Posts Tagged With: bone infection

Flunking Sainthood: Day 1….make that Day 2

I just finished reading “Flunking Sainthood”, by Jana Riess.  It’s a pretty light read, documenting this spiritual tourist’s attempt to reproduce one ancient “spiritual discipline” per month, for a year.  Things don’t go as planned, as she tries to emulate a strict Jewish sabbath, practice Benedictine hospitality, tithe, and sit in contemplative prayer. flunkingsainthood But the sum is greater than its parts, as she finishes the year with some wisdom, and humility at how difficult even simple disciplines can be.  I give it two thumbs up, but I’m into this sort of thing.

Her book got me thinking about a practice I used to embrace.  In grade school, we were taught a simple prayer, traced back to the fourth century mystic “desert fathers” of Egypt.  This prayer is still practiced in Eastern Orthodox Christianity, and has recently regained a toe hold in contemplative Christian practice in the west.  How and why a Redemptorist Catholic priest in Midland, Michigan was teaching this powerful practice to 11 year olds in 1975, I can’t imagine.  But it’s stuck with me:  Breathing in: “Lord Jesus Christ;” Breathing Out: “Son of God;” in again: “Have Mercy On;”, final exhalation: “Me a sinner.”  Lather, Rinse, Repeat.  The desert fathers prayed this ceaselessly throughout the day, and some even prayed it in their sleep.  It was felt that this powerful mantra invoked the name of Jesus in his relationship as King and Son, and then placed the servant humbly in his place in the universe, in need of grace, mercy, and forgiveness.  I dare you to try it:  it’s remarkably powerful, and also a great sleep aid.

The has me considering spiritual disciplines, setting a challenge that will center me on what’s important and making time for something just because it is worth doing.

Here’s my plan: my spiritual discipline will be to write a brief blog, every day, for four weeks. At the end of four weeks, I’m going to be traveling to a country with little internet access, and zero tolerance for Christian bloggers, so that will be that.  And I wrote a blog yesterday, so this counts as day 2.  My spiritual discipline, my rules.

The concept seems a little self-indulgent, like posting on Facebook a picture of what you’ve eaten for lunch that day.  But Jana Riess wrote a whole book about her pursuit of spiritual disciplines, so I feel enabled to write a blog.  I love writing blogs, and kind of feel like it’s a chance to give a glimpse into our life for all of the people who support us emotionally, in prayer, and financially.  But too often, I’m exhausted at the end of the day, and a bowl of popcorn and episode of “Prison Break” take the place of sharing my day.  I can’t promise any profound insights, but I’ll try to just give a fair representation of the day to day here at Kijabe.

So, here we go…

Today is Sunday, and we’re deep into the rainy season.  Our cement-block house has a sheet metal roof, and the only heat is from a log-burning fireplace in the living room.  African rain can feel primordial:  it comes down so hard, so suddenly, so loudly, that it saturates the senses.  We cocoon in front of the fire, secure that our little house has stood for half a century against such tropical torrents.

Duty calls, and I’m up at 8 am to get coffee, french toast, and sausages ready for the troops.  Kenya produces dark, rich coffee beans, the sausages come from Nairobi, and the eggs are laid here in Kijabe. The kids have been on school break for a month, but go back to school tomorrow.  Ann and the kids get ready to go to the chapel up at Rift Valley Academy, but I am on call and have to go in to the hospital.

The northern parts of Kenya, bordering South Sudan, Ethiopia, and Somalia, are very remote and largely outside the rule of law.  Sadly, a wedding party was ambushed by bandits in Marsabit yesterday, on their way to the ceremony.  Multiple members of the wedding party, in traditional garments and face paint, were gunned down.  The survivors were swept up by a missionary pilot in a bush plane, and deposited at our gravel airstrip.  The victims have been undergoing surgery, one after the other, since yesterday afternoon.  Only one of the patients had a fracture, so that waits until this morning.

The surgery goes well, the bone is shattered, but the nerves and blood vessels are okay.

Gunshot wound to the humerus.

