Return to Africa

Several years ago I realized that life was quickly sailing by and some of my longstanding intentions were sitting passively on the sidelines. So, after a particularly convicting message from Dave Stone at Southeast Christian Church on the second chapter of James, I decided to make a change. I started by attending the Global Health Missions conference which is held every November at SECC. To make a long story very short, I truly was urged by the Holy Spirit to do something I thought I had no heart for - take a mission trip to Africa! So, now I sit in the Detroit airport just moments away from my seventh mission trip and fifth one to Africa. I am anxious, but not nervous. I've done this before, afterall. But, each time the people are different and the circumstances are different. It is always challenging both medically and spiritually. I hope to make a few entries while there and probably some after I return. As always, I will try to be brutally honest in the hopes that my experiences can inform, inspire, or even convict those who join me in caring about these people. My mission is simply to do what God asks me to do, knowing that he has equipped me for the challenges ahead. In everything I write, I hope you can see that God is at the center of this and His purposes will be fulfilled. I am honored that He has allowed me to be a small part of His story. Now, it's time to board so I'll close by asking for your prayers in the days ahead. Peace and Blessings!

 What good is it my brothers, if a man claims to have faith but has no deeds? Can such faith save him? In the same way, faith by itself, if it is not accompanied by action is dead. James 2:14, 17

From weddings to funerals

It doesn't seem that long ago that Sue and I were spending our summer days traveling to attend weddings. We had to mark the calendar carefully so we didn't miss anyone's big day. Weddings are happy, joyful and forward looking - reasons to celebrate! But as time has passed, the wedding season of our lives diminished. Now, a new season seems to be upon us - and it's not one I welcome in any way. Seems we're at the age where funerals have come to clutter our calendar. I've recently lost an uncle on each side of my family. 

Most recently, our family vacation was interupted with a 7 hour trip to my uncle Harold's unexpected funeral. Unlike the politeness of weddings, funerals give you no warning and demand you drop everything. They quickly shake you to remind you that we are not in control and that life can't be fully planned. Our days are numbered, but none of us actually know what that number is. Funerals are rude, impolite, backward looking and reasons to mourn. I think I really prefer weddings!

But, I've decided to try a new outlook on funerals. My friend, Bob Myles, passed away last week. I met his stepson and explained that Bob and I were friends from Rough River. Bob was the kind of guy who was your friend if you've spent more than a week and a half or so at Rough River. His smile was both infectious and mischevious. He was either making you laugh or planning to make you laugh. At his funeral we got to see some pictures from his childhood. To our amazement, his warm smile was seemingly identical as a toddler. At 55, Bob died way too young. Bob was the kind of guy who admits his mistakes. As he puti it, he was a smoker who quit too late. Lung cancer took his body, but not his spirit. So my new outlook on funerals is to go back to the basics. Trust God in all things - and learn from those that I've been blessed to know. I'm glad I knew Bob Myles and feel blessed to have called him a friend. 

No empty chairs at dinner!

For so many years, the six chairs around our kitchen table were filled. First, with little girls spilling, making messes and needing their meat cut up. Next thing I know, we're paying college tuition bills and a chair is empty most of the time. But the other five were filled and life goes on. Then, a second chair became empty as another daughter venrured off into the world. Suddenly, the girls filling the chairs didn't outnumber the girls missing from the chairs, and the time passing begins to seem accelerated! Removing a leaf from the table still didn't bring back the complete feeling of a family. 

Allegra returned Wednesday night and her Mom and little sister returned from a school DC trip last night. So, for the first time in a long time every chair was full and there were no empty spots. We prayed and thanked God for his loving care and protection. A lot has happened and safety wasn't guaranteed. It truly is a blessing to have them all home, even if it's just for a little while. I realize these days too, will become shorter and shorter as the next girl already considers where her next chapter will take place. So, for now I'm just enjoying the crowded table - realizing that some parents don't have their kids come back. Some fall to illness or tragedy and the chair remains empty. God's grace has spared me from that kind of pain and I thank him for his goodness. Nothing in this life is certain, so I'm focusing on this day and the abundance of blessings God has given me. 

Nicaragua becomes a family affair!

In just a few days, my oldest daughter Megan will journey with me to the southern part of Nicaragua as part of a large medical team. Megan is a sophomore at Xavier and will serve as a translator; two years ago she lived in Spain where she had a tremendous cross cultural experience and learned Spanish while living with a loving family.Megan with her 'Spanish sister', Sylvia

As for me, I'm not quite sure what to expect. This trip, organized through Global Health Outreach (part of the Christian Medical and Dental Association) will have 15 MD's, 5 dentists, a bunch of nurses and support personel and many students. A total of 68 people will arrive on Saturday in Managua to form the team that will venture south to near the Costa Rican border.  This is not a surgical trip, so I'll mostlly be using my medical side. I'm taking a small surgical set with me, just to be prepared! Hopefully, I'll get a chance to share some of that experience. 

Allegra in Chinandega, NicaraguaMy second daughter, Allegra, is spending the spring semester in the northern part of Nicaragua.She keeps a blog at the Adventures in Missions site.  She turned 19 yesterday and reflected on her 18th year of life. I am amazed at the work that God has done in her life. Much like last fall, I will likely find myself in the same foreign country as her, but unable to connect. Seems to bother dear old Dad more than daughter!

 So, please pray for our family and the work God has planned for us in Nicaragua. So many times, I set out on an adventure such as this hoping to bring a positive change, only to discover that the real change occurs in me. I pray that Megan will have that transformational experience through our encounters with the people of Nicaragua. I humbly ask for your prayers for our team and Allegra's team that our talents and efforts can bring the love of Christ to people in need. Please pray for the many medical and dental students that will be part of our team; pray that their lives will be molded by this encounter into lives of service and thankfulness.

One more day...

