A weekend off, life and thanksgiving

Over the past few years I have discovered something about myself. I am a home body. I like being home where I can do my own thing, I don’t need to travel, and I can just relax. Some of you may be thinking really – is this the same girl who has taken 10 000km roadtrips, and moved across the world to Kenya. And the answer is yes. While I love to travel and visit people I highly value my own space and when I have been busy my favourite thing to do is to hide at home with a book. Living here that works some of the time but not all the time. I have a pager and it lives on my hip. As I am the only Respiratory Therapist I have told the missionaries and staff here that if something comes up on nights or weekends that is outside the ordinary and they can’t deal with it that they can call me. I am not called every weekend and it has been more than a week since I have been called out of bed but it is part of life here. The month of September was busy and I really felt the need for a break. I have learned the best way to do this is leave. So last weekend (the weekend before thanksgiving) I headed out to the big busy city of Nairobi to relax.

I stayed at a nice guesthouse that has communal meals so you can visit with other missionaries/visitors.  It is also close to many shopping centers so I can walk rather than take a cab.

Shortly after I arrived,I heard some sad news from home. A friend had died in a farm accident. This fellow, like my brothers, was a farmer and loved what he did. He was someone I grew up with as our families have always been close. I was thankful for the time away to shed tears, offer up prayers, spend time in God’s word and talk to family.

I was in Nairobi from Thursday late afternoon until Monday noon. I was able to eat lots of good food Chinese, KFC, Italian, frozen yogurt and American. Tenwek does not have much options for eating out. So if you can’t cook it you don’t eat it. It was great to eat some different food. I also did lots of shopping for everything to new CD’s to groceries and was able to visit my teachers from language school. It was great to see my teachers who I spent 3 months with at the beginning of the year we were able to catch up, and have some laughs as I demonstrated how much shang (Swahili slang) that I have learned while at Tenwek. I returned to Tenwek with food to fill the cupboard and freezer and a refreshed spirit to return to work.

KFC in Nairobi, part of my families thanksgiving tradition is to have KFC, I was glad I could too, and only a week early

The week since returning has been busy and fun. One of my friends braided my hair Kenyan style, its fun to see people’s reactions as I look quite different. I do appreciate the lack of maintenance this hairstyle gives me but I don’t think it will last long as my hair is much slipper than the Kenyans hair. A few weeks ago I had some of the interns over for pizza and I introduced them to the card game – Spoons. We had a blast and Friday was the second spoon tournament. There was about 10 of us at the home of one of the interns. We started with a supper of meat, ugali, greens, and salsa. I was shown how to make ugali and put to work stirring the mixture. After that was the spoons game it was fun and we had a lot of laughs.

Ugali in the making

2 of our Chefs for the evening - I contributed my standard of chocolate chip cookies

Nice calm game of spoons, yes that is me with the lines on my head

The spoon dive

Sunday we celebrated Thanksgiving. As Americans don’t celebrate until November I was happy to find 6 other Canadians to join in on the celebration as well as a few others to fill the table. We had a great evening filled with sharing of Thanks and wonderful food – Chicken (turkey is really expensive), mashed potatoes, broccoli, salads and of course pies. Hmm.

The last two weeks we have not had too many people on vents so my time has been spent doing other things.  We got new (to us monitors) for our ICU and HDU so I helped in the sorting of equipment and setting up and training. Some of that has included reading the configuration manual and changing the default alarm parameters – finding a balance between a machine that alarms when the patient needs attention and a machine that alarms some of the time. This is definitely not something I would ever do in Canada but here things are different. I also gave a lecture last week to the Doctors and Residents- titled  "ventilation beyond the basics." It was fun to talk about the more complicated things like PIP vs Pplat, auto PEEP in COPD, permissive hypercapnea etc.

Nice new ICU monitors

Ok so this post ended up being longer than I thought if you made it to the end pat yourself on the back.

