27.3.10

COTW: 10 months old

Right around noon, a nursing student quietly walks up to me. "The child in bed 3 has changed condition." Changed condition, I have learned, is never for the better, and is almost always a dramatic understatement. Usually this means they have stopped breathing, or suddenly look like they are about to.

Within 20 seconds, the child is in a small side room, and myself and two other interns are suctioning her mouth out, bagging her, and performing chest compressions. Such events are never "routine", but since coming here, there has been ample time to develop a certain calm even in the midst of a resuscitation. "OK, guys, let's think through her case really quickly, to see if we can figure out anything that might help."

She's 10 months old. And unlike so many of the kids we see, she appears to have been healthy up until a week ago. She had been having a cough and some fever for a few days, and was seen at various health centers, getting some typical meds. She came to us the day before, in pretty decent respiratory distress, and not feeding at all. She was started on antibiotics, and IV fluids, and given oxygen.

Now she has no heart beat, and her pupils are dilated. We're suctioning milk out of her airways, and we're not sure how that got there, since she wasn't supposed to be eating, given her terrible breathing situation. The compressions and bagging continue, and after a few doses of epinephrine, we realize that nothing is bringing this kid back, and we stop. One intern goes to fill out paperwork, the other goes with me and the chaplain to talk with the stunned mom, who promptly falls to the floor, wailing and beating her fists on the concrete.

By the time everything is done, it's time to head home for lunch. It's a downhill walk, so my feet can just follow gravity, while my mind is caught up in everything that just happened.

I open the door, and Maggie looks up from her baby books. She smiles her big open-mouth, toothless smile. I snatch her up and hold her to me, even as she gently pushes me away, because she wants to get back to her books. I set her down and look at Rachel. It helps to know that she understands, since OB loses their fair share of babies as well.

10 months old. Previously healthy. Maggie is 10 months old. I have no real fears about her health, since she lives in this clean place with quick access to a hospital and practically every adult she knows is a doctor. But I just left a mom who now has no 10-month old. My hands had just been pushing on the ribcage of a girl who is now gone. And here I am, with my fingers now running through Maggie's sparse brown hair, as she babbles happily at her well-worn copy of "That's Not My Bear".

Guilt? A little, in the irrational way that all of us who mourn feel guilty that we're not the suffering ones. But the predominate feeling that such a surreal (and yet common and recurring) situation brings is that of a deep ache of beauty. Gratitude crushes me, and I know that I don't deserve the goodness that tumults over me like waves and breakers. I haven't earned this. That has always been true, and always acknowledged by my mouth, but the reality of it makes me want to gasp and smile and laugh and weep.

This is another aspect of where we live. The beauty around us here, and in the world as a whole, is positive beauty, not just the negation of ugliness and evil. But nonetheless, when it is surrounded by so much tragedy, it shines brighter by contrast. There is a mystery to it which makes me feel small, and thus it has taught me truth.

So pray for our hands and minds, that we might be able to bring as much light and life as possible. Pray for our hearts, for without Christ in them always, we would labor in vain, and that for not very long. Pray for our patients, that they would know life. But pray also for the grieving, for they are always here with us. This is a fitting aspect of the work of anyone who is seeking to follow Christ by getting their hands dirty with the needs around them.

Blessed are those who mourn, for they shall be comforted. - Jesus

The Kipsigis Naming System

Our friend and fellow Tenwek doc Alyssa has put together a nice description of how the Kipsigis (the predominant tribe around here) names their children. And you can call me Kipngetich from now on, seeing as though I was born "when the cows go out".

24.3.10

One Broken Fifth Metatarsal


The event was completely ungraceful and unheroic. I would like to say that I broke my foot as I was leaping to rescue a Kenyan child in danger. But actually I (Heather) just stepped onto uneven grass and fell. With Abi tied to me in the baby carrier, so we are especially thankful that she was not hurt. My right 5th metatarsal was not so fortunate.

It turns out that if anyone has to break a foot, Tenwek Hospital is actually a really good place to have that experience. Here are some of the benefits of living here as an injured person:

Accessible Doctors -
Within a few hours of the injury, I received housecalls from several neighbors: an orthopedic surgeon, a physical therapist, a visiting radiologist, and several other medical specialists just for good measure. Dan the Orthopedic Surgeon also happened to have an orthopedic boot right at his house (across the sidewalk).

Affordable Healthcare -
The multiple doctor consultations were free, and the cost for x-rays was $4.75.

