A surgeon's secrets on picking the right surgeon

A surgeon's secrets on picking the right surgeon

Picking the right surgeon is not an easy task. A friend's wife was recently diagnosed with cancer and ended up with a surgeon they couldn't communicate with. Thankfully, they moved on and things have turned around for them, but picking the right surgeon sure would have saved them some heartache and frustration - especially at such a difficult time as this. 

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A hike up to Motigo

I was happy to welcome an uneventful Friday- full of surgery, but not full of death or despair. Funny, how the past few days made a huge thyroid (bigger than we see them in the States) seem like a routine case. After Saturday rounds I gathered some fellow visiting doctors and we headed across the river and up, up, up. Our goal was a rounded hilltop called Motigo that offers 360 degree views of Tenwek, Bomet, and the surrounding areas.  The walk was a slow ramble, Kenyan style, where we stopped all along the way to interact with the locals. Lots of kids - some of whom were afraid, but most delighted in our attention to them. One little girl was so excited to see us she came running to the road's edge with no pants on! Several of the kids asked for "sweets" - an unfortunate side effect of prior white visitors passing out candy. Yes, it makes the kids happy but it also associates white visitors with handouts. Passing out sweets also makes life difficult for the full time missionaries at Tenwek. An evening walk with a spouse can turn into a mob scene as local kids beg incessantly for "sweets."  So, we resisted the urge to play Santa Claus and simply offered friendly handshakes, hellos, and their favorite - "snaps!" The kids don't understand that we want them to smile, so they'll get real serious for a picture, then laugh in delight when we show them the result on the camera screen.

Along the way, we met a furniture builder whose shop floor was 2-3 feet deep in saw dust and shavings. Cypress was his main wood as he was working on a reading desk for one of the Tenwek doctors.  Large tea trucks passed by on their way to tea collecting stations where locals sell fresh picked tea leaves in 40 pound bags to the trucks. Tea is the largest crop, grown in rectangular fields that make the countryside look like a patchwork quilt. The pictures just don't do justice to the beauty of this place. Tea turns into chai - a national obsession made of black tea, milk, and sugar. It's deliciously addicting and unique but not as spicy as the Starbucks version. In English fashion, work days are interrupted for chai breaks, social gatherings are centered around sharing chai - in fact, the girl without pants invited us in for some chai! 

We relaxed for a while at the top and soon found out that behind us about 20 curious kids had gathered out of nowhere to stare at us. They were terribly camera shy, but eventually they loosened up and in the end, delighted at their own images. While the trip up was mainly a wide dirt road, we took some shortcuts through the tea fields on the way down. A chameleon made for a short break near the end of our 4 hour journey. At the bottom we passed a large group of women who stared with wide eyes at us. As we passed, we could hear the clicking of camera phones. When we turned to look, the whole group had stopped and turned to watch us - now I know how the bison in Yellowstone feel! Back at the guest house, our tired legs were welcomed by a chicken curry lunch, finished off with what else? Chai!

A double dose of deadly delay

A tough, sad day with hard lessons to learn

Today was filled with a double dose of deadly delay. There are some statistics in medicine which you believe, even memorize, but never anticipate that you'll actually experience them. One of them concerns the large salivary glands in your cheeks called parotids. Tumors found in these glands are benign 80% of the time, but we remove all those benign tumors for one main reason: if left long term they can transform into a cancer that will kill you. So, we remove these benign tumors despite the fact that the surgery poses a risk to the facial nerve. Additionally, there are some specific surgical do's and don'ts that are critically important. So far in my career, I've removed these tumors, followed the patients closely afterwards, and have never seen the cancer that I learned the statistic about - until today. 

Seno's first parotidectomy showing facial nerve branches nicely preserved after tumor removal

Each year when I come to Tenwek, they assign a surgical resident to me to allow me time to train them in head and neck surgery. This year, a very talented and extremely bright fellow named Seno is by my side. Yesterday, I took him through his first parotidectomy. The facial nerve was carefully dissected, the tumor removed and she was smiling without weakness this morning. Praise God! Good job, Seno! But, today's news would not be so good. We began the same operation on another lady, but this time it was a revision. She'd had the tumor removed 13 years ago and recently noted a recurrence. A FNA biopsy pre-operatively suggested it was a benign recurrence. As hour after hour ticked away in the OR, it was becoming apparent that today would not be a surgical success. The branches of the facial nerve could not be separated from the tumor - not by Seno, then not by me. We took some biopsies to confirm our suspicion and closed up her incision leaving massive tumor behind. Within the hour, our biopsies confirmed the worst - the tumor was a cancer, one that can't be surgically treated. Perhaps radiation therapy will give her a small chance to live- provided she can raise the funds, make the 4 hour journey to Nairobi, and complete treatment. There's no Medicare or Medicaid here, so if she runs out of money, they simply will stop her treatments. Perhaps if she'd had adequate surgery the first time, perhaps if she'd had routine follow up surveillance, perhaps if she'd been warned about recurrent tumor, perhaps if she'd seen me five years ago on my first trip to Tenwek instead of delaying until my sixth.

