Thank You, Sir, May I Have Another?

With the turn of the new year, and near completion of our first year in the field, it is virtually impossible not to look back on our tenure here thus far.  Peering in the rear view, it’s easy to see many people and situations that have been responsible for shaping our experience.  Some good, some bad, some outrageous, but all of them lasting.

We are currently still in the throws of one of those experiences - the strike.  The strike is now in it’s seventh week.  I have never been a part of a strike.  My only other related strike experience is with the nuclear plant where my dad worked when I was a kid.  My brother and I thought it was cool because he was home all day until its conclusion.  This time, it’s not so enjoyable.  Myself and others like me in surrounding mission hospitals, are logging countless hours to try to ensure that every patient is seen and well cared for.  I have had only one day off since the walk out, and I believe I speak for all of us when I say we are exhausted.

Our hospital is literally bursting at the seams.  There is no more space to put a bed in our medical ward; so, if more patients are admitted, they will have to share beds with their nearest, non-infectious neighbor.  HIPPA is non-existent in this context. 

Recently, while shuffling through our metal wired beds to do rounds, I came upon one of our patients standing in the threshold of a doorway.  He appeared to be studying the ward, but not giving much attention to me standing before him.  As I tried to slide past him and continue seeing patients, he raised his right arm and in it he clinched six feet of rubber coated wire.  Before I knew it, this octogenarian was beating me like I stole something.  It was the only time in my career that I was thankful to be wearing a white coat, as it provided an extra layer of protection from his arthritic, yet effective blows. Needless to say, the five patients in the isolation room remained as such; isolated.  Our demented doorman was not allowing anyone entry.

Maybe he thought I was responsible for cooking the food he was served?  Maybe he thought I was responsible for the strike?  Maybe his smoldering dementia turned to delirium from being in the hospital, which is completely understandable.  Either way, just when I thought I couldn’t be mentally or emotionally beaten any worse from the many consecutive days of work, I got a quick and welt-producing reminder that it can always get worse. 

Reflecting on the call of our lives, we are reminded that in being called, we are not promised to be liked,  successful or fruitful in ministry.  We are not promised safety and security; not even from an eighty-plus year old dementia patient with a solid right arm.  We are, however, promised that the Father will be with us and not forsake us.  That makes the sting of life’s unfairness, or that of rubber coated wire, a little more bearable.

 

TB or not TB? That is the Question.

TB or not TB, that is the question.  Although this may be a clever play on words from Hamlet’s famous manifesto, it is a question that health care providers across the globe ponder all too often.  For Hamlet, these words were birthed out of his existential crisis of whether or not anything but the present is true; suggesting the past and future are illusive and unknowable. For those with tuberculosis, not only is the present a real and imminent danger, it is a reflection of their past and has tremendous ramifications on their future.

Tropical Medicine.jpg

A recent report from the World Health Organization detailed the increasing number of cases of TB worldwide.  A growing number are multi-drug resistant, and give rise to many more deaths annually (1.8 million deaths per year) than Ebola ever claimed.  Common among TB patients from high, middle and low income countries is that this is a disease of poverty.  Crowded living conditions, malnutrition and chronically uncontrolled comorbid conditions place men, women and children at risk for acquisition or reactivation of this aggressive infection.  Therefore, an individual’s past and present situation can have an exponential effect on his or her future.

During rounds in our rural, under-resourced hospital, we are faced daily with this question...Is it TB or not?  Anyone who knows anything about TB knows it’s not only a question of whether or not they’ve had productive cough and fever.  TB is the new “great masquerader” and can present similarly to a myriad of diseases and disorders.  In the short time that I have been here, we have diagnosed cases of pulmonary TB, as well as meningitis, pericarditis, endocarditis, arthritis and peritonitis due to TB.  All of these were in individuals who were HIV negative, and considered immunocompetent.  Now imagine how our patients with HIV or full blown AIDS present.  Needless to say it has been a daily exercise in humility and further education.

