Neil Young, Papal Yogaphobia, and the Power of Prayer

As I intimated in my last couple of post, I’ve been going through a down patch, experiencing some discouragement and burnout.  In our pre-deployment training, we had lectures and sessions on this, and they were helpful, but when you’re in the middle of it, it’s a little tough to see an obvious escape route.

One belief in Christianity is that we often get in the way of our own relationship with God.  The image is one of a door, with you on one side and Christ on the other.  He’s knocking to come in, but the door only has a handle on your side: God’s side of the door is blank.  We often shut the door, and then complain bitterly that God is absent, or doesn’t exist, or doesn’t care.  God is always present, waiting for us to open the door, but it doesn’t work if we close the door, close off the relationship.

Slightly cheesy Bible picture

Reaching for that handle, opening the door, re-establishing relationship with our creator, can be difficult.  Difficult not because it requires knowledge of a certain denomination, or sacrificial practice of an esoteric spiritual discipline.  Difficult not because the key to that door belongs to a certain sect, and not because one needs a mantra or wisdom from a gnome-like guru sitting cross legged in his mountain cave, or in his palace in Rome.

The opening of that door is difficult, because to grasp the handle, we must let go of what we’re holding on to.

From the Gospel of Mark:

As Jesus started on his way, a man ran up to him and fell on his knees before him. “Good teacher,” he asked, “what must I do to inherit eternal life?”…

 Jesus looked at him and loved him. “One thing you lack,” he said. “Go, sell everything you have and give to the poor, and you will have treasure in heaven. Then come, follow me.”

 At this the man’s face fell. He went away sad, because he had great wealth.”

I don’t think this passage was meant to say that everyone is supposed to go out and sell everything and give it to the poor.  If you look carefully, an unusual sentence is inserted into the passage:  “Jesus looked at him, and loved him.”  In his day, Jesus was a hugely popular and controversial figure.  He attracted crowds of thousands wherever he went.  But over and over again in the Gospels, we see Jesus as very “one on one.”  On only a few occasions does he address large groups of people.  Rather, he spent three years wandering around from town to town, engaging individuals deeply.  Touching lepers, dining with people we might despise, confronting the possessed, really “hands on”.

And in this particular circumstance, he stops, looks at this rich young man, looks into his soul,and sees what is preventing this particular person from experiencing God.  In this particular instance, this man cannot reach up and open the latch on the door because he is clinging tightly to his wealth.

The current Roman Catholic Pope Francis is a rock star.  The press loves him, mainly because he embraces humility, poverty, and authenticity, over the trappings of his office.  There was a recent flurry of concern over his comments on yoga!  Is the Pope yogaphobic?  Is he prohibiting Christians from using yoga for core strength or to get those six pack abs? If you take the time to look at what he said, you’ll find this non-controversial statement: “You can take a million catechetical courses, a million courses in spirituality, a million courses in yoga, Zen and all these things. But all of this will never be able to give you freedom”.  The Pope tells us that only the Holy Spirit can “move the heart” and make it “docile to the Lord, docile to the freedom of love”. If we are seeking a zen-like peace from yoga meditation, or wealth, or security, then we are seeking peace from the wrong source.

So the supposed papal statement on yogaphobia also includes a warning that Catholic theology classes (catechetical courses) aren’t the way to go!  It turns out that the path to peace in your heart is just letting that door open, and experiencing God directly.  But again, to do that, you have to put down what you’re grasping.

One of the great poet-sages of our time, Neil Young, captures this pretty well:

Workin’ hard every day
Never notice how
the time slips away
People come, seasons go
We got something
that’ll never grow old.

I don’t care
if the sun don’t shine
And the rain keeps pouring
down on me and mine
‘Cause our kind of love
never seems to get old
It’s better than silver and gold.

I used to have a treasure chest
Got so heavy that I had to rest
I let it slip away from me
Didn’t need it anyway
so I let it slip away.

I don’t know what Neil Young’s spiritual beliefs are, but his song “Silver and Gold” captures exactly the same point.  Holding on to wealth, pride, security, pain, whatever is in our “treasure chest”, gets very tiring.  It’s okay to rest, put down whatever you’re holding on to so tightly, and reach up for the handle on the door.

So I think the Pope and Neil Young would agree:  if what you seek is peace, no amount of striving can get you there.  If you’re burned out and discouraged, trying harder, working harder, wishing people would just see your vision and fall in line, just isn’t going to put you on your zen mountaintop.

One of the advantages of living in a village in Africa is that you can get away from people pretty quickly.  Yesterday afternoon, I was in such a black hole that I couldn’t stand myself.  I put on my running shoes, and within five minutes of old man shuffle, was on a muddy twisty mountain road with dense bush on all sides.

This is a great place to talk with God without looking like a crazy person.  No one to judge you but baboons.  I shouted, I pleaded, I got angry, I let Him know exactly what I thought about my current situation.  But the door was firmly shut.  He was nowhere to be found.  Great.

