10 questions to ask before sending a medical missions team (7/5/15)

Our Medical Director, Dr. Mardi Steere, just posted this insightful blog.  Hospitals, clinics, and health systems in the developing world can be fragile.  Here are some questions to ask to ensure that your short term medical missions trip empowers everyone involved.

10 questions to ask before sending a medical missions team (7/5/15).

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Of Fibonacci, Logos, and Chaos: a Theology of Surgery

I believe our world is broken.

I believe our reality includes suffering, chaos, loss, and death.

I believe it wasn’t meant to be this way.

Turning and turning in the widening gyre
    The falcon cannot hear the falconer;
    Things fall apart; the centre cannot hold;
    Mere anarchy is loosed upon the world,
    The blood-dimmed tide is loosed, and everywhere
    The ceremony of innocence is drowned;
    The best lack all conviction, while the worst
    Are full of passionate intensity.

WB Yeats “The Second Coming”

Anarchy is loosed upon the world.  As in every age, this age seems ruled by the headlines.  ISIS, Leukemia, divorce, war.

Partisan hatred, global warming, spiraling health costs, corrupt institutions.

Young men so devoid of purpose they grasp at fundamentalist straws.  Crowded cities conceal suicidal loneliness.  Young women defined by ad agencies, dying to be thin.

Those south of the equator dying from too little food, those north of it from too much.

I believe it wasn’t meant to be this way.

The falcon spins away from the falconer in the widening gyre.  Society, decency, kindness, gentleness, overwhelmed by division, violence, hatred, ignorance.

But I believe it wasn’t meant to be this way, and Yeats catches himself in a contradiction.  The falcon turns away in an ever widening gyre.  Let’s back up a bit.  A gyre is a spiral, extended into space in three dimensions.  A gyre has structure, mathematical perfection, elegance.  A gyre is the opposite of anarchy.

If we look at the falcons’s gyre, or the arrangement of petals on a flower, or the shell of a chambered nautilus, we find a numerically perfect order, or logic, which in mathematics is called the Golden Proportions.Fibona52  Fibona50 Fibona51

The golden proportions are defined by a simple series of numbers:  0 1 1 2 3 5 8 13 21 34 55 89…..  Add two numbers together, and it creates the next number in the sequence.  This series of numbers is called the Fibonacci sequence.  Divide any number by the number before it, and the result comes out approximating an infinitely long number that starts with 1.618033988749894848204586834.  This number is the golden proportion.  The further out you go in the sequence, the closer the ratio comes to the golden proportion.

What does the golden proportion have to do with chaos, a broken world, and surgery?

It turns out, the Fibonacci sequence and resulting golden proportion are more than a mathematical curiosity.  If we look to nature, we find this order, this organizing principle, everywhere.  Subatomic particles arrange themselves according to the golden ratio.  Galaxies rotate in values proportional to the Fibonacci sequence.  Plant leaves arrange themselves, nautilus shells spiral, pine cones, roses and sunflowers all dance to the music of tFibona48he golden proportion.  Computer programs and search engines rely on the Fibonacci sequence.  Most remarkably for me, the length of the bones in our hands follows a Fibonacci sequence, so as we make a fist, we echo the grace of the spiraling nautilus shell.

The bones of the hand describe a Fibonacci sequence

The bones of the hand describe a Fibonacci sequence

So the falcon, even as he ascends away from the falconer, even as things fall apart, describes an arc which betrays the underlying grace and structure of his being.

How can this be?  How can this world of chaos reveal an underlying structure, an underlying organizing principle?

I believe a clue to this mathematical marvel can be found in the Bible:

In the beginning was the Word, and the Word was with God, and the Word was God.  He was with God in the beginning.  Through him all things were made; without him nothing was made that has been made.  In him was life, and that life was the light of all mankind.  The light shines in the darkness, and the darkness has not overcome it.

This beautiful poem was originally written in Greek, and is the opening verse of the Gospel of John.  The word “word” was originally written as the Greek word “logos.”  We don’t have an exact translation of “logos” into English, but it is the word from which we get logic.  The idea of logos is structure, order, the premise upon which everything else follows.

You’ll notice that the opening verse of this poem is identical to the opening of the Hebrew book of Genesis, the opening words of the Bible:  “In the beginning…”

This puts us intentionally at the beginning of time, the beginning of existence, physicists would say at the moment of the big bang.  And the author of the Gospel of John tells us that God was there, in the form of order, in the form of an organizing principle, in the vibration and spin of the subatomic particles that would give rise to galaxies, stars, planets, earth, and life.

The Logos was there at the beginning, and the darkness has not overcome it.  The falcon’s gyre is ever widening, he cannot hear the falconer, but even in his betrayal, he cannot escape the inherent order of his being as he ascends in a graceful spiral.  This world was created, by whatever means you may believe, but I believe it was created for order.

The Jewish and Christian faiths share what anthropologists call their “creation myth.”  Myth in this sense is a technical term which means a story of ancient and important truth.  We tend to use the term to mean untrue, mythical, like bigfoot.  But anthropologist recognize that creation myths hold great truth for their culture.

