TB or not TB; That is the Question

Welcome back to Daktari Cases.

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.

Power Surges

On Power Surges

The hospital’s hydro-electric dam is not steadily running the local power source until a 3^rd turbine is built.  How one inserts a new turbine into an already built hydro-electric dam I could not tell you.  I can’t help but imagining a little Dutch boy is down there sticking his finger in it though.  Bet he’s tired too.

Hence we have power outages frequently and irregularly.

Our little Miss cannot cope when the power goes out at bedtime and the little princess night light in her room goes black.  So we light candles and flashlights and wonder if all the overhead lights are switched off in case we are asleep when the power surges back on in the night.

Today the power was out when Michael went to play racquetball.  Yes, there is a racquetball court at Tenwek. And yes, he did try to play racquetball in the dark. 

Brown outs: warn us of the pending darkness and surge of electricity when it ends.  They are actually worse than black outs (unless one is playing racquetball) because the power will fluctuate up and down and destroy electronics.  And I ain’t talking about my hairdryer.

Hospital CT scanner: burnt out.  The $100,000 light bulb couldn’t withstand the surge of electrical ups and downs from power surges.  For Daktari, it means he has to guess what is going on inside the patient’s heads (which he’s pretty good at, at least for me).  But these patients come in with embolisms and blood clots and abscesses left and right.  Not knowing for certain from an image is risky business too. 

Burnt out: what happens when people get too tired from 6 months in living cross culturally with no break nearby.

Even my indiglo watch light is burnt out. Not like I need to actually know what time it is after dark anyway.  It’s time to be asleep is all I know.

So here is the little story of some ups and downs that came in our life recently leaving us feeling dizzy, shocked, and thankful.

Last September, we entered Kenya on a visitor visa and had applied for a work permit.  We were told that having applied for the work permit was good enough to begin work.  Due to many factors, Kenyan immigration has slowed some things down lately on issuing work permits and apparently our name was not at the top of the stack for any of the meetings leaving us in a 3month + backlog. On March the 3^rd our visitor visa would expire and we would need to leave the East African community to the nearest, cheapest, safest place in order to exit, re-enter, and get a new visitor visa.  We were prepared to head north to the Land of the Giles: Ethiopia.  We even have good friends there in the capital city- Travis, Emily, and baby Clare Weeks.  However, the US Embassy in Nairobi notified us that to be working under any circumstance in Kenya (even unpaid) on a tourist visa was ill advised, illegal, and potentially hazardous to your health.  Hmm hmm.

Wow.  We are undocumented workers.  What were we to do?  We found out about a special work pass that could take a month or more to process but would cover us until the long-term work permit was cleared.  Well, for a month or more what were we to do?  Brown out.

That was Friday last week.  Saturday I helped lead a seminar for about 30 Sunday School leaders and teachers out in a village where a pastor and his wife have a children’s home with about 50 orphaned kids living.  It is a lovely place with glossy concrete walls of manilla and sky blue trim.  Standard issue rust colored concrete floors.  I find myself oddly attracted to these typical paint schemes and I think “ah that is mid-century chic” (my enculturation rate may be febrile).  There were panorama vistas in the chapel overlooking the green hills that are quilted with tea farms, fallow fields of failed maize crop, trees, and nice wooden stitching of fences.  The window looking up the hill lures with a flowerbed of cosmos.  Oh yeah, I was teaching too, sure.  T

rying to encourage a room full of Sunday School teachers who are young teens and old men, and they each have about 50 kids each week sitting under a tree, struggling to convey the message of the gospel without props when some of them don’t even have a Bible of their own to start with! (Something we will be working on soon.)  But there I was, lost in the cosmos.  Gloriously delighted to be lost in green pastures, beside still waters, at the place of songs.  At this moment, I think, this is what I’m here for!  Power surge.