Just when I need Him, He’s either not paying attention, doesn’t care, or doesn’t exist.

The only thing listening were the baboons, and they had nothing helpful to contribute.

I expected to come back from that run rejuvenated and energized.  After all, I had done my part, I had “gone to the mountaintop”, spent some quality time with God.  It was time for him to do his part.  So why did I still feel so black?

Last evening, we had a dinner engagement at our house with some of my favorite people in Kijabe.  Chege is one of our senior trainees, and his wife Evalyn is a nurse in the operating theatres.  They have a beautiful four year old boy named Nimwell.  They are gentle, loving, kind, amazing people.  Chege is in the middle of a spine surgery fellowship in Egypt, and so hasn’t seen his family in a couple of months.  He’s spending a short break back here in Kijabe, and they were good enough to agree to have dinner with us.

We had a great dinner of Irish stew and mashed potatoes, which, it turns out, is very similar to Kikuyu cooking.  No surprise that mashed potatoes and beef with gravy are everyone’s comfort food.  Great conversation, hilarious stories, just one of those nights of fun and relaxing relationship.  As we stood up to say our good-byes, Chege asked if he could pray briefly.

I’ve heard Chege pray and preach before, and he is a gifted speaker.  But he was moved at this moment to pray for me, to encourage me, to lift me up, to allow me to let go of my treasure chest of pride and insult.

As he prayed, I could feel the anger, resentment, burnout, begin to melt.  I went to bed, and woke up this morning, with the blackness gone, and the enthusiasm and energy returning.

I don’t pretend to understand how prayer works.  I don’t know how Chege knew that I needed prayer to help me let go of my treasure chest.  Theologians could debate paradoxes and mysteries for lifetimes.  But like this laptop, I don’t need to know how it works.  I’m just glad that it does.

I’m heading off on an outreach trip tomorrow, and I wasn’t sure how that was going to work.  The travel, cross-cultural setting, and security measures are all exhausting.  To head into that week depleted looked like a recipe for disaster, and I had contemplated a last-minute cancellation, knowing how disruptive that would be.

But I think that all had to do with what I was holding on to.  And I think my friend Chege saw how firmly I was holding that door closed.  His prayer helped me to just let go of what was bothering me, quit taking myself so seriously, and see the beauty around me.  We hold on so tightly to the chains that bind us, hold on so tightly to what we treasure.  Too often, the peace we seek is right in front of us, but we refuse to accept it.  If you think that might be true in your current setting, I encourage you to pray, find someone to pray for you, let go of your treasure chest, and see what happens when that door opens.

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” … an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”

After my annual evaluation last night, I went back over some of the things I had been discussing with Ann and our team leader Bethany.  Some of the things I was saying really didn’t sound like me:  tired, purposeless, sometimes hard to remember why I came here in the first place.  I do get fatigued here, as much from the cross-cultural differences as from the work itself.  But why was I sounding so negative?  The cross cultural stress inventory didn’t paint a pretty picture.Screen Shot 2015-05-20 at 10.53.50 PM

I got to thinking about burn out.  In the US, physicians experience real burnout at some point in their careers at close to 100% incidence.  Cross cultural living and working also has a pretty high burn out rate.  Hmm, so if I’m a physician in a cross-cultural setting, any chance at all that I might be experiencing a little burn out?

There’s a website call happymd.com which discusses the topic at length.  If any physicians reading this want to learn more about what to look for, I’d recommend you visit.  I can’t speak for other professions, but as a physician, you either have been, are, or will be burned out at some point in your career.

The website defines burnout as being depleted to the point where you don’t bounce back from normal stresses after a day or weekend away from work.  There’s a double edged sword here when in medical work that is also a ministry:  there is no end to the need, no obvious point at which you should go home, say no to another responsibility, or go on vacation.  Serge, our sending agency, is quite intentional about avoiding burnout.  I guess you have to actually listen and take the leadership’s advice for it to work.  But it kind of feels like you’re letting down yourself, the hospital, your patients, your agency, and of course, God.

A researcher named Maslach investigated physician burnout, and describes its effects in terms of physical, emotional, and spiritual depletion.  Burnout leads to fatigue, depersonalization, cynicism, and lack of efficacy.  It has effects on work, marriage, and relationships with family and friends.  She described its effects as ” … an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”

Maslach created an inventory, or questionnaire, to look for and determine the severity of physician burnout.  Just for a laugh, I though I would take the test.  I kind of wish I hadn’t.Screen Shot 2015-05-20 at 10.55.23 PM

On all scales, of physical, emotional, and spiritual burnout, I fell into the “severe burnout” category.  Not good.  Really, quite a wake up call.  I feel like I’m tired, not at my best, but this really tells me I may not be functioning at a very high level.

Thankfully, there is a lot of good work done on what to do with burnout.  Less time at work isn’t necessarily the answer, but looking at what parts of work are depleting, and what parts are energizing, is vital.  The key is to structure the day, week, month, and year, to find ways to engage with those parts of the work which are invigorating, knowing that other parts of the day will be “soul eroding.”