Parotid tumor recurrence that would prove unresectable.

In the afternoon I saw a fellow who presented to the ophthalmologist 3 months ago and was told to follow up in surgery clinic with a CT scan. He went home to raise the money - about $70 US equivalent -and didn't return until today. The small tumor noted in May was now massive. The pictures are too gruesome for public display - his left eye gone and in its place bulging lobes of cancer protruding from his face. His mouth will barely open because the tumor was invading his chewing muscles. Nothing can be done, not here, not anywhere. His delay removed any chance we had for surgery. He will die soon, maybe a month or two. He wears a baseball cap with a scarf draped over that half of his face. His one remaining eye and the half of his smile that still works tells me that this is a likable fellow. My job today was to tell him that he won't be cured. It's not easy to say, not easy to remove all hope - but one thing prevents this from being a tragedy. He believes in Jesus Christ which allowed me to assure him that his healing will come. Not today, but soon; not here, but in heaven - where a God who sacrificed his Son for him will greet him with loving arms - and he will smile back with a perfectly healed face. 

Another African Adventure Begins

39 hours is a long time to do anything continuously, especially sit. I don't recommend you try anything for 39 hours. My entire back side was screaming for a break, but at last we were in Kenya! Five hours of flat sleep and I'd be sitting for another 4 hours prior to my arrival at Tenwek. This is my sixth trip to Tenwek hospital where my mission is to teach head and neck surgery to training African physicians. This trip was a long one, but I have a daughter along to sweeten the ride.  Allegra and I arrived Monday afternoon and the excitement began.  They had been expecting me earlier and had OR cases ready but had to postpone when I was delayed. A quick set of rounds, an evening walk to the Tenwek falls, dinner and I was ready for some shuteye. The power then went out granting me a nice quiet long night's sleep - ok, it really doesn't work that way over here! Yes, the power was out but at 2:30 am the fire alarm started it's warning beep every minute that the power was out! That lasted long enough to fully wake me up and fight jet lag insomnia for an hour or so, only to have the beeping return around 5:30. But it was still better than most residency nights. 

I spent today in clinic seeing an incredible variety of pathology. While thyroid surgery is my specialty, they were keeping them off my schedule because of the large number of highly unusual cases of a more demanding nature. They did put one enormous goiter on for later this week - but all the small stuff (which was bigger than anything back home) was postponed for later. Best of all, nearly everyone we saw had some hope of healing. There were two who face grave prospects, but for an entire day in clinic here, that's quite good. I'm here two weeks and we could have booked three weeks of surgery today - so lots of teaching opportunities await! I feel blessed to be back here, blessed that so many warm, familiar smiles were here to greet me, blessed that God would use me for his purposes. I hope to share more if the internet connections hold up. There should be lots of good stories to come!

Dear Panera Girl, I have news!

When you saw me a couple months ago you brightened my day with a simple compliment. You looked past my braces to compliment me on my smile that was slightly hidden underneath that hardware. I'm happy to report that I'm now free of braces and loving it!  

In my practice, I strive to treat patients like family, like I'd want to be treated. While my practice is far from perfect, I think we do pretty well. But sometimes I come across someone who really has it all together. My orthodontists, Paul Tran and Kristin George, are examples for me to emulate. My experience as an adult going through treatment couldn't have been better. Literally, I can't think of a single thing that they could have done better! And I'm a critic! I spend a lot of time thinking about the patient experience and how to deliver quality care with compassion and understanding. This is a practice who has it right. It's not just the doctors, it's the whole team who makes it work so well. So, Panera girl, I will be smiling a little more often now!


(formerly crooked teeth) Keith



Would you go to this game?


Imagine you're invited to watch the big game. The ticket is free and you have no conflicting obligations to keep you away. 200,000 people will attend! But, there's one small caveat - at this game, it's been determined that there is a 100% probability that one person in attendance will die from bullet wound to the neck. Yes, there is an assassin who will shoot one person and one person only. The shot will not kill you right away, and you'll have a chance to fight for your life - but you will lose and die with 100% probability. Would you take this chance? Would you let your spouse or child take this chance? If it's my spouse or child I'm not letting them take that chance!