Convenient Locations -
Living at Tenwek, I do not have to drive (which would be impossible with the boot and crutches). I can hobble to the hospital, to church, to friends’ houses, and to the mailbox. Those are all the necessary errands around here.

Kind Kenyans -
I have found that Kenyans here express sympathy frequently and sincerely. Everywhere I go, I hear “Pole, pole” (Sorry, sorry) from Kenyan friends, acquaintances, and strangers. Their kindness makes me wonder whether their sympathy reflects the physical suffering that seems more pervasive here in Kenya.

Helpful Neighbors -
Our friends and neighbors are extremely helpful and kind. I can tolerate six weeks on crutches with such great neighbors.
This is Jessica taking care of her baby and mine.
This is Edna and Anna helping with the dishes.
This is our friend Amy cleaning up my living room.
This is Maggie keeping Abi entertained while a physical therapist was teaching me how to navigate on crutches.
This is the gorgeous weather and scenery (not to mention the fun children) in our front yard that help to keep us all smiling.

For the next 6 weeks, though, I should be spending most of my time right here on this couch, hopefully remembering to feel thankful that we live in such a great place.

22.3.10

The Signs of Kapsowar

This past weekend, the McFaders took our van (post coming soon!) on its true maiden voyage up to Kapsowar, another mission hospital where our friends Christina and the Jones' are working. It was a weekend complicated by sick children, but nonetheless a relaxing little visit and great to see friends. We even had a hotdog and hamburger grill out! Kapsowar is smaller than Tenwek, and more rural, without a paved road to speak of for a couple hours. They are also even further up in the mountains than us (8000 vs 6500 ft), and get sweet views like the above picture just when they are hanging the hospital laundry.

The trip also gave me a chance to indulge my amateur anthropological habit of photographing shop signs in Kenya. I hope to develop a collection of them, and here are a few from the weekend.
Just quaint, and just outside the hospital gate.
"Nyama Choma" is grilled meat. The fine print reads "The Best Nyama Choma in East & Central Africa & Asia." I guess that they're better than Asia, but not West or Southern Africa.
Say what you will of him in the US, Obamania is still firmly embedded. Although I'm not sure what Arizona has to do with anything, except that Obama's main opponent was from there.
Sometimes the camera was just too slow, but my other favourites (note the commonwealth spelling) from the drive were "New Hygiene Butchery" and "Lazarus Funeral Home". I just love imaging the conversation where those names were decided on...

15.3.10

Celebrating Pi Day

I (Jessica) have been teaching math to a small class of 6th-grade missionary kids for the past month.  Amy Bemm had been teaching the class, but was eager to pass it off to me since it wasn't her field of expertise.  She has since started a little "pre-school" class for Elise, Anna Fader, and two other missionary kids that meets at the same time.

As some of you know, March 14th is "Pi Day".  (Pi is approximately equal to 3.14 for the non-math savvy out there.)  Since this year's "Pi Day" fell on a Sunday, we were forced to celebrate on Monday.  Nevertheless, the kids were eager to make a special event out of it.  During class time, each of the kids presented their "Pi Projects" which were done on circles split into quarters -- the history of pi, the uses of pi, the digits of pi, and interesting facts about pi.  Then, we did a little activity exploring the circumference and diameter of various sized circles (the ratio of C/d should equal pi).

My little math geniuses (from left to right):  Peter, Joel, David, & Abby
P.S.  In case you were wondering, Joel & David's projects were done on circles, they just didn't cut them out! :)





















During the lunch hour, we had a "Pi Party", complete with pizza pie, coconut cream pie, and pretzels in the shape of pi.  The day brought much joy to the math nerd in me!  
















For the fellow math nerds, here are a few interesting facts about pi that my students discovered:
*Pi Day is also Albert Einstein's birthday.
*If you were to print a billion decimals of pi in ordinary font, it would stretch from NYC to Kansas.
*As of January 2010, 2.7 trillion digits of pi have been calculated.
*Akira Haraguchi of Japan holds the unofficial record of memorizing 100,000 digits of pi.
*There are no zeros in the first 31 digits of pi.
Disclaimer:  These facts have not yet been verified by the teacher! :)

Slug Tales

And now for a diversion into another story about the little things, in particular one that makes me out to be quite a pansy.

Background: We have slugs here. And we did in the states. The principle difference here is that our local slugs here resemble the size and shape of a Ballpark hotdog, though I can't vouch for any similarities in taste. They slide up and down the walls outside our front doors, and sometimes get inside the Fader household. In fact, another couple here found one morning that their doctor white coats had gained some glistening streaks in the night, suggesting that the slug had been and gone.