How to reconcile this workaholic, all-responsible, soul-eroding lifestyle with a life of following Christ?  You really can’t.

The message of the Gospels never promises an easy life, or lack of suffering, when following Christ.  But they do offer hope:

I came so that everyone would have life, and have it in its fullest. “(From the Gospel of John).  Or, from the Gospel of Matthew, ““Come to me, all you who are weary and burdened, and I will give you rest.  Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls.  For my yoke is easy and my burden is light.”

I have to admit, right now I’m not feeling I’m having life to the fullest, or finding the yoke easy or the burden light.  I can identify pretty strongly with the weary and burdened part, however.

So my plan is to take some steps to get back to the enthusiasm and energy that brought me here in the first place.  I’m very thankful that taking care of patients has always energized me.  Being part of a team that comes alongside the sick or injured in the healing process, talking with families, working with residents and other trainees, will always remind me of why God put me here on this Earth.

I’m heading off on an outreach trip beginning Sunday, so I will be gone for a week with some Kijabe colleagues.  I’ve been to this hospital before, and find it extremely challenging and energizing.  This small hospital, outside of a small town, in the middle of a large desert, is really striving to provide excellent and compassionate care.  I will have the privilege of doing surgeries with the resident surgeon, as well as teaching a one day seminar on the treatment of orthopaedic surgical emergencies.  I’m excited and grateful to be part of such a trip, and this is definitely part of the work which invigorates and fills the soul.

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Annual Review

Ughh.

Tonight was the night for our annual review.  Both Ann and I had to review our job descriptions, fill out self-assessments, and then complete a “stress survey.”  I accidentally tore the stress survey into a thousand pieces, so I’m pretty sure I didn’t need to take it anyway.

In all seriousness, these are really useful exercises.  Living outside your home country, in a place where the language, culture, and work practices are unfamiliar, is really stressful.  Researchers have found that levels of the stress hormone, cortisol, rise abruptly just by looking at a roadside sign in a foreign language.  Being immersed in a culture not your own creates a constant low level of stress, that needs to be acknowledged and dealt with.

Bethany is our amazing Serge team leader.  I think most people’s first impression of her would be that she is a kind, gentle person, probably suited to counseling or teaching.  Which is exactly what she does!  And she is amazing at it.  We are blessed to have her as our team leader, as she combines great leadership and organizational skills with the compassionate heart of a counselor.

Having a team leader, and being accountable to an organization, might seem a bit odd, but is an integral part of the work here.  Nothing we do is independent:  everything is interdependent, and all of it is dependent on God’s grace and mercy to sustain us.

Our Serge team here fills the role that an extended family might have filled in more traditional societies.  We all fall down, look silly, fail at our appointed assignments.  But we have a group of people who know us at our best and at our worst, and for some reason still love and support us.  Our team is an amazing group of individuals, couples, and families, who we can trust to be there when we just need support and someone to be with.

We meet with our team for dinner every Thursday, and get together on a Friday for a discussion every 6 to 8 weeks.  We look forward to these times, to learning how everyone’s week has gone, what joys and successes, disappointments and frustrations have punctuated the days since we last sat down together.

These dinners have a sacramental quality.  We get together at someone’s house, relax, and break bread together.  It’s fun just to catch up, get up to date on each other’s work, follow up on some concern or problem.  We share a casual dinner, prepared by the host, and then sit down for a time of prayer together.  It really feels like the early church must have felt, and how church could ideally work now.  No big ceremony, just people who love God getting together to be friends and support each other.

So we spent the evening discussing with Bethany our roles here, what has gone well, what has been frustrating, and what changes we could put in place to help things go more smoothly.  It’s encouraging to be part of such a great team.

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Difficult Discussions: Flunking Sainthood Day 24

Busy day in surgery today, as well as seeing consults between cases.  The surgeries went fine, but what was really hanging over the orthopaedic resident and I today was a discussion we needed to have with a patient and his family.  Last week, we worked hard to save the life of the man who had a terrible injury to his pelvis and leg.  You might remember a photograph of a mangled leg accompanied by warnings not to look if you would find it disturbing.

Thankfully, he has stabilized.  He has gone from the intensive care unit, to the intermediate care unit, and today was able to transfer to the regular men’s ward.  His blood pressure has stabilized, and we have been taking him to surgery every two or three days to clean out his wounds, and remove damaged tissue.

The leg is teetering on the edge of being salvageable.  The bones and muscles are so damaged that he has little hope of a well-functioning limb.  Though his hip, knee, and ankle are fine, the areas in between are mostly devoid of functioning muscle, and severely fractured.  We have had discussions with him over the last days, but wanted to have a family care conference today so everyone was on the same page.

