London again

...there are several drafts pending of the last week of Kenya....for now I'm in London in a skirt made from a Kanga and Masai earrings trying to make the transition of eating ugali and chai to my starbucks chai latte....to a world with surfactant and human milk fortifier coming out our ears after using BUBBLE CPAP and prayers in substation   From being a pediatric consultant (attending) where even in my inexperience I was what we had to being a intern and one of 150 residents at one of the top childrens hospitals in the world. . Back to the world where relationships come after duty and responsibility.... Its a HUGE leap transitioning back and I am grateful that I won't make it the way across the gulf of culture shock  and injustice for several weeks since I have vacation and my sister's graduation this next week. 

 I will write more fully about my day in Nairobi but the traffic at the end was terrible. I nearly missed my transport to the airport. We had to get out our taxi and ran the rest of the way (about a kilometer) to the guesthouse where my luggage and transport were awaiting. I had seconds to say goodbye to my four Kenyan girlfriends who I spent the day with and in a whirlwind I was leaving Kenya.  I admit I had tears in my eyes for a moment as we drove away from the guesthouse. 

Despite all my traveling and Navy BRAT childhood I still hate goodbyes and there is so much left to do and be in Kenya.  Ohio seems so not in need of me....although I course know now more than ever just how much experience and a little education can do. 


for now a week of sleep, Carolina skies, family and non-smart books is very much needed. 

Shock and Awe

Last night thugs held up the emergency department with knives. They forced the interns and nurses to lay down on the ground, while one nurse was taken hostage to open up the cashier office. A patient was hit in the head and has a severe hematoma and a guard has a head laceration. They stole 80,000 shillings or around a 1000 dollars, a huge sum of money for Kenya.

This morning, Wednesday chapel was unusually full and many people stood outside and listened as the news was reported. Shock ripped through the assembly. 

 Kijabe is a bubble.  Its a bubble of western culture in rural Africa where little old ladies sell English muffins and tortillas for a living to muzugus who are homesick. Where a party usually involves baked goods and Kenyan delicacies plus/minus a bunch of multinational children running around and/or an intense theological or medical discussion. Most folks both Kenyan and Western live in housing on the mission station that is often furnished and in close proximity to the hospital.   We are a strange city on a hill.

What we forget is that the rest of Kenya is not like this. Its easy sometimes to forget about the slums of Nairobi that are only 40 mins away or the stories of violence that can fill the head lines of the Nairobi papers from time to time. We forget how much petrol costs or even the poverty that is so close yet so far from our day to day lives around Kijabe. I do not use poverty to justify the actions of the people who did this but I am reminded of how great the desperation can be. And how tempting of a target we must look with our peaceful, little village of muzugus and Kenyan professionals.

When I was in Mombasa last weekend (post is coming), I saw graffiti saying the following:
 
"Life in the Ghetto is Hard"

"Who will fight for the Poor?"

We should be in shock and sad  and we should wish for justice and pray for peace to be restored. But let us not lose our capacity to try to understand, to offer compassion and in the truly divine way offer forgiveness. 

