The Past Few Days

December 15th, 2017 by georginagreen
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I have not posted for several days. I didn’t have the right words and realize that not everything is appropriate for a blog. Some of the words will stay in my journal, and much of the last few days is still in my head and heart being processed. I was gently warned that there would be deaths on the pediatric service. Because HIV, TB, prematurity, heart disease, etc.

 

The first night of my first weekend call, after I did the last post, we had a code. The boy, not much younger than my daughter, did not survive. His father thanked us for doing what we could. I felt he was too gracious. It happened so quickly. I was doing CPR in my white coat. The next morning, I couldn’t bear to wear that same coat, stained with memory. And the transfer we had waited for, the girl with TB, died before she made it here.

 

I received two babies from c-sections the following day. One full-term child was blue and limp. We provided respiratory support until he perked up. Even at five minutes, he was struggling. I was desperately keeping track of his heart rate, praying that he would keep it up. At ten minutes he was much better. That evening he didn’t need oxygen and looked perfect, went home the following day. The other infant was a 34-weeker whose mother had received steroids for premature rupture of membranes. That baby did well. I was not on call Monday night, but two more children died. A 25-weeker who had been on the vent and struggling throughout the day. And a ten-year-old. I saw him earlier in the ICU when he had a lumbar puncture. Emaciated, febrile, septic, his heart with an ejection fraction of 10%, diagnosis still unknown. Tonight we have two very sick babies.

 

The “well” children: We had two toddlers admitted for ingestion, one for kerosene, one for paraffin. They had accidentally taken a swig of a bottle within reach. Both infants had chemical pneumonitis, probably from induced vomiting by the caretakers. One of them also has pneumonia. One teenage girl had a suicide attempt with insecticide after a fight with her mother. She ingested a small amount, but enough for a scary night for her in the HDU (high dependency unit, similar to the ICU).

 

I’m less overwhelmed than when I arrived, but still surprised. Lots of HIV and TB. Some drug resistant TB. Lots of rheumatic heart disease. And every day there is pathology that I have to read about, that would be rare in the US. I’m struggling with the end-of-life care of one patient, who is highly dependent on a family who has given up and is not very involved. The child also seems to have given up. I am so happy to see a child with routine pneumonia or meningitis who recovers and goes home, or to see a “feeder and grower” in the nursery who is on a path to going home.

 

Random thoughts:

*It’s sometimes difficult to get things done. We were given one EEG slot for the week, but somehow the child didn’t get the EEG. The lab is often out of a particular reagent, so, for example, we can’t get a CD4 count on a child with HIV, will have to send out the lab. There is a lot of doing what you can with what you have and not complaining. I have made a long list of what I find difficult about medicine in this setting and what I find uplifting.

 

*The baby Georgina: On rounds I had an urgent call to go to the OB department for a delivery. I raced over to find one of the midwives (who I really like and respect). He had called, because he knew that I wanted to see a “normal” delivery. He was teaching a female midwifery student. The patient had a baby girl, and he told her that she should name her daughter, “Georgina.” I protested, and he said, “She agreed. It’s done.” I hope it makes an interesting birth story for the little girl and that she gets a good middle name, one that her mother picks.

 

*I went to Casualty to see a pediatric patient. Three men had just arrived from a motorcycle accident. I put on gloves and tried to be useful, suctioning blood from a mouth, taking a blood pressure. I was welcome to help. I am often told in Swahili and English that I am welcome.

 

*Please note that in the nursery, on rounds, I might pick up the crying baby so that we can listen to the person presenting their patient. And that’s okay. It’s seen as kind and practical rather than unprofessional. There’s often a baby who didn’t get the memo about the feeding schedule and wants his Mum early.

 

*Outside the canteen yesterday, there was a Muslim man praying on a patch of grass. Prayer is the norm here.

 

*My main impediment here is language. You cannot get a patient history without speaking the language, whether Swahili or Kipsigis. You don’t understand jokes or worries or side conversations. I am ruminating about what skills a person needs to be useful in this setting, am planning and plotting how to grow into that person. Language is near the top of the list.

First weekend on call

December 9th, 2017 by georginagreen
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(They have cats here, too. This one was on the roof. Saw him through the window as I was writing a patient note.)

