on blogging: rich human compost

Frederich Buechner (Telling Secrets), on encountering God in the concrete details of our actual lives:

We believe in God--such as it is, we have faith--because certain things happened to us once and go on happening.  We work and goof off, we love and dream, we have wonderful times and awful times, are cruelly hurt and hurt others cruelly, get mad and bored and scared stiff and ache with desire, do all such human things as these, and if our faith is not mainly just window dressing or a rabbit's foot of fire insurance, it is because it grows out of precisely this kind of rich human compost.  The God of biblical faith is the God who meets us at those moments in which for better or worse we are being most human, most ourselves, and if we lose touch with those moments, if we don't stop from time to time to notice what is happening to us and around us and inside us, we run the tragic risk of losing touch with God too.  

Precious

Precious in the sight of the Lord is the death of His saints.  (Ps 116:15)

A precious child died today, the extremely premature baby boy of dear friends of ours in Nyahuka, a couple with whom we have a parental relationship.  His mother's life is still on the edge as she lost a lot of blood.  All weekend as her saga unfolded we have carried the burden of caring about her and her young husband, worrying about them, and sadly being far away.  We're thankful for Isingoma and Christine, and Travis and Amy, who stepped in with wise counsel and timely medical care.  Please pray for the Isingomas and the Johnsons, who are stretched in so many ways, to have spiritual refreshment and stamina, and to keep investing in the lives of younger people.  And pray for our friends in their grief to turn to God and find new depths of faith in Him, and trust and comfort in each other.  It's been a rough few months for them, and they desperately need a fresh hope.

At the same time in Kenya, I was caring for another precious child, this one a 1 1/2 year old girl NAMED Precious.  When the intern and I decided to admit her to the hospital, it was largely because her mother had brought her to the clinic about four times in that same week, and so even though she did not look as ill as most (she had a normal temperature, breathing, heart rate, no history of vomiting or diarrhea) I felt like her mom was sensing something more was wrong, and it would be prudent to figure it out as in inpatient.  Precious had rickets, a common form of malnutrition here, and was slow in her development.  However when I was called to the hospital that evening for a code, she was about the last patient of the MANY on the paediatric ward whom I expected to find being resuscitated.  She had spiked a burning fever, and possibly aspirated (choked) as she weakly attempted to breast feed.  By the time I arrived she was completely flaccid, with no effort to take a breath, though her heart beat had returned after CPR and adrenaline, and we treated her with fluids and strong antibiotics for presumed septic shock.  Then I had an excruciating decision.  Our ICU resources are very limited, and if she had been pulseless for more than 5 minutes she would be unlikely to ever recover fully.  Her motionless body and unreactive pupils were did not give me much hope.  Yet it is hard to stop breathing for a patient that still has a strongly beating heart.  A wise ICU doctor came to my aid when called, and suggested we ask her mother what her wishes were.  And she said "This is my only child, please do everything."  Ah, the name now made sense, Precious, the only baby.  We intubated her.  And before we could take her upstairs, she started to breath a little on her own.  This morning she opened her eyes.  She has a long way to go, and she may or may not recover.  But I came so close to stopping what looked like futile therapy.  Because though I care about my patients, they are not as precious to me as they are to their own mothers.  

Then I got my turn this morning to move from doctor to mom.  Luke had a pretty serious motorcycle accident riding on a rough road down in the Rift Valley on the way to interview Maasai traditional healers for his research project.  He lost control after a bump, skidded to the side of the road, where his bike stopped abruptly into a boulder and he flew off and hit his head against a rock.  Thankfully his borrowed helmet saved him. He ripped his clothes and had a bloody scraped side, but no serious injury.  When he messaged us on rounds I was eager to run home and just be sure he was intact.  He's precious to me.

Our Medical Director reminded us this morning that God our Father waits for a glimpse of us, delights in us just because of who we are, His children.  This is how my friends feel about their tiny, unviable fetus.  This is how Precious' mother feels about her with her ventilator and tubes and fever and listlessness.  And how we feel about Luke, accentuated by the risk of near-disaster.  A parental love does not flow because the baby has done anything, it exists because the baby IS.  I know I have a hard time believing this is God's passion for me.  