It's been exactly a month since I returned from my last mission trip. It was my third trip to Africa, the first being two weeks duration, the second was three, and most recently a month. But, despite my increasing time spent there, it was just not enough. Throughout my last day there, people kept coming for evaluation. Most were routine problems, but one lingered in my mind. A lady showed up with a tracheostomy (a breathing tube in the low neck) that had been placed earlier. She had fairly extensive larynx cancer that had not yet spread into her neck but was progressively blocking her airway. The tracheostomy allowed her to breathe below the blockage. Larynx cancer often will not metastasize (spread) until late in the disease. She needed a laryngectomy - which given that she had no evidence of disease spread in the neck, would save her life. But, she had already eaten when she showed up in the afternoon, the OR schedule was full, and  I was scheduled to leave early the next morning. A laryngectomy is not within the skill set of general surgeons. The next ENT to visit Tenwek will likely be in February. The only treatment alternative for larynx cancer is radiation therapy, which is available in Nairobi.  But the costs of travel, lodging, and treatments far exceed this woman's financial resources. If she had only shown up one day earlier, we could have offered her a life saving operation. Instead, she'll return in February with the hopes that her cancer is still surgically curable. 

While this was not as devastating as last year's final day at Tenwek (chronicled below), it serves as a painful reminder of how desperately needed surgical care is in Africa. The mission of PAACS to train and disciple surgeons to serve the poor in Africa becomes dearer to my heart with every day spent there. The long plane rides home gave me plenty of time to reflect - and to begin  planning for my next trip. God continues to open my eyes to see both the need and the ways in which I can help. Your prayers for the people, the young African surgeons in training, and their American mentors are so needed!

Cars, Cats, Kittens, and Kids

Well, I had quite the adventurous weekend. I had no clinical duties Saturday or Sunday so I jumped in with some The first of two flat tires!visitors who just arrived and went to Masai Mara for a Saturday evening and a Sunday morning game drive.  In the morning, we arose early to go to a remote area, hoping to see some lion cubs. Before departure the driver had the hood open looking for a sound that he thought was a cat. Sure, enough I soon heard the same meow sound, but we couldn't find a cat anywhere. Perhaps a bird, an engine squeak? We proceeded along without finding the answer.  Half way there it becomes apparent we have a flat tire. No big deal, except when we went to change the tire I noticed a hissing, air leaking sort of sound coming from the rear tire. This was intermixed with more meows that seemed now to becoming from behind the dash board. So, there we sat in the middle of a road, in the middle of nowwhere with two flat tires, one spare, and a hidden cat in or under the vehicle. About 45 minutes later another safari vehicle came and we were able to get two very old tires with little tread to replace the two very old treadless tires that had leaked. Yes, we were now heading further out with no spare and two flats strapped to the back of the Land Rover. This is not the cat that induced fear.

As we get into the area where the lions were known to be, our driver suddenly hears the cat next to his door. The driver radios another driver and the two of them are outside the vehicle, in lion country, looking for a cat. Then, the drivers see a tail - but it turns out these big, burly safari drivers are afrad of cats! No, not the big carnivores we were hoping to see. No, they were afraid of a domestic cat! Wanting to get on with it, I get out and crawl partially under the vehicle, as I am only afraid of the big cats - you know the kind that would feed on a pair of legs hanging out from under a safari vehicle. I see the tail, reach up and grab the rear of the cat and pull - it's a kitten. My size 8 hands cover nearly the entire body of his cute little kitten. 

Crisis averted, I'm anxious to get back into the safety of the vehicle and not become some lion's breakfast. The driver wants me to set the cat in back of vehicle while we drive off! Leave, a poor helpless kitten to become snack food! Now, I'm no cat lover, but even I can't do that! So, I casually walk around the vehicle and set the kitten in the back of the vehicle for safekeeping until the safari is over. Crisis strikes again! One of our traveling companions sets a land speed record for evacuation from the third row of a safari vehicle. Before I was even to my door, she had bolted through the middle of the seats and jumped out of the window! Now, she's wide eyed, petrified, and standing 15 feet from the vehicle! Who knew so many people were afraid of kittens! Now, there's a driver and a passanger standing in the savannaugh, refusing to reenter the vehicle because of the kitten! So, I have to retrieve the now frightened kitten from under a seat. So, a brief standoff occured where I decided it was better to leave a kitten for lion food than a pediatrician and safari driver. So, I tossed the kitten out of the car and it retreated behind a bush. Before we could reload, the kitten was back into the undercarriage of the truck and the meows continued.  So, the rest of the morning was spent looking at wild animals, including lions while the kitten purred in fright under our vehicle.  

Back safely at camp! Unharmed by the fierce kitten!

We arrived safely back to the camp and later departed for Tenwek. Our vehicle troubles were not over! About a third of the way back our vehicle begins to smoke - mostly out of the exhaust. First signs of trouble! It would get worse!

We stop and the driver says that the engine had just been serviced and that too much oil was put in. No problem, it will burn off and we reloaded for the remainder of the trip. So, we thought. The optimist in the bunch pointed out that at least it wasn't raining nor was it dark.

Not 10 minutes later the driver tries to shift to a lower gear and the engine suddenly revs to it's maximum rpm's. The vehicle begins to smoke and one of my companions starts yelling "turn it off, turn it off!"l 

But, the engine is not interested in shutting down and continues to roar at maximum rpm like a child throwing a temper tantrum. The next yell was "everybody out!"Naturally, I can't leave my camera gear behind in an emergency so as soon as my friends and I are out of the jeep, I snapped this picture! The driver finally gets the car to shut down by popping the clutch. Our vehicle is officially dead! 

Our entertainment arrives!We debated walking to the main road with our luggage - one of the locals said it was "not far", only about 10 km. Luckily, we had cell phone service and made a call to Tenwek for help. Word was we'd have help in only 5 minutes! Wow! we must be closer than I thought. We decided not to walk, and just wait it out. Then, it started to rain! Well, turns out time and distance estimation are not Kenyan strong suits. The rain let up and we got back out of the burnt smelling vehicle to find several spectators. Several local men began offering opinions on the problem with the jeep. A motorcyle appeared with some tools. We all agreed we were not risking another ride in the big green smoke bomb, even if they fixed it - which they did not!

Kenyan men of GodSo, five minutes was now twenty and we decided to have some fun with the local kids. We started with pictures, moved to videos of them dancing, then to games. We taught them duck, duck, cow because no one here knows what a goose is. A group from a church walked by and we talked with the men and the pastor for a while. We then got back to the kids and traded songs.

