At Journey's end?

"Are you ok?" A few people have asked us this question. Looking back, we dealt with international travel, a terrorist attack, pediatric morbidity and death, cultural adjustment, sleep depravation, sickness, but also glorious healing, amazing fellowship, new medical knowledge, birth, life saving, Gods creation, closeness of the Holy Spirit, fruit of marriage, and vision building. There is no good answer to that question. We are damaged permanently, but in a really good way.  Our hearts are softened, our eyes are opened, and we are humbled.  Truthfully, I think this is exactly where we are supposed to be.

Returning to the US has been a challenge.  I see soccer moms in their mini vans and SUVs, paved roads, buildings with insulation, windows and roofs, and a notable absence of the trash-burning smell that seems to permeate every developing country I've been in.  I feel like the guy in the movie "Avatar," having difficulty distinguishing between realities.  Kenya feels like an alternate universe, but it was so real.

Gods Word tells me that I'm an alien and foreigner.  In fact, we all are.  I don't fit into the US. I don't fit into Kenya.  I don't fit in anywhere on this earth.  That's because I'm a citizen of heaven.  Why am I still here then? Kenya taught me that it has much more than just evangelizing.  I am an ambassador to this world - to not only testify to the saving grace of Christ's death and resurrection, but also to love people and fight back the darkness.  That's God's story for humanity, also called the gospel.  It's what Jesus did while he was here, and it's what I've been called to do also, whether in Kenya or the US.

One last thing: the Needy Children's fund is needy.  For those who may not know about it, this fund is to provide assistance to families who have a hard time affording the cost of the care at Kijabe (which is already 5-10% the cost of other hospitals).  Even a few dollars can be overwhelming to these folks. Sometimes, their medical bills are really steep.  A single dose of surfactant necessary to save a preterm infant costs 13,500 KES($150 USD- costs several thousand in the US, btw), more than a years wages for some.  This fund helps these families that are over-burdened with theses costs.  Right now, the fund is dwindling a bit.  If you feel compelled by our story, please consider giving.  A few dollars even can go a long way.  You can give through one of the missionaries' church:

INSTRUCTIONS:

1.  Write a check to "Bay Leaf Baptist Church" with "Kijabe Needy Children's Fund" on the memo line.

2.  Mail it to Bay Leaf Baptist Church/12200 Bay Leaf Church Road/Raleigh NC 27614 (USA)

3.  It helps if you email me to know to look for the transfer (drs.myhre@gmail.com)

4.  The church will send you a receipt by mail within a month.  100% of donated money goes to the Kijabe fund, so the church donates the administrative costs.

A couple of blogs to follow for more info.  These are some of the sweet and amazing pediatricians we met while there:

http://paradoxuganda.blogspot.com (Jennifer and Scott Myrhe)

http://journeybeyondtheboat.blogspot.com (Rick and Sarah Gessner)

http://steeres.com/ (Andy and Mardi Steere)

Until next time....

Bryan

Goodbye and Hello

This will be my last post about our trip. It's crazy how fast the month has gone bye in one sense, and yet in another sense it feels like we've been in Africa much longer. I'm anticipating the ,"how was your trip?" Question from many people coming soon, and I'm not quite sure what to say. How do you wrap wonderful/life changing/sad/huge learning experience/greatest challenge/blessing/awesome/grievous into one simple sentence? I don't know.

Our final day was a great representation of all these emotions colliding. We had agreed to round early so that we could be present for all of rounds, facilitating a smooth transition of care to the attendings who would be taking over in both the nursery and on the ward. However, just about a minute after I walked into the hospital Thursday morning, I got a call from one of the interns "Dr. Sarah, it's Samantha. You need to rush." That only means one thing at Kijabe. I was on the ward about ten seconds later, finding one of the patients I've been looking after in cardiac arrest (not breathing, no pulse). My interns had already started chest compressions. Her IV had blown and wasn't working for us to give epinephrine, so we prepared to intubate and give it down a breathing tube. Several minutes and two doses of epinephrine went by and still we had no pulse. One of the pediatricians I was working with came and was able to place an intraosseous line (an IV that goes straight into the bone marrow which has great blood supply). We gave more epinephrine through that line, but still no heartbeat. We gave another drug, atropine, and finally got a heart beat again. It was a miracle. We were able to change the beds around in the ICU so as to get her a spot and moved her there for mechanical ventilation and blood pressure support. Then, our medical interns and the pediatrician missionaries surprised us with a going away party! It was supposed to be at 830 (they fooled us by asking for early rounds) but anyone in medicine knows that plans can change in a moment. So we all took a seat around 1030 when they gave us a traditional African goodbye party, with everyone going around and saying a way that thy had been blessed by us being there. We decompressed and celebrated simultaneously.  Bryan and I agreed that it was one of the nicest things we had ever experienced in our married years. It was really humbling. Apparently, I am strict but funny. I force people to follow up on their patients and I can talk about the same patient for more than forty minutes as i dissect their problems by body system (this is so normal to me but they thought it was crazy!) I also know way too much pediatrics (my how wrong that is!) and help people think outside the box about what could be wrong. Bryan, on the other hand, sweats a lot while working they say! He is "loud like all Americans" but he really cares about finding what's wrong with his babies. He is strict, like me, and the team he worked with laughed as they said his first words in the morning were always "Ok, let's get started," so they knew they needed to be ready. (It reflects a little bit of a culture difference because there is a much more relaxed pace in Africa... Rarely is there hurry). We assured them we had learned as much or more from them. They've taught us to stress less, look at patients Instead of labs and to value relationships even when there is a lot of potential to just stress and "get the job done" because lives are on the line. We've learned to be quicker to pray for people and to trust Gods hand because ours are more tangibly limited. I could go on and on and on. 

