COTW: Post-op Complications

As anyone with a bit of medical training will tell you, it's important to have a differential diagnosis when you examine a patient. You start with the primary complaint, which gives you a category of possible diagnoses, and then ask questions until you can narrow things down. Then you move on to the physical exam to confirm or rule out the list of differentials. So if someone comes in with "stomach pains" for example, you have a pretty good idea of the problem by the time you actually examine the patient. The same goes for a patient you have operated on already. As medical students, we all memorized the list of what causes post-op fevers with the "W" mnemonic: wind, water, walk, wound, wonder drugs (atelectasis, bladder infection, thrombophlebitis, wound infection, drug fevers...etc).

Well, needless to say, here in Kenya we have a greatly expanded differential. Post-op fevers are just as likely to be caused by malaria as a bladder infection, abdominal pain after surgery could be a bowel obstruction from worms or a volvulus (twisted bowels). Enter my case of the week.

N is a lady in her mid-30s who initially came to me in GYN clinic. Her primary complaint was infertility but this was unfortunately due to massive uterine fibroids--approximately the size of an 8 month pregnancy. The fibroids had gotten so large they were compressing her right ureter (tube that drains the kidney into the bladder). We decided the best course of action was just to perform a hysterectomy and I scheduled it for a few weeks. Last week she came in to the ER with severe upper abdominal pain, one week before her surgery. Because of the pain, we admitted her. It's an unlikely spot for fibroid pain, but her fibroids WERE pretty big, so it was decided that the best course of action was to just do her surgery early. By the morning of surgery her pain had resolved.

A visiting OB and I did the hyst, one of the largest uteruses I've seen here. It was a great case! For reference, a non-pregnant uterus should be about the size of a medium pear. We were careful to move the ureter out of the way and avoid injuring the bowel, normal procedures for a hyst. She did well, lost as little blood as we could have hoped for, and was moved to the recovery room.
The "offending organ"...finger is pointing to her RIGHT ovary which was displaced by a big fibroid in the right broad ligament, pushing everything normal into the left lower quadrant. Beneath the finger is the normal looking uterus.
Almost done with the surgery...most of the uterus and fibroid have been mobilized.

On the second day after the surgery, the other OB went in to see N and she was curled up on the bed in the fetal position with a painful and rigid abdomen. She had a fever of 100.5, and severe pain which started after she took some clear liquids for breakfast. An upright abdominal X-ray showed some free air, but she was only 2 days post-op. OK, medical folks, what's your differential? When the other OB told me about it, I had a moment of panic. Did we miss a bowel injury? Could this be related to her ureter? Was she bleeding internally?

Jason was on call that weekend and helped take her back for another surgery--her symptoms were severe enough to justify this. The uterus looked fine. They ran the bowel, no problems. But there was a lot of clearish-then greenish fluid. They eventually found the problem: a perforated duodenal ulcer! No relation to her surgery, but probably the cause of her presenting epigastric pain. Wow. She is now several days out from her second surgery and doing fine. Just reminds us here in the developing world (and everywhere)...keep a broad differential diagnosis!


Missing Kenya: Top 10 Complete List

Here it is in full, the top 10 things the McLaughlins (maybe the Faders and Cropseys, but we didn't specifically poll them) will miss about Kenya!

#10: Cheap Flowers
#9: Sodas in Glass Bottles
#8: Chai Time
#7: Walking to Work
#6: Equatorial Weather
#5: Kenyan Cell Phone Plans
#4: Door to Door Produce
#3: House Helpers
#2: Wildlife
#1: Close Community

Click here to read the posts in full. Stay tuned to our doctorsmclaughlin blog for our next series, Things We Are Looking Forward to in the US.


Uncomfortably Close Baboons: Part III

(You can also read about Part I and Part II if you're interested):

Alyssa and our family just returned from 5 days on the Kenyan Coast for an East African retreat for World Harvest Mission, the agency that we are applying with to go to Burundi, with whom we will hopefully be approved in late September, after we get back. It was a really great chance to get to know some very quality people, and we look forward to working with them in the future. We are even more excited about working with this agency after this experience.

