I was called to Casualty (emergency room) late one Saturday evening to evaluate a patient with a huge left-sided neck abscess. The patient was a young Somali man who spoke no English or Swahili and was obviously in great discomfort. He was lying with his left side down, drooling because he was unable to swallow, and could only open his mouth 1.5 cm. On exam I noted that his trachea was deviated dramatically to the right side of his neck.

He needed to go to the OR urgently to have the neck abscess opened and drained, but the question was how to control his airway (place a breathing tube in his trachea) and induce anesthesia safely for the procedure.

This is the type of clinical dilemma that anesthesiologists face on a regular basis – and like most clinical judgments, you often make a decision without knowing with absolute certainty that it is the correct one.

Ordinarily with this type of situation an awake nasal endotracheal intubation under fiberoptic guidance (placing a breathing tube through a nostril and into the trachea using a fiberoptic scope to visualize the trachea, while the patient is conscious and breathing) would be the preferred technique. But that technique requires a cooperative patient with whom you can communicate. And this patient was not cooperative, and did not understand the 2 commonest languages spoken in Kenya.

So Peter Bird (our chief of surgery at Kijabe) and I agreed that I would attempt to intubate the patient using a video-laryngoscope (a fiberoptic device that is placed in the patient's mouth and allows visualization of the pharynx and hopefully the vocal cords) and that he would be present to perform an urgent tracheotomy should I be unsuccessful.

We prayed with our patient - as we always do prior to surgery. And then had him breath 100% oxygen for 3 minutes (called pre-oxygenating the patient) in order to ensure that his functional residual capacity (the volume of gas remaining in the lungs at the end of a normal exhalation) was completely full of oxygen. This would allow him to maintain a normal blood oxygen content for about 5 minutes after he stopped breathing, and would give me the maximum possible time to intubate his trachea if I could not ventilate him by mask after induction of anesthesia.

While this was taking place Dr. Bird was prepping his neck and ensuring he had all the necessary equipment should he need to perform a tracheotomy.

We then rapidly induced anesthesia and I attempted to visualize his vocal cords using an old Glidescope (a type of video-laryngoscope).  It was difficult to visualize his glottic opening due to the distorted anatomy caused by the abscess. Fortunately, we were able to ventilate him by mask between intubation attempts – and on the third attempt I successfully intubated his trachea. 

Dr. Bird was then able to perform an I & D (incision and drainage) of the abscess and obtain a biopsy of the tongue.

We transferred the patient to the ICU as we did not think it safe to extubate him until the swelling in his neck had further resolved.

As is the case in many patients we see at Kijabe, this patient did not present until his disease process prevented him from carrying out the normal activities of life. He sought medical care only when he could no longer eat or drink. 

The biopsy that was taken in the OR revealed that this young man had squamous cell cancer. He was referred to an ENT physician for specialty care, but died several weeks later of complications related to his cancer.   

This is one of the hard realities of practicing medicine in East Africa. Many patients present late in their disease process, and we cannot offer them all of the options available in high-resource countries. 

But we are called to "walk by faith, not by sight". And walking by faith in this setting means offering the best care possible to those who need it. Not knowing if we will be successful in our attempts to promote healing, but trusting in the fact that we have a sovereign God; who calls us to persevere and to keep our eyes fixed on Jesus - the author and perfecter of our faith

Part of walking with these patients is not just helping them recover their health, but in the event that nothing can be done, it is to help the family process their grief. Please pray for this family, that their time at Kijabe softened their hearts to the gospel, and that God would bring other Christians into their lives.

CARING FOR THE VERY SICK

In East Africa tuberculosis is widespread and a master of mimicry.  It can affect any organ in the body, and has a variety of manifestations. For that reason a high index of clinical suspicion is required. Presentation can occur in the lungs, the central nervous system (CNS), the lymphatic system, the bones and joints (septic knee, osteomyelitis of the spine, etc), as peritonitis or as skin ulcerations.

