“Daktari, can you come to Casualty right away?”

“Daktari, are you around?  Can you come to casualty right away?”  It was Saturday morning and I was on call for the medical service, waiting for a page from my interns letting me know that they were ready to begin rounding on the medical ward.  At the time, I was sitting in my office trying to catch up on some administrative responsibilities after having been back at Tenwek for only a week.  I could hear a bit of anxiety in the voice of my fairly seasoned casualty clinical officer.  As I put on my white coat I asked, “So what is going on?”  (I really miss the days of getting a heads up radio call or a detailed triage report giving me an idea of what to expect when I see a patient!  Most of the time, things here are a complete surprise so when I am able to get a small heads up, I try to take advantage of it.)  “It’s a young guy who collapsed and now isn’t breathing.”  Alright…airway management first.  At least I know what our first steps of management will be.

When I walked into casualty about 60 seconds later, I saw two clinical officers (COs) working with a nurse to stabilize a crashing patient.  He was young (it turned out that he was only 36), with no signs of trauma or other outward signs to explain his condition.  The only history we had was that he was healthy and was found down and unresponsive.  (It is exceedingly rare to have a thorough or accurate history in casualty…at least not in the first critical minutes of treatment.  Sometimes it can take hours or we may never have a clear history.)  His blood pressure was stable but his heart rate was somewhat erratic and his oxygen saturation was barely hanging above 80%.  His lungs were clear and his pupils were only sluggishly reactive.  We still had no definitive answer for his condition, but at least a quick exam has helped to rule out some potential causes.  For now, our priority was to gain control of his airway.

I am continually thankful that my training program was so intentional about making every graduate an “airway expert”.  I have had more than my fair share of difficult, bloody, vomit-filled, distorted and seemingly impossible airways since arriving in Kenya and thanks to that training and God’s grace, there hasn’t been one that we have failed to secure yet.  While my COs were bagging the patient, I prepared the necessary equipment along with our nurse.  After several failed attempts by both COs, it was my turn.  Definitely not the easiest airway but using a bougie (a long blue plastic tube – an amazing donation) to assist, I was able to pass the tube.  After we confirmed tube placement, we mobilized to transport the young man to CT.  (I am still so incredibly thankful to have this technology available in our rural African setting!)  As the CT whirred to life, the top diagnosis I had given to a relative was unfortunately proven accurate…a bleed in his brain.  Later we found out that the patient had complained of a headache the day before, took some pain killers and went to bed.  He reported some improvement in the morning but then suddenly collapsed and never regained consciousness.  As I scrolled through the images, I saw the source of the blood…a massive aneurysm (a weak area in a blood vessel causing it to expand like a balloon.)  Surrounding the aneurysm was a significant amount of blood along with swelling of the brain.  In an ideal setting, a bleed of this severity would likely be fatal.  In this setting, it is a guarantee.

One family member was with us in the CT control room so I explained as best I could what had happened and the probable outcome.  As we waited for the rest of the family to arrive, I found out more about the man to whom I was giving a terminal diagnosis.  It turns out he is married, had been completely healthy, and has two young children (one is 5 years and one is 5 months).  These conversations are never easy and I hate them.  Who wants to be the individual who tells a person that their loved one is dying or has died?  My face will forever be associated in the minds of many with this type of devastating news.  I’ve been involved in delivering bad news for about ten years now (not counting medical school years where I was just an observer).  I’ve given so much bad news since arriving here in Kenya…far more than I would like to even think about.  Reactions typically vary from full out denial to anger to complete emotional collapse and a whole range in between.  I knew that this would not be an easy conversation to have or an easy diagnosis to accept.  Here is a young man only a few months older than I am.  Like me, he has no significant medical problems and he has a young family.  But now his family is about to be told that he is going to die.

I returned to the medical ward to continue rounding on our full census of patients.  When my patient’s wife and other family/friends arrived, I was paged to come back to casualty.  There were about 10 new faces anxiously waiting for answers and it was easy to tell which one was the spouse of my patient.  After carefully explaining his condition and poor prognosis, his wife asked me to lie to her.  It has happened before and each time I so badly wish that I could.  “Daktari, please tell me that he is going to be alright.  Tell me that he is going to make it!”  Similar to other instances, I could say no such thing and it broke my heart.  Each time I have to discuss unexpected death like this, I feel more pain than most families would ever realize as it reopens the unseen wounds that I will forever carry after Hannah’s death.