The Judeo-Christian creation myth began as an oral tradition, and was eventually written down as the book of Genesis.  Christians believe it is inspired revelation, and there are various interpretations as to how it should be read.  Regardless of interpretation, we see a world created in Logos, in order, in perfection.  Only when mankind chose pride, knowledge, and power over kinship with the Logos did things fall apart, and mere anarchy was loosed upon the world. 

So I believe our world is broken.  It was created for logos, for order, for perfection, for shalom.  But separation from the Logos, the creator, leaves us with mere anarchy.

This would all seem a bit dark, but for one thing.  Christians also believe that the Logos, the organizing principle of the universe, returned, and entered human history, entered time and space, as a human being.  He entered this world of anarchy, and by perfect Logos, perfect order entering this world, he redeemed it.  He began the process of restoring it to its rightful state.  He didn’t come only to save souls, to redeem individuals, but to redeem creation itself.

What would this look like, a redeemed creation?  I can’t begin to imagine.  It’s easier for me to imagine what it is not: it is not suffering, it is not loss, it is not loneliness or death, it is not painful separation from our creator.

From the standpoint of a surgeon, a redeemed creation does not include broken femurs, shattered pelvis’, or children with bone infections or incurable tumors.

There is no doubt in my mind that we live in a dark world, but I take hope in the fact that “the light shines in the darkness, and the darkness has not overcome it.”

Yeats stumbles again when he declares that “the best lack all conviction.”  I believe this is precisely where he was wrong, and I believe this is precisely how the darkness cannot overcome the light.  God calls us to be that light, to work with and be part of the Logos, the redemption of this broken world.  He calls us not to lack conviction, but to stand convicted.  To struggle in the chaos,to lose our way, but in our efforts describe the breathtaking spiral of love, compassion and beauty we were created for.

For a surgeon this means working to restore the order of the human body, approximating the way the Logos intended it to be.  It means healing those who can be healed, and comforting those who cannot.  It means teaching others to view their job as their calling, as a priesthood, as a privileged servant-hood allowing us to shine the light of God’s love into the darkness of suffering.  It means being the light to those overcome by the darkness as we cling to the hope of the redeemer, the centre that will always hold.

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A VIP Visit to Kijabe (Flunking Sainthood Day 13)

Thursdays are often a busy day for Kijabe orthopaedics.  As the weekend draws near, we try to strategize so patients aren’t left waiting for surgeries on the weekend.  We’re not always successful, as the constant stream of injured patients keeps our plans shifting continuously.  But we try.

For the last two years, I’ve been taking care of a young lady from the local girls’ school who suffers from a number of medical conditions.  She has rheumatic heart disease, and chronic osteomyelitis (bone infection) in both her arm and leg.  She had a surgery about a year ago where an antibiotic-impregnated spacer had been placed in her leg bone.  She came in because the spacer had eroded out of the skin, leaving a large wound and exposed bone on the front of her leg.  We did a “flap” surgery where a muscle is moved from the back of the leg to the front, and then covered with skin graft, to close the defect in her leg.  This should take care of the problem, though she does have a chance of the infection coming back someday.

Following this surgery, I left the next patients in the very capable hands of one of our surgery residents, Dr. Shelminth.  I checked in on her from time to time, but she is very capable and finished the rest of the surgery day without difficulty.  This wraps up many of the surgeries we needed to get done before the weekend.

This gave me time to prepare for the arrival of our VIP visitor:  Dr. Vincent O’Neill, Ireland Ambassador to Kenya!  Dr. O’Neill is a physician who has practiced in various African countries, working with HIV and community health.  Eventually, he saw the opportunity to make a difference in the political realm, and entered the diplomatic world.  Ireland has not had an embassy in Kenya in 30 years, so Dr. O’Neill has been tasked with re-opening the Irish Embassy in Nairobi.  Ann and I had had the pleasure of meeting the ambassador and his wife Brona at some Irish functions in Nairobi, and he was good enough to come out for  a tour of the hospital.

After the first surgery, I make my way up to the house to grab a quick cup of coffee, and there was a large refrigerator in the middle of the road at the bottom of my driveway.  The beautiful thing about living in Africa is that this sort of thing requires no explanation.  There is a refrigerator in the middle of the road simply because someone put it there.

A Refrigerator

A Refrigerator

Kijabe and Ireland have some unexpected connections.  Ireland has sent missionaries to Kenya, primarily priests and nuns, for generations.  These are humble servants who come to teach, to build hospitals and schools, to provide food security.  Some of the people in highest leadership at Kijabe were taught by Irish nuns in Kenya.  Recently, the Irish-Kenya association donated three highly specialized mannequins to train emergency providers in the resuscitation of children.

Most remarkably, Ireland has a direct connection to the surgical training we do here at Kijabe.  Our programs are certified through a “college without walls”, the College of Surgeons of Eastern, Central, and Southern Africa (COSECSA).  COSECSA is founded by African surgeons, with offices in Arusha, Tanzania.  But much of the curriculum development, assessment tools, conduct of examinations, and logistical support, comes from the Royal College of Surgeons in Ireland (RCSI).  RCSI, through a collaboration with  COSECSA and IrishAid, helps make it possible for us to teach surgeons in Africa.