Gunshot wound to the humerus.

I just clean out the wounds, apply a splint, and we’ll come back later in the week to put a SIGN nail down the humerus to let it heal.  He should be fine.

Next up, a disaster.  Kenya has one of the deadliest road systems in the world.  14-passenger vans, often dilapidated wrecks, serve as share taxis:  Uber taxis on drugs.  The drivers are often lawless, pulling out into oncoming traffic to pass, forcing drivers to the shoulder of the road or be hit head on.  Eventually, the Pauli exclusion principle prevails, and people are horribly injured.

Kamau was a passenger in such a vehicle, and survived with a relatively simple tibia (leg) fracture, which had protruded through the skin.  He was taken to a rural hospital, where antibiotics were started, and surgery performed to clean out his wounds.  Perfect care, up until this point.  Unfortunately, at the end of the surgery, they tightly sutured his wounds, trapping any residual infection inside.  Over the next week, huge amounts of pus built up, eventually stretching the surrounding skin to the point where it died.

Kamau came to us with fevers, a horrible smell, and whitish green pus dripping through his bandages.  After his spinal anesthetic was placed, we peeled back his splint and dressings.  Seasoned operating room tech’s fought the urge to gag from the stench.  The skin of the leg was dead from knee to ankle.  Pus dripped from his leg, onto the operating room table, and pooled on the floor. We spent the next two hours excising dead skin and muscle, finding yet another pocket of pus, cleaning the infected bones, and applying an external fixator to stabilize the fractures and allow access for wound care.  At the end of the surgery, the wounds looked much cleaner, but he will need several more surgeries to eradicate the infection.

Leg cleaned out, external fixation applied.

Leg cleaned out, external fixation applied.

Once the infection is under control, we can swing muscle flaps to cover the exposed bone, and then skin graft over the muscle flaps.  He’ll probably be in the hospital for a month or so.

As I finished the surgery, the heavens open again.  I walk home grateful for the cool, cleansing shower, the scent of wet grass and mud replacing the terrible stench of infection.  Surgical scrubs go into a bucket filled with bleach and water, and I climb straight into the shower, fearful that I could bring these aggressive drug resistant bacteria into the house. Ann has been hanging out with our new friends the Higgins family, who are here for three months from Utah.  The kids are off playing somewhere, and we start organizing for dinner.  The night gets chilly, we light the fire, and get ready for another week at Kijabe.

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Hope

As we’re closing in on the end of the second year since we left Bend, some things are starting to seem normal which probably shouldn’t.  While many Kenyans in and around Nairobi or other large cities lead lives similar to people in the US or Europe, far more live in rural areas with little access to health care.  As a result, we see things at Kijabe that are unimaginable in the western world.  And sometimes I forget what a shining star, what a ray of hope, Kijabe represents.  There are times when I feel overwhelmed by the need, and feel hopeless myself.  But what always brings me back to enthusiasm are meeting patients whose lives are changed by this little hospital.

Yesterday, we operated on one patient, all day.  The main road to Kijabe is called the Nairobi-Nakuru highway.  It was recently listed by a British firm as one of the 22 deadliest stretches of road in the world. 

Poor road conditions, insane passing maneuvers, huge trucks, overcrowded buses,  motorcycles, pedestrians, goats, cattle, donkeys, and the occasional baboon all combine for an experience that would be comical if it weren’t so deadly.

There’s a surprisingly sharp turn on this highway, near the city of Nakuru, about 80 miles north of here.  About two years ago, a large fuel tanker lost its breaks, slammed into oncoming traffic, killing many.  The truck then began leaking fuel.  As local villagers rushed to gather the valuable fuel, it burst into flame, incinerating many more.  Unbelievably, this just happened again.  This time the truck exploded immediately, so no crowd had gathered, so I guess that’s a horrible silver lining.  Fewer people were burned this time.  The local hospitals were quickly overwhelmed, both by the number and seriousness of the injuries, so Kijabe received some of the most severely injured.