His social situation is far more complex than I could have imagined.  He is an orphan.  Both his mother and father have died, but we did not discuss how they died.  His father had three wives, two of whom are still living, so we had the discussion with a dizzying array of uncles, in addition to his brother and older sister.  Decision making authority rests with the patient, as he is lucid and capable of making his own choices.  Kenya has a strongly family-oriented culture, however, so group discussions and consensus building are vital.

The relatives strongly recognize that they may be held accountable by other family members for medical decisions, so they made it clear that they would abide by “whatever the doctors decide.”  This puts a little too much authority in our hands, however, as the final decision needs to be up to the patient.

Thankfully, the family had outstanding English skills, and communication skills in general, and the Kenyan resident I’m working with filled in my language and cultural blind spots.  We had a long and intricate discussion, and each person voiced his perspective and concerns.  I’ve been in discussions like this a number of times, and I’m often struck by the patience, careful listening, and gentle pace of the dialogue.  It is vital for the health care providers to understand the depth and breadth of implications of decisions like this.  In the end, we met privately with the patient, who was markedly comforted by the group consensus.  We discussed his options again, prayed with him, and he expressed his decision.

The plan is to do everything we can to save his leg, regardless of cost, number of surgeries, or length of treatment.  If at any point we feel like the endeavor is hopeless, or is putting his life at risk, we will communicate this with the patient and with the family.

For this man, I think this is the best decision.  If things go well, his leg will work a little better than a prosthesis would.  Moreover, his psychological and social situation would make amputation an unusually devastating blow.  He and his extended family realize that this is a real possibility, but they would all rest easier with this decision knowing that every effort had been made.  Remarkably, one of the uncles present is on a disability awareness council, and repeated the mantra that “disability doesn’t mean no ability.”  He is encouraging his nephew that, regardless if he winds up with an amputation or not, he can continue with a productive life.

I feel privileged, if also saddened, to be part of discussions like this.  Kenya is a country with a high incidence of motor vehicle violence, and few doctors to treat the suffering.  We may or may not succeed in saving this man’s leg, but I am pleased that he knows he is cared for by his family and by the staff here at Kijabe.

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Weekend Away: Flunking Sainthood Day 23

Twenty three days ago, I committed to writing a blog for 28 days straight.  I got this idea from a book called “Flunking Sainthood” by Jana Riess.  In it, she attempts one spiritual discipline per month for a year.  She’s not quite successful in any of them, but learns a lot in the process.  I feel I’m authentically following her book, as I’ve now failed to make the 28 consecutive days, I feel I’m authentically reproducing Jana Riess’ experience!

The Higgins and Mara families took off for Nairobi for a weekend away.  Ann found a funky lodge (with no internet:  thus flunking my 28 day commitment) south of Nairobi, in a town called Karen, which was reasonably priced and close to the amazing Sheldrick Trust Elephant Sanctuary.  The trust is an amazing organization which rescues orphaned baby elephants from the wild.  Generally, the mothers have been poached for their ivory, leaving the babies to die.  The Sheldrick trust has a hotline which tribal herders, game wardens, or anyone worried about a baby elephant can call.  They then dispatch an emergency flight with veterinarians and technicians, to pull the elephant out of the well or away from the pack of threatening hyenas.  The team then returns to the sanctuary, where the baby is nursed back to health.  The baby elephants then go through an eight year re-introduction period, and are eventually released back to become wild elephants.  They have an extremely high success rate.

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Curious ostriches oversee the baby elephants’ rehabilitation

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Rescued Rhino and Happy Boy

Rescued Rhino and Happy Boy

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In her element!

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Hard working dung beetle, trying to stay out of the way of the elephants

Hard working dung beetle, trying to stay out of the way of the elephants

Future Veterinarian

Future Veterinarian

Babies coming in from the bush for their bottle of warm milk and a nice soft bed!

Babies coming in from the bush for their bottle of warm milk and a nice soft bed!

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We had an extremely relaxing weekend, lots of laughs and very muddy kids.  The drive home was a little more eventful than we would have liked, but we returned to our little house in Kijabe safe and sound.  This week is the centennial celebration for the hospital, so lots of events, speeches, and dignitaries.

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Another Long Day

Today was a tough one, long day, starting with a tense meeting.  Blaming, half truths, not much progress.  Patient care is always the way forward, though.  Dr. Higgins tackled some tough cases in Room 8, I worked with some residents in theatre 6.  Our first patient was a guy who had a terrible elbow fracture, a pedestrian who was hit by a car.  His elbow was shattered, and had protruded out through the skin.  He had had a surgery a few days ago to clean things out, so was ready to have his fractures fixed.

These are really tough fractures, and I enjoy fixing them.  It’s gratifying to take a “bag of bones”, as it’s called, and end up with something that works like an elbow joint.  It took about three hours, but the pieces came together pretty well, and I’m hopeful he’ll have a good recovery.

Next was a very unfortunate 11 year old boy, who had suffered from tuberculosis (TB) of the ankle.  The TB had healed with treatment, but his ankle joint was destroyed.  This left his foot fixed in an awkward position, like a ballerina standing on her toes.  Furthermore, the involved leg had been so damaged by the infection that it was about four inches shorter than the opposite leg.  This left him with a bizarre and painful gait.

