This is not an overly timely post, but several weeks ago I surpassed a milestone that bears mentioning. January 29th, 2012 was the 10th anniversary of my first tattoo. It was also my 30th birthday. While 30 is no longer The Birthday In Which Your Life Is Over that it was even in my parents’ generation, I still approached this particular year with some amount of trepidation. Twenty and twenty-one were my last big milestone birthdays, and I couldn’t fathom how 10 years had passed already… I had lived a full decade of my adult years, and did I have anything to show for it?
Almost as soon as I asked that question of myself, I knew of course the answer is yes. I’ve never been one to exercise excessive bragging rights, but in looking back on my accomplishments over the past 10 years, I believe I have the right to a certain amount of – to borrow a phrase from my college sorority – “pardonable pride.” My life between 20 and 30 has brought me no small number of endeavors to be proud of, and even more importantly, a seemingly infinite number of joys, experiences, and indelible memories. I could probably spend a lifetime writing about all of them, but then no one would finish reading this post, so instead I have compiled my own personal “Top Ten Greatest Hits” from the past decade:
10. Triathlons: During my third year of medical school, Mike and I had the brilliant idea to train for a sprint triathlon. It was a moment of temporary insanity, but we joined a training group, went through the approximately 4 month training process, and actually finished the 750m swim, 20km bike, and 5km run. No records were set to be sure, but I do remember feeling an incredible sense of accomplishment after it was over. For someone who has never been, shall we say, athletically gifted, to be able to finish something like a triathlon was quite exhilarating. It was even fun – so much fun, in fact, that in another moment of temporary insanity I signed up for, trained for, and completed a second sprint triathlon during my fourth year of medical school. An IronMan I will never be, but every year since then I have wanted to do another one, but of course residency always seemed to derail that plan. Maybe this will be the year I pick it back up again.
9. Carnegie Hall: At the end of my intern year, I had the opportunity to travel to NYC with my church choir and sing in a concert at Carnegie Hall. The music selections were superb, and we actually got to rehearse with and perform with the various composers as our conductors. As a lifelong music lover, to be able to sing with such outstanding musicians in a building rife with musical history is a once in a lifetime experience that I will never forget.
8. Tori: Speaking of music – anyone who knows me even a little knows that Tori Amos is my absolute favorite musician of all time. My love affair with her music started in high school (probably almost a little tritely – what love-sick, angsty teenage girl did NOT love Tori Amos in the 90s???) and has continued ever since. I’m not nearly as crazy about it as I used to be (I was quite crazy), and I think that my appreciation of her music has matured as I’ve matured, and her music has matured as well. But really, the point of #8 is that I actually MET TORI AMOS. When I was a 2nd year medical student, Tori was doing a combo book tour/concert tour, and one of her stops was in Chicago. I got tickets to go to her book signing, and actually got to meet had have a 30 second conversation with the One and Only Tori Amos.
7. Putting on my Bowling Shoes: There were many things I loved about Vanderbilt, unfortunately the football team was infrequently one of them. That’s why, when I was an intern and Vandy squeaked enough wins out of the 2008 season to be bowl-eligible, I rearranged my entire holiday call schedule to be able to attend the game. Not only was I at Vanderbilt’s first bowl game since the year I was born, they actually WON the Music City Bowl that year. I spent New Year’s Eve driving back from Nashville to Indianapolis and went to call the next day on about 3 hours’ sleep, but it was totally worth it.
6. Parlez-vous Francais? As part of our whirlwind post-Kenya trip around the world in 2010, Mike & I spent a week in London and Paris. This was my first visit to Europe, and again I could pen multiple pages about our fantastic week and the various experiences we had (which in theory I will do someday). One highlight amidst a week of highlights was dining at Le Jules Verne, the restaurant in the Eiffel Tower. It was a 4-hour, 5-course, wine-fueled dining extravaganza, and by far the most expensive meal we have ever eaten. It was also another once (or hopefully twice- or thrice-) in a lifetime experience, and arguably the best food we have ever eaten (or second best… which is a leads me to…)
5. Maui: I need to preface #5 by saying that Mike & I share a love of travelling. We have been truly blessed to have both the means and the opportunity to travel to a wide variety of places in the US, Canada, Mexico, the Caribbean, Africa, and Europe. This was of course B.C. (Before Children). We have been on many fantastic vacations, but our unanimous favorite was our trip to Maui in February of 2010. Hands down the best vacation we have ever been on. Also something I will in theory write about more extensively someday, that trip was the ultimate combination of perfect timing (the winter of my 2nd year of residency), perfect weather, perfect hotel, perfect car, perfect adventures…. It was just… perfect. We snorkeled in Molokini crater, watched humpback whales breach only yards from our boat, biked down Haleakala at dawn, drove the white-knuckle Road to Hana, and ate THE best dinner of our entire existence at Mama’s Fish House. Between #5 & #6, Mike and I spend a lot of time discussing our dining adventures, and we vacillate between Paris and Maui being the Best Meal of All Time. Despite being over two years ago, we still talk about our vacation to Maui all of the time. Given that there are still a huge number of places I want to visit in my lifetime, I don’t frequently like to repeat vacations; however, Maui is a place I hope to visit many more times in the years to come.
4. Education: You’ve probably noticed that I’ve framed the experiences of my previous decades based on where I was in my medical training. Of all of the things that shaped my 20s, my education was by far the most influential and pervasive. I graduated from Vanderbilt at age 22, medical school at age 26, and residency at age 29, so literally the entirety of the past decade has been spent in some type of formal education. My journey to becoming a physician has been one of immense personal growth and satisfaction, and the relationships I have made over its course have shaped my identity as both a physician and an adult. Thirty is a milestone of years, and also of career. I have finally completed the training portion of my career (well, for now anyway) and I look forward to starting my first “real” job in July.
3. Kenya: If you’re at all familiar with the genesis of this blog, you know that it started out as a chronicle and tribute to my now two experiences living and working in Kenya. Literally hundreds of pages have been dedicated to the various events of 2007 & 2010, and there is no way I could overemphasize the importance of these experiences in my life. They shaped me as a doctor and a human being, and gave my career a direction I could have never have previously anticipated.
2. 9/8/11: The birth of baby J, our first child. No words could describe the importance, the joy, the frustration, the elation I have experienced in becoming a mom. If my life’s work were nothing more than bringing her into the world and raising her, I would be nearly completely satisfied.
1. Mike: After almost 8 years of marriage, I have no shortage of words of praise (or sometimes seemingly criticism ) for my life’s partner. We married at 22, young and naïve, and over the course of the past decade we have grown, grown up, and grown closer together. While marrying later might have made us better prepared for the trials and travails of marriage, I would not trade our experience of mutual maturation into adulthood for anything. After 10 years of “going steady,” the innumerable experiences, memories, joys, and sorrows have simply melded into the unbroken warm glow of Our Life Together, and I could not be more grateful for his presence in my life. Maintaining a relatively normal, drama-free, adult relationship through the ups and downs of life, career, and family is not easy as I’ve discovered, and amongst all of my accomplishments, of this I am the most proud.
If the next decade holds as much as the previous, I am happy indeed. After all, age is just a number and 40 IS the new 30… but if 40 is the new 30, then 30 must be the new 20 (and 20 is the new… 16? 10?), but I’m not sure I really like that comparison. While my 20th birthday marked a time of great excitement and promise in my life, I don’t think I would want to be 20 again. Indeed my first tattoo at age 20 was also my last tattoo. My 20s were great, but I did what most do in their 20s – I grew up. And the thing is, I actually kind of like being an adult now. I am grateful for the memories and experiences of my 20s, and look toward those of my 30s with anticipation and hope.
Saturday, February 25, 2012
Thursday, January 12, 2012
Watermelon Seed
Gathering with family over the course of the past week, I heard number of stories about my grandfather: some whimsical, some bittersweet, some ribald, some downright unbelievable. Their variety spoke to what a truly unique and diverse life my grandfather led. The most amazing story by far was related by my dad, and is as follows:
Just after returning home from his deployment, my grandfather and his twin brother took a trip to Michigan together. (My dad was hazy on the details of said excursion, but in his words: “I don’t think they were going to church camp.”) On the way home, with my great-uncle driving and my grandfather sleeping in the backseat, they were involved in a terrible car accident. Upon arrival to the hospital, my grandfather was declared dead, sheet pulled over his head, and his gurney rolled into the hallway to await transport to the morgue. A doctor walking by happened to see my grandfather’s foot move, at which point, per grandpa, “the doctor slit my throat” (grandpa speak for a tracheotomy), and removed a single watermelon seed from my grandfather’s trachea.