We met one of the moms of a mutual patient of ours (I admitted her premature baby from clinic with severe sepsis at 1 month of life and Bryan took over her are in the hospital). She asked us to come see her baby before we left and say a prayer of thanksgiving with her because of the baby's improvement (truly a miracle that the baby lived). We went with her and I took a picture of her with the baby and Bryan. "You gave me hope" she told us. "God told me to bring my baby to Kijabe." It was a huge encouragement, as our hearts were still heavy from the morning. We have seen so many kids not make it this month, but we have also seen so many miraculous recoveries. It's good to be reminded of them.

We had to hurry to turn in phones and grab our bags afterward. And ever since we've been journeying toward Greenville. 

There is no question that I already miss Africa. I never expected that. In fact, I may have told some of you in the past that I didn't feel called somewhere like that, so far away. For sure I knew that I felt no calling to a career in academic medicine. God has a way of changing things, doesn't he? Im pretty sure ive already said this. Im bad about repeating myself. Bryan and I feel like our job there has just begun, and its easy to want to be frustrated by leaving. I don't want to be that way though. I think that while God has given us a huge love and vision for Africa, he's also clearly assigned us somewhere else for now.

Back to life as we knew it, but I believe it will be different. I'm excited about all that I have yet to learn. I'm excited about becoming a better teacher. I'm excited to complete my assignment to be a resident who glorifies God in all aspects and pray for the power of the Spirit to finish well. I'm excited to see Sarge and to ride my bike. I'm excited to see all of you and give you a hug! 

Words can't say enough thank-yous for all of the prayers and support you have given over the past four weeks. They have been heard and we have been abundantly blessed as we've sought to be a blessing.

The journey has just begun! Goodbye to Africa but hello to home. We think we will keep the blog so folks who so desire can keep up with us. Stay tuned.

SB

And Last but certainly not Least...

Tonight is our last evening in Kenya. Our hearts are heavy, and we feel like the job isn't done - in fact, we feel like the job has just started. Our last week here has been particularly challenging. For me (Bryan), probably the toughest nursery week yet. This past weekend was wonderful. We took our safari and saw just about every animal possible with the exception of cheetahs and elephants, which are not endemic to the park we were at. We took some amazing pictures! Sarahbeth will have to post them on facebook. We went with a local driver, Philip, and a missionary from Passion church named Emily. I think our time on the safari was magnified 100x because during the trip we sang hymns, hillsong, and Chris Tomlin (who is huge in Kenya! Philip knew all of his songs). We shared our stories on the way back and bonded in a really neat way. I also learned a little swahili. Philip was sad to see us go. We returned Monday with Sarahbeth on call (we take call from home, so I was also on call...). I learned a very valuable lesson - I grumbled a bit as she asked me to assist her with a delivery. I was convicted of my bad attitude and swung my feet over the edge of the bed at 11:30pm and headed to the hospital. Boy, am I glad I was there. The resuscitation was a nightmare. The call was a meconium delivery with bradycardia. The baby came out totally lifeless. I intubated and suctioned 3 times. Sarahbeth was able to get some practice and intubated and suctioned once. I have never seen so much meconium in a baby's airway! Every time we suctioned we got more and more out - I kept thinking "there is no way this baby could fit more meconium in his airway. The heart rate began dropping and I was preparing to start CPR. Fortunately, the baby started crying after Sarahbeth suctioned the last time (it took a woman's touch). Two days later, the baby is doing great, on room air and will likely go home tomorrow. Later that night, another one of my meconium babies (don't ask me why we've had so many) started deteriorating, so we put him on the vent. He's required a little dopamine, but now doing a bit better. Sadly, there have been several other babies that did not do so well in the past week. Notably, I had a trisomy 13 (patau syndrome) baby born on Sunday and die the next day of a heart defect. Mom was devastated. There really isn't much prenatal care and she was expecting a normal infant. We were able to provide comfort measures. Sarahbeth lost a patient to lupus nephritis. She was a 14 year old that presented with decompansated heart failure. We suspect she also had some cardiac involvement, but not having a full time peds cardiologist, we couldn't get an echo. Our hearts are heavy at these losses. Sadly, things present so late here. In the words of Sir William Osler, when a patient presents late, the diagnosis is easy but the treatment difficult. We are packed and ready to head home tomorrow. We cannot wait to see everyone and share what we have seen and what God has done! We also can't wait to return to finish the job... - Bryan

Safari in Lake Nakuru National Park

Just a couple pics I snapped this weekend! We had so much fun (and yes I am this close to the giraffe... Crazy crazy.)