We sang Our God is an Awesome God, and they sang the hip bone connected to the thigh bone song - about 5 times. We sang Jesus loves the little children, they sang some Kipsigi song whose title translated to God is a Lion. Literally, two hours passed and we were still playing with the kids when a Tenwek vehicle showed up! 

Kipsigi girls were happy to see us!the crowd steadily grew as our wait approached 2 hours!

So, it turned out that our vehicle breakdown was the best part of our trip. Our misfortune turned into a true blessing from God. We shared what we could with the locals, and they in turn blessed up with smiles, laughter and lifelong memories. The six of us and our luggage then crammed ourselves into a Honda CRV - yes, seven adults of in a small passenger car.  

The sunset as we were nearing Tenwek

But we were happy to be moving as darkness was setting in. Turns out we were 31 km from the main road. That's over 18 miles we would have hiked with luggage and darkness setting in! Not to mention, there were two forks in the road and I would have definitely taken the wrong road at the first divergence point.

Our friend from Tenwek, upon hearing of our vehicle troubles throughout the day, asked which one of us was the Jonah? I love a man who knows his bible! So, in the end, we were all happy to have broken down and partaken in God's clever plans! 

Back home again

This is Sue, Keith's wife, writing now. Returned this past Sunday and still waking at 4 in the morning. Don't know how others shift so quickly back to local time!

I wanted to also blog during our stay but internet was just so spotty. Then, grand hopes of sharing pictures and stories upon our my return only to find that in all our camera swoping/sharing with others, I didn't come home with the right camera card. So, pictures of my outings will have to wait.

This picture was taken in the church on the hospital grounds. Keith had run up to check on a patient at night and quickly came back to get me. Being the only white people sitting in the back of the church experiencing the praise and worship music and then the preaching in both English and Kipsigis was awesome. This little girl kept running back to me.

This is my second trip to Africa with Keith. Our first one in Feb of 2010 we visited 3 different hospitals in Kenya and Ethiopia. While I loved that, we didn't get an intimate look at any given place. This trip was a bit different. While I was only there for two weeks, I got to know the surroundings and some of the locals more. Not being medical and confined to the hospital, I sought after experiences that Keith never got to experience....

....helping to weigh babies in a village from a scale hung from a tree

....being in a vehicle that is constantly dodging donkeys, cows and people along the rough roads

....going on followup bio sand filtration visits into mud and stick constructed homes

....being serenaded by little preschools singing Jesus songs

....visiting 2 orphanges and witnessing the love the caretakers extend to these kids who have nothing

....seeing the scared look of little ones who had never seen a white person before, let alone a blond

....testing the drinking water from several sources with a testing kit I obtained from Edge Outreach http://www.edgeoutreach.com/  before going . Most disturbing was a spring that the locals said was "clean water" only to find it has all kinds of bad things in it

....going into some of the local churches with dirt floors, rough wooden benches, & open windows

....being invited as the first white person into a teachers home (by our standards a shack really) who insisted on having us talk via cell phone to her father, mother, fiance' and friend

I found these people who have materially practically nothing, live to survive, but many have the faith as big as the plant from a mustard seed. A great challenge to my faith.

Hope to share more upon Keith's return.

Overwhelming need

Since returning from Safari, I've been extremely busy. I gave 4 lectures in three days. Since Tenwek now has a CT scanner (just opened 4 days ago) I taught a session on reading head and neck CT scans. Tuesday I taught on Head and Neck disorders - a topic that covers most of my specialty, but I thinned it down to 45 minutes by skipping nearly everything! Also Tuesday I taught a lunch session with clinical officers on handling nosebleeds. Wednesday morning was a session on Approach to Neck Masses. Again, a huge topic boiled down to 30 minutes. 

I was relieved that they went well and I could focus on patient care the rest of the week. Wednesday after lecturing I repaired this baby's cleft lip. The result wasn't perfect - which is the only thing I'm not happy with, but the family was pleased and this kid won't grow up as an outcast.

It's a national holiday here in Kenya. Heroes day it is called. But, I've been working all day but at a more casual pace than most days. Only one trip so far today to the OR (or theatre as it's called here). A young lady who presented to casualty (their name for an ER) with 5 days of lockjaw. This wasn't the tetanus variety, but the kind that comes from a persistent open bite deformity. Her pterygoid muscles were in chronic spasm, so we had to put her under anesthesia to reduce her jaw dislocation. She really needs a good orthodontist as this is going to keep happening over and over again. Since that will never happen, a surgery where the jaw is essentially broken and reset to give her proper alignment may do the job. Problem is, I have no room on my remaining OR schedule for it. So, we put an elastic bandage on and will see if she can get some banding and elastics from dental clinic after the holiday.

Being the holiday, I'm working without residents. So, I'm using nurses and nursing students as translators. In many ways, it made things easier as my words are getting translated directly, instead of being filtered by another doctor. They call me "daktari" which I believe is Swahili for "funny looking pale man." Some of the real young kids are genuinely frightened by my white skin. They sometimes cry just when they see me, then really wail in fear if I look right at them! I try to smile but maybe that appears like an animal bearing it's teeth. Come to think of it, my very presence used to frighten my nieces so maybe it's not just the white skin?

Finally, I want to close with the story of this young lady who we are desperately hoping to help. She has an aggressive tumor, called rhabdomyosarcoma. It's pushed her eye aside, is flling her sinuses and is growing near her brain. We're working her up today to determine if it has metastasized. If it has not, then we'll be operating on Monday to remove the tumor. 

It seems that God has put all the right people in place to help her. I was worried about whether this tumor was into the brain, but a neurosurgeon arrives on Saturday. So, even if it has, we might be able to remove it with a craniofacial resection - an operation not possible without this unique combination of visitors. We have a radiologist here, who has been valuable in studying the films to make sure we can accomplish a resection. Amazingly, we also have a pediatric oncologist here who is assisting in her work up. I am praying that this tumor hasn't spread. If we an remove it, she'll still need chemotherapy and possibly radiation, but she'll have a fighting chance. Without surgery, her prognosis is dismal at best. Your prayers for her are needed!