At this point in the story my brother and I looked at each other incredulously. I suppose I should mention that this accident happened prior to my grandparents marrying and having children, before they even met. We were both thinking: this is how close we came to not existing? Unbelievable.
To think that my existence in this world was decided on so narrow a margin is both mind boggling and eye opening. How can I ever take life for granted again when I came so close to not even being? How can I not live every day to its fullest, when any minute alteration in timing or circumstance could have stolen them before they began? And most importantly: how can I ever look at a watermelon the same way again???
When I think about my grandfather’s watermelon seed, I am amazed. When I think about the fact that he was born a healthy twin in 1936, I am incredulous. And when I think about the fact that his own mother was also born a healthy twin in 1916, I am awestruck. If I ponder too long the curious set of happenstance and circumstance that led to my life, I begin to feel that I have to right to exist at all.
Except for this one thing. Purpose. I truly believe, with every fiber of my being, that we all exist for a purpose. We were placed on this earth thoughtfully and intentionally, with a set of skills and circumstances uniquely our own to complete the task at hand. I also believe that the vast majority of us will never fully comprehend the purpose for which we were placed here, or understand the amplified magnitude of our seemingly inconsequential every day existence. It could be that my purpose is simply to be a physician. It could be that I was placed here because my children will do amazing things. It could be that I rescued a stray dog that would have otherwise injured or killed someone. Most likely it is an infinitely intricate tapestry of opportunities, decisions, and circumstances interwoven to create my Purpose.
If you find my grandfather’s story a little far-fetched, I don’t blame you. My grandfather was a consummate story teller, and he did enjoy the odd embellishment every now and then. Regardless of the details though, the significance for me remains the same. We all have those watermelon seeds in our lives: those near misses, those almost never was-es, those too close to call moments. The thing is, most of us never even realize it. The point is not to drive yourself crazy thinking about it though. The point is to realize that life is indeed an extraordinarily precious and rare gift, and that we as people should be much better about living every single day like the miracle it is.
Just after returning home from his deployment, my grandfather and his twin brother took a trip to Michigan together. (My dad was hazy on the details of said excursion, but in his words: “I don’t think they were going to church camp.”) On the way home, with my great-uncle driving and my grandfather sleeping in the backseat, they were involved in a terrible car accident. Upon arrival to the hospital, my grandfather was declared dead, sheet pulled over his head, and his gurney rolled into the hallway to await transport to the morgue. A doctor walking by happened to see my grandfather’s foot move, at which point, per grandpa, “the doctor slit my throat” (grandpa speak for a tracheotomy), and removed a single watermelon seed from my grandfather’s trachea.
At this point in the story my brother and I looked at each other incredulously. I suppose I should mention that this accident happened prior to my grandparents marrying and having children, before they even met. We were both thinking: this is how close we came to not existing? Unbelievable.
To think that my existence in this world was decided on so narrow a margin is both mind boggling and eye opening. How can I ever take life for granted again when I came so close to not even being? How can I not live every day to its fullest, when any minute alteration in timing or circumstance could have stolen them before they began? And most importantly: how can I ever look at a watermelon the same way again???
When I think about my grandfather’s watermelon seed, I am amazed. When I think about the fact that he was born a healthy twin in 1936, I am incredulous. And when I think about the fact that his own mother was also born a healthy twin in 1916, I am awestruck. If I ponder too long the curious set of happenstance and circumstance that led to my life, I begin to feel that I have to right to exist at all.
Except for this one thing. Purpose. I truly believe, with every fiber of my being, that we all exist for a purpose. We were placed on this earth thoughtfully and intentionally, with a set of skills and circumstances uniquely our own to complete the task at hand. I also believe that the vast majority of us will never fully comprehend the purpose for which we were placed here, or understand the amplified magnitude of our seemingly inconsequential every day existence. It could be that my purpose is simply to be a physician. It could be that I was placed here because my children will do amazing things. It could be that I rescued a stray dog that would have otherwise injured or killed someone. Most likely it is an infinitely intricate tapestry of opportunities, decisions, and circumstances interwoven to create my Purpose.
If you find my grandfather’s story a little far-fetched, I don’t blame you. My grandfather was a consummate story teller, and he did enjoy the odd embellishment every now and then. Regardless of the details though, the significance for me remains the same. We all have those watermelon seeds in our lives: those near misses, those almost never was-es, those too close to call moments. The thing is, most of us never even realize it. The point is not to drive yourself crazy thinking about it though. The point is to realize that life is indeed an extraordinarily precious and rare gift, and that we as people should be much better about living every single day like the miracle it is.
Monday, January 9, 2012
Beyond
“It’s very sad,” said my mom.
“Yes it is,” I replied. “But it happens to all of us, at some point.”
Replied mom, “Yes. I’m glad this isn’t the only world, that there is another after this life, that we go…” She paused.
“Beyond?” I offered.
“Yes, beyond.”
I suppose it’s a little inauspicious that my return to blogging (one of my goals for 2012 is to start writing more) picks up where my 2010 blog left off: with the death of a grandfather. My dad’s dad passed away peacefully with his oldest son, my uncle, at his side on Friday night. But I also suppose that there is no better way to honor his memory than to share what I remember of him, what I knew of him, and what I loved about him.
One of my earliest memories of grandpa is from Christmas, when I was 3 or 4 years old. The only thing I REALLY wanted that year was a Cabbage Patch doll (which was the toy to have that year and impossible to find). But of course, grandpa found one for me. He never did tell me how many people he had to wrestle for that doll. I still have Rory, packed away in a box somewhere. He reminds me of that Christmas, and how important my happiness was to my grandfather.
When I was in Kindergarten, grandpa came for “bring your grandparents to school” day. I remember thinking that was the coolest thing, to spend an entire day at school with my grandpa. I can now imagine that spending an entire day with 30 5-year olds was not the most tranquil day of my grandfather’s life, but he was there nonetheless. He sat in the circle, talked to my friends, and played with me at recess. One of my favorite pictures of the two of us is from that day. Outside on the playground, grandpa in a baseball cap and suspenders, me in a bright red sweater and a huge smile.
There are countless other memories, some overwhelming in their significance: Grandpa at our wedding, at my medical school graduation, Grandpa going to France for his 70th birthday, him meeting my daughter for the first time the day before he died; while some are small moments: the feeling of riding behind Grandpa on his motorcycle, Grandpa taking Brant and I and the dogs to Dairy Queen in the El Camino, the way he would always say “Hey, Meagan, what do you know?”
Not all memories are particularly happy either: Grandpa’s life-threatening motorcycle accident when I was very young, and the all-too frequent visits in Indianapolis with him when he was hospitalized at the VA over the past decade. These are all a part of life though, and when I think of Grandpa, it is easy to call to mind a host of happy memories to overcome the sad ones.
So now he is no longer with us, his physical pain and frailty have passed, and he is Beyond. Capturing a multitude of ideas and concepts in 6 letters, beyond has long been a favorite word of mine. It is a particularly germane description of death, being a word that means both “farther on than, more distant than” and “outside the understanding, limits, or reach of.” Grandpa is farther on from us now. His life now is outside our understanding. He is Beyond.
Given Grandpa’s lifelong love of travelling, it is very comforting for me to think of him this way. It is also comforting for me to consider who is waiting for him there, who preceded him beyond this world into the next: his mother, his father, his twin brother, his sister. Numerous other friends and family whose separation from this world was as difficult for him as his is for us. It is comforting for me, as I consider my own mortality, as I consider this great gift of life that we all only receive once. It is comforting for me to know that, when my own time comes to pass beyond this world into the next, those who have gone before will be waiting for me.
We gather as his friends and family to mourn his death and celebrate his life. Though not always perfect, I would judge his life to have been a good one, full of love, friendship, happiness, and the constant companionship of his faithful dogs. He will be missed, but I will remain perpetually grateful for his presence in my life.
“Yes it is,” I replied. “But it happens to all of us, at some point.”
Replied mom, “Yes. I’m glad this isn’t the only world, that there is another after this life, that we go…” She paused.