 

*A ten-year-old boy recently admitted, has a three month history of fatigue, fevers, and increasing shortness of breath. He is stable in the ICU on oxygen. A chest x-ray shows a large effusion on the right side. An echocardiogram shows a VSD (ventricular septal defect, a hole between the bottom chambers of his heart) with “vegetations,” infection in his heart, infective endocarditis. His hemoglobin was very low. His kidneys are showing signs of stress. And he seems scared. We have him on antibiotics and have been talking to surgery about possibly trying again to drain the fluid in his lung. There’s also a cardiothoracic surgical team visiting here in three weeks who may be able to help. Antibiotics, oxygen, labs, watching carefully for now.

 

In the US, as a family medicine resident, especially if I had been rotating on a pediatric ward, we would have consulted pulmonology, infectious disease, cardiothoracic surgery and possibly nephrology. Here we usually discuss management options with colleagues at the hospital. And there are daily Phone-a-friends to the US. But ultimately it’s our patient. It’s so very different here.

 

*A five-year-old boy has been sickly for several years, is sweating, underweight, has increased work of breathing. Has nodules on his back and a new one on his chest. He has pulmonary TB which is now in his bones. We’re trying to pull the records together, get him stable so that he can follow up with his pulmonologist in Nairobi. It’s not clear why he doesn’t seem to be getting well with current treatment.

 

*Another girl on her way here by ambulance from another hospital, is four hours away. Pulmonary TB, on treatment, continuing to decline, may need to be intubated. I will go to Casualty (ER) for the little girl with TB and anyone else who comes in.

 

*In the nursery/NICU, the babies are well today. Another baby is off the vent, and I (we, but I…I’m mentally checking off all of these firsts, so I…and PS I think I’m more brave here, so I) extubated her this morning, put her on bubble CPAP. I just checked on her, and she is doing well. We don’t have a chest x-ray (baby gram), because the portable x-ray isn’t working, hasn’t worked for the past few days. It would be nice to see what her lungs look like. The 25 weeker is still on the vent, also stable. And I had time to cuddle a baby who was upset after getting an IV placed.

 

*On the OB floor: Tonight several women are in labor. I asked the midwives to call me when people are in labor so that I can get more experience. A woman’s water broke at home this morning, and shortly thereafter the umbilical cord came out, and a foot, and the cord stopped pulsing. She has lost her baby, and I will get to do a breech delivery. The male midwives on call tonight will teach me. Through the curtains next to her, she will hear other mothers delivering their live babies, hear their loud heartbeats on the monitors while she waits until her ordeal is over. There are no epidurals here. But this woman, she received pain meds.

 

*Almost 10pm. The little girl has not yet arrived at the ER. The breech delivery was done by a midwife, a different one after change of shift. I think he was a bit less enthusiastic about teaching. Nice, though. The baby appeared to have died some time ago. The mum had tremendous pain, is resting now. Before that baby was born, another full term IUFD (intrauterine fetal demise) arrived. That mum had no idea. Was there for a labor check. So the first mum delivered without having to hear the joy of another mum, but possibly, if she was listening, she heard the similarly tragic situation of another mum.

 

In the nursery, I cuddled a few babies who were crying before feeding time. Because I can. And I talked to the mum of the baby who was extubated this morning. She hadn’t realized her baby was breathing on her own and stable, said she was beginning to give up hope. The tubes and machines can be confusing, so we talked through what each reading meant, what CPAP was doing. She gave her daughter a middle name in Swahili which is apparently a really good name. It means something like “many people coming together to help the child be born” (?). That mama is reassured tonight. I hope the baby continues to improve.

 

Again, I must learn Swahili. It is isolating to not speak the language. Rounds are in English. Notes on the computer are in English. Life is in Swahili.

These Mothers

December 8th, 2017 by georginagreen
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(On a hand-written poster in the nursery. A quote often used by pro-life groups, not my intention here. It’s a beautiful, daily reminder that each child in that nursery is precious, is Loved.)

 

These mothers. Coming into the Nursery/ NICU every two or three hours, all day, for weeks and weeks sometimes, with cups of breast milk hand-expressed, which they they will put in the nasogastric tube or a cup to feed their babies. Every. Two. Hours. They don’t have bottles here. Not one bottle in this hospital. The mothers do most of the care for their own babies. They come in at the feeding time, wrapped in striped, cotton maternity gowns, barefoot or wearing flip flops found in a basket by the door, sit in plastic chairs, and do the work that needs to be done.