Dr. Higgins emailed his pictures and data to a paediatric limb deformity correction specialist back in Salt Lake City, Utah.  The doctor there put the young boys measurements through a software they use for deformity correction!  He emailed us back the specifications for the surgery, and we did that today.

First step was to correct the deformity.  I took a wedge shaped piece out of the front of the fused ankle, which allowed us to move the ankle back into the proper position.  This was then fixed with a special angled device Dr. Higgins had brought with him from Utah.  This worked beautifully, and we sewed him up.  Now time to address the limb length deformity.

The doctor in Utah had calculated that if we stopped the function of the growth plates of the opposite leg at both ends of the tibia (shin bone), then as he grows, the previously infected leg would catch up in length with the well leg just as his skeleton stopped growing at about age 18.  We made four tiny incisions, one on either side of the knee and one on either side of the ankle.  We drilled and placed some robust screws across the growth plates, immediately stopping the lengthening of that shin bone.  He’ll have very little pain on this side, and can start walking with crutches immediately.

He’ll be in a cast for about six weeks, and can then start walking on his new ankle.  The exciting part of this case, is that it involved equipment and expertise imported by Dr. Higgins from Utah, but was accomplished by Kijabe Hospital.

Pretty tired and going to call it a day.

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Sean and Amy need your prayers

I saw a patient a few weeks ago who has really stuck in my mind.

Sean is 31, a gentle, kind person.  Amy, his wife, looks like a kid to me.  They have been married for only three years.

Sean started having pain in his left leg in October.  Strange, because he hadn’t injured it, but it got worse and worse.  Finally, he couldn’t sleep, and it was difficult to walk.  He decided to get it looked at.

He brought the X-ray to us several weeks ago.  Certain X-rays give you the chills.  A poorly defined hole in his tibia, just above the knee.  Ragged edges, hard to say where it began and ended.  The thick walls of the bone eroded from the inside out.  X-ray experts, the radiologists, call this a permeative lytic lesion.  In all but the luckiest of circumstances, this equals cancer.

The only way forward is to get answers, a biopsy.  This is a surgery, where we take a piece of the tissue and surrounding bone, and send it to the lab, where the pathologist looks at it under the microscope.  We got his report back, and asked him to come in to the clinic to discuss the results.

His pathology report was grim.  Sarcomas are a rare form of cancer.  In orthopaedic surgery, in the US, a surgeon would see a few in his or her career.  Here at Kijabe, we see several a month.  All sarcomas are cancerous, and most require amputation of the affected limb, as well as chemotherapy and radiation therapy.  Survival rates are not high for some sarcomas.  This is among the worst I have ever seen:  a high grade, very malignant cancer.  My gut feeling is that he has several months to live.  I would love to be wrong.

There is no good way to give a person bad news.  As I looked at this young couple, I had information in my head which I knew would devastate them.  I wished I could just make it go away, just not tell them.  But the horrible truth was real, was in their world, they just didn’t know it yet.

A trivial analogy:  When Ann and I were first married, Ann moved from her beloved Ireland to Bend, Oregon, USA.  Nothing could have been more foreign to her:  long chats over a cup of tea were replaced by bragging over a long run or epic ski session.  She felt isolated, alone, a foreigner.

Bucci was a mutt Border Collie mix, the most gentle, quirky, loving dog you can imagine.  My beautiful old yellow lab, Betsy, had died, and Ann had gotten Bucci from the Humane Society to ease my grief.  It worked!  Though I’ll never forget Betsy, Bucci was comic relief, an insanely smart and nutty little rascal.  Amazingly, Bucci also eased Ann’s transition to life in the US.  He was her constant companion, easing her loneliness as she adjusted to West Coast culture after living in Africa and Ireland her entire life.  He became our “fist born”, a beloved member of the family, before we ever had children.

My mom was sick with cancer at the time, and we went down to Florida to visit her.  We put Bucci up at a doggie resort, where dogs could play all day and rest comfortably in their quarters at night.  We were so infatuated with this little dog, that we missed him and decided to check in with the kennel owners from Florida.  Cell signal was poor on the little island where my mom lived, so we had to stroll down a sandy lane as I rang the kennel.

“Hi, it’s Mike Mara, just calling to check on Bucci.”  “Oh, sorry to tell you, he jumped the fence, got hit by a car, and died yesterday.  We were going to call you.”

Shock.  Grief.  Then the realization that I had this devastating news in my head, and Ann, walking by my side, did not.

I remember wishing I could just keep the news inside my head.  By speaking it out, it becomes a reality, causes shock, harm, pain, suffering.

As I said, a trivial example.  A dog versus a man, a son, a husband, maybe someday a father.  I’m not comparing the two situations.  Just the idea that you wish some things didn’t have to be said.