Faith and patience

I read this morning in Hebrews that we should be diligent to not become sluggish in our faith but rather follow the example of those who've gone before us, "who through faith and patience I inherited the promise." Faith and patience. It's easier for me to have faith than patience personally. Once God shows me something to believe for, I have no trouble. He can do the impossible! It's the waiting,the patience, that is harder for me. I think the best example is probably Heaven. I am already a citizen of my true home, the kingdom of God. I have the faith to look forward to it and it's where my hope is. But what I experience of Heaven now is only a shadow. So often I long for Heaven on Earth. I want every one of these patients to get up out of their bed totally healed. I hate having to watch their mom's grieve when they die, and I love rejoicing with them when they improve. But the complete promises of God are inherited with faith AND patience. Not all of his promises are immediate. Not all of his healing is in this world. All of my patients will be healed, but for some I have to be patient to wait and rejoice with them in heaven. 

I'm not sure if that makes sense to you. My heart is heavy today because another one of my patients died last night. She was a really sweet 14yo female with Lupus. She came in with renal failure as well as a pleural effusion and seemed to be doing better clinically. We cant get many labs here and the turn around time is really long, so we didn't have a perfect picture of everything. She started bleeding in the night though and the physician on call couldn't resuscitate her. I'm not sure if she had such bad nephrotic syndrome from her Lupus that she was hypocoagulable or if her lung disease was so severe that she had a pulmonary hemorrhage. Families don't do post-Mortem autopsies here so I will never know. It breaks my heart. I will have to patiently wait for Heaven to see her healed.

Another example is just being here at Kijabe. It has stretched my faith to follow God's leading us to Africa (the only place I was sure I wasn't called to go about a year ago). Now that we are here, I have had my heart so enlarged for not just the patients but the medical students who are in need of teaching so much (another thing I was fairly sure I was not called to do... Academic medicine). And now that I have faith that God has purposed me for the mission of caring for the really poor and training up physicians, it's time (almost) to go home. It's time for patience. 

So for today, faith and patience in every arena of life is what God asks. I am patiently waiting to see Ruth again in heaven. And my heart is full of faith, knowing that God has fulfilled his promise to heal her because she is his child.  My heart is also being stretched for faith to believe that I am and can be  a missionary in a way i didn't think before now was for me. And I'm patiently wondering... when and how we will get to come back to Kijabe to continue the work we've started. 

That's the way the toilet flushes...

So my only disappointment with this trip is watching the toilets flush. For years, I've been told that toilets in the southern hemisphere flush in the opposite direction. Well, I was all ready to video record a toilet flushing when I got here. Unfortunately, the toilets don't flush in any direction. They flush straight down. Oh well. I traveled around the world to answer this one pressing question and now the madness will continue. I was also able to start a fire in our furnace...consistently. This was a monumental occasion as the anatomy of the furnaces here require kerosene or charcoal, neither of which I have. However, I have learned that obscenely large amounts of dry grass acts as kerosene. Who knew? Our living room looks like a stable, but at least it's warm. On a more serious note, we had a couple of small premies admitted to nursery last night. One of them was a 28 weeker weighing in at a whopping 850 grams. We had the necessary surfactant to save the baby's lungs. I think the baby has a really good chance. Fortunately, we have already broken out the TPN (IV nutrition, very $$$) for our TEF baby, so we can spare 10cc/day and start this baby on trophic (trickle) feeds to reduce the chance of NEC (really bad gut death thing). Sarahbeth tells me my posts are too medical, so I'm trying to make it easier to read. I continue to be amazed at the need for a neonatologist here. I think each person's calling is unique. Is the need here more desperate than anywhere else? Certainly not. However, I have always felt that teaching was part of my calling, and it is an awesome opportunity to equip others to reach children in the far reaches of Kenya and Africa. Every one of the people I talk to here has a different reason for coming. I don't think there is a unifying idea or theology that one must subscribe to in order to minister in a particular setting. It's simply a individual and unique calling that each person has. Sarahbeth and I have become more and more settled and comfortable with this idea during our time here. It's easy to compare and contrast, to scale, and to stratify calling to calling. The truth is that the master said the exact same thing to the man who invested 5 talents as he did to the man who had invested 10. Somehow, you can't quantify the kingdom of God. One physician's calling is no more or less than the next. What He wants from us more than anything is a willing, obedient and faithful heart. This is the beauty of the body of Christ. Well, we are going on Safari this weekend! We plan to drive through a place called crescent island where we will be able to do a real walk about with the giraffes and zebras. Then, it's off to Nakuru Saturday night to stay at a guest house. We will go into the park at sunrise and hopefully see some great animals. The last couple that went saw 20+ lions! We'll take some great pictures for you!! - Bryan

Wish I had some Propofol...

I'm getting better at my lumbar punctures. However, in Africa there is no such thing as routine sedation for children that go through these procedures. So, I've been faced with the challenge of a rapidly moving and screaming target. Today, I've been trying to sedate a girl who is 8 because the intern was unable to successfully do the procedure earlier. I'm trying, giving her dose after dose of IV versed with her not seeming much sleepier. Where is a child life specialist when you need one?! Or a dose of Propofol... That would be nice.

