Nurse in Kenya: May 2014

"Knowledge comes, but wisdom lingers. It may not be difficult to store up in the mind a vast quantity of facts within a comparatively short time, but the ability to form judgments requires the severe discipline of hard work and the tempering heat of experience and maturity."

– Calvin Coolidge

"In the heavens God has pitched a tent for the sun. It is like a bridegroom coming out of his chamber,  like a champion rejoicing to run his course. It rises at one end of the heavens  and makes its circuit to the other;  nothing is deprived of its warmth. The law of the Lord is perfect,  refreshing the soul."

– Psalm 19:5-7

You’ll just have to forgive me (as is said in Kenya) for not writing for so long. It has been two full months since I posted last and it feels like just a few weeks have gone by. I tried to sit down a few times and get something out but I couldn’t bring myself to write. I’ve known what I was going to talk to you about since it happened, now nearly almost two months ago, and I guess I’ve just put it off until now.

It all started within an hour of posting the last blog. It was a Sunday night and I was lounging around in my pajamas sipping a cup of tea. (Suffering for Jesus, eh?) I had spent a little while punching out a few keys to the tune of emotional availability at the expense of personal vulnerability… nothing earth-shattering happening. I had been thinking about the kids a lot but hadn’t seen much of them that day, as it was my off, as we say. I was about to go to bed when I heard a knock.

It was Jeff. He was in his nightclothes (track pants and a sweatshirt with the hood up, always) and was very calm. He was holding a baby I didn’t recognize. It was light-brown gray, with sunken eyes and a dent in the top of her head I could see from feet away. She was looking at me from under her eyelids that were halfway closed. I gasped. As I was asking him who this was, I realized I knew that baby. Her name is Jackie. She was three months old at the time and weighed just five kilograms.

I grabbed my keys and opened up sickbay, and we placed her on the exam bed. Jeff said that the Aunties had brought Jackie to him – that she wasn’t eating, and that she was having diarrhea. I touched her skin and a moment later my brain registered the abnormality that was the heat she was radiating. An ominous odor was coming from her that reminded of me of something I had smelled when I worked in the Intensive Care Unit. Her appearance frightened me in a visceral fashion.

Fever is commonly treated clinically as malaria in these parts. If a baby has fever even without any other symptoms, regardless of the blood smear results, it’s commonly accepted, at least rurally, that they need to be treated for malaria. In this case, she had become dehydrated in a short period of time because of diarrhea, fever, and, as I shortly discovered, she was also vomiting. Babies can dehydrate quickly due to the fluid and electrolyte losses from diarrhea alone, but when they can’t take in additional fluid because of vomiting or even decreased appetite, it accelerates the process of becoming “dry”, as we used to say on the unit. Fever alone can also cause dehydration, as increased metabolic demand (like increased heart rate, and increased respiratory rate, for example) leads to increased fluid demand as temperature regulation and fluid balance are closely linked.

So, there we were, on 11pm on a Sunday night with a formerly 5kg baby (now less due to fluid loss) with severe dehydration secondary to malaria. Her mucous membranes were relatively dry, her fontanelle was sunken (the dent on top of her head I mentioned) and I could barely feel her peripheral pulses. She wasn’t crying much when I messed with her, but she did cry weakly. I knew what had to happen, but decided to use a lifeline and “phone a friend” (who wants to be a missionary?). I called our local doctor, explained my assessment, and he agreed that she needed a line (an IV) and fluid resuscitation along with antimalarials and antipyrexics (for fever). I knew I could call him again if I had a problem.

I made three or four attempts on her tiny peripheral veins, but every time I did make it in to her deflated vasculature she would wriggle kidogo (a little bit) and the vein would “blow” (collapse, and bleed into the subcutaneous tissue). Jeff was holding her for me, and we were using the flashlight from my phone to increase the lighting so I could try to see a shadow of what I was attempting to cannulate. Baba really kept his cool, unsurprisingly, as he has dealt with many seriously ill kids during his decade in Kenya.

