Friday, 1 June 2012

I'm Back

So I'm back in Kenya.  And have been for over 8 weeks.  I've just been appalling bad at blogging this time.  But, in my defence, it doesn't feel like almost 2 months have passed.
So...what have I been up to?
I'm back at Tenwek Mission Hospital working in the paediatrics department as a "consultant" though I feel my role is more like a registrar really as I have nowhere near the knowledge or experience to call myself a consultant.  The first couple of weeks were strange because just after I restarted here all the long-term missionaries left for a retreat at the coast, leaving the running of the hospital in the hands of the visiting staff (and the 1 Kenyan consultant, Matilda).  This meant that even more inter-departmental referrals of patients and discussions about patients occurred around the guesthouse dining table.  It's much easier than the official routes (ie bits of paper you fill in and fax) that you have to go through in English hospitals.  In the last 4 weeks we've had a large paeds department with 4 consultants (though one was meant to be mostly in casualty....) and it's been the most culturally diverse department with English (me!) and New Zealand blood to add to the usual Kenyan and American.  (We even had a Korean with us for a couple of days this week.)  
I've been here for almost 5 months in total so far and I've been contemplating recently about what I've learnt in that time.  I sure I've learnt lots about paeds just by doing it and learning as I go through and asking for direction when I need it (a lot!).  I panic much less with ill babies (mostly babies not breathing) in front of me.  Calling for help occasionally is for "moral support" as Dr Bemm described it at one point.  I think the things I've learnt more about are in terms of leading a team.  In the absence of "The Bemmster" aka "The Bemminator" often I end up being the one to lead the rounds and general organisation of the day.  This includes delegating jobs to interns (and sometimes other consultants, sometimes them to me) when there are many things happening (eg ill patient in casualty + delivery to attend + resus in nursery + morning ward round to do).  One of the strangest things has been giving feedback about the interns.  I'm used to being the one receiving the feedback, the exception being 360 degree appraisals.  And it's different being on the other side.  Especially when they are the same kind of age as me (sometimes older).  It makes me wonder what I would have said about myself in my house officer year (which does not really compare to what these guys have to do).  I think this also pushes me on because I start to evaluate myself more and, of course, come out worse than any of the interns, but it helps to push me on to do better or improve (I hope).  I've also been learning more about integrating my faith with my medicine.  It's much easier here.  I'm expected to pray for patients and it makes talking to them about bad outcomes or potential bad outcomes slightly easier.  In England holistic approaches are spoken about a lot, but often the spiritual side is missed out.  This is not necessarily just about Christianity or even God, though here it is.  I hope to be able to put some of this into practice in England within the confines put on us in this area.  I became a doctor mostly because I believe it's what God created me to be (and there was nothing else I wanted to do) and hopefully this experience is helping me to grow in that (though He still hasn't told me anything past my ST years - guess there's still a while to go).
Recently I've found out that I'll be starting my paeds training in August in Barnsley and have had to go through the form filling in that accompanies such things.  (It's not so easy when you're in a different country - praise God for internet access and scanners!)  This has made me think about what it will be like being an ST1 (SHO) in paeds in England after being here.  Dan Landi (a visiting paeds doc) was convinced that I would be bored.  Dino Crognale (a long-term family practice doc) commented that I'll probably be relieved/enjoy it (or something along those lines).  I was thinking more in line with Dr Crognale - less responsibility generally equals less stress and sleeping more easily at night - but I think it's probably somewhere in the middle.  I was thinking about this earlier when I was contemplating the fact that I am the senior doctor looking after a 5 month old with DKA in ICU today.  There's no way I'd be dealing with that by myself in England.  In some ways that's nice - less pressure/worry.  But less learning experience and less sense of achievement when it goes ok/well.  I feel a bit like I'm "playing" doctor here, but that's not really the case.  I think I'm doing more of what I thought doctors did than I have been doing at home (A&E being the exception).  Having the responsibility of being the senior on call definitely grows you (even if it could potentially cause my hair to go grey, curl up and die).  As does learning to run resuscitations and speaking to parents about the fact that their child is really sick/going to die/has died.  These are things that I see as the downside of the job, but they help to shape you.  (Though the sound of a mother's cry when her baby/child has died is like no other!)  The thing that does worry me about August is that I don't know much about the simple things and I'm unlikely to be diagnosing cerebral malaria, typhoid perforations and TB meningtitis (and if they occur I'm even less likely to be the primary person managing them) so I don't know if I'll be all that much ahead.  As long as I can spot a sick child hopefully I'll be vaguely ok.  (I'm using "sick" in the doctoring sense, not the lay person sense of "surely all patients are sick".  When we say "sick" we mean "really really sick" generally.)
I apologise for the lack of photos.  I have not put any on my computer yet, but I'll try to do a photo blog soon.
Tomorrow, I head for safari, meeting my dad and sister en route.  They will be boarding the plane as I'm typing this (assuming all's going well).  Looking forward to the break (including a day off on Monday - today is the bank holiday here and I'm on call).  It will be strange having them in Tenwek and probably strange for them too, being in a place they've heard me speak about on numerous occasions but never seen.
I'm just going to end with a few brief patient stories as I know that's what a few of my medical friends like to hear about.
I praise God for a few healings in patients we believed were pretty much past help.  3 involve probably TB meningitis.  One girl was in ICU when I got here and we didn't know what was going on with her at all.  She was very unresponsive and so we kind of treated for everything (bacterial meningitis, TB meningitis, typhoid, sepsis, cerebral malaria etc).  She walked out of here pretty much back to her usual self.  Another was boy I admitted during a (bad) Sunday on call.  I found out on that day that a traditional healing method for a cold is a uvulectomy (ie cutting off the uvula at the back of the throat).  He became septic post-uvulectomy and  very unwell with meningitis.  We expected that he would probably be bedbound with double incontinence and be nothing like his previous self.  I last saw him the day before discharge and he was sitting on his bed.  The next day he also walked out!  The 3rd patient is still an inpatient, but one that is slowly improving, though still has significantly neurological deficit from probable TB meningitis.  We are praying for his recovery and are pleased to see him get slightly stronger each day, though how much function he'll have left, I don't know.  There is also a baby in nursery who we'd completely given up on.  She was preterm and then kept becoming very ill with necrotising enterocolitis.  However, she's now been improving for the last couple of weeks and tolerating feeds and gradually(!) gaining weight.  She's by no means the sickest baby we have any more.  I heard her mum singing to her in the nursery today - one of those things that touches my heart the most is a mother taking delight in her child.
One patient who touched me the most was a teenager called Cheprono.  She was in and out of hospital for about a month with pneumonia and congestive heart failure secondary to rheumatic heart disease.  We would give her a full course of antibiotics and then a few days after they were stopped she would become ill again and be readmitted.  On one of my nights on call I got the dreaded page "bed 1 in room 204's condition has changed".  Despite the fact that the phone was put down before any of my questions were answered, I've been here long enough to know that's essentially a resus call.  Sure enough I headed up there to find a resus in full swing and took over leading it.  However, despite our best efforts we couldn't do anything.  Cherono, despite spending so much time in hospital towards the end and being so ill, nearly always had a smile on her face.  She was a strong Christian and in the day or two before she died she wrote about how she thanked God for watching over her and thanked the doctors for giving her medicines and looking after her.  She also drew a picture of the heart.  Her dad allowed me to take a photo of that piece of paper and it's one that in some ways will remind me more of this place than most of my photos.
I apologise for the rambling nature of this post.  It's been 8 weeks in coming....  (And my current facebook status points out that rambling is directly proportional to tiredness.)
Till next time......

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