“Beyond?” I offered.
“Yes, beyond.”
I suppose it’s a little inauspicious that my return to blogging (one of my goals for 2012 is to start writing more) picks up where my 2010 blog left off: with the death of a grandfather. My dad’s dad passed away peacefully with his oldest son, my uncle, at his side on Friday night. But I also suppose that there is no better way to honor his memory than to share what I remember of him, what I knew of him, and what I loved about him.
One of my earliest memories of grandpa is from Christmas, when I was 3 or 4 years old. The only thing I REALLY wanted that year was a Cabbage Patch doll (which was the toy to have that year and impossible to find). But of course, grandpa found one for me. He never did tell me how many people he had to wrestle for that doll. I still have Rory, packed away in a box somewhere. He reminds me of that Christmas, and how important my happiness was to my grandfather.
When I was in Kindergarten, grandpa came for “bring your grandparents to school” day. I remember thinking that was the coolest thing, to spend an entire day at school with my grandpa. I can now imagine that spending an entire day with 30 5-year olds was not the most tranquil day of my grandfather’s life, but he was there nonetheless. He sat in the circle, talked to my friends, and played with me at recess. One of my favorite pictures of the two of us is from that day. Outside on the playground, grandpa in a baseball cap and suspenders, me in a bright red sweater and a huge smile.
There are countless other memories, some overwhelming in their significance: Grandpa at our wedding, at my medical school graduation, Grandpa going to France for his 70th birthday, him meeting my daughter for the first time the day before he died; while some are small moments: the feeling of riding behind Grandpa on his motorcycle, Grandpa taking Brant and I and the dogs to Dairy Queen in the El Camino, the way he would always say “Hey, Meagan, what do you know?”
Not all memories are particularly happy either: Grandpa’s life-threatening motorcycle accident when I was very young, and the all-too frequent visits in Indianapolis with him when he was hospitalized at the VA over the past decade. These are all a part of life though, and when I think of Grandpa, it is easy to call to mind a host of happy memories to overcome the sad ones.
So now he is no longer with us, his physical pain and frailty have passed, and he is Beyond. Capturing a multitude of ideas and concepts in 6 letters, beyond has long been a favorite word of mine. It is a particularly germane description of death, being a word that means both “farther on than, more distant than” and “outside the understanding, limits, or reach of.” Grandpa is farther on from us now. His life now is outside our understanding. He is Beyond.
Given Grandpa’s lifelong love of travelling, it is very comforting for me to think of him this way. It is also comforting for me to consider who is waiting for him there, who preceded him beyond this world into the next: his mother, his father, his twin brother, his sister. Numerous other friends and family whose separation from this world was as difficult for him as his is for us. It is comforting for me, as I consider my own mortality, as I consider this great gift of life that we all only receive once. It is comforting for me to know that, when my own time comes to pass beyond this world into the next, those who have gone before will be waiting for me.
We gather as his friends and family to mourn his death and celebrate his life. Though not always perfect, I would judge his life to have been a good one, full of love, friendship, happiness, and the constant companionship of his faithful dogs. He will be missed, but I will remain perpetually grateful for his presence in my life.
Friday, October 15, 2010
Beautiful Souls
This trip across the Atlantic has been an emotional one, partly due to the intensity of the Kenyan wards and also because of reasons much closer to home. In mid-September, we learned of the passing of a good friend and choir buddy back in Indianapolis. While she had spent some time in hospice care at her home, we grieved her loss from many miles away.
And now, today, we learned about the passing away of my dear grandpa Phil. While also neither sudden nor unexpected, it was still a great emotional blow, especially to learn about so far from home.
Grief is such an individual experience, and as a physician I have both the advantage and the disadvantage of experiencing death and grief in a very objective way. So objective, it seems, that I don’t know quite how to deal with it personally. We spent most of today, our last day in London (as planned) the only way we could in such a situation: lights off, curtains drawn, in silence.
My grandfather battled over the last decade with leukemia, bone marrow transplants, infections, graft-versus-host-disease, and chronic lung infections. Despite his all-too-frequent trips to various hospitals across Indiana, I will always remember and admire my grandfather’s perseverance, positive attitude, and faithful spirit. Though his leukemia diagnosis in 2000 started a tumultuous and at times heartbreaking last decade of his life, it was also one of great milestones and triumphs in our family. Five grandchildren graduated from high school, two from college, one from medical school; two grandchildren married, a seventieth birthday, a fiftieth wedding anniversary, and even the birth of an eighth grandchild – these are just a few of the many, many celebrations we’ve had in our family since 2000. He had said, and I truly believe it, that he would not have traded the last ten years of his life for anything. I hope that when my time comes, I can say the same thing.
And so we grieve. Individually, and as a family. We grieve not as for the young, in a life lost too soon. Our grief is a mixture of sorrow for ourselves, for the loss of a presence in our lives, as well as joy and celebration. We celebrate the ending of pain, of suffering, of being trapped in a failing earthly body.
My medical training has brought me greater understanding over the past few years of everything that Grandpa went through. Despite the knowledge of the risks and tolls of two bone marrow transplants and the severity of the myriad infections he suffered, I will not remember him this way. To me, he will always live in my mind’s eye, in my heart, as the young, strong, whistling farmer in overalls who could do no wrong in young Meagan and Brant’s eyes. In my childhood, he knew everything, could do everything, could be anything. Quick with a corny joke, never a man to lose at cards, and always demonstrating a love for his land and for his animals, these were the essence of my ‘Pa, to me. And they always will be.
Today, thinking about Andrea and Grandpa Phil, thinking about these two Beautiful Souls who have passed from this world in the last two months, I am finally ready to go home.
And now, today, we learned about the passing away of my dear grandpa Phil. While also neither sudden nor unexpected, it was still a great emotional blow, especially to learn about so far from home.
Grief is such an individual experience, and as a physician I have both the advantage and the disadvantage of experiencing death and grief in a very objective way. So objective, it seems, that I don’t know quite how to deal with it personally. We spent most of today, our last day in London (as planned) the only way we could in such a situation: lights off, curtains drawn, in silence.
My grandfather battled over the last decade with leukemia, bone marrow transplants, infections, graft-versus-host-disease, and chronic lung infections. Despite his all-too-frequent trips to various hospitals across Indiana, I will always remember and admire my grandfather’s perseverance, positive attitude, and faithful spirit. Though his leukemia diagnosis in 2000 started a tumultuous and at times heartbreaking last decade of his life, it was also one of great milestones and triumphs in our family. Five grandchildren graduated from high school, two from college, one from medical school; two grandchildren married, a seventieth birthday, a fiftieth wedding anniversary, and even the birth of an eighth grandchild – these are just a few of the many, many celebrations we’ve had in our family since 2000. He had said, and I truly believe it, that he would not have traded the last ten years of his life for anything. I hope that when my time comes, I can say the same thing.
And so we grieve. Individually, and as a family. We grieve not as for the young, in a life lost too soon. Our grief is a mixture of sorrow for ourselves, for the loss of a presence in our lives, as well as joy and celebration. We celebrate the ending of pain, of suffering, of being trapped in a failing earthly body.
My medical training has brought me greater understanding over the past few years of everything that Grandpa went through. Despite the knowledge of the risks and tolls of two bone marrow transplants and the severity of the myriad infections he suffered, I will not remember him this way. To me, he will always live in my mind’s eye, in my heart, as the young, strong, whistling farmer in overalls who could do no wrong in young Meagan and Brant’s eyes. In my childhood, he knew everything, could do everything, could be anything. Quick with a corny joke, never a man to lose at cards, and always demonstrating a love for his land and for his animals, these were the essence of my ‘Pa, to me. And they always will be.
Today, thinking about Andrea and Grandpa Phil, thinking about these two Beautiful Souls who have passed from this world in the last two months, I am finally ready to go home.
Friday, October 8, 2010
Goodbye to Africa
After a long day of travelling behind us, and an even longer one looming up before us, it is time once again to bid a fond farewell to Africa. This goodbye feels different than the first, if only because I'm fairly certain I will be back again.
Our travels through Kenya were adventures both big and small, and will have seperate posts dedicated to them. In short, Masai Mara was as grand and amazing as I remembered, and Mombasa was beautiful, but very touristy and not quite what I expected.