I still feel so blessed to be here! My energy levels remain high as I realize my time here is approaching a rapid end. My surgery schedule is full, but patients continue to come who need surgery. I wish there was a way to even things out. My first two weeks, when there were two ENT's here, we weren't overly busy. Now, Im wishing I had more time to help some of these very unique patients. I miss my family, but I know that they understand my call to be here and try to help. Thanks to all who continue to pray for these people and my ministry here.

Safari time!

No photoshop here, we were this close to this white rhino!The internet connection here has been nearly non-existent but I met with the hospital IT department today and I think they've found a way for me to blog! So, hopefully more stories coming soon. The weekend was a time to forget clinical duties and relax. What better way than a safari! So, our group of five headed to the Fairmount Mari Safari Club for an unforgettable weekend. We took game drives Friday evening, Saturday  morning and evening and Sunday morning. Friday evening we took a "walking safari" led by some National Park rangers. They carry AK-47's and guard these rhinos 24/7/365 from poachers. Legend has it that the horn contains a powerful aphrodesiac. Shame that they have to guard them so closely, but tourism is a huge industry in Kenya. These magnificent creatures are one of the big 5 that people always ask if you saw on safari. Our first night was magical - we saw 4 of the big five!

Not one of the big five but I never tire of these beauties! Zebras are like bison in Yellowstone - the first one you see you stop and take tons of pictures, then by the end of your stay your hardly paying attention to them. Unfair, because each has a unique striping pattern - like our fingerprints . These two were first scratching each others backs, then it turned into this neck biting activity. I learned from our driver that their spines are not sturdy enough for carrying water or packs like mules do. Probably why they've never been domesticated - but they sure are prettier to look at than mules!

The most elusive of the big five is the leopard. We saw this one on our first night! Our waiter at the hotel told us that some people stay for a week and don't spot one. I'd love to see one in a tree someday, but felt lucky to see this one so clearly. What a thrill! 

The greatest part of the safari was sharing it with my wife, Sue. Last year, I had a great safari but kept thinking - I wish Sue could see this. Well, this year she was here and got to experience it first hand. Despite the fact that I talked her head off about what I saw, she still didn't get it. You just have to see the beauty for yourself. The pictures just don't do it justice!

All good things must come to an end, and in this case it was bittersweet. I returned to Tenwek on Sunday, but my wife, the Murphys and Stephanie all returned to the airport to go home. Sad to say goodbye, even if it's only for two weeks. After great food and fellowship on safari, I spent Sunday dinner alone in the guesthouse. There are other guests here but I they were all scattered. I heated up leftovers and considered the stark contrast. My loneliness was brief though. I worked out, spent some extra time in prayer and realized that despite saying goodbye, I'm glad I'm still here. There is so much work to be done and I'm am blessed to have the ability to do it. God is so alive in this place - from the beautiful creatures to the desperate poverty. It is easy to be a believer here.  

Somewhere else in this vast country, my daughter Allegra continues her mission. Seems unfair to both be so far from home, in the same country, but not able to talk or communicate. I hope during her time she gets to see the magnificent wildlife. 

I hope to load more photos from our safari onto the Gallery section of this website. Tomorrow I'll be back to telling more clinical stories. Thanks for all the encouragement from those following along, it sure makes home feel less far away!

Hopefully, Sue will put some posts on this site. She spent some time in the villages and people's homes. So if you see Sue, encourage her to tell her stories, and tell her there's still two people in Kenya who love her and can't wait to see her. God Bless!

the Maasai baby

Shortly after arriving at Tenwek, the head of pediatrics showed up in the specialty clinic to see me. Seems he had an urgent case to run by me. In fact, so urgent that he didn’t page me, he just walked over to find me. The child had some swelling around the left eye that started the day before. The baby was brought to Tenwek, admitted and begun on treatment of IV antibiotics for infection. By the next morning the baby had severe swelling of the neck that was rising to just under the ears. 

Now, if Dr. Chuck Bemm walks from pediatrics to consult me, I’m certainly going to see the patient immediately.  I examined the child and found the worst swelling I’ve ever seen in an infant neck. I quickly passed a fiberoptic laryngoscope  to examine the baby’s airway. What I saw in the baby’s airway was shocking! The baby had a severe case of epiglottitis. That’s swelling and infection in the epiglottis - the flapper that keeps food out of your airway. Although rare, I’ve seen enough of these before. 

One of the advantages of doing mission work in the same place is that the locals get to know you. This paid off, as when I approached the OR charge nurse, my call for an immediate OR was taken seriously. They knew I wasn’t one to hit the panic button and quickly bumped a case to accommodate this baby. It was a struggle to get a breathing tube in, as the swelling was massive. In the OR I noted an odd, purple color of the epiglottis as well as some fibrous debris along the baby’s base of tongue. I collected it for culture and got the baby to the ICU. Later that day, I learned that the baby had anthrax! Yes, anthrax! I’ve never seen anthrax before, but I’ll know it now! Turns out, the baby had either played with or eaten part of a dead goat. Not he kind of history I usually get on my Louisville patients! 

Having a diagnosis, we started appropriate antibiotics but the baby began to decline. A day later, the swelling now consumed the baby’s whole head, but no other part of the body. After consultation with Dr. Bemm, we started the baby on high dose steroids. The next day, my exam showed that the baby’s neck was starting to improve. The antibiotics were working! Praise, God! But, this was not to be a happy ending. Three hours after rounds, during mid morning, the baby had an acute event in the ICU. The ventilator alarm either didn’t go off, or was not noticed. The baby didn’t have a cardiac monitor - something that would never take place in the U.S. The baby’s breathing tube plugged and then he had a cardiac arrest. He was not noticed for about 5 minutes. I was called stat to the bedside where we performed CPR for the next 30 minutes. During our attempted resuscitation, I removed and replace the breathing tube. The epiglottis and larynx had dramatically improved! But, the baby was dead. My resident, Phillip, informed the family while I tried to remain calm as I discussed the events with the ICU nurses. 