But this post isn't about that. It's about monkeys.

The group of beach cottages where we stayed has the most impressive local monkey population I have yet encountered. We saw some of the seasonal residents there putting plates of food out for them, which may explain a lot. There are 3 main types:

1. The Vervet Monkeys, of which there seemed to be two varieties.

2. The Colobus Monkeys, which always have a sagacious look about them.

3. The Baboons

Now, baboons are generally recognized as peaceful creatures, but they can grow pretty big, and are known for aggressive tendencies once in a while. On arrival, we were told to keep our doors shut, lest the monkeys get in to go after the food. One morning, a vertiable troop of about 10 baboons made their way onto our veranda. Three of them stood on the opposite side of the glass, checking out Maggie, who stood there fearlessly proclaiming, "No come in my house!" You tell those monkeys, Maggie! Here is one of them:

In an impressive show of domination, one of the big males climbed up on our veranda chair, seen below, then grapped the cushion, set it up on the rail, let out a big yawn (baring his huge incisors) and laid down for a brief nap.Though we hadn't left any food out, we had left a few beach things, notably Maggie's swimsuit as well as a pink, inflatable fish intertube pool toy. These were seized by the troop of baboons and run through the common area between the cottages. Here's a picture of the baboons running around with our pool toy. Seen below, baboon teeth and inflatable pool toys do not always make the best playmates, and Maggie's fish suffered a fatality on behalf of the activity.

My wife, ever dauntless of baboon mischief spotted the swimsuit in the hands of a few young ones across the lawn and decided she was up to the task. I tried to argue that the big ones would come to the aid of the little ones if they looked threatened, but she would have none of it. She ran quickly and excitedly towards the little gaggle, and they scattered in true cowardly monkey spirit. Here she is with the spoils of her victory.

Maggie's linguistic development is really coming along, and she is putting more and more words together every day. She proudly told everyone that day: "Baboons take my fish!" There it is. Subject, action verb, correct possessive pronoun, and direct object. All together. How bizarre that it was actually true.


COTW: Man vs. Elephant

Apparently one of the occupational hazards of being a Masai herdsman is the occasional run in with an elephant. What an elephant would want with a bunch of cows I do not know. Maybe the herdsman provoked the elephant's attack somehow - I could ask him when he gets off the vent.

"We have a teenager who was gored by an elephant" was the call I received from my resident the other night. The goring had occurred at 2pm the day before, but the herdsman couldn't move well enough to get home - so it wasn't until the following day that his family came looking for him because the cows hadn't come home.

We took him to the operating room where we pulled grass and dirt out of the three areas he was gored. The first site was through the left chest, where the tusk had gone through his ribs and then up the inside of his chest. Aside from the big hole in his chest, there was no damage to his lung or his heart.

The elephant tried again to inflict a more serious injury - this time running his tusk down the herdsman's neck. I could stick my fingers in the wound and I was right on the carotid artery! But no serious injuries there either. Strike two for the elephant.

The third time, the elephant went for the thigh and got really close to the femoral vessels, but he missed. Strike three.

It is hard to tell whether the elephant's aim was just a bit off or if he was just trying to send this boy a message.

But I think the herdsman wins this one - he is going to have a great story to tell to his buddies the next time they play two truths and a lie - and this helps confirm my theory of the Masai being the toughest people on earth.


Visitors' Footfalls are like Medicine

Visitors’ footfalls are like medicine; they heal the sick.
~ African Proverb

In Kenyan culture, it is seen as an honor and a blessing to host visitors. We have taken the same view. In the last month, various visitors have really blessed the McCropders. Here is the pictorial recap of our series of visitors:

Grace and Abby, two young friends from our home church in Michgan, spent the last month here, helping with a whole host of projects. Among their many contributions, they organized the surgical library; they fed babies in the nursery; they played with children at orphanages; they ran a VBS for all the neighborhood kids. Perhaps the greatest blessing to the McCropders was that they loved and watched all the McCropder children. Grace and Abby also kept a fantastic blog of their experiences. We all miss them now that they have returned to Michigan.