This entire trip has been a very interesting packing experience, as we've never had to pack for a safari, a beach vacation, and a week in Europe in the fall in one fell swoop. Also take into consideration six weeks of work supplies, and it's a grand understatement to say that our luggage situation is out of control. With two checked bags apiece as well as two carry-ons, we've had no small amount of trouble figuring out how, exactly we will be transporting ourselves and all of our stuff from Heathrow to City Center tomorrow. Our Nairobi hotel room tonight looked like a war zone as we literally upacked and then repacked every piece of luggage.
Regardless of the minor annoyances and hazy details of actually travelling, I still do love to travel. I am very much looking forward to the second half of our vacation. I think it is well deserved for both of us, assuming we make it to London with ourselves, our luggage, and our sanity intact.
Despite the anticipation of another week of leisure, I am still reticent to leave Kenya. It has once again been an experience full of triumphs and tragedies, happiness and heartbreak, beauty and sorrow, life and death. I am quite sure that the shock of returning to Western culture will be much greater than when I arrived, as I found when I returned home the first time. It is just so difficult to remember why all the things that matter actually do, after seeing the struggle for basic survival in a developing nation.
I hope I will have a greater opportunity to reflect on and report more of my experiences from this, my second trip to Africa.
Wednesday, October 6, 2010
Life and Death on Upendo Ward
During my short six weeks working at MTRH, I have had the opportunity to learn medicine in a whole new way. I have seen disease processes here that I will never see in the US, I’ve witnessed children die of pathology that is easily cured only a half-day’s plane ride away, and I’ve treated a wide, wide variety of infectious diseases with the same four antibiotics. Mostly, I’ve had the privilege of caring for an entirely new population of amazing little people and their families. The lessons I’ve learned from their reactions to serious illness, tragedy, and economic hardship will stay with me long after the milligrams-per-kilo dosing of antimalarials and HIV-treatment algorithms have faded from my memory. Below are just a few of the many children I have cared for this season at MTRH.
Shelly – The most memorable of the deaths on our firm, I actually cared for Shelly twice in the course of six weeks. Stricken at a young age by rheumatic heart disease (the sequela of un-treated strep throat, unfortunately very common here where strep throat is not often diagnosed or treated), she had had chronic heart problems and symptoms of heart failure for the past three to four years. Now, at age 14, she presented with acute worsening of her symptoms, was short of breath at all times and completely unable to lay flat. We improved her symptoms with medication during the first admission, but she returned five days later with even worse complaints, as well as a new requirement for supplemental oxygen. During the second admission, Shelly did not really respond to her medicines as well as the first time, and a repeat echo showed severely diminished heart function. One Friday afternoon with the help of an interpreter, my medical student and I had a very hard conversation with her mother. The “your child is going to die” discussion is never, ever easy, but it is even more difficult when you can’t even convey such an unthinkable concept in the same language. Thankfully, our interpreter had worked frequently in the peds heme/onc unit and did a wonderful job. At the end, when I asked Shelly’s mother if she had any questions, she said no, and with tears in her eyes said “I just thank God that you have told me this, because now we know.” As simple as that. I am rarely thanked at home when I actually do something helpful, but here, parents thank us for simply taking the time to talk to them, even when we are saying something horrible. As soon as we left the bedside, Shelly’s mom pulled the curtain around them, and woke up her beautiful, sleeping, 14 year-old daughter to tell her the news we had just delivered. I can’t even imagine the strength it takes to do so such a thing.
Shelly lived through that weekend, but started to clinically decline early the next week. We had told her mother our goal was to get her symptoms controlled well enough that she could go home; however, one look at her Monday morning and I knew this would not happen. Tuesday morning during rounds, the curtain was pulled around her bed, but we could all hear her groaning in pain and gasping for air. The Registrar told me that he had called the ICU about transferring her, but she was already pulseless in her extremities, so we knew it wouldn’t be long. Most unfortunately, and for many absurd and complex reasons that I won’t go into right now, Kenya has really no form of IV pain relief on a country-wide level. Morphine would have been a perfect drug in this case. Despite the fact that our team was essentially ignoring her (every time I asked the Registrar a question about her – his response: “We’ll see what the ICU wants to do.” Dude! She’s not going to make it to the ICU), I sent the pharmacy student to see what form of IV pain medicines we may have. The best we could do was an IM shot of ibuprofen. I knew we were doing the best we could do, but it was one of those times the best just wasn’t good enough. As I stood by Shelly’s bedside in her last moments, I put one arm around her mother, who had a single tear running down her cheek. That tear said so much: the loss of a child, the loss of life’s hopes and dreams that have been built over the course of 14 years, the failure of a medical system in a modern world to prevent this one very preventable death. Of all of the patients I cared for at MTRH, I felt the most attached to Shelly and her mother, and I was very saddened by her death. I have always found teenage deaths to be the hardest and the saddest. Teenagers are just becoming individuals with their own identities and plans for the future, they are old enough to understand when they are dying, and they are old enough to be mad about how unfair it is. It is, simply, unfair.
Sarai – one of many children abandoned at MTRH, Sarai was a patient on my team before I arrived. She was found alone outside the hospital at the beginning of August. Immediately noticeable was her macrocephaly (fancy doctor talk for “large head,” and truly, the largest head I’ve ever seen) as well as severe malnourishment. She was estimated to be about a year old. Her head CT on admission showed hydranencephaly – basically a condition, usually congenital, where there is far too much fluid in the head and the remaining brain structures don’t form correctly. Indeed, Sarai has very little-to-no brain tissue, she essentially has a brainstem and that is all. Sad to say, but she will never have anything we would consider any quality of life; she will never roll over, sit, walk, talk or interact meaningfully with the world around her. She has primitive brainstem reflexes (including sucking, which is probably how she is still alive), and will require skilled medical care for the rest of her life. She has had a complicated medical course since admission, and I have advocated several times to my team that discontinuing further aggressive medical management might be the most ethical course. Sarai’s case is further confounded by the fact that she was abandoned, and is therefore now a ward of the state, so the legal aspects of stopping further care must also be considered. Even if Sarai could reach a point of being medically ready for discharge, the chances of finding a children’s home that could attend to her many complex medical needs are slim to none. As it is, on my last day on the wards I left my team still piecing together the vast moral, ethical, and legal components of Sarai’s care, and I don’t think there will be a resolution any time soon.
Jake – another very sad little boy I took care of. A previously healthy 3 year old, he came in with a story that sounded a lot like meningitis. He received appropriate treatment for his meningitis, as well as treatment for pneumonia and malaria, but he just did not get better. In fact, he got worse, to the point where he was very lethargic, could not sit, walk, talk, or eat on his own. In the end, based on his lab studies and clinical course, it was thought he likely had a viral encephalitis (inflammation of the brain). Even in the US, sometimes kids with this condition recover, and sometimes they don’t. As with other conditions caused by viruses, most of the time there is not a specific treatment either, and we just have to wait and see if the child will improve over time as the brain re-wires itself. Yet another one of my difficult Friday afternoon conversations was with Jake’s mother (why did we always do these on Fridays? I don’t really know. “Friday Death Rounds” my team leader glibly called them). We actually had the Kenyan medical student caring for Jake have the conversation with his mother, and she did a fantastic job, and said it was a meaningful experience for her, which was about the only silver lining. Again, Jake’s mother’s response to us telling her that her previously normal and healthy son would probably never be normal again was: “Thank you so much for telling me.”
Jane – very similar to Jake, a 2 year old previously healthy, beautiful little girl who came in looking and sounding like meningitis. She was even in the same bed he had previously occupied, which was more than a little uncanny. When we did her LP (spinal tap), she had frank pus that came out of her back (should be clear, like water) so our diagnosis of meningitis was a little more confident. Unfortunately, like Jake, she showed no improvement, continued to be very lethargic, irritable, unable to sit, walk, talk, or eat on her own. She also continued to have high fevers for at least a week on what is considered appropriate treatment for meningitis, indicating that the infection was not adequately treated. Suspecting bunk drug product (all too common here), our pharmacist advised us to change from the generic to the brand form of one of the antibiotics, which did seem to make an improvement in her fever curve. Unfortunately, by this time, the damage had been done and she showed no clinical improvement. It’s hard to know if her deteriorating condition was the result of un- or under-treated meningitis, a complication of meningitis (ie brain abscess), the result of an adequately treated but bad case of meningitis, or even some other condition such as seizures. In her case we will probably never know, though it makes no difference now to Jane or her mother.