In other news, baby Cecilia is doing much better. She is the little girl who came in with the wound infections the first day I was attending on the ward. She had her chest tubes taken out today and her sounds were closed! After just a few more days of antibiotics she will get to go home. Bryan mentioned several of my kids who have passed away. There was a baby with a type 4s neuroblastoma which is a rapidly growing tumor in the abdomen. Typically, in the states the baby would be intubated to avoid respiratory compromise caused by the tumor making it hard for it it breathe. Then, after a few weeks the tumor would begin involuting  on its own (isn't that crazy?). Sometimes, a small dose of chemotherapy would be given to help the tumor shrink faster, but this puts the infant a risk of tumor lysis syndrome, where the dying tumor cells release certain things that are very harmful to the body. For this baby, she stopped breathing because the tumor had compressed her lugs so much. I and my team were able to resuscitate her, but she started having seizures and repeated episodes of respiratory arrest. It was impractical for us to intubate her and wait several weeks because there are only two ICU beds in the hospital for children. It would have take the bed away from many children who would need it during that time. We also were unable to and her to another hospital that does chemotherapy because her parents didn't have the government insurance. Her parents decided that given their financial situation it would be best for us to provide their baby with comfort care until she passed away. She died the next day. The other child who passed away this morning had severe malnutrition and a skull abnormality that is very rare. At 7mos of life, he weighed less than his birth weight. He went to surgery yesterday to start repair of his skull abnormality. This is really important for normal brain development. We were treating him appropriately for his malnutrition as the medicine team, and after he went for his first surgery yesterday to repair part of his skull he did very well. However, as the night progressed he seemed to be dehydrated as he wasn't making urine. You have to be very careful giving fluid to a malnourished child because you can overload their heart. But he got some small amounts of fluid and initially did ok until his heart rate just precipitously dropped. He initially was resuscitated but had another event about one hour later. We aren't entirely sure what happened, but we speculate that his malnutrition made his body so weak that it couldn't handle the stress of surgery. His mother was so stricken with grief. 

There is definitely more death here than what we are accustomed to, and often times you don't have the comfort of knowing "why." It's hard, but we are doing the very best we can to take good care of the patients and their families seem to know And be thankful for that.

Tonight we are going to a missionary family's house for dinner and I am getting ready for a presentation on congenital and acquired syphilis for tomorrow based on a recent case I've had. I'm doing it morning-report style for those of you who know what I mean! I think and hope it will be interesting :) 

Love you guys! Thanks for staying tuned.

Sb

Dinner with Friends

A long overdue post from Bryan. Some internet issues, so my last post didn't go through. It's amazing how accustomed you become to something strange. Ultra pasturized milk now tastes as if I've been drinking it all along (they keep it at room temp...weird). All our food cooked from scratch. Rinsing your toothbrush needs to come from water from a pitcher next to the sink instead of the facet (yes, I've messed this up a time or two). The blank stare I receive while asking why CSF studies on my septic baby weren't run 12 hours ago. Do I miss the things that are "normal" to me? Not really - the states seems more like an alternate reality than an actual way of life. Thus, without the distraction of TV and media, the families here are experts at self expression - they all have hobbies that they are gifted at ranging from pottery, coffee, music, photography, to hiking and mountain biking. The richness of one aspect of life is simply transferred to another. People have someone over for dinner or go to someone's house several times a week. Relationships and friendships are built in a very lasting and enduring way that I find quite refreshing. Two nights ago we had Moses, one of the interns over to dinner two nights ago. He shared with me how much he had appreciated what we had done for him and his fellow interns. It was really good to hear about some of the benefit that he had received through our trip. I can't take personal credit either. Many of the medical pearls of wisdom I learned from my days in NICU I have been able to pass on (I only learned them months ago!). I was able to give the interns a copy of all the review articles and educational materials our residents back home have worked so hard to compile (thanks Cady and others for your work on the dropbox!!). We've also run several "code strategy" scenarios thanks to some NRP cards. I was reading about Barnabas and S/Paul (that's my new term for him) in Acts - Barnabas took S/Paul under his wing because I think he believed the best about him - that S/Paul would go harder, longer and farther than Barnabas would. Jesus himself took the same attitude toward his apostles - "the things you have seen me do, you will these and greater." The only way one can teach in humility is to value the learner above him/herself. This was a really neat lesson. Baby Grace is doing much better! Bilirubin is now down to 6.8. As soon as we started meropenem and acyclovir, her bili started dropping. Now, 5 days later her color is more normal. Her exam is still abnormal, but much improved. The conscensus (thanks Drs. Walker, Clark, Kevan!!) was that her degree of direct hyperbili could not have been from Klebsiella sepsis alone. At one point it was total 43/ conjugated 31. We have dont just about every lab the hospital could run. I am still waiting for the resutls of a peripheral blood smear. We have had 3 babies with VACTRL (someone needs to do a study here...). One of them isn't doing so hot - difficult to extubate, bradycardia from acidemia (the Hs and Ts really do work - thanks Amanda O'Kelly!!), anastomosis leak. His prognosis is starting to look pretty grim. The other esophageal atresia baby is doing remarkably well. We are working up on his feeds and expect him to do pretty well. He will have a colostomy for several months until he's big enough to repair the imperforate anus issue. He's also missing a kidney. Thankfully, none of them have had any clinically significant cardiac defects. All my other babies are doing reasonably well. I was thankful to be able to give surfactant to one of my 30 weekers. I believe she will have a much better outcome. I'm also thankful to have bubble CPAP - has saved more than one baby here. Sarahbeth has had a couple of deaths on wards recently. One of the babies had a rapidly progressive neuroblastoma, another with a congenital skull deformity. She also has a very sad case of congenital neurosyphilis. She's becoming an expert at severe malnutrition, dehydration, TB meningitis, malaria, etc etc. You know, routine. I just got called about another delivery, so need to wrap up quickly. Thanks again so much for the love, prayers and support!!! -Bryan

Espresso, waffles, whip cream and strawberries!

