It seems that episodes of profound discouragement are a regular part of the missionary surgeon’s diet. Day after day we toil alongside incredibly sick patients to bring healing, and too many times the outcomes are poor. Whether from patients arriving late in a disease course, or from underlying nutritional deficits, the outcome is often grim. Often these patients are children and their untimely death carries added sting. Other times, in our resource limited setting, resources are…well…limited. This past week I helped care for a patient injured in a car crash who required surgery for a bleeding spleen and liver. The team that operated on him did the right things and stopped the bleeding. However, after receiving 2 units of blood the blood bank was depleted. Hours after his operation he received additional units of blood, but the many hours of low blood pressure had taken their toll on the patient’s kidneys, lungs, and liver. A few days later he died from multi-organ failure.
Nevertheless, there are successes and at times these moments will catch me off guard by challenging my chronic discouragement and fatigued compassion. Recently, the critical care nurses at Tenwek put on a “Critical Care Day” to celebrate and draw attention to the some of the gains that have been made in providing care to the sickest of sick at our hospital. I arrived that morning tired from a couple of busy weeks of work. I was scheduled to give a lecture on how to care for the critically-ill trauma patient and anxious to get this done so that I could focus on wrapping up the work week. As the day unfolded, however, I was blown away by what the nurses had put together. Once again, Kenyan ideals of community and thanksgiving collided with my American ideals of efficiency and productivity. Thankfully, the result for me was unexpected joy in seeing God’s hand at work.
The day started in typical Kenyan fashion with speeches from numerous stake holders including a surprise speech from me (at least I was surprised). Hymns followed speeches, and a sermon followed the hymns. By mid-morning I was checking my watch so frequently that I began to wonder if my watch was broken and stuck on the same time. Following a obligatory chai break, which was now an hour overdue, the conference resumed. Time to get down to business. But before the educational part of the day could start, some additional introductions were made. Two patients who had survived major illnesses had come with their families to join in the celebration. Both of these patients I knew well and it is their stories that I want to share.
DL is a 10 year old who was admitted to Tenwek with acute pancreatitis. The exact cause was never clear- some thought it was “herb” ingestion. Home remedies from local plants are often used to treat illnesses in our region. Herbs are often toxic and it may be that DL’s pancreatitis was a result. Regardless, his pancreatitis was really bad and within a few days his abdomen was distended like a tight balloon to the point where he had difficulty breathing. Many liters of fluid were removed and analysis showed that it was pancreatic fluid. In a couple of days he re-accumulated and again the fluid was removed. This cycle continued on and on as a result of rupture of his main pancreatic duct. This made him quite ill. He couldn’t eat and he was in constant pain. Repeated attempts were made to use feeding tubes snaked beyond his stomach to provide nutrition, but even this resulted in vomiting. He was wasting away from malnutrition and we were forced to start nutrition through his IV. This is regularly done in the U.S., however, in our setting it has been difficult to safely and reliably use this form of nutrition for extended periods of time. But our team was incredible. The nurses worked tirelessly caring for this incredibly sick young man. Four surgeons from our team worked together, including our pediatric surgeon, the admitting general surgeon, and the two of us who work as critical care surgeons. I consulted with a hepatobiliary surgeon in the U.S., and a visiting gastroenterologist performed multiple procedures attempting to deal with the leaking duct. DL had all sorts of problems during his stay- the most alarming was a severe stomach bleed which resulted in such brisk bleeding that his heart briefly stopped requiring CPR. One day, 60 days after his admission and after I had returned from a short vacation, I came in to see him. He looked better but still wasn’t eating. We had tried many times to feed him, but his GI tract simply would not tolerate food. However, today something looked different. So, we fed him and this day, he kept food down. The next day he ate more. The day after that even more. Within 3 days we were able to stop his IV nutrition and within a few more days we were discharging him from the hospital.
The other patient who joined us at critical care day is PN. He is a patient who came to Tenwek with a life-threatening infection of his right thigh which required an amputation of his entire leg at his hip late one Friday night. This surgery is a highly morbid operation usually performed as an act of desperation to attempt to control infection. I took over his care as the surgeon on all on Saturday and we returned to the operating room to be certain that the infection was controlled. We discovered bowel contents pouring between the muscles separating the abdominal cavity from the thigh. So we explored his abdomen and found appendicitis which had perforated at its base on the large bowel requiring us to remove this segment of his intestinal tract. It was clear that this was the source of his original infection and what appeared to be a muscular infection of the thigh was in fact perforated appendicitis gone crazy. We found liters of foul-smelling pus around his right kidney and behind his liver. Over the next few days we made several trips to surgery to control the infection. The infection also spread to his right chest cavity which eventually required us to take him again to surgery to wash out his chest. We found extensive infection of his chest wall and it was clear the this was a no-win situation. Instead of proceeding with what would have been a radical debridement of his skin and soft tissue we decided that the situation was futile. The infection seemed to be beyond what we could treat. Chaplain staff visited with him. He re-affirmed his faith and was even baptized while he was in the ICU. We kept him on antibiotics but expected him to pass at anytime. Two weeks later, we were still rounding on him. Bewildered, I chose to change course and to step up our care. No longer were we simply doing “comfort measures.” A couple of our residents labored to be certain that he was getting adequate nutrition. Within a week PN was gaining weight and looking better. Ultimately I took him back to surgery for a thoracotomy to clean out the residual infection in his chest. A week after this, all of his drainage tubes were removed and he was sent home. PN maintained an incredible spirit throughout his entire stay. Our entire team noted his persistent smile even during the worst times. He shouldn’t have lived, but here he was now talking to us in a conference expressing his gratitude to God and the critical care team for seeing him through such a difficult situation.
Watching these two families and seeing these patients now fully recovered and living their lives filled me with gratitude to the point were I was almost overcome with emotion. I was not alone. Our critical care nurses were proud. Residents who had cared for these patients came by to see them for themselves. The consistent comment was: “That’s amazing. Look how fat they are!” All of us knew that something special happened here, and for me it was a shot in the arm that I needed. Afterwards I started my lecture- the thing that I thought would be the point of all of this. But by the time I started the first slide, I knew that it wasn’t.
Our family has spent 4 of the last 5 years at Tenwek, and I must admit that for me the thrill is gone. The victories often feel few and far between. We try to rationalize away the pain and sorrow by discussing our failures and creating action plans to improve “the next time.” We pray for God to be at work, recognizing clearly that true change is beyond our human abilities. But while I was lost in this struggle, our nurses, through their cultural values of relationship and thanksgiving, brought to light moments where they have seen God working. I had failed to see this as clearly as I should have. But as the day wrapped up, I left grateful for the work being done at Tenwek and for the opportunity to be a part of it. Most of all, I was grateful for the outcomes of these patients and to see their lives restored.