Steven – a very, very malnourished little guy, 2 years old, who came in about the weight of a 3 or 4 month old. Upendo peds wards certainly sees its fair share of malnourished children; however, Steven was quite severe. He also had HIV (actually AIDS based on clinical criteria) for which he had not received treatment, and chronic diarrhea and poor feeding. We were able to make little headway with him in the short time he was on the wards, and he died suddenly one night. His case is a perfect example of how long diseases can go on at home here before being brought to medical attention, as well as the still-present devastating effects of untreated HIV infection.
Emmanuel – by far the biggest diagnostic dilemma we saw, Emmanuel is a 10 year old with a six month history of worsening abdominal swelling, fatigue, and fevers. And by “abdominal swelling” I mean he looks like he’s nine months pregnant. Or really, like twelve months pregnant. He has a massive, massive spleen that is taking up most of his abdomen, in addition to stealing his blood cells from his peripheral circulation, making his white blood cells, red blood cells, and platelets dangerously low (leading to infection, anemia, and bleeding, respectively). The list of diagnoses that causes such a huge spleen is short, even in Kenya. Despite its brevity, we were still unable to make a diagnosis. His bone marrow aspirate showed no malignancy or infection, his abdominal ultrasound showed nothing but a big spleen (which we already knew about), and his splenic aspirate was negative for the two most likely infections. So, he sat. Sat and waited for expert opinions, for more blood, more platelets, more answers that we could not provide. Every day on rounds we would discuss the risks and benefits of just treating him for one or both of the infections that this could be… but the tests were negative… but it depends on how reliable you think those tests are here… well why did we get them if we weren’t going to believe them… and on and on and on we talked ourselves in circles until every day, we decided for one more day to “wait and see.” By the time I left the wards he had been there for three weeks and really nothing had been accomplished. In addition to my most difficult diagnostic dilemma, Emmanuel’s case was also my most frustrating.
And now, so I don’t convince everyone (including myself) that MTRH wards are all death and despair, a few of the kids I’ve taken care of who did well.
Elizabeth – ok, so I’m not sure if she really belongs in the “happy ending” category, but I have a lot of hope for her, so here she is. Also on my team before I even arrived, she is a darling 19-month old little girl who presented in early August with severe malnourishment, cough, and fevers. In the course of her workup, she was newly diagnosed with HIV, which resulted in a new diagnosis for her mother as well. She was also diagnosed with and started on treatment for tuberculosis. Her primary problem continues to be poor weight gain. She weighed 5kg (~10lb) when she was admitted in early August; when I left her in mid-September she weighed 4.97kg. This child is eating massive, massive amounts of calories every day and refuses to gain weight. Because of the severity of her illness when she came in, she was not immediately started on treatment for her HIV, but by the time I left, our team thought that antiretrovirals might be the key to her weight gain. The reason I think, hope, and pray that she will do well in the end is her mother. Despite a devastating new diagnosis for herself, Elizabeth’s mother has been the absolute model of patience, devotion, and dedication to her little daughter. Despite the tedium of a (so far) six-week hospitalization, not to mention an eventual bill she can’t even dream of paying, she is always smiling, has a fantastic attitude, and celebrates, even leads our team in celebrating Elizabeth’s small victories. That Elizabeth is tiny carbon copy of her beautiful mother made these two my favorite people to see every day on rounds. I truly hope she will eventually experience a significant improvement.
Franky – a very sick, scary little guy when he first came in. 3 months old, HIV-exposed but not yet diagnosed, he was admitted with a short history of respiratory symptoms: cough, wheezing, and fast breathing. The first day we rounded on him, he was still on oxygen, looking so-so, but being treated appropriately for pneumonia. On the second day of his admission, the Registrar and I took one look at him, and I thought to myself, “ok, so THIS is how today is going to go.” He had probably the most severe respiratory distress I have ever seen in a baby, and frankly, looked about 75% on his way to being dead. Very quickly, the registrar got an IV in the baby and called the ICU, while I frantically wrote for, tracked down in pharmacy, and administered myself every medicine that I thought would possibly be helpful. We ended up broadening his antibiotic coverage for bacterial pneumonia, as well as starting him on treatment for PCP (a specific type of AIDS-related pneumonia) and tuberculosis. He actually turned around so quickly that by the time the ICU came to see him later that day, he was no longer sick enough to have one of their beds. After three or four more days of good IV antibiotic treatment and steroids, he looked like a new man, normal oxygen levels, feeding well, looking for all the world like a normal baby. In addition to some good teamwork, we were helped out that day by a few other things. First off, he happened to be in the very first bed. If he had been later in the rounding queue he very well might have died before we got to him. Secondly, his mother had told us earlier that she had a previous child die from some type of respiratory infection. While not uncommon, I think this revved up our team’s “not to this baby, too” mentality. Lastly, one of the very first things I personally collected was a resuscitation bag and appropriately-sized baby mask, just to help ward of the bad joo-joo. I truly think it helped in Franky’s case.
Milo – Very similar story to Franky’s, was admitted only a few days later. A 17 month old little boy, also HIV-exposed but not diagnosed, he too came in with pneumonia-like symptoms and low oxygen levels. He was an irritable and cantankerous little squirt who refused to keep his oxygen tubing in his nose. Problem was, whenever he yanked it out he would become lethargic, dusky, and very, very hypoxic. The sat monitor would mostly read “lo” or somewhere in the 40s or 50s. This is bad. Luckily for him, he got very sick a few days after Franky, so we were prepared for his foray into the world of Trying To Die. Like Franky, with a little more antibiotic on board, PCP treatment, and TB treatment, he came off of his oxygen and turned around quite well in the end.
Irene – a fantastic 4 year old girl who came in with seizures and history concerning for meningitis. I actually assisted with her LP (spinal tap) and got to talk one of my med students though the procedure, which he completed successfully. In addition, I supervised her conscious sedation for the procedure. Conscious sedation is when we give kids (or adults) a little (or a lot) happy juice medicine to sedate them for painful procedures; specifically procedures where they need to hold still. While this is fairly common practice in the pediatrics world, CS in the US is not something any resident should ever, ever, under any circumstances do without a staff physician present. Considering I was the only physician for miles around even involved in the procedure, that left… me. To direct my first unsupervised conscious sedation while teaching one American med student and two Kenyan clinical officers about CS and LPs. Oh poo. It actually went very well, and overall I was happy with the teaching-learning-patient care dynamic that had taken place. Irene turned out not to have meningitis, and after she recovered from her seizure and its associated medications, she got to go home happy as a clam.
Diana – by far the most memorable clinical experience in Kenya, probably in my life of medicine thus far. Diana is a 3 month old baby, not even on my team. All of the American doctors and medical students happened to be on the pediatric ward one afternoon during a teaching session; we were there because the only XRay viewer happens to be on the peds side. One of the medical students looked at me and asked “is THAT your patient?” Past his pointing finger I saw a baby, looking for all the world like she was dead, being frantically, ineffectively bag-masked by a nurse. Our peds team leader had gone out to Mt. Elgon for the day, so as the only pediatrician, all eyes were on me. Oh boy, here we go. I turned the baby, positioned her, corrected the nurse’s bag-mask technique (the mask was actually upside-down on her face, this is what we were dealing with), quickly assessed the rest of the situation. No breathing, no heart rate, this baby was dead. Bagging continued, I started chest compressions, we gave epinephrine. The rest of the Americans found the baby’s chart and tried to track down at least one Kenyan physician for me to confer with. In the pauses between cycles of bagging, chest compressions, and epinephrine, I listened. For the sake of full disclosure, I must say that I didn’t expect to hear anything, and that eventually I would be pronouncing this baby. But, against all odds, eventually I did hear something. Faint at first, thinking I was only imagining things, but yes, the baby DID have a heartbeat again. We stopped giving epi, we stopped compressions, and eventually we were even able to stop bagging the child. Many, many things were happening during this resuscitation; people were running meds, starting additional IVs, taking over bagging when the nurse got tired, holding up the baby’s mother who was literally on her knees in anguish… but in the end, my little team of people, we saved this baby. We pulled her back from the brink. When I met her she was dead, when I left her, she was breathing on her own and stable enough not to go to the ICU. This is the first time I have led a code, the first time I have seen a code result in non-intubated survival, the very first time I have said to myself “Holy Shit, I’m a doctor.”