After my last attempt to secure the line in little Jackie I stood up off my knees and put my hands down at my sides, still holding the tourniquet in one hand, and the catheter and alcohol swab in another. I took a step back and looked at the two of them. It was almost eleven thirty by then. I took a deep breath and noticed a realization intrude into my consciousness: it had happened many nights before, standing over an adult with more tubes and lines coming out of them and going into them than I could quickly count. It is the heavy moment, as the beating of your own heart ticks time away in your ears, however loud your surroundings. It is the moment you feel like a lemon is being squeezed off the top of your kidneys and your stomach contorts itself into an elaborate knot. It is the moment a fire starts inside your guts which fuels the motivation to keep a human being whom you care about alive. Then that fire runs through your veins like powdered glass, lights up every part of your brain you need, takes over your arms and legs, and moves you to do what is necessary. I felt the fire, I breathed into it, and felt it grow in my heart. My eyes floated over her now closed eyes and unmoving limbs. Living in that moment for an eternity, which probably passed in a second for Jeff, I realized that Jackie was going to die unless we did something else. The only way to get out of that moment and to get the job done, in my experience, is to just take a deep breath, put your head down, and focus on the task at hand.

I told Jeff that if she didn’t get intravenous hydration as soon as possible that I thought she would probably die from this. I told him that as much as I wanted to be the one to help her, I had to admit that I just couldn’t successfully place her line. I called the doctor back and asked him to place it for me.

The next thing I knew I was out of my pajamas, pulling on my jeans, and running. I grabbed my bag and threw whatever I thought I’d need into it - a handful of 24-gauge IV cannulas (American and Kenyan styles), IV start kits, extra IV tape, drip sets, fluid bottles, ORS packets, baby wipes, toilet paper. Thirty seconds later I find myself running back to the baby room where I had just handed Jackie off to the Aunties just a minute or two before and they then told me she had just had another diarrhea diaper. They changed her and wrapped her in a blanket since we were going out into the cold night (as it was probably in the high fifties, Fahrenheit). Diapers: check. Bottle: check. Supples: check. I looked down at my patient as the outside lights of the main house shone on her face – she was falling asleep. As I hurried toward the passenger seat of our white Subaru Forester I put my hand on her chest and felt her rapid breathing, and put my fingers on her wrist and tried to feel for her radial pulse but never found one. I put my hand over her head and felt her temporal artery thumping away and could feel her heart beating in her chest. I called her name and her eyes didn’t open. I jostled her arm and she didn’t budge. I rubbed her chest, against her ribs, a bit more firmly than usual with my fingertips and she opened her eyes. I never thought I’d give a baby a sternal rub.

While we drove I tried to see if she would drink ORS from a bottle – World Health Organization issue Oral Rehydration Salts. ORS comes as a powder in a small sachet that is to be diluted in exactly 500mL of clean drinking water. It contains sodium, potassium, and glucose in an appropriate balance to replace fluid and electrolyte losses characteristic of dehydration. It’s a bit like diluted Gatorade.

As we drove I could barely keep Jackie awake. She would suck on her bottle for a minute and then tire out and drift off. I confirmed that she had no palpable peripheral pulses and her hands and feet were cold while her core was burning up. These findings signaled to me how severely dehydrated this little babe was, and I knew she was in trouble.

Once we found the doc’s house it was after midnight. He welcomed us into his living room, neatly decorated and illuminated with a few fluorescent bulbs. A lace curtain separated the living and dining area from the bedroom. Jeff sat on the sofa with the baby while daktari and I knelt on the ground in front of them – we stabilized her arm and again used the flashlight from my phone for better visibility. Jackie cried some and made some screeching sounds and I was happy to see that she was fighting a bit as the Kenyan man beside me poked a very tiny needle into her hand. Every few minutes a dog would come in through the curtained entryway, enter our workspace, and daktari would yell in Swahili for it to shoo. It was a “this is Africa” moment. It took a few tries, and we were probably at it for at least fifteen minutes, but he got that line in and oh, did I ever tape it down! At the end of it all, daktari couldn’t stop thanking me, which I thought was ridiculous. I knew he had just given our kid a chance to live to see the next day.

She started vomiting more on the way home. She got a weight-based normal saline bolus and then daktari ordered “Hartmann’s solution”, a D5-normal (5% dextrose with 0.9% sodium chloride) maintenance drip until the morning hours. I didn’t actually have any D5-normal (but I did have D5 and NS, so I did my best) so had to be careful to make some. After all was said and done, we were back in sickbay at home by two in the morning. Jeff stayed with her for ten or fifteen minutes while I got enough supplies to last until the morning so I could just sit out the rest of her drip. I set up a little bed area on my exam table (a standard single bed with a black vinyl cover) with a wool blanket. I didn’t have a pole for IV fluids so I hung the bag on the hook used to hold the curtain wire. In case you’re wondering, I’ll tell you that I definitely did not have an infusion pump. Nurses, you know what that means.