To combat one of the other collateral effects of this horrid disease, domestic and foreign governments have worked to offer TB medications at no cost to our patients here in Kenya.  This allows them to gain access to the medications, while not diverting their household income from other essentials items like food, transportation or school fees.  However, this is not without its own complications as the incidence of multi-drug resistance is increasing globally, at times rendering us completely helpless.

While Hamlet remained anguished and paralyzed by his current suffering, we likewise should be anguished about the suffering of our marginalized brothers and sisters around the world.  Though being anguished, let us not be paralyzed.  Let us move forward in love and deed to those across the street and across the globe who are suffering because we have One who knows our suffering and has suffered for us.  

Bloodlines

A few weeks ago, a middle aged man was admitted to our medical service and was found to have a hemoglobin of 3 g/dL (normal 12-15 g/dL), white blood cell count of 4,000 mm/³ (normal 4,500- 12,000 mm/³) and platelets of 5 (normal 150,000-450,000).  Needing to act quickly, we typed the patient’s blood for transfusion (O Positive) then queried our lab to find the nearest bag of platelets.  The result was Nairobi, four hours away, and to make matters worse, our hospital was fresh out of O positive blood.  Crap. 

We moved to plan C and asked the family to donate blood, hoping for a match, but not one member was.  So, now what?  It then occurred to me that I was O positive, so I proceeded to the lab to provide the blood. 

After being on the business end of that needle that I remembered being much smaller the last time I donated blood, I had a few minutes to think about the current situation. I thought about the importance of blood, and how it is a vehicle to take oxygen to the far reaches of our bodies so our cells can carry on countless molecular processes without us giving it a moment’s thought.  Wow, what an amazing Designer we must have.  I wrestled with the reality of the finite nature of my blood, only capable of being a literal and proverbial Band-Aid for this man.  I then reflected on the One who not only gave His blood, but His entire life for all regardless of tribe, nation or tongue.  My feeble attempt at giving of myself seemed incredibly minuscule.

Interestingly enough, this patient was not from Kenya.  He was from a neighboring country that does not have a good working relationship with Kenya.  As a non-Kenyan with only a short history here, it was easy for me to view this person as an image bearer and not an enemy.  For others, though, perhaps this was more difficult – he was one of “them.”   In a day and age where “us versus them” leavens every aspect of our lives from politics to sports to bathrooms to peanut butter (crunchy definitely), it can become easy to dehumanize “them.”  It challenged me to think about my definition of “them.” Would I have been so eager to give my blood to someone who I defined as “them?”  Thankfully, there was One who gave His blood for me when I was still an enemy.   

Bag filled, needle out and back to the list I went: internal medicine, pediatrics, neighboring and trying to love because we have been loved first.

Until next time...

What Did I Just Say?

When you’re young, you have those things that you’ve heard others say that you swear you’ll never say.  These are not those.  These are things I haven't considered saying before now.  Sometimes, I laugh after hearing what has just rolled off my tongue. I'm sharing so that maybe you, too, can have a little chuckle with me.

1.       Get the glue gun and Velcro…the screens on the windows are coming loose.

2.       Turn…turn…turn…no...I don’t see any blood. 

3.       How many days have you worn those socks?  2?  Sure, you can wear them again today.

4.       Don’t throw that ziplock bag away.  I'll wash it and hang it out on the clothes line to reuse.

5.       The kitchen’s flooding….AGAIN!

6.       No thank you – I don’t need a live chicken today.

7.       Quick, blend everything we need for dinner...the power is flickering.

8.       Don’t put the eggs in the fridge; just sit them on the counter…I’ll wash the poop off as I use them.

9.       Expiration date was when?  Two weeks ago?  We’re good; it’s only a suggestion.

10.   Is that a live animal on that motor bike with 4 other people?  Yup!

11.   Uuuugggghhh – I just fried another electrical device!

12.   Open the oven door to let out some of the heat; otherwise the nobs start melting!  [Our oven doesn't have a thermostat.]

13.   As usual, you look nice today, sir. [speaking to the working farmer who is wearing slacks, a button-up and a blazer.]

