who created it all.

California Coast

At the Foot of a Giant

The Painted Desert

Between the Painted Desert and the Petrified Forest

Petrified Forest

Grand Canyon at Dawn

Grand Canyon in the Morning

    

Grand Canyon with Clouds Rolling In

The Maasai Mara savanna was one of those places which inspired such awe. The landscape was extremely beautiful and quite vast (see sunset pics on the previous post), but here it was the wildlife that triggered such captivation. Our photos (see the last post), though quite amazing to me, still do not do justice to what we actually saw. I couldn't help but wonder what this must have been like 100 years ago or so, before these lands were disturbed by overhunting and tourism. Teddy Roosevelt came to Kenya to hunt (and laid the cornerstone at Rift Valley Academy while on one such trip) nearly a century ago. What must it have been like back then, before the endangered "big five" (lion, leopard, elephant, cape buffalo, and rhino) became endangered? It is difficult to fathom how much more impressive it might possibly have been.

Whenever I am awed by creation, I am reminded that this is one of the ways that God reveals Himself to man:
Romans 1:20     For since the creation of the world His invisible attributes, His eternal power and divine nature, have been clearly seen, being understood through what has been made, so that they are without excuse.  New American Standard Bible : 1995 Update. LaHabra, CA : The Lockman Foundation, 1995, S. Ro 1:20

After our return from the safari, I was apparently rather busy the next three days, because I did not have the opportunity to jot too many notes on the events of Monday through Wednesday.  I made a few notes about Wednesday, but I was apparently a bit sleepy when I wrote them, because they are largely indecipherable.  There was a preterm baby who was admitted after a home delivery.  This child had an encephalocele (a fluid sac at the base of the skull, which may or may not contain brain) and apparently never cried after delivery.  The baby presumably had birth asphyxia and was to be treated for possible sepsis, as well.  One of the other babies in the nursery finally got an echo because of a persistent murmur (actually, two murmurs: a contiuous machinery murmur and a loud systolic murmur) and turned out to have a large patent ductus arterious (a persistent fetal blood vessel that is supposed to close after birth) and pulmonic stenosis (narrowing of the valve that leads from the right heart to the lungs).  Another baby had an echo late the previous week and was found to have an atrial septal defect and pulmonary hypertension, which contributed to a persistent oxygen requirement.  One of our preterm "feeder-grower" babies was reported by the lab to have a bilirubin of 23 (possibly dangerous) but did not appear jaundiced at all.  A stat repeat bili was performed and turned out to be 2.  Doesn't instill a lot of confidence in the reliability of the lab.

Over on pediatrics, a Somali patient was admitted with spina bifida and a massive encephalocele.  This poor 9-month-old had an encephalocele that was roughly 3/4 the size of the rest of her body.  Just turning her from one side to the other was at least a two person job.  How this mother managed to take care of this child for 9 months is beyond me.  We were consulted by surgery on a child with massive hydrocephalus who was going to eventually get a shunt to decrease the fluid and pressure in his head.  I was saddened to hear that our girl with the low calcium had passed the previous night, presumably from sepsis (severe infection).  The cause of death will never be known for sure because no post-mortem labs or autopsy was done.  We crowded about 10 people into a rather small hospital room the next morning to talk with the family.  The conversation was translated from Swahili to Somali, so I truly did not understand a word of the conversation.  I did the only thing I could, which was to stand there and pray for this family to be comforted and to come to know the Comforter personally.  Fortunately, or rather, providentially, there is a missionary couple in Kijabe that had spent several years working with Muslims in Somalia.  They were present for the conversation and remained with the family after our discussion.  Feel free to pray for the family of this Somali girl.


As Wednesday drew to a close, less than a week remained for us in Kijabe, but it would be a challenging and memorable week.

Safari Days 2 & 3

The Fairmont Mara Safari Club has 2 game drives each day for its guests, one in the morning and one in the afternoon.  The morning game drive starts at 6:30, so your room waiter brings coffee, hot chocolate, and tea to your tent at 6:00 to help make sure you are up in time for the game drive.  Now I don't usually like to get up at 6:00 a.m. on my vacation or weekend days, but this would undoubtedly be worth getting up for.  Amy and I got up a bit before 6:00 and began to rouse the kids from their slumber so we could make the drive.  I elected not to have coffee since we would be in a land rover in the middle of the Maasai Mara for several hours.  We had been advised not to hang our hands out the windows while on the drives, so I gathered that it would not be advisable to get out of the land rover for a code brown.

The morning drive was also fantastic.  It was quite exciting to watch the king of the jungle meander from the trees to the grassy brush to meet two lionesses, coming within about two feet of our vehicle as he walked.  He clearly did not feel threatened by our presence.  As we continued on our drive, we encountered many more zebras, gazelles, wildebeests and topis.  The Great Migration is said to involve about 1.3 million wildebeests, 500,000 Thompson's gazelles and 200,000 zebras, as well of tens of thousands of topis, elands, and other game.  Given the huge numbers of these animals we saw personally, I must say that I believe those numbers to be correct.

