Tuesday, June 23, 2009

Return to Rondo -- and Reality

Emmah shyly told me two months ago that she had heard Rondo Retreat described as a "little bit of heaven in the Kakamega Forest." I agreed with her and privately tucked away the thought that she should see it for herself. So last weekend Emmah and I took her niece Sheila and Dr. Hardison's assistant Linet with us to Rondo. A brave young male visitor from Boston, Brandon, accompanied the four of us. It was a glorious, if gluttonous, 28 hours. We thoroughly enjoyed the serene surroundings and fabulous food. (Please pardon the alliteration and see more pictures of our Rondo retreat at www.picasaweb.google.com/dianne.smith.rn)

While at Rondo, we walked the beautiful Yala River Trail. It took a concerted effort to explain the importance of the rain forest's ecology to three wonderful women who were nervous under the canopy of tall trees while marveling at the abundance of "firewood" -- and understandably hoping to carry some of it home. Fortunately, Brandon was reading the story of Wangari Maathai's "Green Belt" movement during our trip. Sheila picked up the book and began to read -- and to appreciate even more of the world's complexities.

Kenneth, the Hardisons' driver, picked us up at Rondo and coaxed "Private," the Hardisons' vintage van, into struggling and sputtering its way home. The radiator has been unhappy, in and out of the shop, for months, so our 90-minute trip turned into an anxious three-hour drive. It is not a good idea to be out at night in Kenya. At one point, we were prepared to abandon van (vs. ship) and hop onto the next available matatu/taxi. I carefully stowed my camera and laptop in my carry-on bag because Emmah warned me about keeping a vigilant eye on the luggage, should we need to use public transportation.

"People will jump off, take your suitcase from the boot/trunk and insist that it is theirs," she solemnly counseled. "That happens a lot, especially around the holidays. Everyone knows that people are carrying food and money home. Of course," she added, "once in awhile, they get surprised." Surprised? I asked. She and Sheila nodded in tandem. "Yes. You see, some people are too poor to have the bodies of their dead loved ones embalmed, but it is very important for them to be buried at home. So people pack bodies, especially children's bodies, in suitcases to get them back to their villages for burial."

I am grateful to report we didn't need to take a matatu.

Re-entry was interesting, nonetheless. Mbwa, our neighbor's dog, had secured the premises during our absence, but she had obviously had the help of three very attentive friends. She's in heat. And (sorry) speaking of heat... The day we returned, Kenya Power turned off the hospital's electricity because last month's bill was not paid in full. Again. Fortunately, a visiting surgeon was able to continue his efforts on nine-year-old Felicia, who is suffering from osteomyelitis. We had enough gasoline this time for the Operating Theatre's generator. It hadn't yet been siphoned into the ambulance for a joy-ride.

Sunday, June 21, 2009

Glimmer of Grace

Thank you, Mungu/God, for teaching us how to love -- and be loved -- unconditionally. And thank you for your patience. Some of us are very slow learners. Amen.

Friday, June 19, 2009

Call of the Wild

The dogs of Maseno, domestic and wild, sometimes howl at night. We recognize the familiar sounds of our Mbwa as she joins in the nocturnal chorus. Once in awhile, though, we are awakened by a very particular pitch and intensity: the howling is eerie and prolonged. We don't hear his own rasping voice, but we wonder... Is the legendary local leopard-cat on the prowl in the nearby rocks and dense underbrush?

Stealthy, strong and shrewd, his natural territory is wide-ranging but ever-diminishing. Although he was once a solitary symbol of wisdom, neighboring farmers would now exterminate him if they could. He has an unfortunate habit of absconding with chickens and other small livestock. But the leopard is an elusive creature by instinct, and I confess that I am glad. I like to think of ours as wild and free -- while I am safely ensconced in my bed at Rotary House.

Wednesday, June 17, 2009

Orphan (Di-)Annie Post Script

Dear faithful readers, in answer to your questions:

(1) I had no idea if the snake was harmful. He didn't spit, rattle, sink fangs into me or coil himself around my ankle and cut off circulation, so -- ever my oblivious self -- I didn't ponder the possibilities. Guess I'm learning to "let go, let God" when it comes to things we can't do much about. The neighbors tell me it was probably a black mamba. Oh, well.
(2) I slept very well on Sunday night, as usual. (Of course, Emmah was on duty for both of us...) I am occasionally awakened by a whining midnight marauder who slips through the cloud of Doom sprayed on my mosquito net. Otherwise, it is only worrying about our patients, not our critters, that interferes with my sleep. "What else could we have done?" I wonder, still clearly lacking the all-important wisdom to know the difference.