 

These mothers. Cuddling their babies. Patting the baby in the next cradle if she cries. Living in the hospital in what seems like NICU mommy purgatory, waiting for your baby to grow until you can go home. In the US, you are often discharged from the hospital if your baby is admitted to the NICU (though some places do have individual rooms and parents can sleep in, I think it’s not the norm). I believe the thought is that the care is intensive, and you would be in the way. Here, the care is intensive, and you are only feet away.

 

The NICU nurses are the same as any NICU or charge nurse I have ever met. They know their babies well. They care for the mamas as they can. They give meds, baths, watch vents and babies on CPAP and bili lights and keep constant watch. The charge nurse made an executive decision to let a mother rest today, a mother who is physically (and possibly emotionally, though she is strong and doesn’t complain) exhausted. So that nurse, in addition to her many other duties, is also feeding the baby today.

 

I would love for some of my friends who work in the NICU to be here. It’s different but universal.

 

Another sick baby today, brought in during morning rounds from another hospital, in respiratory distress. Had a seizure in the afternoon, now intubated and on a vent. Her mum hasn’t named her yet. 25-weeker also delivered during rounds. So tiny. Stable.

 

We prayed for the team on call tonight. That they may have the wisdom and strength to care for the children tonight. Every one of those children needs prayer. The newly-diagnosed type 1 diabetic who will soon go back to boarding school and is learning how to give herself insulin, the child with gastroenteritis that might be malaria, the child recovering from meningitis who is not yet walking and has a long road ahead. And all of the babies in the nursery and their parents.

Firsts

December 6th, 2017 by georginagreen
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-First time leading the group in prayer before rounds

 

-First time doing CPR on a baby (I did think later that perhaps it wasn’t a good enough prayer, but that’s narrow thinking. For the intern I talked to later, it was not her first time. Infants are frequently brought to the hospital too late.)

 

-First time checking on baby shortly thereafter and finding no heartbeat

 

-First time initiating CPR

 

-First time seeing devastating effects of herbal medication (common here)

 

-First time praying with the family after the death of their newborn child

 

They love him. They thought they were doing what’s best. There are always some difficult days in medicine. But some days are more heartbreaking than others.

 

The sun was hot and bright when I walked outside after he died. And it has rained all afternoon. The rain seems much more appropriate.

 

Walking home, a young child playing in puddles, delighted with the rain, saying to his friends, “Come here! The water’s warm! Come see!” Such life and joy in that child. And up the hill a family is grieving.

 

And for me, am feeling the weight of the limit of my abilities and my training, wanting to do better.

Getting used to Tenwek…

December 5th, 2017 by georginagreen
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A few random thoughts:

 

-The water has alum in it. All drinking water must be filtered. I brush my teeth with filtered water. My hair is not a great fan of the water. Some people rinse their hair with collected rain water or do periodic vinegar rinses.

 

-The mosquitoes are huge. Seriously huge. Not as big as birds but certainly too big to get through a mosquito net. Except the other night when a creature came through a hole in the top of the net and was buzzing in my ear. They aren’t all over the place like the ones that feast on us during summer evenings in Kansas, but they’re here.

 

-At 6700 feet we’re not quite above the malaria line, but the long term staff don’t do malaria prophylaxis. Most of the patients here who have had malaria contracted it somewhere else. Short-term staff tend to do prophylaxis, because if we get sick, we might be useless during our time here.

 

-The weather here is technically perfect. Pretty much 50-70 year round. Flowers and plants grow well.

 

-Milk comes in small bags. It’s whole milk, UHT. The cook in the guest house, Emmanuel, taught me how to make proper chai tea today. Lots of milk. Would be a challenge if one were lactose intolerant.

 

-The hospital staff all seem to have mandazi or chapati and chai tea breaks mid-morning and maybe the afternoon. I will miss tea time.

 

-The hospital does a lot of surgery. Lots of burns and trauma. And the residents and attendings doing surgery are rock stars to me. It’s amazing. If I were a surgeon, I would probably be even more drawn to this place.

Pediatric Wards Day 2

December 5th, 2017 by georginagreen
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Last night before I went to bed, I looked through the charts of the children who were on our service, making mental notes of the things I needed to review, questions about physical exams and medications, etc.