Finding Home

   Yesterday I came home and was on call (Mombasa epic post is coming...).  It was an odd day, it was a holiday but the outpatient clinics where open so it was crazy busy with only two interns and a few consultants (attending like folks). I was playing a role in the later. The consultant on the day before me (who actually kindly switched calls so I go to Mombasa had a terrible, terrible night the night before). She paged me at 6:20 AM to ask if I could come in early so she could sign out. We had multiple premies, two codes and a kid with severe, severe dehydration and bilious aspirates to inherit. I rounded on the most of nursery and Gen Peds. It took me till 2 PM to get it all squared away. My severe dehydration kid had to have his labs drawn three time to get adequate sample. I felt inadequate because I am inexperienced with access because I get such few chances to try. Glad for my Anesthesia rotation next year. Finally when the labs came back his sodium was 199 and his Crt was 10.  So dialysis is not an option, we aggressively hydrated him and I prayed that it would help. I honestly felt ok about the gen peds patients but some of the sick critically ill newborns are above my pay grade as a peads intern on my own.
   I loved my first two weeks on nursery. But I am no neonatologist.  My attention span is severely lacking  when it comes to advancing feeds (about 5 mins in I am daydreaming about something else). I like the delivery room, the procedures and the codes best. I like talking to the parents (because we all know I like to talk and that there is really no one I won't talk to...including myself or the walls ;)). Details are not my strong suit and my big picture thinking makes NICU torture if I had to do it forever or ALL the time. But in small doses I like it which is good becuase I am going to do it in the future if I live here.
    I have been on general paeds the last week or so and its not nearly as organized as nursery. Honestly, its barely organized chaos. But I sort of like it that way which most likely indicates some sort of odd personality flaw. (Although my highly OCD, complete opposite of me partner last month on Cards says that I am amusing and refreshing in this way). The attending treats me like a senior resident on steroids and I ran rounds by myself this AM.  And surprisely despite the fact I am still very, very dumb. Somehow it worked and it was like I had been doing it for a long time. I admitted that I have no idea what to do with my GCS of 5 TB meningitis teenager minus praying (not really a candidate for a vent when we only have limited number and he is going to be in a coma indefinitely). But there were also things that I did know. I went back over the patients with the attending later and much to my amazement we changed very little of what I chose to do...awesome and scary.
   I gave a presentation today on Diagnosing and Initially Managing Congenial Heart Disease (on a Shoestring aka NO ECHO and basically NO ECG).  I really enjoyed it. Teaching makes me happy. In general, being here makes me happy. I love this work so much.
    Everyone keeps speaking of HOME and how I am going there in three days but I find that a confusing idea. Where is Home?  Is Home OHIO?   Honestly...not really. Ohio is sort of like boarding school or boot camp or something of the like. I enjoy my work, my friends and my church but it still feels like I am camping there for a time.  Is Home NC/VA?  In some ways YES. I pine for old friends, BBQ, humid afternoons, Southern Draws and mountains.  But there is no work for me there.  Is Home Kenya/Mission Field? Yes, in some ways it is. It certainly is my professional home. In the same way my classmates seem to be finding homes in hematology and PICU and neonatology. This is what makes me excited about pediatrics. And even deeper, this is where some my most profound and most cherished relationships are. 

I am both leaving and going home simultaneously in the strange paradox that is my life. 

Photographic Essay of Kenya So Far

 Here is a random collection of Kenya so far....

Sunset from my flat

Translating my talk I gave at Joytown. My translator Kelvin was awesome and a little bit of a tease.

Some of the Joytown Kids

Minus the word Special just about perfect!

Adventures in driving in Kenya

A sweet patient the day she went home after a month of being in the hospital for Meconium aspiration syndrome

CPAP in Africa, so simple yet saves a lot of lives. Kijabe is doing a study on CPAP right now.

Intern Bonfire and Dinner

Tea fields

Sweet little girl carrying her brother outside the hospital

                                                      My sweet friends Miriam and Joel

My sweet cardiac baby who is going to get surgery at Tewenk! AND IS OFF CPAP and O2!!

29 weeker I admitted last weekend!

 

 

How to Ride in a Matatu when you are a Muzugu

So  last Sunday, I braved the rain with my friend Loise and we went to Nairobi for church via Matatu. Matatu-es are a vast mini bus system that spans East Africa. The mini buses are privately owned and when you are muzugu (white person) in East Africa you are told many, many horror stories of traffic accidents, muggings and general mayhem in whatever sort of orientation/mentor/etc you have prior to coming. However, they are the staple form of transport here and I trust my Kenyan friends and wanted to go to church with them. 