This morning we slept in a little since we were up late with a new 31week baby. She did really well, but we ended up having to intubate her and give her surfactant (a lipid normally produced by mature lungs that allows your alveoli to open easily). It's something done fairly routinely in the US for premature infants, and isn't uncommon here but the cost Is usually difficult for the family so careful thought is given to whether the baby really needs it. It costs about $13,000 KSH which is about $150. in the US, a dose would be Several thousand! Isn't that crazy?  The parents have to pay for it ahead of time so that if the baby needs it there isnt a delay in care to make sure they can afford it. These parents were able to pay, and She's doing great now! I'm sure you are wondering what happens if they can't pay, which definitely is a reality. First, they usually try on their own to come up with the money. It seems very common here for community members like friends and church members to help families with their medical bills. Whereas in the US it would probably be very shameful or embarrassing to ask people to help you pay for something, it's part of life here. Everyone helps each other as much as they can. If the family still doesn't have the money, there is a Needy Children's Fund which can be accessed to help for life saving things like this medication. It is entirely dependent on donations  outside of the hospital, so it's variable if and how much money is available. For anyone interested in giving a little bit of money that can go a long way for someone else, this is definitely it. The physicians are in charge of it and get to determine who for and how the money is used.

After sleeping in and making some coffee (I drink it black here... It's just easier) Bryan was off to quickly round on the sick babies since he's on call and I went to worship at the local church. We met up after service since he got held up at a high risk delivery (baby was fine!) and went over to the Myhres. Scott and Jennifer Myhre have been in Africa for twenty years this month, ever since finishing their medical training in the states. They were initially in Uganda for 17 years and have been at Kijabe where he is an internal medicine physician and the field director for World Harvest Mission and she is the medical director for pediatrics. They have four children too! Scott made us espresso that was delicious and Jennifer made waffles and whipped cream like it was the easiest thing in the world. We all sat around their table and enjoyed what I have to say was like a total feast while we prompted them with lots of questions about being missionaries, living in Africa and of course how one is to avoid being eaten by a lion. It was so much fun. We are going to try to explore around a little today, but we have to stay close so that we can be here in case we are needed at the hospital (we are on call after all!) 

Tonight, our MO intern Moses is coming over for dinner. He came for left overs from a recent Mexican fiesta we had for the interns we work with  last night, and I told him to come back again tonight for Teriyaki stir fry. He does a good job and has been fun to get to know. He seems to love Bryan, and if I could give you an audio of how he says "Doctor Bryan" in his accent I would! It is priceless.

Thanks to those of you posting and letting us know how you are! Have a wonderful, restful Sunday.

Sb

Learning better skills!

Hi everybody! Hope you're doing well. I'm totally recovered now and have been back in the swing of life here. Unfortunately, one of the pediatricians here (one of four) went into premature labor this week which has put a lot of strain on the others. It's amazing that God knew many months ago that our help would be needed at this exact time even more Than usual. I have been running the rounds on the wards and Bryan has been running things in the nursery. This frees up the staff to run around seeing the most critical patients and attend their other administrative responsibilities. 

It's neat how no matter where you are in the learning process, you can learn from your teammates. I am in charge of a team of a medical officer intern (just finished medical school, no residency but to do residency here is rare after you complete the general internship). We also have a clinical officer (like a NP basically) and a clinical officer intern. Because there are so many children here with hydrocephalus (I speculate one reason is untreated neonatal meningitis) and because kids are generally pretty sick when they come to the hospital , they folks on my team do lumbar punctures all the time! And they are really good at it! They do it differently here than we do in the states, and here if you don't get what we call a "champagne tap" (no red blood cells get into the spinal fluid) people look at you funny and think you must be really new. The technique they use here is that try sit the baby up instead of laying him down, and they use a one inch 23 gauge needle. So yesterday I had them let me do it their way, and what do you know if it wasn't a champagne tap! I think I will be changing my method! 

Last night, we had several of the MO interns and one of the pediatric MOs over for dinner. We had a great time learning about how thy came to practice medicine and hearing about their lives. We laughed a lot about different stories we all had from taking call, and there were serious moments too when we talked about our faith and how it motivates us. It was a great little party!

Today we are rounding early so our teams can get out and enjoy the weekend. Rounds on Saturdays are quick and on Sundays no one gets seen except the sickest patients by the attending on call. That's definitely different than what we are accustomed to! 

We love hearing from you guys so please feel free to send emails and updates on how things are going stateside. 

