Julia's Baby

When I arrived the youngest and smallest baby in the NICU was Julia’s baby. He was born early at 22-24 wga due to placental abruption. He weighed 600 grams at birth. By the time I arrived he was slowly but surely gaining weight. He was still on oxygen. We given Aminophylin here to stimulate respiratory drive (in the states they use caffeine). He was transitioning from IVF to NG tube feeds. I continued to advance his daily intake until he was taking in 180 kcal/kg/day. He was gaining weight at a slow but appropriate rate (goal is 15-30 g/d). He was the smallest baby that Kapsowar had every cared for and managed to keep alive. Even for the states he’s a miracle. After 3+ weeks he was at 810 grams on Wednesday. Then in the morning he aspirated and stopped breathing. They resuscitated him and he started breathing again. He stopped breathing to more times around midday. And then 2-3 more times that evening. Finally the nurses called the on call doc at 8:30p that he’d stopped breathing for 2-3 minutes. He ran to the hospital. They coded the child, gave chest compressions, rescue breaths and iv epi, but never the less he passed. It was a great loss for his mother. She’d been expressing breast milk every two hours for weeks and feeding him through his NGT, every patient and hopeful. Please pray for her healing.

Frieda

HIV/AIDS is common here due to a number of reasons, one of which is the break-down of the family unit. Many families live apart because the husband may find work in a city several hours away, and consequently adultery is more common. It’s a shame to be associated with the diagnosis so many people are in denial of their diagnosis as well. I admitted a 5 year old 15kg female about a week ago who presented with fevers, abdominal pain, tachypnea (rapid breathing), and tachycardia (rapid heart rate). Her HIV test came back positive. We started her on prophylactic dose of Bactrim for PCP, but otherwise waited for CCC to see the patient. CCC is a department of the hospital that manages informing the patient and family of the diagnosis, investigates the social situation, and arranges medications and further follow up and management. They kept deferring to discuss with the patient because the woman with her was claiming to be her aunt and not her mother. Finally they found out that the woman was in fact the patient’s mother, and she was 7 months pregnant. They tested mom and she was HIV positive too. She had another small child at home as well. We suspect that the mom was already aware of the child’s diagnosis and that she’d been trying to hide the child and not seek medical attention because then everyone would know her AIDS status as well. We treated her for dysentery and pneumonia but she continued to have high fevers to 104 at night. So we treated for Malaria even though the test had been negative. She was very thin though she had a large abdomen so we treated her for worms. The fevers began to come down and she improved clinically, but she continued to be tachypneic and hypoxic. An abdominal xray had been performed on admission and Ces (one of the surgeons) had seen it and said bilateral lung fields looked whited out, but we could never find the film. The child’s lungs sounded clear on auscultation but due to the tachypnea and hypoxia I kept trying to reorder an Xray. But the staff and the family continued to refuse because they didn’t want to pay for the second film. Finally they accepted because they were told the hospital would cover the cost since they’d lost the first film. The films were a classic example of miliary TB. So we started her on TB medications. This story hasn’t ended yet….