We took a private car of a friend of Loise that took us far as the top of the mountain up at the junction where the Nairobi road joins in with the partly paved road to Kijabe. It was pouring and we stood in a little hut that was built from sticks, traps and mazie sacks and waiting for a Matatu to come by. They did. I had my forearm crutch. My knee is nearly cured but I have been very protective of it and tend to take the crutch for anywhere longer than a little bit outside of my house. Although I can walk without it just find now and around the hospital forget where I leave it hourly. Anyway, everyone in the Matatu was pointing and gawking at the muzugu with the crutch and saying that I was sick so they gave us the front seat.   

Step 1: Front SEAT!!! The most coveted spot: Seat belt, leg room and less vibrations.  (use whatever means possible including possibly masquerading as a “sick person” ;) )

Step 2: Put on the seat belt, pull it tight. 

They tried to over charge us because I was a muzugu but my fearless friend Loise told them NO and paid the normal fare.

Step 3: Know what the fare should be prior to boarding.

Step 4: Praying is helpful.

Step 5: Prepare yourself for frequent stops and breaking to pick up people along the road.

Step 6: Prepare for the general Kenyan driving adventure of avoiding pot holes. 

Joking aside, it actually was fine especially up in the front. We arrived safely, walked around the U of Nairobi area, Central Park and then went up to church. The sermon was excellent and the worship was nice.  We spent the afternoon with my friend Jackie, who is a pediatric resident at Kenyatta the national hospital here in Kenya. We watched Kenyan soap operas and lounged around and chatted.  Then we went shopping and then we went to the Matatu stand. 

The front seat was taken. So we got in the back.  More and more people came. We hit capacity. So I thought my knee was cured but unfortunately when you stuff it in a very small contorted position with groceries, it is NOT cured. It was hot, crowded, there crying babies and very loud Rap music. 

Step 7: Distraction is key, I counted 15 donkeys on the way home.

Step 8: Showers are nice afterwards.

Step 9:  Its really not that bad, it reminds of riding the trams in Bucharest on a hot day or even the subway in NYC. 

In the End we were home safe and sound with all our stuff and my knee has fully recovered.

What if for a moment we believe....in the crazy

Its been said I am optimist. Its also been noted I lack certain social norms...or rather choose to ignore them. You could blame my hearing loss but I think its mostly my cultural upbringing.

Although I grew up American,  I think I really grew up as a gimp and disability has a cultural education all its own.  For one thing pretty much no matter where you are born, you start out at the bottom of the totem pole of society. We are the beggars on the streets, the man selling pencils on the corner, the hunchbacks in the bell towers and the people that sometimes make you squirm because of our struggle to talk/walk/etc. The thing though that I have come to a greater personal awareness in the few years is that while the people at the top of totem pole (ironically including my peers, young professionals) look at me as different, scary, pitiful, the others who might be different/scary/pitful for many other reasons see me as a person who they can relate to (never mind my excessively expensive education, my car, my ethnicity or my profession).  I.e. every janitor, every cafeteria worker including the ones who spoke primarily Spanish knew me by name at Wake in undergrad and half the janitors at Childrens know me. All the project search (young adults with developmental disabilities) employees know me by name and we have had a meal together.  I have friends in Eastern Europe who happen to be Roma beggars who most of my peers are terrified of being mugged by. I have drunk champagne with a refugee family in Belarus who might have terrorist connections but had a daughter with a cerebral palsy who I adored and faithfully visited weekly for two months.. When my family went on a cruise I befriended the lady who cleaned our rooms, she was from Costa Rica. My family thinks I am nuts but mostly tolerates it because they know its hopeless to reform me normalcy at this point.  I give this background to say that I have grown up in a world where the social axis is turned on its head. And sometimes I forget that the rest of the planet does not think like this. That the rest of the world system of value of human beings is pretty much the opposite of the way my tribe thinks.

Combine this with optimism and you get a lot crazy schemes and ideas.....

