The Africa you think I live in.

Before coming to Tenwek and since coming I have often heard comments about how hot I must be, or asked about how I live, or how the locals dress. For the most part Tenwek is westernized Kenya and the climate is wonderful. In a few weeks I will follow this post up with one called "the Kenya I call home" but this post is about a trip I have taken to the Africa that due to pictures from National Geographic you have embedded in your minds as the place Annette is living. This is not where I live but a place where I am currently visiting.

Back in February, I met a wonderful couple from England. They were engaged to be married and I spent a lot of time with A as we went to language school. D was around for a few weeks as he recovered from a broken toe. A and D spoke a lot about the place they were coming to Lodwar, Kenya. As they talked a picture kept coming up in my mind of “National Geographic Africa” however, I have learned not to assume anything and to not create false expectations of this place knowing that someday I would come and see it. Finally that time came. A and D got married earlier this year in England but decided to have a celebration of their wedding with the Turkana people. They have worked with one of the local villages asked the village to host a traditional turkana wedding for them. I took a week off from work and traveled north.

I decided to fly from Eldoret (instead of Nairobi) and was able to visit Dr M his wife and family, who finished residency at Tenwek a few months ago. I spent a day with them it was great to reconnect, cuddle their children and see more of Kenya. From there I flew to Lodwar. I landed on a paved airstrip walked down the stairs over to the pile of luggage they were making grabbed my bag and walked out the gate. Now I know “gate” is a term common at airports but by gate I mean the door in a chain link fence. There I met my friends and off we went. It was dark so my first glimpses were limited. I did realize one thing – it was hot, not the muggy humid oppressive heat of the coast. But the dry windy hot that this southern Alberta gal had experienced before. I arrived and met many people both local missionaries and guests for the wedding, together we had a feast to celebrate American thanksgiving. The next morning I got my first look, I was staying at the home of a missionary family who are away who graciously opened up their home to guests who had come for the wedding. I looked out my bedroom window at the pool, (yes they have a pool, that’s a conversation for another day) and saw a goat walking under the palm trees.

In the morning we all piled in the land rover and headed out to see lake turakana. This was about a hour and half a drive on bumpy roads and my first view of the areal called turkana. I saw the goats and sheep which I expected and camels which caught me by surprise. The people live in homes made from sticks with grass/leaves pulled through. People were wearing blankets tied around them and some of the ladies were topless. I decided I have arrived in the National Geographic Africa. We had a wonderful time at the lake, wading (or paddling as the brits call it) and enjoyed a picnic of leftover thanksgiving dinner. When its 38 degrees C. cold potatoes and chicken taste great. We finished up with leftover pumpkin pie. Yum.

Saturday was the wedding so off we headed to the village another long bumpy road but you get used to that out here. We were ushered inside one of the grass homes. It is a great design as the grass lets some of the light and breeze through but you are still shaded so really they were quite comfortable. We sat around the bride got dressed in her goat skins the men came in their outfits,my favourite being the ostrich feather hats. The bull and goat got butchered we danced and jumped ate some meat and went on our way. This is just a summary the day that was long but fun. At one point I even got a short nap in I woke up to a bunch of turkana men singing outside the tent and swinging the cow hide. I was thankful that the hide was not thrown into the house.

I now have a few more days in Turkana visiting with A and D It is great to experience life with them.

Dancing

Resting between dancing, all the men sit on little stools, that they carry around

Enjoying leftover pumpkin pie on the shores of lake turkana

Turkana Beads

The Bride and I, she's wearing goat skin

Camels next to an unfinished home

moving and BiPap

I know my last post was medical and I said my next one would be more about life so I will start by saying I moved this weekend. Since arriving at Tenwek I have been living in the home of one of the long term missionaries who was in the states for a year. She returns this week so it was time to move out. My roommate had left a few days earlier so that left me to pack up the house, most of it was mine anyway. My new home is right next door to my current one, which you think would make moving easy, just a few steps. However there are currently people living in “my” house who will be there for another month. So I have moved to a temporary home. This is the biggest place I have lived in yet and the walk from the kitchen to my bedroom feels long. I was thankfully able to move many of my things from my former place to my future place to store in the bedroom, however, I now have things in storage that I wish I had access to. It’s one ofMurphy's laws that you do not need something until it is placed in storage. So the weekend was spent moving and now that’s mostly done and I have been back to work.