The first patient we treated was a 46 year old woman, Jane, who’s legs were severely crushed.  She was awake and alert, but in incredible pain.  Examination of her legs showed they were both dead, and her crashing vital signs showed that the acid and potassium leaking into her body from the dead legs was quickly causing her heart and other organs to fail.  As she was on a ventilator, with a breathing tube, she couldn’t give informed consent for surgery.  I phoned her brother on his mobile, letting him know the gravity of the situation.   We rushed her to surgery for emergency amputation of both legs, but to no avail.  She succumbed to her overwhelming injuries a few hours later in our humble intensive care unit.

Another victim, Jacob, had injuries which seemed incompatible with life.  He had shattered all four of his limbs, including both femurs (thigh bones).

Both Femurs Fractured

Both Femurs Fractured

His forearm bones on the right were sticking out through the skin.  His left wrist was broken.  His right ankle was dislocated and crushed, and most of the bones in both feet were crushed.  He had second degree burns from the mid-shin down to the toes.  His rib cage had been crushed, with fractured ribs on both sides and a chest xray that showed his lungs were bruised and filling with fluid.

left femur fracture

left femur fracture

open forearm fracture

open forearm fracture

skull, wrist, and foot xrays

skull, wrist, and foot xrays

Burned and Broken Ankle

Burned and Broken Ankle

crushed and burned ankle

crushed and burned ankle

right femur fracture

right femur fracture

Keeping Jacob alive would be a challenge at the best university hospital in the US or Europe.  And this is where Kijabe is beyond belief.  Using patched together instruments, donated ventilators and surgical equipment, patients like Jacob are routinely given state of the art trauma care.  We were allowed a brief surgery to stabilize the most urgent problems, and the patient was then whisked to the ICU to support his breathing, blood pressure, receive transfusions, and pain control.  Several days later, we were given the go-ahead to complete his trauma surgery.  He entered the operating room at 8 am as a shattered person, and was wheeled out at five pm, ready to get out of bed.

Everything fixed, ready to get up out of bed!

Everything fixed, ready to get up out of bed!

The amount of teamwork this requires is beyond description.  I’ve seen shows on TV where surgical teams rehearse complicated surgeries ahead of time.  None of that happens here.  When the situation calls for it, everyone just shows up, does her or his job without fanfare, and gives the patient hope for a decent life.

Amazing Anesthesia Team

Amazing Anesthesia Team

Today in clinic, one of the clinical officers from the outpatient department came in with an xray, to ask us about a child she was seeing.  Eight year old Samuel and his mother had been sent to Kijabe to have his leg amputated.  He’d been seen at a large national hospital a few months ago with leg pain, and sent away with pain killers.  A few weeks later, the main bone between the knee and ankle protruded out of his skin.  He’d been living like this for several months, before being seen at another hospital, which referred him to Kijabe for amputation.

I reviewed the xray with a junior orthopaedic resident,

Protruding bone due to osteomyelitis

Protruding bone due to osteomyelitis

who I asked to describe the findings and make the diagnosis from the xray.  He did well, answering correctly that this was chronic osteomyelitis, a deep infection of the bone frequently seen in malnourished children.  As the infection worsens, parts of the bone die, and then migrate out of the skin until they fall out.

I was grinning from ear to ear, both because the resident was doing well, and because I knew that Samuel did not need an amputation.  We rushed over to the outpatient department to meet Samuel and his mother.  As we entered the room, we were greeted by the familiar stench of infected, dead tissue.

I carefully explained to Samuel and his mother that, though he would not need an amputation, he had a long road ahead of him.  With good nutrition, several surgeries,  and months of antibiotics, this can almost always be cured or brought under excellent control.  Children who have been ostracized and unable to attend school can have a decent life, can have hope.

I then asked the resident to perform a “sequestrectomy”, or remove the dead bone.  This is usually a large surgery, done under general anesthetic.  However, with Samuel’s bone sticking out through the skin, there was no reason not to remove this part of it immediately.  As the tissue is dead, there is no sensation.  With some hesitation, the resident put on gloves, and tentatively gave the exposed bone a pull and a twist.

protruding dead bone

protruding dead bone

Dr. Nyambati's first sequestrectomy!