14 day old with VSD/ASD and pulmonic stensois, otherwise perfect.  I have been praying for babies on ECMO (see below) and I just can't live with leaving this baby here to wait the 2.5-3 yr wait and present like my other patients in failure with cardiac asthma gasping for air with deadly pulmonary hypertension. I realize this is a needle in a giant haystack of stories and injustice.  But I feel like this is achievable somehow...So I write some e-mails, I sell my case, this child has a repairable heart defect, this child has a beautiful family who love him......  And low and behold, somebody catches the vision and tells me there is a CT surgeon team coming to another hospital in Kenya in 6 months. 6-9 months is EXACTLY when the surgery should be done.  The cardiologist takes my history, my echo and is optimistic that if we can keep his weight up, my baby is a great candidate for surgery.  Every once in a while, miracles happen and for a moment our world shifts and babies with heart defects in East Africa get a chance.

Then there is my friend  Miriam, she has some kind of dwarfism variant (I debate every time I see her....its an Acondroplasia like dysmorophology but worsening hip and hand disease...which does not fit). She was an orphan raised by her grandfather, who dropped out of school in 8th Grade to support her grandfather. She is now a single parent with a 9 yo also with the same disease who is wickedly brilliant  (scored 585/600 on his national exam) and tells you in beautiful English that he wants to be a engineer when he grows up and figured out how to make games work on my computer in about 30 seconds.  She has severe hip dysplasia, with bone on bone disease. Her hands have worsened. She used to operate a knitting machine but her hands have gotten too bad. She now sells what she can buy cheap in Nairobi textiles wise in the market here in Kijabe on the days her pain is not so bad and she can make it the 3 miles down the mountain. The locals tell me its getting worse. The peds ortho here says there is nothing to be done. I know how difficult and precarious adult skeletal dysplasia surgeries (ha!) are especially little people joint replacements. But of course this cuts me to my core because I have been exactly where she is (minus that I was not a single parent with an 8th grade education).  There is very little I can do about this.  But I have tried anyway, I have sent emails and am begging and persuading. And trying to think of micro finance endeavors.   I have been unsuccessful. 

So I did something that made my neighbors stare a bit. I invited her to dinner.  I had no idea if she would say yes but she did. She showed up with Joel her son in their Sunday best. I made rice, Kenyan stew, potatoes and ice cream and chai for dessert. I showed them pictures of LPs from around the world that I collected on my computer. I listened to their stories and I found something remarkable. Miriam grew up in my tribe too and has the same ridiculous optimism.  She asked me why shouldn't there be a Little People Group in Kenya like there is in America and Uganda and South Africa and England....  She said she wanted to start one for Joel.  She also said, they could have a project that provided employment for people who would otherwise not have it. I sat there again and was amazed.  Most people would not see her as an activist, most people wouldn't think much other than either hopelessness or sadness.  About half way through dinner, I got a knock at the door. There was the very persistent woman who has been coming around to the Westerners begging for money. She saw that Miriam and Joel were there eating at my table.  She looked stunned, she spoke to Miriam in Swahili, gaped at me open mouthed and then back at Miriam. She apologized in Swahili and English for interrupting our supper and left without every asking me for a dime. 

And I realized that as inadequate as serving dinner seemed in the light of the bigger problems, I realized all over again as my tribe as taught me so well that just acknowledging the dignity and the worth of our fellow human beings is a far greater endeavor than all the medical endeavors and crazy development schemes.  

Dignity and worth are a different kind of healing, a divine sort. 

A good cup of tea....

Last Sunday,  I met a lovely couple in church Heather and Phillip Ashley. Heather will be one of my interns! She is a med-peds rising intern at Childrens!!! Phillip is a rising ortho intern at UK. We had a three hour tea party on my porch  after church where we discovered that we share much in common in  life plans, philosophy about medical missions and intense love of chai.  It has been a delightful blessing to have them here.

One of the things, I have tried to perfect this time is being able to have visitors both Western and Kenyan over and serve them in close to proper Kenyan fashion.  Thanks to some excellent teachers, I can make Kenyan chai. I usually pair Kenyan chai with cookies or cake. My chocolate chip cookies are a favorite around here and are requested at EVERY social event I attend. Apparently, last time they tried to make them after I left and were unsuccessful.