I was awake much of last night, for instance, because Ritah went home to lie (die?), probably alone, on a kanga/cloth on the dirt floor of her one-room home in Esiola. We could feed and medicate her through an NG tube in the hospital, but we couldn't make her want to live. Tracy, who had originally rallied in response to oxygen and antibiotics but whose lungs unfortunately never cleared, was transferred via ambulance to an ICU in Eldoret yesterday. We will probably never know the outcome. And little Zebedee's mama signed him out against medical advice last evening, although his fever had spiked again. She couldn't afford the $6.50 a day it cost to keep him here.

The sun'll come out tomorrow... Actually, God "makes the sun to shine" every day in Kenya. There's a reason.

Tuesday, June 16, 2009

Leapin' Lizards!

We make it a practice to welcome guests at Rotary House, but the place became a little too crowded recently for even gracious Emmah. I mentioned Sunday night that I had been startled by a two-meter snake slithering over my foot as I stood at the back-door sink earlier in the day, brushing and flossing my teeth. (Hear that, Dr. Adams?) I didn't realize Emmah was terrified of snakes, so no amount of reassurance helped after that. Hours before, I had promptly swept the intruder out the hole he had probably come in. The snake was long gone, but poor Emmah was in orbit.

First she burned a bucket of plastic in the house because a friend had told her that would help prevent another similar uninvited guest. Eyes and throat burning, I retreated to my bedroom and closed the door. The fumes took hours to dissipate. Snakes are more welcome than burning plastic any day.

Then she doused kerosene around the entrance ways because another friend had advised her that would help. Fortunately, the kerosene was poured after the smoldering plastic had cooled. With one last burst of adrenaline, our indomitable Emmah stuffed the (admittedly numerous) foundation holes with old newspaper. She was up all night.

I thought the worst was over yesterday, but Emmah told me today that she hadn't slept a wink. This, from a fiercely-determined housekeeper who wages daily war (and invariably wins) against ants, flies, jiggers, spiders, cockroaches, banana slugs, mice, mosquitoes and all manner of mean microscopic menaces that cause wazungu to get sick. The only critters left alive at Rotary House are the geckos who feed on the mosquitoes and the frog in the toilet tank who feeds on their larvae. (The frog apparently swam in as a tadpole and grew too big to get out.)

Ordinarily, Emmah has full confidence in "Doom," the equivalent of "Raid," which successfully gasses (in its tried-and-true, bullet-spray fashion) most living creatures known to man. This time, however, we may need to resort to nuclear weapons before Emmah can sleep again. I suggested an old-fashioned panga/machete at her bedside, but that didn't go over too well. And somehow I don't think de-sensitization will help -- either of us. It is obviously also too late to worry about any respiratory or environmental damage. So much for biodiversity.

At least we haven't seen any more snakes lately.

Thursday, June 11, 2009

Kids in Crisis

We thought we were finishing afternoon rounds about 5 PM yesterday. Then Tracy and Zebedee were admitted.

Tracy, 11 years old, was struggling to breathe. Her oxygen saturation was 74%, temperature 40 degrees Celsius (104 Fahrenheit) and pulse 176 (that's right, not 76). Her shallow respirations were 66. According to Tracy's anxious mother, the child began getting sick one month ago, about the time her baby sister died from biliary atresia. Tracy's chest xray revealed diffuse infiltrates in all three lobes of her right lung. An ultrasound confirmed there was no pleural effusion. Her platelet count was low, she had 50% bands, and petechiae were present on both palms. DIC? we wondered. And why?

Tracy was critically ill, and we did not know if she would make it through the night. She was tucked into a bed next to the nurses' station on the ward, the best "ICU" care we can manage, and given stat doses of an antipyretic and IV Ceftriaxone, the only broad-spectrum antibiotic available. But Tracy was still gasping for breath until we found an unkinked nasal cannula and connected the oxygenator that had been donated to Maseno Mission Hospital by parishioners at St. Barnabas Episcopal Church in Falmouth, Massachusetts. Tracy's breathing eased immediately, although we needed to keep the flow at 3-4 liters throughout the night.