But I do miss home.  We miss our family.  We miss our times at the Mexican restaurant by Kroger, we miss stability, we miss anonymity, and so much more.  So maybe this will be time for us to go back to the States for a few weeks.  Or more.  So we sent out an urgent prayer request on Sunday morning, seeking wisdom, grace, favor, etc.  And we concluded that indeed for far too many years have far too many white people put themselves above the Kenyan law and created a cycle of symbiotic disdain.  But we are here to be whole Gospel people, not indispensible medical saviors or missionary super saints who would go to jail for our right to treat people and not submit to authorities.  Because this story is bigger than what we can see- this story that goes back to a long, long time ago, when a man looked up in the pitch dark of an ancient near eastern night sky and seeing the stars burn from billions of miles away with the beacon of light that still reaches my eyes today.  They echo to me: live by faith.  And we put our dream on the altar.  We would submit to the authorities and leave those 50+ patients to be unseen by Mr. Daktari Monday morning.  We will live by faith, even though fear knocks at the door.  The fear started to tell me “you may be gone for a long time before your work permission is granted”.  And I cried to think of our kids missing this dreamy life they have.

Sunday morning I was watching a banana leave wave in the wind and its chartreuse reflection on the polished wood floors.  I listened to Andrew Peterson sing “Hosanna.  See the long awaited King come to set His people free.  We cry Oh Hosanna.  Come and tear the temple down, raise it up on holy ground.  Hosanna”.  The Gospel is lifting up the lowly and bringing down the haughty. 

Monday morning there was a pre-scheduled executive board meeting at the hospital.  Michael was getting dressed to go to work because he is a creature of habit and loves going to work.   But he didn’t go.  Back and forth.  Up and down.  Emotions were on the same power grid as our house.  Then we got word.

The medical superintendant told the board we had this problem and would not come to work until it was legal to do so.

 Within minutes someone was on the phone with someone else and deciding that there would be a special pass for work issued tomorrow!  The immigrations office would also renew our visa to be here tomorrow!  It was a battle of our hearts over right and wrong and hubris v. humility. Someone else was able to fight it for us, thanks to the many prayers from you all.

So now we are still here at Tenwek, keeping calm and carrying on after all the surges of emotions.  And left dizzy by the goodness of our God.

And we have a one-month extension on our visas now, in hopes that the long term permit comes through by March 26.

And the CT scanner has a new bulb being installed too.  So when Daktari gets back to work tomorrow, (legally) he can really see what’s going on inside people’s heads. Light in the darkness.  Dazzling light.

Daktari Mother-In-Law

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When I look at my daughter, who says she is “freeee” years old in every sense of the word, I think of my mom and how she has loved me for all my thirty free years.

Our internet has been inoperable for a few days now so I will send my mom a birthday blog.  Although disconnected from the web and facetime and skype, I feel more connected to her when I see Annie and me together.

My mom pinned wings on my soul before I was born.  She was a flight attendant who set out to see the world and she met a handsome and humble former fighter pilot who was settling down for the domesticity of commercial flying.  She told him she was going to marry him and within six months they did. 

My mom sacrificially left her work aside in order to raise little girls at home.  But the wings were still there on her heart.  So she took us all around the world.  She taught us how to see the world. One day in Clayton County she helped out a lady who was walking home from prison.  My mom established mercy and justice in my heart.

My mom would give of herself to care for another, though it cost her dearly.  That, and she likes to dance.  She likes to have fun and water ski and laugh so loud she snorts.  My mom and her mom and my little girl, they all are passionate and wholehearted about what or who they care for.  They don’t do things half way.  You should hear Annie singing in the yard.  You should feel her tiny forceful running hug.

My mom’s mom was a World War II nurse in training who married a handsome and humble service man named Mr. Jolley who would take her dancing and stay faithful his whole life.  My mom found one just like that; minus the dancing.  My dad just took mom flying.  We have some purty lucky ladies in my family.  I pray Annie finds one like her daddy too.