In the end, this baby didn’t die of anthrax, but of poor ICU care. In the US, this would never have happened. We have so far to go in training these people how to care for critically ill patients. They are good hearted people, but training to the degree of US standards comes very slowly. In the meantime, patients die, sometimes unnecessarily.  I’ve been grieving over this baby. More Kenyans have died since then and these people just move on. Death is so much a part of their culture - but not mine. A single death like this one lingers with me and I wonder why it had to happen. There are no simple answers. Some seem obvious, like train the nurses better! But once you learn the details of it, the simplicity goes away. Culture permeates everywhere, even the ICU and culture is slow to change. My prayer is for that sweet baby’s soul, the grieving parents, and those nurses who don’t even realize what they failed to do. I’m not bitter toward them, but just sad that they don’t realize what great things are possible and that fewer have to die. This hospital needs an ICU specialist to come here full time and change their work culture. Short term trips like mine, aren’t enough to change things. I pray that God will call someone here soon to fill this critical need. 

Tenwek is keeping me busy!

Hello, everyone! I'm sorry that I haven't posted as promised. The few times that I've had time, we've had no internet! I've been seeing patients, operating everyday, and giving lectures. Tomorrow I start the morning by giving devotions. I love the fact that part of the residents' curriculum are devotions! I'm talking on Peter and Paul and contrasting their revelations of Christ. It's suppose to be a half hour talk - I planned it to be 20, but likely I'll be rushing it to finish in 30. I hope to post more soon, but it's late and I've been sleeping poorly because of the altitude and the occasional late night surgery.

Feels like residency again - lots of work, poor sleep, and not getting to see my kids! Blessings to all of you from Kenya! (My wife will likely be doing some blogging here! She's been doing some great stuff! Hope you enjoy her sharing!

Arrival - now get to work (& don't sweat the luggage)!

Palpating one of many, many thyroidsAs with most my recent travel, there were a few glitches. Our plane out of Amsterdam was delayed and had to be switched to a smaller version. Fortunately, we were not among he 80 passengers who got bumped. Unfortunately, our luggage must have gotten bumped, because upon arrival in Nairobi – no checked luggage! I had surgical supplies for the OR as well as nearly all my clothes and scrubs. We heard tonight that we'll likely get our bags tomorrow, or maybe the next day...

 Our first consult call came before I even got a foot into the guest house. We had just unloaded from our drive to Tenwek when the guest house phone rang. There were two patients to be seen – the first was a personal friend of the hospital CEO. It gave me a chance to meet him and tell a few stories from last year's mission trip. The second was a 16 year old boy that fell from a motorcycle and broke both sides of his jawbone, ouch!

Both sides of the mandible are displaced

I started the morning by giving a lecture on thyroid anatomy, function and benign thyroid disease. My interactions with the interns and residents during these teaching sessions are amongst my favorite parts of being here. In Kenyan culture, it is impolite to be loud. As a result, they are quiet and very difficult to get to speak up. Nevertheless, I don't believe people learn as well by just passively listening, so I ask a lot of questions and make them interact. It was quite fun! Next week, we'll be discussing thyroid cancer and the parathyroid glands.

Phillip taking a history in clinic -I really need to learn Swahili!The day proceeded with a mixture of clinic and theatre (operating room). Bryan Murphy MD, on his first mission trip to Tenwek took a young surgical resident through his first open mandible fracture. The surgery went well enough that Bryan was able to release him from his IMF (intermaxillary fixation) – meaning that his jaws were wired shut and after the operation could be released – saving him from at least 8 weeks of drinking and eating through a straw! But that wasn't nearly the end. We saw lots of stuff in clinic, but none more interesting than a one year old Maasai baby – who will be the subject of tomorrow's post. So , check back – you won't want to miss that story!

Departure!

We're on our way! Our team of 5 are now camped out in Atlanta with a 5 hour wait for a trip to Amsterdam. 8 hours on the plane, a five hour layover, then 9 hours to Nairobi. My butt is sore just thinking of all that sitting! But, so much nicer than traveling alone (like last year). It's the first mission trip for three of our crew and it's so exciting to see their anticipation. For Stephanie, it's the first time out of the country! What a destination to pick for your mainden international voyage. 

We all realize with humble hearts what a magnificent opportunity this is to serve for God's glory. We depart with open hearts and minds trusting in the Lord's care and guidance. If' this is like my previous trips, we will all return so fully enriched, feeling like we recieved more than we gave - which is opposite of our goal. Your prayers play such an important part! Special thanks to our friends, partners, and family who are looking after our kids, homes, and patients while we pursue God's call. We could not do this without you and your role in sendiing us is not taken for granted. Thanks, God Bless! Onward to Africa!

My last day at Tenwek

As I sit on this plane to Ecuador I realize that it is finally time to write the final chapter on my Africa blog.  If you’ve read my stories from Kenya you may note that they seem to end abruptly- no wrap up, no final thoughts, no happy ending. And therein lays the problem. My final day at Tenwek hospital was one of the toughest I’ve faced as a physician and surgeon.  There are so many things that are different in the United States and despite 5 weeks of experience I encountered new situations on my last day. The issues concern a young mother of two who presented to the clinic with one of the worst mouth cancers I have ever seen. She could not close her mouth because the tumor was growing between her teeth on the right side and filled most of her mouth. She could swallow her secretions and liquids but was not able to chew and thus could not eat solid food. She was suffering constant, agonizing pain. The familiar smell of a cancerous tumor was evident to me from my first encounter. She clearly needed surgery soon as this tumor would soon fill her entire mouth and suffocation would soon follow.  The full extent of the tumor could not be determined -without a CT scan – which brought up our first challenge. Her family was very poor and the $250 surgery to save her life was going to require every financial resource she had. The $70 CT scan was beyond their means but critical to my surgical planning.

