A Day in the Life . . . Friday in the ICU

I walked the long way into work (its not long really) because we have closed off all but two entrances into the hospital so that all can be temperature screened before entering. It is nice to enjoy the very brisk morning air, watch the monkeys, and listen to a podcast.

8:30 AM     Time for the weekly audit of mortalities and close calls on the internal medicine service. This week a lot of time was spent discussing the COVID ward and some ICU complications from the past week. At the end I got a nice despedida with a coffee mug that I had been hoping to get with the Kijabe Hospital logo.

10:00 AM     Rounds in the ICU. In the last 2 days we have added 8 new patients. Yesterday was worse when I had six new patients in the span of just a few hours. Today it is just two new patients. Severe hyponatremia, a patient with a adrenalectomy in whom we have to closely watch the potassium and blood pressure, a myasthenia gravis with mucus plugging causing one lung to not function well (she got a tracheostomy yesterday), a traffic accident with a broken hip and ribs, status epilepticus, sepsis in a patient with esophageal cancer, another who has had her right shoulder and arm removed for cancer complications, severe diabetic ketoacidosis and sepsis . . . the list goes on!

12:30     Time to do some record keeping of the patient for the last week so that we have good records of what they presented with, how they did, how long they were in the hospital. We do this to see trends in our care and illness and improve quality over time.

2:00     No lunch today. It made me wish I had eaten breakfast. The coffee from the morning was serving me well. Time to teach EKG reading to my trainees. One is an orthopedic resident. The other is a medical intern (1st year out of medical school). They have been with me all week on the ICU service.

3:30    Afternoon rounds on all the patients from the morning to see how they have progressed. Everyone seems to be ok, although many are still sick. Several are well enough to leave the ICU.

4:15     I get a call from one of my ECCCOs (ICU clinical officer) stating there is a problem in one of the HDU (like an ICU but without a ventilator). One of the surgical patients we have been rounding on who had major spinal surgery now has a heart rate of 200! This is new to us. An EKG is ordered. She is stable, and I take the moment of getting the EKG to take Dr. Steve on rounds of all the patient in the ICU service. Steve is on call tonight, and I confess I am relieved that he can take the lead on dealing with the tachycardic patient. Is it a sinus tachycardia or atrial fibrillation with rapid ventricular response. Hopefully the EKG give him some clues.

5:00    Steve is in charge. I leave notes on all the patients for the weekend coverage doctor, and head home to start packing for my flight on Saturday. A pretty full day for my final ICU day for awhile.

Being at Kijabe has to be one of the best jobs in the world!

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Our Internal Medicine team after morning audit.

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Passing Head of Department duties happily off to Dr. Tony

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Friday Morning Internal Medicine Audit

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Teaching EKGs

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Poverty

I have nooooo idea what it means to live in poverty although I see it all the time.

I helped a local youth buy a motorcycle (piki). He was so thankful because with that piki he can earn a reliable $3.50 each day giving mototaxi rides. That is enough to provide his family with food. He recently had his piki impounded by the police because they said he was driving it after curfew (he denies this and says it was around 5 PM – there is a good chance the police are using the curfew as a way to line their pockets during this time of financial stress). They were also upset because he was driving without a face mask. He told me there was no way he could afford a mask because they cost $1.00 which is an incredible amount of money for him. He also was asking if I could help him with $10 dollars to get his piki out of the impound lot, which was completely unattainable, especially now that his piki was impounded.

Despite living around it, I cannot understand what it is like to live with this type of financial stress. True poverty is inconceivable for an American.

How Do You Manage This

This is the big question that is not being answered as much as we wish it were.

From the AFP News Agency . . .

 

Nairobi (AFP) – Women and children fell to the ground, bloodied and trampled in a desperate surge for food being handed out in a Nairobi slum, as police fired teargas and men with sticks beat the hungry.

As African countries grapple with the coronavirus pandemic, observers warn that the traumatic scenes which played out last Friday will not be the last if governments fail to help millions of urban poor who live hand-to-mouth.

“I give them (the government) one to two weeks before things get worse. Not in terms of coronavirus, but in terms of hunger,” said Kennedy Odede, who runs Shining Hope For Communities (SHOFCO), a grassroots movement which works in the Nairobi slum Kibera and other informal settlements in Kenya.