Ambassador O’Neill texts that he is approaching Kijabe, and Ann and I make our way to the front gates.  We were delighted when we saw the SUV with red diplomatic plates and the Irish flag streaming in the wind. IMG_5011 The ambassador was quickly ushered in for a tour of the hospital and meeting with the hospital administration.  As a surgeon, I couldn’t wait to get him down to “theatre” to show him our remarkably well equipped operating rooms.  Our medical director, Dr. Mardi Steere, (a paediatrician), takes a more holistic view of Kijabe, and also includes our nursery, patient wards, ICU, and children’s ward in the tour.

Ambassador O’Neill is a good sport, and dons surgical gown and cap to enter the surgical suite.  As we tour the operating theatres, I make a special point of introducing Ambassador O’Neill to Dr. Higgins, the ortho surgeon who is with us for three months.  Dr. Higgins is a first generation American, his parents both born in County Mayo, in the west of Ireland.  Dr. Higgins is just finishing a big case, and strides up to us wearing a bloody gown and dripping gloves.  The seasoned diplomat takes this all in stride, and warmly greets Dr. Higgins, posing for a photo for Dr. Higgins’ dear mother from Mayo.

Next up, the meeting with the hospital administration.

The hospital administration greets Ambassador O'Neill

The hospital administration greets Ambassador O’Neill

Down to the board room for introductions, greetings, tea, and cake.  Great discussions ensue, good questions asked back and forth, and relationships formed.  The older I get, the more I value relationships.  To be part of a conversation with earnest, honest, intelligent people, all pulling towards a common goal, is a treasure to be savored.IMG_9822

Traveling after dark isn’t a great idea around here, so we usher Ambassador O’Neill back to his car for the return trip to Nairobi.  IMG_9827

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Wednesday Clinic: A Sampler

Today is the Wednesday Ortho clinic at Kijabe Hospital, and I decided to record each patient I consulted on before lunch time.  I think this represents the type of patients we see, the types of problems they have, and the types of treatment required.  I’m just going to go ahead and list them as I saw them.  This was the first half of the day, the afternoon is kind of a blur, and I stopped recording the patients, but was pretty similar to the morning.  I’ve left off most of the names for patient privacy, and shortened any names I’ve included.

Patient 1)  A 6 year old girl who has been draining pus from her shoulder since she was 5 years old.  She’s had a big surgery done, to remove the infected bone and replace it with bone from her leg.  I took her splint off, she has a small area of pus draining, and the bone graft has not healed.  Her arm is unstable, and still a little infected.  She’s going to need another big surgery.  Long term bone infection (chronic osteomyelitis, COM) is a plague in Africa.  There is often no cure, and it cripples many people.

Patient 2) A 55 year old woman with back pain.  She’s a farmer, which means she spends her day working the ground by hand, bent over from the waist.  Her Xrays look fine.   She needs ergonomic education and strengthening of her pelvic, stomach, and back muscles.  We send her to physiotherapy for education, and give her some mild pain killers.

Patient 3) This is an older gentleman who fell and broke below his hip joint, a sub-trochanteric fracture.  This is a difficult fracture with high complication rates.  He had had a plate and screws put in, which had failed, and we place a type of nail.  The fracture is healing very nicely, he’s walking without crutches.  We’ll see him back in two months for new Xrays.

Patient 4) A 45 year old lady who was admitted two weeks ago for surgery for a hip fracture.   The morning just before she had surgery, she suffered a stroke.  She has mostly recovered, with just a little facial weakness remaining.  But no one has determined the cause of her stroke:  her blood pressure and cholesterol are normal.  She still needs to have a heart test, and some blood clotting tests done.  We can’t really do the surgery when she’s at high risk for another stroke, so we arrange to just see her back in a couple of weeks.  Meanwhile, she has to live with a broken hip, using crutches and pain medications.

Patient 5) This is a 5 year old girl who broke her elbow and hand it pinned a few weeks ago.  This is the same fracture which I had to fix on Jane several months ago.  Her name is Amani Angel, which means peaceful angel.  She is not a peaceful angel.  From the moment I began to gently remove her ACE bandage, she belted out the most blood-curdling scream.  We backed off, tried to console her, the little amani angel.  Her mother did her best to reassure her.  Amani wasn’t fighting us at all, she let us remove the dressings and splint without a struggle, but our eardrums payed the price.  I quickly pulled the pins out, just with my fingers, as they slip out quite easily.  The screaming increased in pitch for four or five seconds, then returned to baseline.  She returned to her normal amani self the instant I walked out of the room.  Her fracture is healing nicely, we’ll see her back in a few weeks for a check up Xray.

Patient 6) Our next patient is an 18 year old boy.  Six weeks ago, he was playing soccer and was tackled from the side.  His knee bent sideways with a loud crack.  I saw him in casualty, where his leg was definitely at an unusual angle.  Xrays showed that he had fractured his femur (thigh bone) just above the knee, through the growth plate.  Thankfully, in an 18 year old, the growth plate is essentially done growing.  We did a surgery on him where we straightened the fracture, and then inserted two screws through tiny incisions to hold everything in place.

Broken Distal Femur

Broken Distal Femur

Healing fracture

Healing fracture

Happy young man, ready to go back to soccer.

Happy young man, ready to go back to soccer.