Weekend DIY

'Tis the season of goodbyes. Last Sunday afternoon there was a tea for the Bransfords and the Riches, with a combined years of service something like 60. Jacqui and Sue created a spread fit for a magazine from local fabrics and flowers, and everyone contributed homemade cookies and fruit. Yesterday Jack's 8th grade class had their celebration, a rite of passage to high school. No catering, no restaurants, so here you see many parents and students in the RVA school cafeteria kitchen (an impressive facility, pretty new, my first time behind the scenes) doing food prep. We served salads, breads, a main course of grilled beef fillet, linguine alfredo, and parmesean tomato. Then for dessert . . I did mousse duty with Jacqui, creating 50 mousses from local chocolate bars, cream, and eggs. I had never made it before but by the time we worked our way through four double recipes I got the hang of it. Jack at his table, wearing Scott's tux jacket from college over his best shirt (we didn't really get the formal aspect until the last minute). The kids did a drama and Jack was the star of act 3, a talent I suspect we'll see more of in the future. After kitchen duty in the afternoon, I worked as a server in the evening. I did leave a little early to get home by 8 for the birthday dinner Scott and Luke had cooked me! DIY celebrations. Caleb was on choir tour all weekend--here is a preview shot from church last week. He is not yet back from the third straight day of going to schools, churches, slums. They are presenting a drama based on Job, with music. DIY entertainment and enrichment. Caleb's class party: all the girls got to choose (somewhat athletically, like a major capture-the-flag week-long contest where the girls trap boys and tie a scarf on them) a boy to be their costume partner. Caleb's was pretty fun and benign, as Mr. and Mrs. Santa, pictured here with Peter Pan and Tinkerbell. DIY costumes. The latest on the pizza oven, Scott with the kids, enjoying the project and the time together. DIY pizza, someday. Tomorrow we have another goodbye party . . . and everyone is supposed to bring lasagna. So here is DIY lasagna in process. Ricotta made two nights in a row from two days' worth of fresh milk, tomato sauce made from scratch this afternoon, pasta made by hand, and local sausage and cheese. Rolling out the pasta. The pictures are from my phone, which explains the low quality . . . and I do not include the approximately 16 hours spent in the hospital Sat and Sun (so far) . . including middle of the night last night . . . DIY doctoring. One of the challenges of missions is that if you want it, you have to make it. It's also one of the joys.

Life is Iterative

Luke just buzzed out of our drive on a motorcycle, with notebooks in his back-pack, heading down into the roadless Rift Valley to interview Maasai people about their use of traditional herbal medicines. He and his good friend Thomas developed a research project based on the observations of some Kijabe doctors that patients were coming in with difficult-to-explain symptoms that might be caused by unintended effects of these plants. He had hoped to be much further along in the project by now. But the original Maasai questionnaire confused people, the motorcycle transport was not ready, the local partners serving as guides and translators have at times had their own agendas, the randomization by overlaying a grid on a Google Map projection of the valley and selecting quadrants by random number table can make some of their target areas fairly inaccessible . . . it's a daily process of adapting in order to move forward. Qualitative research is supposed to be iterative: you take what you learn on day 1, and follow that lead on day 2. Most people are not comfortable with that. We'd like a plan that is laid out in advance, tested and true, and then the task is simply to get it done. But life is not that way.

Last weekend I was covering for another doctor and got called to see a lovely little baby girl who had been born with a meningomyelocele (defect in the lower spine/spinal cord) and was not breathing as well as she should have been. We admitted her to the ICU nursery, in an incubator, with CPAP to assist her breathing, and a full court press of medicines and monitoring. But she continued to deteriorate, and by 48 hours later it was clear that her brain lacked the capacity to regulate her breathing. Her somewhat fix-able spinal cord problem was only the visible side of a deeper and fatal nervous system deficit. We consulted the neurosurgeons, the chaplains, the parents, meanwhile reviving her multiple times in order to keep her alive. In the end the baby was discharged to go home to die. Her parents lived many hours away, and the intensive care had been expensive for them. But it would cost more to transport a body than a live baby-in-arms on the bus, so they were eager to get started on their journey before she died. Should we have let her go at the very beginning? Perhaps. It might have saved grief, time, effort, resources if we'd had a clear prognosis and plan to act on from day 1, instead of a several-day process of groping through a dim perception of her survival chances only to have to give up. But life is obscure at times, a process of trial and error and correction and change.

A similar story on Tuesday, though with a shorter course. I was sitting in nursery marveling at how calm and quiet the afternoon had been when nurses from the women's ward next door rushed in the door with a bloody little bundle of cloths and said a preemie had just been born, as it turns out in the mother's bed, from a precipitous labor (she had not even been in labor on admission for a urinary tract infection, so no one was prepared for the baby). As we unwrapped the cloths we found a blueish limp ball of baby, low heart rate, and went into gear for bagging breaths into his lungs, turning up oxygen, warming and drying. But a quick look at this baby showed he had many severe birth defects. Legs scissored up over his head, no openings for his urethra or anus, only a rudimentary tag of a penis, no hip joints, another meningomyelocele of soft fleshy cauliflower of skin on his back, a contracture of his arm, peculiar little clovers of split thumbs. His lungs were hard to expand, and we suspected that all his lower-body defects might be associated with absent kidneys, which would mean little amniotic fluid, which would man poorly developed lungs in utero, which would explain his blueness. But like the baby above, at that moment we didn't know if he could live or not live, and on the principal that God values every life equally whether it is contained in a perfect body or a crippled one, whether it lasts 30 minutes or a hundred years, we kept working to keep him alive until we could more clearly outline his anatomy. As it turned out our radiologist was able to come do an ultrasound which confirmed that he had not developed any kidneys. No one can live without kidneys. I went to get his mother, who almost broke my hands squeezing in pain as she was still dealing with bleeding and clots and stitches post-delivery. She didn't want to see him, to have a picture in her mind forever of a less than "perfect" infant, but her sister-in-law came with us to the nursery briefly to see him alive before we stopped resuscitating him. Then he died, quietly, winding down. Later I was the one to break the news to his father, which is always a holy and terrible moment, telling a parent that his child has died, trying to testify to God's love at a very bleak moment in someone's life. Again, this was not an outcome that was anticipated or smoothly planned for. We had to react to what we found, try therapies, adjust, make decisions. It would have been kinder all around to have realized the need for an antenatal ultrasound, to have known ahead of time and made a plan, but life did not work that way.