Thompson's Gazelle

Abby was thrilled later in the drive when we came upon a herd of giraffes.  As someone else has stated, I think God was expressing His sense of humor when he made these things.  When we approached the herd in the land rover, they all turned their heads to stare at us.  Most of the other animals on the safari ignored the vehicle, but the giraffes all took notice.  Although I cannot attest to the veracity of this, giraffes can supposedly outrun most of their predators and have been known to kill lions with a kick.

After the morning drive, we had breakfast at the club and then went to a Maasai village.  The Maasai villagers were very welcoming, especially once you pay the $20 entry fee (U.S. dollars).  The female villagers sang as we entered and the men demonstrated their jumping ability, which is how they prove they are ready for marriage.  If you jump high enough, you qualify to marry.  Good thing that's not the case here, because I have quite a few buddies who would be destined for singleness.  (I am not going to single out anyone specific, like Jamie Wolfgram or Chris Strickland).  We were then invited to join them as they sang and danced. 

The chief's son then led us around the village and was quite proud to show us their homes and inform us that the walls are made of cow dung.  I've got to say, the pediatrician in me just kept thinking "E. coli, E. coli, E.coli".  Each home had a room for the calves to sleep in at night.  That's right.  The calves slept in the home with the people.  Medical note: one of the big problems in Africa which can lead to blindness is trachoma.  This eye disease can be spread by the flies which are forever surrounding cattle.  It would be a good thing if the calves did not sleep in the home with the people.  After the "tour" of their typical home, which clearly indicates that the Maasai are not a claustrophobic people, we were invited to go to their market.  Each family had their own little stall in this market, and we were expected to visit each stall.  Somehow Amy and the kids got way ahead of me, so I got the hard sell at each and every stall I visited.  I am not real good at saying "no", so I now have two pieces of wood that theoretically can start a fire.  Maybe I will try them next time I fire up the grill.

Proud of the dung walls

After escaping the market, we returned to the club for lunch and a little relaxation before the afternoon game drive.  The kids ventured to the pool, but only John was able to handle the cold water.  After a short time at the pool, we met our driver, Cosmas, for the afternoon drive.  The afternoon drive again presented things to us that we had not yet seen.  As we left the compound, we saw a little flock of guinea fowl, which resemble the peacock, but without the distinctive tail plumage.  We then saw a group of impalas, which were quite graceful in appearance.  Interspersed with the impalas were a number of topis, an antelope species which I found to be quite beautiful.  We made our way to the foothills to find the rhinos known to inhabit the area and along the way had our first encounter with a jackal, which looks remarkably similar to our own dog, Dottie.

Guinea fowl

An impala (foreground) and a topi

Dottie, I mean, a jackal

 As we approached the rhino habitat, we were met by a group of rangers that informed us that this is where we were to get out of the vehicle for a short walk.  Surprised that we were asked to exit the vehicle, with kids (!), we climbed out and followed the ranger up the path.  He led us to an area where a group of 4 rhinos were grazing.  We began to take photos in front of these apparently docile behemoths, until the ranger motioned for us to move away.  He then informed us, "That one is aggressive...sometimes we run."  It was quite reassuring to know that the ranger was there to protect us with the rather small stick he was carrying.  We proceeded back to the land rover and then had the opportunity to watch one of the greatest sunsets I have seen.  The hymn, "How Great Thou Art", sprung to my mind and "How Great is Our God" to Amy's.  Absolutely breathtaking.

We returned to the club for another excellent dinner and a great night of sleep.  We were again greeted with coffee, tea, and hot chocolate on Sunday morning prior to our final game drive.  The girls and I headed to meet our driver at 6:30 as Amy prodded John along to get ready for the drive.  As Amy and John left the tent, they met a baboon helping himself to the tray of coffee and tea.  My return to see what was taking so long apparently scared the little guy off, but Amy was able to get a couple of photos of the event. The Sunday morning drive provided another opportunity to observe the great cats.  We then drove on to find some hyenas finishing off a wildebeest.  Along the way we saw a little vulture, a tawny eagle, and several jackals.  It was fun to see the jackals try to sneak in among the hyenas and still some breakfast.  John had a potty emergency and got to contribute some fluid to an acacia tree in the middle of the savanna.  How many 6-year-olds can say they urinated among a bunch of wild African animals?  John's kind parents decided not to take any pictures to use for future blackmail.  We then had another giraffe encounter and our driver found an ostrich egg (I don't know how he found it) for us to see.  We returned to the club and prepared to leave.  We said good-bye to the staff, who had been quite taken with the kids, and began the long drive back to Kijabe, still overwhelmed by the vastness, diversity, and creativity of God's handiwork.

What do you get when you cross a baboon with caffeine?

Tawny eagle

Hyena breakfast

A dik-dik

Secretary bird