 

I was looking forward to seeing two new admissions. There was an 11-year-old girl with HIV and cancer. Her medication list included zinc supplementation, another random gap in my knowledge, so I read more about zinc deficiencies. There was also a 15-year-old boy who came in with an inability to talk, generalized weakness and excess salivation. I came up with a broad differential including diphtheria, toxin exposures, etc. I was so curious. (Really, ask me about diphtheria now.) We are told as medical students that when we hear hoofbeats, look for horses instead of zebras. What’s common is common. Today I was told by one of the long-term doctors to look for zebras. I have always loved zebras. (I saw one in the wild on the way here from Nairobi.)

 

When I got to the hospital this morning, I learned that the young girl had died a few hours before, discovered by the intern while pre-rounding. And on rounds, it was apparent that the teenage boy had a conversion disorder, i.e. psychosomatic illness. He was upset after having an argument, “a disturbance,” with his family the night before his symptoms appeared. He was matter-of-factly discharged after a full work-up was negative, including head CT on arrival.

 

The head CT was a big deal. Again, here it is sometimes cheaper to do surgery than to get a CT, which costs about $100. Just let that sink in.

 

During didactics one of the interns gave a presentation about DVT and pregnancy. Lots of good take-aways. Did you know that blood clots during pregnancy are more often in the left leg? We ended with a discussion of management guidelines in Europe, different medications that are used, and what would be practical in this setting. For example, machines are routinely used in the US for intermittent compression of the lower limbs to prevent blood clots when people are on bed rest. They are not part of routine DVT prophylaxis/prevention over here or in Europe.

 

We rounded for another hour then took a break for “chai talk” with chai tea and mandazi (Kenyan buns) as one of the Kenyan interns discussed management of meningitis. This led to a debate of whether one of our patients had bacterial or TB meningitis, as well as the best way to control her high blood pressure. This 13-year-old girl, who was not talking when I first saw her before the weekend, is now able to talk. She knows who she is and where she is and is able to verbalize her pain and other concerns. She was treated for bacterial then TB meningitis and is showing significant clinical improvement. I spent much of the afternoon reviewing diagnosis and treatment of various forms of meningitis. It’s a bread-and-butter topic for physicians, and every time I come across it, a little more sinks in. As a visiting resident at Children’s Mercy I saw a baby who had a stroke from GBS meningitis, and I saw several children with viral meningitis. TB meningitis is new to me.

 

This brings us to the topic of blood, wound, and CSF cultures. The cultures that are sent to the lab here rarely grow anything, which makes treatment difficult. I think about the Infectious Disease docs and lab directors that we rely on so heavily at Research Medical Center and how nice it would be to have their brains here to try to fix this problem. Automated machines are the gold-standard in the US, but it’s not affordable here right now. Smart people here are putting their heads together to figure this out.

 

After chai talk, we went upstairs to round in the nursery with mostly preemies, some of whom are getting better, some getting worse. More about the NICU later.

 

Dr. Caldwell helped us determine treatment for the lower extremity wounds of an 11-year-old boy with heart failure secondary to rheumatic heart disease and a VSD (ventricular septal defect, a hole between the lower chambers of his heart). It’s not operable (there are visiting cardiac surgeons who do all kinds of things here…), he’s on palliative care, and probably only has a few months to live. If he were a healthy boy with the same wounds, he could have surgical management and would be taken to the OR (called Theatre here) for debridement, and then skin grafts. As it is, he will have only medical management, with antibiotics and wound care, with the goal of prolonging his life and minimizing his suffering.

 

I helped the intern change the dressings on the boy’s leg then remove dirty sheets from the bed. The interns left to do other work, and I asked the uncle if he needed help putting new sheets on the bed. So he lifted the boy while I changed the sheets. The teenage boys in the bed beside him thought this was hilarious. I don’t speak Swahili or Kipsigis, and the uncle was at first reluctant to speak English to me. Then the uncle ordered/asked me to get clean blankets and told me to report back to him, which was also amusing to the boys. I asked a nurse to help find blankets. I guess doctors don’t change sheets. The family members are probably expected to do it. And I realize that the only way to function well in this place is to learn Swahili, since I’m constantly asking the interns, “What did he/she say?”

 

PS There are 14 beds in one ward and 18 in the other, not all occupied. Beds are next to each other with a bedside table separating them. On the far wall of each ward is a mural that needs touching up. One is Daniel in the Lions’ Den. But the lions don’t look too menacing.