To my surprise, he walked into clinic today with no splint, and no crutches!  He wasn’t even limping.  Xrays showed the fracture is healing very nicely, so we just asked him to stay out of soccer until we see him back for a new Xray in six weeks.

Patient 7) The next patient is a 48 year old lady who presents with excruciating back pain.  Back pain is very common in every country.  In Kenya, we always look for “red flags”.  These are clinical signs or symptoms that the back pain is something other than the typical wear and tear.  Red flags include excruciating pain, inability to get comfortable to sleep, fevers, draining wounds, weight loss, and weakness.  This poor lady had many of these signs, indicating that she has something bad going on.  She came in bearing Xrays and MRI that she’d had done in Nairobi.  The Xrays showed destruction of the disc space between the 2nd and 3rd lumbar vertebrae in the low back.  MRI showed the typical bone involvement and abscess of Tuberculosis of the spine.  This plague from the middle ages is alive and well in Kenya.  She’ll need one year of TB medications, and will likely need a spine fusion to help with the pain.  She can be fit with a back brace for comfort and started on TB medications immediately.

Patient 8) The next lady was a bit of a breather from the severe problems we’d been seeing.  She had some shoulder pain, called impingement syndrome, which generally responds to some rotator cuff strengthening exercises, some medications, and sometimes a cortisone shot.  We started her on physio and gave her some anti-inflammatory meds, and can give her a shot if she doesn’t see improvement over the next month or so.

Patient 9) This 25 year old man had been knocked off when riding as a passenger on a piki (motorcycle).  His elbow is broken and partially dislocated.  He’s booked for surgery within the next few days, to put the joint back together.  His elbow won’t be normal afterwards, but he should have good motion and very little pain.

Patient 10) The next patient is a 35 year old woman, who had stepped in a hole and broken her ankle about ten months ago.  She had been placed in a cast, but still had a lot of pain and swelling, and her ankle is crooked.  Xrays show that she had had a fracture and dislocation of her ankle, which should have had surgery immediately.  At this point, the joint has degenerated into arthritis, and she will need to have her ankle fused.  We talked about options with her, and she would like to go ahead with surgery.  Our waiting list is about two months long for non-emergency cases, but she is willing to wait.

Patient 11) The next patient had some sort of bite on the back of his hand, and has a draining wound, and pain all the way up to his shoulder.  As near as we can figure, he had a spider bite which is caused some skin death.  We teach him wound care, put him on some antibiotics, and show him some exercises to avoid undue stiffness.  We’ll see him back soon to see how the wound is healing.

Patient 12) The next patient is another child with heart breaking chronic osteomyelitis.  She has had some surgeries to remove the infection, but still has a little pus coming out of her wounds.  Thankfully, she has stayed in school through all of this.  We change her antibiotics, and will see her back in a few weeks.

Patient 13) The next patient is a 10 year old boy who lives in a very remote, lawless part of Kenya where health care is not widely available.  A year ago, he fell out of a tree and had severe hip pain, with shortening of the leg.  He went to a traditional healer, but has had continued problems.  His leg is about three inches short, and his hip is very painful to move and very stiff.  Xray shows that he had dislocated his hip, it is still dislocated, and the “ball” is trying to wear a new “socket” in the side of his pelvis.  Probably the only solution for him is to remove the hip joint, or to fuse it.  We send him over to our brothers at the pediatric Cure hospital in the village for another opinion on this unsolvable problem

Patient 14) The next consult is a patient who is already in the hospital.  He is a 75 year old man who was admitted to the internal medicine team about a month ago, in a coma from out of control diabetes.  He was found later to have a hip fracture.  He’s been in bed so long that he has some bed sores, but needs surgery for his broken hip.  We devise a plan to get his hip fixed.  He’s extremely anemic, so we arrange some blood transfusions for him to begin today.

Patient 15) The next patient has been shot in the humerus.  The bones are nicely aligned, there is no infection, and the fracture should heal fine.  We keep him in his plaster splint and will recheck xrays in a couple of weeks.

Patient 16)  The next patient is a great guy who I have know for more than a year.  He was in a terrible car wreck more than a year and a half ago.  He had broken his arm (humerus), femur, and tibia.  All of the surgeries had failed to heal his fractures, so we re-did them at Kijabe.  He walked in without a limp or crutches today, all smiles.  Xrays showed the leg fractures had healed completely, but his arm fracture had not, and the screws were beginning to fail.  He will need another surgery, a nail in the humerus with a bone graft.  He accepts this news without a blink, delighted to be up and walking.

At this point, I had to walk up to my house to get a little lunch, some coffee, and write some emails.  One of the emails is finalizing arrangements for a VIP coming out from Nairobi to visit our little hospital (not John Kerry!).  More about that tomorrow.  Once the emails were done, back to clinic for the afternoon session.  A very satisfying, if exhausting, day in clinic!

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Short Term Visitors

One of the great joys of working at Kijabe is the amazing series of visiting doctors and their families who come to spend time with us.  These are families who uproot children from school, parents from jobs and routines, and the comfort and familiarity of their homes in the US, Canada, or England.  They travel thousands of miles, endure jet lag and chaos, to come alongside the work we do here at Kijabe.

Some come for two weeks, some for three months.  Some come alone, some with spouses and children.  Some are super-specialists, here to teach their highly advanced corner of medicine, others are broad ranging workhorses, taking on any challenge thrown at them.