14.   To the left, to the left… (repetitively singing Beyonce’s song while driving to remind myself to stay on the left side of the road.)

15.   Could someone bring me a bucket of water to fill up the toilet?

16.   Hurry, get the clothes off the line – they just set the trash on fire again!

17.   Why does it sound like there’s a [fill in any given animal] right outside of our window?  Oh, because there is. 

18.   It’s 65 degrees.  You know you should have on your toboggan, gloves and coat to go to school.

19.   Relax.  I know it's time for church to start, but we’ve got another 10 minutes before we’re actually late.

20.   Scalp ringworm, you say?  Is that better or worse than lice?

Until next time…[hopefully my head will have stopped itching by then.]

Ready or Not?

Volume and variety were the norm inside of the historic walls of the Los Angeles County Hospital, providing a robust clinical foundation to propel the avid learner out into the world of medical practice. Training at Mother County made me ready to handle a multitude of things, but it only took a single patient in Chogoria to point out all the ways I was not fully prepared for medicine in this new setting.

When the intern covering the pediatric service called in the middle of the night about a 10-day old baby girl, I was confidently ready to:

  • Address her serum sodium of 175 (normal 135-145);
  • Cover her for bacterial infections given her age;
  • Intervene when the potassium and creatinine (marker of kidney function) in her blood began to rise;
  • Manage respiratory distress with minimal equipment;
  • Treat her oliguric renal failure.

However, I was NOT ready to:

  • At best, check the baby’s labs once per day because of our hospital’s fickle machine;
  • Hear we could not obtain cultures…of any kind;
  • Learn that we do not have common medications to lower her potassium;
  • Hold a piece-meal face mask to her tiny face to supply oxygen while the intern went across the hospital property to find our lone CPAP machine;
  • Use the smallest nasogastric tube I could find because we had no urinary catheters;  
  • Fight off a bird during the process until it finally showed itself out the open window.

When this tiny patient’s condition was not improving, I was ready to transfer her to Nairobi for a higher level of care.  However, I was not ready to:

Our hospital's bay where we met the ambulance to take us to Nairobi.

Our hospital's bay where we met the ambulance to take us to Nairobi.

  • Hear that the parents would have to pay her hospital bill in full before she would be released;
  • Learn that because it was getting close to night fall we would not be able to travel until the morning because of the numerous dangers of Kenyan roads after dark;
  • Ride four hours in the back of a hulled out Land Cruiser while holding the baby in my arms because it was the safest of all our options (i.e. no car seat, isolette, papoose or gurney) as her parents sat scrunched in the front next to the driver;
  • Listen to the siren’s unrelenting plateau next to my ear as we navigated the insanity of Nairobi traffic;
  • Argue for two hours at the receiving hospital to have her seen by a nephrologist such to get her started on dialysis.

After leaving the hospital, I replayed the scenario hundreds of times in my head and wanted to fast forward to see how it would all work out.  Interestingly enough, two weeks later in the market, I felt a tap on my shoulder from the patient’s mom who asked me, “Daktari, do you remember me?”  When I saw her, I was completely ready to hear how her baby had received dialysis and was improving.  I was far from ready to hear how she was in the Nairobi hospital for three days, and never once received dialysis.  When finally taken to the operating room on the fourth day for insertion of the dialysis catheter she arrested and died on the operating table.  

At that moment I was ready for her to be angry, hurt and express her disappointment in our ability to care for her young daughter; all the things I likely would have done if our roles were reversed.  I was not ready for her to say thank you and then give me a hug.  In the midst of her pain and loss and suffering she offered me something that I so often am ready to receive, but am not ready to extend.  Grace and mercy.  

In moving my family to Kenya I was ready to use all that I had learned to listen, teach when necessary, and do when needed.  I was not ready to be taught so much by a young baby and her mother.  This lovely woman reminded me that when we are not ready, in the midst of our weakness, there is One who is ready to fill us with what we need.  By grace and mercy strength is made perfect in weakness.

