Monday – The men’s ward, which had a few empty beds on Saturday (a rare event), was completely full again Monday AM when we started rounds. Anne, my intern, and I were the only two on the team today due to our CO being on vacation and our registrar off on other duties. Still the service was quite manageable in size and we had only a couple new patients to add on to our rolls. One gentleman in particular, seems to have a problem that is amazingly prevalent – obstructive nephropathy from an enlarged prostate. Like the 5L liter patient last week, this man had 3L in his bladder but it has been going on a long time and I’m afraid his kidneys are nearly dead at this point. His BUN was 96, his creatinine 9.1 (both 9 times what they should be). Dialysis is not an option in Kenya for chronic renal failure (for the average person, anyway). We catheterized him and hydrated him, hoping that he will recover enough kidney function to live, but he has been minimally arousable for the last 24 hours so I am not sure if we are going to see any improvement. This morning it appears by his bloody urine that he may have acute tubular necrosis (another bad kidney insult).
But, the challenge of the day was coming up – call night and covering the ICU was my main assignment. Charles was to cover the pediatric and adult medical admissions with the intern on call. The night was pretty quiet except for the one call from the newborn nursery. There is was a 1 month old who had been in the nursery since birth due to a very complicated course of airway problems due to a malformed nasal passage (choanal atresia) requiring urgent surgery on day one of life and 3 trips to the ICU due to tracheomalacia (a weak windpipe that collapses with rapid inspiration). A peds surgeon called me to say he thought the baby needed to be intubated and transferred to the ICU. I went down to assess the baby and she was fighting hard to breath past her retracting airway and was using every accessory muscle to breath. She also had a fever (new) and a stent placed in her left nostril that didn’t seem to be improving her breathing (since the problem was below that part of the airway). We made ready for the transfer to the ICU and I called Steve Letchford, the intensivist, for some guidance on how to use the pediatric ventilator and sedation protocols here. Steve said, “Man, wouldn’t it be nice to have one of the ENT docs that is here with a team for another couple days to take a look at this kid tomorrow?”.
I returned back to the nursery to get ready to move the baby. Standing above the baby was a very familiar face – Billy Giles. Ok, Billy is someone that most of my current friends and family don’t know. But Billy and I go way back – 1979-1983 at Wheaton College. Took most of our premed classes together – funny, wisecrack of a guy who was really sharp and a young man with great compassion and faith. Well, here he is at 9 PM at Kijabe Hospital, in the middle of nowhere, Kenya – a pediatric ENT specialist now, right where God (and all of the rest of us trying to sort this out) needed him. Ok, I was just telling Charles the stories of how amazing it was here when specialists with just the right skill set show up just when you need it the most. This little girl has a very rare defect, something that I’ve never seen before but read about.
Billy looks up and grins – we both just laugh at the odds of us being at this place at the same time in this situation. “Yep, I just pushed this stylet past both choanae and they are open so she can breathe fine through her nose but her lower airway is still the problem.” Billy, with his usual wry humor was just sliding this coated heavy wire in and out of this kid’s nose like it was going out of style. “Yeah, you want to be careful not to push too far and go into the brain”. Gulp…
After a lot of deliberation with the baby’s mother and 5 docs standing around this little 2500gm newborn, we decided her only hope was a tracheostomy (with all of the long term complications that entails in a 3rd world setting). We transferred her to the ICU –which caused her to get into real trouble for a few minutes – nearly had to intubate her but with some ketamine sedation, she calmed and breathed much more effectively. This morning, she is in the good hands of Dr. Billy Giles getting a new airway that will allow her to grow. Without it, a simple cold virus would likely have killed her. At least now, she has a fighting chance.