A recent series of articles on thyroid cancer has hit many media outlets. They describe a recent publication from Mayo clinic that recommends "low risk thyroid cancer"  be treated with observation only (which actually, is not a treatment). Part of their logic is that only 1 in 200,000 die of this type of cancer - called micropapillary thyroid carcinoma. As a thyroid surgeon, I'm dedicated to the preservation and improvement of my patient's health. Notice, that I state that in the singular, not plural. My dedication is to the single patient whom I'm treating. I can't look at a single patient and tell whether they are part of the group of 199,999 who won't die or the one who will. If it's my spouse or child, I'm not letting them take that chance.

My new website

So, what was wrong with the old site? Nothing really, but times change and mobile devices are becoming more prevalent. So, I've moved to a platform that should work well with smartphones, ipads, and tablets. Adding content should be easier as well - which means I can get more stuff onto the site! Please let me know if you'd like to see more of a certain thing - more robust explanation, more videos, subjects to cover - any suggestion you might have. I hope you like the new site and stay tuned for more content!

My Father's Eulogy

Below is the text to the eulogy I gave at my father's funeral, Dec 28, 2012. I ad-libbed just a bit, but the text is pretty close to the actual eulogy. My father was a blessing to me and my hope is that this short synopsis gives some glimpse into a great man who taught me so much. 

Dad spent a day seeing what I do, first handFirst, on behalf of my mother and our family, thank you all so much for coming today. The love and support that you’ve shown us over these last 3 years and especially these last few weeks has meant so much to us. There are some who couldn’t be here today, and so we’re videotaping this message, so that they might hear - provided I don’t become a blubbering idiot - I do reserve the right to edit or delete that tape! Thank you, all so much. 

I don’t think many of you realize the real reason you are here today. In fact, I feel lucky that I happened on it myself. Just the other day, I stumbled across an unusual Twitter feed. It was from God - I bet you didn’t know God had a twitter account! It seems that God had tweeted that heaven was having a bit of a problem -that nearly all of the projects in heaven were nearing completion. So the following message was sent down: Needed, an ambitious worker to start projects that seemingly have no end, hashtag heaven help us. Now, the angel Gabriel responded quickly saying he had the ideal candidate and his name was Donald Joseph Forwith. But God, probed saying how do you know this is the right man for the job? Gabriel responded that he had visited in a dream the person who knows him best, who’d been his high school sweetheart, who’d been his best friend, lover, and life long companion. Someone who’d he’d laughed with, teased, yelled at, and worried over. In fact, he’d dedicated his whole life to her - 52 years of marriage! So, who would know him better than Carol Baker Forwith? So, Gabriel asked her in a dream, could Don be our man? She responded with confidence, “Lord, he’ll start so many projects it will take an eternity to finish them all.” And the Lord said, then it’s time to call him home. 

My name is Keith, and I’m Don and Carol’s oldest son. I live in Louisville KY where i practice medicine and with my wife of 24 years have raised four daughters. A few weeks ago, I discussed with my Dad the content of this eulogy. It may seem an odd thing to do, but it turns out that Dad had a few things he wanted you to know. So, what you are about to hear is a little bit of me, and a whole lot of Dad. Some of you may not like what you’ll hear, but Dad always told it like it was, whether you wanted to hear it or not. I will talk about some matters that involved me, in fact, in a little while,  I’m going to read you a short letter that he wrote to me just a few years ago, before he even knew he had cancer. I want you to focus on what kind of man would write these things and what it says about him. 

My father was not a highly educated man, he pretty much went to work after high school and set about the business of providing for a family. Because he didn’t pursue higher education, he often would comment that he wasn’t an intelligent man. But make no mistake, Don was very smart - especially when it came to that not so common characteristic of common sense. Dad could fix anything or at least start to. I was inspired and pushed by my Dad to do a bit better in the education department. For those that don’t know, I have a Bachelor’s in chemistry, a PhD in biochemistry and a medical degree. But, after all that - if I thought myself a wiser man than my Dad, well - I would be a fool! So, I’d ask - or warn - each each of you. Don’t dismiss what this wise man thought to be important.

Dad realized that his time was near four days before he passed. He knew his time was limited and his doctors had warned him he’d finish life in a coma. So, what does a man say when he realizes his remaining words are few? Dad talked about love and family. He said the most important thing in this life was to love one another and not to let anything stand in the way of that. Dad had faithfully read his bible, especially over the last three years. In the gospel of John,  Jesus states “My command is this: Love each other as I have loved you. Greater love has no one than this, that he lay down his life for his friends.” Laying down one’s life for those he loved is something Dad did on a daily basis. I remember a good portion of his life, he’d head off to General Electric where he knew his work didn’t provide the kind of challenge and fulfillment he’d dreamed of, but that job and his dedication to it provided for his family. His work ethic was unquestioned, something that I learned a bit of and it’s served me well. 