When I was a student at Binghamton University’s Decker School of Nursing (’11) there was a portion of our curriculum that I had a lot of fun with, that a lot of other students found irritating. (Yes, I’m a nerd. I’ve accepted this.) We were instructed how to manually calculate drip flow rates of intravenous infusions based on the drip factor of the infusion set. It’ll make more sense to those nonmedical readers if I explain it this way: if you go to the hospital in the States and need an IV set at a particular rate of mL (cc) per hour, the nurse will most often just prime (put fluid through) an infusion set (tubing) and then put it into a computerized infusion pump. The infusion pump manually controls the rate of infusion so that the fluid enters the patient at the exactly specified rate determined by the physician. Pumps also monitor for air bubbles, and will alert you when your infusion is complete. In nursing school I remember hearing other students say, “why are we learning how to do drip rates? I’m never going to need to know this,” and I remembered thinking, “I wouldn’t be surprised if I really do need to know this someday.” Let me tell you – after I had quickly scribbled out drip calculations, (he told me just to give her a certain amount over four hours) when I was counting the drops in Jackie’s gravity infusion set, with the roller clamp in my sweaty palm, I can tell you that I was glad that I had paid attention to manual drip calcs in school.

I knew we had done the right thing with her rather quickly. She had been really lethargic and, in my opinion, in and out of consciousness before we put the line in. Within the first half-hour or forty-five minutes with the fluid bolus (large amount delivered at once) she really perked up and became agitated, which is what I’d expect from a moderately, but not critically, dehydrated baby. Her color improved and her limbs weren’t so cold. I could feel weak pulses in her wrists and feet again. She was more alert and wasn’t breathing so fast. She wasn’t out of the woods but she was moving in a positive direction.

I sat pretzel-style and held Jackie, with my American Red Cross Pediatric Advanced Life Support (PALS) manual at my feet. Surrounding me on the bed were diapers, wipes, a half-liter of ORS, a thermometer, my phone, a wet washcloth. She was fussy and cried every time I stopped rocking her. And so, every fifteen to thirty minutes for the rest of the night, amid her abnormal crying, I just checked and counted. Apical heart rates. Pulse checks. Respiratory rates. Urine checks. Drops of fluid. Temperature. Next dose of this and that. It’s what nurses do.

Around four in the morning I could feel that she was again febrile. She had fallen asleep for, maybe, five minutes and I set her down on the bed so I could get up and double check a few things without her on my lap. I realized I had been awake for twenty-two hours, and that I hadn’t eaten in ten as I had had malaria within the past few days and was on the mend myself. Actually, that Sunday was the first day in almost a week I had felt really well. I had forgotten it all during that time and was just running off of the energy from the fire that had started in me five hours earlier. I didn’t feel tired at all, and was focused on this little girl.

At some point during those minutes while that precious baby girl slept I took another step back for about thirty seconds. I just watched her lying on the bed alone with the IV in her wrist. I prayed. She looked so much better than she had, even a few hours ago. I took a photo.

Jackie, morning of March 3rd

Taking a moment to reflect inside myself, I noticed something still burning – ardently impassioned to keep her alive, igniting a practical compulsion to continue working. The warmth of that fire flowed through me and I was overwhelmed with affection for this little child. Suddenly, the heat of that night seemed to engulf me as I became suddenly and very acutely aware of the simultaneous privilege and responsibility that God, and our directors, had placed with me. My heart burned with a fever, like that which had earlier burned in the tiny infant, with a fierce love for this baby. Just a few hours before I had been contemplating the choices involved in loving unconditionally in an insecure world, and there I stood before my great example. Here was a tiny lady who I couldn’t deny I loved; for whom my affection was involuntary, and to whom my dedication was required. As I watched her chest rise and fall I felt my own do the same. The reality of the past hours’ events flashed awake something inside of me which then put my evening’s thoughts into perspective.

That Jackie. She set my heart ablaze; she ignited my spirit. The light cast from the fire in the heat of that night, whether from her malarial fever, or from my own personal increases in serum catecholamines, flickered against a truth within myself that, even that very day, I didn’t want to admit. This is all the simplest way I can explain that between what I observed in her, and what I experienced in myself that night, I had some kind of revelatory understanding about the struggle I had expounded upon in my writing earlier that very evening.