Overall it was one of the best run resuscitations I have seen or been a part of. I’m not sure if it’s because I actually knew what I was doing or if everyone else was so scared they ended up listening to the only person talking (me). Diana and I owe a huge debt of gratitude for the outcome to the nurses, clinical officers, and medical students who were there with me. We were also assisted tremendously by an angel in the form of a respiratory therapist named Mark. Here I will break my “do not use first names” rule; the fact that he shares the same first name as my father and appeared at exactly the time I was desperate for some respiratory expertise confirms my belief that he was sent to me by a Higher Power. After the baby was breathing on her own again, but still very sick, Mark, Respiratory Therapist appeared out of nowhere and just got things done. In minutes, he found the nebulizer machine and medicine that I had been asking for for a half hour, administered the treatment, was able to obtain a blood gas and run it in under five minutes, hook up the oxygen tank and tubing the nurses had been struggling with, and make the old, microwave sized suction machine work with only a few curse words and a swift kick. For all of that and the thousands of other things he was helping me with, his long white coat fluttering out behind him looked like nothing more than the cape of superhero. In short, this man saved me, and in doing so, he saved Diana.
Having never, ever seen an RT at MTRH until this very moment, I was curious to find out more about him. Turns out Mark started out as a clinical officer (Kenya’s equivalent to NPs) in Eldoret, but then went on to train as an RT in Chicago for three years. Now he works mostly in the ICU but does do some things in the regular wards as well. He and I chatted for a long time afterwards about what is possible in the MTRH wards and what are the limitations. It is true, as he says, that many lives could be saved with a few simple respiratory interventions: more oxygen, more tubing, more advanced support such as CPAP and BiPAP. He communicated to me a desperate need for more nebulizer machines, and especially the tubing and masks that go with them. In America, we discard these after one use, but at MTRH, the same masks and tubing are used for every patient on the ward. In the end, I thanked him profusely for his invaluable help (which he deferred by saying he was “just doing his job”) we exchanged contact information, and I promised to keep a sharp eye out for discarded respiratory equipment once I return home.
In the end, this is both a remarkable and an unremarkable story. In the end, yes we were all just doing our jobs. Though I personally had little hope for a good outcome of this code, there was never any question of whether I would be involved. It’s what we do. As physicians, it’s who we are. Despite the chaos of any code (especially in Kenya), when it comes down to it, the training just takes over, it’s automatic. Position. Clear. Bag. Chest Rise. Compressions. Cycles. Epinephrine. Re-Assess. It’s been engrained into me over years of study and good medical education. Because of where I was at the right time with the right people and the right training behind me, a child now lives. It’s this exact experience that we all hope for when we write our personal statements for medical school, with the vague intention of going into medicine to “help people.” At the time, I hadn’t the foggiest idea what that meant. Now, because of Diana, I do.
Shelly – The most memorable of the deaths on our firm, I actually cared for Shelly twice in the course of six weeks. Stricken at a young age by rheumatic heart disease (the sequela of un-treated strep throat, unfortunately very common here where strep throat is not often diagnosed or treated), she had had chronic heart problems and symptoms of heart failure for the past three to four years. Now, at age 14, she presented with acute worsening of her symptoms, was short of breath at all times and completely unable to lay flat. We improved her symptoms with medication during the first admission, but she returned five days later with even worse complaints, as well as a new requirement for supplemental oxygen. During the second admission, Shelly did not really respond to her medicines as well as the first time, and a repeat echo showed severely diminished heart function. One Friday afternoon with the help of an interpreter, my medical student and I had a very hard conversation with her mother. The “your child is going to die” discussion is never, ever easy, but it is even more difficult when you can’t even convey such an unthinkable concept in the same language. Thankfully, our interpreter had worked frequently in the peds heme/onc unit and did a wonderful job. At the end, when I asked Shelly’s mother if she had any questions, she said no, and with tears in her eyes said “I just thank God that you have told me this, because now we know.” As simple as that. I am rarely thanked at home when I actually do something helpful, but here, parents thank us for simply taking the time to talk to them, even when we are saying something horrible. As soon as we left the bedside, Shelly’s mom pulled the curtain around them, and woke up her beautiful, sleeping, 14 year-old daughter to tell her the news we had just delivered. I can’t even imagine the strength it takes to do so such a thing.
Shelly lived through that weekend, but started to clinically decline early the next week. We had told her mother our goal was to get her symptoms controlled well enough that she could go home; however, one look at her Monday morning and I knew this would not happen. Tuesday morning during rounds, the curtain was pulled around her bed, but we could all hear her groaning in pain and gasping for air. The Registrar told me that he had called the ICU about transferring her, but she was already pulseless in her extremities, so we knew it wouldn’t be long. Most unfortunately, and for many absurd and complex reasons that I won’t go into right now, Kenya has really no form of IV pain relief on a country-wide level. Morphine would have been a perfect drug in this case. Despite the fact that our team was essentially ignoring her (every time I asked the Registrar a question about her – his response: “We’ll see what the ICU wants to do.” Dude! She’s not going to make it to the ICU), I sent the pharmacy student to see what form of IV pain medicines we may have. The best we could do was an IM shot of ibuprofen. I knew we were doing the best we could do, but it was one of those times the best just wasn’t good enough. As I stood by Shelly’s bedside in her last moments, I put one arm around her mother, who had a single tear running down her cheek. That tear said so much: the loss of a child, the loss of life’s hopes and dreams that have been built over the course of 14 years, the failure of a medical system in a modern world to prevent this one very preventable death. Of all of the patients I cared for at MTRH, I felt the most attached to Shelly and her mother, and I was very saddened by her death. I have always found teenage deaths to be the hardest and the saddest. Teenagers are just becoming individuals with their own identities and plans for the future, they are old enough to understand when they are dying, and they are old enough to be mad about how unfair it is. It is, simply, unfair.
Sarai – one of many children abandoned at MTRH, Sarai was a patient on my team before I arrived. She was found alone outside the hospital at the beginning of August. Immediately noticeable was her macrocephaly (fancy doctor talk for “large head,” and truly, the largest head I’ve ever seen) as well as severe malnourishment. She was estimated to be about a year old. Her head CT on admission showed hydranencephaly – basically a condition, usually congenital, where there is far too much fluid in the head and the remaining brain structures don’t form correctly. Indeed, Sarai has very little-to-no brain tissue, she essentially has a brainstem and that is all. Sad to say, but she will never have anything we would consider any quality of life; she will never roll over, sit, walk, talk or interact meaningfully with the world around her. She has primitive brainstem reflexes (including sucking, which is probably how she is still alive), and will require skilled medical care for the rest of her life. She has had a complicated medical course since admission, and I have advocated several times to my team that discontinuing further aggressive medical management might be the most ethical course. Sarai’s case is further confounded by the fact that she was abandoned, and is therefore now a ward of the state, so the legal aspects of stopping further care must also be considered. Even if Sarai could reach a point of being medically ready for discharge, the chances of finding a children’s home that could attend to her many complex medical needs are slim to none. As it is, on my last day on the wards I left my team still piecing together the vast moral, ethical, and legal components of Sarai’s care, and I don’t think there will be a resolution any time soon.
Jake – another very sad little boy I took care of. A previously healthy 3 year old, he came in with a story that sounded a lot like meningitis. He received appropriate treatment for his meningitis, as well as treatment for pneumonia and malaria, but he just did not get better. In fact, he got worse, to the point where he was very lethargic, could not sit, walk, talk, or eat on his own. In the end, based on his lab studies and clinical course, it was thought he likely had a viral encephalitis (inflammation of the brain). Even in the US, sometimes kids with this condition recover, and sometimes they don’t. As with other conditions caused by viruses, most of the time there is not a specific treatment either, and we just have to wait and see if the child will improve over time as the brain re-wires itself. Yet another one of my difficult Friday afternoon conversations was with Jake’s mother (why did we always do these on Fridays? I don’t really know. “Friday Death Rounds” my team leader glibly called them). We actually had the Kenyan medical student caring for Jake have the conversation with his mother, and she did a fantastic job, and said it was a meaningful experience for her, which was about the only silver lining. Again, Jake’s mother’s response to us telling her that her previously normal and healthy son would probably never be normal again was: “Thank you so much for telling me.”