So this week I'm thinking a lot about this reality: life is iterative. The veil over glory, over reality, over the future, is thick. We walk out a few steps, then look around and adjust our course. Every day brings mistakes, from which we learn, and redirect. This is true on the scale of individual tiny lives of hours to days, as well as on the scale of two-month survey projects, or programs that represent the investment of years and lives. We gave a lot of responsibility to a head teacher once, thinking this was the best thing, who later turned out to be unable to lead the school in the direction we hoped. We started programs in nutrition that blessed many lives for many years, but later had to be suspended due to lack of personnel. A new team built very communal housing for survival, and later grew to value a bit more independence. So many times in life we cannot see far enough ahead to anticipate the outcomes of our actions, we attempt a rescue, invest in what looks good and right, only to find out by living a few more months and years into the process that we have to change course. New surveys, intensive care, hours of agony, closing programs, funding buildings, all these course corrections are costly to someone, on some level. It is natural to then assign blame somewhere, perhaps to God in particular, for not preventing our mistakes, for not protecting others from our painful learning process.

But somehow in the sovereign order of the universe, we walk by faith not by sight. We are called to hand over our two fish and be stripped of all our resources, without knowing if the multitude will be fed. We set out for a land unknown, without a road map. We pour into others' lives, without knowing which of the young people will break our hearts and which will become pillars of the Kingdom. We fiercely apply a face mask and squeeze the bag of oxygen, sometimes only to regret prolonging the inevitable. We get it wrong, and all too often the very people we meant to help are the ones to pay the price. The human condition seems to require this learning-by-living process. Life is iterative, but grace fills in the gaps and wrests some good out of every iteration.

Reflections on the Cesarean Section

"Cesarean Section: a surgical operation for delivering a child by cutting through the wall of the mother's abdomen."

I first wielded the scalpel in a Cesarean Section (C/S) as a resident while rotating at the Harbor-UCLA Hospital in 1990. Since then, my opportunities to operate in Bundibugyo were limited by competing demands. But Jennifer and I are refreshing and refining rusty skills with the help of encouraging colleagues here at Kijabe and the hope of using those skills for the good of the patients at Kijabe and beyond. My experience as a surgeon doing the C/S over the past month has resulted in a few conclusions about this particular procedure.

Chiefly, I have determined that the C/S is an absolutely unique surgery. No other surgery issues life in the same way. A new life is released, set free. While most surgery falls into categories of either resection, reconstruction or repair, the C/S is ultimately a rescue. The baby inside is either trapped by an inadequate escape route or suffocating for the lack of sustaining blood flow. Like the Chilean miners who were trapped in the dark recesses of the earth and waited patiently for an external extraction, so are many trapped inside of their mothers. This extraction, this salvage, also parallels the release that Christians find in the gospel as symbolized in baptism. When a believer is baptized, the complete immersion in water represents burial (Romans 6) and then the believer rises from the water into new life, a rebirth, a resurrection. In the same way, a fetus is immersed in fluid and rises to life, gasping for breath as he emerges from the womb. The water and the blood flow abundantly (no sprinkling here) as the baby surfaces. So, much so that under our surgical gowns, we wear a floor length rubber apron and rubber boots!

Like many Myhre vacations, the C/S is both exhilarating and terrifying at the same time. A technician can learn the basic steps of performing an uncomplicated C/S in a short time. However, to progress from technician to surgeon, is to progress from rote mechanical execution to a responsive management of treacherous complications such as severe hemorrhage, adherent placenta, or fetal malpresentation.

I love everything about the C/S. The sharp dissection through the many layers of the abdomen, the incision into the uterus and the immediate fountain of amniotic fluid, the extraction of the gasping blue infant, the restoration of the bleeding uterine wound, and ultimately the mending of the abdominal layers and skin. There's a lot of art and science, planning and preparation, thinking and doing, manipulation and judgment that go into the successful completion of the operation. But beyond the combination of dexterity and discerning which I must bring to the table, I am principally thankful for the opportunity to participate in small way in God's ultimate creative process, that of crafting a life.

A Toast to Nathan and Sarah, of battles and banquets

(Very early this morning, as in 4-something a.m., we got out of bed to answer a skype call.  Heidi had graciously set it up for us, so we could offer a toast to Nathan and Sarah, at their rehearsal dinner.  Scott had only come home at 3:30 from the ICU, but he managed to offer the toast below anyway.  Sarah and I were both teary-eyed, and it was frustratingly short and awkward to connect this way, but still a great blessing to us.  In this life it is a great joy to be part of two people coming together and we were grateful to be allowed to greet them on this occasion).  Here is the toast:

Isaiah 25

O LORD, You are my God.

I will exalt You,

I will praise Your name,

For You have done wonderful things;

Your counsels of old are faithfulness and truth.

 

For you have made a city a ruin,

A fortified city a ruin,

A palace of foreigners to be a city no more;

It will never be rebuilt.

Therefore the strong people will glorify You;

The city of the terrible nations will fear You.

