Final day in Kijabe

Final Day in Kijabe and travel home

I finished work just in time on Tuesday to get home and change in time to go to dinner with Rhett and Megan at Mama Chiku's.  Rhett, Megan and their kids drove to our apartment, then we all walked from there to the restaurant.  As usual, it was a pleasantly cool, breezy evening and we had a nice conversation as we walked.  With my clinical responsibilities behind me, the evening was nice and relaxing.  We arrived at the restaurant and worked on getting tables set up.  The ten of us took up about 2/3 of the space in the restaurant.

Mama Chiku's

We ordered a family style meal that included chipatis (thick tortilla-like bread), ugali, beef, potatoes, carrots, and something like collard greens or cabbage.  The kids mostly liked the chipatis and tasted a few of the other things.  We tried everything they brought and we liked the chipatis best, too.

Ugali with cabbage

Chipatis

We finished dinner and walked back to the apartment to pass on our leftover groceries to the Shirleys.  After a little more time of fellowship, we said our good-byes and returned to the apartment to work on packing to go.  It had been a great blessing to have the Shirleys there to help us get settled and involved in the Kijabe community.  I am still amazed by the greatness of their faith that led them to take their 3 small children halfway around the world to serve God in Kenya.  Megan and Rhett would soon be visiting the U.S. and Megan would have to travel from Atlanta to Amsterdam on her own with the children since Rhett had to return to Kijabe earlier.  They will continue to serve at Kijabe for another year, please keep them in your prayers.

We spent our last night in the apartment with mixed feelings.  There were many things we were looking forward to about returning home: 

• not having to remember to turn on the hot water heater on before dinner, off before bed, on upon awakening, and off again after everyone had showered in the morning
• not having to shake our shoes to make sure no spiders had taken up residence during the night
• not having to remember not to wet our toothbrushes with water from the sink and to rinse our mouths with water bottles rather than sink water
• no longer dealing with very unreliable dial-up internet access
• not wondering what animal was the source of the meat in the rather tasty samoosas (we hoped it was beef, but who knows?)
• not wondering why the samoosas started turning red once they were in the fridge for a few days
• not having as many "OC!" moments while I take care of patients ("Oh, crud!")
• sleeping in my own bed with my own pillows
• we were all looking forward to having a little Chick-fil-A when we got back
• college football (never mind what was actually happening with UGA's season)
• worship services at WFBC

Samoosas

There were, however, many things we would miss about Kijabe.  There was a greater simplicity to life there, and I can't say that I really missed much of the electronic aspect of our lives here (Amy will be shocked by that statement since she likes to call me Mr. Technology).  I greatly enjoyed watching how the children played creatively with each other and how they really had a great time together.  We would certainly miss the graciousness of the Kenyan people.  I had greatly enjoyed going to chapel at the hospital and working with people at a place whose purpose was to glorify God in what they did.  It was fun to see Rhett singing at chapel as the only white face in the choir.  Despite the stress that came with taking care of much sicker kids than I take care of here, I would miss the expanded use of my training there.  The easy access to specialists here and time pressure of running the office here leads to earlier referral of patients than I would like.  Although I should be dependent on God on a daily basis in my work here, the fact is that the lower severity of most illnesses here does not often push me to depend on Him like I should.  I spent more time on medical reading in the 4 weeks there than I have in the last 3 years here in the U.S.  Nothing inspires you to read like a patient you can't figure out.  


I would also miss the opportunity to work with some of the most talented physicians I have ever been around.  I have not been more impressed by any two physicians I have ever worked with (and I have been blessed with the opportunity to learn from some of the best in their fields in the U.S.) than I was by Dr. Steve Letchford and  Dr. Paul Jaster.  The breadth and depth of their knowledge and skill is, in my opinion, unmatched by anyone I have ever worked with here in the U.S.  I had the pleasure also of working with Dr. Bert Lee, Dr. Leland Albright, and Dr. Joshua Tjong during my time at Kijabe Hospital.

Wednesday morning was spent finishing packing and distributing the remaining medical items we had brought with us.  We went to the nursery, pediatrics, and to the chaplain, Mercy, to say good-bye and then I stopped into the ICU to talk with Dr. Letchford and check on the girl who had surgery for her enormous encephalocele the day before.  I was pleased to find her doing well in the ICU without a ventilator and to find the other baby stable on the ventilator.

We returned to the apartment, finished packing, and waited for our driver to pick us up to go to the airport.  The trip to the airport took us through Nairobi at rush hour and included some portions that took us through some of the infamous Nairobi slums.  The poverty was really quite shocking, even though I have been exposed to extreme poverty in Mexico and Venezuela in the past.  We were instructed not to have our windows open (or even cracked) as we drove through these areas.  This was the only time during our trip that I felt any concerns about safety.