We also enjoyed a visit from Jason’s cousin, Katy, and her son (who fit in extremely well with the kids here). Katy worked at the hospital as an FP doctor, where she did an outstanding job of treating rare patient presentations in an unfamiliar hospital setting. Meanwhile Jack an Anna made an impressive bug collection. One highlight for me was that Katy was eager to go running with me, even at 6am and at 6500 ft elevation. Another memorable moment from their visit was going to Masai Mara together and seeing 10 lions eating a wildebeest.

The Ramaker family's visit was a fabulous time for us, the Fader family. The Ramakers helped out at the hospital, at an orphanage, in Heather’s Sunday School class, on a community health outreach, and with various other projects. Their two little girls are totally adorable, and Anna loved playing with them. Their two-week visit flew by. So much fun!

When the last of our American visitors flew back to the US this past weekend, it felt empty and lonely around here. For about 2 hours. And then Baby M came to stay for a while. Baby M is a beautiful 1-week-old baby who has a foster home with us until he enters an orphanage next week or the next. Isn’t he precious? We love having him.

We really thank God for the blessings of our visitors, and we look forward to the last of all the McCropder visitors: Heather’s dad comes to Kenya next week!


Kenyan Money Matters

A terrible tension we live in:

The micro view: A man stops me in the hospital today and greets me. I recognize him as the father of a 3-week old baby that died last night. The baby came in from home in a serious state, and despite our best efforts, did not pull through. It came about that the parents are strong Christians, they have six kids, and this was to be their last, mom having gotten her tubes tied in the last couple weeks. Because his child didn't make it long, his bill is not big, maybe 50 USD. I would guess that his standpoint is that he is a poor Christian man, who brought his baby to us, and we didn't save him. He looks to his brothers and sisters for help.

The macro view: Tenwek Hospital has been here for over 50 years. We see 130,000 outpatients a year, and admit over 13,000. We do innumerable surgeries. We have tons of donated professional labor from missionaries and volunteers. We have donated meds. People give donations for our buildings. We receive HIV/AIDS grants from the US government, to provide care for HIV patients. The patients are charged for the care they receive. And if you come to the hospital with a monetary need, say to hire another doctor, or to pay the nurses more than the sub-government wages that they currently receive (resulting in high turnover which affects patient care), you will get a single answer: There is no money for this. Why? I have talked to a lot of people about this, and though I'm sure the answer is multifactorial, the biggest piece seems to be collections. We don't actually get paid for the fees we charge. Why? Again, multifactorial, but the biggest reason seems to be that the community has had 50 years to learn that we are money-givers, and won't enforce our collection policies. Thus, even many who can certainly afford to pay, don't. I'm told that the hospital has the deeds to huge amounts of land, taken as collateral for bills. They could claim them, force the people off their land, sell the land, and then we could run our hospital better, with less turnover, and more financial sustainability. Anyone want to go for that option?

My reaction to all this is to largely take a 100% retreat from any financial investments or giving. Just be here to be who I am, instead of what I can give. This is less than satisfactory, for reasons I'm sure I don't have to enumerate (read the book of James), but also because (from what I gather) becoming a full member of African society includes some element of financial interdependence. So the answer doesn't seem to be at either extreme, which means that the answer is going to reside in some place of tension. And it can be terrible at times.


Back in the U.S.A.

We (the Cropsey family) arrived safely back in the U.S. on Thursday evening.  We had an uneventful trip, made all of our connections, and didn't lose any luggage along the way (despite the fact that one of the duffel bags had to be tied together with zip ties and bungee cords at the airport due to a broken zipper).  Our one hour layover in Zurich was a breeze, thanks to the efficiency of the Swiss.  Our 5 hour layover in Frankfurt went by quickly thanks to McDonald's and the children's play area featuring a huge rocket ship and ball pit.  The kids did great and we all got some sleep on the two long flights.  Jess had some minor leg swelling issues, but that has mostly resolved.  Many thanks to all of you who prayed for our travel.