Jane – very similar to Jake, a 2 year old previously healthy, beautiful little girl who came in looking and sounding like meningitis. She was even in the same bed he had previously occupied, which was more than a little uncanny. When we did her LP (spinal tap), she had frank pus that came out of her back (should be clear, like water) so our diagnosis of meningitis was a little more confident. Unfortunately, like Jake, she showed no improvement, continued to be very lethargic, irritable, unable to sit, walk, talk, or eat on her own. She also continued to have high fevers for at least a week on what is considered appropriate treatment for meningitis, indicating that the infection was not adequately treated. Suspecting bunk drug product (all too common here), our pharmacist advised us to change from the generic to the brand form of one of the antibiotics, which did seem to make an improvement in her fever curve. Unfortunately, by this time, the damage had been done and she showed no clinical improvement. It’s hard to know if her deteriorating condition was the result of un- or under-treated meningitis, a complication of meningitis (ie brain abscess), the result of an adequately treated but bad case of meningitis, or even some other condition such as seizures. In her case we will probably never know, though it makes no difference now to Jane or her mother.
Steven – a very, very malnourished little guy, 2 years old, who came in about the weight of a 3 or 4 month old. Upendo peds wards certainly sees its fair share of malnourished children; however, Steven was quite severe. He also had HIV (actually AIDS based on clinical criteria) for which he had not received treatment, and chronic diarrhea and poor feeding. We were able to make little headway with him in the short time he was on the wards, and he died suddenly one night. His case is a perfect example of how long diseases can go on at home here before being brought to medical attention, as well as the still-present devastating effects of untreated HIV infection.
Emmanuel – by far the biggest diagnostic dilemma we saw, Emmanuel is a 10 year old with a six month history of worsening abdominal swelling, fatigue, and fevers. And by “abdominal swelling” I mean he looks like he’s nine months pregnant. Or really, like twelve months pregnant. He has a massive, massive spleen that is taking up most of his abdomen, in addition to stealing his blood cells from his peripheral circulation, making his white blood cells, red blood cells, and platelets dangerously low (leading to infection, anemia, and bleeding, respectively). The list of diagnoses that causes such a huge spleen is short, even in Kenya. Despite its brevity, we were still unable to make a diagnosis. His bone marrow aspirate showed no malignancy or infection, his abdominal ultrasound showed nothing but a big spleen (which we already knew about), and his splenic aspirate was negative for the two most likely infections. So, he sat. Sat and waited for expert opinions, for more blood, more platelets, more answers that we could not provide. Every day on rounds we would discuss the risks and benefits of just treating him for one or both of the infections that this could be… but the tests were negative… but it depends on how reliable you think those tests are here… well why did we get them if we weren’t going to believe them… and on and on and on we talked ourselves in circles until every day, we decided for one more day to “wait and see.” By the time I left the wards he had been there for three weeks and really nothing had been accomplished. In addition to my most difficult diagnostic dilemma, Emmanuel’s case was also my most frustrating.
And now, so I don’t convince everyone (including myself) that MTRH wards are all death and despair, a few of the kids I’ve taken care of who did well.
Elizabeth – ok, so I’m not sure if she really belongs in the “happy ending” category, but I have a lot of hope for her, so here she is. Also on my team before I even arrived, she is a darling 19-month old little girl who presented in early August with severe malnourishment, cough, and fevers. In the course of her workup, she was newly diagnosed with HIV, which resulted in a new diagnosis for her mother as well. She was also diagnosed with and started on treatment for tuberculosis. Her primary problem continues to be poor weight gain. She weighed 5kg (~10lb) when she was admitted in early August; when I left her in mid-September she weighed 4.97kg. This child is eating massive, massive amounts of calories every day and refuses to gain weight. Because of the severity of her illness when she came in, she was not immediately started on treatment for her HIV, but by the time I left, our team thought that antiretrovirals might be the key to her weight gain. The reason I think, hope, and pray that she will do well in the end is her mother. Despite a devastating new diagnosis for herself, Elizabeth’s mother has been the absolute model of patience, devotion, and dedication to her little daughter. Despite the tedium of a (so far) six-week hospitalization, not to mention an eventual bill she can’t even dream of paying, she is always smiling, has a fantastic attitude, and celebrates, even leads our team in celebrating Elizabeth’s small victories. That Elizabeth is tiny carbon copy of her beautiful mother made these two my favorite people to see every day on rounds. I truly hope she will eventually experience a significant improvement.
Franky – a very sick, scary little guy when he first came in. 3 months old, HIV-exposed but not yet diagnosed, he was admitted with a short history of respiratory symptoms: cough, wheezing, and fast breathing. The first day we rounded on him, he was still on oxygen, looking so-so, but being treated appropriately for pneumonia. On the second day of his admission, the Registrar and I took one look at him, and I thought to myself, “ok, so THIS is how today is going to go.” He had probably the most severe respiratory distress I have ever seen in a baby, and frankly, looked about 75% on his way to being dead. Very quickly, the registrar got an IV in the baby and called the ICU, while I frantically wrote for, tracked down in pharmacy, and administered myself every medicine that I thought would possibly be helpful. We ended up broadening his antibiotic coverage for bacterial pneumonia, as well as starting him on treatment for PCP (a specific type of AIDS-related pneumonia) and tuberculosis. He actually turned around so quickly that by the time the ICU came to see him later that day, he was no longer sick enough to have one of their beds. After three or four more days of good IV antibiotic treatment and steroids, he looked like a new man, normal oxygen levels, feeding well, looking for all the world like a normal baby. In addition to some good teamwork, we were helped out that day by a few other things. First off, he happened to be in the very first bed. If he had been later in the rounding queue he very well might have died before we got to him. Secondly, his mother had told us earlier that she had a previous child die from some type of respiratory infection. While not uncommon, I think this revved up our team’s “not to this baby, too” mentality. Lastly, one of the very first things I personally collected was a resuscitation bag and appropriately-sized baby mask, just to help ward of the bad joo-joo. I truly think it helped in Franky’s case.
Milo – Very similar story to Franky’s, was admitted only a few days later. A 17 month old little boy, also HIV-exposed but not diagnosed, he too came in with pneumonia-like symptoms and low oxygen levels. He was an irritable and cantankerous little squirt who refused to keep his oxygen tubing in his nose. Problem was, whenever he yanked it out he would become lethargic, dusky, and very, very hypoxic. The sat monitor would mostly read “lo” or somewhere in the 40s or 50s. This is bad. Luckily for him, he got very sick a few days after Franky, so we were prepared for his foray into the world of Trying To Die. Like Franky, with a little more antibiotic on board, PCP treatment, and TB treatment, he came off of his oxygen and turned around quite well in the end.
Irene – a fantastic 4 year old girl who came in with seizures and history concerning for meningitis. I actually assisted with her LP (spinal tap) and got to talk one of my med students though the procedure, which he completed successfully. In addition, I supervised her conscious sedation for the procedure. Conscious sedation is when we give kids (or adults) a little (or a lot) happy juice medicine to sedate them for painful procedures; specifically procedures where they need to hold still. While this is fairly common practice in the pediatrics world, CS in the US is not something any resident should ever, ever, under any circumstances do without a staff physician present. Considering I was the only physician for miles around even involved in the procedure, that left… me. To direct my first unsupervised conscious sedation while teaching one American med student and two Kenyan clinical officers about CS and LPs. Oh poo. It actually went very well, and overall I was happy with the teaching-learning-patient care dynamic that had taken place. Irene turned out not to have meningitis, and after she recovered from her seizure and its associated medications, she got to go home happy as a clam.