Many of you recall that Dad nearly lost his life in a horrific chainsaw accident. What he suffered in that event, has shaped my life perhaps more than any other moment. Dad’s pain, his recovery, my mom’s courage through it all and her dedication to him shaped my life in so many ways - we wouldn’t really have time to scratch the surface on this one. But, while Dad took pride in what he did, he was a humble man. He allowed a seeming tragedy in his life to change and shape him. And I noticed as a young man that his change was for the better. Life was more cherished after that, and Dad’s love for us was more evident. In his suffering, we all benefited. 

I would like to read an excerpt from a letter he wrote me about five years ago. I attended a retreat at my church and Dad, in an unusual moment of openness, wrote me the following letter. Let me warn you, I couldn’t get through this letter when he was alive and healthy, so I may struggle now but here’s my best effort:

Don wrote: “While pondering on what I could talk about it came to me to tell you how my life as a young man became part of your life. 

I was around 18 to 19 years old when I got my first job. My job centered around a lot of other people, both men and women. I started studying everyone’s personality and picking out their good and bad points. I thought if I could develop their good and avoid the bad I could grow into a good man. While this sounds easy, it certainly isn’t. It seems as good comes some bad tags along. I learned each of us has to struggle with their own life and pray to God for help. In my studies of people, one particular man stood out from the rest. He was an engineer that seemed to overlook everything at the factory when he walked through the door. A happiness was about him. He would speak to everyone no matter what their job was or where they came from. He wore regular clothes and never showed off his above average intelligence. I noticed how everyone liked him and enjoyed being around him. His name was Keith. 

I prayed to God asking him that if he ever blessed me with a son that he would be very intelligent and yet be modest, respect others and being respected himself. He would have high morals, love life and respect it. I prayed he would be blessed with a family and love them with all his heart, to always love his wife and respect her, to be true to her, to have God at the center of his life and others would see this godliness in him and thank God for him and that everyone would enjoy his company and his intelligence and he would never degrade them. This was my prayer to God. 

Well, as I was developing from a boy into manhood, my thoughts were what I’d like to be. An engineer or a doctor would be my dream. As time passed I knew that I didn’t have the intelligence or finances for this to ever happen, so once again I prayed to God. I asked that if I couldn’t be a servant to his people that he would let my son do his work through him. I asked if I wasn’t chosen to be his servant that my son would be. I asked God to bless this son and teach him to heal the sick. Before you were even conceived your destiny was prayed for. When you were born a prayer was answered and now I know I can look back and remember that God listens to our prayers and answers us with his blessings. 

Before you draw a drop of blood from God’s people stop for a moment and ask God to be with you, to fill your mind with knowledge and to guide your hands. God will give many rewards and blessings for being a servant to his people. 

Even if you are far away, you are in our hearts and our love. I’m very proud of you, Keith and the life you lead.

Love, Dad

That, in a nutshell, is Donald Joseph Forwith. A man who laid his dreams aside to provide a path for his son to reach his dreams. A man who suffered in quiet dignity and taught his son and family lessons even to his very last day. I thought it fitting that at the moment he died, I was seeing patients in the clinic - carrying out his dream and mine.  

My family at our last holiday with Dad, Thanksgiving 2012Today is a joyous day. Dad is in heaven with Jesus and no longer in pain. He has already heard the words “well done, my good and faithful servant.” He is happy. But, he wanted me to tell you something. Don’t think of him as in a better place - he’s in the best place! The only sad part of today, is that some of you may never see him again. To see him, you’ll have to go to heaven because that’s where he is. I say that with certainty because I can. You see, we’ve slipped into this false idea that good people go to heaven. Especially at funerals, we like to think of the good in people. Today, that should be easy as my Dad was a very good man. But, that is not why he’s in heaven. He wanted you to know, he wasn’t good enough for heaven. I joked with him that I could make a long list of why he shouldn’t go to heaven - but of course, today is not about Dad’s weaknesses or sins. Dad is in heaven because he was forgiven. Good people don’t go to heaven, forgiven people do. 