Strangely, it almost seems like we never left the U.S.  Things remain largely the same, but here are a few things that have struck us in the last 48 hours:
  • McDonald's is every bit as yummy as we remembered.  We don't know why those little cheeseburgers and chicken nuggets taste so good, but we're lovin' it.  
  • American milk is SO delicious.  
  • It is very pleasant to go for a jog and not be followed by children asking, "How are you?" and "What is the time?"  No worries about being run over by a motorbike either.
  • American q-tips are incredibly fluffy and feel fantastic.
  • Some food delights -- blueberries, amazing strawberries, black olives, croutons, and deli meat.
  • It's so nice to drive in a place where you can count on people obeying the traffic signals and laws.
  • Our feet have really missed soft, fluffy carpet.
  • It's wonderful taking a shower without having a separate bucket of rainwater to prevent your hair from sticking together.
  • Being able to drink straight from the tap is truly a wonderful blessing.
We recognize these things as fleeting pleasures, but are thankful that God is giving us this time to enjoy them.  We are so thankful for our families who have warmly welcomed us back and gone out of their way to make our transition smooth.  We are looking forward to worshiping with our Knox church family on Sunday. 


COTW: Cyanotic Heart Disease

The baby was brought into the NICU by his mom on his second day of life. He had been born at some other facility, and was now having a terrible time breathing.

The oxygen saturations (which should be easily over 90%) were about 30%, and so we grabbed an oxygen mask and a bag, and began pumping air into the baby's lungs. The levels never rose above 60%. A tube was placed down into the trachea, and we focused the air into the lungs. No progress.

We listened to his heart, and there was a loud murmur. The combination of these findings suggested cyanotic heart disease, one of a number of heart deformities where the plumbing is messed up in a way that the blood from the heart and the air in the lungs don't meet up with each other properly. A chest x-ray in another hour showed an abnormally huge heart, consistent with this diagnosis.

In the US, a child like this gets immediate infusion of a medicine to keep the pre-birth heart plumbing open, and then is taken soon to corrective surgery. It's not all fun and games for those kids from then on out, but they live. At least, that's how I gather it's done in the US. I didn't actually get any practical training in it myself.

Here we don't have that medicine. So we just hope that the pre-birth plumbing stays open, keeping the kid alive. And surgery... Well, in Nairobi, the extremely wealthy can sell all and maybe get a corrective surgery. And Tenwek has a pediatric cardiac surgery team that comes out once a year and does a few cases. It's an amazing work, but the candidates for surgery far outstrip the work they can do. Plus, that's several months away, and the family has to get there first.

A conversation ensued, and mom and dad cried as it came home that their baby was unlikely to survive. They were trying to decide whether to sell the farm to chase a one-in-a-million chance of saving their baby. We prayed. The nurse called the chaplain. I wrote the "do not resuscitate" order.

Surprisingly, in the morning, the baby was still there. Mom wanted to know if she should try and produce breastmilk. I said yes as much out of pity as anything. We managed to get an ultrasound of the heart, which confirmed a type of heart disease known as "tricuspid atresia". A few more days, and we started to put some of that milk in a tube through the nose. A couple more days, and the child was breastfeeding without difficulty. The oxygen saturations were still incredibly low in the 60's, but the baby looked OK. We weaned off the oxygen, and the baby's numbers and condition were just the same.

So, we arranged for the parents to take their little baby home, with a detailed note from me to take to a Nairobi specialist on their own, without bankrupting their family to pay for an ambulance transport.

Mom is sitting there on a stool, holding her little boy and smiling at him. She and I both know that he's unlikely to live very long. But this small grace is theirs, this moment for them together. This moment that I certainly didn't think would be theirs. This trip home to see his family. How many more will there be? I wouldn't think many, but I didn't think this one would be there either.


Kwaheri, Kenya!