Diana – by far the most memorable clinical experience in Kenya, probably in my life of medicine thus far. Diana is a 3 month old baby, not even on my team. All of the American doctors and medical students happened to be on the pediatric ward one afternoon during a teaching session; we were there because the only XRay viewer happens to be on the peds side. One of the medical students looked at me and asked “is THAT your patient?” Past his pointing finger I saw a baby, looking for all the world like she was dead, being frantically, ineffectively bag-masked by a nurse. Our peds team leader had gone out to Mt. Elgon for the day, so as the only pediatrician, all eyes were on me. Oh boy, here we go. I turned the baby, positioned her, corrected the nurse’s bag-mask technique (the mask was actually upside-down on her face, this is what we were dealing with), quickly assessed the rest of the situation. No breathing, no heart rate, this baby was dead. Bagging continued, I started chest compressions, we gave epinephrine. The rest of the Americans found the baby’s chart and tried to track down at least one Kenyan physician for me to confer with. In the pauses between cycles of bagging, chest compressions, and epinephrine, I listened. For the sake of full disclosure, I must say that I didn’t expect to hear anything, and that eventually I would be pronouncing this baby. But, against all odds, eventually I did hear something. Faint at first, thinking I was only imagining things, but yes, the baby DID have a heartbeat again. We stopped giving epi, we stopped compressions, and eventually we were even able to stop bagging the child. Many, many things were happening during this resuscitation; people were running meds, starting additional IVs, taking over bagging when the nurse got tired, holding up the baby’s mother who was literally on her knees in anguish… but in the end, my little team of people, we saved this baby. We pulled her back from the brink. When I met her she was dead, when I left her, she was breathing on her own and stable enough not to go to the ICU. This is the first time I have led a code, the first time I have seen a code result in non-intubated survival, the very first time I have said to myself “Holy Shit, I’m a doctor.”
Overall it was one of the best run resuscitations I have seen or been a part of. I’m not sure if it’s because I actually knew what I was doing or if everyone else was so scared they ended up listening to the only person talking (me). Diana and I owe a huge debt of gratitude for the outcome to the nurses, clinical officers, and medical students who were there with me. We were also assisted tremendously by an angel in the form of a respiratory therapist named Mark. Here I will break my “do not use first names” rule; the fact that he shares the same first name as my father and appeared at exactly the time I was desperate for some respiratory expertise confirms my belief that he was sent to me by a Higher Power. After the baby was breathing on her own again, but still very sick, Mark, Respiratory Therapist appeared out of nowhere and just got things done. In minutes, he found the nebulizer machine and medicine that I had been asking for for a half hour, administered the treatment, was able to obtain a blood gas and run it in under five minutes, hook up the oxygen tank and tubing the nurses had been struggling with, and make the old, microwave sized suction machine work with only a few curse words and a swift kick. For all of that and the thousands of other things he was helping me with, his long white coat fluttering out behind him looked like nothing more than the cape of superhero. In short, this man saved me, and in doing so, he saved Diana.
Having never, ever seen an RT at MTRH until this very moment, I was curious to find out more about him. Turns out Mark started out as a clinical officer (Kenya’s equivalent to NPs) in Eldoret, but then went on to train as an RT in Chicago for three years. Now he works mostly in the ICU but does do some things in the regular wards as well. He and I chatted for a long time afterwards about what is possible in the MTRH wards and what are the limitations. It is true, as he says, that many lives could be saved with a few simple respiratory interventions: more oxygen, more tubing, more advanced support such as CPAP and BiPAP. He communicated to me a desperate need for more nebulizer machines, and especially the tubing and masks that go with them. In America, we discard these after one use, but at MTRH, the same masks and tubing are used for every patient on the ward. In the end, I thanked him profusely for his invaluable help (which he deferred by saying he was “just doing his job”) we exchanged contact information, and I promised to keep a sharp eye out for discarded respiratory equipment once I return home.
In the end, this is both a remarkable and an unremarkable story. In the end, yes we were all just doing our jobs. Though I personally had little hope for a good outcome of this code, there was never any question of whether I would be involved. It’s what we do. As physicians, it’s who we are. Despite the chaos of any code (especially in Kenya), when it comes down to it, the training just takes over, it’s automatic. Position. Clear. Bag. Chest Rise. Compressions. Cycles. Epinephrine. Re-Assess. It’s been engrained into me over years of study and good medical education. Because of where I was at the right time with the right people and the right training behind me, a child now lives. It’s this exact experience that we all hope for when we write our personal statements for medical school, with the vague intention of going into medicine to “help people.” At the time, I hadn’t the foggiest idea what that meant. Now, because of Diana, I do.
Kakamega
A few weekends ago, Mike and I, along with two of our IU House buddies, went to Kakamega Rainforest. Many of you will remember Kakamega as one of my favorite trips from Kenya v. 1, and I was excited to go again, as well as to have Mike with me this time. Also exciting was that we got to spend the weekend at Rondo House, which is the best place to stay in Kakamega (Rondo was booked when I went the first time, so we ended up camping instead). It’s actually an old compound of manor houses dating back to the British Colonial times, now converted into a very nice, if a bit quirky, hotel. We stayed in the main house, which has a full wrap-around patio with excellent views of the rainforest.
We left Eldoret Saturday morning, and in a quick ninety minutes on surprisingly good roads, we were at Rondo. We spend the rest of the morning reading & relaxing, then left after lunch for our afternoon hike. We hiked for about three hours until we reached the Yala River, which, according to our guide, flows directly into Lake Victoria. The views of the forest on the way to the river were as stunning as I remember, with countless birds, flowers, trees, insects, and monkeys to keep us (and our cameras) occupied along the way. After reaching the Yala, which was a sight to see in and of itself after all of the recent rain, we hiked another two hours through the forest, through a large guava orchard, and then finally along the road back to Rondo. We were lucky in the weather department, we got rained on only once and for not that long. As soon as we got back to Rondo; however, the skies let loose an impressive deluge that we rather enjoyed from the porch. Being in it probably would not have been nearly as much fun.
After an early dinner and a quick game of Catan (which I won, by the way, DESPITE the fact that Mike was also playing), it was an early bedtime for everyone. At 5AM on Sunday morning, we awoke for our sunrise hike. We hiked about an hour in the dark, up some very steep and muddy trails, but the view at the top was so worth it. We saw a beautiful sunrise over the rainforest canopy, took tons of pictures, then hiked back down for breakfast. Afterwards, we spent the morning reading and relaxing. I found a reading spot further out on the grounds, right next to the forest, and proceeded to fall asleep almost immediately. I awoke to the sounds of a church service occurring in the compound’s tiny chapel right next to me, including familiar hymn tunes with Swahili words. Interesting. After lunch we checked out, made the quick trip back to Eldoret, and got ready for another week. On the way home, Mike was able to get some great shots of the various things you see along the road in Africa: the bustling Sunday markets, families walking home in their Church Best, donkeys and goats mingling with shopkeepers and matatu stands… it’s easy to describe the individual components, but the collective image of everything is difficult to convey completely. As our new buddy Danielle says (one of the IU House crew this time around): “TIA!” Which simply means: This is Africa.
We left Eldoret Saturday morning, and in a quick ninety minutes on surprisingly good roads, we were at Rondo. We spend the rest of the morning reading & relaxing, then left after lunch for our afternoon hike. We hiked for about three hours until we reached the Yala River, which, according to our guide, flows directly into Lake Victoria. The views of the forest on the way to the river were as stunning as I remember, with countless birds, flowers, trees, insects, and monkeys to keep us (and our cameras) occupied along the way. After reaching the Yala, which was a sight to see in and of itself after all of the recent rain, we hiked another two hours through the forest, through a large guava orchard, and then finally along the road back to Rondo. We were lucky in the weather department, we got rained on only once and for not that long. As soon as we got back to Rondo; however, the skies let loose an impressive deluge that we rather enjoyed from the porch. Being in it probably would not have been nearly as much fun.
After an early dinner and a quick game of Catan (which I won, by the way, DESPITE the fact that Mike was also playing), it was an early bedtime for everyone. At 5AM on Sunday morning, we awoke for our sunrise hike. We hiked about an hour in the dark, up some very steep and muddy trails, but the view at the top was so worth it. We saw a beautiful sunrise over the rainforest canopy, took tons of pictures, then hiked back down for breakfast. Afterwards, we spent the morning reading and relaxing. I found a reading spot further out on the grounds, right next to the forest, and proceeded to fall asleep almost immediately. I awoke to the sounds of a church service occurring in the compound’s tiny chapel right next to me, including familiar hymn tunes with Swahili words. Interesting. After lunch we checked out, made the quick trip back to Eldoret, and got ready for another week. On the way home, Mike was able to get some great shots of the various things you see along the road in Africa: the bustling Sunday markets, families walking home in their Church Best, donkeys and goats mingling with shopkeepers and matatu stands… it’s easy to describe the individual components, but the collective image of everything is difficult to convey completely. As our new buddy Danielle says (one of the IU House crew this time around): “TIA!” Which simply means: This is Africa.
Subscribe to:
Posts (Atom)