For you have been a strength to the poor,

A strength to the needy in his distress,

A refuge from the storm,

A shade from the heat;

For the blast of the terrible ones is as a storm against the wall.

You will reduce the noise of aliens,

As heat in a dry place;

As heat in the shadow of a cloud,

The song of the terrible ones will be diminished.

 

And in this mountain

The LORD of hosts will make for all people

A feast of choice pieces,

A feast of wines on the lees,

Of fat things full of marrow,

Of well-refined wines on the lees.

And He will destroy on this mountain

The surface of the covering cast over all people,

And the veil that is spread over all nations.

He will swallow up death forever,

And the Lord GOD will wipe away tears from all faces;

The rebuke of His people He will take away from all the earth;

For the LORD has spoken.

 

And it will be said in that day:

"Behold, this is our God;

We have waited for Him,

And He will save us.

This is the LORD;

We have waited for Him;

We will be glad and rejoice in His salvation."

 

We raise a toast to Nathan and Sarah tonight, of wines on the lees and choice marrow-filled pieces.  Isaiah 25 is breaking into our world right now in this gathering.

If there is anyplace on earth less conducive to romance than Bundibugyo, we don't know where that would be.  It is a place of frequent death, heat, discomfort, complete lack of privacy, cross-cultural stress, intense ministry demands, and much heart ache, not to mention a context of strict mission rules and pressure to not upset the balance.  The veil lays thickly over that valley.  And yet there in Bundibugyo, Nathan and Sarah found beauty in the midst of sorrow, and joy in each other in spite of the difficult context of their lives.  In the mud of poverty and hard work a seed of love was planted and grew.  This is more than just a lovely story for the two of them, it is a tangible picture of the way God's Kingdom comes, improbable, against-the-odds, persistent, with much waiting, we find that we are finally rescued from the heat and noise of the war to enter the feast laid out on the mountain. 

This evening, and tomorrow, and the rest of your lives, may you look back and see that you waited on the Lord, and he came with salvation and gladness.  May your entire lives continue in this pattern of waiting through impossible odds, and then tasting and seeing that the Lord is good.  Of battle and banquet.

Tonight is a foretaste of the final feast of the Bridegroom and bride.  The veil is torn so we can see the shadows of the ultimate reality, but it is not completely removed.  Otherwise we would be there with you instead of trying to greet you by skype from the Kenyan highlands at 4 in the morning!  We love you Nathan and Sarah and count your friendship as one of the great gifts of our life in Bundibugyo. 

May your marriage be a place where death is swallowed and tears wiped, in anticipation of the ultimate marriage banquet that ends all death and tears. 

To Nathan and Sarah, battles and banquets, Bundibugyo, team, and love!

Simon

Most of my patients are less than a month old, and less than a few kilograms in size. Today though I was called to the outpatient clinic to help the excellent Dr. Sarah there evaluate a very complicated patient, Simon. This 9 year old found his way to Kijabe to see the also-excellent plastic surgeons, because of an apparently erosive lesion that was destroying his face, thought to be cancrum oris (a nasty bacterial infection). His desperate situation had attracted the help of someone who hooked him up with a Safaricom sponsorship for surgery. Only when he came, and our doctors evaluated him, it turned out that the lower left side of his face has not been destroyed by a tropical disease, but by his own picking and scratching. He's mutilating himself. And the surgeons did not want to operate until someone tried to stop this behaviour. Me? Not likely, but it you're known as the paediatrician, then the desperate cases come your way. I admit that I entered the room and saw a child that I assumed was completely devastated since birth, and I was only thinking of how to get back out, wishing I knew of some magic-buliet-sedating drug to put this kid on.

But I didn't know any magic medicines, so I sat down with Dr. Sarah, and started to ask questions. Shockingly, this child was completely normal until two years ago. He was a 7 year old in second grade, with friends, playful, and learning to read. He was cared for by his single mom, and no doubt the center of her life and hope for her future. Then he came down with TB meningitis. He escaped with his life, but lost his vision, and use of his left side. He's blind, partially paralyzed, and has a shunt for post-infection hydrocephalus. To survive, his diminutive mother sells charcoal near her house, but when she does, she leaves him there alone. And when he's alone in the darkness of his world, and hungry, he starts to pick at his face. The sensation was an antidote to the boredom and hunger, and became addictive. Now his jaws are scarred so that he can barely open his mouth to eat. And his dear mother, who looks like she doesn't weigh more than 90 pounds herself, became more and more desperate to help him, and carried him here on her back.

When I realized Simon was blind but not deaf and not mentally impaired, I took his hand and introduced myself and started talking to him in Swahili. And he answered me in perfect African-school-English, "how are you?" He tried to smile some, and to answer questions from Dr. Sarah. He likes chapatis and avacados and balls and listening to the radio. Belatedly I realized we are dealing here with a little boy, a person, locked into his blind and immobile world, and desperate for attention. I called the nutritionist to come and help hook him up with fortified porridge and plumpynut to get calories past those clenched teeth. We made a plan with the mom for music (which she had noted stops his self-mutilating), toys, things to do and touch. We made a plan to use rewards for time periods when he doesn't touch his face, a positive feedback system. And we'll see him again in a month to see if any of this is helping him heal enough for surgery. Dr. Sarah, competent and caring, thinks she can get the same Safaricom sponsorship to perhaps hook him up with an organization for disabled people, to find out if there is any school for the blind he could attend. I was reminded of Kabajungu Grace, the little blind girl that several years of Bundibugyo summer interns and I bonded with. She and Simon would have made great friends.