Paul reviewing a case with a surgical resident

                I would love to claim I was the answer at this stage, but to my embarrassment I was not. A fellow general surgeon from the US showed me the limits of my thinking and the lack of generosity I still suffer from. He quickly stepped forward to tell the family that he would pay for the scan, stating “we really want to help you.” As I write this it seems like such a simple solution - $70 really isn’t much money to an American surgeon - I’ve tried so many times to come up with reasons for my thoughtlessness but none seem to hold up. In the end, I still have so far to go. I thank God for Paul, the surgeon, whose actions so clearly demonstrate the type of behavior and attitudes that I need to emulate.  (A quick side note: Paul is a remarkable man who spends half the year as a missionary surgeon in Africa and the other as a preacher in a Houston church. He’s a great role model and his humble nature would certainly object to me praising him in this manner so I won’t reveal his last name. He does happen to have a famous brother who is also a preacher in Houston J)

We scheduled her for surgery on Friday, my last operative day in Africa. We turned away another man with cancer because I simply didn’t have enough OR time remaining.  She got her CT the day before and was bringing the films with her on Friday for my review prior to surgery. I still had to make sure we were planning the right surgical approach and that I was prepared for the surgical challenges that lay ahead.  A problem with getting the film read delayed her hospital arrival nearly  all day. We managed to convince the hospital OR employees to stay late to give this woman a chance at this life saving operation. This surgery was her only chance. The next ENT scheduled to come to Tenwek wasn’t arriving until February –much too late, she would not live that long without treatment.  Finally, at 4:00 her films arrived and I got my first look at them.  The film was of poor quality compared to what I typically see in Louisville, Kentucky and they were reminiscent of scans from 20 year old scanners.  I was devastated to see that the tumor was worse than expected. I could not see a clear plane between the tumor and her spine. Was it just the poor quality of the film? Would I get halfway through the operation to discover it had invaded bone and could not be resected? Could I find that it encased her carotid artery and resection would leave her with a massive stroke during surgery? Would I encounter uncontrolled bleeding as I attempted to remove the posterior (back) deep aspect of the tumor? What was the likelihood of her dying on the table?  These questions were overwhelming and I had the OR director asking me to make a timely decision as the OR personnel were eager to go home if we weren’t operating.  Confusing the issue even more was that this was a rare tumor type, a chondrosarcoma. The most common tumor in this anatomic location was a squamous cell carcinoma, a type that carries a much better survival rate than what she had.  I called a quick conference with Greg, an anesthesiologist visiting from Bellingham, Washington and Jason, a full time missionary general surgeon.  I reviewed with them my impressions of the scan and the issues – but neither of them shared my area of expertise and a second opinion was not to be found.  I have great confidence in my CT reading skills but here I was, required to make an immediate call without backup – no radiologist to call, no other ENT’s to bounce impressions off of. I was truly alone with this woman’s life hanging in the balance.  I was able to discuss with Greg and Jason whether it was right to even attempt the surgery. The surgery costs the equivalent of 6 months living expenses for her family and the hospital stay for several weeks of recovery would impoverish the family.  So, even if I was able to get the tumor out, how much of a chance would I be giving her to live and for how long? We quickly looked up some survival numbers – she had about a 25% chance of survival with radiation therapy being used as extra treatment. But, radiation therapy was only available in Nairobi, five hours away and she could never afford it! So, how much would we extend her life and at what cost to her family and for how long? Practical questions must be asked –would she choose to perhaps take away money that would feed her children? Would she give up her life to make sure her family could continue to afford food?

The tumor is bulging out her right cheek. The left edge of the tumor is adjacent to her upper teeth.

In America, even the toughest decisions that I face I share with the patient and family. The patient and family help bear the burden because physicians advise and recommend, but we rarely have to completely make a decision.  I rarely feel that I’m alone- I share my thoughts and rationale with the patient and they bear much of the decision making load. If I have doubts, there are experts in so many accessible places. But here I was, unable to communicate in her language, and dealing with an uneducated patient and family who weren’t capable of understanding all the issues. Talk of tissue planes, pre-vertebral fascia, metastasis, radiation, chemo, etc. were of no use here.

I quickly reverted to my training. I trained with some of the best head and neck cancer surgeons in the world. What would Jack Gluckman, my chairman at Cincinnati and role model, say about this scan and this situation? I imagined his voice in my head counseling me and could feel his comforting hand on my shoulder telling me that I can’t save everyone. I could hear his South African accent telling me some situations are beyond our abilities. I hated hearing those words in training; surgeons are fighters and fixers. We fix things that are wrong! We act! We choose to be surgeons because we’re built for action. Saying ‘I can’t’ isn’t part of the character set that allowed me to succeed in medical school and residency! But, wisdom comes from experience and sometimes experience is a cruel teacher.

I decided that the tumor was unresectable based on my best reading of the scan. Greg and Jason were kind to accompany me to tell the patient. We had to find a translator, who ended up being a native nursing student. What a cruel position to put that poor student in. She had to translate some of the harshest words I’ve ever had to say. I told the family how sorry I was and that we could not operate on her. I then had to tell her there were no options; she was going to die soon and the best we could do was to get her on some morphine to control the pain that would be unrelenting until her death.  Her husband and sister were there as we gave her the news.  The patient sat stunned as tears began to flow quietly down her face. Her sister began a loud and painful wail that remains burned into my memory. She was inconsolable and for the first time in my career I had nothing to offer. No chemo, no radiation, no second opinion, no hope for a cure.  I told them that we have no way of predicting her time left with any certainty but it would probably be 2-6 months.  I didn’t have the heart to tell her the 2-3 month estimate that experience leads me to believe.

Later that night, I ate dinner alone, packed and got ready to leave the next morning. On my last night, I thought I’d be celebrating a job well done and thanking God for the many gifts he has so abundantly blessed me with. I thought I’d be recounting all the opportunities where I felt I made a difference. I thought I’d be blogging about how much I got out of it and trying to inspire other ENT’s to join in the cause. Instead, I lay awake with tears streaming, wondering why my time had to end like this. I’d promised her I’d pray for her but my prayers seemed so inadequate for her needs.  I believe that God can do all things. I wanted God to save her by my chance encounter with her at Tenwek. I wanted to be the healing hands of God, but instead I was the bearer of devastating news. I wanted to make the game saving shot as the buzzer sounded but instead I came up short and the game was over.