On Tuesday, we (the Cropsey family) drove away from Tenwek Hospital.  It was a day of many tough goodbyes.  On Wednesday night, we board the plane that will reunite us with our families after almost two years.  Please pray for our travel.  As you may recall, we had a memorable trip coming to Kenya.  We’d prefer not to relive some of those memories!  These are our specific requests:

*Timely flights and good connections with no lost luggage.  (First, we fly to Zurich with a short, one-hour layover.  Next, we take a quick flight to Frankfurt and have a 5-hour layover.  Finally, we head to Detroit, arriving around 5:00PM on Thursday.)
*Good rest (especially on the first flight) and an extra measure of patience for each other. 
*Smooth transition to life in the United States and quick recovery from “jet lag”.

Thank you for your prayers for our family over the last two years.  We look forward to seeing many of you soon!  


Group Photo Outtakes

With the imminent departure of the Cropseys, we had attempted last week a group photo of all McCropders (sans Carlan). A decent amount of logistical effort went into getting the kids clean, finding a time and place, etc. And we'll try it again. But sometimes you have to wonder how realistic we're being. There are just too many variables, all under the age of 5. Enjoy these outtakes.
There are at least 6 different places that we are looking at here.

Where did Elise go?

I guess these pictures give the impression that Ben suffers from torticollis. This is actually not true.

Heather doesn't look too sure about this one, and rightly so. It sort of looks like Jason is trying to duck, so that Maggie is not blocked, but alas.

Come back, Maggie! Micah, watch that finger!

And finally, success. Or...? (Yes, this was the best one)


Missing Kenya: A Top 10

On our other blog, we have been putting up some posts, counting down the Top 10 things we will miss about Kenya. We're about halfway through, and thought we would alert the general audience here:

Or you can click here to read them all in a row. We'll be posting #5-#1 in the next few weeks, to be followed by the Top 10 things we're looking forward to about returning to the USA.


Our Good-Bye Adventures

With less than one week remaining before we leave Tenwek, we (the Cropseys) have begun the formal good-byes.  A week and a half ago, we visited the home of Tenwek's ophthalmic technician.  We had a very nice lunch with Wilson, enjoyed meeting his family, and touring his property on the side of a mountain.  The kids had a wonderful time playing with the animals and making a total mess of themselves in a dirt pile.

Adventure #1:  Getting to the bathroom...
*As is common in Kenyan homes, the latrine is typically located some distance away from the house.  Getting to this particular latrine required some athletic prowess.  First, you have to climb up an almost completely vertical make-shift ladder and then climb over the fence that is immediately at the top.  After walking through a cow pasture, you have to climb over another fence before ascending the small hill to the latrine.  Trying to accomplish this in a jean skirt with a toddler (or two) in tow while being 28 weeks pregnant was no small task!

Adventure #2:  Eating the rooster...
*Wilson's family was extremely generous and we left with quite a few gifts which included two large bundles of bananas, fresh milk, and a live rooster!  Elise and Micah enjoyed his company for the rest of the weekend until reinforcements arrived Monday morning who could help us with the butchering process.  We decided to try a fried chicken recipe which probably wasn't the best choice in the end.  He's a mountain bird after all and was quite lean.

This past weekend, we visited Richard, the community eye health director.  Our visit was supposed to be "short and sweet" with just chai, but it turned out to be 6 hours long due to adventure #3.

Adventure #3:  Mudbogging...
Since "Jolly" (the McCropder van) was in use on this particular day, we used the Tenwek Eye Unit Land Cruiser.  The roads were certainly rough and it was good we had a 4WD.  Perhaps that gave John more confidence than he should have had!  We had almost arrived at Richard's when we saw a field up ahead with some water in it.  It had rained the night before, so we thought it might be a large, but shallow puddle.  John sped up hoping to just skim on through.  Unfortunately, once we got closer we realized there was a drop-off, and this "puddle" was actually a spring-fed, "bottomless" mud hole.  Our front tires skidded over the edge before we came to a stop.  We left the vehicle wedged on the edge of the hole and enjoyed a pleasant visit with Richard (which included an archery contest and a tree planted in memory of our friendship).  After our visit, John and other friends tried to extract us from the goo using boards, rocks, and a car jack.  After about two hours of failure, a pick-up came to our rescue and pulled us out.  The kids did great and were amazingly patient.  

There are more farewells in the days to come and we look forward to the adventures they bring!