Something about this weak but sincere mother and her trials really touched me. Or about Simon himself, a normal little boy trapped inside a sightless and still body, with a frighteningly skull-like disfigured face but a soul that reflects God's glory as much as mine or anyone else's does. Praying now that he turns a corner back towards life and health, and longing for the full-healing touch of Jesus to make all things (his brain and his face) new.

Weekend Highlights

Friday 5 pm: The weekend begins with a downpour so violent and drenching that I decide to get sign-out for call from my house instead of going into the hospital (the picture above Mardi took, it is symbolic of our new life of sharing the nursery job . . ). Start to cook dinner, and call comes about a 4.8 kg two-year-old being admitted post-op to ICU. Thankfully I'd planned ahead on this meal so it's almost good-to-go, but it turns out the child does not need a ventilator and I'm not needed. Another call about a newborn with a slow adjustment to life-outside-the womb. Both stable. So back to family, spaghetti, one of the kids' friends comes for a home-cooked meal, I realize that with 5 teens I should have made more, so Julia helps me get a batch of cookies into the oven, while the boys clear and begin to watch a rugby game on TV.

9 pm: I've dozed while reading when the phone rings, there is concern about the labor of a woman in maternity, who happens to be the wife of one of the doctors. I hurry over to the hospital to find the baby already born, a lovely full-sized vigorous girl. One of those pleasant paediatrician moments, just hold the baby and congratulate the parents. Check in on the two other kids, both doing well, which bodes well for the night. I love the quiet corridors after dark, the slumbering hospital with its continuing pulse of life. Back home by 10.

3 am: calls from hospital about post-op 8 day old with tachycardia (fast heart rate), hemoglobin drop by half, discuss plans for transfusion. Intern says baby is breast feeding and alert. Baby also has rising creatinine indicative of renal failure, but weight constant, so not dehydrated or overloaded. Complicated child who has had meningomyelocele (opening in back exposing spinal cord) repair, colostomy (because born with no opening of rectum in anus), ureterostomy (because born with only one kidney which is cystic and malformed, and obstructed outflow). There are so many babies like this at Kijabe, it is a magnet for rolling back the Genesis 3 curse about bringing forth children in sorrow.

6 am: up for early rounds, go direct to neurosurgical area to see the baby above who now is in the middle of a blood transfusion, with a dangerously high heart rate and murmur, and wonder if cardiac anomalies are part of her complicated anatomy. The baby is wide-eyed, but her mom is fast asleep in bed with her, and I don't wake her, certain that she's had an exhausting night. Write a note about her critical condition and marginal prognosis and go to make arrangements to transfer her to NICU. Which requires moving another baby out, because we're full. Scott is meanwhile starting OB rounds at 7 and finds a mother who needs an immediate C-section. He goes to theatre with one intern while I start rounds in Nursery with another, a competent and efficient young woman who has already done most of the morning's work.

8 am: Ready to transfer baby, go back to ward to inform nurses and primary surgical team . . .only to find out baby has just died. Mercy, or too little too late. Short discussion with medical staff. Back to finish rounds in Nursery.

9 am: home, kids getting up, time to make biscuits, cut up golden dripping sweet mangoes and an orange, set table . . but by the time I'm done it's almost 10, so I leave Luke, Caleb, and Julia to eat breakfast, Scott still not back from his morning rounds, and hurry up the hill to be on time for . .

10 am: Under-13 Rugby 10's mini-tournament, RVA and two other Kenyan/British Nairobi schools. Jack it turns out is captain of his team! I am just on time, and join the handful of other parents as swooping darting swallows comb the field for insects after the night's rain, and the sun warms the earthen bleachers cut into the hill on the sideline. Jack scores the first try, and kicks the conversion. By the middle of the game the whole family has joined to cheer. Jack is sometimes put in the U15 games, but here he is playing with his actual age-mates (though I think that "Under 13" is defined as having turned 13 after the previous July, and since he's a March birthday he's on the young side, but he's still among the tallest and fastest). RVA wins both of its games by huge margins, they dominate the other two teams. Jack scores about a third of the total points, and has many good tackles and runs. THIS IS A HIGHLIGHT DAY: whole family here, sunshine, Jack running about 60 yards through many opponents, tough, clutching the ball, scoring a try and touching it down over the end line. All of us standing and yelling as he makes this play. It is a joy as a parent to see your child affirmed in who he is and how he's made. I remember my Dad, my Uncle Harold, and Paul Leary always telling us that Jack should play American Football--this is probably as close as he'll ever come. A mental snapshot of that moment is filed in my heart.

1 pm: As we walk down the hill after the tournament, the joy of the day is tinged only by the sad ache that I wish my Dad had lived to see this, as a football fan, he'd have loved watching Jack run with that ball in his hands. And the realization that every kid should get that thrill, should have at least a few moments in life like that, cheering crowds, admiring parents, fun in doing something they love.