 

I’ve been reading The Miracle at Tenwek, which most visitors probably also read during their first visit here. It’s the story of Dr. Ernie Steury, and it’s fascinating to learn about the recent history of this hillside in Kenya. I’ve been walking the paths of this complex today, going through the gates of the hospital, and thinking about the people who have walked these same paths and the work they’ve done. There is a river and waterfall just down the hill from where I am. The hospital uses hydroelectric power from the waterfall to generate power for the hospital, has its own water supply and water treatment and is largely self-sufficient in that way. There are so many stories here.

 

I want to take pictures of the area right around the hospital, but I don’t want to be rude. Let me just say that there are chickens, dogs, and cows randomly in the street. There are little lizards on sidewalks and walls. I haven’t seen any cats. I wish I could just show you a picture, so I’ll work on that. There is a narrow, paved winding road at the edge of the hospital that curves down and to the left, there is a covered entrance to the area behind the hospital where the missionaries live. On the paved road, the edges are crumbling, and there aren’t sidewalks. There are moped taxis lined up at the top of the hill. It’s common to see four people on a moped. Or more.

 

On the left there’s an ambulance bay for the ER (they call it Casualty) and a gated courtyard where patients enter for outpatient or emergency services. On either side of the road there are small stalls, as if built by hand out of bricks or wood. Once brightly colored, paint now faded, they have unlikely names on their hand-painted signs, like Computer College. There is a butcher in a tiny stall with plexiglass doors with a large carcass hanging down. There are women selling bananas, sodas, clothes. There are so many men, women and children on the sides of the streets standing about.

 

There’s a lot of hand-shaking here. A lot. Germaphobes would not do well here. It’s a nice custom, and I’m not quite used to it yet.

 

The people that I sat next to on the plane said that I would love the Kenyan people. I teased them both, saying they were only saying that because they’re Kenyan. They were right. Lots of good people here.

 

I went to an HBCU in Atlanta for grad school, a historically black college, and got used to being one of the only white people on campus. It doesn’t feel strange to be white here. It feels strange to be a foreigner, a non-missionary, and mostly, to not speak Swahili. I think if you spoke the language and made friends, this could easily become home, or at least home away from home.

 

Note: I keep saying, “the intern,” because I haven’t asked if I can use their names in this blog. I will have to post separately about the interns on my team and the family medicine resident. They are…so great.

 

I would post this, but the internet is down, has been since I got off work. Will post when I can.

Church and Jenny

December 3rd, 2017 by georginagreen
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Yesterday evening I stopped by the Roberts’ house to drop off Christmas-themed paper plates, napkins, and baking supplies that I had brought from the US for the missionaries for a Christmas party. I’m staying at the guest house, and the Roberts live in the first house on the right, wreath on the door, Christmas lights strewn outside.
Jenny, her husband and their 3 boys have been here for the past 11 years working as missionaries.

 

GG: So where are you from?
JR: …Pensacola, Florida…
GG: Me, too! What year did you graduate from high school?
JR: 1991 (Note that she’s my age but looks about ten years younger. I blame residency.)
GG: Me, too! Where’d you go to high school?
JR: Woodham
GG: PHS
JR: Were you in I.B.? My friends Matt Garland and Matt Maillian went there
GG: I was actually in a church choir with them at First Baptist Church my senior year of high school.
JR: Me, too!

 

I am thousands of miles from home, and I used to be in a choir with the girl next door. I told Dr. Caldwell (a visiting surgeon doing wound care) about it, and he said maybe this is a sign that God wants me to be here. Or maybe it’s random chance. Either way, it’s the kind of coincidence that grabs my heart and stops my breath. Annette, the respiratory therapist, is less surprised, says these coincidences seem to happen quite often. Still…

 

My family went to a small Episcopal church that didn’t have a big youth group or choir, and I’m guessing Matt Garland invited me along to First Baptist. I participated in their Easter service. It was a big choir, and it makes sense that we vaguely recognize each other.

 

I had the day off yesterday, so hung around OB (as we do when we want to see deliveries, when we just have an affinity for pregnant bellies!) for a bit and scrubbed in on a minor surgery. The intern led a beautiful prayer for the patient just before anesthesia was given. I often pray for my patients and for me to have strength and grace and not screw up. I might pray on my way to work, on my way home, when I’m putting my daughter to bed, when I’m in the hospital. It feels unusual and very comfortable to pray with people in a hospital.