What they all have in common is a dedication to providing care for the most vulnerable and teaching the next generation of Kenyan doctors.

Think of this:  climbing onto a flight, landing in the heat and chaos of a large city in the southern hemisphere.  Their driver awaits, a hand printed sign with their name, takes them to a spartan guest house.  The next morning, the driver picks them up, stops at a grocery store in Nairobi, where they pick up enough staples to last a week or two.  They are then brought out to Kijabe.

The drive out to Kijabe starts in the center of Nairobi, a large, bustling, and sometimes chaotic African city.  Traffic congestion forces stops on the large divided road, next to and usually behind large trucks belching diesel fumes.  Hawkers and beggars press against the windows, heart-breaking glue-sniffing children ask for food.  As the driver passes out of Nairobi, the countryside opens up to red-earthed hills, deep green fields, herds of goats, and shanties made of mud with tin roofs.  Innumerable small shops line the roads, where everything from bananas to diesel fuel to sheep skins can be purchased.

As the drive progresses, traffic thins out, and they begin the climb up the Rift Valley escarpment.  As they pass through 8,000 feet elevation, the road drops away to the left for 2,000 feet, as spectacular vistas of the African plains unfold below.

This serene journey takes a turn for the bumpy as they turn off Highway A104.  The next three miles drop 1,200 feet down one of the worst roads in Kenya.  There is no vehicle, no driver, no speed, no way to avoid the teeth jarring bumps of the infamous Kijabe Road.  As they arrive in Kijabe village and are taken to their house, our friend Helen greets them and welcomes them.  She is in charge of introducing them to the house, showing them how to filter water for drinking or cooking, where to shop at our small shop, and provides them with their first hot meal.

The community is always excited by new arrivals, and greetings and dinner invitations ensue.  Fatigued and jet-lagged, the first order of business is usually food, water, a hot shower, and a change of clothes.  We try to give people a little space to unwind and relax, but definitely don’t want people to feel alone or abandoned.

We never cease to be amazed at people’s flexibility, acceptance, and ability to adapt to very unusual circumstances.  Within a day or so, people are often itching to get to work at the hospital.

It’s hard to over-emphasize what these visitors mean to us here.  Of course, we appreciate the hard work and how it helps our tired doctors get a bit of a break.  In orthopaedic surgery in particular, we are always understaffed and trying to catch up with the work load of helping injured patients.  When an orthopaedic surgeon comes to work with us, our staffing increases by 25%.  This really helps patient care, and we try to let one of our full time doctors

The amazing Higgins family: Thomas, Meghan, Corrine, and Owen.

The amazing Higgins family: Thomas, Meghan, Corrine, and Owen.

take a bit of time with family, away from Kijabe.

Having made this transition myself, I can remember adjusting to the unusual presentation of conditions at the hospital, as well as the different equipment and procedures.  Never once have I heard any of our short term missionaries complain or report distress over the change in conditions.  Each has just buckled down and gotten to work, immediately making a huge contribution to the work here.

So many have become close friends, couples and families we look forward to seeing again, either here in Kijabe or on visits to the US.  Conversely, one of the hardest parts of this life is growing close to people in the intense and focused world of Kijabe, only to say sad goodbyes a few weeks or a couple of months later.  But we feel bonded together in a virtual community of people who understand Kijabe, understand the need, understand us.

If you have had an interest in working overseas, in a kind and Christian atmosphere, please let me know and I will help answer questions and make connections.  Working here has been an unforgettable, life-changing experience for many families.

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Back to Reality….Flunking Sainthood Day 10

Monday dawns, enough fresh air and time with friends, and the reality of working in Kenya hits hard.  Some badly injured patients have been admitted over the weekend, and, due to a lack of anesthesia, have not yet had surgery.  Open fractures edge closer to irreversible infection, a child sits with his displaced wrist fracture untouched, and the list of patients awaiting surgery already today is more than we can get done today.

Decisions have to be made.  Cancel his surgery for a broken leg, cancel her surgery for the broken ankle, they aren’t as urgent as what’s before us now.

The first patient is the man with the machete injuries, here for reconstruction.  A sour smell emanates from his bandages, and I can feel the dampness as I undo the wraps.  Infected!  Badly.  Too infected to proceed with the reconstructive flap.  Wash out the infection, clean bandages, next case.

The lady who’s surgery was cancelled last week due to dangerously high blood pressure is back, her blood pressure is under excellent control.  Her wounds don’t look great, but not too bad, so we make a judgement call and proceed with fixing her fractures, using minimal internal metal due to the borderline state of her wounds.  Don’t want to encourage infection.  The surgery goes well, the orthopaedic resident does most of the case, I just assist, and he does a good job.

Next up, the boy with the displaced wrist fracture.  He just needs to be put to sleep, the fracture manipulated back into position, and a small pin put across the fracture.  I assist the general surgery resident, and she does a nice job.  He can go home tomorrow.

Meanwhile, in Room 8, our visiting surgeon Dr. Thomas Higgins is tackling a brutally hard case.  Fractures of the elbow are always very difficult due to the many small fragments, and the difficult three dimensional anatomy.  This fracture, however, has been healing in the wrong position for the last six weeks, increasing the degree of difficulty exponentially.  He gets the fracture back together in fine form, however, and then runs up to the school to pick up his son from kindergarten.