The other night Rachel commented that she was bringing her shoes inside, since she had seen some giant slug outside the door and, as everyone here knows, shoes are vulnerable to invaders. Thus, the truism "In Africa, always check your shoes before putting them on."

I passively thought Rachel's move a wise one, but didn't take any action myself. However, 2 days later, when I was going to play racquetball with Jason, I went to fetch my tennis shoes. Though I thought myself a bit paranoid for it, I was thinking about the slugs, and thus glanced under the tongue of my shoes, and knocked it on the ground a bit, but nothing came out.

Well, apparently slugs can be a bit tenacious, because nevertheless, when I put my shoe on, there was a distinctly squishy sensation at the toe, which caused me to yelp, yank the shoe off, and hit it quite a bit harder on the ground, where this little fellow fell out.

Rather small by Kenyan slug standards, which is maybe fortunate, though I think the full-grown size would have been noted prior to the shoe donning, and not after. We shared a good laugh with the Faders, and a napkin used to wipe the stickyness from my sock and shoe, and we moved on.

What did I learn?
1. Look inside your shoes a bit more thoroughly.
2. Anticipating your fears can sometimes alleviate those same fears. However, in some cases, like this one, it can make the whole experience a bit more nightmarish, which I'm pretty sure is the technique employ by suspense thrillers.

12.3.10

COTW: Ectopics and Outside Hospitals

One of my former attendings at St. Joe's where I did my residency used to say that getting pregnant is the most dangerous thing a woman can do with her life. Basically, if you look at the statistics of maternal mortality, and even in the US dying from abortions, infections, bleeding, and the “morbidities” (or bad side effects) that come from pregnancy it's worse than women dying from, say, motor vehicle accidents. I never really appreciated that fact until I came here, because women are dying at a much higher rate than I've seen before. So far in the hospital, I think around 10 women have died from complications of their pregnancies, just in the last three months that I have been here. Contrast that to no deaths in four years at St. Joe's (although we came close a couple of times). It's tough to see, mentally and emotionally, when women that “shouldn't” be dying, are.
Sometimes I get a chance to save women that would have otherwise died. One of the biggest life-saving interventions involves ectopic pregnancies. For the non-medically initiated reading this blog, an ectopic pregnancy is when the embryo implants outside of the uterus—usually in the fallopian tube, but sometimes on the ovary, inside the abdomen, etc. It's life threatening to the mom because as the pregnancy develops, it can rupture through the tube (or wherever it's located) and cause severe bleeding. Unfortunately, there is no way to save the developing pregnancy, but quick surgical intervention by removing the pregnancy and sometimes the tube can save the mom's life. In women who come in with severe belly pain, we always try to keep this diagnosis high on the list in our minds to make sure we don't misdiagnose it. I've done about half a dozen of these surgeries here, and it's been rewarding.
My case of the week is related to this topic, sort of, and also to the fact that Tenwek gets a lot of referrals from surrounding hospitals for more severe illnesses and diagnoses. Many of these patients, however, come with little to no documentation of what has been done for them, or a note bearing a diagnosis that is not true. It's a challenging situation. Several weeks ago my intern, Elijah, called me to the delivery room to see a “critically ill” patient. She was lying on the stretcher, moaning and writhing about, while he was trying to start an IV. Although her belly was distended and extremely painful to the touch, she didn't appear obviously pregnant.
“What's going on here?” I asked. Elijah tried to explain what he knew, and handed me the referral note from the “outside hospital.” Now, medical people will know what I mean when I say the note was a SOAP note. Basically, this is our standard form of medical documentation where you first record the patient's story, then your exam, and finally your assessment/diagnosis and your plan of care. Her note was scribbled on the back of an advertising flier, and read:
S: Abdominal pain
O: Distended abdomen
A: Ruptured ectopic
P: To Tenwek for surgery
This, my friends, is a pathetic note. There is no patient history, no vital signs (blood pressure, etc), no lab tests, and no indication of why this particular physician (or whoever) thought the patient had a ruptured ectopic pregnancy, other than the fact that she was a female in her 20s. Now, the key to diagnosing an ectopic pregnancy is actually (surprise, surprise), a positive pregnancy test. If you're not pregnant, you can't have an ectopic pregnancy. We did not have a pregnancy test result for this patient. She was obviously in pain, though, and appeared to have a surgical abdomen, so I asked Elijah to put a catheter in the patient so we could get a pregnancy test documented before we wheeled her to the OR. I placed the ultrasound on her belly and saw this:
Just then, Elijah placed the catheter in...and got over TWO LITERS of urine out of her bladder. Normally, you would pee about 1/8 of that amount. The patient received immediate relief. Diagnosis: urinary retention. The pregnancy test turned out negative, and she went home happy. So some days you save lives in dramatic ways, and some days you don't really save lives at all but do provide comfort, and it's cause to laugh at the system and be glad for easy solutions that offer big relief. And it's always a lesson to never assume anything about previous care received by a patient!