Dad was forgiven because he accepted the sacrifice of Jesus Christ.  His trust was in the Son of God who gave himself up so that our sins may be forgiven. Jesus suffered so that we all would benefit. It is by God’s grace that Dad was welcomed home. Dad wanted you to know, each and every one, that he wants to see you again. He wants to welcome you home. He told me at Thanksgiving that the only fear he had of dying was that he didn’t feel he’d talked to the people he loved enough about the saving grace of Jesus. So, I would like to close by asking you - are you one of Dad’s unfinished projects? Would you rather believe that this man of wisdom was a fool? Would you set aside the very foundation on which he based his life? I promised Dad I would continue to work on this project - to tell you in no uncertain terms, that heaven is real, that God loves you, and that Jesus has paid the price for your admission ticket. Don is waiting there to rejoice if and when you come. Don tried to not die so that you would know this message - that Jesus willingly died to give you eternal life if you would only accept it.  I thank God for giving me an earthly father who showed me a glimpse of my heavenly Father’s endless love.  I pray that each of you will know that same love. God Bless you all. 

He is with his Savior!

My Dad passed at 9:43 am this morning after a three year battle with prostated cancer. He suffered quietly and privately (with the exception of his son blabbing about it on his blog and on Facebook). His pain is no more and by the grace of our Lord, Jesus Christ he is in heaven. Praise be to God!

I find it fitting that I was seeing patients in the office while he passed. I saw him last night and he wouldn't have wanted me to not be there for my patients on his account. Guaranteed, he'd see it that way - that's how he saw the world. I know he was proud of me for becoming the man I am, and the doctor that I strive to be. He would have been happy that I was trying to help others as he departed. He told us all -  "no tears for me, I'll be in a better place and relief will finally come." He said he knew he'd see me again - so long, Dad! Enjoy your journey - see you in God's time! 

He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away. Rev 21:4

Near Death, Near Christmas

My father has drifted into a deep sleep. His last meaningful communication was Tuesday when he told my mom goodbye. He was so sweet - telling her that he has always loved her. It's unusual these days to see a man die in the loving care of his high school sweetheart. He will moan a bit when getting turned or moved to bathe him, but otherwise rests comfortably in his bed. His pain seems to be controlled and our family has been gathered around, ensuring that he is not alone when that final moment comes. I believe it will be soon, I pray that will be so. 

For all the negatives we hear about modern communications, I must say that Facebook and the responses to this blog have been so helpful to me. It has been so comforting to know that people are praying for my father and family. I can't thank everyone enough for their kindness.  On Tuesday as he was drifting off, I read from the Bible - starting with some selected Psalms. I ended up consulting my FB page as so many had suggested great verses that were comforting. So, thanks for your prayers and I hope everyone has a blessed Christmas. I know my family will, as all this is part of God's plan. The joy of Christ's coming into the world is celebrated at Christmas - we will celebrate because His coming has granted my father salvation and eternal peace. That we know, and we can be sure of! Merry Christmas!

"I'm ready to go...if the Lord will take me"

Dad, 71, with his wife, Carol, of 52 years!Those were Dad's words when our family was called to his bedside yesterday. After three years with metastatic prostate cancer that is beyond hope of treatment, my father finally says that his time has come. Just two weeks ago, we talked and he said then that he wasn't ready to die, that he still had some things to take care of. But, last week he was stricken with blood clots in both legs - perhaps the worst I've ever seen. He can't walk 15 feet to the bathroom without extreme pain and as he says, "this is no way to live." So, when he began getting short of breath yesterday he said for the first time, that he was dying. He is in pain and suffering, and he says that it will be a relief when he dies - so we're not to be upset. Growing up, Dad was my baseball coach and I can remember him telling his very competitive son (that's me, of course) not to be upset - that losing was part of playing the game. That there will be victories and there will be defeats - that the game wouldn't be the same without them. So too, is life. We've had so many blessings to remember and cherish; cancer is a defeat but only a temporary one. 

Another victory came just last night. Dad's parish priest came to administer last rites. We crowded around his bed and prayed as the priest gave Dad his final blessing. We prayed and thanked the priest for his kindness. Then, my wife - who still suprises me with the depth of her goodness, began to sing. She started Silent Night with a few reluctant family members joining in at first. But then came the deep, weak, slightly out of tune, voice of my Dad. The rest of us joined in and soon had gone through every carol we could think of. When we ran out of meaningful ones, we resorted to Rudolph, Frosty and the like. We were searching for song suggestions and lyrics on our smartphones and ipads. The music proved to be therapeutic for all of us. My Dad loved it!- he'd join in on random lines here and there. The music ended with my wife and daughters singing Breath of Heaven as Dad drifted off to a temporary sleep.  We soon said our goodbyes, perhaps for the last time. 