Why I Do what I Do – Mary’s Story

I love what I do as a Respiratory Therapist, but the work has its difficulties. Most of my time is spent in the ICU working with the sickest of the sick. What I say here may offend some people – which is not my intent. I also need to state that I value life highly and am against euthanasia of any kind. Now that that is clearly stated I will explain why. I operate machines that breathe for people, people who without such machines would die. Now this may sound like a good thing but not everyone who goes on a breathing machine, in my opinion, should. I distinctly remember one Christmas in Canada where we had a 90 year old fellow with MS on a ventilator. We kept him alive with machines over Christmas and when the patient’s family realized he would not recover the machine was removed and he passed. Placing him on a machine did not prolong his life but his death. I, and my, co-workers all have many similar experiences and many of us have said if this happens we don’t want to be put on machines in certain situations. RT’s are often the first ones in the ER to ask the difficult question – how aggressive in this individual's care do we want to be? If this patient gets worse will they go to ICU? Why – will they get better?

This is the work that I do and given that it is easy to ask the question – why? Why - Because some patients have a high chance of getting better and without the care that I can help provide they would die. To illustrate this I will tell you Mary’s Story.

                I met Mary a week ago. She had been at Tenwek two weeks ago when she had a C-section for twins, at the time she suffered from pre-eclampsia (dangerously high blood pressure that can happen during pregnancy). After the C-section, for healthy twins, she was doing much better and was sent home. She returned with severe shortness of breath and dangerously low oxygen levels despite oxygen (Spo2 60s on NRM). Her chest x-ray showed pulmonary edema. We tried her on biPAP, a tight fitting mask to help her breathing (I used the servo 900C as my biPAP machine as my VPAP can’t give 100% O2) with no success so she required intubation and ventilation.  On the ventilator her oxygenation improved some but she required the maximum my machine would give her (I wish I had APRV). I checked on her over the weekend, with medication (lots of lasix) and time she slowly got better. After five days on the ventilator, she recovered and we weaned her off support from the ventilator, and just before we did rounds where the decision to take out the breathing tube would have been made – she made the decision for us and pulled out the tube herself. She did well breathing on her own and was discharged to the ward.

                So this is why I do what I do. This young lady would have not recovered without the care an ICU can offer.  She would have left two babies without a mother but now in a few days she will be able to go home to her babies and return to her life.

I cannot take the credit for her life although I worked hard, without God’s hand on this lady she would not have recovered. 

Working in a resource limited setting

 Tenwek is a fairly well equipedhospital and we can do a lot. We have a total of 13 ICU beds, a CT scanner, a well-equipped OR with talented surgeons, an inpatient and outpatient medical service that also boast wonderful physicians. However, we also have challenges that are unique to mission hospitals. We are one of a handful of ICU’s in the country: the next closest CT scanner is a two hour drive. We don’t have STARS air ambulance to fly patients to another critical care site. When patients come to our door they are ours and we have to treat them the best as we can. We can occasionally transfer patients out for dialysis or other care but these cases are few and far between.

                I mentioned that we have 13 ICU beds but for these beds we only have four ventilators, and five fully functioning monitors (more monitors are coming – Praise the Lord). Doing care in this setting has its challenges. We have many sick patients, and not all will recover. So we ask ourselves: can we intubate and ventilate the 70 year old with a stroke who may not recover? Probably not. What about the young man with meningitis and brain abscesses? The man with meningitis might not recover and if he is on a ventilator does that mean I can’t ventilate the young lady who tried to commit suicide because she found out she is pregnant and has no support? The suicide attempt has a high chance of recovery and finding the Lord and hopefully a support network when she recovers. These are questions I am asking every day. As well as the question: is this patient getting better – does he need a ICU bed? What about that young man he has not improved, will he recover? Should we send him to the normal floor. As I work with every service (medicine, OB, Peds, & Surgery) I am facing the pressure of the resource crunch every day. When a Doctor/Resident needs a ventilator they turn to me. Sometimes I can say yes; other times the answer is not now but I will see what I can do. I walk away thinking, what am I supposed to do, make a ventilator out of thin air (there is some irony in that statement). Every time I have received that request, by the grace of the Lord, we make something work. The patient who has been on the ventilator for about two weeks and was recently trached as he was a difficult wean breathed on his own all day. So at 3 am,  we try him again on trach cradle and he does well. Another time I was able to get a new ventilator working just before another one broke keeping the census at 4. (Our machines are old and it does not take much for one to quit working). These are just some of the challenges I face regularly. It does not cover the other problems we face such as an inconsistent supply of blood for our blood bank, lack of certain labs, lack of beds, lack of pillows etc.