 

Swahilbilly

Growing up in rural Appalachia, it goes without saying that we have a special way of expressing ourselves.  Syllables and vowel length have been mere suggestions.  Creating melodious, multisyllabic words in a single bound are somewhat of an inherited super power.  However, our proverbial kryptonite is learning a new language seeing that we are still trying to master our first one.

This is Millicent, one of our amazing language helpers.

This is Millicent, one of our amazing language helpers.

While at our training in Colorado, we were taught many techniques on how to learn a new language.  We were introduced to a new phonetic alphabet, how to execute glottal stops, what on earth a fricative is (my favorite new word) and that sometimes it’s ok to spit when you speak.  We were also reminded that learning a new language, and in turn a new culture, is a wonderful exercise in humility.  Our octogenarian instructor said we would spread great cheer amongst the locals while learning the language.  He would often repeat, “no one will speak your target language quite like you.”    He enthusiastically encouraged us to get out there and “butcher it to death” because in his mind, there is no other way to learn than to give it a shot and make a million mistakes along the way. 

So far he has been right.  No one in Chogoria has spoken Swahili quite the way we do; at least no one around here has a southern accent like ours.  And over the last 7 weeks, we have done everything in our power to butcher Swahili.  We have spread cheer in the market, at church, the matatu stand and to our language helper.  Rarely have we seen another grown person laugh so hard.  The great thing about it is that it is not a laughter of mockery, but one of endearment.  Our language helper has gracefully loved us while we have destroyed her native tongue with our non-stop onslaught of pronunciation snafus and grammatical mishaps.  At times subject verb agreement eludes us in English, so you can imagine how many mistakes we make when the sentence structure is completely opposite of what we are accustomed to (yes, I just ended that sentence with a preposition).  Some of our greatest hits are as follows:

1.       When asked what my favorite food is, I quickly replied “tacos”!  I was subsequently informed that taco (spelled tako) in Swahili means buttock.

2.       While attempting to put together some incredibly rudimentary sentences, I supplanted the word for “show me” with the word for “breastfeeding.” 

3.       Again to my surprise, and to our language helper’s enjoyment, the word for house and the word for fart are only one letter different.  You can guess which one I used.  Despite my intended kindness, inviting someone over to your fart, doesn’t quite extend the same courtesy in any culture.

4.       Lastly, the word “prepare” is very, very close to the word “circumcision.”  I’ll let you fill in the blanks.  

So, we will continue to lay our pride aside and continue to walk in humility towards some semblance of fluency.  Along the way we will likely be able to create our own dialect out of our innumerable mistakes.  We’ll call it Swahilbilly.  Regardless, this has been another area for us to lay down our ideas of success and self-sufficiency, and fully rely upon the Father for provision.  We may never fully learn Swahili, but we will never forget the lessons of unconditional love, mercy and kindness we have been shown by all throughout this process.

Kwaheri…

Shock to the Heart

Defibrillators.  In the U.S., they are found in nearly every public location.  Walmart, shopping malls, airports and even sports arenas all have these devices for the treatment of cardiac arrest.  Until a few weeks ago, our 300+ bed hospital here did not have a single defibrillator.  Pause for effect…

Additionally, only a few of the interns had heard of Basic Life Support (BLS) or Advance Cardiac Life Support (ACLS), and none of them had ever received formal training in either of these.   (To the non-medical community, BLS and ACLS are effective means of providing CPR to an individual who has stopped breathing or whose heart has stopped beating.)  Thus, last week, we taught 16 hungry learners how to perform chest compressions, administer correct medications, manage airways and recognize abnormal cardiac rhythms.  It was amazing to see how eager they were to learn these new skills. 