And these women in my line all stand up for what they believe in.  Like it or not.  I don’t know if it’s Southern or just who we are, but at least I know my mom believed in me.  And she never asked me to be someone I was not even when I marched to the beat of my own drum.  Even when I was a typically bad attitude teenager, she didn’t give up on me and persisted in love.  Oh, mom I hope to be strong like you when Annie is stubborn like me.

Once in my year after college I went to Switzerland to try to figure out life before I moved to Africa (the first time).  What I figured out was that I missed home and my mom came to rescue me.  We dipped our little bread in a Swiss fondue in that Alpine village and went back home where everything was all right.

Back to that Georgia dirt in the garden where she stood like an angel in her nightgown among the white blooming spirea of our home as I drove out to meet my next destiny.   That Georgia dirt from which I grew up too.  Sometimes it is just clay but sometimes it is sweet Georgia brown dirt. You planted us with deep roots and a firm foundation.  And you taught me how to see the beauty that comes out of what was once just dirt.  Potential is what my mom looks for.

So last month she and my dad flew around the world to come visit me and my hero husband and their grandchildren.  My baby girl she says, is so much like me.  And we take her out on adventures too.  As we drive through Kenyan farm land, a man as black as the dirt he is hoeing stands bare chested in the field.  I think of Adam, of the ancestor of us all here in Africa.  And how many generations have treated him like the dirt from which God grew him.  But how my mom taught me to see the Image of God breathed into the Adam like life of that black man.  Even when history is wrong, even when the systems of generations is wrong, she helped me to stand tall for what is right.

My mom gives so much of herself to others.  Now I am starting to see it in the mirror and in Annie.  It’s her image poured into us.  She pinned the wings on my soul after all.   

Happy Birthday Mom.

Heart Reconstruction

Welcome back to Daktari Cases.  It’s been a few weeks since I’ve posted a case; not because there has been a dearth of interesting medicine, but really because there has been a surplus.  In addition to the usual holiday busyness (and we do have a less commercialized version of that here), there was a nationwide strike of healthcare workers in government institutions.  The details and causes of which I’ll omit (because I’m sure I don’t understand them).  The result was a very full hospital and outpatient department at Tenwek, which always runs at full capacity, over the past few weeks has approached “two-to-a-bed.”  With the New Year has come a settlement, and the reopening of the government hospitals, good for the patients and a breath of air for Tenwek.

So, I’ll start 2014 with a story.  The young lady’s name is Soi.  She is a 20 year-old woman from a village about 15 kilometers away who was married last year and is expecting her first child.  She finds herself getting tired and short of breath as she enters her 4th month, and when she asks her mother, she learns that this is a part of bearing a child.  Reassured, she continues to go about her day as a young wife and mother-to-be, working in the garden, carrying firewood, cooking and cleaning.  She lives beyond the reach of the electrical lines and water system, and beyond the reach of our prenatal care.  She carries on with life in the cool lush dirt-floor equatorial sun until one day she can’t walk to the river.  Then everyone notices that something is really wrong.  And they find a driver with a car and take her to Tenwek.

I meet her in casualty (the ER), and she is clearly in distress.  Her initial vital signs are a heart rate of 164, BP 94/68, RR 30, pulse oximetry 82% on room air.  These are her initial chest x-ray and electrocardiogram.  Her heart is beating faster than it can fill up with blood and she is going into heart failure.  We have to slow her heart down or this downward spiral will get out of control.  We have to decide to try to use medicine to slow her rate down, or to cardiovert her with the electric shock of a defibrillator (it’s not a good idea to shock a patient when you don’t know how long she’s been in this rhythm (foreshadowing: it could cause a stroke), not to mention that I don’t want to shock a mom and baby).  After some calling around, we locate some drugs that were left from the last cardiac surgery team at Tenwek that will ease her heart rate down, and give her some diuretics to pull off some of the fluid that has collected in her lungs.  This happens over the course of the first night, and so as the beautiful African equatorial sun rises on the next morning, we start to ask “Why?”