Sb

The Kenyan Stomach Bug

Much like the American stomach bug... Horrible! I'm not sure what sweet little kiddo I gleaned it from, but this past Saturday night I started vomiting and ended up on my back for about two days! It takes a lot to slow me down (I'm always incorporating movement aren't I Hannah Robey?!) but this bug definitely did it. There isn't good access to hand washing here (few sinks, little soap) so I'm sure it's something I probably got on the ward. However, today I am back to myself and back to work! I am so glad it was short-lived. I continue to be the so-called attending on the wards where I am pleased to report that baby Cecilia is getting better! She had her eyes open and was looking around the room today and is breathing on her own now without support. She ended up needing a chest tube over the weekend when it was discovered that her chest wound was communicating with her pleural space (pus was accumulating between her lung and chest wall). She's doing great though! I'm so thankful. I have other kids that I'm treating for malaria, complicated kidney infections and seizures from hypocalcemic rickets. Needless to say, the learning curve continues! I have a great team and great back up physicians that help me when I'm clueless. One funny thing happened today on the ward- a baby who we just discharged with HIV and TB meningitis to go home suddenly developed stridor on her way out the door (this is after developing a seizure earlier because her HIV meds interfere with the metabolism of her seizure medications). I think to myself, "oh my goodness! This child. She just can't catch a break!" She had impressive expiratory stridor and was suddenly working hard to breathe. I couldn't hear good air movement on her left lung. Started asking mom questions and, no, she hadnt swallowed anything recently. This just started a few hours ago. I was stumped. There are reasons for this but none that would make sense in her right now- she had just been fine!! She did have a tube going from her nose into her belly to help us feed her that she was going home with. "Mom, any problems with this tube today?" As it turned out, the tube had come out earlier! Mom says she just put it back in though. "You put it back in...yourself?! Oh Lord have mercy" is somewhere along the lines of what I'm thinking. I think the mom probably put her tube down her trachea instead of down her esophagus. Suddenly it all made sense! We got the tube out and gave her some breathing treatments which helped her. Mom says she didn't put food down the tube... I'm not sure I will believe it until I see it on her CXR. I really hope she didn't though! Medicine is really like mystery solving. If you ask enough questions enough ways, you can usually find your answer!  I still can't believe she got the tube down her baby though... Goodness gracious. 

That's about all for today. I'm getting ready to work on a project to improve HIV screening on the kids admitted to the hospital and bryan is on call to tonight. Thanks to those of you who leave us messages! We love hearing from you.

Kernicterus, meconium, and good Kenyan Food

Hey Everyone,

Bryan here.  A few medical updates:

I saw my first case of acute bilirubin encephalopathy.  Consequently, I also performed my first exchange transfusion.  We received a 5 day old on my first day of call.  Not believing that he had a bili of 35 from the outlaying facility, we repeated his bili.  No, it wasn't 35....it was 47.  For the non medical folks out there, I start getting worried around 18-20.  He was continuing to have fevers, so we repeated the septic workup and did an exchange transfusion that went into the middle of the night.  It worked, but his direct bili continues to be high.  My blood culture just came back positive for Klebsiella that is resistant to just about everything except carbapenems and zosyn (and chloramphenicol...yep they still use it over here).  Scary.  It is this exact same organism that has given rise to the infamous NDM-1, which basically can't be killed with antibiotics.  I count my blessings there is something we can treat this baby with.  Sadly, she has some neurologic findings that are consistent with the intermediate phase of biliary encephalopathy, nearly ensuring that she will end up with kernicterus.  Her bili is back up this AM.  Please pray for Baby Grace.

I also performed my first solo resuscitation on a baby with meconium aspiration.  I have never been so terrified in all my life!  I had an intern and midwife with me who had virtually no experience.  For the first time, I had no one around to back me up if somehting went wrong.  By God's grace, I was able to intubate and suction.  Got a big old plug out and the baby started breathing and crying.  It was a very emotional moment for me.  He only required a couple of days of CPAP then O2 and miraculously has had no major complications.  Baby is doing great and should be discharged tomorrow.  The irony of the situation is that I was a very sick baby with meconium aspiration that nearly died at delivery had it not been for a pediatrician..  I've now come full circle!

On a lighter note, we went to church today.  It was really good to worship with the folks here at Kijabe.  A few of the songs were in Swahili, which was fun to listen to (although felt a touch out of place...).  It's good to be able to relate to other believers through the international language of the Holy Spirit.  The people here are truly wonderful.  They have a very connected church and welcomed us very warmly when they asked us to introduce ourselves.  We are quickly falling in love with the people of Kenya!

We have also really connected wiht the long termers (=long term missionary physician) and short termers here.  We have gone out to eat, had someone over, or been over to someone elses house nearly every night.  We share some really good laughs and conversation.  I was encouraged to hear that they would really like to have a neonatologist in country.  There are no neo fellowships in Kenya, so when the occasional neo comes to visit for a few months, they feel spoiled.  They have been excellent counselors.  I am very humbled to be among them.  All these people have given up the life of an American (or european or australian - gooday mate!) physician, but none of them regret it.  One is even a pediatric surgeon, another a pediatric neurosurgeon.  By the world's standards, this idea is complete foolishness.  However, none of them consider this to be suffering but an honor.  To boot, they are also very normal people - no weird long dresses, bonnets and kumbaya (my impression of what missionaries would be like).  They all confess that it isn't for everyone, however.  God will work out when and how long, but we both know we will be coming back to Kijabe!

Our hearts continue to be full!  Thanks again for all your encouraging posts!

- Bryan

First day as the attending...

