The kids
are watching the preview for Toy Story 3 (Andy goes to college) and I'm tearing up.Somebody please.Stop
personifying kids toys and making my heart ache over these fleeting moments of
little pleasures.It’s a present
tense nostalgia. It's the fear of missing it. My friend Mary said she was so happy at her son’s high school graduation while all the
other moms cried, she was really celebrating his accomplishments without
regrets.She just delights in the
simple present tense. I have so
much to delight in our simple present tense too. Like 20 people eating homemade missionary pizza in our house on Friday night, watching Toy Story.
I usually
think of our man-cub as more like Buzz Light-Year than Andy, the boy that grows
up. But he is changing.People do that, you know?He went and turned six this week.
I wasn’t
planning this to be any big deal.In fact, I wasn’t planning much celebration because I got lost under the
stress of waiting for a work permit to come through for Daktari, which it
did.Hallelujah and happy birthday
to us from the Government of Kenya! Thankfully we live in a mission community
that is somewhat like living in a yellow submarine and a friend offered to plan
a party for us to have together with their son turning 2 years old.It was quoted as being “An awesome
birthday party” too.
Missionary
kid birthday parties are so great and so simple.No Pintrest pressure to perform, no need to collect clout
with cute cupcake presentation, no pressure on kids even to give presents
really.Mostly we dig in our
little closets for something that would be a nice up-cycled gift, or maybe find
something local like a stone carved animal or goat skin drum.The little things really mean a lot to
us at six.
We don't mind at all if you wear tie dye and plaid on the same day. In Africa you are judged not by the color of clothes you wear, but by the content of your character.
Man-cub, you
are my big Kindergartener who can bound out the kitchen door at lightning speed
yelling to the world “I love you mom!” as you take yourself to school every
morning.Or to infinity and
beyond, whichever.
There are
little joys we share here like a dad coming home for lunch every day to take an
intermission from the dramatic realities of intensive care medicine in rural
sub-Saharan Africa.You are
starting to get it a little at a time.And when we see you show compassion in your own way to your kittens or the
neighbor kids, my heart wells up to overflow. It's in the here and now for you too.
You beg
for tickle time and you love it even though you let me in on your secret the
other day about losing your ticklishness. But we both pretend it never happened
cause I can’t handle that kind of change so suddenly.Let’s just enjoy you today.
Just a simple little
five years of present tense moments have gone by building for us the two best accomplishments of my
life.You and your little sis. You make me proud.
This case comes complete with a soundtrack courtesy of Merle Haggard, as well as an existential reference from Hamlet Act 3 Scene 1; so the recommended gameplan, start Merle out and have him playing in the background while you read the story.
The story of Charles goes like this: he is a young man of 25 years, a local guy from Bomet who grew up in the burgeoning Kenyan middle class. He has lived the good life for our area: always had food on the table and school fees keep him on the track to success: education is the way out of poverty here, and Kenyans take it very seriously.
Then three years ago he started to get a cough. He shrugged it off for a few weeks, until people started to notice. Then he went to the clinic and told them his story: he'd had a chronic cough, and was an otherwise healthy young man. In our part of the world, that means he has pulmonary tuberculosis (TB), plus or minus HIV. His chest x-ray showed the abnormalities on the left upper lobe, and a sputum culture was sent. Sensitivity for sputum culture in our setting is @ 50%, so most clinical decisions are made based on clinical evaluation. For Charles, the clinical evaluation said, "TB" and he was started on TB treatment.
He felt better over a couple of weeks, but kept taking his treatment for the full prescribed 6-month course. 4 drugs x 3 times per day.
Nothing happened for a few months after he finished his initial treatment. He returned to work and led a normal successful life for another quarter of a year. Then his cough came back...same symptoms as before, and he returned to the clinic. This time the exam and the x-ray showed the abnormality on the right side of the chest. This was deeply concerning to the clinical staff, at the back of our minds there is always the question of evolving drug resistance in tuberculosis, and when we see these HIV-negative patients returning to clinic with a relapse or recurrence, there is a fear that they are in the 2-4% of patients with drug-resistant TB in our area. Another sputum sample is taken and is negative.
So, Charles gets second-line treatment for the new set of symptoms and radiographic findings. This time he gets 4 drugs 3 times per day, and a daily shot of a drug called Streptomycin, a very painful and inconvenient everyday experience for 9 months.
Once again, he gets better for a few months, and then has a recurrence of his symptoms. He gets treated again with another course of intramuscular Streptomycin.
On the fourth recurrence of his symtoms, I get involved in his care. He is admitted to the Tenwek Medicine Teaching Service, and we go back through his story. He has had 4 treatment courses for sputum-negative TB that seems to move around from one side of his chest to the other. Maybe there is something else going on here? Some of the dangers of working in Africa amidst so much TB is that you start to call everything TB.
And for this case, I wasn't convinced. I spoke with my surgeon colleagues, and asked them to do a biopsy of his lung. At Tenwek we can do a procedure called a video-assisted thoracoscopic surgery (VATS), illustrated here. This gave us a piece of tissue to examine: is this TB or something else?
And it turns out this case was of something else: Bronchiolitis Obliterans Organizing Pneumonia (more handily named BOOP). It's an inflammatory lung disease that responds to a short course of steroids, something as simple as a week of prednisone like you get for poison ivy.
Charles doesn't have TB, nor does he need the stigma and fear associated with it.
That takes us back to the existential question that we on the medicine service ask ourselves daily: TB or not TB; that is the question.