Kenyan Chai:
-fill a pan half with water and then with milk
-add 1/3 cup or so of free standing Kenyan tea leaves
-Boil
-Strain the tea into cups and serve hot enough to burn your tongue!

Chocolate Chip Cookies KENYAN style (adjusted for high altitude and Kenyan butter)
-Combine 2.5 cups of flour, tsp of salt and tsp of baking soda. Combine 2/3 of white and then brown sugar, two eggs, half cup of kimbo (shortening) and half cup of butter +/- vanilla. Slowly add flour. Add Chocolate chips. Bake at 375 (or around 180 C) for 10 minutes.

I have been a busy, busy hostess.



Right after the Ashleys left, my lovely former Kenyan roommate Joyce and several friends arrived and we had more tea. :D. I continue to attend bible study on Tuesdays with the same group (minus Joyce who now lives in Navashia!), this past Tuesday I discovered mendazi which are Kenyan donuts which are excellent! On Thursday, I had the group plus Heather and Phillip over for more...yep you guessed it CHAI. We had some diverse, serious conversation about palliative care, death,  faith healing, Somali pirates and Kenyan politics. I am blessed to have such good Kenyan friends here. Although I am running out of tea and milk.

This week I will attempt to make Kenyan dinner for a sweet single Mom and her son  who are both little people who have some variant of SED.

In honor of chai and my new friends the Ashleys we went on a spontaneous trip to the tea factory/plantation. I had heard about this from my neighbor and turns out I think we went to the wrong place because it was very much a modern factory rather than a hike through fields of tea. But oh well, we saw the tea fields, learned A LOT about making tea, sampled tea and discovered how much TEAVANA  rips us off after buying some wholesale tea. Not to mention how much I bet the Kenyan farmers get ripped off. hmmm Fair Trade? I think not.

We came home and had tea and Kenyan food at the local cafe Mama Chicos.

How to Pray for a baby on ECMO while in Africa....

I have been terrible about updating. I have just been so busy from sun up to sun down.

First all, I interrupt this African journaling to mention a momentous event in the life of some friends from North Carolina. Their daughter was born with a congenital diaphragmatic hernia (CDH) three weeks ago, she survived the surgery and today she got off ECMO after being told last week it might not go that way and I admit to telling my own family a week ago that I didn't think it was going to go this way. :)  I am thrilled for them as I am thrilled for all my dear mentors and friends who are their doctors.  I am entirely happy to eat my own skeptical, callous doctor words and accept a minor miracle. I am planning on smuggling myself into the NICU when I am there in NC in May to meet this wonderful, resilient young lady. (I have mad connections and people like me down there :) ).

Its been a week of deaths for  the pediatrics team here. We lost our T-E fistula baby to cardiogenic shock due to an unknown cardiac defect (we knew it was there but have no ECHO and no CT Surgeons). We lost our CDH and omphaloceale baby to a wound infection. Then on Wed I diagnosed a baby with NEONATAL/Congenital LEUKEMIA.  He had a white count of 80,000 thousand, a smear full of blasts. I had repeated his CBC from Tuesday thinking it was a lab error only to get a call from pathology telling me about the blasts. I went and saw them with my own eyes. 32 days old and has leukemia. The prognosis is terrible no matter where you are, we transferred him to Nairobi knowing that he will most likely be gone within a few months. And they just kept coming....On Tuesday, the neurosurgery team asked us to take a baby with inoperable hydrocephalus because Mom had passed out in the clinic and was hemorrhaging and being admitted to OB.  The Baby has a HC of 62 cm.  She is entirely palliative, I put her on scheduled Tylenol, feeds (because Mom was insistent) and every day instead of pre-rounding on her I spend five minutes holding her.  Then there was my perfect term baby with a nasty sounding murmur who I can't get off CPAP. I begged and pleaded and convinced a team mate to go with him in the ambulance so he could get an ECHO (first ever CPAP transport in hospital history). He has a VSD/ASD and mild pulmonic stenosis