I always find it interesting how things at the hospital go in trends, currently we are on a Bipap trend. Bipap is a way of helping someone breathe without putting a tube in their throat. Before I came it was done infrequently but we keep using it more and more. We have a few “home” style bipap machines that work well for some of our patients but they don’t work well for our patients who need a high percentage of oxygen. For these patients we would have to intubate and place them on the ventilator. However a few weeks ago when we had an elderly, hypoxic, COPD patient who I really did not want to intubate  I tried something different. I hooked the bipap mask up to the Servo 900C ventilator and popped it on the patient. It worked like a charm I was able to set the sensitivity so it would not autotrigger, the alarms were easy to set and that patient did well. Since then I have used the servo 900c for multiple patients as a bipap machine and it has helped save many lives. Earlier this week I had a young man who developed a PE and consolidation after he was in a motor bike accident. This man was fully awake however his oxygen levels were low despite oxygen via non rebreather mask. Rather than intubate him, onto bipap via servo 900c he went for 24 hours and then he was fine.   I am thankful for the machines I have to use and the ability to use them for various purposes.

 

BiPap via Servo 900C

In  closing I ask for prayers for a few patients I intubated a 6 month old (the first time I have intubated a baby) and she is very sick and we are not sure why. Please pray she will recover. We also had a young lady come in the other day after a motor bike accident and her leg had to be amputated, Picture is below, don’t look if you can’t handle gross medical pictures. 

to give reference the tourniquet is between her thigh and where her knee should be

Not What I expected

Before I start I should warn all you non-medical people this is a highly medical post, I'm sorry if it is boring or confusing for you.

  When you do anything for a while it becomes your normal. There are occasional variations in the normal but you have the expected variations that you are prepared for. Working at Tenwek there is a type of patient that I have gotten to know very well – the “poisoning patient” these are individuals who have attempted suicide by ingesting chemicals, often pesticides that they have on hand.

We have 1-2 of these patients a week and the treatment is usually along the lines of gastric lavage, intubation and ventilation if unconscious, atropine for low HR, watching electrolytes and if all goes well in a few days extubate them.  They get them some counseling and they go home. Depending on the poison taken some patients end up dying due to electrolyte or other abnormalities but this is still in my thought process of “this is normal for a poisoning patient”. 

 

So when I got called to help set up a ventilator for a poisoning patient I did not think much of it.  The patient came, I placed him on a ventilator – no problems. A few hours later I got a call from the physician.  The patient now had subcutaneous   emphysema and it was getting worse. My immediate thought was my ventilator did something funny – so I asked the staff to bag the patient and went up the hill to see what was up. The ventilator was working fine – well not fine, it's old, but it was not doing anything that would cause a pneumothorax. However, an x-ray was done and it showed a large left pneumothorax the surgeons came placed the chest tube and things went back to normal. Not sure how he got the pneumo as his ventilating pressures were normal – did he have a pre-existing bleb that popped? After a few more days on the ventilator,a chest tube removal, reinsertion and removal again. The patient was eventually transferred to the ward and I pray that with the help of counseling from our chaplains that he will make a full physical, spiritual, and emotional recovery.

                This patient was not my only abnormal poisoning that week. This time it was a 2am page – we have a poisoning patient and we cannot get him oxygenating well on the vent can you come help? So up the hill I went.  When I arrived I saw the patient settled on the ventilator with Spo2 -80’s. I took a listen and didn't hear any air entry on the left side. So I took a look at his x-ray and saw that his left side was completely whited out. OK,not normal. I didn't think this was in relation to the fact that this man had taken poison. So after fiddling with the vent – high PEEP, low PEEP, high rate, lower rate etc. I finally got to some vent settings that the patient managed to oxygenate with. The next day he went for bronchoscopy and he had a huge mucus plug blocking of his left mainstem bronchus – not normal. The next morning I also try to put together more of the history, he had seized in casualty – secondary to hypoxia? Had this man even taken poison? This patient had questions continually running through my brain. Sadly I never found out the answer, I left to Nairobi for a few days and when I came back I learned he coded and died. I pray that he knew The Lord. 

 Sorry to have this post end on a sad note. My next post will be much less medical and be a little more fun.

                

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