Nothing in my medical education to date gave me an explanation of why an otherwise healthy 20-year-old woman would have this tachyarrhythmia as she enters her second trimester.  But the first storm has passed, and it’s time to get to the thinking part.  As I repeat her exam, and now that her heart rate is down around 100, I can hear new sounds: the “whoosh-thump-whoo” of a mixed systolic and diastolic heart murmur.  We are blessed at Tenwek to have echocardiography capability and this is what her echo looked like.  It shows an extraordinarily scarred and narrowed mitral valve with just a teeny jet of blood flowing through it, along with a very large blood clot in her left atrium.  This is a picture of severe mitral valve stenosis from longstanding rheumatic heart disease.  RHD is a disease of poverty from repetitive bouts of untreated strep throat.  She has been living, miraculously, with this severe heart disease, likely since her childhood.  Yet in pregnancy, her blood volume increases by about 50%, to accommodate the baby.  The way her body changes to nurture the baby has overwhelmed her damaged heart.  And the strain on her body will accelerate over the next few weeks; she won’t survive pregnancy without open heart surgery, and having that large clot in her left atrium gives her the added risk of a major stroke.

This is one of those times when I’m thinking about what it would be like to work in a walk-in clinic in Tennessee: “Oh, you have a backache, I’m sorry; here are some painkillers.” or “Is that a sniffly nose?  Should I give you some antibiotics (editorial note: NO!)” 

Anyway, I snap out of that daydream after about 1.4 seconds and call in a lifeline: Dr. Russ White, cardiothoracic surgeon extraordinaire.  I am SO thankful to work in a place like Tenwek with such awesome colleagues.  Yes, he’s seen this before. Yes, it’s a tough case with a lot of risks no matter what we do.  And Yes, we can do open heart surgery, replace her valve, remove that dastardly blood clot, and give her a chance to live.  The downsides: there’s very little or no chance that the baby will survive being on cardiopulmonary bypass, and there’s a fair chance that clot will travel up into her brain during the operation and cause a stroke, and the family will likely have to go bankrupt to pay for the operation and ICU care (even though it’s the cheapest open heart surgery in Africa).  We have a few days to weigh the risks/benefits while we try to optimize her health, and the family involves their community in a fundraising drive and all-night prayer meetings. 

At this point, we decide to go ahead with the surgery, and this is the point in the story where you come in.  Because many of you are our supporters, and I told the hospital finance department that we will pay to make this surgery happen.  The community in their village gave, the family sacrificed greatly, and we filled in what was lacking.  To the Operating Room…

The procedure was long and complicated.  The valve was deeply scarred into the surround heart muscle, the clot was hardened and calcified, making it difficult to remove (but able to be removed intact).  The baby didn’t make it through the procedure, and there were times when the survival of the mother was in doubt.  But this time when they shocked her to restart her heart, it beat in a smooth, healthy, regular 88 beats per minute.  Several days of recovery later, she walked out of the hospital and caught a ride back to her village, with a story of a miracle.  Reminds me of a story that the prophet Ezekiel told
-->: “I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh.” (Ezekiel 26:36).  And to those of you who are our supporters, this is your story too.  Thank you for giving and praying, so that we can be here, and giving so that people like Soi can be healed.  A piece of her new heart comes from you.

Life is a Gas

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We used to say in our family that our stuff was like a gas.  When we travel and have a suitcase of tiny condensed proportions, upon opening it combusts and takes up as much space as is available.  Since moving to Tenwek we have certainly reduced our stuff and the amount of traveling we do too.  But even in a house one may find that stuff will expand to take up any available space.

In Africa, time is like that.  Time is in fact, one of the most valuable natural resources in Africa.  You may have stereotyped Africa as a place where people pay no attention to time.  But in fact, I am learning that people actually place a very high value on time but they expend it much more generously than we Westerners typically could fathom.  Now being from the South does modify a little bit of that shock and awe of unscheduled life.  Southerners have some deep commonalities with Africa that helps me feel so comfortable here.