As hard as it may be, I try to follow his counsel not to be sad.  Afterall, he's suffering - his pain is constant and his quality of life is poor. I know that I will see him again as he knows Jesus and trusts in His saving grace. He knows where's he's headed and now says he's ready to go. So, now we're waiting to see not if, but when the Lord will take him. I pray it is soon, as Dad wants to go. He has run with perserverence the race marked out for him. He is in the Lord's hands - in that we can trust and be thankful.

But you, man of God, flee from all this, and pursue righteousness, godliness, faith, love, endurance and gentleness. Fight the good fight of the faith. Take Hold of eternal life to which you were called when you made your good confession in the presence of many witnesses. 1Timothy 6:11-12 NIV

An answered prayer

Radiologist and friend, John Hutchinson MD in the conference roomI've been trying to stay upbeat these last several days. Things here have not been going as I'd like. Certainly, I'm not in control of this situation over here! I've seen so many people that I could have helped - if they had presented 6 months ago instead of now. I've lost track of the number of patients that are too advanced for any hope of a surgical cure. For these impoverished areas, it is rare that patients have the money to travel to Nairobi and pay for radiation therapy - something even the uninsured in America would get. So, if there is not a surgical cure, most cases there's not a cure at all. I've spent too much time helping the surgery residents explain that there's nothing that can be done for them. Their life is in God's hands and they will be healed, but maybe not on this earth. I believe that God can cure any of them, if it be His will. Ironically, my tea bag at dinner tonight had a verse on it: For my thoughts are not your thoughts, Nor are your ways My ways. Isaiah 55:8 If I were God I'd cure every last one of them! But, certainly I am not and I don't understand His plans. But, I know that He has plans for each one of these people.  

So, I have prayed the last several nights for just one victory. One patient who we can save. Just one, please! Well, today God gave me what I prayed for, but not exactly as I thought it would come. The man came to us with difficulty swallowing for over a month. I was working with a family practice resident, Dr. Castro Mugala, whom I admire very much. Unfortunately, I had been able to show him several types of head and neck cancer - all unresectable (too far advanced for surgical removal). This patient was actually no different. His tumor started at the back of his tongue and came all the way forward to just behind his teeth. He couldn't lift or move his tongue on the right side because of the cancer growing just under it. His neck was full of metastatic nodes and the tumor had invaded his mandible (jaw bone). He was having pain which radiated to his right ear. Cerainly, he was not a surgical candidate and even radiation would not work on this advanced disease, even if he could afford it. So, how was my prayer answered by this man? Dr. Mugala and I planned for hospice, discussed tracheostomy and a feeding tube for him. But, we also discussed the need to talk to him about Jesus Christ. I believe that the sacrifice of Jesus on the cross atoned for all of my sins and this man's sins. It is a free gift of grace that we need only accept. This patient, whose days are few in number on this earth, accepted Christ right there in the clinic. He got on his knees and prayed with Dr. Mugala in swahili - oh, how I wish I could speak swahili! Later, a chaplain came to follow up with him and he left just after getting a bible - in his own language! 

So, my prayer for victory was answered. Not through surgery, but through the saving grace of my Lord and Savior Jesus Christ. Yes, he will die - as we all will. But this man came to Christ today! I smiled all morning because what he recieved today is more precious than any surgery or cure. His life will now be eternal! God, indeed does have His ways.

I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future! Jeremiah 29:11

It's Midnight in Kenya

It's midnight in Kenya and I'm wide awake! I've had trouble sleeping these last few nights so I'm short on sleep, fatigued,  but somehow not tired. Perhaps the half cup of chai at the Men's bible study tonight was not such a great idea! But, I've only a few days left and chai is such a special part of this place. Perhaps their tea fetish is remnant of the British colonial days. The altitude here is above 6,000 feet and I typically sleep fitfully at higher elevations. My bed is exactly 6 feet long and I'm exactly 5 foot 10 inches so there's not room to spare before Im kicking the footboard. The mosquito net makes a cozy little nest but sometimes I wake up with it on my face or tangled in the blankets. Ok, so I'm rambling... but it's midnight and I'd rather not think about the fact that I'm loosing way too many battles over here. But, that's a post for another day. Time to pray, think of my wife and girls, pray again, read, and perhaps dream. God Bless, everyone! Goodnight!

Wedding Day!

After my last post, I had resolved not to let my impatience get the best of me. So, on Friday I was calm and not concerned that we were more than two hours behind schedule. I was enjoying operating with a young resident who was eager to learn. I love to share with students and residents who are hungry for knowledge and wisdom! I think that they bring out the best in me. As we were close to finishing, a wedding invitation was delivered in to the OR. Two residents who I had known from previous visits to Tenwek saw me arrive Tuesday and had sent an invitation to me. If we had been running on time, I would have missed the delivery! I was honored to be invited and certainly wasn't going to miss my first opportunity to attend an African wedding! 