“If it continues like this, we might be playing with fire.”

Kenya has so far cordoned off the capital and parts of its coastline and imposed a night-time curfew and other social distancing measures.

Many of these restrictions are having a wrenching impact, causing loss of jobs among the poor, said Odede.

While President Uhuru Kenyatta has wielded the threat of a full lockdown to get citizens to comply with the rules, officials admit it is an agonising choice, especially as 60 percent of Nairobi’s residents live in slums.

“Locking up people in the slums will be the last option. A lot needs to be done before that,” a high-ranking security official told AFP on condition of anonymity.

– ‘Unenforceable and unsustainable’ –

The coronavirus arrived late in Africa, but is slowly taking hold with over 15,000 cases and 800 deaths across the continent.

While much of the developed world waited weeks to begin taking action, countries in Africa rapidly shut borders and banned mass gatherings.

Mauritius, Rwanda and Tunisia were the first to impose full lockdowns — with Mauritius going so far as to shut supermarkets and bakeries for 10 days.

South Africa is the biggest economy on the continent to completely confine its citizens, while Nigeria imposed lockdowns on Lagos — the continent’s largest city — and its capital Abuja, which on Monday were extended for another two weeks.

Both have millions of people packed tightly in urban slums.

“The inevitable reaction has been to follow what the rest of the world is doing,” said Jakkie Cilliers at the Pretoria-based Institute for Security Studies (ISS), who has called for Africans to come up with a “unique solution” to stave off the virus.

“A lockdown is unenforceable and unsustainable across much of Africa. You are trying to do something that is not possible and you are condemning people to a choice between starving and getting sick.

“It’s not possible for 10 people living in a tin shack… to not go outside for three weeks.”

– ‘Make ends meet’ –

In sub-Saharan Africa, Liberia and Zimbabwe have also imposed full lockdowns.

However most nations across the continent have stopped short of forcing all of their citizens to stay indoors.

Madagascar and Ghana have completely locked down selected regions and towns, while Senegal, Mauritania, Guinea, Mali, Ivory Coast, Burkina Faso and Niger have imposed states of emergency and night-time curfews.

Like Kenya, Benin has cordoned off key cities — preventing movement in and out — while the capitals of Ivory Coast, Burkina Faso and Niger are also cut off.

Ethiopia, with a population of over 100 million, has closed borders and schools and discouraged large gatherings, but has yet to restrict citizens’ movement.

“We can’t impose a lockdown like more developed nations, as there are many citizens who don’t have homes,” said Prime Minister Abiy Ahmed.

“Even those who have homes have to make ends meet daily.”

On the other end of the spectrum are Burundi and Tanzania, where life largely continues as normal and whose governments have so far downplayed the dangers of the epidemic.

“Coronavirus should not be a reason to destroy our economy at all,” said Tanzanian President John Magufuli.

– ‘Ineffective and unproductive’ –

Experts agree that for the different levels of confinement to work in Africa, significant state support is needed — a challenge in a continent where many countries are already heavily reliant on donor aid.

Kenya has lowered taxes and is delivering free water to slums, Senegal’s government is paying electricity bills and Ugandan President Yoweri Museveni has urged landlords to let people live rent-free until the crisis is over.

However political commentator Rachel Strohm said such measures mainly benefit people “in the formal sector”.

In Lagos, Uganda, Rwanda, South Africa and elsewhere, governments are distributing food, however often only to a “fraction of the vulnerable”, said Strohm.

She argued that many of the measures taken are “ineffective and unproductive” — curfews on top of transport restrictions create greater crowds as citizens rush to get home in time, and thus enhance the risk of infection.

Strohm and Odede back the idea of direct money transfers to citizens — especially to avoid the inequality and chaos of food distribution.

Foreign donors — battling their own virus-induced economic crises — will need to step in, they say.

Cilliers argued you need to try and “get the maximum economic activity going so people can survive, but try to keep opportunities for infection limited.”

Another solution to avoid complete lockdowns and economic collapse is mass testing, with South Africa so far the only country seeking this approach.