Community Health Project

So we have to wear skirts in the villages and even spouces are discouraged from publically showing affection, yet premarital sex and teenage pregnancy seems to be just as common here in Kapsowar as back in Tulsa. This along with several other issues are what motivated Kyle Jones and the Kenyan social workers, Ruth and Zef to start the community health programs. At the primary school Kyle and Zef first talked to the entire school of about 400 on the hillside. They talked about health, hygiene and safety until they were cut off by the rain. They then crammed 120 6th, 7th, and 8th graders into one room and talked to them about alcohol, drugs, premarital sex, teenage pregnancy, STDS, and the gospel. Kyle talked for a while in English. Then Zef, who is a native Kenyan and is familiar with the local culture, began talking to them very animatedly. He switched back and forth between English and Swahili and had all the students laughing. He was quoting all the lame pickup lines and exposing the selfish intentions of the guys. I watched the girls’ eyes as Zef spoke, and they reflected the pure yearnings of their female hearts--- to be loved, cared for, and called beautiful--- as they soaked in all of Zef’s words. We talked to Zef and Ruth afterwards about the frequency of sexual activity in this age group. They said maybe some was common in 6-8th and a lot more in the 9-12th grade age. We then went to the all girls secondary boarding school in the afternoon. Kyle was planning to talk, and he also asked Zef, a nursing student who had come with us, and myself to give a little testimony about the topics he planned to cover. He talked to the girls about alcohol, teenage pregnancy, premarital sex and STD’s. He related it all to the Christian faith and God’s will for our lives. Kyle then turned and asked me to share next. We were inside a class room but the building had a tin roof and the rain on the roof had been periodically drowning Kyle’s voice out. From learning Spanish I know that the best chance of understanding a foreign tongue is loud and clear, where as your native tongue you can understand even when muttered under someone’s breath. Many of the Kenyans speak English but their accent is difficult for me to understand and mine is difficult for them to understand. So I knew that the students would definitely not be able to understand me if it was raining. Right when Kyle asked me to talk it began to rain. I deferred to Zef, who went dancing around the room, enchanting the girls and causing them to laugh--- especially when he counseled them on not selling themselves to their boyfriends for French fries, which he made sound like a common occurrence. While he spoke the rain began pouring and pounding on the roof until even we couldn’t hear. But he ran to the middle of the room and the girls continued to listen enraptured. I sent up a prayer to the Lord that the rain would stop for me so that I could profess His truth to the girls and they could understand. Then came my turn. The rain had completely stopped when I started and didn’t start again until the next speaker. I shared the testimony of various patients I’ve cared for over the years, and the truth they’d realized too late. I’d asked Ruth why sexual activity was so common in these communities, and she said due to peer pressure (both from friends and boyfriends). I asked the girls and they agreed with Ruth’s answer, but then I told them that wasn’t the real reason because they could just say no. The true reason is their innate desire to be loved, valued and desired. I shared the testimonies of my patients who had tried unsuccessfully to fill that desire with boyfriends and popularity, and then spoke true fulfillment in a relationship with Christ and in living to love and care for others for Christ. I gave examples why God’s ways is better in the current moment than the worlds, and focused on less on long term rewards and blessings. At the beginning of the day I’d thought that all this was kind of boring, especially during the group session at the primary school. But the smaller group settings where we could see into the students eyes and heart was such a precious precious reward. Kyle asked Zef whether he thought these talks would have long term effects. Zef responded that already he would visit the villages near the schools they’d already visited and asked them if they remembered what they’d told them. And the children would reply “yes,” and proceeded to reiterate a lot of what had been spoken to them. The greatest strength and value of these talks was it allowed the team a chance to speak the gospel to the students, offer them the opportunity to accept Christ, and encourage them in a more mature faith and relationship with Christ.