In Africa, time sharing is how a person gives friendship, respect, and honor.  It’s not my friend’s condo on the coast, but it is my friend who will sit for an hour on a bench waiting for a word from the surgeon.  It’s time shared by having a cup of tea together- hot with milk and sugar, but still if there’s no sugar there’s no tea.  That’s Southern too.  And time shared just to “chew the news” and exchange greetings. 

I’m finding that not having an agenda on paper (or a screen) daily frees me up to be available.  I’m available for favors, errands, stories with my kids, toy sharing with neighborhood kids, or like today, available to be a walking blood bank. 

There was a 28 year old lady today needing emergency brain surgery so I went to donate for her very messy situation.  We call it the walking blood bank.  Anyway, my veins are so very thin that lab techs always have difficulty getting a needle in my arm nicely.  My blood is good, but the vessels are weak.  And my pulse rate is slow. And bp low.  First stab and no blood came out.  It’s supposed to fill that tube and flow down into the little baggy for transfusion.  But it was a collapsed vein (so said the lab tech) and he’d have to get someone else to try.  Great.  Other arm, another stabber, and bingo the blood trickled down in triumph.  At long last, it filled the bag for one unit of blood.

Time will expand to take up whatever space you give it.  Erma Bombeck said “going to the store for a loaf of bread and coming out with just a loaf of bread can happen.  But the odds are 3 billion: 1”.  Life is like that.  It was just going to be a simple day at home with my mom and dad here visiting.  We were just going to do one outing to have dinner with someone in the village.  But because there was space available and the right blood type, boom!  Time has taken over my day.  African time. 

This thought actually occurred to me after the blood donation while I was waiting for the ATM to work.  It takes about 10 minutes per transaction.  Apparently there is some software problem inside but can you imagine the panic if your ATM held your card for 10 minutes?  Here, it’s normal.  Perhaps I should think the machine is trying to honor me by keeping me company for a while. Hardly the case, but just an example of life in Africa.

It can be internet, facebook time, a job, or a thinking pattern, but things tend to expand to the amount of space allowed.  For our kids, it’s play time.  They seriously play outside for 4 or 5 hours a day.  It’s awesome.  They are so happy with the freedom to be children in a very pure way here.  And our little man-cub would extend his play hours to be 24-7 if his biological machine would allow for that.  The kid burns so much energy he even sweats in his sleep.  He wakes up like a rocket every day ready to take on the world with questions, ideas, adventures, and a bowl of cereal right away.  Even my children would take up as much space in my life as I’d allow them.  And while they are the most precious gift we have in flesh, I can’t obsess so much over them that no one else crosses my line of vision.  That would be a disservice to them as well. 

Life comes at us here in a new pace.  It’s a bit like jet-lag for the soul.  The days can be so incredibly full of microscopic interactions that it could seem trivial, but never ever banal. All these small things take up all our extra time and create a culture of relationship over time value.  Where I am now is where I’m supposed to be.  What happens in this moment is more valuable because we are together than what I want to do in a few minutes apart from you.  It’s hard for a couple of introverts to recharge in this context.  But we can’t find our energy and source of strength from our internal meager reserves anyway, that psycho-babble-hog wash.  My Source is not my anemic self.  Pray for us to be filled to overflowing with Life that comes from the Giver of Life in Abundance. 

The Daktari is working hard and fighting uphill battles on most patients.  He has watched too many tragedies in the last 4 months.  Too much dying of babies, pregnant ladies, bright young men, beloved parents.  Death is coming at us here in a new pace too.  Survival is never taken for granted on the local level.  Have you ever been to a staff Christmas party and heard in the speech “none of us has died this year, so let’s thank God for that”?  (!) 

Writing could take as much space as I will give it too.  Let me stop abruptly.  Life is a gas on a good day, a vapor on others.   