2 pm: Somehow the entire house took a spiral into chaos since Friday . . time to attack counters full of dishes, put clothes on the line for a few hours of drying, sweep several meals worth of crumbs, while Scott and Luke mix mortar to add the first layer of bricks to the pizza oven foundation, Julia goes to play soccer with her former JV team, Caleb works on never-ending homework, and Jack recovers from a morning of effort. Finish the last sweep just in time for . .

3pm: Two sequential visits from friends, one needs me to review all her daughter's immunizations and see what is lacking for their upcoming trip back to America; the other needs prescriptions for inhalers refilled. Both are women whose company I appreciate, and I'm glad that medicine gives the excuse for them to have come by, the setting for talking about kids and life. From walking into the delivery room to pre-college physicals, I like the longitudinal family-centered depth of paediatrics as a background to the day-to-day challenges of extremely ill inpatients. And having left intensely close community in Bundibugyo, I value highly such friend-time, when it happens (not often enough really).

4pm: I'm technically covering call during Saturday too, for one of the other doctors who wanted to go into Nairobi to see his senior son play on a rugby all-star team. Which is very important. It's been a quiet day call-wise, but just before he comes back another neurosurgical baby starts to have breathing difficulties, so I'm back to the hospital to meet the intern, examine, ponder, plan, draw blood, transfer to nursery again. We're just about done when the real on-call doctor returns, so I'm free to . .

5pm: go on a short run with Star just to stretch our legs and get fresh air, Scott and Luke are still finishing the brick-laying, one layer takes a lot longer than they thought (doesn't everything). Try to hurry everyone along because Saturday night is a special event at RVA. Our water pressure is limited, so showers have to be staggered, I jump in at a quarter-to-six. This is a dress-up evening, and my hair has been even worse than usual with frizz. What to do? Options limited, so at five-to-six I decide to give myself a haircut, an inch or two off all over, since it's been many months since my last visit to a salon in America. With springy hair like mine an inch cut translates into about 3 or 4 inches shorter when it dries. Put on my one fancy outfit, my Christmas skirt and shirt, call a friend with good taste like my sister's to borrow jewelry, in time for . . .

6:15: Sophomore Restaurant. An RVA event that is part fund-raiser for the 10th grade class, and part social event of the term. The sophomores sell tickets, and the adults an upperclassman buy them to come to the cafeteria which has been decorated in a theme (China this year) and be served a special meal. We had been invited to sit with two other couples, both are doctor-nurse pairs. It is a rare evening of going out, being served food I didn't have to cook, adult conversation. I enjoy learning about their pre-Kijabe lives, and hearing about their adventures and plans. The food is probably what you expect when American missionaries are cooking mass-production Chinese, but the atmosphere is very fun. The only sad moment, realizing both of these couples are finishing their terms in July. Sigh. More goodbyes loom.

9 pm: back home in another drenching rain, dripping wet, time to warm up. Jack and Julia are watching Ratatouille and we all watch the end. Chat about the evening, the week, consider watching a post-younger-kids-in-bed movie but the sound doesn't work on this disc, and we take it as a sign to get to bed by 11 anyway to recover from call and be rested for . . .

SUNDAY: family breakfast with coffee-cakes which stick to the pan but are so buttery that everyone declares them the best ever even if they are eaten in crumbles, iced juice, bacon and eggs, coffee. Our Sunday morning tradition has been more difficult to keep up here at Kijabe, but this morning it works. Kids off to Sunday school as I clean up, then we meet again for church, great worship.

1 pm: after church our houseworker Abigail has invited us up to her house for lunch, a rare chance to get off the insular world of Kijabe/RVA and into a real Kenyan home. Abigail lives with her son, her sister, and their elderly mother, surrounded by the homesteads of her brothers, with their kids. And their gardens, a polka-dot of cabbage and spinach, bordered by corn and pumpkins. Their village Maingi is on the top of the escarpment, about 9000 feet, chilly, in the clouds, which part for stunning views. Abigail's sister was our houseworker when Jack was born here, and we've stayed in touch ever since. ( There are pictures of our kids at various ages on the walls of their greeting room). We are escorted in to sit on plush red-velvet-floral covered couches, with low tables draped with lace in front of us, and two stuffed antelope heads leaning out of the split-log-painted-blue walls. This time we can at least exchange a few sentences in Swhalii with the non-English-speaking family members (small progress?). We pray together, and eat a mashed mixture of potatoes, beans, corn, and pumpkin leaves, accompanied by a stew of diced carrots and tiny pieces of meat, and chapati. When we insist "nimeshida" (I'm full) she clears the plates and all three women sit with us to drink chai and talk. This family has truly blessed us, and we pray for God to care for and bless them too.

