December 15th, 2017 by georginagreen

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.