Dichotomy: one thing definitively cut in two

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Going on safari with our happy healthy children, who have learned to be so much happier with so much less stuff.

 

Then the sheer splendor of entering Eden at the Sekenani Gate. 

But first the Maasai ladies rush up like angels with flaming swords and stretched earlobes, selling their beads, tapping the windows, crowding the doors, but they are not there to keep me out, they are there to survive their family.  Josiah asks “why does everyone want to sell you something”?  He doesn’t understand yet that people are forced to work for a living outside of Eden.

If I were in America today I’d be asking the same question.

Effie used to tell us “the joy of overflow comes quicker when the cup of need is smaller”. What do I need? Consider these:

Then we enter.  Bam! 1. Giraffe 2. Zebra  3.Thomson Gazelles 4. Wart Hogs   5.Cape Buffaloes  6. Wildebeest  7.Grant’s Gazelle  8. Topi  9. Impala 10. Elephants 11. Ostrich 12.  Maribu Stork 13. Secretary Bird  14. Waterbuck 15. Lion 16. Serval Cat 17. Mongoose 18. Stoney Eagle 19. Guinea Fowl 20. Hot Air Ballon!  21.Spotted Hyeana 22. Plover Bird 23. Cheetah 24. Jackal 25. Elephant (worth listing again) 26. Lilac Breasted Roller (most beautiful bird in the world) 27.Black Eagle 28. Mouse 29. Eland 30. Ruppell’s Long tailed starling 31. BLACK RHINO 32. Black Bellied Bustard 33.Wattle Plover 34. Egyptian Goose 35. Superb Starling 36. Crocodile 37.Hippopotomus 38.Reedbok 39. Tiny white Butterfly 40.Hartebeest   

God I love Africa!  Thank you for this!

And the adventure of game drives and broken down vehicles after sunset, did I mention the lions? 

And the Maasai guides named Jacob and John who weren’t afraid of lions but worked relentlessly and selflessly to get us out of our broke-down place.  Then they found out we had a missionary doctor. 

So John went there.  He took us out of our ethereal vacation and into the heart of life after the fall.  But he had to try.  This is Africa.  He has been trying for the past 3 years to get help for his little boy, Anderson.  Anderson had a loss of oxygen at birth.  There is no help that will cure him except the mom dripping milk into a nasal tube for him as he lies in bed, unable to walk, stand, sit, or grasp.  And the dad guides tourists through Eden.  Once he guided 10 cows up through the Great Rift Valley to Kijabe mission hospital to exchange for any help he could get for his little boy.  All his stock in it.  But nobody can do anything more.  I do grasp it. But.

I don’t want your pain.  I don’t want your tears.  I don’t want your tragedy to touch me.  Not now.  Please I’m on vacation. Please.  God please.  And I’m underwater in the grief and love of this man for his child. 

God I hate Africa.  And yet, thank you for this Father’s love.

But here is the Beauty.  It is an invitation to the reality that we live on Earth.  This is not some middle kingdom in between heaven up high and hell down below.  This is the battle ground of 2 kingdoms at war and they are actively interpenetrating right here daily.  The Kingdom of God is at hand!  That is Good News.  But the kingdom of man is actively building gates to keep me out.  The boundary line is inside my own heart, this Rifted Valley.  My vacation please, your suffering no thank you.  I think my vacation should get me back to Eden.  Or my home as close as possible.  Or my daily existence can be my own little graven image of Eden.  If only you won’t contaminate my pleasure with your suffering.

Dichotomy.  I can’t hide from you in Africa.  You are there looking in on me day and night.

I feel like a bird trying to snorkle.  This world is so different.  I can’t breath sometimes.  The smells of a different eco-system fill my lungs and I need gills.  Or a pipe to breathe.  Or a cigarette. God help me. It’s hard here.  It’s so real here.

