Posts Tagged With: global health

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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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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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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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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Day 4….Some days are better than others

As I sat down to write this, my phone rang.  It was the excellent resident I’m currently working with, calling with bad news.  He had brought our patient from Sunday, the one with the terrible leg infection, back to theatre to wash out the infection again.  Instead of finding the leg improving, he found toes turning black, and the muscles dying.  We got to Kamau too late.  The infection had gone too far.  This young man is going to need an amputation.

I can feel the resentment build:  why did this have to happen?  It wasn’t a complex problem: with some basic surgical care from the outset, he could be planning his recovery, this episode soon relegated to a painful memory and tales to tell his children and grandchildren.  Instead, he will be an amputee, in a country which doesn’t look kindly on disability.  Here we have no “Kenyans with Disabilities Act” to put in sidewalk ramps, require accessible public transport, or prevent employment discrimination.  Disability is sometimes viewed as a curse, creating fear, suspicion.  He will have some difficulty finding and affording a good prosthesis.  This is a huge setback for his life.

If this were an isolated instance, it would be simply frustrating.  But it is a regular occurrence, even here in Kenya, one of the more developed countries in sub-Saharan Africa.  I’ve been to countries where things are much worse, where there is simply no hope for patients with significant injuries.  The suffering across this continent is unimaginable.

There’s a lot of people working on this problem.  My Notre Dame classmate and roommate from medical school, John Meara, has risen to the highest echelons of the academic world, and is spearheading the Lancet Commission.  The Lancet, one of the oldest and most prestigious medical journals in the world, has decided to undertake a major project, looking at the effect of this severe lack of surgical capacity in the developing world.  The governing body of the World Health Organization meets in May and will pass a resolution declaring basic surgical care a right, much like access to clean water, food, security, and vaccines.  This is a watershed moment for the billions of people suffering worldwide from lack of access to adequate surgical care.

In our lifetimes, this problem will be reversed, and severe lack of surgical capacity will go the way of smallpox and polio.  But that doesn’t help Kamau today.

Our first patient for the day, a young man in a car wreck, was due to have his hip socket reconstructed after a fracture-dislocation of his hip.  Unfortunately, due to a scheduling error, we had to re-schedule his surgery for Thursday.

Our next patient was due for wrist reconstruction after a mangling injury a year ago when his van rolled over as his arm was out the window.  As we were preparing him for surgery, I pressed gently on a little opening in his arm.   To my surprise, a 3/4 inch seed pod popped out, followed by pus.  Apparently, despite multiple surgeries at two excellent hospitals in Tanzania and Nairobi, this remnant from his roadside injury had hidden inside his arm for a year.  It decided to work its way out on the day this patient was finally scheduled for his reconstructive surgery.  We cleaned out the infection and took him to the ward for intravenous antibiotics.

The third patient today was a middle aged lady who had fallen down some stairs, shattering her wrist.  She was scheduled for a combination of plating and external fixation today.  Though she has a history of hypertension (high blood pressure), she has been well controlled by medications.  Until she got onto the operating table.  Her blood pressure shot up to a dangerous 200/100, and persisted despite intravenous anxiety and blood pressure medications.  Surgery cancelled.

Next up, a two year old boy who fell down some stairs, hyper-extending his elbow to the point where the elbow broke just above the joint.  Jane had this same injury just last November.  The treatment is a surgery where the bones are manipulated back into position, and then held there with two pins introduced through the skin into the bone using video xray.  This went flawlessly, all the equipment worked perfectly, and he should be fine.  Finally, we accomplished something for the day.

Our last patient was the disastrous Kamau, wrapping up an all-too-typical day in the battle against trauma in Africa.  When he wakes up, we’ll need to give him the bad news and obtain consent for amputation.

In the big picture, I know progress is being made, systems are being formed, surgeons are being trained, the John Meara’s of the world are pushing global organizations to wake up to this unseen epidemic.  But day to day, my picture isn’t that big.  My picture is the men, women, and children in my clinics and theatres who suffer agony and disability from lack of safe roads, safe drivers, and access to safe surgical care.  Though we’re too late for Kamau, my prayer is that his children will live in a world with less suffering.