Don’t get me wrong, I love working here and the challenges keep life more interesting, however, there are times when I envy my life back in Canada where I had a storage room full of machines, extra ICU beds across the city and the ability to safely transport patients to such ICU beds. Please pray for wisdom and patience as the staff and I deal with these problems on a regular basis. Also praise the lord, as I have a few new (to us) ventilators that have been donated and will hopefully arrive here within the next six months. As a side note if anyone has a BEAR 1000 ventilator sitting around that they are willing to give me some parts for let me know. 

Saturdays

A few weeks ago I was asked by a short term Tenwek Visitor what I do on weekend off – I didn’t have a great answer for her. Why? Because I am doing life here. Living here is not a long holiday but normal things. Just like you sitting in your house right now, my Saturdays are busy.  Last weekend was a slower pace.  I was watching two boys as their parents were  gone for the weekend. They are ~11years old and therefore fairly easy. However, being responsible for them has given me an excuse to turn down some other requests for the weekend so it was rather relaxing – I took a short nap, backed up my computer, baked some cookies.

I also made 2 trips of to the hospital. We have been having a difficult problem, I only have four functioning ventilators and they are all in use. Last Saturday, I got a call as they needed to intubate a fifth person and needed a ventilator. OK. Hard decision time – we tried one of the patients on T-piece and she did okay so her ventilator went to the next patient. I also looked at the other three patients on ventilators trying to figure out if I get called again, who is next?  Is it the septic young man, the fellow who has poor muscle strength for unknown reason or the craniectomy patient who is not waking up? Hard decisions I am praying that another ventilator will not be needed until we can get the existing patients extubated. However I was able to get a plan in place with the surgeon if we need another machine. We have a few broken down machines and I am hoping they can be fixed to prevent this problem from happening again.

Anyway back to my Saturday. As you can see last weekend was rather relaxing – I am completely serious, it was. Another Saturday I was expecting a relaxing weekend but found out my Youth Group had a soccer tournament at Tenwek. Being there to show support to these boys is important so I spent the day in the sun watching soccer – it was a fun day but not the day I expected to have as I only found out about it the day before.

The weekend before that I had an adventure with my ICU and HDU nurses we travelled to a place called 14 falls on the way we stopped for chai.  Chai to Kenyans is like coffee time for Dutch people, it must happen. We also stopped to see a pineapple farm – I had never before seen pinapples grow, I thought they grew like cabbage but they are off the ground – it was neat to see. The water falls were beautiful, however, I was disappointed by the amount of pollution in the water. Usually I am the first one to get my feet wet but I refused to touch this water. Regardless the day was fun and it was great to spend time with my co-workers outside of the hospital.  

That is life at Tenwek. I often wonder where the time goes as there is always something to do, someone with a need, or a game to play. Please pray for me to have wisdom and strength for the busy times and the courage to say no.

 

14 Falls

Soccer game

Where has the time gone?

Two weeks ago, I reached the seven month mark since arriving in Kenya, my six month tourist visa had already been extended for a month, and I was still waiting for my work permit. So a few days before the expiry, I started to make some phone calls about where I was at. I had numerous conversations while continuing to help with a sick child. Conversations progressed from having to travel out of country for a few days to being told to go to Nakuru, 4 hours away, as there is a helpful immigration official who will help me out. So I ran home, grabbed a quick bite to eat, called a driver to pick me up in an hour, sorted out who would feed the dog I was watching, and put some things in a bag. Off I went to find my car – to my surprise there were two drivers. I went off with the one who I was told was coming. I had a good weekend in Nakuru relaxed in the home of the country directors of WGM Kenya, wonderful people. I also got to do some fun shopping, eat some tasty Chinese food and most importantly I was able to get a two month extension on my visa. Hopefully before Oct 2, I will get my work permit, or I will have a repeat of two weeks ago.