I want to perform miracles, but only God can do that. God chooses the time and the place and I’m reminded that witnessing his love and generosity, in the way that I do, is a privilege that few are afforded.  He has blessed me with the skills and ability to perform surgery and in some instances save lives. But, He is in control and I am His instrument when He allows me to be.  With that thrill comes heartache and this was one of the worst for me. I don’t understand His timing or His selection. It is not my place to even question it. But I will bear it and go on with faith that there will be joys in the future and that he will guide my path if I just trust and allow Him to do it. 

Kenyan Medical Care

16 year old with swollen lymph nodes from Tuberculosis (TB) This is my second visit to Kenya this year and I'm learning more and more about his country, its people, and its medical care each day. I want to preface my remarks by saying that I am far from an expert on this subject, but I’m far from being totally ignorant (as I was just 10 months ago)! So, if you have knowledge that differs from mine, please share!

My first visit to Africa was in February where I traveled with Bruce Steffes, MD, the CEO of PAACS. He has spent 25+ years in and out of the mission field and is, without doubt, an expert. PAACS runs 8 residency programs scattered over the African continent. He referred to Tenwek, the hospital I’m serving at now, as the Mayo clinic of mission hospitals. I correctly assumed that it is an advanced hospital offering the highest level of care among mission hospitals. What I didn’t realize until this trip, is that Tenwek provides higher level care than the big government hospitals. During this trip I have encountered many patients who have had poor or inadequate care at these hospitals and present to Tenwek for improved care. One such patient presented last Thursday. The problem was simple enough – she had fallen while running with a stick and it had poked into her right neck just below the jaw line. The government hospital had stitched her up, but the family was concerned that after several days she wasn’t getting any better. After a brief evaluation at Tenwek ER, she was sent to theatre (the operating room) where I assisted a resident in a surgical exploration.

This is no small stick!What we found shocked us all! We cut the stitches loose to drain what we assumed was an abscess only to find that a 2 inch piece of the stick was still embedded in her neck! The government hospital hadn’t even washed out the wound – they just sewed the skin closed! Now for those of you who may not be medical, it doesn’t take much training to realize that when a stick makes a cut anywhere on your body that washing out the wound would be the very first thing to do! We removed the stick, cleaned up the wound, and closed her up over a drain that stayed a couple of days. Unfortunately, this young lady will be left with an ugly scar that didn’t have to be that way.

Kaposi's Sarcoma in a 6 year old with AIDS Another young lady presented after being seen at the government hospital where a biopsy was take of her upper gums and the family was told that they couldn’t tell what the problem was. So, months later, the family came to Tenwek, where in one afternoon period covering about 4 hours, we diagnosed her with HIV, a lung infection that was most certainly from TB, and the gum lesion was a Kaposi’s sarcoma. She had three conditions – all which should have been diagnosed months ago when she presented to the outside hospital. She is six years old and likely in her last year of life. Sadly, this child is in full blown AIDS with an AIDS related cancer that is not curable. After informing the clinical officer of the findings, I walked away thankful that I didn’t speak the family’s language.

Giving bad news is the worst part of my job, but this would have been especially difficult. Her HIV certainly came from her parents, who were both in attendance.  How do you tell a mother and father who are clearly concerned about their child that the end is near? How do you answer the question that’s bound to arise – could the outcome have been any different if the first hospital hadn’t missed the diagnosis? How do you look the mother in the eye when she asks if it’s her fault?

The sad part of the HIV/AIDS epidemic here in Africa isthat it doesn’t have to be this way. Education, includingsex education and teaching about sexually transmitted disease is critically lacking. Testing and preventionmeasures will do more than anti-retrovirals and improved treatments ever will. But, there are so many cultural barriers to overcome. Male promiscuity is an accepted way of life. Prostitution, evenRight lung TB pneumonia with a cavitary lesion evident on this chest x-ray among young teenage girls, is also way too common here.  In a country that surveys show to be 80% Christian, there is a true disconnect between the true message of the gospel

and the behavior of large segments of the population. I pray for my patient’s family, that they will find

forgiveness in Christ. I pray that they will be comforted by a God who loves them despite their circumstances. I pray that they will find peace in Jesus who can lift them from their deepest sorrow. I pray that there is someone who speaks their language who has comforting and guiding words for them. I pray that Tenwek stands as the shining example of medical excellence and compassionate care that this family needs in the days ahead. I pray that next time I can find some better way to help. Finally, I offer my prayers of thanksgiving that my family, safely back in America, has been so abundantly blessed.

Unexpected Blessings

Looking up to the porch for our bible study.

I had fully intended on writing on the Kenyan health care system, but tonight’s events just won’t allow me to focus on anything negative. So, instead let me tell you about the wonderful evening I just completed. Here at Tenwek, the residents and interns meet for bible study every Wednesday evening. Most of the time, the men and women meet separately. But tonight was one of the occasions where they meet together. Tonight’s format was new and different. They did a quiz game on the book of James with men vs. women. The evening featured chai and biscuits. Translated, that means the preferred Kenyon tea mixture of chai tea, sugar and milk along with an assortment of bread and cookies (biscuits). The room was a second floor screened porch area with a warm fire burning. The setting couldn’t have been more perfect (ok, having my wife, kids and friends along to witness this would have been perfect)!

 

Some of the 30 residents, interns, and consultants (like me) who attended.



The night opened with a prayer and some of the most beautiful singing you would ever hope to hear. The voices were loud, strong, and in harmony. The first song was in Swahili and the second was in English. I couldn’t sing because I didn’t know the words but even if I did, the moment was so moving that I wanted to just focus on taking it all in. The songs of praise were so deeply heartfelt and there seems to be no embarrassment in Kenyan culture. Everybody sings their praises! The woman leading the songs could rival any recording star I’ve heard!



Todd (far right) is an engineer missionary who who designed and judged the quiz.



    

The game consisted of 40 short answer questions and 10 long answer questions. There were points for getting it right, deductions for wrong answers, and also for an appropriate rebuttal. The evening was filled with laughter – not the dainty, polite kind – the bellowing laughter that comes from the heart with gusto! I was happy to contribute a couple of right answers but truth be known I was out of my league. I know a little about the book of James but these Kenyans knew verse after verse after verse. They had a knowledge that was both accurate and instant. This wasn’t just a memorize the phone book sort of thing, they had clearly thought about how each memorized piece of scripture applies to their life. Their knowledge was truly astounding. For the first time on my trip, I saw that we could learn so much from them!