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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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The New Normal

A little less than three years ago, the Mara family drove away from our house in Bend, Oregon, with a mixture of excitement, fear, sadness, and anticipation.  Ann and I had lived there our entire married lives, brought our newborn babies in through the front door, and we shared a little fear that we would never feel quite as “at home” again.  As I walked to work this morning, however, I realized we now have a new normal.  Things which would have seemed bizarre, exotic, or even frightening three years ago now simply add to the richness of life here.  Over the last three years, we have experienced close encounters of the best kind:

Murit, Jane's adopted baby elephant.

Murit, Jane’s adopted baby elephant.

Michael and Jane with two new friends

Michael and Jane with two new friends

Simba and her litter

Simba and her litter

We have become patients ourselves:

Prayers for Jane with her surgeon and anesthesiologist

Prayers for Jane with her surgeon/dad  and anesthesiologist Dr. Newton

Ann, very stoic as she gets an IV in casualty.

Ann, very stoic as she gets an IV in casualty.

Mike going in for the first of his two surgeries at Kijabe.

Mike going in for the first of his two surgeries at Kijabe.

My friends and I have had multiple bike wrecks:

My friend Andy:

My friend Andy: “I feel cold. Tell my wife I love her” (He had sprained his shoulder)

Adam attracts a crowd after his bike disintegrated beneath him.

Adam attracts a crowd after his bike disintegrated beneath him.

We’ve gotten used to driving three hours round trip for groceries, not being able to understand most conversations around us, and sometimes feeling like a novelty or curiosity.  Happily, we also feel embraced by a culture which values time spent face to face, gentle suggestions over confrontation, and family life over consumerism.  I’m slowly learning that relationship is more important than achievement, love more important than efficiency, and compassion more important than titles or degrees.

Sadly, the most constant rhythm of life at Kijabe is the incessant flow of very sick and badly injured patients.  Some of these patients are too injured, or come to the hospital too late, for us to be able to give them a good outcome.  But the thing that amazes me the most about Kijabe Hospital, is how miracles happen on a weekly basis.  I’d like to tell you about two recent patients that demonstrate this.

Ahmed broke his leg when he was struck by a passing “piki piki” (motorcycle) in a remote and lawless area of Kenya.  With no access to health care, Ahmed’s family did the best they could, taking him to a local bonesetter.  He was quite malnourished at the time of injury, and the forced bedrest in his hut led to huge ulcers, bedsores, which covered his back side and injured leg.

When Ahmed was finally brought to Kijabe, he was semi-conscious, with foul smelling pus and bodily fluids contaminating his wounds.  He was in marked pain, with his unstable fracture allowing his damaged leg to flop around during the long car ride over bumpy roads.

I must admit, when I first saw Ahmed, I wasn’t sure he would survive, and I even wondered briefly if the most merciful thing would be if he passed away quickly.  But of course, that’s not why we’re here.  A team of compassionate nurses, pediatricians, pediatric surgeons, plastic surgeon, and orthopaedics took him under their wing.  Intensive nursing care helped heal his wounds and improve his nutrition.  Hospital chaplains came and poured love and prayers over Ahmed and his family.  The paediatric surgeons performed a colostomy to avoid his wounds being soiled by bodily fluids.  And our talented plastic surgeon managed finally to close the gaping wounds in his leg and buttocks.

Due to the gross contamination of Ahmed’s wounds, we could not risk operating to fix his fracture.  But due to his huge wounds, treating him in traction would worsen his life-threatening bed sores.  The solution was unusual, but we placed him in traction after rolling him onto his stomach.  For four weeks, he had to lie on his stomach while his femur and wounds slowly improved.

And then, remarkably, he was healed.  And several weeks later, he walked into clinic!

Ahmed, gravely ill, and now walking under his own power!

Ahmed, gravely ill, and now walking under his own power!

I didn’t recognize him.  He wasn’t even limping.  Instead of the poor, dying, semiconscious, badly infected patient, he was a happy, energetic, funny young man.

Some things can never be the “new normal.”  Joyce’s story is one of those situations.  Last week, in the midst of our busy orthopaedic clinic, with 90 patients waiting to be seen, one of the clinical officers came over from “casualty” (the emergency department).  “Dr. Mara, could I show you an MRI scan”  This is a common request, usually patients with back pain who have gotten a scan done in Nairobi and want someone to look at it.  I always ask the clinical officer to describe the patients history and physical exam before we go over the scan, to emphasize that careful history taking and examination are really more important than expensive tests.