The second weekend of August was also busy. I headed out to Nairobi as I had a Respiratory Therapy student coming to Kenya for two weeks to work at Kijabe and Aga Khan Hospital. His coming was part of another group I am involved with called Respiratory Therapists Without Borders. Sunday afternoon the RT student and I arrived at Kijabe hospital we got settled in and planned our lecture for the next morning. Monday and Tuesday were busy. We gave two lectures a day, checked  and fixed baggers, put together about 40 new baggers, did rounds, checked out all the vents, etc. Tuesday afternoon a second RT arrived from Canada – three RTs from Canada in one place in Kenya – WOW. I spent the afternoon orientating the new RT and then I packed up and returned to Tenwek. These two RTs will complete the week at Kiajbe and hopefully have a good experience.   Maybe they will return to Kenya or help out elsewhere in the future. I was also thankful that these individuals brought many supplies that were split up by three mission hospitals in Kenya,- Kijabe, Tenwek, & Litein.

A lot of baggers - THANK YOU

The view from my front door a Kijabe - the Great Rift Valley

Three Candadian RTs in Kenya

Tuesday afternoon, I left to return to Tenwek. The driver and I left at 4pm which should have given us plenty of time to be back at Tenwek before dark, as traveling after dark here is not advised. So we left Kijabe and got to the town at the bottom of the hill. We stopped in a gas station and were told “hakuna” (there is none).  The driver said we will be fine until Narok. So we stopped in Narok, at the first station we heard "hakuna", the second station: "hakuna", the third station: "hakuna". The fourth station we saw a fuel truck ready to unload and 100 piki pikis (motor bikes) and 75 cars in line. The driver looked at the gauge and said we should be fine. Five minutes out of town the low fuel light turned on so we turned around and joined the line. The fuel delivery truck had just arrived so first we waited for him to unload and then the line started to move. We slowly inched forward until eventually our turn came. The Piki Piki’s were in line first and they just kept coming. Also other piki piki drivers would get to the front with an empty bottle pay for their 1 liter and happily take off. We waited about an hour and a half to finally get gas and then it was dark and rainy making the hour and a half drive to Tenwek not fun. I was thankful for a good driver who was familiar with the road – he knew where all the speed bumps and potholes were. I finally made it home a little after 9pm. A three hour trip that turned into five hours.

So now I am back to work.  Please say a prayer for us at the hospital as we have a lot of head injuries and other traumas lately. Also recently, we had a morning where in the space of three hours we coded and lost two babies under the age of one, both in the ER department.  Please pray for the families as well as all the staff and me as it was a tough morning.

The line for gas

This man was excited to get his 1L of gas - yes it is in a water bottle

It's the little things

So what is it that makes living and working in Kenya so much different - it’s the little things. Many of these things are good and many of them drive me crazy. Sometimes it’s the same things that at one point I will enjoy and another time will make me crazy.

To illustrate these points I will show case a few normal everyday things that are made different by little things.

My walk to or from work.

I love that my house is just a short walk (300m) to work. Mornings are beautiful with the sun peaking up over the clouds, the birds are singing and its quiet with no hi-way noises. When I reach the road I take a quick peak to make sure there is no motor bike coming up the road. I often see a certain motor biker waiting for his passengers. He wears a Canada Post Jacket. It’s a nice touch of home. Often when walking home I get delayed with greeting people. Here a simple hi or wave is not appropriate. You must shake hands and ask how things are going. The other day I met a young man from my youth group. I saw the cows that he herds before I saw him. We chatted for a bit as his cows kept walking on, once the conversation was done he went off and tracked down the cows – he said they knew the way. There is no rushing or worrying. This is a great thing…outside the hospital.

Cows in my back yard

Making Supper

I have house help a lovely lady who comes a few days a week to help me with cooking, dishes, laundry etc. However the other day I had some visitors for supper on a day when J was not around. So supper was up to me. I asked a friend to pick up some lettuce from Nairobi. Once I got the lettuce we (my roommate and I) washed it in a weak bleach solution and then rinsed it in filtered water. We had to do the same with the tomatoes. Avocadoes are in season so we had fresh guacamole. I walked to a few different fruit stands before I found the limes needed to go in the guacamole. I took three and asked how much. I was told 30 shillings. I paid and the lady gave me 5 limes. Not quite sure how that worked, and I did not really need 5 limes but it was easier that way. I had J make the tortillas the day before so I did not need to worry about that and I had some taco spice from a visiting Dr. There. Tacos done. I picked tacos because it was an easy meal.