Of course, the reality pre-exists the knowledge.  Sean had cancer before we did the biopsy, before the biopsy result came back, before he or I knew he had cancer.  But the devastating news doesn’t enter his reality until I speak it to him.

As I spoke the grim news to him, I could see that I wasn’t getting through.  My swahili is poor, but his English was excellent, so I couldn’t figure out quite what was wrong.  I asked one of our Kenyan residents to come in and try to help me communicate this news.

It turns out, the word cancer can be interpreted different ways here in Kenya.  It isn’t quite as clear as I would have thought.  We had to carefully and painfully explain that the problem in his leg had the potential to spread to his lungs, his brain, other bones.  That it could shorten his life.  That treatment would involve chemotherapy, maybe radiation therapy, and amputation.  Cruelly, the only way amputation would not be necessary was if he had such a short time to live that amputation would not be helpful.

How does a young couple receive such devastating news?  I can’t imagine.  I wish I didn’t have to.

We made practical steps.  I phoned a colleague who had connections with a top oncologist in Nairobi, one who welcomed Kijabe patients regardless of ability to pay.  I wrote a referral letter, and carefully explained to them what the next steps would be.

Then, with the practical matters addressed, the real issues sit before us.  A young, recently married couple, dreams of a life and family together, cataclysmically interrupted by a visit to the clinic.

We sat together for a few moments.  His head on the examination table, cradled in his arms, crutches by his side.  Her crumpled over, wide eyed and disbelieving.

We prayed.  Together.  We prayed for healing, for strength, for Amy to be a strong support as Sean went through treatment.  We prayed for Sean, that he would be healed, whether miraculously, which is rare, or through surgery, chemo, and radiation therapy.  Almost equally as rare.  We prayed because that is all we could do, to turn to a compassionate God who watches and suffers with His children.

I don’t know what will happen to Sean, or Amy.  But they know they are loved, by the staff at Kijabe, by a God who suffers with them, by a God who knows suffering.  I am grateful to serve at a place where prayer, love, compassion, and kindness are expected, not mocked.  Please join me in praying for them over these next few months.

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Hard things are Hard

Mountain biking is our mental health break around here.  There’s a group of four or five of us who get out two or three times a week, sometimes a quick loop around a favorite trail, sometimes a huge climb up the rift and back down to Lake Naivasha, sometimes an exploratory probe to find new trails.  Our regular trails have names that reflect their personality:  Lunatic Express, an insane twenty minute 2,000 foot adrenaline-charged descent; Wall of Pain, self explanatory; Red Eye, named after a guy who touched the wrong plant and went blind for a little while; Brick yard, after Dr. Brick who fell off it and broke some bones; Awesome Sauce, a swoopy gentle high speed descent below Kijabe; and finally, Grave Yard; don’t want to talk about that.  I’m pleased to say I’ve never had a trail named after me, as it’s never a good thing.

Hard things are hard.  There’s no way to get up Wall of Pain without suffering.  There’s now way to get down Lunatic Express without a little fear creeping in around the edges of exhilaration.

When I was first in practice, I found certain cases really hard to do.  I love hand surgery, have loved it since the first time I saw a slide projected of the internal anatomy of the hand.  But there were a few hand cases I was concerned I wasn’t giving the patient the best possible care.  So I went back to school, spending a year at the University of Utah, studying hand surgery.  There, I got to work under the tutelage of four accomplished hand surgeons, Dr.s Hutchinson, Coleman, Rockwell, and Wang.  These were highly trained university hand surgeons.

And I noticed something.  Hard cases were hard for them, too.  They had more skill, more knowledge, training, and confidence, but when they ran into a case that I thought was hard, they thought so too.

Like the Wall of Pain, there were some problems, some surgeries, which just couldn’t be faced without some suffering.

I’ve seen this again here at Kijabe.  We struggle with orthopaedic problems that just aren’t in the books.  We think, we read, we pray, and then we give it our best shot.  These cases are hard, there’s no getting around it.  They would be hard anywhere, with any doctor.  This is reinforced when we have gifted academic surgeons come work with us and teach us:  cases that we think are hard, they think are hard too.  This is actually reassuring to us here, to see the masters struggle with the same cases we would struggle with!

Several time in my life, I’ve run into situations which were hard.  Sudden and tragic death of someone I loved, lingering cancer deaths of my parents, betrayal of business partners…

These things are hard.  There’s no way to get through them without suffering.

Too many people, books, and websites offer “solutions.”  “Oh, you’re in the anger stage of grief, don’t worry, you’ll go through bargaining and depression, then you’ll learn to accept it.”  Give me a stick….  There aren’t solutions to some problems, they’re just hard, and you suffer through them.

One thing that helps me believe in the Christian faith is that it doesn’t shy away from the hard stuff.  A faith born in the suffering of slaves, the God of Abraham hears the cries of the Israelites.  After a period of exultant walking with the God who delivered them from the cruel slavery of the Pharaoh, the story of this downtrodden people continues with betrayal, and a return to enslavement by the Babylonians.  Throughout this long history, the story is one of a suffering people and a loving God who relentlessly pursues, forgives, and redeems them.

