Monday, June 27, 2011
Sunday, June 26, 2011
Friday, June 24, 2011
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.
Monday, June 20, 2011
"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.
Friday, June 17, 2011
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!