Earlier this year as I was preparing for a mission trip to Nicaragua, our team leader recommended the book Foreign to Familiar: A Guide to Understanding Hot -and Cold -Climate Cultures. Turns out the book was exactly correct in its descriptions of cultural differences. The invitation states the wedding begins at 10:00 am. So, being the cold climate creature that I am, I showed up exactly at 9:00 to catch a ride with the White family to Kericho - one hour drive away. The Whites are long term missionaries here and they knew better. Beth White was still feeding children breakfast and hadn't started getting ready yet. She informed me that the bride's mother was still in Nairobi and that it would be at least a couple of hours! I returned to my room to do some reading and remembered the book's description of this very situation. We left three hours later and arrived just on time to the wedding. A full four hours past the stated start time. According to the book, this was typical because hot climate cultures regard the start of the wedding as when preparations begin - the arrival at the church comes later - well after the start of the event! I spoke with a few residents who confirmed that it's always a guessing game as to when the bride will show for the wedding. Four hours late was not out of line! TIA!


Mike and Liz are both first year surgical residents who have centered their life around serving the Lord and His people. Their day and their ceremony were likewise God centered. The wedding was outdoors and began with the typical bride processional. The biggest difference was the women who did this high pitched trill that is unlike anything we do in America! The groom awaited at the front of a small tent which was lined with about 50 chairs that formed a small aisle. The tent provided an intimate setting for the ceremony. The bride's mother then gave her away with a short speech that was heartfelt and moving. She described Liz as her only jewel and asked for God's blessing on her new home with Mike.  A worship team offered two Swahili songs which found everyone in strong voice - except the English only speakers like me. One thing that's been abundantly clear is that culturally, Americans have a hang up about singing and dancing. These Kenyans sing with an abandon which I envy. Most have good voices, but the quality of the voice doesn't determine a person's volume as it does back home. Singing is for celebrations and enjoyment is for everyone. Wish we were like that! 

The ceremony had the typical elements of sermon, vows, ring exchange and candle lighting. The newlyweds were announced by the pastor and the emcee took over right there in the church tent. He had them dance, not walk, down the aisle followed by the wedding party and family. It sounds like a stereotype, but there is no doubt that Africans are blessed with rhythm. I could have watched them process all day! Age is no barrier, kids and elderly all dance with ease and grace. The only awkwardness I saw were the white folks whose attempts were, to be kind... lame! I was safely behind my camera which was probably best for everyone! 

A buffett was served while the wedding party disappeared for pictures. One of the coolest parts was when the couple returned to the festivities. The women went out to escort them in. A Swahili song was sung by the crowd as they danced their way in a parade that encircled the grounds for the next half hour or so. Two or three songs were sung, with never the need for any instruments other than the voices. Harmonies, rhythms, and melodies blended together as the party danced it's way around in no particular hurry. The bridal party nestled under a tent with the head table. Their meal would be followed by gifts, toasts and more dancing. Unfortunately for me, we had to hit the road back to Tenwek. Missionaries are not permitted to drive after dark (for safety reasons) and the late started meant we'd miss some of the festivities. We arrived back just before dark at Tenwek.

I feel so honored to have been invited. The love of family and friends was so abundantly clear to me, even though I understood none of the Swahili that made up most of the conversations. Africans are really good at relationships and family. They celebrate without reservation and take joy in the simple act of spending time together. Time is not their master. Life is often hard in Africa, but days like today are for celebrating the love of friends, family and God. Their remaining surgical training will be difficult and once finished, their lives will be taxed by the overwhelming need of their community. I pray for God's blessings and protection of their marriage. I know that they will be a blessing to so many in their lives and surgical careers. 

A painful withdrawal from my addiction

I love efficiency! I crave it! I spend a good deal of my normal days figuring out how to be more efficient. When I operate I have everything planned out. Like a chess match, I know my next moves and am planning for all the variations that may thwart my plans. I even have figured out how to hold my open hand in certain unique positions so that my scrub tech can tell what instrument I want without me saying it. Afterall, an extra 2.3 seconds of me speaking the word and her hearing the word means inefficiency. So, I get a great feeling when an operation flows smoothly. When every detail goes as planned and everthing flows it gives me an indescribable feeling of satisfaction and accomplishment. Efficiency means less anesthesia time and less risk to the patient. Efficiency means protecting critical structures and operating strategically. Mistakes slow you down, so I've honed my technique knowing that efficiency is surely a Godly attribute! 