 

I think it would be less comfortable to be here at the hospital if I weren’t Christian. This country is 85% Christian and 11% Muslim. The very first sound I heard when I woke in Nairobi was a Muslim call to prayer over the loud speakers at a local mosque, which before now I’d only heard on TV. I wonder what percentage of the population is actively practicing a religion.

 

This place reminds me of the church we went to when we lived in Rota, Spain. I was only five when we left, so my mum may need to correct me, but there was love and acceptance. What I see here is people trying to be good Christians, trying to share God with their friends.

 

This morning I’m going to the Africa Gospel Church at the hospital, where all the missionaries go, with a potluck afterwards. I was in church with Jenny 26 years ago and will be again this morning.

 

After church: At first I thought Ben Roberts was a preacher, but it turns out he’s an ophthalmologist. They’re in the process of building an eye and dental center, so will write more on that later. They broke ground four years ago and hope to finish it in the new year.

 

The service was unlike anything I’ve seen before, like many things here in Kenya. The pastor is Kenyan, and there’s also an American pastor who gave a sermon. Every seat was full and people were standing in the back. We had communion, served by the elder men of the church. There was a special collection for a child who needs chemotherapy. At one point they asked visitors to stand up. Ummm, no, not comfortable standing up in front of a few hundred strangers and introducing myself 🙂 Jenny organized a lesson about Advent and lit the first candle of the Advent wreath. And the potluck afterward was good, too, with a plate that was overflowing.

 

It’s very hard to be in church without my daughter. Starting Advent away from her makes me realize just how far away I am. And now I have the afternoon to study and also hang around OB and scope out deliveries.

When Big Tonsils Cause Heart Problems

December 2nd, 2017 by georginagreen
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Motigo

It’s going to take several days to fully process that first day in the hospital. I’m on the children’s wards for the next three weeks. To orient you, the interior part of the hospital is open to the air, with covered walkways. The buildings look like white painted cinderblock, with glass paned windows that open to the outside. On the interior wall there is an opening near the top, open to the outdoors. The climate is Garden of Eden: sunny, birds, flowers, occasional rain showers. Wherever you are, you may hear people or birds singing. The floors smell of bleach, and there is constant cleaning. The wards also smell of illness, close quarters.

 

The older children are in one ward, beds close to each other, parents in/on the beds with the children. The younger children are in an adjacent ward. Parents take care of the children, along with the nurses. Parents are expected and welcome. On the first day, I showed up for rounds early and found a group of women singing praise songs just outside the wards.

 

The other place that I work is in the nursery/ NICU. We took off white coats, put on gowns, and washed- as you do when you go into any NICU. There are babies in incubators, which are wooden with glass front doors. The heat is provided by light bulbs underneath, and the humidity by water in a plastic bowl. If the baby is too hot, they turn off a bulb. There was a 28 weeker who recently had surfactant (pretty high tech, reduces surface tension, helps the lungs to inflate). There was another 28 weeker under bili lights. The mothers are with the babies or are close by, nursing, holding, cup feeding, washing. I also hear that kangaroo care is coming soon. The nursery has protocols and well-trained nurses, and babies often survive and do well at 28 weeks.

 

Your medical topic for the day deals with Adenotonsillar hypertrophy, when adenoids and tonsils get too big. There was a 15 month old child with large tonsils who came in with malnutrition and heart failure. This has taken me a full day to wrap my head around: the enlarged tonsils led to the heart problems. I knew this was theoretically possible from med school, but I’d never seen it and honestly forgot that it was a possibility.

 

In simplest terms, your blood leaves the left side of your heart, goes around your body delivering delicious oxygen, then comes back to the right side of the heart. From the right side of the heart, the blood goes on a short trip to lungs for more oxygen, then back to the left side of the heart and out to the body again.

 

If parts of the lung don’t have enough oxygen, the alveoli (tiny air pockets in grape-like bunches at the ends of the lungs smallest branches) sense there’s not enough oxygen and close up shop, sparing that part of the lung. It’s meant to be protective, to let the well-oxygenated parts of lung do more work. But when parts of the lung aren’t open for business, you get back pressure in what is usually a very low pressure system. The blood that is trying to go from the body to the right side of the heart has to push harder to try to get through to the lungs. Pulmonary hypertension (increased blood pressure in those pulmonary arteries that go from the heart to the lung) ensues, along with remodeling of arteries that are trying to cope with the increased pressure. And the right side of the heart can stretch out, dilate, and fail. We call this cor pulmonale, when the right side of the heart starts changing and doesn’t function properly. The back pressure can cause problems in the liver, fluid in the abdomen (ascites), swelling in the legs, etc.

