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