Here is the interesting thing about death here, it happens.  But you don't talk about it. Its Taboo. There is always hope, there is always room for a miracle.  In fact I have seen again and again us try to send palliative cases home only to have them return or go to another hospital.  On the one hand I so greatly admire the faith of my families here. Their faith entirely lacks my years of North American realism and skepticism  brainwashing. They know how to pray for babies on the brink of dying better than I do despite all my training both in medicine and ministry.  But on the other hand I just don't know what to say sometimes because when they look me in the eye and say "Doctori, how is my baby doing?"  I try to tell them the truth and they tell me they will pray that its not true, that their baby doesn't have a hole in his heart or that the continuous seizures that took us  hours to stop and the baby now won't wake up, that he will be fine and grow up and be a  developmentally normal child.  And some times I stand there with tears in my eyes, wanting so badly to believe.

The CDH/omphoceale baby was from a Sudanese refugee camp on the remote Northern border of Kenya. No one speaks her language, we could never find an interrupter despite days of trying. He died early on Tues AM. I went to the ICU and he was already gone. I saw the Mom several hours later.  We had a brief but profound silent conversation, where I told her how heart broken for what she had lost and she told me how grateful she was for us for trying to save him.  We held hands for a moment. I have to say for all my family centered rounds and love for talking to families, it was by far the most moving conversation I have had my entire year as an intern.

We do extraordinary medicine here with so much less than what I am being trained with. I got called (not on call but the FP resident had never done NICU and the peds attending is on vacay so I am the pediatrician for the weekend) to the hospital this afternoon for a 29 weeker premie resuscitated to CPAP surviving in a world where surfactant costs a years wages.  The mother was at the bedside when I made it down there, stoic but broken. I asked her what the baby name was, she looked at me and said she is 29 weeks old.  I told her to look behind her at the the other incubator which held a former 27 weeker who is on RA, full feeds and growing.  I told her her daughter was doing so well and that she was alive and fighting.  We have had two spinal bifida babies who had successful repairs, we had an encephaloceale nasal mass removed, we had a former 650 baby now 3kg come back in follow up clinic.

I love the medicine we do here, this is my calling, this is why I went to medical school. We are getting better too all the time and I want to be a part of that.

But I am human and its hard to pray for a baby ECMO in Africa while you watch babies with the same diagnosis die and not weep. Its hard not wish for just a moment that I could take my congenital heart baby home in my arms and carry him to the ward I was on a mere 2 weeks ago where we saved babies with far more complicated heart defects.

 There is a  bottomless pit of injustice. Its easy to get lost in especially when you are still so rooted in both sides. This not NEW to me. I have known about for years. But I think in some ways my training OHIO has spoiled me, its such an amazing place where we do the seemingly impossible at times, the gap just got a whole lot bigger.

All you can do is celebrate the miracles, be humbled when you are proven wrong (daily) as a physician, hope with those who hope even when it seems contradictory to everything you have been taught and weep with those who weep.

And as one my colleagues told me off hand tonight as I was running NOT on call to the 29 weeker, dont forget to pray for the babies.

Muscular Dystropy Conference/Joytown

On Friday, I had the extraordinary opportunity to go to Joytown which is a boarding school for children with disabilities (everyone goes to boarding school here so this is NOT to be confused with the institutions in E. Europe).  I went with Mercy the pediatric chaplain, who is Kenyan and probably my favorite mentor here.  Her two daughters (in their 20s) and grandson (14 mons old) came as well.  We hired a car and drove from Kijabe to Thika, a town about 1.5 hours east.  We were to be part of a seminar (conference) for families with children at the school with muscular dystrophy which I find to be a subtlety ironic reoccurring theme in my life*. 