Kenya is not the place for me! I nearly went into convulsions today over efficiency withdrawal! I spent too much time thinking of all that needs to be done while realizing all the obstacles that are standing in the way. I did three operations today that consumed most of the day! Three 45 minute cases in an entire day! I felt like crawling out of my skin! In one case, I walked into the room to see the nurse sitting on a chair, seemingly content. The instruments I needed weren't in the room and opened. The injection wasn't drawn up. No gloves were pulled for the case. The Mayo stand wasn't prepared. In fact, she had done absolutely nothing - nothing to prepare the room, nothing to help the surgeon or anesthetist, and nothing to help the patient. I then recalled that I remember her pretty much doing the same thing last year; so why was I surprised? In fact, I've spent enough time here that I should have expected all this! 

But that is the intellectual side of my brain reasoning over the situation. My heart and my ambition were screaming "let's get to work! let's help some people! I didn't come half way around the world to relax! I only have two weeks here and my time is valuable!" Funny, I had a similar feeling three weeks into my stay last year - when I only had a week or so left. I remember telling myself that "this is a waste, I'm never coming back, these people don't appreciate me, these people aren't helping themselves!" But, this is Kenya. Kenyans don't see things my way. They are in no hurry; they don't understand why I would rush by and not visit. They don't seem to compile checklists each day. Their culture is not mine and I'm called to honor theirs - and that is not always easy! So, I returned to my room late afternoon and succumbed to the jet lag and took a nap! Those of you that know me well, know that I don't nap! Fortunately, the ER had an emergency and I was paged out of my nap. Yes, I'm still tired, but now there's a need - a chance to get something done! A chance to feed my addiction! Turns out, it was just a simple nosebleed that was well managed before I got there. No excitement, but I think I'm ok now. 

Just had to get that off my chest. I'll pick up tomorrow trying to work within the system and help where I can. I just have to take it a Kenyan pace. I have to shred the mental checklist; I have to stop the mental comparisions (if my OR team at home...) I have to trust that God put me here to serve, not to dictate. So, when frustration comes, I'll just shrug my shoulders and say "TIA!" (This is Africa!) and I'm glad to be here. 

Not all surgeons are created equal

The familiar smells of Kenya hit me the moment I deboarded from the plane in Nairobi. Everything on this trip so far is very familiar to me - in a back home again, comforting sort of way. The trip to Tenwek took about 4 hours; friendly faces welcomed me back with a number of "karibu(welcome) Dr. Keith" refrains. After a quick lunch I headed to clinic where it took less than an hour for me to be shaking my head in disbelief. This afternoon I saw 4 cancer cases - two of which had incomplete operations recently at government hospitals. 

One patient had a vocal cord paralysis from a botched thyroid operation. She had several extra scars from where the previous surgeons had carelessly cut through the skin as they were raising the subplatysmal flaps. Ironically, this is one of the easier parts of the operation! Not surprising that the most delicate part of the procedure was not performed well. 

I want to emphasize that these were not Tenwek surgeons. The surgical residents I've worked with here are outstanding. It mainly motivated me to keep coming back to help train these young physicians so that disasters like this aren't inflicted on these poor people. The worst part of this is that her thyroid cancer has spread into the lateral neck. God willing, we will be doing a much bigger operation to save her next week. 


This 26 year old gentleman was told that they completely removed this tumor - just over a month ago! Obviously, that was not the case. He had two different nerves paralyzed by the poor surgery. The ending on this one may not be so happy. We need a CT scan - which he says he can't afford - to determine if there is a chance of a life-saving operation - which he can't afford. 

Each year I come, I bring extra money to help patients get the care they need. Each year I get here and realize that I haven't brought nearly enough! This year the exchange rate changed dramatically so I have 37% less than I anticipated. Even so, it is always challenging to know when to offer and when to hold back. The culture here is much more communal and most patients have to rely on their relatives or village for surgical funds. And this is not neccessarily a bad thing. So, when to offer help is a tough decision. I especially worry that a more heartbreaking story or situation may present tomorrow. Triage with your funds is a painful process! Wisdom in this area is something I will pray for tonight.

In the USA or in Africa, surgical residency is a demanding 5 year process that truly matters. Residency is the process where doctors become surgeons. It is not overdramatic to say that lives are on the line. Poor training leads to unneccessary suffering and poor outcomes. Life here is tough and both these patients deserved better. The surgical training that PAACS offers these African surgeons rivals the quality of American programs. As more PAACS surgeons graduate and begin working in their communities there will be fewer of these tragic cases. That is a reason for hope and the reason I continue to return.