“This is a 7 year old girl.  She was healthy until 10 months ago, when her legs became clumsy.  Then she became paralyzed.  She hasn’t been able to walk for five months.  Now she can’t move her arms or legs.  And since this morning, she’s having trouble breathing.”  A quick glance at the MRI scan in the CO’s hand showed an extremely rare condition which is fatal if not treated.  Due to a birth defect in her upper spine, her head was not properly attached to her neck.

Joyce's MRI, showing severe compression of the spinal cord

Joyce’s MRI, showing severe compression of the spinal cord

This creates instability which had progressed to the point where her spinal cord was severely compressed at the base of her skull, at the junction between her spinal cord and her brain stem.  We ran over to casualty.

Over the last months, the spinal cord damage had progressed to paralyze her legs, then her arms, and finally, that morning, was beginning to paralyze the muscles which allowed her to breathe.  She was within hours of dying from respiratory arrest.  We put her on oxygen, and I ran back to clinic to get Dr. Muchiri, our spine specialist.

We left 90 patients waiting in clinic, to quickly put Joyce in traction.

Joyce lying comfortably with the life-saving traction applied to her head.

Joyce lying comfortably with the life-saving traction applied to her head.

Michael and Jane on their way to visit Joyce.

Michael and Jane on their way to visit Joyce.

This is a medieval-looking but painless procedure, done under local anesthetic, which pulls the skull away from the damaged spinal cord and allows healing to begin.  Within minutes, her breathing improved, and she required less oxygen.  Dr. Muchiri and I were breathing a little easier too.

I came home from work that night and shared Joyce’s story with Michael and Jane.  Without hesitation, they adopted her, and decided they needed me to take them to the hospital that night.  Michael went and got a favorite blanket he’s had since he was an infant, and Jane collected a stuffed bunny, an embroidered pillow, a story book, and another blanket.  We went to the children’s ward, prayed for Joyce and her mother, and delivered the gifts.

Joyce, a little scared, but comfortable, and awaiting her life-changing surgery.

Joyce, a little scared, but comfortable, and awaiting her life-changing surgery.

This past Monday, Dr. Muchiri and our neurosurgeon combined their considerable skills to decompress and stabilize Joyce’s spine.  This involved removing some of the bone from the upper spine, and base of the skull, and then using metal plates and screws to fix her skull solidly to her neck.

Joyce is now able to move her arms and legs!  She has a long way to go, but there is every chance she will be able to walk and use her arms normally again.  Children have such amazing powers of healing, and the care she got at Kijabe Hospital has given her the best chance possible for a full life.

Our new normal involves some challenges, but also allows us to witness miracles like Ahmed and Joyce on a regular basis.  As a family, we feel incredibly fortunate to be part of showing God’s love to the thousands of people who come to Kijabe.


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We need your help

One of the great joys of this life adventure, living and serving in Africa, is being part of a community that stands with us as we work at Kijabe Hospital.   Each month we receive emails from supporters, asking for prayer requests, staying in touch, and reminding us that we are the boots on the ground for an amazing group of people that cares about suffering here in Kenya.  When times are difficult, when futility and chaos seem to have the upper hand, we are lifted and encouraged by your prayers, and by knowing that you join us in advocating for the most vulnerable.

We have written blog posts before asking for help with a sick child whose family is devastated by medical costs, and you have responded.  We have been able to pay for hospital bills and a prosthetic leg for a teenager with cancer.  You have enabled us to travel into the most bleak, unstable regions of Africa, to provide medical care and compassion, to let those on the margins know that they are not, indeed, God-forsaken.  The monthly support provided by our dedicated community of supporters has sustained us over the last two and a half years. You have allowed us to serve at Kijabe Hospital, to train doctors, to pray with gravely ill patients and their families, to quietly pay a hospital bill for a dedicated pastor who’s leg was lost to infection, to try, in our imperfect way, to tell people, in word and deed, that God loves them.

But now, it is our turn to ask for help.  As part of our work here, we are sustained through one-time and monthly contributions from over 100 individuals, families, and churches, who allow us to serve here by supporting us financially and prayerfully.  There is a natural attrition rate as supporters’ situations change, and over the last 6 months, we have fallen behind in our financial support.  For the past two months, our account has been “in the red,” requiring us to urgently seek additional financial support.