 

A different night when we had a lasagna making lesson

Work

I can’t outline all the little things that make work different but here’s just a simple story that has happened many times. This is a typical story and here’s how it may go.

I get paged to help out in casualty (ER) I find a young lady in the back room unconscious, not on a monitor and a Dr saying we probably need to intubate. I go assess the patient – make sure she is still breathing, check her sats and see how awake she is. As these are all fine I go set up for intubation. I set up suction – I grab the tubing and canister off the drying rack as they have just come out of the bleach we use to disinfect. I discover that one of the tunings does not quite connect to my yankeur so I go find another one. I take the bagger out of the bags we recently hung that should contain my needed supplies, I discover that the mask is the wrong size so I dig through  a container of masks mixed with random connectors and find a better one. Get the laryngoscope out of the drawer – thankful that we have a complete laryngoscope set in a good box. Now that I am all set up the Doctor and I and possibly a nurse go to put the tube in after the 2^nd attempt the tube goes in the lungs – I hear air entry on both sides and the SpO2 stays good –confirmed ETT placement. Now the patient who was previously breathing isn’t breathing so much on her own. So I stand in casualty and breathe for her by squeezing a bag. While doing this I keep the gastric lavage going to clean out her stomach. I cannot leave the patient for more than a few seconds at a time as if I leave patient does not breathe. After 30-60min I hear we have a bed ready in ICU but they need me to go setup the vent. So I call a nurse to take over my job of bagging and head to ICU. The nurses set up the vent well and with a minor change we are ready -  I tell them I will be back in a few minutes with the patient. I walk back to casualty and grab an oxygen cylinder to use as we transport the patient – but after turning it on I discover it’s empty. I than switch the regulator to the next tank. It’s also empty. I walk back to ICU and ask to borrow there tank they give me permission as long as I promise to return it. I turn it on and discover there is a large leak around the regulator. I remove the regulator and see that there is no O-ring to help seal the regulator to the cylinder. I find an empty plastic IV bottle and cut it up to make an O-ring. I manage to finally to get it to seal and then I hear a commotion behind me. The casualty staff decided they were sick of waiting for an O2 cylinder so they made a mad dash from casualty to ICU. The patient is still on my SpO2 probe – the only monitor aside from the odd BP we have done since her arrival at Tenwek, anyway the mad dash brought her SpO2 down to 83 – not bad. I throw her on the vent and she recovers. The casualty staff take their bagger back to casualty and I hunt up an ICU bagger to keep by her bedside in case the power goes out and my vent shuts off. The first bagger I find has a small leak – I pull out the glue that is in my pocket and seal it. Now we are good to go. Patient looks good on the vent and is stable. Hopefully she will wake up in the next day or two and then we can take her tube out.

Rounding outside on our ICU patients. They have (all 3) recovered from their suicide attempts.

So I will end there. Please pray for me for patience to deal with and enjoy the little things.

Mystery Patient Part 2

So a few weeks ago I shared here on this blog about a mystery patient. I have been asked to share what we figured out with the patient. The truth is we figured out nothing. He remained in HDU(High Dependeny Unit - same as a step down ICU) for a few weeks with intermittent episodes of increased work of breathing and increased PaCo2- 105. In between the episodes he would have some signs of mildly increased work of breathing but was otherwise fine. He would walk around, eat, talk etc. We did a few blood gases during these periods and they were normal.

After doing this for many days with no diagnosis in sight and realizing that whatever the diagnosis was we probably could not treat it. With this knowledge in mind a discussion was held with him and his family and a decision was made to send him to the general ward and stop the bipap. A few days later he went home. He was off the bipap for about 5 days straight before he left and had no episodes. I don't know if God healed this young man or if he since he went home and he passed on. However, I do know that this man knows the Lord and whatever happens I will see him again whether here or in heaven.