Dr. Nyambati’s first sequestrectomy!

Bone Removed

Bone Removed

To his, and Samuel’s amazement, the dead bone eased out of the infected leg.  It took a bit of convincing, but Samuel eventually understood that he was going to keep his leg!

Samuel after "sequestrectomy"

Samuel after “sequestrectomy”

Hope.

For Jane and her family, we failed.  But they know, and they told us, that we did everything we could for her.  In Kenya, that means a lot.  They know we really cared about her, talked to her before surgery, suffered a little with her.  They are grateful for what we did, even though we feel we failed.  I guess that gives me hope.  For Jacob and Samuel, conditions which would frequently be crippling or fatal can be treated.   They can both have hope for a good life.  And all of these people come to Kijabe because this rather small, nondescript building on the side of a muddy escarpment means hope.  Probably the hardest part of living and working here, both for Ann and myself, is swinging between despair at the overwhelming suffering, and gratefulness to be a part of something so amazing.  As always, thank you for being here with us, supporting us and praying for us.

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Jonah has made it through surgery!

Today was Jonah’s big day, and all of your prayers and support have paid off.  He was actually looking around the operating theatre a bit before anesthesia, the most alert he’s been since his cardiac arrest.  Every patient gets prayed for as they undergo anesthesia here.  For Jonah, we paused a second time just before we began the operation, surrendering him to the God who created him.

Surgeons don’t usually pay much attention to the anesthesiologist’s monitors, but both Dr. Muchiri and I kept an ear, and occasionally an eye, tuned in to Jonah’s heart rate and blood pressure.  Jonah wouldn’t be Jonah if he let us relax completely, but he remained remarkably stable throughout the surgery.  When we re-entered his spine, we found almost no evidence of the TB which had caused the paralysis.  The prior operation, in concert with the five anti-TB drugs, seems to have already nearly eradicated the infection.  The operation proceeded slowly but smoothly.  When we finally installed the metal “cage” which supports the front of his spine, and tightened down the wires which secure the rods in the back of his spine, Jonah had grown almost three inches!  He has been so folded over from the spine destruction, he’s always looked quite small.  With his spine straightened out, he looks like a pretty normal eight year old.

This little man still has a huge road to travel.  He’s in the intensive care unit, as planned, on a breathing machine.  Strong narcotics for his pain.

Jonah resting comfortably in the ICU

Jonah resting comfortably in the ICU

A total of six antibiotics.  Tubes coming from everywhere.   A long list of potential complications.  He still needs to wake up from all the surgical and cardiac arrest trauma.  After that, assuming all goes well, we wait to see how much his spinal cord can recover.

My dream, and my plan, is to take a little walk with Jonah in his village in Samburu.

Samburu women who have sewn clothes to support Jonah's family

Samburu women who have sewn clothes to support Jonah’s family

The women in his village have gotten together to sew clothes to sell at the market to help his family.  I just met a pastor who speaks his language and is serving the nomads in his area.  So many people here and around the world have reached out to him.  I feel connected to his fate, as are all of you who’ve prayed for him and sent your love and support.  I can’t know God’s plan for his life, but he’s already touched more people than many of us ever will.  I’ll keep you up to date on his progress over the next days and weeks.

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Jonah struggles on

If there’s one overarching feeling since moving to Kenya, it’s one of inadequacy.  There are just so many people who are so sick, so in need of so much more than I can provide.  Impossible choices, weighing what this man, woman or child needs, compared to what I can provide for them.  Kijabe hospital is an unbelievable oasis of love and competency, but is incessantly overwhelmed by unending demands on its limited resources.