The very responsible policy of Serge, our sending agency, is that if we carry a negative balance for three consecutive months, our “salary” is reduced, and if the situation is not remedied, we must temporarily return to our home country to increase financial support.  A good friend of ours, also working in Kenya, is currently in the US, not able to do his work here, for just this reason.  As a faith-based non-profit, Serge is responsible to both their donors and the IRS.

Due to this shortfall, we need $7,800 in one-time contributions, to bring our account balance even.   We also need 17 new supporters of $100 per month, to bring our budget into balance.   We are reaching out to you, to see if you, your family, your church, or your organization can come alongside us in our work here.  Please know that any financial support is put to immediate and hard work here at Kijabe hospital.

Here are the practicalities of how to provide support to our ministry.   All donations are tax deductible.

1) Go to the link: https://www.whm.org/give/missionary?ID=51553

2) This will take you to the Serge/World Harvest Mission page for donations to our work here in Kenya.

3) In the box, enter how much you would like to donate, and make sure you use the menu right below that to indicate whether this is  a one time donation, monthly, or annual donation.

4) After you click “Add to Donation Cart”, you’ll be taken to a registration page to checkout.

5) Your options are to donate by credit card, or by Electronic Funds Transfer (EFT).  EFT is the most simple and secure way to donate.  Setting up EFT allows Serge/World Harvest Mission to transfer your donation directly from your checking account to our mission account at Serge/WHM.

To do this you’ll need to look at one of your checks, to get the routing number and your account number.

Image

The routing number is the nine digit number to the left, and your account number is the next set of digits, after the colon.

Follow along the rest of the registration page, and you’re done!

We consider ourselves amazingly fortunate and blessed to be serving in Kenya, and we hope and pray you will join us in our work.  If you have any questions about our work here, or about financially supporting us, please email Mike at michael_mara@hotmail.com or Ann at annmoran2002@yahoo.co.uk.

Mike, Ann, Michael, and Jane

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Two Happy Stories

Sometimes, things seem really hard at Kijabe Hospital.  We see a constant stream of really sick and badly injured patients.  We talk and pray with them, give them the best medical care we can, and hope for the best.  Most patients thrive, heal up well, and go on with their lives.  Others suffer greatly, and not all of them survive.  Kijabe can be an intense place to work.

 

Which is why it is so important to celebrate victories.  We have had two small children with really unusual problems this week, but both should go on to have normal lives.

The first patient is Ahmed.  You wouldn’t know that this child lives in a famine plagued corner of Kenya, in the largest refugee camp in the world.  Dadaab is known as an arid, hostile, often violent place where Somalis flee to escape the war and terrorism in their home country.

Happy little Ahmed

Happy little Ahmed

So imagine our delight when this fat, happy, funny baby arrived from that awful place.  Ahmed is six months old, and born with an unusual condition.  He was born with his urinary bladder incompletely formed and outside of his body.  A part of this problem is that the bones of the pelvis don’t form completely, and so don’t come around to meet in the front.  Thus, there is nothing to “hold his insides, in.”  So I got to work with my good friend, Erik Hansen, a paediatric surgeon, and our amazing anesthesia team,

Ahmed safely undergoes anesthesia

Ahmed safely undergoes anesthesia

to fix this problem.  Erik’s assignment was a long and difficult process of forming a new bladder from the tissue available, and placing the new structure inside of the pelvis.  My smaller part was to cut the bones of the pelvis on each side so we could fold them inward, containing the structures on the inside.  I hadn’t done this exact procedure before, so it took a little longer than it should, but it seemed to turn out alright in the end.  Ahmed is doing well, recovering comfortably in his new turtle shell of a cast.

Ahmed, done with surgery, and in his new home, a body cast for six weeks.

Ahmed, done with surgery, and in his new home, a body cast for six weeks.

We’ll plan on removing the cast in about six weeks, and Ahmed can go on his way.

 

Today, I saw a beautiful two day old girl named Elizabeth.  She is a health, happy, peaceful little thing, but has a couple of problems with her legs.   The right knee has a fairly rare problem called “congenital dislocation of the knee.”  For reasons not fully understood, occasionally a child is born with their knee joint dislocated, bending the wrong way, with the foot up near the face.

