A tale of 5 watoto (31/12/15)
We celebrated our fourth Christmas in Kijabe this year. I had arranged with the pediatric team to work full-time caring for babies and kids for the Christmas week so that we could give some of our other clinical staff the holidays off. A week, including Christmas Day, on the wards, nursery and ICU. It was, as always, a season of comfort amidst grief, a season of joy.
I meet baby J on December 22, born after a difficult labor – during the birth she has inhaled her own stool. We hope some oxygen will be enough to help the lung swelling and pneumonia, but as her breathing becomes more laboured, by 9pm it is clear she needs intensive care. I already know the ICU is full – no empty beds, no available ventilators. I run there anyway to see if anyone is improving enough to give me their bed – and instead see a surgeon closing a patient’s eyes, dejected – she has just died. I feel relieved – a bed is open! – then guilty – how can I feel relieved that a woman has just died?
I put my emotions away and quietly ask if I can bring a patient up to use that space. I am told – maybe in 30 minutes – so I change the ventilator settings and tubing from middle-aged lady-size to 2.5kg baby-size as the nurses prepare the body next to me for burial. I run back to nursery and we place a breathing tube, then for an hour pump oxygen into the baby’s lungs while a grieving family upstairs says goodbye to their daughter and sister. At 11pm we push the baby’s incubator upstairs, start several medications and infusions and pray.
Four days later, her lungs are recovering, she no longer needs the tube, she breathes alone and goes back to nursery.
Life, after death.
S, a 7 day old baby girl, comes in on December 21 with difficulty breathing. Her lungs sound and look fine – so we suspect her heart has a problem. We do an ultrasound, and from the pictures, suspect a fatal condition in which a baby’s heart has only 2 chambers, not 4. As I consult with our other clinicians, we realise that 0f the 40 children and babies in the hospital at the moment, we suspect serious heart problems in 10 of them. I call a private cardiologist in Nairobi, who agrees to make the trip from Nairobi to Kijabe on Christmas Eve day and look at all of these hearts with her echocardiogram and skills and confirm our suspicions.
She comes, and of the 10 babies and children we ask her to see, 9 have serious heart conditions: aortic coarctation, mitral regurgitation, pulmonary hypertension, pericardial effusion, cardiomyopathy.
Baby S’s is the worst. I sit with 4 of her family members and explain that her heart has not formed properly – a single ventricle with truncus arteriosus – and would require 4-5 surgeries in an expensive private hospital over months to work at all, at a cost of thousands of dollars – and she would be unlikely to survive all of them. I tell them gently that their daughter and niece will die in the next 1-2 days, and I recommend that we let her go home to pass away in peace. The family asks a few questions. They thank me. They ask me to record an audio summary of our conversation on a smart phone to send to their uncle and sponsor in the Middle East.
They take her home to die.
N is a 7 month old boy who comes with a tumour on the spine. A tumour which, in a resource-rich setting, should respond to chemotherapy – but in Kenya there are only two government hospitals that do chemotherapy, and the waitlist is so long that most children don’t start their treatment until far too late and succumb. Tentatively, we accept him as our second-ever pediatric chemotherapy patient at Kijabe hospital. He successfully receives his first rounds of chemo, and the “roadmap” of the next 6 months of treatment, and goes home to return next month – with hope.
Life, when a death sentence seemed certain.
P is a sweet boy treated successfully at Kijabe Hospital for hydrocephalus: water on the brain. 11 years ago at birth, a pediatric surgeon placed a tube (VP shunt) to drain the extra water from his brain to his abdomen and he grew and thrived – walking, talking and doing well in school, a success story of East Africa’s only children’s neurosurgery service.
Until 4 days ago. He experienced a headache followed by progressive unconsciousness – signs of dangerously high pressure in the brain due to a shunt malfunction requiring emergency surgery. But his grandmother lacked the $1 for a bus fare to hospital – and so when he finally arrives on day 3, the damage is done. Urgent surgery replaces his shunt and we hope and pray. But as we do rounds on Christmas Eve day, he suddenly stops breathing, needing full resuscitation.
We place him on a ventilator, but it becomes clear that his brain is damaged beyond hope and the machine is the only thing keeping his heart beating. A grieving, keening grandma agrees with our choice to stop the machine and let him go. A chaplain comforts and prays with her and us as 11 years of precious health end.
Death, after 11 years of possibility.
Christmas day, as we get ready to join another family for lunch at 1pm – a phone call. A baby has just been born and, while breathing, is silent and floppy. I drop the cheese ball I am preparing, grab my bag and run to the hospital – I phone as I run, what is the heart rate? are you giving the baby oxygen? Heart rate is fine, yes we are. I arrive and now the baby is crying, and moving. The midwife and junior doctor have done well without me – the newborn girl squalls but is still shell-shocked from the rude awakening of a c-section. Over the next 2 hours she becomes feisty and vigorous.
Life ensured by a well-trained nurse and intern.
These babies and children are a handful of the precious lives in our hospital as I covered pediatrics over Christmas week. Tidings of comfort in the midst of grief. Tidings of joy.