Another man with a broken arm, and then on to our trauma list.  It’s 7 pm, and we have no less than four patients with a combined seven compound (open) fractures waiting for surgery.  Going to be a long night.

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Mountain Bike Safari (Flunking Sainthood Day 9)

One of the great joys of living at Kijabe is living on the Rift Valley Escarpment, a 2,000 foot ridge which drops from the alpine forests above us to the semi-arid plains below.  There are no level surfaces here:  every road, driveway, and forest sits on a steep pitch.  Combined with the heavy foot traffic and herds of cows, sheep, and goats, the area is interlaced with world class ready-made mountain bike trails.  Over the years, different people living here have pieced together routes to nearby villages, as well as faraway towns and lakes, entirely on trails.  We decided to set out today on a mountain bike safari.

There are a handful of bikes and bikers here, and we have two skilled mountain bikers visiting, Thomas and Meghan Higgins.  They live at 6,000 feet in Salt Lake City, and love to mountain bike, so they are looking forward to the challenge.  Both Thomas and I are not on call this weekend, so we decided to put together an adventure.

We’re grateful for the loan of David Shirk’s mountain bike, as he is back in the US at the moment.  Four of us assembled at our house, got tires pumped up, found helmets that fit, and packed enough food and water to get to our destination, a small hostel called Longonot Lodge, about 20 miles away.  This lodge sits on a stunning plateau, surrounded by plains full of zebra, Thompson gazelle, hartebeest, and the occasional giraffe and buffalo, and ostrich.  The lodge was originally built by Ernest Hemingway for his wife, and is now run by a German/Kenyan couple as a guest house.  We had called the day before to book lunch at their outdoor restaurant.

We set out mid-morning, a brief climb followed by a high speed descent on a twisty, muddy road which descends through dense bush to “Old Kijabe Town”.  This is the real Kenyan village, Kijabe Hospital being a later addition about a hundred years ago.  As we reached the village, Michael suffered an early set back, a flat tire.  We spent a good bit of time getting this fixed, as we went through two spare inner tubes which had holes in them, a pump which didn’t work, and finally used the wrong-size tube for his tire.  Any port in a storm.

We continued the journey, climbing up above the village to bypass a deep ravine filled with stinging nettles.  A brief, twisting descent on cow trails brought us to a broad, rolling trail called “old railway bed.”  A non-imaginative name, as this trail represents the remnants of the colonial era Mombasa-Uganda railway, otherwise known as “the Lunatic Express.”  This railways features in movies such as “Out of Africa” and “The Ghost and the Darkness”, and is best known for the two male lions of Tsavo which ate many workers and nearly halted the railways construction.  As we ride, we are journeying over dark history, as the railway represents the worst of colonial ambitions.

We make our way down the fast paced, twisting trails.  Segments of mud, spectacular vistas over the Kenyan planes, deep ravines where we form a human chain to transit bikes and each other to the far side.  Thumping drum beats from local village churches , squealing groups of children, intimidating cacti lining the trail, dodging herds of cattle, goats, and sheep, and finally we arrive in the heat and humidity of the valley floor.

The trail is a major route for herders.

The trail is a major route for herders.

Meghan makes some friends

Meghan makes some friends

Next, we pass across the current railway, underneath a two lane highway, and set out alongside Mt Longonot, a dormant volcano that the Higgins family climbed several days ago.  With Mt Longonot on our left, we wrap around its flank on dirt roads, climb up a thin steep road through a lava flow, and then a blazing descent onto the plain nestled between the heights of Mt. Longonot to the south and the glistening expanse of hippo-laden Lake Naivasha to our north.

We come to a crude gate, manned by no less than three “guards” who are a bit startled by our arrival.  In a halting mix of swahili and English, we struggle to understand each other.  Ann has passed by here an hour earlier with both ours and the Higgins children in the car, so we are eventually ushered onto the property.  This gate marks the boundary of a massive land holding, Kedong Ranch, which itself is part of the bloody history of the Lunatic Express Railway.  We descend further onto the plain, and enter paradise.

We are many miles from the nearest building, the nearest paved road, or any other signs of civilization.  As we pedal across the plain, we are surrounded by herds of hartebeest, Thompson gazelle, and zebra.  The many giraffe and buffalo in this region are nowhere to be seen today, and the ostrich are hiding somewhere as well.  A short climb brings us to the top of the hill, where Ann and the children are already enjoying the peace of Longonot Lodge.

We sit down to a lovely lunch of locally caught tilapia (fish), buttery potatoes, and slivered carrots.  Not bad for the middle of nowhere!  The lodge uses solar water heating, and has a small wind farm for electricity.  Hot coffee washes down the delicious food, and helps energize us after the long and tiring ride.  The fatigue, gentle heat, lazy breeze, and overwhelming vista lull everyone into a state of relaxed contentment.

But the inevitable time for departure arrives, we load the bikes onto the car, and head back to Kijabe.

Bikes loaded up for the trip home.

Bikes loaded up for the trip home.

The trusty rig, ready to take us home.

The trusty rig, ready to take us home.

