Birds and Blankets

Swallows nest under the eaves of the new surgical theatre as well as the OB ward. In the afternoons they come out to swoop around in intricate aerial dogfights with adversaries I cannot see. While they swoop, some so close as to make me believe I can feel the breeze of their passing, they make this incessant chatter; as if congratulating each other on their expertise.

There are numerous birds at Tenwek; African Robin, Crested Bulbul, Superb Starlings (no, I am not kidding), Weavers, Sunbirds, as well as a bird who serenades me at breakfast with a one note song which seems to repeat every one second, like a metronome.

The most sinister of these birds is the Black Kite, usually a scavenger. However, I have noticed that when the long sharp-winged shadow of the Kite drifts silently over the grounds, all the small birds seek shelter. The Kite, a trim small raptor, sails silently in the blue skies, barely ruffling a feather, solitary stolid and deadly., reminding those who are able to hear, that sudden death is always at hand.

It has been a difficult week. The rains and the fear of famine continue. One of the patients on the ward has been abandoned by her family after she was admitted for a serious fracture. The father apparently has a drinking problem, the girl’s mother has run off; he is subsistence farming while squatting on a Maasi preserve and it appears has no intention of retrieving his 9 year old daughter, now completely healed. The nurses have set her to work distributing meals but she may be found almost anywhere on the grounds in her cast-off green skirt and Manchester United rugby jacket. Last night we admitted a girl in congestive heart failure, unable to breathe, wasted, and cold to the touch. She is better this morning after restarting the medications her family had stopped due to cost. An infant was sent in with three contradictory diagnoses; unfortunately missing the major heart defect which would kill him two days after he arrived here. “In many words, there is little wisdom"

Another girl came in with a bloody nose...which refused to stop even after we gave her blood. Her platelets, the small particles which provide the "thumb in the dike" when bleeding occurs, are dangerously low. I did a bone marrow for the first time in 30 years and was walked through doing a biopsy as well. The results suggest she has a chronic viral infection destroying he platelet-making cells in her bone marrow. We have no treatment.

A two year-old with a large heart on Xray was admitted for congestive heart failure on treatment from a district health center; she responded to none of the usual treatments and her physical was wonky, none of the expected heart murmurs. I was able to abduct the OB ultrasound machine under cover of darkness and do an exam showing her heart is not floppy and dilated as expected but rather thickened and "muscle-bound." We stopped the meds she had been on two days ago; she is now able to breathe better and is in room air. We returned the machine before it was missed.

The nursery staggers on. Of the 9 deaths we have had since I came, all but two have been associated with major failures of temperature control. This seems too trivial to most people but careful control of the temperature of the environment for premature infants was the first intervention to show that mortality can be decreased by medical care. That study was done in the early part of the 19th Century with the (then) new technology, the mercury-glass thermometer. It is difficult to convince people that the mundane business of newborn care, what I call the “housekeeping” functions are the things that make the difference in survival.

A high school acquaintance who I have not talked to in 44 years started writing me in Facebook (yes, I confess, I Facebook). I was describing the mission and he asked if he could donate something and while I was hemming and hawing about what little space I had, he suggested “Space Blankets,” the thin silvered Mylar sheets used in emergencies to reduce heat loss. I think it was a brilliant suggestion. The day before I left the package arrived and I used the 250 little packets for padding. Each sheet can be cut up into individual 24 x 13 inch sheets which can be used to swaddle small infants in the largely unheated highland homes at night. The man is a genius. Who woulda thought Timmy Cahill would turn out so well?

I was called to a delivery last night. A mother had been laboring at home for two days and came in exhausted from the effort. She eventually delivered this limp, blue, non-breathing infant with a scant slow heart rate. The mechanics of resuscitation are pretty routine and I started to breathe for him after clearing his airway. He responded very well, his heart rate jumped up, he turned pink, his pulses became strong and his tone improved somewhat. He would not breathe on his own, however. Each time I tried to “let him solo” his chest showed no sign of movement. His legs remained floppy and his eyes seemed to stare fixedly from his head without moving. After 50 minutes of hand-bagging the baby, I called the code and pronounced him dead. The sun was just coming up as I left the OB ward and heard the start of the high-pitched wavering ululations of the mother’s sisters and aunts as they learned of the son’s death.

Stepping out into concrete grey walkway in the soft light of dawn, I glanced up to see the Kite drift silently on the morning updrafts; his shape a featureless black against the morning sky.

As I walked back to my quarters, I also heard the swallows in their nests making the noisy chatter of their small lives, tucked into the eaves of the hospital ward; calling out rebellion to the silence of the grave