Here I was standing over my little patient, who I, especially unintentionally at that moment, really cared for deeply. Emotionalism has little place in medicine, though allowing myself a moment of it at an appropriate time seemed a healthy allowance, and I did quickly refocus. It sounds strange, but caring about someone can really impede your ability to help him or her, especially in an emergency. Our emotional nature as human beings can be a real liability. Certain types of emotional experience leads to the activation of structures in the brain which even cause centers of decision making and logical thinking to become inhibited; this is one reason why the professional and clinical “wall” really needs to exist between patients and care providers. But, back to Jackie, at the moment, everything was okay. I had my “holy cow, I didn’t know I loved you so much” moment when she was asleep, as I kept my eyes on her intently. A few moments later I sat right back down, picked her up, and started counting again.

What I realized that night as I stood over Jackie is that the “choice” I thought was mine to make, as I described that very day in the previous entry, appeared to me then as a naïve joke. Although I described several instances in my previous blog about how I felt apprehensive about allowing myself to care for these kids as much as I wanted to on the inside because it might not last forever, and how I had to accept the uncertainty and move along, I’ll say today that the idea that a choice exists in this matter is a shortsight. Me deciding to walk wholeheartedly into interactions with the children, or with anyone, I suppose, will end up being reflected in how I behave, and not how I feel. I can act one way and feel another, or feel one way and act another. I guess part of growing up requires doing just what needs to get done no matter what we feel, while simultaneously finding healthy and meaningful ways to be true what we do, in fact, feel.

However, It was comforting to gallivant carelessly in that delusion that I could put up an emotional defense against the inevitability of pain and loss, but that’s just not how my heart works, apparently. When have I ever been so powerful to have a say about whom I loved and whom I didn’t? When did I ever get a choice in the secret and mysterious decisions made in the longest fourteen inches on earth, between my head and my heart? I do pray that God will continue letting me guard what comes in and filter what comes out, but it’s a work in progress. I am so grateful that, however secret my own heart can be even to me, it is still like a compass: whether I spin around, take a different path, walk in circles, stand on my head, or travel halfway around the world, the largest needle on my heart always points North, in One Direction. He never leads me astray. And at the end of the day (or the middle of the night), what choice does a person have but to follow what they believe, and what they love?

My personal experience is that if I’m going to attempt to consciously mount an emotional defense against something on a long-term basis, outside the scope of having to ground oneself during a stressful situation that requires my focus, that such a defense will likely fail. I’m not Spock or Data from Star Trek; I am human, and I do have emotional vulnerabilities, even in the clinical setting. We probably all do. Times when I have been “emotionally immune” I have only seemed to be able to be so by an unconscious and unlikely unhealthy process. God gave us emotions as human beings, and I know that I get by many days by bringing him as much of my fear, joy, uncertainty, pain, and gratitude as I can. Some day there will be a day without pain and tears, but that day is not today, not on this planet. In the meantime I will continue to sort out the mysterious, challenging, hopeful, and beautiful matters of the heart one day at a time, with my feet on the ground, my brain still attached, and God as my guide. These matters always have a way of working themselves out.

As my quiet moment with Jackie ended as quickly as it arrived, she continued to stabilize, relatively, over the next few hours. Carla kept her with her from that point on so she could be monitored and cared for as a one-to-one. I took a nap, and she was doing a little better later, but it was short lived for her, and for me alike. Over the next few days I came back down with malaria myself and ended up on injections. Jackie declined again and began vomiting, and her diarrhea continued. She became dehydrated again, but not as severely. Thankfully I had maintained the IV (by protecting it with dressings, and flushing it with saline) and it was still patent even four days later when she needed it. I know in the States we would have tried to get another line in, but I wasn’t that easy, and I wondered if we would have had luck (or grace) like that again. By Thursday I was mixing my very first Quinine drip and Jackie and I got to hang out for half the day while I administered it and monitored her. That drip was harder to monitor because of the micro-drip factor of the infusion set was larger than I hoped (the amount of fluid delivered in each drop) and I had a tight range (between 8-10 drops per minute) I had to keep the drip at in order for it to be effective but not dangerous. Intravenous quinine can be lethal if administered too quickly, as it can cause QT-prolongation (an abnormality in the electrochemical interval on the heart monitor, reflecting activity of the heart’s conduction system itself) and arrhythmias even under normal circumstances.