This story is full of prophecies of a messiah, a Savior, who would once and for ever redeem this suffering people.  When he finally arrived, few recognized him.  When he claimed to be the prophesied redeemer of his people, the idea of a humble suffering servant was repulsive to the existing Institutional Church, and threatening to the Roman Empire.  He had to be done away with, in the most cruel and humiliating manner available at the time.

I don’t believe in a God who is distant and ethereal, a disembodied deity floating around above it all.  I believe in a God who was conceived in disgrace, swaddled in a cow’s stall, was forced to flee a genocidal massacre as a baby, and who’s career lasted all of three years before he was convicted of a capital offense.  Dead at 31.

It’s comforting to know, when I think things are hard, that I can turn to a God who probably looks back on his short lifespan here on Earth as pretty hard also.  Like a true friend during hard times, He can just be there, be with me, and not have to try and solve the problem.

The fact that my faith doesn’t depend on things going well, on things being easy, actually encourages me.  When I look backwards over my life, I can appreciate that God has always been there, even when I didn’t recognize him or even believe in him.  I don’t need to know what the future holds, because I know the same faithful God who endlessly stood by the feckless Israelites, and who sent his Son into this mess, has my future in his hands.

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Mother’s Day

There must have been some time in the past where I did Mother’s Day right.  I know I did for my mother, but too often, I’ve been on call for Mother’s Day.  This past Sunday was no exception, so I get the giant L for loser this year.  But Ann and the kids had a great day, heading off to Crescent Island for a hike with our good friends Thomas, Meghan, Corine, and Owen.  Crescent Island is really a peninsula, curving out into Lake Naivasha.  If you’re familiar with the movie “Out of Africa”, this is where many of the game scenes were filled.  It’s about 45 minutes drive from here, and always worth a visit.  There aren’t any lions there, so it’s one of the few places where you can comfortable go for a hike, and bring a picnic, surrounded by African game.

Today was a great but tiring day at work:  rounds begin at 6:15, a meeting, followed by surgery.  Most of today was taken up by completing the “flap surgery” on the poor man attached with a machete, who was cancelled last week because of infection.  We washed out his elbow and hand today, and rotated a “reverse radial forearm tendo-fascio-cutaneous flap” to cover the hole in his hand and fix the tendons that had been cut.  I’m still a little worried about infection, but he’s on some good antibiotics and we’ll hope for the best.  Tomorrow, a 7 am meeting with the head of physiotherapy for some planning, and then administration work and probably some surgeries!

Here are some pictures of the kids’ fun time at Crescent Island.

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Mucky Kids

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Traffic Jam

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Rainy Day at Crescent Island

Back Home, the Rains are making the garden bloom

Back Home, the Rains are making the garden bloom

Mother's Day Love from Michael and Jane

Mother’s Day Love from Michael and Jane

Michael putting some dead animal bones to good use.

Warrior Michael putting some dead animal bones to good use.

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Four happy kids on a hike

Four happy kids on a hike

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French Toast and Trauma: Warning, Disturbing Image

Weekends are hard to predict around here.

I’m on trauma call for the hospital, so I need to stay close to home and close to my phone.  But beyond that, life goes on as usual.  Saturdays and Sunday are great family days, we try to sleep in, make coffee, and I’m on breakfast duty.

Saturday morning French Toast, Bacon, and Hot Coffee

Saturday morning French Toast, Bacon, and Hot Coffee

The kids get “screen time”:  Finding Nemo for Jane, Minecraft or reading books for Michael.  It’s the cold and rainy season, so a roaring fire and fuzzy PJ’s are mandatory.

Contented and Cozy

Content and Cozy

It’s great not having to rush off somewhere or have anything to do.  I make my way down to the hospital storage room to organize some donated equipment and get rid of a huge pile of useless junk.

The kids have friends within walking distance, RVA has high school rugby games to go watch, and dinner plans with great friends round out a perfect Saturday.  A peaceful start to the weekend.

Organizing the Store Room

Organizing the Store Room

Sunday is another story.  My phone jars me out of a sound sleep, the screen tells me it is the ortho resident calling.  I don’t really know what time it is, I just know it’s dark.

“28 year old guy on a piki (motorcycle), hit by a bus about 4 o’clock this morning.  Pelvic fracture, bad open floating knee.  Has had 4 units of blood, his BP is 100/50, and we’re on our way to theatre. His Hemoglobin level is 5 after the third unit of blood”  To translate, this man is bleeding to death, he has already lost at least two thirds of his blood volume.  Only healthy young people survive such blood loss, but they can die very quickly once their ability to compensate is overwhelmed.

Okay, I’m awake now.  I volley back some questions:  is the pelvic fracture stabilized with a binder, does he have two IV’s flowing wide open,  is more blood available, is he alert, can you feel a pulse in his leg, have antibiotics been started, has he gotten a tetanus shot, any chest or abdominal trauma, has his c-spine been cleared?