10.3.10

Sudan on a Wing and a Prayer

My trip to Sudan was the stuff dreams are made of.  Some of them are my own silly dreams, like operating in the middle of nowhere in blazing heat, barefoot, dressed in shorts, t-shirt, baseball cap and sterile gloves (too hot to wear a gown).

The first leg of the journey involved taking a twin engine plane to Lokichokio, northern Kenya.  Upon landing, you realize this is not a normal airport.  On the tarmac sits the Samaritan's Purse DC3 as well as a fleet of Cessnna Caravans with things like AIM AIR (African Inland Mission), MAF (Missionary Aviation Fellowship), Medecins Sans Frontieres (Doctors without Borders), and United Nations Humanitarian Relief painted on their sides.  Loki, happens to be the hub of most aid work flowing into South Sudan.  It seems to exist solely to run this airstrip, a lifeline into a vast land torn by decades of war.

We hop into the AIM AIR Caravan for a two hour flight to Akot, Sudan.  The door opens and we are greeted by a blast of 100+ degree heat and a group of enthusiastic boys.  One has an AK-47 while two others proudly adorn identical Barak Obama t-shirts (Obama's Luo tribe in Kenya migrated from the Sudan centuries ago, and he is thus part of their family too).  I decided it was best not to take a picture of Mr. AK-47.






We quickly refuel the aircraft with a hand pump and two 50 gallon drums because our pilot has been asked to medivac out a child 30 minutes away who suffered a gunshot to the face during a cattle raid by an opposing tribe.  He underwent reconstructive surgery at Kijabe Mission Hospital in Kenya.









We then head to the mission hospital just off the airstrip to begin seeing the blind that have already arrived on this Saturday afternoon.












Most are led by a family member, often a small child as young as four or five.  The child leads by one end of the stick, and the blind person follows by holding onto the other end.  We quickly identify 11 patients needing surgery while half the team has already begun setting up the "O.R." in an empty clinic room.

We want the first round of patients seeing as soon as possible in order to spread word through the community.  We felt this would be important for mobilization for the week to come as many blind were hesitant to travel due to the recent violence mentioned in my prior blog.  Did I mention the SPLA army barracks happen to be at the other end of the airstrip?

By mid-afternoon, the O.R. has been prepared and we are able to do all 11 cases!

Sunday morning everyone was doing well.  One lady in particular stood out.  She wore a bright green dress and scarf.  She had been blinded in both eyes by dense cataracts.  As soon as her bandages came off Sunday morning, she looked down and exclaimed, "What am I wearing, these aren't my clothes!"  Later that morning on the way to church, we passed her in the bush in our pick-up.  We stopped 100 meters after seeing her to give her a ride.  She then RAN and JUMPED into the bed of the truck.  I have it on video!  Only a day earlier, she was being led around by a stick blind as a bat in the bush of Sudan.


Sunday, I had the privilege of being invited to be the preacher of a bush church which meets under a big tree.  With just a few minutes to prepare, I prayed for the Spirit to touch my tongue!

Monday, clinic was packed!  This was due to the prayers of many of you, the good report of those done Saturday, and the hard labor of the community health workers months in advance to our arrival (Reuben, Josiah, and Joy).  Despite hearing gunfire the first three nights, God enabled us to perform 101 surgeries in six days.  Our prayer was to reach 100.  I'd love to share a few specific stories

When I was a young boy, my dad once told me of an old Togolese man who had never seen his grandkids.  That is, until his cataracts were removed.  Watching that grandpa see those kids was one of the most moving moments in his medical missionary career.  I've always dreamed of getting to see that happen.  To the left is a grandpa I had the honor to operate on who had been blind for decades.  His grandson had lead him with a stick and was known for his big, pink gums when he smiled.  This is grandpa taking in the moment, seeing the big, pink gums for the first time. 

