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