Annette, the only respiratory therapist here with African residents and interns.

 

While the judges were tallying up the final score, I shared a bit of my story and how the book of James was responsible for my presence in Africa. James 2:26 says “Just as the body is dead without breath, so also the faith is dead without good works.“  I shared that the Holy Spirit had guided me here to work with PAACS. My original plans were to go on a mission trip to central or south American. But, God’s plans were different and I’m so glad I listened! These residents and interns have been such a blessing to me. They live each day by James 2:18 “I will show you my faith by what I do.” I once again find that my service here brings more blessings to me than what I offer to them.  So, tomorrow I will begin anew to give more than I receive.  This place makes that task a difficult one!

 Listen, my dear brothers: Has not God chosen those who are poor in the eyes of the world to be rich in faith and to inherit the kingdom he promised those who love him? –James 2:5

 

Life at Tenwek

Jason (right) playing guitar is a young surgeon  teaching here in his first year after residency.

Sunday I was invited to breakfast at Barbara Pinkley's home. She's a career missionary who teaches in the nursing school. Homes are not big here by American standards so there were about ten of us tucked around a cozy little dining table. It was quite nice - made me think my dining room at home is way too big! Actually, my entire house is way too big! We then went to worship at the Church on the Tenwek campus. By African standards, it was pretty short at 2 hours. I was invited back to the orphanage for worship but couldn't make it - which is probably good because they ask their visitors to preach!

The pumpkin mashed  potatoes were the best!

Monday was a mix of operating in the morning, a short lull in the early afternoon followed by chaos! I ended up back in the operating room for a biopsy on a man who we'll likely be doing a laryngectomy on soon. We nearly lost him on the table thanks to some bad medicine - which I'll post a story or two on soon! Today was clinic day but I managed to find myself in the OR for three short cases. I had lunch at one of the national's homes where I had a dish they just call "mash." Basically it's a delicious mix of pumpkin and mashed potatoes. Some cabbage, flat bread and chicken over rice gave me plenty of fuel for another chaotic afternoon. Tuesday clinic here is a madhouse. Patients wait for hours and some loose their patience and get angry. But, they are never angry in English, so I don't know exactly what they're yelling. Swahili and Kipsigi sound the same to my ears. There are 58 different languages spoken here in Kenya. The least educated speak only their tribal language. The next group speaks their tribal and Kiswahili while the most educated 20% or so speak tribal, Kiswahili and English. Most children in boarding schools and higher end schools are learning English- a great investment in the future of Kenya!

My one room apartment is the second from the left on the second floor.

I'm staying at the guest house on the hospital grounds. I love being so close to the hospital but ordinary things of life are little harder here.I sleep under a mosquito net, so I won't get malaria. I have to brush my teeth using bottled water so I won't get dysentery. There's running water thats safe to wash your hands or shower in (providing you keep your mouth closed) but you can't drink it. The shower varies from lukewarm to very lukewarm. I've yet to turn on the cold water for a shower which flows at a small slow trickle - feels like you're showering under a drinking fountain. The water will turn your whites a slight brown so I made sure to bring colored shirts. You can eat vegetables as long as they are cooked. Raw vegetables and fruits you can't peel, like grapes, are off limits. But the bananas are so sweet and the pineapples are unbeleviable. Last week, for the first time ever, I ate an entire pineapple at one sitting. I intended to just cut it up and share it later but one bite just led to another... I don't know if there's such a thing as pineapple toxicity, but if there is I'm risking it! I finished the last pineapple in the kitchen last night and five more appeared today! The guesthouse cook is named Livingstone and made this guacamole that was the best I've ever had by far! Well, tomorrow starts with rounds and devotion followed by surgery all day. Tomorrow evening is bible study with the residents. What a great day that lies ahead!


This is the day the LORD has made; let us rejoice and be glad in it. Psalm 118:24

Kitoben Children Vision Centre

Today was a day of great joy for me! Three of us from Tenwek went to a local orphanage to assist in the building of a new girls’ dormitory. When we arrived the children gathered to see us and welcome us to their home. The orphanage is run by a wonderful couple, Alice and Samuel. They have five children of their own who live alongside the 65 orphans. The children come from all over and their stories are varied. Many have lost their parents to HIV/Aids. Some are the youngest in their family and as a result are neglected because the family resources aren’t enough for everyone. Often, they are made to tend to the cattle and are not given the chance to go to school. So, upon entering the orphanage they are suddenly well fed, attend school, and are cared for. They are also taught about a God who loves them and provides for them. Alice has them present memory verses each week at Sunday worship.

Alice and Samuel  the only time they weren't smiling!

Charles, Tom, and me at Kitoben

Eating African style with the fingers!

Tom, a family physician from Kansas City, has been here many times and has worked with this orphanage by providing funding, organization, as well as manual labor. Charles, a retired builder from Kansas City, is here overseeing the construction of the thirty bed dorm. I mostly helped lay brick walkways between buildings. We used the dirt we dug up to place the walkway to do some grating so that water would run away from the housing area and not puddle up near the sleeping quarters. Standing water here means mosquitos, and mosquitos mean malaria for these children! The kids are genuinely happy and I loved hearing their laughter as we worked. The Kenyan adults worked right alongside of us. I was most impressed by the women, who work non-stop including hauling bricks, sand, and dirt. We had a vegetarian African lunch featuring some stringy green stuff, some brown pasty stuff, and some beans that looked like garbanzo but were way better! My only question about the food was to make sure it was cooked as raw African vegetables and my American GI tract do not mix! Prior to leaving, Samuel shared with us the story of starting the orphanage. His friends told him it was impossible, others said he would be harming his own children; others told him he didn’t have the resources or know how. But, he told us he knew that he could count on God’s strength to see them through. He stated “God knows what we have and what we don’t have. I know that I am not strong enough to do this, so we must rely on God’s strength.” 

Pure and genuine religion in the sight of God the Father means caring for orphans and widows in their distress and refusing to let the world corrupt you. -James 2:27