A quick check shows that the patients for tomorrow include the man who suffered a machete attack with multiple fractures who needs his wound covered with a “flap”, two women with broken legs, one with a broken ankle, and the lady with a broken wrist who was cancelled last week due to high blood pressure.

Weekends like this really allow us to dive into the week ahead with enthusiasm and energy, hopefully giving the best to our patients and staff.  Family time, laughs with friends, and enjoying the amazing creation surrounding us fill our souls and make us all thankful for the work we’ve been called to do.

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The Big Fig

Saturday, a break in the rain, blue skies with serrated clouds, brilliant sunshine.  Time for a hike!  The Big Fig is a famous tree near Kijabe, with huge roots winding through boulders, perched on the edge of a 200 foot drop into a small canyon.  The tree is about an hour’s hike through the bush from Kijabe.  We gather our friends the Heins and Higgins families, load back packs with snacks and water bottles, and head out.  Our first stop is at our friends the Davis’ house, where Rich bluetooths the path from his gps to mine.  Once you’re in the bush, it’s difficult to follow the correct twists and turns to the Big Fig, so now we have satellite navigation!  The Davis’ dog Radar decides to abandon his family and join us on the hike.

The hike down is a little muddy, but the footing is good.  Monkeys stalk us in the trees, giant centipedes wiggle across the trail, black ibis, hawks, and colorful song birds punctuate the walk.  An animal skin on the trail is animated with a lacy white fungus.  The gps takes us straight to the big fig, where we take a welcome break in its  cool shade.

The tree is remarkably large, and precariously set.  Roots more than a foot in diameter snake their way through 10 foot boulders, leaving the trunk hanging out over a precipitous drop.  We herd the kids, all kindergarten to fourth grade, away from the edge so the adults can relax.  Michael and his friend Noah impress each other by getting ever closer to the edge, pretending to slip.  Somehow we don’t find it as funny as they do.

The tree’s rocky home provides comfortable seating as we take our break.

Mara family, On the Edge!

Mara family, On the Edge!

The canyon opens up to farmers fields planted with maize and kale, and lazy cows drift from one field to the next in the valley below.  Red-garbed Masai herders dramatically decorate the lush green vegetation.  Rock hyrax duck in and out, resenting our invasion, and Jane finds an 8 inch lizard.

Heading back up, the heat kicks in, but we make good time and relax in the cool of the house.  Jane heads up to a friend’s house, I make grilled cheese sandwiches for Michael and Noah, and Ann takes Bosco out for a walk.  He’s getting a bit old, and we don’t take him on big steep hikes anymore, but he hates to be left behind.

Tonight, we’re looking forward to having the Higgins family over for dinner.  Meghan is cooking, which is a sure sign of Ann’s friendship with her.  Normally, it takes years before an Irish “mammy” will allow another woman to lift a finger in her kitchen, so they must be tight.  Either that, or Ann is just really sick of cooking dinner every night.

I had the pleasure of running into my good friend, Dan Galat, today.  Dan is my doppelganger at Tenwek hospital, about three hours west of here in Bomet, Kenya.  Dan is an orthopaedic surgeon from the US, who came to Kenya straight out of his residency at the Mayo clinic.  We are twin brothers, both sharing a passion for providing orthopaedic care and teaching Kenyan surgeons.  Dan recently started an orthopaedic surgery residency at Tenwek, and we are finding ways to collaborate for better care and training.

It’s nothing short of miraculous that I can sit here in a muddy little village in Kenya, and be working alongside talented Kenyan surgeons such as Dr.’s Muchiri and Wamae, as well as surgeons from the US.  If defies logic, but you have to get used to that once you quit living on your own power and trust that God will provide what you need, and when you need it.  You might not know what tomorrow will bring, but you can have confidence that God has it covered.  And He never fails!

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Labor Day (Day 7)

May 1st is labor day here in Kenya, so it was a national holiday.  Kenya takes its holidays seriously:  everything shuts down.  We can’t schedule any surgeries, as the staff gets the day off.  A skeleton staff is in place for emergencies.  One of my Kenyan colleagues is on call for the holiday weekend, so I had the day off!

Rift Valley Academy, being an international school, does not have the day off, so Michael and Jane headed off for class at 8 am.  This left Ann and I with a whole day to relax!  My friends Andy and Richard and I quickly organized a mountain bike ride, and headed out.  We started out with our standard trail, “Awesome Sauce”, which winds through villages and breathtaking vistas of the Rift Valley for 14 miles.  Midway through the ride, we scream down from 7500 feet almost to the valley floor at 6,000 feet, twisting and sliding past farmers fields, passing through herds of goats and cows, and providing the days entertainment for groups of school children.  Then a big climb back up to the village on a muddy dirt road.

Andy had to head home to work on a paper, but Rich and I still had time to kill.  I called Ann to see what her plans were, and she was more than happy to have me stay away from the house.  It almost felt like she enjoyed her peace and quiet more than my company!  Rich and I headed to a trail we call “Red Eye”, after the guy who touched a cactus plant, then wiped his eye, and suffered painful but temporary blindness while riding the trail.