We arrived at the Nairobi airport and had to kill a couple of hours before boarding the plane to Amsterdam.  Personal space is apparently a concept that is lost when one is standing in line in Kenya and our progression through the security check was unpleasant for someone with a tendency to claustrophobia.  The kids nearly got arrested (joking, a little) for having scissors in their bags for crocheting.  The same scissors were perfectly acceptable in the U.S. airport and the Amsterdam airport.  The kids were made to throw the scissors away before they could enter the holding area at the gate.  The waiting area was packed full of passengers and we moved to an open area at the front so the kids could sit on the floor.  We chatted with a guy who was married to a Kenyan girl and visited periodically.  Though they were married, neither could get a permanent visa into the other's country and they were forced to make periodic trips to visit each other in each country.

The airport staff once again showed kindness to those of us with kids and allowed us to board the plane before other passengers.  I was happy to be out of the overcrowded gate and into the plane to begin the long journey home.

Last Two Working Days at Kijabe Hospital

My last call night ended Monday morning and I was off to round at the hospital again.  Overall, there were no terrible occurrences that day, for which I was thankful.  On pediatric rounds we learned that our girl with the huge encephalocele was going to get surgery the next morning.  Hallelujah!  Despite the concerns of the surgery resident over the weekend, the surgical team ended up agreeing that she was healthy enough to undergo the anesthesia and surgery risks.  I thanked God that she was finally get the intervention she needed and I looked forward to the final result.

We were consulted by surgery on a wheezing baby who turned out to have too high a dose of ceftriaxone going. We reduced the dose to the weight-appropriate levels and the patient's wheezing improved by the next day.  Wheezing is a little known and rarely occuring side effect of ceftriaxone and that appeared to be what was going on with this child.

I was consulted on a child in the clinic who was having some issues with possible syncope (fainting).  A chest x-ray was done and was unremarkable.  An EKG was done to evaluate this as well.  In the U.S., I have the luxury of having all the EKGs I order being read by a pediatric cardiologist.  No such luxury at Kijabe.  I then had to read the EKG from scratch, which I haven't done since my last pediatric cardiology rotation in residency.  It was a nice refresher on EKGs.

Tuesday would be my last pediatric conference with the interns and residents, so I spent most of the rest of the afternoon and evening preparing my talk.  I decided to hit a variety of topics that I felt would be important for family medicine interns and residents to know about pediatrics.  Among the topics was IV fluids, which is one of my least favorite topics, but I felt it was something I should review with them.  The overriding theme was that you have to make most of your medication and fluid decisions for kids based on their weight, not just their age.

Tuesday also brought no major disasters, but still kept me busy.  I was thankful to see that a pediatric resident had arrived the night before and would be taking over the supervision of the nursery.  One of the family medicine residents who was there for a month would be taking over the pediatric wards once I left, so both the nursery and pediatrics would be covered.  I recognized in the pediatric resident the same sense of both excitement and inadequacy that I had experienced at my arrival.  Knowing that she had done her Neonatal ICU rotations much more recently than I had, I was confident that she would do fine.

The boy we had intubated over the weekend remained stable on the ventilator and, as I had resolved, I did not extubate him prior to my departure.  The girl with the encephalocele was recovering from surgery and spent the night in the ICU, though not on a ventilator.  The blood sugars on the diabetic girl finally stabilized and she was transferred from the ICU.  God had answered my prayer that no one else would die before I left, and I was thankful for that.

Although there were only a few deaths in my short time there, it quadrupled the number of deaths I have had in my practice in 6 years in the U.S.  If that rate continues over the next 6 years (the amount of time I have been practicing and out of residency), that would equate to over 300 pediatric deaths in the same time span that produced 1 death here in the U.S.  By no means is that a scientific statistic, but it does illustrate the difference in pediatric health here and there.  What a great need there is for quality health care in the developing world!