Which brings us up to now. A weekend with friendship, community, work, worship, family, sports, food, home, projects, rest, all the essential ingredients of full life. At dinner last night someone asked us if we feel at home here yet, and today I would have to say yes. Which is no small thing.

comfort from Psalm 9

For the needy shall not alwasy be forgotten;

The expectations of the poor shall not perish forever. (v 18)

This verse leaped out of my Bible this morning, in the context of our Bundibugyo Team's mourning.  The four-year-old son of one of our CSB teachers died on Monday, after a very long dwindling illness characterized by pancytopenia (no red blood cells, white blood cells, or platelets to carry oxygen, fight disease, and clot blood) and massive hepatosplenomegaly (big liver and spleen) that was possibly leukemia or some other form of childhood cancer.  Jason's father K.F. was a WHM-kid in many ways, one of those little boys who hung around the mission looking for friendship and help and role models.  He found that in the Fillyaw family and then others, and after finishing his education came back to teach at CSB.  Unlike many parents of sick kids in Bundi, K.F. and his wife were able to take Jason to the nation's central hospital.  They exhausted every avenue of possible care in Uganda, and had the huge advantage of personal attention from Dr. Travis and Dr. Jessica. Travis consulted many people about his care, spent hours getting him transfusions and antibiotics, and even provided the last few days of care via personal visits to the family's village home where they had taken him to die.  An illness like cancer is rarely survivable in Uganda.  It's a terrible and threatening disease, but the underlying issue is poverty.  In Africa the medical system lacks the resource and expertise to rescue a kid like this.  We mourn with the psalmist and cry out for this promise to be fulfilled, that the poor shall not perish forever.

Please pray for our team.  Jason was Patton's age. The CSB staff are like extended family to each other, and to our team.  No doubt there is an element of Job-like spiritual attack here, a taking away of that which is precious from someone like K.F. who has seemed to benefit from mission attention and care.  The Johnsons in particular invested a huge amount of heart and sweat in just helping Jason survive this long, and going through the grieving will be exhausting for them as well.  (One of my babies died last night, a preemie with an anomaly of her bowels, whom we had struggled to keep alive for a week . . . and one of Scott's did too, a post-partum mom of twins who seemed to have a sudden bleed in her brain, both tragic, but both relative strangers to us, it's not the same as walking through the intensity of community in Bundibugyo . . )  PRAY that Jason's dad would miraculously continue to testify, as he already did at the burial, to God's goodness and love in spite of personal tragedy.  This is where the real test of faith comes.  We who have healthy children can only marvel from the sidelines and pray as those who suffer cling to Jesus.

Surgery and Construction

Today there were three Myhres in the operating theatre for a few moments: Scott performing a C-section, me waiting to receive the baby for paediatrics, and Luke there to observe. Scott has been on a grueling schedule for OB for the last couple of weeks, but it is paying off as he's had a solid number of opportunities to refine his surgical skills. He can write more about his experiences with the scalpel. It feels a bit awkward to take photos as women have their abdomens sliced open . . . so I've documented the other side of his job, that of construction engineer. The original surgeons were also barbers, so I guess it makes sense to be a person who saves lives by cutting and sewing and also creates new buildings. In this case, the long-awaited pizza oven. Scott and the boys started on Saturday, after the Longonot hike. Above they are digging out the site for the foundation. Making concrete from cement, sand, and stone on our driveway. Caleb ferried uncountable loads to the foundation site. After the first layer of concrete, a wire mesh, and then more. Smoothing the layers, adding more. Meanwhile Julia was inside, washing and paring 2 kilos of strawberries bought from a local farmer.When the foundation was full, they smoothed the surface with this board. Final touches. If you can see the stack of local stones in the background, quarried from a site very nearby. Unfortunately when we tried to stack them the next day to prepare for the walls that support the oven, we found them to be rough, uneven, and unsuitable. So . . .Scott spent his only day off driving into Nairobi to purchase bricks. He contracted a lorry to drive them out to Kijabe, rushing to get home first, which was rather pointless as it took the lorry 8 hours to get there. Meaning the massive load arrived in the dark . . Here we are at 8:30 pm unloading 1,400 bricks. With Thomas L. It took the seven of us plus two lorry drivers about half an hour to carry them four at a time off the truck and onto our porch. Calebtopia . . . Scott and Caleb constructed piles. The proverbial ton of bricks was actually 4.2 tons. Dreaming of pizza . . . which is still a couple months away.

LONGONOT!!

There is something about mountain-climbing as a family that we just love. This is the kids' long weekend mid-term school break, but my dreams of exciting and memorable camping trips had to bow to the reality of Caleb's intense school-work load of things due in the next couple of weeks, our post-call weariness, some unpromising weather, and general lack of planning and skill to know where to go in Kenya. So . . . we decided instead to drive to Mt. Longonot, which we can see from our yard, less than an hour's trip away, for a day-hike. The extinct volcano rises from the floor of the Rift Valley to over 9 thousand feet, and the hike from the base and around the rim and back down is about 20 km. The soggy misty cold of the last few days lifted, and we had a gloriously sunny morning. It took us about four hours (which is a pretty typically Myhre-intense pace) to do the circuit, pausing to look at the distant tree-tops below us in the crater, or to scan the dry acacia-strewn slopes for wildlife (saw one giraffe and one probable leopard at a distance). Steep rocky climbs, a narrow ledge of rim, dozens of species and colors of small wildflowers, a diving eagle, swooping swallows, sun, passing clouds, inches of billowing dust with every step, adrenaline moments of running down and peering out, a snack at the peak, conversation, long draughts of water, memories.