Congenital Dislocation of the Knee

Congenital Dislocation of the Knee

Though this seems like it should be painful, it isn’t.  Her other foot has a common condition called calcaneovalgus foot deformity, which resolves over time, sometimes with a bit of gentle stretching from the parents.

The treatment for congenital knee dislocation usually requires some manipulation and casting, once a week, for six or eight weeks.  Most babies then develop normally.

gently stretching the dislocated knee back into position

gently stretching the dislocated knee back into position

Elizabeth’s mom was delighted and relieved to know the treatment was so simple, for a condition which looks strange and potentially disabling.

A baby sized cast holds the leg in good position

A baby sized cast holds the leg in good position

Thankfully, the family lives in a village not far from Kijabe, so it shouldn’t be too much of a burden for them to come once a week.  It’s really nice to be able to help these babies, hopefully give them a normal life, instead of one of shame, poverty, and disability.  Patients like these help remind me of the ministry of Kijabe, to show God’s love to people in this part of Africa.

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20 Beds in 60 Days

Whew!  We have just finished our first “home assignment.”  As long term missionaries, we spend about 10 months of each five-year term outside of our host country.  This time is spent resting and recuperating, praying about the direction of our lives, visiting with friends, families, prayer and financial supporters, and spreading the word about Kijabe Hospital.  The last two months have been some of the most amazing of our lives:  we’ve been overwhelmed with the kindness, love, and generosity extended to the Mara family.

The first leg of our trip took us from Kijabe to Michigan, where I grew up.  The flights were seamless, and somehow Michael’s blood sugars stayed stable through ten time zone changes.  We enjoyed a fun family reunion with all five of my sisters’  families, including no less than fourteen cousins!

Crazy Family Dinners

Crazy Family Dinners

Kid heaven, we walked to the beach every day, rode bikes, ate and drank together, and generally put the “fun” back in dysfunction.

Zen Moment on Lake Michigan

Zen Moment on Lake Michigan

We took a quick trip to my home town, Midland, and to my alma mater, Notre Dame.

Sacred Heart Cathedral, Notre Dame

Sacred Heart Cathedral, Notre Dame

We had a great visit with our friends from Kijabe, Norm and Carolyn Boeve.  They treated us to beautiful dinners, great conversations, lots of rest, and even took the kids out tubing behind their boat!  They introduced us to Harvest Bible Chapel in Spring Lake, and Pastor David Wisen and his wife Kristen.  Before we departed, Norm and Carolyn blessed us with prayer and sent us on our way.

From there, we re-united with my classmates from residency, Steve Kimberly and Jeff Recknagle and their families.  Jeff lives on a beautiful lake which connects with Lake Michigan.

"Tubing" at Norm and Carolyn Boeve's house

“Tubing” at Norm and Carolyn Boeve’s house

The kids had a riot, learning how to water ski and drive a jet ski.  Michael terrified me by going full throttle on Lake Michigan in six foot swells, screaming “big air!!!!”  I think he gets it from his mother.  It meant a lot to me for Ann to meet two guys and their families who have meant so much to me.  There were a few uncomfortable moments when my old friends related stories from my “B.A” (before Ann) era, but grace was extended all around!

One of the highlights of the trip for me has been the opportunity to speak at Orthopaedic Surgery Grand Rounds in Michigan and Oregon.

Orthopedic Grand Rounds in Portland, Oregon

Orthopedic Grand Rounds in Portland, Oregon

Antique Orthopaedic Surgeons

Antique Orthopaedic Surgeons

My good friend from medical school, John Anderson, both made the arrangements for me to speak, and invited us to spend time with us at his cottage, also in west Michigan.  The kids couldn’t believe their luck, three different lakes with boats for inner tubing and water skiing in one summer!

We said our sad good-byes to my sisters and friends in Michigan, and got back on the plane, now destined for Bend, Oregon.  Here, we were extended the incredible gift of a beautiful home and car by Laura Wytsma.  The house was our home from mid-July to late August.  It is truly a sanctuary of peace and relaxation.  The Wytsma family has taken us under their wing, spoiling us with their generosity and kindness.

In Central Oregon, we got to connect with almost all of our close friends from the time we were first married.

Jane Kayaking on Elk Lake, with Mt. Bachelor looming behind.

Jane Kayaking on Elk Lake, with Mt. Bachelor looming behind.