One of the things Amy has pointed out when we show our pictures from out trip is the sign at the entrance to Kijabe Hospital that includes an arrow guiding the way to the morgue.  Death, tragedy, and poverty are a part of life to the Kenyan people, yet they maintain such a joyful attitude.  We could learn some lessons from the Kenyans.  I am reminded of the verse in Proverbs that states:

Proverbs 30:8b     give me neither poverty nor riches; feed me with the food that is needful for me,

⁹ lest I be full and deny you and say, “Who is the Lord?” or lest I be poor and steal and profane the name of my God. The Holy Bible : English Standard Version. Wheaton : Standard Bible Society, 2001, S. Pr 30:8-9  

We have reached the point in the U.S. where we congratulate ourselves on our wealth and accomplishments and deny God as the source of our prosperity.  We use "the American dream" and "retirement planning" as justification for the hoarding of our wealth.  When compared to the rest of the world, there are few (some, though) in the U.S. who are not wealthy.  May we recognize God as the source of this prosperity and understand that God gives us this prosperity to use for His glory, not to guarantee that we will not have to earn a living past the standard retirement age.  In fact, I think we should expect to labor throughout our living days.

Gen 3:17  And to Adam he said,

     “     Because you have listened to the voice of your wife

                    and have eaten of the tree

     ^l     of which I commanded you,

               ‘     You shall not eat of it,’

     ^m     cursed is the ground because of you;

               ^n     in pain you shall eat of it all the days of your life;

¹⁸           thorns and thistles it shall bring forth for you;

                    and you shall eat the plants of the field.

¹⁹           By the sweat of your face

                    you shall eat bread,

          till you return to the ground,

                    for out of it you were taken;

     ^o     for you are dust,

                    and ^pto dust you shall return.”

The Holy Bible : English Standard Version. Wheaton : Standard Bible Society, 2001, S. Ge 3:17-19

Don't misunderstand the above.  I don't particularly hope to continue working through my 70s and 80s; in fact, I am rather lazy by nature.  I prefer not to work even now in my 30s, at least not as hard as I must.  I like the idea of retiring and would love to do so someday.  I am just not sure that saving for retirement should prevent us from using our resources for God's glory now.  How many BILLIONS of dollars are tied up in the 401K accounts of Christians (including me)?

Last Night of Call in Kenya

After the night of a thousand blood sugars, I was looking forward to attending the AIC church in Kijabe, though I knew I would have to do another greeting ("Hello, my names are David Sprayberry.  I am saved.  I am visiting Kijabe for this month with my wife Amy, and my children, Madeline, Abby, and John.  We bring you greetings from Watkinsville First Baptist Church in the United States."  or something like that).  

Prior to leaving for church, however, I was paged to Casualty (the ER) to admit a baby with a temp of 42 degrees Celsius.  If you are like me, you don't know exactly how high that is, but you know it is higher than it should be.  I pulled out the trusty Blackberry and discovered that 42 degrees Celsius is equivalent to 107.6 degrees Fahrenheit. (!!!!!)  I rushed down the hill to Casualty with only a nod toward the security guards instead of the usual brief conversation that Kenyan courtesy dictates.  I arrive in Casualty to find one of the new ER docs already working on getting blood, urine, and spinal fluid, leaving me to obtain the history from the parents and get admission orders and notes done.  Being just a few days old, the baby would be admitted to the nursery for further management after the labs were obtained.  Unfortunately, by the time this was all done, it was too late to make it to church, so Amy and the kids went on their own (which left Amy to give the greeting).

Upon my arrival to the nursery, I found that one of the babies we had previously intubated and ventilated was having difficulty again.  He had been doing well with CPAP since he was extubated the last time.  We had been working on gradually increasing his feed volume and he apparently had another aspiration event, which resulted in respiratory distress.  He had deep subcostal and intercostal retractions despite a CPAP of 5 cm H20.  I REALLY did not want to intubate him again and put him back on the ventilator.  I decided to check his venous carbon dioxide level to confirm respiratory failure (blood gases are not available at Kijabe).  The level was quite elevated, supporting my assessment.  I decided to reintubate him, and he proved to be even more difficult to intubate this time.  Fortunately, the ER doc had decided to come by the nursery to help with the intubation and we finally succeeded in intubating this baby for the second time in this admission.  

In a previous post, I mentioned that this was a 28 week infant who had made it through his first 10 weeks or so without any surfactant, intubation, or ventilation.  This was now my second intubation of him in my 3 weeks at Kijabe.  I resolved that I would not extubate him before I left Kijabe in a couple of days; I was not going to intubate him a third time.  After intubation, we decided to carry the baby to the ICU while bagging him, rather than try to maneuver an incubator through the halls and bagging at the same time.  We set the baby up on the ventilator and he remained quite stable the rest of the time I was there (but I did NOT take him off the ventilator before leaving).  HIs mother, the one who had said "please help my baby" before the first intubation, was understandably quite upset by the need for reintubation.  I attempted to comfort her and assured her that I would be praying for her baby.

