Adventures of an American RN in Kenya: A Sad End to a Sad Week

It's been a rough week. The patients on medical ward seem to be more critical lately. There is so much suffering, and I sometimes feel so powerless to help anyone.

But this week I am also grateful that my grandmother at home, who underwent surgery and was in critical condition a few days ago, is alive, doing better, and showing a better prognosis. Before surgery, her breathing was labored and she had to be intubated in the ICU. While it was difficult not being there with her and the rest of my family, I am so grateful that she lives in a place where people have access to life-saving equipment such as mechanical ventilators.

Today I lost yet another patient, this time to meningitis. Had we had access to a mechanical ventilator, we might have been able to save his life. In the late afternoon, the patient’s relative called me to the room to look at his swollen abdomen. But what worried me when I saw the patient wasn’t his abdomen, but the fact that he was coughing on his own saliva and was barely breathing. I immediately set up the suction machine (which barely works) and cleared his airway. I then checked his oxygen level, which was a staggeringly low 45%, possibly the lowest I’ve ever seen. We are running very low again on oxygen, so I had to remove the oxygen from another patient who was less critical and give it to this man. By this point he was only taking a breath a few times per minute.

I had already informed the other nurses, but not one of them came to help. It wasn’t until I asked one of them to bring a replacement suction machine that anyone came, and she didn’t even set it up; just left it next to the bed and took off. I ran to the phone and called for a clinical officer to come quickly and see the patient. I knew it was unlikely we could help him, and yet he still had that strong pulse and a stable blood pressure, and if we could just identify the cause of the respiratory depression, just maybe we could reverse it. Maybe it was a simple metabolic imbalance? Or a possible reaction to the antibiotics? The clinical officer arrived, and could offer little help or explanation. The only possible explanation he could come up with was that the blood sugar might be low. That seems to be the only explanation that the clinicians can ever think of, but it’s rarely ever the case. So we checked his blood sugar and it was of course normal. It was now clear that the patient could no longer breathe on his own, and yet he still had a strong pulse, so we began manual ventilation with the mask and bag. The clinical officer said we should just stop. But with the manual ventilation his oxygen was at 95% and his heart was still going strong. I wanted to at least have an explanation for the respiratory failure before we just gave up. I asked him to call the physician on duty to come see the patient. He phoned and said he would come in a few minutes.

It was more than a few minutes. For 30 minutes I manually ventilated that man. Whenever I stopped to check if he was breathing on his own (which he wasn’t), I saw his oxygen levels immediately begin to drop. What a strange and terrible feeling to know that your hands are the only thing keeping someone alive. During this half hour, still nobody came to help me. There were two other nurses in the room, but they didn’t seem at all concerned. In fact, at one point both of them came over to me: one to remove the BP cuff from my patient to use elsewhere, the other to take the thermometer that I was using. Neither said anything about the patient dying in front of them. I was so frustrated. Doing manual ventilations is extremely exhausting, and I lost a good bit of sweat over that man; I would have really liked a little assistance.

When the doctor finally showed up, he assessed the patient but said that there was little we could do. I still wanted an answer. What would cause a patient to lose his respiratory drive? He said it was possible that the intracranial pressure had increased as a result of the meningitis and lead to respiratory depression. I asked if high dose steroids would help, but he explained that it takes a long time to work. Steroids might have helped prevent this if given earlier on, but not now… would have been nice if one of the doctors had thought of that when he was admitted. And so we stopped. I left the oxygen mask on him, hoping to at least ease his suffering in the last minutes of his life. I instructed the nurse to return the oxygen to the other patient after this man died, and then I went home.

The patient had a son, about my age, who spent a lot of time over the past few days at his father’s bedside. He wasn’t there today. It makes me so sad to know that he will come back to the hospital and have to learn that his father has died. I spent a bit of time at home after work reading up on meningitis. Maybe we can identify these problems sooner in the future.

Now that that story is through, I should end on a happier note, so I’ll describe my Christmas in Mutomo…

A couple days before Christmas, the hospital was decorated up and down the main corridor with silk flowers and poinsettias. Near the front of the corridor just outside the pharmacy was a nativity scene, lit up and decorated with green branches gathered from outside.

On Christmas Eve there was Mass at church, all done in Kiswahili. In typical Kenyan fashion, the 7pm service started at 8pm, so I waited a long while. People afterwards were laughing at me: "You didn't actually show up on time, did you?" The church was decked with ribbons and banners, and another large nativity scene. It really was a beautiful sight. The music was not the familiar Christmas carols we are used to at home, but the lively and festive Kiswahili hymns, accompanied as always by drums, clapping, shouting, and dancing (see the previous blog entry for a video). During communion the electricity went out, but flashlights were immediately brought out and the celebration continued.

Nicholas, the cook, posing with Pope Francis.

After the service I had a quick cup of tea and some chocolate bars with the sisters at the convent. They were all exhausted from a long day and went to bed early. The priest was also hosting a gathering at his house next door, and so I joined them. Everyone visited with each other while enjoying sodas, popcorn, and mandazi (a triangular-shaped fried bread which tastes kind of like a doughnut). For a little while we watched the midnight Mass with the pope in Rome on TV… this was the only chance I got to hear the Christmas Mass in English.

The Sunday school children performing on Christmas morning.

The next morning I went to church again, also in Kiswahili. Afterwards, the children from the Sunday school program put on a performance of singing, dancing, and reciting poetry. It was all in Kikamba, the local dialect, but still very enjoyable.

Christmas supper with sisters Mary, Jeniffer, Esther, & Stella.

In the afternoon I had a bit of rest before another dinner with the sisters. We had a feast of chicken, rice, sukuma wiki, and chapatti bread. Then one of the sisters pulled out the party crackers. We have these at home sometimes, but I’ve never enjoyed them so much as I did here. We popped them open and were rewarded with party hats, toys, and jokes (which weren’t very funny). The party really started when I took out my camera and started taking photos. As with most Kenyans, the sisters put on their serious faces for the photos, until I told them they had to do it “the American way” and smile. They found this amusing and eventually got really into it. “Take my photo, take my photo!” they kept asking as they arranged all their props and put on their party hats for a pose. I then set up the camera on a tripod and put it on self-timer for a group shot. This impressed them all very much.

The next day, Anastasia (my housekeeper/cook) brought over a chicken as a Christmas gift. She raises chickens at home and tells me she has about 50 of them! The bird was alive when she arrived. It was funny to walk into my kitchen and see it sitting there with its legs tied up. I watched with fascination as she took it outside, killed it, and then brought it back inside to put in boiling water for defeathering. As I looked at the carcass sitting there leaking juices next to my kitchen sink, all I could think of during this process was that I needed to boil water to sterilize my countertops after she left. Despite my concerns of sanitation, the chicken was delicious (cooked in a stew) and I was very grateful for the gift. I don’t know which I enjoyed more: eating it or watching it being prepared. As fascinating as it was to watch, I don’t think I’d enjoy killing my own chickens; I’ll stick with the pre-killed and defeathered birds from the supermarket.