I haven’t always been a Christian.  I know that label makes some peoples’ skin crawl, and I don’t like some of the connotations myself, maybe “follower of Christ” is better.  Whatever you call it, I’ve arrived there by a number of different roads.  Some have been direct experiences of the mystical, others more practical.  The sustaining structure of my faith, however, is that it helps me make sense of the world that I see, taste, breathe.  If I look at the world without blinking, with the insulation removed, my mind has trouble making sense of the paradox.  How can so much evil, so much suffering, exist alongside such sublime beauty and structure.  How can a God who loves infinitely allow so much suffering in his creation?

For me, the question contains the answer.  A God who loves so much He would release control, allow free will, allow betrayal.  A God who loves so much He would love anyway, knowing the cost.  A God who loves so much he would suffer and die so his children could live.  Love involves risk.  Risk of loss, risk of rejection.  Maybe ultimate love involves ultimate risk.  So I’ve turned it all over to a God who I believe risked it all to be in relationship with us, with me.

This all helps me make sense of a child like Jonah.

Jonah was scheduled for his big spine surgery today.  Weeks of anticipation, discussion, tests, consultations.  Weeks of TB medications, good nutrition, surrogate mom’s and dad’s scooping him up and taking him on “walks” in his wheelchair.  We got Jonah to the OR early, before he could sneak some rice or milk from another child on the ward.  With Jonah on the OR table but not yet asleep, I got a call from our anesthesiologist:  ” Don’t put him to sleep, we may not have an ICU bed and ventilator for him after surgery, a neurosurgery patient just had to be put on a ventilator.”  We can only have five patients at a time on a breathing machine here.

Jonah was taken back to the waiting area, and we went ahead with another surgery, then later in the day got the go-ahead to proceed.

Finally, Dr. Muchiri (the gifted head spine surgeon here), myself, and the anesthesia team were all set to go.

Jonah’s a bright little boy.  In his region, they don’t really keep track of birthdays, but he’s about eight years old, same as my son Michael.  He’s been in the hospital about three weeks, so he knows my face, and he likes it when I take his picture with my phone and show it to him.   He doesn’t speak English or Swahili, only his native tongue Samburu, so we can’t talk much.  Lying on the OR table, hundreds of miles away from his parents and unable to speak to anyone in the room, he was scared.  I grabbed his hand, just the same size as Michael’s, and he squeezed hard.  If I even looked away to get some piece of equipment organized, he squeezed harder and used his other hand to pat my arm.  I played “spider” walking my fingers up his arm to tickle him, and his little body was wracked with giggling.  We kept this up until the intravenous propafol put him off to sleep.

Finally, Jonah was under anesthesia, and we then rolled him prone (onto his stomach) for the surgery.  We all paused and watched the monitors.  Smooth sailing!   Unlike the previous attempt, Jonah’s blood pressure and heart rate remained stable.  We proceeded with the surgery.

Surgery for TB of the spine involves two general stages.  First, the spine is opened, and the tissue compressing the spinal cord is “debrided”, or removed.  The second stage involves stabilizing the segments of the spine destroyed by the infection.  The first stage went very well:  the spine was opened, and the pus, dissolved bone and soft tissue fragments were removed.  We were gratified to see the sac around the spinal cord begin gently pulsing, indicating the paralyzing pressure on the spinal cord had been relieved.

There exists an unspoken communication between surgeon and anesthesiologist.  The surgeon’s job is to complete the surgery.  The anesthesiologist’s is to care for the patient during the surgery.  A thin sheet of sterile  cloth separates us.  But both surgery and anesthesia have a certain tone, pace, and rhythm. And when that rhythm is disrupted on either side of that sheet, you just know.  As we finished the first stage of Jonah’s surgery, we could sense a change in the tone of the anesthesiologist.  A quick glance at the monitors showed the reason:  Jonah’s blood pressure and heart rate had plummeted.

We quickly called for suture to quickly close the foot long spine incision.  Rather than the usual meticulous layer by layer closure, skin, muscle and connective tissue are swept up in deep sweeps of a large needle, closing the incision in seconds.  Sterile drapes torn off, and we flipped Jonah onto his back.  Monitors flat line.  No pulse. No blood pressure.  For the moment, Jonah is not alive.