Several weeks ago I had the opportunity to help care for a young man who came to the OR for thoracic surgery.  He had severe pulmonary tuberculosis, which included scarring in the left upper lobe of his lung and significant entrapment of the entire right lung.  TB had created a thick rind around the right lung that was preventing normal expansion and function. The patient had been started on appropriate medications for treatment of TB - but required surgery to free his trapped lung.

The needed surgery involved opening the right chest cavity and stripping off the material surrounding and constricting his lung.  In order to accomplish this safely the left lung needed to be ventilated with a high oxygen concentration, while the right lung was allowed to collapse - thus giving the surgeons the access necessary to perform the operation.

This is not a difficult anesthetic in the US - but there were challenges to performing it in Kijabe. We did not have all of the device options usually available for intra-operative lung isolation, we did not use invasive monitoring, and Kijabe hospital does not have an OR stat lab that provides rapid and repetitive arterial blood gas analysis.

We always pray for our patients after the entire team is assembled and prior to beginning the procedure.  Following prayer and induction of general anesthesia, we placed a 39 Fr left-sided double-lumen endotracheal tube under direct laryngoscopy, which permitted independent ventilation of each lung and specifically allowed right lung isolation.

Though the current standard of care is to confirm correct placement of this type of endotracheal tube with a fiberoptic scope, I trained prior to that technology being widely available - and so we confirmed placement using older techniques; a stethoscope and our physical senses.

The surgery was long but went extremely well and the young man is on his way to recovery.


This is the young man in the ICU the day after surgery. He was extubated, breathing without distress and smiling. His father was thrilled to see his son breathing comfortably and healing well.

It is a privilege to work with a team of professionals who can work together to accomplish excellent outcomes in spite of limited resources.

The phone call had come at a little after 4:30 AM.  I had somehow forgotten I was on ICU call and so was initially disoriented.  Who is this? Why are you calling me? The soft lilting voice of the Kenyan head nurse told me that a patient involved in a motor-vehicle-accident was persistently hypotensive (low blood pressure) following surgery, and was being admitted directly to the ICU from the OR. Would I come and see him?

And so at 5 in the morning I found myself heading-out to see a patient.  As I locked the door behind me I noticed that for the first time in weeks the sky was completely clear.  I paused just a few feet into the 5-minute walk to the hospital and looked up. Without a single cloud in the sky the stars were like bright hard diamonds on a black background; it was absolutely beautiful. The stars do not appear like this at home.  The many lights in the Philadelphia area reduce stars to barely observable overhead dots.  But on this clear night in Kenya I could see Orion’s belt low on the horizon and the Pleiades in their tight cluster were not quite directly overhead. As I looked up I also noticed that the smells of the early morning were incredibly fragrant. I found myself marveling at the beauty and multi-dimensionality of God’s creation.  

In the 5-bed ICU I found the new admission - a disoriented man in his early 30s who had been in a motor vehicle accident.  He had been the conductor on a Matatu (Kenyan bus).  Miraculously no one else had sustained significant trauma, but this man had terrible injuries to both legs. The left had been severely fractured and was now in an external fixation device to stabilize the bone.  But the other leg had been crushed and so amputation was the only option.  He had been drinking alcohol and chewing miraa (cannabis) prior to the accident and so his disorientation could have multiple etiologies.  There was no evidence of other injury on physical exam, lab studies, or x-rays; and no localizing findings on neurologic exam. So I was left to conclude that the need for physical restraints would be short-lived. I wrote up my findings, added some orders to those left by the surgeons, and after chatting with the nurses about another patient, I left the ICU. 

On the walk back the sky was already lightening to the east and so the stars were now quite dim.  I thought about the contrast between the night’s testimony to the beauty and magnificence of God’s creation – and the evidence provided by this patient of the fallen nature of that creation.  And I was thankful that we have a Savior who endured the cross on our behalf.