This morning, I went early to the ward, half-expecting (and fully-dreading) to find an empty bed. Miraculously, the child was alive, conscious and resting comfortably. Her mama, who had slept next to her all night, was smiling. During the course of the day, we have been able to gradually reduce the oxygen flow to just 1 liter via nasal cannula. We do not yet know the source of Tracy's sepsis (RSV? viral pneumonia? shock lung?), but she has survived the first 24 hours, thanks be to God -- and to the people of St. Barnabas.

Seven-year-old Zebedee was waiting patiently in his mother's arms while we stabilized Tracy. The clinical officer took his history while I took his temperature. We watched in dismay as the column of mercury (yes, sorry: mercury) rose to the very tip of our thermometer. It read 41.5 degrees Centigrade, or 106.7 degrees Fahrenheit. We promptly administered an IM antipyretic, IV fluids and began to sponge him down. But even gentle sponging caused Zebedee unremitting pain because he was in acute sickle cell crisis. We administered two units of blood, but all of his joints still hurt. A large fluctuent abscess adjacent to his right elbow was incised, drained and irrigated with normal saline. We removed 20 cc's of pus and dressed the wound, then began IV Ceftriaxone when the lab culture revealed Salmonella. And we prayed that yet another child might make it through the night.

Zebedee was still listless, feverish and in pain today, but his temperature has ameliorated somewhat. This afternoon we changed the dressing, irrigated the wound and replaced the wick after draining another 15 cc's of purulent fluid from his elbow. Zebedee is a very sick, but very patient, little boy. He wept only a few silent tears during the procedure. His relieved mama smiled at the camera for both of them. We hope we can get them through this crisis, with God's help and your prayers.

Tuesday, June 9, 2009

Peace Happens

Barack Obama made a historic speech in Cairo a few days ago. Entitled "A New Beginning," it addressed our commonalities and our differences around the globe. As a North American nurse working at an Anglican Church's mission hospital in Maseno, Kenya, I have felt blessed to witness our president's kind of peacemaking on an ongoing, daily basis. So have the nurses working at the Al Ahli Anglican Hospital in Jerusalem, Israel. And so have clinicians in mission hospitals everywhere.

Patients of every faith who come through our doors are treated with the same medicine and the same respect. Disease and injury know no boundaries, nor do our mission hospitals. I celebrate the continuation of medical services to all of God's children throughout the world. I celebrate all of you who have made that possible. And I celebrate people everywhere who may be inspired to make "a new beginning" and a more peaceful planet.

Over two years ago, 13-year-old Miriam was brought to the Outpatient Department at Maseno Mission Hospital by her mother. There are many clinics between Maseno and their home in Kisumu, 20 kilometers away, but Mama Miriam had heard about "Daktari Hardison" and had sought him out. Their traditional Muslim garb was the primary visible difference between the Somali women from Nyanza Province and their Christian Luo/Luhya counterparts here in Western Province. Medical needs are the same beneath our bui bui's, our kangas and our skirts. And medical needs are all that matter here.

Miriam was (and is) a beautiful girl who had suffered an apparent seizure at 8 months of age. She had met all her developmental milestones until the night she cried out in her sleep. Her mother found her lying in her crib with right-sided paralysis. Miriam's creeping was delayed after that, but she gradually recovered most of her motor function over the next year. She was left with only a slight limp and minimal residual right-sided weakness. Her social, intellectual and emotional development were unimpaired.

In 2007, Miriam began having intermittent seizures, evidenced by rigidity, then shaking, of her right arm and leg, and a brief loss of consciousness. After each seizure, she would fall asleep for several hours. Her mother then brought her to our hospital. Upon history and physical examination, Dr. Hardison determined that Miriam had suffered some type of event, perhaps at birth, that manifested 8 months later with epileptic focii, probably as a result of scar formation.

Miriam's course did not suggest a focal neoplasm or an infectious process. There was no CT scan available in western Kenya at the time, and her family could not have afforded one, anyhow. Her seizure disorder has been successfully managed by Dr. Hardison with Phenobarbital and Carbamazepine, the basic medications available to us. Miriam has been seizure-free since her initial visit. She returns to Maseno Mission Hospital for periodic checkups,with great gratitude and quite mutual affection. 

A happy, healthy child. Peacemaking at its finest.