ICU and Pressors

Last week we admitted a patient to the ICU which recently built at the hospital. It was the first time I'd ever used Pressors in a Developing country (ie. anywhere other than the USA). (Pressors are medicine that you give through an IV drop by drop in order to keep the blood pressure up in the normal range so that blood can still get to the brain, kidneys, and heart (you vital organs needed to survive). People dieing from heart failure, infection, or blood loss will have blood pressures that get lower and lower until they die-- usually of an arrhythmia due to the heart not getting enough blood supply. In the US we're able to keep very sick people alive and allow them a chance to get better with Pressors). We we're caring for a 26 year old female who had end stage (meaning about to die, probably within 6-12 months) heart failure secondary to rhematic heart disease. Earlier that year the workers/staff in the hospital had raised enough money to send her to Tenwick (a larger mission hospital in Kenya) to have her heart valve (which was damaged by the rheumatic heart disease and causing her heart to fail because it was working extra hard pumping blood to make up for the valve) repaired--- unfortunately see was sent back without the surgery because it was too late and her heart was too damaged. During morning devotion Kyle was called and told that she had coded (her heart had stopped) and the nurses were doing CPR on her. I went with Kyle up to the hospital. The nurses had brought her back to life--- had a faint pulse (ie low BP) and was breathing. Kyle told them to shift her to the ICU. Then we went up to the pharmacy. Kyle had heard a rumour that they may have received some pressors--- though they weren't on formulary (ie the meds that a pharmacy aims to always have in stock). We searched the shelves and found a small box of 5-6 vials of dopamine. Down to the ICU we went where we sat down with pen, paper, and calculator trying to figure out if we mixed one vial into 500mL of IV fluids how many drops per minute the fluids needed to run at in order to give the minumum and maximum amount of medicine. A "drip" is a medicine given drop by drop. Drips for the most part are given only in ICU's in the US because they're labor intensive--- you can go up and down on the dose minute to minute. Drips in the US are easy because each medicine has an electronic box that you can program how many mg/min or mg/hr of a medicine you want and it will adminsister it. The dose of dopamine is between 1-50 mcg/kg/min. In developing countries you have to compress the IVF tubing just enough that however many drops per minute you want are released. Because the dose of many of these meds are so small and our set ups in developing countries aren't as precise as in the US, we have to dilute it first and then calculate from mcg/min to ml/min to drops/min. The goal BP needed to make sure adequate blood gets to the kidneys, brain, and heart is measured as a MAP of 60. MAP= mean arterial pressure. Meaning 1/3 of the time BP is equal to the systolic number and 2/3 of the time BP is equal to the diastolic number, so the MAP is [SBP + (2 x DBP)] / 3. For instance for a BP = 90/60, MAP = 70. The goal MAP is >60. So that was the target with our pressors. With max dose of dopamine she was maintaining MAP 40 - 60. Then we ran out of the dopamine. So we calculated a drip of epinephrine (adrenaline), which I maybe saw used once at JPS during med school, but they don't use it much in the US to my knowledge (I guess because they have better pressors. We used it anyways because she was going to die anyways if we didn't. And it was working pretty well initially anyways. The other major thing going on was she was in renal failure though. She was fluid overloaded due to the heart failure, but her kidneys weren't responding to Lasix (a "water pill", ie a diuretic) and she wasn't making urine in 3 days. She needed dialysis but her sister refused transport --- she probably would have died in route anyways (the next large hospital was 2 1/2 - 3 hrs away). Kyle had spoken to her about her faith over the last several years, and he talked with her again. Earlier she had asked him in Swahili if she was going to see the Lord today. Kyle responded, "Not yet." But now it looked like death was winning. He comforted her and prayed with her and her sister. Over their heads through the window a double rainbow decorated the sky we went out and looked at them. They were very strong. You could see the entire bow across the sky reaching from hilltop top hilltop. With the promise of the double rainbow like a banner through the window over her bed we left her --- and she went to be with the Lord that night.

Justice

Its easy to complain able politics and police in the US until you realize how corrupt the government is around the world. On the way driving from Eldoret to Kapsowar the missionaries who where driving me in their vehicle were stopped by the police at a check point. The police comes to the window and asks Kyle (one of the doctors I'm working with who trained at my residency program) if he can arrest him. Kyle replied that he'd rather not be arrested. This went on for an hour. We weren't sure if they wanted a bribe initially, but they were trying to arrest him and then trying to confinscate the vehicle because the license plates weren't right. Evidently a lot of strict traffic rules were just passed this year. In that moment there was a feeling of not being in control and not being able to expect justice. WHile Kyle was nagociating with the police outside the car, Aaron, one of the other American doctors here told me a story about Ces an american surgeon who is also serving in kenya through samaritan's purse post residency. Ces had been pulled over a couple months ago and the police told her he wanted to arrest her for speeding (though she wasn't sure she was). She ended up spending a couple days in jail. After alot of phone calls they were able to get her out and all charges were dropped. Kyle ended up paying a fine (his "bail") and had to return the next week for a court hearing. He did his research and took a bunch of Kenyans with him. God provided a god fearing judge who returned his fine and told him that he could press charges against the police if he wanted, since the police handled the situation inappropriately. The whole thing makes you thankful for justice in America.

Arrival

Hey I've arrived in Kapsowar and hit the ground running! I flew from tulsa to atlanta to amsterdam to nairobe to eldoret and then drove to kapsowar a couple hours. We arrived at Kapsowar late thursday. I worked in the hospital friday and today. Friday we did 3 c-sections, rounded on maternity and newborn nursey/nicu, and admitted a bunch of medicine patients. Today I rounded on the whole hospital except for surgical patients with Kyle Jones. It's been a busy but very educational and fun 2 days. The weather is beautiful. Sunny, blue skies, green, and about 70 degrees. I've got my running route set. We're at 8000 feet elevation and its up hill, then down hill and then uphill again. PART OF the route is asfault but most is dirt. I'll post more stories later. Having internet issues so just wanted to give a quick update. God bless!

Off

Hey friends! And I'm off. I left the USA yesterday the 1st and should reach niarobe, kenya later tonight. Tomorrow I'll fly to Eldoret and then drive to Kapsowar, where the hospital is.