And I stay on the surface peering into the world I came to serve.  But in crossing culture and worldview and systems I am like a flapping bird, not viable in this habitat.  The food is hard on my stomach. Beans, bland rice, beef fat. (You all should ask Michael about his special missionary food experience)  I tell myself “5 more bites, you can do it Katie”. . A bird trying to swim.  An albatross at worst, a loon at best. 

Dr. Doolittle's Pushmi-pullyu embodies the feeling.

Some Days Are Harder Than Others

Greetings from the Daktari Cases blog (we've decided to marry the clinical cases with the family life and missions blog, beware medical images and descriptions.  Previous cases: www.daktaricases.wordpress.com).  One of my goals in writing is to introduce you to and connect you to our work here.  And that includes the tragedies, as well as the victories and the comedies.  Our patients come to the hospital desperately sick, often on the brink of death; and our inpatient medicine mortality rate averages 10%.  Of the 40-50 patients that I see every day, 4-5 of them will die in the hospital.  These are a couple of their stories.

Joan was a 37-year-old woman who came to the hospital after having a septic abortion.  All abortion in Kenya is illegal, and when it is done by the hands of a non-medical practitioner it is called a “criminal abortion.”  When I was asked to see her in the ICU, she was unable to speak, and I will never know why this happened.  I was asked to see her in the ICU for multi-organ failure and sepsis.  

 The source of her infection was a necrotic uterus, an all-to-common complication of these illegal “procedures.”  As we attempted to resuscitate her with IV fluids and antibiotics, there was an ongoing discussion with the obstetricians about whether or not she would have to have a hysterectomy to remove her uterus, her womb, and the source of her overwhelming infection.  Through the course of the day, a repeated CBC showed that her hemoglobin and platelet counts were dropping precipitously.  Her body was consuming her own blood products (a condition called DIC: disseminated intravascular coagulation).  The treatment for this condition is with replacement of those blood products; ideally with FFP (fresh frozen plasma) or cryoprecipitate, neither of which are available at Tenwek.   

What we can give is fresh blood, straight out of the donor, through the screening process (to insure against transmission of HIV, hepatitis etc) and into the patient.  And there was no fresh blood.  Her blood was typed: A-positive.  Do you know who else is A-positive?  I am.  By this time, it’s getting late in the day, and I was on-call the night before, and I’m tired.  The only chance this woman has to live is to receive fresh blood during the night and then have surgery to remove her necrotic uterus after the transfusion.  So we come up with a plan: I go to the blood bank, give my blood for the transfusion, and then we set-up the OR for the moment the transfusion is accomplished.  After the blood bank, I go home, pretty well spent.  That night, during her second transfusion, her heart stops beating, the code team comes to resuscitate her, and is ultimately unsuccessful.  And in one week last month 3 pregnant women died: one of AIDS complications, one of status epilepticus, and one of a stroke from a rheumatic mitral valve.  Prior to moving here, I had never seen a pregnant woman die in the hospital.

Stanley Rotich was a Good Samaritan.  He was 28-years-old and had cared for his brother dying of AIDS complicated by tuberculosis in their 10x10 foot one-room home.  It only takes one deep breath in the right circumstances to acquire TB, and when  Stanley was brought to our hospital, he was in respiratory failure, requiring high flow oxygen to keep him alive. This was his chest x-ray, which showed miliary TB, one of the most aggressive and advanced forms of TB, spread through the bloodstream.  He remained in our ward for 5 days, and this image is copied from the clinician and chaplain notes of his last 18 hours of life before he passed.  This is one of the cases that are so hard to understand that challenges my clinical judgment, and my faith.  Is this a tragedy?

These are some of the cases of note from the past few weeks.  The stakes are very high here; the acuity of these patients once they get to the hospital is almost always a matter of life and death.  There are no cases here of indigestion in an 85-year-old great-grandmother that undergoes a nuclear stress test to insure that it’s not a subclinical heart attack.  Sometimes I miss those cases.  But this is my dream job- to be living out my true vocation (calling).  Thank you for being interested enough to read these stories, to pray for us, and to support us.