Sunday, June 7, 2009

Nursing Considerations

Nothing's simple. If we had a Maseno Mission Hospital manual for nursing care, it might include a few extra NB's, or caveats, to accommodate our fragile infrastructure here:

(1) "Encourage nutrition and ambulation" sounds like a simple enough medical order to implement. But it can be a challenge to coax a sick and weary patient to eat and walk, even in the U.S. It is a very tall order for 66-pound Ritah in rural Kenya. She is 38 but looks 68. Although she is on ARV's, Ritah remains frail and bedridden after recovering from miliary TB. She also suffers from HIV-wasting, painful genital and decubitus ulcers, and concomitant depression. She has had no visitors since her admission ten days ago. Ritah's adult daughter is the full-time caregiver for her own brother who suffers from dementia.

Ritah must struggle to sit up in bed to feed herself, but we are reluctant to resume IV fluids and are trying instead to help her regain strength via oral medications and nutrition. She must also struggle to get to the bedside commode, but we are equally reluctant to catheterize her. She might otherwise not get out of bed at all. So we sit and talk quietly with her while she eats, buy occasional extra treats to supplement her hospital diet (beans and rice, porridge and "eggnog," an egg-enriched soy formula), and assist with her personal care -- a laborious task when there is no water on the ward, and a painful one for her, regardless. Bed linens are changed as needed. So far, so good. But we are short-staffed with only 11 nurses for three 8-hour shifts.

Because of her muscle-wasting, it is also painful for Ritah to stand. We began with dangling, of course, and then progressed to daily trips outside in a wheelchair. We wrapped her in a sheet because there are no "johnnies" on Wards I, II and III. They cost money. (There is something to be said, after all, for those much-maligned hospital gowns in the U.S.) The first day we helped Ritah walk, we needed to find her some clothing. She had only the shirt and soiled kanga/wrap she had worn upon admission. My size-4 skirt swam on her. There were no safety pins anywhere, so I appropriated adhesive tape and strapped the skirt almost double at her waist to make it fit. (Photo below shows her in a gown borrowed from Maternity!)

Although pleased with her new skirt, Ritah protested the walker mightily and asked for "an injection for strength" instead. Injections are often perceived as the only answer to illness here. Ritah clearly didn't believe we were taking proper care of her without them, and no amount of "education" helped. The first day with the walker, she ambulated two bed lengths before collapsing and insisting she be returned. We coaxed her to "return" herself. The next day she progressed to four bed lengths, and today she made it the length of the ward and back -- neatly sidestepping two scavenging chickens underfoot. Ritah thinks she's getting better because of the injection of sterile water that was finally administered to her by a frustrated staff nurse. We know it's because she's eating and using her muscles. Whatever works...

(2) "Encourage socialization" sounds equally straightforward, but family and community dynamics are sometimes complicated. Repha, 24, was admitted with a high fever and cerebral malaria. She was considered by her family to be "bewitched" because of her delirium. Before admission, Repha had twice been treated by a local practitioner with blood-letting and herbs. Two dark circular bruises on her forehead surround undoubtedly non-sterile incisions. "Everyone was disappointed when snakes and cockroaches didn't come out," explained our clinical officer.

When that didn't happen, and when Repha didn't improve, her family brought her to the hospital as a last resort. Had she been a child, she probably would not have survived her prolonged fever and dehydration. (Little Vincent, age 3, didn't live long enough to be admitted from Outpatient today.) Fortunately, Repha is now on the mend, after three days of IV fluids and quinine. Thank goodness they were in stock this week. She still needs a blood transfusion, but there is no blood at the Kisumu blood bank again. (It runs low whenever school is out and the donor population disappears.) Repha was also given a tetanus shot because of her head wounds. She smiles weakly at us, but her family still doesn't visit. We will ask Matron to intervene. Her family needs to witness Repha's recovery. Seeing is believing...

(3) "Administer oxygen via nasal cannula" is another fairly routine nursing order. But if we have cannulas in stock (no money again), they are often poorly-packaged, kinked and unusable. Fortunately, thanks to St. Barnabas, Falmouth (Cape Cod, Massachusetts), parishioners, we have a wonderful new oxygen concentrator that has saved several lives since Christmas. But we also have four wards -- Male, Female, Paediatrics and Maternity -- in separate buildings at Maseno Mission Hospital. Even a dual-capacity oxygenator can't help a patient on another ward.

So who gets to breathe? The 70-year-old grandmother with CHF who cares for three orphans? The 35-year-old father with PCP pneumonia who is the sole family wage-earner? Or the infant with malaria-induced anemia? And who decides? And, oh, by the way, what happens when the power goes out -- which is becoming the rule rather than the exception in Maseno? Nothing's simple. Except prayer. Yours and ours together. Thank you/Asante, Everyone!