But only around 70,000 tests have been conducted so far, a level that is still “way too low”, Health Minister Zweli Mkhize has admitted.

The majority of countries are still only able to do limited testing.

Meanwhile, ever-stricter measures across the continent have led to a rise in police violence as authorities struggle to get desperate citizens to comply.

“I think we will continue to see excesses and relatively substantive brutality,” said Cilliers.

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April 13 and COVID 19

I am back into the hospital today after the weekend off for Easter. So far no cases in Kijabe Hospital which makes us wonder what may be going on in Kenya and in Africa in general. We keep saying we are a week or two away, and then nothing. I am glad, and I confess each day makes me more optimistic that we will miss the worst of it. There are multiple reasons that could play a role in what appears to be a less significant outbreak. We live in a tropical zone with lots of direct sunlight. Most of the population has received a BCG anti-tuberculosis inoculation which could impart some partial immunity. A higher percent of our population is on anti-retroviral medication (the treatment for HIV). Maybe there is a genetic predisposition against the virus. Also we have quite a few corona-type viruses that circulate through our community that could be imparting a partial immunity. Possibly an early move to partial quarantine slowed the infection rate. In the end it is confusing, because none of the listed reasons above seem to explain what appears to be less cases here. So maybe we are just behind, and it will come on strong in the next month. In the end I am thankful that it is not bad, and I pray that God will have mercy on the people of Africa, especially the poor.

Happy Day after Easter from our family!

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Obstetrics Call

Another night in the hospital last week has passed, and I again think about how weird and different practicing medicine is in Kenya, even in our great Kijabe Mission Hospital. The nigh of obstetric call started with handover. This is where the doctors who are leaving, but have covered the day, “hand over” the care of the patients in the hospital to the doctors covering the night. As I listened I felt my stomach drop a little as I realized the night would begin poorly. There was a young mother in the hospital whose baby had fetal hydrops which is a problem in which an en-utero infant for a multitude of reasons has swelling all over the body. These babies do not do well. She needed emergency delivery at 27 weeks of pregnancy, and we knew the baby would likely not be able to survive after delivery. Even more problematic was that she had a scar from a previous cesarean section which meant that we were going to do a preterm surgery. These usually go well, but they have their own increased risks. We took her back to the OR, and as I delivered the baby’s head through the uterine incision it looked so perfect, and I thought nervously that maybe we had the diagnosis wrong. But as the rest of the baby delivered the terrible swelling over the rest of the body was very obvious. He lived just 10 minutes before dying.

I came out of surgery to hear that a twin pregnancy that had arrived just a bit earlier had been evaluated and only one heart beat could be found. I placed the ultrasound on her abdomen and confirmed that one of the twins had passed. The mother cried as I told her, and her husband looked angry wondering what had changed in the last 10 days when her last appointment had shown two healthy babies. What could we say? She went quickly for an emergency surgery, and on delivery the first twin showed signs of having died several days prior. Its hard for a pregnant woman with twins to sort out the movements of her babies. She could not have known that all she was feeling were the movements of one of them.

Obstetrics can be a great joy when it goes well. But when it is bad, it is so sad. God help us all to show compassion!

Allison is the Name

Devotional Thoughts

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Devotional thought before midterm break

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I am thankful for a school that tries to instill the deep truths into their students. I am glad Allison teaches there. This year was English, next year back to her first love, Spanish.

AIC Kijabe Mission Hospital

I took these from the AIC Kijabe Hospital Facebook page. I think they are good demonstrations of the work going on in the hospital ranging from showing compassion and Christian friendship, caring for the weakest, medical education, and research. Please pray for our hospital as we continue to strive for excellence.

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Visit the Sick

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I was sitting outside the hospital when to my glad surprise some of Annie’s class passed by after they had been doing visitations in the pediatric ward of the hospital.

“Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.”

Then the righteous will answer him, “Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?”

The King will reply, “Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”

Good Quote

Increasingly, I am of the view that republican government, in the classical sense of that term, is possible only in a polis where the citizens are committed to trying to understand one another affectionately and believe in showing mercy to their ideological opponents. Short of that, it is hard to see a way out of the current mess. And that problem is of concern to far more people than just conservative journalists. – Jake Meador on Mere Orthodoxy