Vanovers' Travels: Why am I here?

Greetings from Kenya to all our friends and family.

Most years when we come to Tenwek there is that one special patient (or sometimes several patients) that seems to answer the recurring question: “God, have you really intended for me to be here”? I have spent much of the last week feeling like I wasn’t being particularly useful to the medical team, and again found myself wondering anew, “Why am I here”? While on call last night, I met the “reason” for this year’s trip. Her name is E.O. (to preserve her privacy). She is a 28-year-old Kenyan woman who had been healthy (to her knowledge) all of her life. She had never been under the care of a physician and had no significant past medical problems. Her family brought her into Tenwek last night (Tuesday) with the story that she had begun having difficulty with her breathing when she would try to do anything strenuous. This reportedly started about a year ago and gradually worsened, but she had never sought attention for these symptoms. About 2 weeks ago, she began to have more difficulty breathing, and had been rapidly worsening since that time. They reported that she was now having difficulty breathing even when sitting and resting, and was no longer able to lie flat at night to sleep. They also noted that her feet had begun to swell and that she was fatigued, weak, and lethargic. The family became concerned, and brought E.O. into Tenwek for evaluation…they had to carry her into Casualty (the emergency dept.) because she was no longer able to walk. On arrival, she was assessed by one of our visiting Emergency Medicine fellows from the U.S. Dr. Swanson was alarmed by her appearance, and noted that her BP was quite low at 70/40; he was able to perform a bedside ultrasound evaluation of her heart and found massive enlargement, as well as evidence of rheumatic valvular disease (severe mitral stenosis and mitral regurgitation for those of you in medicine, or for those just curious!). She also had a rapid heart rate and an irregular rhythm, which was aggravating her rheumatic valvular disease (atrial flutter with variable block to be precise). The mitral valve narrowing was making it difficult for blood to flow into her left ventricle, and the rapid heart rate meant that the time between contractions, during which filling of the ventricle could occur, was shortened. In all likelihood, this rhythm change may have occurred a couple of weeks prior, and “tipped her over” into fulminant heart failure with a reduced cardiac output. This is a very tenuous and critical situation for a patient with these valve lesions, with death occurring in a significant number of these patients. To complicate matters, there were no ICU beds, and no ventilators available in the hospital. My intern for the night had not previously dealt with this particular set of circumstances (nor had I, at this level of severity) and was having difficulty prioritizing the various aspects of her urgent needs. I found myself whispering a silent prayer (and not for the last time over the course of the night!) ….”Lord, now would be a good time to show up if you intend for E.O. to survive”. We set about attending to her most urgent needs, and trying to stabilize her blood pressure. While we were doing so, 2 of our other patients became unstable, arrested, and required our efforts at attempted resuscitation. Sadly, these resuscitative efforts failed, and there were grieving families to console. Meanwhile, E.O. had been teetering on the brink of cardiopulmonary arrest herself, but amazingly, had not done so while we were occupied with others. As a result of these patient deaths, one of the much- needed ICU beds had become available, and we were able to reserve it for E.O. A few hours after getting her into this ICU bed, she began to have more restlessness and more difficulty keeping her oxygen levels up. She began to struggle and fight against efforts to keep her oxygen mask in place. She began to exhibit “air hunger”… a frantic effort to keep breathing…and during this time, pulled out the IV catheter that was providing her with medications to support her blood pressure and to treat her rhythm disturbance. It was now obvious that she was going to require sedation, placement of an endotracheal tube, and support from a ventilator if she was to survive…but there were still no available ventilators in the hospital. As we were furiously calling around to different units in the hospital, we discovered that the operating theater was holding 2 ventilators for planned cardiovascular surgery patients who were scheduled for surgery the following day! We decided to push ahead and to intubate E.O, and to delay worrying about how we were going to support her till directly faced with the problem…at worst, we could “bag her” (use a compressible bag to force oxygen into her lungs through the endotracheal tube) until a ventilator became available. This generated yet another urgent prayer on E.O.’s behalf…. “Lord, I am only going to get one chance to get this tube into her airway, or she is going to arrest…please guide my hands, and spare her life…and, please make a ventilator available for her”….needless to say it has been years (thankfully!) since I have been in a similar situation, and I was feeling the stress acutely. My own heart was threatening to escape my chest, and yet, I felt with some certainty, that God was there with E.O. (and me), and did not intend for her to perish. During the intubation, I was not able to see her airway well, but the tube went into proper position with a single effort. Thanks be to God!! We now had control of her airway, and she was very relaxed after the IV sedation. Now what!? We had an intubated patient, but no ventilator!! The night nursing staff in the ICU began to rotate turns “bagging” E.O. This effort went on for about an hour, while we started making some calls and begging for release of one the reserved ventilators. In order to obtain release, I had to directly appeal to one of the on-call Kenyan cardiovascular surgeons. He was very gracious and listened to my patient’s story with great interest. He made a personal visit to the ICU (now about 4 a.m. local time) and not only approved release of the ventilator for her stabilization, but also promised to review her case with his cardiovascular team the next day. For E.O. to survive for any extended period of time, she was going to need surgical replacement of her diseased mitral valve. In the meantime, it was our job to “tune her up” to the best of our ability with medications and other forms of support. After securing a ventilator for her, and getting a central venous catheter placed (another long story which I won’t go into now!), we were able to administer her critically needed medications, and safely administer her much needed supplemental oxygen. She has been steadily improving into the early morning hours, and now looks as if she may continue to stabilize. The cardiovascular team has seen her, and will be putting her on their waiting list for a much needed valve replacement sometime in the future…I’m confident that it will happen if God wills it….I’m betting that He does. I don’t know what God has planned for E.O.’s life, and certainly she has a long way to go before she can be thought of as stable. I only know that I am thankful to have been led here… to have an opportunity to join God in the work that He is doing in E.O.’s young life. On Wednesdays (today) at Tenwek, all the medical and surgical staff gathers for morning devotionals. Here, a member of the hospital’s staff is asked to speak. Today’s topic turned out to be “Why does God allow suffering”? We were taken through the story of Jacob’s son Joseph, and how he was sold into slavery, imprisoned, and seemingly hopeless, only to emerge years later as a trusted advisor to Pharaoh, and ultimately a savior to the nation of Israel during a period of drought and hunger throughout the land. The speaker’s message was: “that which man intends for evil, God can use for own His good purposes.” The message that I heard was: “ we don’t always understand why God allows suffering to occur, but He often uses suffering for His own good purposes”. I trust and hope that E.O.’s suffering (as well as that of many other patients here at Tenwek) will only bring some future “divine good” into their often difficult lives. May that be true for us as well.

With love,

Randy.