Much of the rest of my day and night were spent managing blood sugars on the diabetic child.  There was a little disagreement between the surgery resident and the intern on pediatrics about whether the child with the huge encephalocele was septic or not and I was paged that night to try to settle the dispute.  The pediatric opinion was that the child was not septic, but that the only way the erosions on her encephalocele would resolve would be for the surgeons to remove the whole thing.  The pediatric intern proved to be correct, but the surgical resident was nowhere to be found to inform of this, so my involvement in the dispute was unnecessary.  I will confess that I was thankful that I was not on call Monday night, so that I could finally have some uninterrupted sleep.   

Next to Last Call Night at Kijabe Hospital

Saturday, the 2nd of October:

On Saturday, I arrived to round on pediatrics and in the nursery.  I was saddened to learn that, during the night, the baby with the encephalocele who was just extubated on Friday was unable to respire adequately and passed away.  Although this was not a surprise, it was still difficult to hear.  I can't imagine the sorrow that parents experience when they lose a child.

On pediatric rounds we found that the child with extreme cholestasis had begun to improve.  This was an answer to prayer because I did not have much to offer this child in the way of medical treatment.  The child with the huge encephalocele had begun to develop erosions on the encephalocele.  These erosions were being treated, but I doubted that topical or systemic antibiotics would do much good.  The cure for these erosions would have to be surgical removal of the encephalocele, but surgery was apparently not ready to take her to the OR.  I could only hope and pray that they would take her to surgery before the erosions caused sepsis and, ultimately, death.

The other notable event on Saturday was that a child with diabetes had been admitted the night before with severe hypoglycemia.  As this was treated during the night, the blood sugars began to rise and she needed to be restarted on her maintenance insulin regimen.  This regimen was ordered correctly by the intern, but the nurse, being unfamiliar with insulin administration, gave the child 24 units of regular insulin instead of 24 units of 70/30 insulin.  That was a HUGE dose of regular insulin for a pretty small child (4 years old if I remember correctly).  Regular insulin is fast-acting and its effects last a few hours; 70/30 insulin is a combination of regular insulin and long-acting insulin. The net result of this error is that the child received over 3 times as much regular insulin as she should have.  Because this error put the child at risk for severe blood sugar problems and seizures, we had to admit the child to the ICU.  Blood sugars would have to be followed very frequently until they stabilized, which meant I would be called with blood sugars very frequently for the rest of the weekend.  The calls aren't so bad during the day, but you just can't get decent rest when you are awakened every couple of hours.

Just a few more days until our time at Kijabe would be over.  Hoping for no more deaths before we leave.

Friday, October 1 - extubation

So, after the overly eventful Thursday, my last few days at Kijabe hospital arrived.  I would work a regular day Friday, be on call Saturday and Sunday, and then finish with two regular work days on Monday and Tuesday.  I arrived Friday and went to the ICU to check on the child we had intubated on Thursday.  He was doing "well" on the ventilator, meaning that oxygen was going in adequately, carbon dioxide was coming out adequately, and his lungs were not requiring high pressures to achieve this.  This is not truly good news because it means that his breathing problems from the day before were not caused by a lung problem, they were caused by a brain problem: his brain was not telling his diaphragm to breathe sufficiently.  On my examination, he would withdraw from pain but had very little else that was positive from neurologic standpoint.

We had talked with neurosurgery prior to intubation the day before, and they said they would give him a trial of a few hours on a ventilator to see if he would recover respiratory function.  We had decided to give him longer than a few hours and allowed him to spend the night on the ventilator in order to be certain that he was not going to recover adequate respiratory function.  After another round of discussions with Dr. Letchford (ICU/med/peds), Dr. Lee (ICU), and Dr. Albright (neurosurgery), the consensus was that if the child was going to recover, he would have resumed spontaneous respirations and started to "overbreathe" the vent, which he had not done.  

The prognosis was discussed in depth with the parents and they were given the choice to transfer to Kenyatta Hospital in Nairobi for further ventilation care or he would need to be extubated and allowed to try to breathe on his own.  Kijabe Hospital did not have the resources to perform prolonged ventilatory care on a baby that would most likely never recover.  We advised the parents that if the child was extubated, he most likely would not breathe adequately and would likely pass away.  The parents decided against transfer for continued ventilation and chose extubation, with the understanding that the child would not be reintubated if he began to have respiratory failure again.  We extubated Friday afternoon to CPAP (continuous positive airway pressure) to give him the best chance to make it and the child initially did breathe some on his own with the assistance of CPAP.  Prior to extubation, the chaplain came up and we prayed with the family before stopping the ventilator.  At the end of the day he was still breathing spontaneously, though somewhat irregularly, and there was a glimmer of hope that he might make it.