In this rare situation, the surgeons are perfectly positioned to provide chest compressions (CPR), while the anesthesiologist administers fluids and epinephrine, or adrenaline.  We compressed his little heart to provide blood flow to his precious brain, and to allow the life saving epinephrine to circulate through his body.  As we did CPR, we also prayed out loud for his life.  Twice we paused the chest compressions, only to see that he still had no heart rate or blood pressure.  I was starting to think about what I would tell his parents.  Miraculously, on our third and perhaps final pause, Jonah’s heart took over!  His heart rate and blood pressure, while not normal, were remarkably good.

We got Jonah to the ICU and connected him to a ventilator to breathe for him.

Jonah resting comfortably in the ICU

Jonah resting comfortably in the ICU

Thankfully, his pupils were reactive, some indication that he did not suffer brain damage from the stoppage of his heart.  His blood pressure and heart rate normalized.   And I just received a text from the anesthesiologist in the ICU:  “Jonah awake and off the ventilator”!  He survived.

Jonah’s still got a rough road ahead.  Once he’s stabilized, we have to go back to surgery to stabilize the segments of the spine destroyed by infection.  After that, he’s got a long recovery ahead of him

The only way I can make sense of all this is by surrendering to a God who loves Jonah, who loves me, and who understands suffering.  To believe that there’s a bigger picture than pus and paralysis and a scared little boy.  And to believe that there’s a God who loves each one of us so much he allows us to be a part of His plan.  Thanks for praying for all of us.

 

 

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The Samburu Duo

The two boys from Samburu are doing well.  Saidimo, the boy with chronic osteomyelitis (bone infection) of the shoulder and hip had his surgery done on Thursday.  He’s done great!  He had an active infection in the shoulder

Saidimo's shoulder with chronic osteomyelitis (bone infection)

Saidimo’s shoulder with chronic osteomyelitis (bone infection)

, and we removed some infected bone and put him on antibiotics.  The hip had been previously damaged by infection, but he had no active infection that we could see.  The problem with his hip is that the leg had become contracted to the point where it was very difficult to walk.  The surgery relieved the contracture in his hip, and he’s starting to get up and around.  We have high hopes that he’ll be able to walk with nothing more than a bit of a limp.  Time will tell.  Here’s a short video of him getting off the missionary flight with the hip severely contracted, and now with the contracture released and his leg out straight.   vimeo.com/77347277

Saidimo after surgery, leg nice and straight.  Next step, learning to walk again!

Saidimo after surgery, leg nice and straight. Next step, learning to walk again!

Jonah’s surgery is scheduled for Tuesday.  He’s had a complete evaluation by a pediatric cardiologist in Nairobi.  He has no problem with the heart, so it seems the blood pressure problems we experienced are from the large TB abscess behind his heart.  When he arrived at Kijabe, he was very weak and painful.  Now with a couple of weeks of TB medications and nutrition, he’s very comfortable and much stronger.  We now find him sitting up in bed under his own power, something he couldn’t have attempted when he arrived.  So he’s going into the surgery in the best shape he can be in.

Jonah sitting up under his own power!

Jonah sitting up under his own power!

We’re worried about his surgery.  When we attempted it before, he couldn’t tolerate the anesthetic and we had to abandon the surgery.  The pediatricians, anesthetists, and surgeons have all done everything possible to give him the best chance for the surgery.  We’ve also had to discuss this with his parents, who realize the gravity of the situation.

Already, the needy patient fund has been able to provide care for

Esther after surgery

Esther after surgery

Esther, the baby with the knee infection, and Saidimo, as well as paying for Jonah’s MRI and pediatric cardiology consult in Nairobi.  Thank you all for your generosity in spreading the word about these kids, praying for them, and donating to help pay for their care.

One of the most difficult things about operating on Jonah is that he’s the same age as my son Michael.  I can’t imagine Michael being far away, in the hands of people I’d never met, and about to undergo a surgery that he may possibly not survive.  The faith and trust of his mother is overwhelming.  Please pray for all of us.

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