 

And if you are unlucky enough to also have a hole in your heart (this child has an ASD, atrial septal defect), you can end up with shunting in which the unoxygenated blood from the right side gets pushed through to the left and out to the body without getting oxygen put into it. Making it even harder for the child.

 

What can cause hypoxia? COPD (chronic obstructive lung disease), lung disease, OSA (obstructive sleep apnea, high altitude. We’re at 6700 feet here, but that shouldn’t make a big difference. For this child, it’s his tonsils. We call them kissing tonsils when they are so large that they touch.

 

I wasn’t there when he was admitted, but the symptoms could include shortness of breath, fatigue, lower extremity swelling, increased abdominal girth (ascites). How does a toddler tell his mum and dad these things? On arrival he looked like a child with heart failure. And an echocardiogram, an ultrasound of his heart, helped with the diagnosis.

 

So the child gets oxygen and sildenafil (AKA Viagra), which helps. I remember an episode of Top Gear, the British TV show about cars, in which the presenters were trying to win a race from Bolivia to Chile and wanted to take a shortcut across the Altiplano at about 16,000 feet. They thought they might fare better if they took Viagra at high altitudes to prevent pulmonary hypertension. In the end, they had altitude sickness and oxygen saturations of 84% (not cool), so they turned back and went a different way. I remembered that show when I was at KU Med and the pulmonologists were prescribing “Viagra” (using a different name) and its friends for pulmonary hypertension.

 

Sildenafil works by decreasing the activity of PDE5 (phosphodiesterase-5) so that more cyclic GMP is available for the blood vessels inside the lungs. Think of it as helping the muscles in the walls of the arteries to relax. When they’re relaxed they can open wider and let more blood flow through.

 

The solution for the child is to have the tonsils and adenoids removed. There is a hospital an hour a way with an ENT who can do the surgery, but the child has to gain weight first. He’s malnourished and has to “make weight” before he can have the surgery safely. He’s now off oxygen and getting ready to go home. The discharge plan involves the social worker helping them get fortified milk.

 

The families have to pay their bill before they leave. So they sometimes get “discharged in,” which I think is the time between settling up with the hospital and going home. So the next time I round, he will have been sent home: stable, off oxygen, with a plan for sildenafil, fortified milk, and hopefully surgery in the near future.

The Thank You Post

December 2nd, 2017 by georginagreen
Posted in Uncategorized|

I shall try to begin and end this blog and this journey with thank you’s. In residency, as in med school, it takes a village to get through it. I need to thank:

 

-The foundation that is funding this trip, Baptist Trinity Lutheran Legacy Foundation, and Dr. Salanski and Beverly Cline at Research Family Medicine Residency program for helping with the logistics.

 

-To InMed, including Dr. Comninellis, Elizabeth Burgos, Nick Edwards for making this happen.

 

-To the Tenwek staff, especially Annette and Eunice. Helping me to get ready for the trip has been like wrangling cats, and I appreciate all the kindness and patience.

 

-To Rich, for feeding the fish and feeding the humans. There aren’t enough big words to properly thank you or explain what you do, so I’ll leave it at that.

 

-To Zoe, for understanding, for being supportive. It is like leaving a limb or my heart behind, and I’m surprised to find that my heart can still beat, and I can function so many miles away from you. And thanks to Skype, I can still ask you about homework and soccer practice.

 

-To the rest of the family and my friends for being so interested, so invested, so loving, so patient. Especially Lexi for being in tune with my mixed feelings about leaving, for noticing. It’s actually fine 🙂

 

-To Dr. Parvin and Mother Kelly Demo for letters of recommendation. Thank you for taking time that you didn’t really have in order to do that for me.

 

-To Margaret and Lionel, for tea and love on the journey through London, for being my other set of parents. Thank you and Phillip for the posh taxi to the airport. Thank you for telling me your stories of Kenya, looking through the Atlas, and teaching me how to order beer in Swahili. I won’t need it on this trip, but will keep it in my back pocket!

 

-Thank you to Chris and Gewel for covering my “beans” at work while I’m gone.

 

-Thank you to Lisa, my favorite nurse, for taking care of so many things.