The drive reminded me of all the things I fell in love with about Kenya the first time: the people the red, rutted roads, the Ascasia trees, the flowers, the women in bright colored kangas, the colorful booths and shops stuffed in every little village no matter how small or how run-down, the women with their wares spread out over a kanga on the side of the road, the mist burning off the mountains so similar to my own beloved mts at home, the men with bicycles piled high with heavy loads, the motorcycles with four people on somehow (the ED doc in me shudders a bit),  the children in their bright school uniforms waving and yes even the crazy mario-kart esque driving.  Mercy says that I am not very American.  She and her family call me “Wageri” (I think that is how it is spelled) which means (or so they tell me) “Mother of a Clan”:  Implying that I am really apparently a Kenyan who will start a new clan.  I took this as a compliment. 

The school was set up with dorms, several class room buildings, a small performance hall/chapel, a dining hall/kitchen, a gym for sport and therapy and a swimming pool (for hydrotherapy)!  It was FAIRLY accessible by wheelchair. The rutted, rocky roads were not great although my Kenyan students put me to shame doing wheelies over the whole thing.  Most of the children are on Easter holiday (the whole month of April) but some where there to be part of a camp to start next week, to go on a field trip to play wheelchair volleyball on the coast or for the conference we were speaking at. 

We were greeted and pulled quickly into the performance hall where the parents and students were already waiting. After an elaborate set of introductions and greetings, Mercy spoke to the families. We then had a chai (tea) break. I of course had not been part of the program but was quickly told/asked/expected to talk.  Since my Swahili is currently at the level of an 18 mo, I had an interrupter. His name was Kelvin, he is an occupational therapist and a bit of a clown, he teased me about being a fast talking American. He was wearing an OBAMA 2008 shirt and told me proudly he was Luo (the tribe of Obama’s Dad).  I told him Obama talked fast too, he laughed. We were fast friends. I told them about my life growing up with Kniest, the surgeries, various spiritual and life milestones. The parents had lots of questions.  A few were medical (an ortho (in fact the same ortho who looked at my knee) had been there the day before), a few were about how my family thought me but what we spent 40 mins talking about was  if I thought I was cursed or not.  Thank God, Thank God I was a religion major and did my honors work on that very issue because medical school totally did not prepare me this vital, question that ALWAYS comes up in global child health even if I never mention my own life experiences. This was the first time though I ever been asked that question bluntly in a public forum as a doctor (seen as a figure of great authority in the culture I am in).

The families were really receptive and I was really touched by how quickly they accepted me as one of their own.  It will never cease to amaze me how quickly being disabled can transcend all cultural boundaries.  Even though I have chosen NOT to do PMR or developmental peds (because the actual medicine bores me), I know this will continue to be part of what I do when I grow up and become a Peds EM/Global Health Doc/Nomad for Jesus/Mother of a Clan.

We had lunch. I got to know some of the kids which was awesome. They were articulate and fun. I also got to know a young Kenyan woman who was 8 mons pregnant with CP and several of the PTs/OTs. In the afternoon, Mercy insisted I go with her to counsel the mothers who wished to speak to her. Most of it was in Swahili which means I understood a lot of pronouns, numbers, colors and yes/no. Mercy took notes though and would show me them. Several of them brought concerns you would expect either they had been left by their spouses because of their sick child or had great financial hardship because of their sick child.  Several though came in strictly to ask about circumcision which I thought was really interesting. It is a typically a rite of passage when boys reach manhood. Some Kenyans will do it in the hospital these days.  The moms wanted me to tell them if I thought letting their son get circumcised would affect their MD.   I initially was somewhat flustered by this. I finally went strictly medical which was they could bring their child to the hospital have them looked at by our anesthesiologist and if they thought their lungs and heart were ok, we could probably do it.  (which seemed the culturally correct response despite my reservations for the poor teenage boys). We prayed with them (especially the ones with non-circumcision complaints) and referred several to a child sponsorship program who can help with medical financial woes. Meanwhile, one student and two Moms became Christians because of the conference (Kenya is a very religious country and having a revival and a support group meeting at the same time may seem odd to my American colleagues but is quite acceptable here. In fact there is very little separation between medicine and the spiritual aspect of people lives here people think of them as being connected…which I think has pros/cons and is a topic I can expand on a while later).  