Over the next several hours more family arrived and they debated back and forth if they should transfer his to a specialist.  Pictures were taken and sent to a neurosurgeon who agreed with our diagnosis and prognosis.  The family continued to struggle with what they could/should do.  I wish I could tell you that he defied the odds and somehow survived.  I wish the deepest desires of that wife were met and her husband woke up.  But like so many other wishes made on so many other days in casualty, they did not occur.  About 12 hours or so after arriving at Tenwek, his brain became swollen to the point that it caused his heart to stop.  Knowing we could do nothing to save him, we just did our best to keep him comfortable in his last hours.

Death and suffering seem to be the norm here some days.  I’ve lost count of the total deaths I’ve been involved with since returning to casualty three weeks ago.  While there can be a numbness that develops as a protective mechanism from this, mostly it just hurts.  It hurts all of the staff when we see the pain of our patients and their families.  It hurts to know that so often, there is simply nothing we can do.  It hurts when you step into the lives of others at the most painful points of their lives.  But we are so privileged to do it.

Recently there was a tragic car accident in which a family lost two relatives (who were cousins to one another).  Later during that day, the mother of one victim collapsed under the weight of the loss.  Towards the end of the day, she seemed to be improving but I was told by family members that she was refusing to eat, drink, etc.  It seemed as though she didn’t want to or couldn’t listen to the many friends and family members who were surrounding her.  One of these people asked me what we could do to help her.  As difficult as it was, I felt prompted to tell her about Hannah.  I didn’t explain a lot.  Basically I just told her that no one could ever understand her pain or her loss but that I may understand more than most.  And I told her about losing my baby girl a few weeks after moving to Kenya.  While I could do nothing to remove her pain, she was able to listen and began to drink some milk.  I wish I could have done more.

I think I speak for most of us at the hospital (Nationals and visiting missionaries alike) when I say that although this job is difficult and often hurts deeply, we couldn’t imagine doing anything else.  We train for what seems like a lifetime to learn about diseases and injuries.  We learn how to combat infections, repair injuries and so many other things.  But here, even when we have no medical assistance to offer, we have the opportunity to be the physical presence of God to suffering people.  When we come to the end of medicine, technology and knowledge, we have the chance to step into the lives of others and show them love and compassion when they need it most.  It often appears that we are hopelessly losing the battle to save lives and improve outcomes, but even in loss there can be gain.  At Tenwek, we do our best to offer the hope that can only be found in Jesus Christ.  While most of you reading this may never get to physically visit our hospital, you too are an important part of our ministry and our mission to help a sick and dying world.  Steph and I (and the kids) all appreciate your prayers, financial support, letter/emails/notes of encouragement more than you will ever know!  We sincerely thank you for playing a part in this mission.

Prayer requests:

1.  Please pray for this family and others that have suffered tragic loss.  Pray also for those who care for them.

2.  Continue to pray for the Ebola outbreak.  While we are so thankful for the recover of Kent and Nancy, so many have been much less fortunate.  We are developing a plan here at Tenwek in case Kenya becomes another country to which this disease spreads.  Samaritan’s Purse is still holding off on sending in additional teams but remains active in sending supplies to the affected countries.  Please pray for Rick (an SIM missionary doctor who has contracted Ebola) that he could also have a full recovery.  Pray for protection of those on the front lines and that through this tragedy that many will come to know the saving grace offered by Christ.

3.  Pray for Tenwek as we continue to serve many, many patients.  Every day is a challenge as we never have enough space for those who need it.  May we always reflect Jesus in word and deed.

4.  Pray for interview season.  Over the next couple months we will have interviews for both CO and MO interns as well as for our residencies.  May we have clarity in choosing those people that God wants to serve at Tenwek.  May we also continue to grow in our discipleship of our trainees.  I recently was able to travel to Nairobi with several other consultants, residents and interns to represent Tenwek at the World Health Missions Conference.  We met many potential interns for our next classes.

5.  Pray for additional donations of funds and appropriate medical supplies.  Recently casualty received an incredibly generous donation of an IO drill and needles.  (A fancy drill that places a needle into bone for giving fluids when other lines aren’t possible.)  We recently had a baby girl come in looking as close to death as a living person could look.  (She was severely dehydrated from a severe case of diarrhea.)  There was no possibility of getting an IV but thanks to this donation, we were able to have fluids infusing within minutes of her arrival.  After only two hours, she was awake and alert (although still very weak).  She was even able to breast feed!

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Aaron Kelley

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