Bryan mentioned yesterday that he was running rounds in the nursery. He'sbeen learning   the challenges of being an attending and has been in awe of the complexity of these patients we've been given responsibility for. I am right there with him. We are providing relief for some of the long time missionaries here, which means some days of being the most senior person in the nursery or, in my case, on the ward, while they tend to some much needed admin or personal time. Humbled is probably the best word to describe how I feel about this. I am by no means qualified to take care of these very sick children on my own. I am still overwhelmed by the complexity of their diseases as they are so different from what I typically see. However, I am so thankful in this moment for my education which allows me to think critically, identify problems and do my best to lead our team in solving them. Cecilia was my first patient as the attending, and I doubt I will ever forget her. I came in yesterday to find a five and a half month old who had been admitted with hydrocephalus, wounds that had developed from pustules on her chest and thigh, a cough and fever. She was very ill appearing with shallow breaths and poor responsiveness. Her wounds were unlike anything I have seen. They were well demarcated but the flesh was completely gone, exposing her deep tissues and musculature. We obtained a few labs and ordered a few tests. I was concerned about a deep soft tissue infection and possibly necrotizing fasciitis, so I started her on empiric antibiotics to cover for the common bugs associated with these problems. When I reviewed her Chest film, she had what appeared to be pulmonary edema or acute respiratory distress syndrome. Thankfully, her renal function was good so I could give her a diuretic to help get rid of the extra fluid making it hard for her to breathe. I gave her pain medicine and then we waited for her to be taken to surgery for debridement. Today she is doing a little bit better. In the OR they found infection tracking from her chest wound into her mediastinum, the part of her chest that contains her heart and other important structures. This confirmed our suspicion of necrotizing fasciitis. Unfortunately, the CT scan here is broken so we will continue to aggressively treat her and pray she improves as we can't completely visualize where the infection has affected or monitor her response other than clinically. We have a few labs pending, a wound culture and blood culture. Her white blood cell count had come back at 41,000 (very high) and her peripheral blood smear doesn't show any ongoing destruction of red blood cells which can happen in serious infections. There was no infection surrounding her brain either. Please pray for her and her mother who sits by her bedside day and night. She will be taken to the OR again today for a dressing change and then will have a cranial US to  evaluate her hydrocephalus. 

Medicine is definitely different here. With limited tests and lab results, you rely heavily on your physical exam and clinical judgement. I am so thankful for our medical education which has taught and is teaching me well. I know that there are things I'm missing in taking care of these patients, and I hate that. However, I'm doing my best and praying for God's wisdom, knowing that ultimately He is their healer, not me.

We appreciate your prayers so much! Love you guys.

Not your garden variety nursery

I'm assigned to nursery this week.  What I've found is that nursery = NICU.  Most infants born here are not evaluated by a physician unless they are sick.  The admissions are from sick babies born here, referred from other facilities, or people that walked into clinic.  Most of the infants here are very sick.  Here's a few of the things I've seen in just three days:

- gastroschisis

- Esophageal atresia with TE fistula (ruling out VACTRL)

- encephalocele x2

- Unknown syndrome: interrupted aortic arch, bilateral cleft lip, smooth filtrum, ambiguous genitalia, bilateral hyperextended knees, club feet (thought about Patau b/c of overlapping 2nd and 5th digits, but not sure)

- posterior urethral valves

- urosepsis

- hyperbili (bili was 31 on admission!)

- A form of skeletal dysplasia - not likely achondroplasia

- lots of prematurity

- grade IV IVH - baby also has a large PDA and heart failure

So it's been busy. The gastroschisis baby died the first day we were here.  The interrupted aortic arch is a ductal dependent lesion, so the baby wasn't doing well this AM.  The parents are taking her home for palliation.  Unfortunately, we do not have the resources to perform cardiac surgeries.

Any of these problems would be a challenge back home, but to add, I'm considered a "consultant" and lead teaching rounds.  It is certainly stretching me as a physician.  I'm developing a new appreciation for my attendings! It's hard!  That being said, I've been happy with my training so far - some of the above listed things I've seen before, so I was able to diagnose and treat them.

Sarahbeth is having a similar experienced on wards.  I know all this sounds depressing, but the parents all appreciate what we are doing and are thankful even in bad outcomes.  There is no entitlement mentality here, which is very refreshing.  The patients often offer as much money as they can to help pay for their hospitalizations.  

We are still doing really well.  We are having a great time getting to know the missionaries and short termers.  We have been at someone's house for dinner or desert every night we've been here, so we feel very welcome!  

Thanks again for your thoughts and prayers.  Sorry the post is a bit choppy-  the Internet only works on my iPhone right now. See you all soon

- Bryan

First two days at Kijabe

We have gotten settled in since arriving at Kijabe and have found this to be a very hospitable and friendly place. A sweet older woman named Helen greeted us and made sure our apartment was equipped with everything we needed and another lady, Grace,  showed us the way to the local market. We oriented around the hospital and met the long term missionaries who will be working with us while we are here. Then last night we went to a desert night where the missionaries from Kijabe get together to greet new people (like us!). The missionaries are from the US, UK and Australia mainly I would say.  It's a really neat group of people. 

This morning, we've been at our respective assignments (on the wards for me and in the not-so-well baby nursery for Bryan). On the wards, they tell me the patients aren't very sick, but with diagnoses like TB meningitis, neonatal HIV, Malnutrition and gastroenteritis that presents as hypovolemic shock I'm wondering what the definition of sick is! I have so much to learn. I'm on call tonight covering the ICU, nursery and ward so I'm hoping for a good night (and reviewing all of my NALS/PALS just in case!) 