I loved it. It was an amazing day. I was completely exhausted by the time we left. We stopped at a big supermarket in Thika and stocked up on CHEESE (!!!), laundry detergent, mangoes (always need more) and various other sundry items. I came home and slept for 11 hours.  

*For those of you who have not been following my global health adventures from the beginning…way back in 2004 I went to Bucharest, Romania for the first time. My mentor that summer was a young woman named Laura who was 28 and had a form of muscular dystrophy.  She was a brilliant, writer, activist for our tribe (disabled people).  She passed away Sept 23, 2004  about two months after I left Romania.  It was very hard on me and I struggled with the meaning of her death for a long time.  I had a little bit of a relapse when the first pediatric patient who ever died on my watch was a 18 yo with MD during my AI as a 4^th year medical student. 

work, work, work a little bit of PLAY

 SO everyone told me to stay home with the knee, but we all know I am NOT good at staying home. So I went on crutches and found people to drive me up and down the hill.

Work is busy and a little odd. 

The pathology here is as expected, phenomenal.  We have a visiting peds surgeon who is here for a year who has done some crazy cases this past two weeks: omphalocele, congential diaphragmatic hernia and trachea-esophageal fistula. On the peds ward we have a nephrotic syndrome, a refeeding syndrome (from a prolonged complicated appendicitis that turned into peritonitis after appendectomy an another facility) and various pneumonia and bronchiolitis.  In the nursery/NICU we have THREE cases of direct hyperbilirubeminia which is bizarre (most babies with jaundice have indirect). One kid came in with a total bili of 35 and direct of 24. We ended up doing an emergency exchange transfusion. I manually did the procedure under the guidance of my FMG colleague (an excellent example of something I have NEVER done in my ritzy American education). The repeat bili was 24 with an indirect of a 13 and continues to trend down. The AAP/WHO recommendations for direct hyperbili are vague and there is very little evidence of what actually helps beyond if you can find a metabolic disease you can treat it.  But it says you can try exchange transfusion as a last ditch efforts.  I have spent most of my time in the nursery this week partly because we are short a Kenyan resident and partly because it’s a good place to be if walking is a problem because its small. 

The odd part...There is a FMG (foreign med grad) physician (not Kenyan) who graduated from medical school four years ago elsewhere and has been working in pediatrics since then informally at various mission hospitals around the world.  Its hard because its unclear who is Sr to who and everyone is fawning over my education (all 8 mons of it) but he knows way more than I do especially about how things work in this kind of setting.  To make matters more awkward he desperately wanted to get a spot at the program where I am in the states and every day asks me about it. He applied and was turned down for an interview (which really is a shame because he is great doc and  we take 3 FMGs a year).  He keeps asking me about making connections and such.  I of course have little to NO power and he has already accepted an offer from a community pediatrics program elsewhere and the Match is over and done with. Its hard. I am not exactly sure how to handle it. I appreciate prayers and thoughts. 

I did on Thursday after the knee had started to mend start my growth chart project so hopefully we can get that going. I did have a minor setback. The peds surgery ward is trying to get a scale donated and until then there is a very little I can do about daily weights. So I am focusing on general peds and then the outpatient clinics for now.  Having been here before is a HUGE advantage because the nurses all know me and were not hard to convince to participate in the project. So far, so good.

Monday night before I HURT my knee I went to two parties. One was for all the new residents/students run by several of the full time Western Staff and the other was a surprise party for my Kenyan friend. The surprise party was particularly fun and I had such a good time catching up with everyone and of course Kenyan chai, cake and music.  On Thurs night I went to a Kenyan worship service led by two of the pediatric C/Os (PAs).  I was the only white person there (this happens to me a lot and I often wonder what all the other white people do all the time…especially the young people without kids…I have no idea!). It was a great time the music was half Swahili which I understood some of and half english (with a lot of Hillsong!).  There was the obligatory dancing which I did some of despite my knee.