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.