We also had the opportunity to restore sight to a Spear Master.  These are priest like men in the cattle camps.  Legend says that they arise out of the Nile, they are not born.  Traditionally, they are buried alive when the Spear Master alerts his tribe that it is time.  Yikes!  Each morning as we removed the patches, men and women would burst into spontaneous singing.  His was especially animated.  Here we are hugging after his vision was checked.  He was deeply touched by God's gift of sight being regained.

Michael is a 32 year old teacher who came to clinic completely blind in his right eye with 95% of his vision gone in his left eye as well.  He could no longer read, but could still walk slowly without assistance.  Glaucoma had robbed him of his sight.  It is irreversible.  His eye pressure was extremely high.  Without intervention, he would surely lose all vision.  I attempted a surgery which proved very difficult, but was working very well on my departure.  However, in the weeks and months to come, it has a high likelihood to fail, especially as I did not have the normal tools used to improve success.  Please pray for him.  He also gave me a beautiful rooster.  Another dream of mine, to be paid in livestock. 

As we finished our last case, #100 for the week, a 4 year old boy arrived with a traumatic cataract with a scarred corneal laceration from a stick injury.  We had no anesthesia to offer except a local injection.  With much prayer and bribery (coke and treats), the child allowed us to administer a retro-bulbar block.  He did not move during the entire surgery until I placed my last suture!  He then totally broke down.  If it had happened a few minutes earlier, it could have been a disaster.  On our return to Kenya, a fellow missionary said she had been burdened to be praying that very day for a young boy to come out of the Sudanese bush for the eye care he needed before we left.  "We don't believe in miracles, we depend on them." - source, my dad (missionary surgeon), proven true a million times over by medical missionaries around the globe, century after century.  There are many things on my heart and mind after experiencing Sudan, but alas, it is very late.  I must sleep.   Thank you for your prayers.  I am so happy to be with Jessica, Elise and Micah again.     
     

6.3.10

What We Learned at Brackenhurst

As some of you likely noticed from our earlier post, the three McCropder men were able to spend 5 days at the CMDA Brackenhurst conference outside Nairobi a couple weeks ago. This is held every other year in Nairobi, mainly for medical missionaries to get some good continuing medical education and to get credits to keep up their international licenses. However, we had a different agenda. We did attend some good lectures and workshops, but we were mainly there to meet a bunch of people from all over Africa, in hopes of getting some leading as to where we should be heading after our two years in Kenya are done.

We met some amazing people, and hopefully came away with some good leads. We also had a lot of long conversations amongst ourselves, trying to further clarify what it is we believe God is calling us to. A few McCropder distinctives:

1. We need a place big enough to facilitate 3 surgeons.
2. We feel compelled to pursue training of medical providers (docs, PAs, med schools, residencies...)
3. We are interested in the places to which less people are otherwise going.
4. We have a strong interest in working with the government system in some way, hopefully to help them improve their own level of quality.

So, when you take that profile to a bunch of missionary doctors from all over Africa, what do you find? Well, we are still open to looking at other places, but there were 4 specific opportunities that we learned about that we thought were worth pursuing: Chad, Madagascar, Rwanda, and Uganda. I won't go into the specifics of each opportunity, but they each meet the above objectives in a different way.

If you're Africa-savvy, you may have noticed that 3 of the 4 above countries speak French (though Rwanda is in the process of transitioning to English). For me, this was the biggest single epiphany, namely that if you want to serve the neediest of African populations, most of them are French-speaking, presumably because missionaries and aid workers come more frequently from the US, UK, and other English-speaking nations, and they may prefer to work in countries with an English-speaking heritage. So, will we be attending a French language school in a couple years? We'll see.

So, pray for us. We will be trying to get more information on these opportunities, and may get a chance to visit them before too long.

3.3.10

Case of the Week: Baby Bumps

It is an interesting phenomenon in the field of medicine that diseases seem to present in groups. For example, one night in my residency, 6 patients came in with appendicitis, where we typically saw 2-3 per week. This cluster phenomenon occurred the other day when I operated on 2 babies with rather large bumps on their backs (or bums). One was a myelomeningiocele, which develops when part of the spine fails to form, and part of the spinal cord and some of its covering protrudes out of the spine. The other baby had a large sacrococcygeal teratoma. This is a benign tumor protruding from the buttocks, which can often contain weird things like teeth and hair (this tumor had neither).

While I had removed myelomeningioceles before (well, two), neither I nor the resident operating with me had ever removed a sacrococcygeal teratoma. So much of our conversation during the case was comparing what we had read in different articles and books, and then trying to figure out which we should go with. Thankfully all went well and both babies should lead completely normal lives.




I wonder what our patients' next cluster of diseases will be....