The gifts and the promises are amazing.  Forgiveness for sins (past, present, future), the righteousness of Christ credited to our account, adoption as sons and daughters, coheirs with Christ, the almost unfathomable promise of a future perfect relationship with our God and fellow believers in a new creation. 

The ultimate sacrifice was made on our behalf – but there is no regret. Instead we are told in Zephaniah 3:17 that God rejoices over us with singing. And in spite of the fallen creation in which we find ourselves we too are encouraged to be joyful. Nehemiah 8:10 tells us that “the joy of the Lord is your strength”. Isaiah 12:2 comforts us with these words - “Behold, God is my salvation; I will trust, and will not be afraid; for the LORD GOD is my strength and my song, and he has become my salvation.”  And Isaiah 61:10 states “I will greatly rejoice in the LORD; my soul shall exult in my God, for he has clothed me in garments of salvation; he has covered me with the robe of righteousness, as a bridegroom decks himself like a priest with a beautiful headdress, and as a bride adorns herself with her jewels.”

I do not want to seem disconnected from reality; Ginny and I are well aware of the trials and tribulations of this life.  We realize that “joy is a fruit that comes in its own season”.  Yet we also recognize that our trials are ‘light and momentary troubles’ in the light of eternity.  There is an eternal glory that far outweighs them. Praise God for our Savior - who for the ‘joy that was set before him endured the cross, despising the shame’.  Even now he intercedes for us at the right hand of the throne of God. 

We left Philadelphia on Thursday, July 3 and arrived safely at Kijabe, Kenya on July 5; we will be here for just over 2 months.  While we are here Rodger is filling in for Dr. Mark Newton - the only Anesthesiologist at Kijabe Hospital - and Ginny is working with the Infection Control nurse, helping her review and revise the Infection Control Policy Manual. Though we are scheduled to leave Africa in early September, we will return in the summer of 2015 to begin a 5-year commitment at the AIC Kijabe Hospital, where Rodger will partner with Dr. Newton, and teach and practice Anesthesiology and Critical Care Medicine.

In the 3 weeks that we have been at Kijabe Hospital we have seen that the needs are great and the resources limited. It is frustrating to see patients die when you know they would have survived in the US.  However, it is a privilege to work alongside so many dedicated professionals; and to realize that there are many patients who do survive because of the efforts of these physicians and nurses.

We are here at Kijabe without a car – and that means most of our travel - to the hospital or duka (store) or friends’ houses - is by foot on dirt roads or paths.  These roads and paths are incredibly uneven and rocky, and since Kijabe is located 7,500 feet above sea level, on the escarpment overlooking the Rift Valley, you are almost always traveling either uphill or downhill.  We would never have guessed how much work is involved in traveling in this manner! You must constantly be aware of where you are placing your feet in order to avoid twisting your ankle on a rock or in a rut or ditch.  And this significantly slows the speed at which you travel.  When we do come to an infrequent level stretch it is pleasant to be able to walk easily and turn your attention from the path to the beautiful surroundings.

These experiences made us think of Isaiah 42:16 - "I will turn the rough places into level ground....".  The prophet Isaiah (informed by the Spirit) looks forward to a time when God fulfills His promise to redeem this broken world.  We have in the past viewed this as being strictly metaphorical – but being at Kijabe has given us new insight into this passage.  In the culture in which Isaiah lived having to walk and transport goods on uneven ground was difficult, dangerous, and a daily reminder of struggle.

We are thankful there is a time coming when the brokenness we see in this world will be in the past and all will be made whole.  We have this assurance from the Word (Romans 8:18 – 23).  We know that the restoration of the creation will follow the revealing of the children of God; that the creation in fact “waits with eager longing” for this to occur. And all of this will take place because of Christ’s finished work on the cross.  As we share in resurrection with Christ and the transformation of our bodies - all of creation will be restored. The healing of the creation will be all encompassing; it will mean no more sick, severely injured and dying patients, and the end of our mundane daily struggles. God will indeed turn all of the rough places into level ground.