A great addition to the area is Cafe Ubuntu.  Located directly down the escarpment from Kijabe, on the valley floor, sits a beautiful cafe, complete with Italian espresso machine and wood fired pizza oven!  Hard to believe, this diamond in the rough.  From the Red Eye loop, we found a dirt trail/road which drops directly down through a small village, then fords a rushing stream, before depositing us at the doorstep of Cafe Ubuntu.

We’re definitely their filthiest clients, coming in covered in Kenyan mud from the river crossing and muddy trails.  But they couldn’t be friendlier (as we sit outside), and bring us two steaming hot Americanos.

Muddy but happy at Cafe Ubuntu

Muddy but happy at Cafe Ubuntu

An hours climb, and we’re back in Kijabe in time for lunch, 30 miles of muddy exhilaration behind us.

Back home, the bike has to be disassembled and the mud worked out of every cog, nook, and cranny.  Bike parts are impossible to get in Kenya, so maintenance is key.

Next up, Ann and I get ready to host our discussion group.  It’s my turn to lead tonight, discussing being brought up Catholic, dispelling some myths about Catholicism, and having a really open discussion about the different streams of the Christian faith.  Thanks to all of you who provided such thoughtful insights, I was able to use these in the discussion tonight.  We really love our Serge team here:  it would be hard to find such a kind, earnest, humble, and friendly group of people anywhere.

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Day 6: Dawn to Dusk

Today was a hard, but great day.  I like working, though at 51 years old, the energy doesn’t hold up quite as late into the day.  The day started with a 7:30 meeting called by our gifted medical director, Dr. Mardi Steere.  The medical director is an important job here, as the liaison between the medical staff and the Kenyan leadership and hospital board.  The medical staff itself is remarkable, with about 30 doctors, half Kenyan, half expat, all dedicated to providing health care to the most vulnerable.  This morning’s meeting dealt with the big picture, strategic planning, and was really encouraging.

Following the meeting, straight to surgery.  We are extremely fortunate to to have Dr. Thomas Higgins working with us.  Thomas came out with his wife Meghan, and two children Owen and Corine.  Amazingly, they have taken a leave from their comfy life in Salt Lake City to work with us here in Kijabe.  They have settled in like pros, the kids jumping right into kindergarten and second grade at RVA, Thomas being the work horse at the hospital, and Meghan going for runs in the hills around Kijabe and shopping “madukani” (at the shops) like she’s lived here for years.

Thomas took the first case in Room 8, pinning a badly fractured elbow in a 7 year old child.  Meanwhile down the hall in Room 6, I cleaned out a man’s broken leg which had suffered a bad infection.  He’s almost ready for a SIGN nail and bone grafting, maybe in a month or so.

As I was finishing the first case, a friend from Bend showed up in the operating room.  David Utley, a professional photographer, and his wife Cindy used to live in Bend, but now work for Samaritan’s purse, based in North Carolina.  David was passing through Kijabe on his way back from a photo shoot of Samaritan’s Purse’s work in the Congo.  He snapped a few photos in the operating room, and then I walked him  to a friend’s house in the pounding rain.

Following this, Shelminth, a talented general surgery resident in her second year, removed some pins from a child who had previously had his elbow pinned.  Later in Room 6, we had to amputate the leg of the poor man with the overwhelming infection.  Amputation is heart breaking for everyone, and is a last resort when all hope is lost for the limb, or when continued efforts to save the limb would gravely endanger the patients life.  Sadly, Kamau fit both these criteria.  Though tragic, he can now get on with healing, his chances of survival are much higher, and he will eventually walk with a prosthesis.

Meanwhile in Room 8, we are preparing for a big case, fixation of an acetabular (hip socket) fracture.  Dr. Higgins is a trauma specialist from a large trauma center, and acetabular fracture is one of the signature surgeries for a trauma surgeon.  I took the opportunity to scrub in with Dr. Higgins to learn from the master.  I have done these fractures here, but he makes it look easy and taught me a number of “pearls”.  The surgery went extremely well, and both the resident, Dr. Kingori, and I learned a lot.

Back in Room 6, a big upper extremity case.  This poor woman had been shot through the arm during a church bombing a couple of years ago.  Remarkably, she has essentially the same condition as the young lady, Caroline, we saw yesterday.  The problem is that the gunshot wound had removed most of the ulna (forearm bone), one of the bones was dislocated from her elbow,  and her hand and wrist were no longer linked to her arm.  The injury had been about two years previously, the arm was badly scarred, and the surgery proceeded slowly.  In the end, however, she had a nice stable arm, so much so that we didn’t even need to put her in a cast.  She’ll be painful for several weeks, but can start using her arm immediately.

Meanwhile back in Room 8, Dr. Higgins repairs a badly broken wrist.

The day went much longer than expected, and as I walked up our driveway in the dark at 7:30 pm, it seemed much steeper than usual.  We had had 17 people over for dinner from our team, and they were just leaving as I walked in.  Ann had graciously hosted them and had a beautiful dinner of salad grown in our own shamba (garden), and creamy tomato chorizo pasta with fresh home-grown basil and toasted pine nuts.  Amazing!  I warmed mine up in the microwave, and plopped down in front of the fire with Michael and Jane.

Tomorrow is a national holiday, and I’m not on call, so I plan on sleeping in, going for a bike ride, and preparing for a talk I’m giving tomorrow night.  Thanks for walking with us here in Kijabe.

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