In the middle of the second group’s BLS/ACLS workshop, the Resident on internal medicine burst into the classroom, and yelled “Where’s the defibrillator!?”  Someone pointed to its location beside the CPR manikin, and the Resident grabbed it and ran.  A young woman on the ward had collapsed at the bedside.  When the Resident returned to the collapsed woman equipped with the defibrillator, he found the Intern doing chest compressions just as he had learned only days before.  The Resident placed the defibrillator pads and quickly recognized ventricular fibrillation.  Shock advised!!!  The surge of electricity converted the disorganized fibrillations back into a regular, life-sustaining rhythm and the woman's pulse returned.  Success!  Immediate return on investment, and immediate improvement in the standard of care.  Praise God!

If this situation would have occurred just a few days earlier, the outcome would have most likely been different.   Already the Lord is using a donated defibrillator, passionate teachers and hungry learners to improve the overall quality of healthcare here.  That is not only exciting, but also life giving to everyone involved.

Until next time…

Jason teaching a group of interns BLS/ACLS.

Jason teaching a group of interns BLS/ACLS.

 

 

Karibu Kenya

We’ve been in Kenya for a little more than a week now, and the jet lag has nearly waned.   Our flights were thankfully uneventful, and praise the Lord, despite the TSA rummage sale, all of our luggage made it too!  We were graciously greeted in Nairobi by a family that has been in Kenya with another organization for nearly two years.  They helped us get our luggage and secured a place for us to stay for a couple days.   

While in the capital we were able to purchase some things that are not available in our rural area (believe it or not Ree’L found a few bottles of Mountain Dew in Nairobi), and we were able to take Sylis on a little excursion to an elephant orphanage.  For $5 we got to see the feeding and play-time of 24 elephants, aged baby to adolescent.  Because there was only a thin piece of rope separating you from these rambunctious creatures, an occasional body check or a tap from their trunks came free.

Once we regained some of the sleep lost from the flights and stocked up on items, we made the 4.5 hour drive out of the city up to the eastern base of Mount Kenya.  A good, but windy road led us on a connect-the-dot tour between towns and markets, from Nairobi up to Chogoria.  We had to take two cars from Nairobi to our new home - I wish I could have been in the car with Ree’L and Sylis to hear their impressions of what they saw as this is their first time in Africa. 

Much like at the airport, we were greeted here in Chogoria with open arms.  In our flat (i.e., our apartment), there was a fresh bouquet of flowers picked earlier that day, two dozen eggs and a fresh jug of milk still steaming from the cow’s utter.  Another family from our organization arrived here last month, and they have been a tremendous blessing during our initial transition. 

Since in Chogoria, we have met many wonderful Kenyans who have gone out of their way to make us feel welcomed.  Over the last several days we have been busy meeting our language helper and neighbors, visiting the hospital, solidifying Sylis’ schooling during our language training, getting mattresses to sleep on and unpacking. 

Sylis quickly found his Legos and got to work.  He also found the tree swing, and another tree he easily scaled.  We discovered him about 12 feet up with a puzzled, but “I’ll figure it out later” look on his face as to how to get down.  We should have brought his bike helmet.

Spending some time in the market, we procured milk from the “milk guy,” got new keys cut and filed by hand, and tried to identify the best produce prices.  We have also seen several feats that defy all laws of physics.  The greatest of these was a pikipiki (imagine small dirt bike) hauling a full sized couch.  If that is of no consequence to you, then imagine someone sitting on the couch!  I can’t even make that up. 

On Monday, we will put what we learned at our training in Colorado to use and begin our three months of intense language training. For two people who do not feel as if they have a tremendous grasp on the English language, this is going to be a great exercise in perseverance and patience.  Thankfully mangos are in season and there is plenty of push-pot coffee to go around.  With his own language helper, I’m sure Sylis will make laps around us and pick up the language in no time. 

Here are our top 5 lessons from the last week:

1.       You cannot return anything after it is purchased, even if it doesn’t work (ouch!).

2.       Unpredictable electricity requires far greater planning than expected.

3.       You can put anything, and I mean anything, on a pikipiki (i.e., dirt bike).

4.       Milk straight from the cow is utterly delicious.

5.       It’s impossible to get in and out of the cell phone store (Safaricom) in less than 2 hours, regardless of your cellular need.