Jesus always took his friends up the mountain to get away, and we find it refreshing too. A heavenly dimension of sorts, quieter, different atmosphere, the extreme effort and thin air. Thankful for today. And it's probably a very good thing we're back home and not camping, because as soon as we returned Scott and the boys started working on our long-awaited new pizza oven. Yes, the Bundi tradition shall live on at Kijabe, eventually. It's a big project, but they're off to a good start.

Paeds Team

The problem with hellos, is that they carry within them the seeds of goodbyes.

Departure is the dark side of team. Missions has an inherent instability, throwing people together who are all outsiders and have some degree of temporariness. Add to that the fact that Bundibugyo pretty much chews people up and spits them out, and it often felt like we were always saying goodbye to our colleagues there. Here in Kijabe, we're part of a much larger community, the very size of which blunts some of the impact of the losses. But both of our nearest neighbors are due to leave in July, families with 20-30 years of service here. As is the former medical director who gave us our jobs, and his wife with whom we've worked closely in the RVA clinic and just enjoyed as a person. And the superintendent of the school, who has been here most of his life. Every year has turnover, but many are saying this year will be a record one.

The first goodbye of the season, though, hit very close to home. Anand M and his wife Sophia came here as missionaries from India last Fall. Both were from southern Christian families and grew up as third-culture-mission-kids in the North. Both have a great heart for missions and a connection to Africa. Anand finished his medical internship, and Sophia qualified in paediatric dentistry. And by God's grace they found themselves here at Kijabe. I have worked more closely with Anand than anyone else since I arrived, rounding and pondering and resuscitating and reviewing our patients together nearly every day for the last five months. He's one of those cheerful, competent, can-do sorts of doctors that are a joy to have on staff. And as a couple they invested in Bible studies for the interns. We spent some fun evenings together. In the course of his time at Kijabe he was accepted to a Paediatrics Residency program in the USA, in Cleveland, a wonderful opportunity to further his training. So on Monday we gathered as a Paeds Team at our house for dinner, prayer, and goodbye.

I'm thankful for Dr. Mardi and her family here via SIM for at least 2 years, for Dr. Dan E. and his family volunteering for two months as they transition from a long career in Africa probably back to the States for at least a year or more, and Bob and Lillian the married clinical officer couple who provide continuity and good clinical judgement as the rest of us come and go. I'm thankful for Dr. Immaculate M, who is on a two-month leave so missed the party. But I will miss Anand and Sophia very much. I've had a heavy irritable heart much of the week and finally realized why. Losing a colleague who has become a friend hurts, even for a good cause.

This goes out to . . .

All our teams in Africa, but in a special way to the Massos, getting on the plane today to return to Sudan, and Scott Will, living in Mundri team-less but embraced by the people.  John C, taking his ophthalmology boards today, and his family whom he left in Kenya. Kimberly T, who plugs away in an under-equipped clinic serving refugees.  Martha and George M, taking on interns and a church team and kids-home-for-summer and leading all of those into pioneering ministry situations.  Jessica, figuring out how to live in Bundi, and Anna pitching in to cover for unexpected personnel lost to sickness.  And most of all the Johnsons, who have now reached the 1-year mark of team leadership in a very tough place and are realizing what a toll it has taken.  

And to me, too, at the end of a pretty stressful week.  Almost had a baby die in my hands because in the hour it took to get an xray I didn't think of a tension pneumothorax as he turned bluer and bluer and his pulses faded (I had called in the chaplain and told the mom he was dying from his congenital heart disease, which may still happen, but when I finally got the xray and threw it up on the light box I was so glad to be wrong).  Looking back on our life in Bundi more this week too, and feeling the inadequacies of all we did and didn't do.  Evaluated a child for potential sexual abuse, which is always a heavy weight, and heard of another case in the hospital.  

So here is a meditation from the highly recommended Jesus Lives by Sarah Young.  She writes as if Jesus is talking to you.

My power flows most freely into weak ones aware of their need for Me.  So take heart:  Though the journey you're on is one of faltering steps, such steps of dependence are links to My Presence.

Today you feel the journey more than usual.  It's a challenge to take the net step--and all too easy to be aware of you neediness.  Sometimes you get discouraged bout your ongoing weaknesses.  You know that dependence on Me brings spiritual blessings, yet at times you feel trapped by your limitations.  Only the knowledge that I am with you keeps you out of the pit of despair.  

Awareness of your need for Me is what creates a strong connection to My Presence.  My Power flows into you continually:  It gives you strength to take the next step, strength to ressit discouragement and despair, strength to know Me in intimate dependence.  Only My Power can enable you to live abundantly in the midst of your limitations.  Your day-to-day perseverance, in dependence on Me, is every bit as supernatural as an outright miracle.  So don't think that your difficulties signify lack of faith or lack of blessing.  They are means to help you stay on the path I have chosen for you.

Because you are My beloved child, I choose to bless you, but I bless you in ways that are unique to your needs and My design for you.  Though the way before you may be steep and rocky, it is nonetheless the path of Life.  It is where you encounter My luminous Presence--radiating Peace that transcends all understanding.

May we all be people who find the inexplicable, miraculous peace of persevering when when we have nothing left to give.