True friends are the ones where it feels as if you’ve only been apart for a few days.  I got to go on a three day mountain bike adventure, punctuated by an emergency room visit for an emergency epinephrine injection and IV steroids when my airway began to close up.  It’s a great idea to mountain bike with your personal physician!  The really fun part of that is no one really knows why it happened.  So I get to travel with two epi pens from now on.  Hmmmm…  We got to have some great dinners and outings with my sister Shannon, her husband David, and my nephews Will and Ian.  Michael and Jane love their cousins, so it was great to see them get to spend time together.

Our great friend and gifted photographer Benjamin Edwards invited us to speak at Redmond Church of God Seventh Day, and Pastor Sean Mills and the entire congregation immediately made us feel right at home.  They blessed us with kindness, generosity, and prayer, and really started the Oregon leg of this journey out on the right foot.  Paradoxically, Ben was in East Africa, climbing Mt Kilimanjaro while we were in his home church in Oregon.  Ben is shooting a video for the Elisha foundation, and climbed Kili with Eli, a boy with Down’s Syndrome who has also been to Everest Base Camp.  If you want to get rid of any self-pity in your life, check this out further at Ben’s website,

http://www.benjaminedwardsphotography.com/blog/travel/mountains-documentary-film-on-disabilitykilimanjaro-trek/

A really surprising highlight of the Summer was our visit to Emmanuel Bible Church in Salem.  Dr. Bob and Sally Zirschky have been over to work at Kijabe, and they put their church to work praying for us, and then supporting us financially, before we had ever visited the church!  We had the most amazing weekend with the Zirschky’s and EBC, and they invited us to speak the message from the pulpit for both services on the Sunday.  So exciting (and a little nerve-wracking) to be able to tell stories of how God works at Kijabe and in our lives.  The Zirschky’s again showered us with their amazing generosity, and Bob even drove up to Portland to support me as I spoke to the ortho residency there.

We took a pause from public speaking engagements to attend the joyful wedding of Ann’s great friend Erin Lytle to Jay Jones.  Ann co-officiated the ceremony with our friend Pastor Brandon Reynolds, who we know from his time at Antioch.  What an amazing and blessed celebration.  A great bonus of being in Ashland for the wedding was getting to spend more time with my sister Colleen and her family.  Returning to Bend, Ann’s brother

Paul, Amanda, Michael and Jane

Paul, Amanda, Michael and Jane

Paul and incredible chef Amanda came up from San Francisco and prepared us an amazing feast.

Back in Bend, God blessed us with an amazing evening with our dedicated supporters at Aspen Hall.

Supporter Evening in Aspen Hall, Bend, Oregon

Supporter Evening in Aspen Hall, Bend, Oregon

So many people made the effort to come out, we had great conversations, and got to catch up with many of our friends, prayer partners, and financial supporters.  The time was too short, but we are grateful that we at least got to say hello to many of the people who allow us to do our work in Kenya.

In the midst of all this crazy travel, we carved out three days of real vacation.   We dropped Michael

Adam Duritz of Counting Crows, as seen from the front row!

Adam Duritz of Counting Crows, as seen from the front row!

Hard to tell if he's excited about camp!

Hard to tell if he’s excited about camp!

at the first ever Type 1 Diabetes Camp in central Oregon, and dropped Jane with her best friends in Portland.

Ann and I relished three days of rare treats like sleeping in, spare time, lazy breakfasts, sushi, and uninterrupted conversation.

We even spoiled ourselves with concert tickets to see Counting Crows in Portland!!

We then returned to Bend to speak at Antioch Church on August 17th, some shopping for last minute essentials, and then departed Oregon on the 21st.  We enjoyed a quick lay-over with Ann’s parents in Dublin, enjoying their amazing hospitality, and spending some good family time.  All too quickly, we were back on the plane to Nairobi, where our friend John was waiting at the airport to drive us back to Kijabe.

Kijabe really feels like home, seeing our little house, getting a feverish tail wagging greeting from Bosco, and seeing our good friends here.  I’ve been back to work for a little over a week, with renewed energy and enthusiasm.  Ann has jumped right back in to trying to find funds to keep the place running, and the kids are overjoyed to be back in school.  Overall, an amazing, somewhat exhausting two months.  We can’t thank you all enough for standing with us in so many ways.

 

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