Our Internet connection is very sporadic because of the amount of people streaming the news on the terrorist attack. We are going to do our best to keep you guys informed! There is still some uncertainty here that these attacks are over as it sounds like there has still been gunfire, but for now everyone at Kijabe is ok and safe. 

Thanks for your prayers! We love you.

Sb

"Do you like Tumeric?" Musings from Nairobi

We landed in Nairobi around lunchtime yesterday and spent the night here. As Bryan's post eluded to, we landed to find a city in distress and battled against fear and anxiety in our own hearts regarding the situation. A man named Odyssemus picked us up from the airport and recommended we go ahead to a small market store to buy some staple groceries before heading to Kijabe. It was similar to an American supermarket, and we did our best to think through converting dollars to shillings. I loved the spice isle where I picked out spices like coriander, garlic, cumin, curry and last but not least ... Tumeric. I have heard of this exotic spice before, I thought to myself. But I can't remember if I like it or what it's like. The bag was quite big so I proceeded to ask several locals what they thought of Tumeric. Unfortunately all I got back was some strange looks and comments along the line of "I don't know what you are saying." Oh well. I bought it! We will see how it goes! After leaving the market, he took us to the Mennonite Guest House. I loved taking in the scenery of Nairobi on our way. It is definitely the nicest, cleanest third-world city I have been in. The Guest House is very charming. We arrived at "tea time" so after we got our bags tucked away in the room we got to enjoy Kenyan tea and coffee along with donuts. It was at tea that we met several others staying the night- a nurse from Charleston whose wife and adopted Kenyan daughters hen had come to visit (after two years their adoption still isn't final so she stays here with them) and a nurse named Jeffrey who works on a Navajo reservation doing research on a new strep pneumo vaccine. He has family here in Kenya. After tea, Bryan and I did some exercise and took much needed showers. They served us a  grilled cheese with a curried butternut squash soup for dinner. It really hit the spot after so much traveling. Sleep last night came quickly for Bryan but not so much for me. We could hear the helicopters that were surrounding Westgate mall which severed as a constant reminder of our nearness to evil. God's word helped me battle against the Restlessness. It is so comforting to know that in John 17 he promised, "My peace I leave with you... I do not give as the world gives by fear not. I have overcome the world." Evil will not prevail in the end. Nevertheless, it was sobering to experience for a night what so many people in the world live in on a daily basis. This morning, we were up early for breakfast and eggs, granola, papaya and bananas before loading up our bags for Kijabe. We are on the way there now and it is a cloudy, cool day since the beginning of the rainy season is here.

Thanks for praying for us! We will do our best to keep you posted on how it goes with the Tumeric... And all of the much more important things too of course.

Sarahbeth 

We're ok!!

Thanks everyone for your concerns, prayers, and emails.  You can probably gather that we made it safely, and we are doing great,! We are a bit jet lagged, but we are strangely accustomed to being sleep deprived - residency isn't all bad!

For those of you that haven't connected with the news for a couple of days, there was a terrorist attack on a mall in Nairobi.  We actually didn't hear about it ourselves until after we landed here because we were disconnected from the rest of the world for about 24 hours.  We are out of the dangerous area, and the ongoing hostage situation is being contained.  We are still on schedule to leave Nairobi for Kijabi tomorrow AM.  Tonight we are staying at a beautiful Mennonite House for missionaries passing through.  It's very secluded and private.  We have already met some wonderful people - one of them is a nurse from MUSC!

Thanks again for your thoughts and prayers.  God continues to keep us in high spirits!

Bryan

PS> SB said this was such a boy post.  Sorry ladies. I just don't do details well!

It's not about us

We safely made it to DC this evening.  We learned that Ethiopian Airline travelers should tag on an extra hour to check in.  Who needed an extra hour of sleep?

Many of you have asked how to pray for us.  I've thought about our main prayer needs.  There really is a lot to say, but I think the most important thing that we need is to learn to adopt a "me last" attitude.  It's easy to go on these trips and wonder what the experience will be like, what one might learn and take home.  I don't want this trip to be about self improvement.  Sure, we will certainly be stretched and grow as physicians and followers of Christ, but this doesn't need to be our main objective.  Our desire is to be servants to the people that we are coming to in every way possible. 

Thanks for all your support!  Look forward to update you when we get to Kenya!!

- Bryan and SB

Preparing to leave...

Hey everyone,

So this is our first blog post ever!  We feel so much cooler.

We are very excited about our trip.  For those of you not up to speed, here's what's going on:

Sarahbeth and I will be traveling to Kijabe, Kenya for four weeks to work at a missions hospital.  We will be taking care of infants and children who we expect to be fairly ill as they do not have access to the same care that we do.  Kijabe Hospital seeks to provide "first world" medical care to Kenyans and Africans regardless of their ability to pay.  We will be working alongside longterm missionary physicians, local healthcare professionals, and Kenyan resident physicians.  We will also be taking an active role in teaching the hospital staff there.  You can find more information at the Kijabe Hospital website: http://kijabehospital.org/

We will be using this blog to tell stories from our medical experiences, share what God is teaching us, and ask for prayer.  Thanks so much for hopping on and reading through.  We hope you enjoy following our story!

Bryan and Sarahbeth