Yes, yes, yes, yes….The systems have worked, protocols have been followed, and this young man is going to have the best chance he can at survival and keeping his leg.  I’d like to repeat that sentence 10 more times, because it is amazing.  At this little hospital clinging to a muddy hillside in rural Kenya, this patient is receiving world class trauma care.  This is all down to the excellent work of the junior residents who met this man in the emergency department.  We don’t have a sophisticated lab to know his acid-base balance, we don’t have invasive monitoring to know his exact fluid resuscitation status, but within our abilities, every possible thing has been done, and is being done, to save this man’s life and limb.  In medical parlance, we move into “damage control” surgery.

The goal of damage control surgery is to stabilize the patient, quickly clean wounds, stop bleeding, and  get him into the expert hands of the intensive care unit doctors.  Damage control does not involve meticulous repair of wounds or fractures, just quickly trying to move him out of a life-threatening situation.

I gulp down a cup of instant coffee to clear my head and walk into the pink sky of the breaking dawn and down to the operating room.  The patient is just being wheeled into theatre, and I introduce myself and talk to him, in as reassuring tones as I can, about his injuries.  I’ve had more than one patient here with these same injuries never wake up from surgery, but he doesn’t need to know that right now.  “Your blood pressure has stabilized, things are looking good, we’re going to clean up your wounds and begin stabilizing your broken bones.”

With that, the nurse anesthetist gets him off to sleep while we stabilize his neck.  He hasn’t yet gotten an Xray of his neck, and has no pain there, but could easily have a broken neck and not know it.  The pelvic and limb fractures are painful enough to mask the pain of other injuries, so we always assume the spine is broken until proven otherwise.

The leg looks bad.  The thigh bone (femur) is broken and sticking out the front.  A large segment of the tibia bone is missing beneath the knee, and there is a clot of blood behind the knee.  Through my gloves, I can feel a pulse behind his knee, so we know the main artery to his leg is intact.  With a doppler probe, we can see that he has good blood supply to his foot.  So the leg is probably salvageable. But that clot behind the knee looks ominous.  We leave it alone, to be looked at more carefully a bit later.   Before he went to sleep, we had tested his ability to move and feel his toes, and this was normal.  Some reasons for optimism.  But the clot worries me.

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Floating Knee:  Open Fractures of the Femur and Tibia

Floating Knee: Open Fractures of the Femur and Tibia

We wash debris, paint chips, gravel, sand, and pieces of his trousers out of the wounds.  The fractured ends of the bones are tattooed blue from the paint on the bumper of the bus.  We meticulously clean everything, excising dead tissue, until the wounds look clean.  The residents and I install an external fixator, a stabilizing device which uses pins inserted into the bone to attach to a carbon graphite frame.  This can be applied in a matter of minutes, from his upper thigh to just above the ankle, to provide some stability to the leg.

The patient is getting cold.  Hypothermia, or below normal body temperature, is a common and ominous sign in severe trauma.  We get hot water bottles and blankets to cover every square inch of the patient that is not being operated on.  A cold patient can have severe metabolic disruption, including losing the ability to clot his blood.  This can be irreversible and fatal in a severely injured patient.  We turn the room temperature up to 86 degrees Fahrenheit.  While garbed in hats, masks, gowns, and lead vests, this becomes very uncomfortable, but is standard trauma protocol.

The wounds are clean, the fractures stabilized, and now it is time to go back and look at that clot.  I carefully place retractors to hold the surrounding tissues out of the way, and gently remove the clotted blood.  Before the case started, I had insisted that everyone in the room was wearing eye protection.  And this was why.  As I removed the clot, bright red blood began spraying out of the wound.  We had found the reason his hemoglobin blood levels were so low.  As the bumper of the bus hit his leg, one of the bone fragments had torn a hole in an artery in the back of his leg.  Gentle fingertip pressure stopped the bleeding, and we called for the talented general surgeon, Dr. Jack Baraza.

Jack was waiting in the wings, and quickly arrived to calmly explore the vascular injury.  There are three vessels which supply blood to the lower leg, and two were still intact.  So the repair was a simple matter of isolating and tying sutures around the offending blood vessel.  We rechecked the blood supply to the foot, and after a few tense moments, were rewarded with pink toes and a visible pulse on the doppler ultrasound screen.

Dr. Baraza checking the blood supply to the foot

Dr. Baraza checking the blood supply to the foot

Thick dressings are applied, a plaster splint reinforces the external fixator, some other wounds are quickly sutured, and the patient is ready for transport to the ICU.  He has a long and difficult struggle ahead of him.  The next 48 hours will show us how much reserve he has left.  As he stabilizes, we can begin to plan reconstructive surgeries to fix his pelvic and femur fractures, and restore the bone missing from his leg.

I walk back home to an empty house.  Ann and the kids are enjoying Mother’s Day by going on a hike at Crescent Island with some friends, so I have some breakfast and get ready for a nap.

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