Jackie on March 4th

Jackie on March 6th, with her quinine drip

Jackie receiving additional intravenous hydration

The day she was on a quinine drip especially rough because I really wasn’t feeling well, was discouraged by Jackie’s decline, and I knew our directors were really concerned about her. We discussed with the local doctor whether or not she should be admitted to the hospital. He explained that if her IV hadn’t been patent, if the drip couldn’t have been managed at home, and if Carla couldn’t subsequently have monitored her closely, that she would obviously need to be inpatient. In the United States this baby would have been in Intensive Care, no doubt. That day I really saw how much malaria can impair me, as I was trying to take care of a very sick infant who was also suffering with it, and I struggled. I prayed, and we both got through it. I am grateful for God’s help and for the compassionate support of my coworkers, especially that day.

Carla kept a close eye on Jackie for at least a week or two and gradually allowed her to be back with the rest of the babies. We did discover that she also had typhoid (which, yes, can cause fever, and could have presented similarly except that usually it does not make infants so sick so fast here) and as she was treated for that she continued to become well. Her appetite was knocked down for a while but after a few weeks she started eating well again. Just a couple of weeks after this whole ordeal, we saw her smile again for the first time, and might have cried a little bit.

So, March started, as it would proceed: with malaria, malaria, and more malaria. We had a change in climate – a week that was very rainy, and then many farmers were preparing their fields in the surrounding area – we had a surge in malarial episodes. That month we treated seventy-six cases of malaria in sixty-six children, as some of them needed retreatment. For one solid week in the middle of the month I was giving more than twenty injections every day – I’d line them up in the hallway outside sickbay, take them in one-by-one as Adam would hold them (as many of them would fight) while I’d administer the medicine. We gave out a lot of stickers that week. We were going through liters, and liters, and liters of ORS to prevent dehydration in the ones who were having bad diarrhea, but not vomiting, though many of them were. In the really intense week I felt like every time I turned around a kid had vomited or had diarrhea on the floor (mmmmm, aren’t you glad you decided to read my blog while having lunch?) In the end, every single baby got malaria except just a few, but none of them were as sick as Jackie. I was, if anything, hypervigilant and demanding about forcing fluids on the babies at risk for dehydration, and about aggressively rehydrating those who were still taking the bottle. Everyone here worked together to keep a very close eye on all of the sick kids. They all turned out to be “just okay,” as we say here. Thank God.

It is estimated that today, as happens every day in Africa, between 1,500 and 3,000 children will die from malaria alone[1]. As I’ve said in many entries, malaria is fatal if left untreated. It’s also estimated that more than a third[2] of all antimalarial drugs available in Africa are counterfeit[3]. I just want to take a moment to thank God that through donor support, and a reputable pharmacy, we have a reliable supply of antimalarial medication to cure our kids. The meds worked, and our sick kids got better. Even Jackie.

By the time the next Sunday had rolled around I was looking forward to an enjoyable, or maybe even relaxing, day. I was still a bit under the weather and had hoped to catch up on sleep, with the malaria. In the morning hours Carla texted me and let me know that one of the other tiny babies didn’t do well overnight and had just been brought to her by the staff with a chief complaint of “she looks like Jackie”. It was teeny Rael, just two-and-a-half months old, looking gaunt in the eyes, but still alert. She was definitely dehydrated, but was nowhere near as bad as Jackie had been. I happily took her into my room with a couple of armfuls of baby supplies and we hung out for the day. She was having bad diarrhea but thankfully only vomited once. I was able to rehydrate her orally and medicate her for the underlying malaria, and for diarrhea. She and I snuggled and watched Star Trek while she took ORS and formula, and then slept. As the evening progressed I noticed her starting to get warmer and felt that she had fever. It turned out to be another warm night – inside a teeny onesie and inside that muscle beating in my chest. She did very well, as did the rest of the kids. More than 150 injections later, and too many doses of Tylenol to count, One very Loving and Caring God came through for us yet again.

We all have moments when life startles us and causes us to step back, reassess, and confront certain realizations that hadn’t yet been brought into our awareness. Life catches us off-guard and lessons punch through to our hearts in ways that we don’t expect, don’t want, and don’t know how to handle. Loved ones become ill, circumstances challenge us, and demands placed on us by life can sometimes seem more than we believe we can bear. The power of our most intense experiences needs balance in our perspective: these experiences can consume us, warp us, and burn us, but they can also catalyze change in us, ignite a vast source of energy within us, and temper strength in us. Whatever the circumstance bringing to life the heat of our hearts, the Spirit has the power to move in us with a real fire, a real passion, and a real love, just to the extent that we allow it, in any situation. Our moment-to-moment, and day-to-day decisions can open our hearts to more of this power, or smother its welcome. I’m grateful that this Power is very real, and doing great work, here in Kenya.

Scroll down to the last photo to see Jackie in May 2014.