 

-I’m writing this to you from my dad’s iPad. My sister bought it for him earlier this year two months before he died. I was reluctant to use it. But I think he would be excited to know that it’s here with me, being put to good use. And thanks to my mum and dad whose love always carries me.

 

-And since I’ve arrived…thank you to my Kenyan seat mates, one on either side of me on the plane from London to Nairobi. For helping me to feel calm, for letting me know a little bit of Kenya and feeling good about it before touching down. To Isaac, for talking to me about haggling, exchange rates, politics, weather, clothes, families. To to the older Indian Kenyan, thank you for being just so kind, lovely, normal.

On My Way

December 2nd, 2017 by georginagreen
Posted in Uncategorized|

Rift Valley, Kenya

Hello Mum! Hello Lisa (my favorite nurse)! Just want to acknowledge the two people who I know will actually read this blog, who want to know that I’m okay, who would like to to be stow-away mice in my pocket, like Stuart Little. I will try to share with you the days as they happen. The other thing I’d like to do is share information about an illness each day.

 

Written en route: The first illness is SHINGLES! Which I had one month prior to departure, on my face, which I didn’t know was shingles, which put this trip in jeopardy. On Oct 27th my boyfriend, Rich, was working in Western Kansas. The girls had the day off school, so I also took the day off work. That day I had my eyebrows tweezed at a cosmetology school. Two days later there was a small blister between my eyes and my left eyelid was itchy. I thought nothing of it.

 

The following day, the preauricular lymph node on the left near my jaw was tender and large, and there was swelling around the blister. I thought I was getting an infection in my face, possibly from dirty tweezers. One day 4, the left side of my face was visibly swelling and hurting. I could feel individual lymph nodes in my upper cheek. I went to an urgent care and was prescribed Augmentin. Each day for the next five days the symptoms got worse, I saw a different physician, and the antibiotics were increased (Rocephin, Bactrim…) On day 9, the swelling started to recede, and there was a pattern of lesions down the left side of my nose that looked like shingles. Herpes Zoster. Herpes, the great imitator.

 

On day 13, when I could no longer ignore my blurry vision, I went to an ophthalmologist who said there were lesions on the epithelium of my eye, so on my eye but not in my eye, and he started me on an anti-viral medication.

 

Written after my arrival: Official diagnosis is herpes zoster opthalmicus (cranial nerve V1). The blurriness has gone away and for the most part, I’m better. The pain was as though someone was leaning on the blunt end of a screwdriver in the middle of my forehead for over two weeks, plus the nerve and skin manifestations in the area. I could go on for hours about the pain, how humbling it was, how I wasn’t sure if I would be able to go on the trip, how people around you don’t seem to be empathetic enough, how frustrating it was to go without proper diagnosis and treatment, how I should have taken time off, about lessons learned. Dealing with shingles dominated late October and November.

 

On my first day in the hospital at Tenwek on Dec. 1st, the second patient I saw was a teenage boy with HIV who was admitted with shingles on the lower part of his body. He was quiet and patient through rounds as we talked about the plan for him and when he would be able to go home.

 

It’s not that my experience with shingles wasn’t important, but it pales in comparison to what I saw with just one patient. My recent experience gave me a small window of empathy, perhaps. But this child. His pain. His burden. It’s hard to take in. And before lunch I had seen TB meningitis, heart failure, malnutrition, pneumonias, etc., and seen a just-delivered preemie too young to survive. It was and is overwhelming.

 

Being at Research Medical Center for residency has been good preparation for illness and tragedy. Med school was helpful, too. But this place is new to me. I think there are over 20 (?) long-term physicians here on medical missions doing ophthalmology, cardiothoracic surgery, OB, primary care, etc. I wonder what it’s like when this is not new and overwhelming every day, when this is your home, and this is the way you get to practice medicine.

 

I’ve been placed on the pediatric service which also covers nursery and NICU. When we finished rounds I joined the medicine rounds seeing the adults. And this weekend I will spend some time in OB.

 

On rounds the residents prayed at the bedside of every patient with their families. It’s a missionary hospital, and I was also asked to lead some of the prayers. It’s humbling to be here. Also, I’m considered a consultant or attending here, which is interesting. I’m with the long-term staff who young, enthusiastic, whip-smart and evidence-based, and who are teaching me, too. I feel like the resident that I am. But a lucky one, because there is time for learning here. So I’m studying every day and loving the time to think and learn and sometimes also teach.