Sunday Contrasts

Yesterday we spent in the misting rain, shivering at times, cheering most others, back and forth between 3 football (soccer) games for Jack's JV and 5 for Caleb's Varsity in the annual RVA football (boys) and basketball (girls) tournament. It is a community event, with seniors selling grilled burgers and chicken and pizza and salads, parents meeting up with kids and old friends, faculty mingling. The best moment for me was Caleb scoring the tying goal in the first round against the team that won the whole tournament in the end. The final game came down to overtime and then a penalty shoot-out, which we lost 3 to 2. But it was valiant and muddy and crazy and tense. And followed immediately by Acacia's pizza party for a handful of her classmates, celebrating her 14th birthday. A great thing to be able to host this with Karen. Due to rain we had to be mostly inside, but the girls' chatter and the candles on Karen's home made apple pie were cheery. At Acacia's request, Karen and I made a breakfast this morning of crepes with strawberries and whipped cream, before they went off to Nairobi for the day with family. I love our blended family here, the extra mom and dear friend staying under our roof, the shared Bday fun.

About the moment the party was all over Scott starting shivering, and within the hour he was knocked over by some infection. The last few days (weeks? months?) really wiped him out anyway, a complicated patient with unusual neoplastic tissue only a few weeks post partum, a difficult surgery, and then a long hard phone call which was the culmination of a week's worth of sorting out a conflict. I think his body was just over-the-limit, so when an infection hit, it hit HARD. He's not spent a day in bed like this in ? I can't remember. So he missed the early morning visit to plant a tree with our friends who lost their baby. I sort of invited myself when I heard they were commemorating her birth and death, and they were gracious to let me come. After days and days of rain there was a moment of sun, fresh earth, a simple scripture, tears, memories. As we talked it struck me that I was glad to be there on so many levels. As a fellow mom who lost three babies of about the same size, the lonely mourning of miscarriage now shared. As a doctor, closure to walking through this week with the frightening bleeding and shock and transfusions and ICU. But mostly as a person who misses the intimacy of our small team, someone peripheral to the massive intricate complexity of Kijabe/RVA, in this small moment we were able to delve deeply into a life, and I'm thankful for that.

Birthday and burial, all within the hour. Life is so like that. Sickness and crepes. The clouds part for a few hours of sunshine, and then return. A toddler giggles as mourning parents weep. All true no matter how incongruous.

Prayers for Scott's healing appreciated. I am just emerging from almost two weeks of intestinal issues, still not sure if the disease or the cure caused the most problems, but it wasn't pretty. Hope he doesn't take that long to improve . . . we need him.

Things that make me happy

It is raining, incessantly, the kind of build-your-ark drenching that leaves us with a muddy floor, damp clothes draped over chairs, and a harrowing ride back from the airport last night as many cars stalled in the gushing rivers that flooded Nairobi's streets. ( You have to be in a foot or two of water on a major highway, being sprayed by trucks, slipping in the dark, to realize how important it is to think through where all the water which falls should go, and how important engineers are!). Rain does NOT make me happy. But it makes everyone else happy. Thankfulness for the rain is the first phrase out of everyone's prayer mouth this week, Kenyans, missionary kids. They get it, that we need this moisture to eat, to survive. I am cold, and would like to see the sun, and dreading standing in the rain to watch soccer all day and to cook pizza for Acacia's party tonight. But I dutifully put rain first because it makes Kenya happy. This is the spread of loot from Dr. Raymond, visiting paediatrician from Alabama who has been a voice of wisdom and stability working in our department this month; Dr. Lesley, Mardi's friend visiting from Australia for two weeks; and Dr. H who could not come this time but sent a suitcase with others from Europe! We now have some really important life-saving items like ambu-bags for infants and preemies, oxygen tubing, specialized IV lines. Some donated, some bought at these doctors' own expense. Mardi and I spread it all out and divided it up and delivered it, Christmas in October. One thing that REALLY makes me happy is that my dear friend Karen came to visit. A perk of holding her daughter hostage I guess. Yesterday she and I took a long walk, then later slipped into 7th period choir class to listen to Acacia (top left), Julia (a few girls down the back row) and Caleb (with the bass section in the middle of the back) rehearse Christmas music for their concert in late November. Glorious. This rug makes me happy. We had a disintegrating cheap mat in the bathroom, until I was craft shopping with my Mom on her way to the airport yesterday, and found this cheerful rag rug. It is heartening to see the colors with the blue bathroom walls, and step out of the shower onto it. And while I was buying gifts to send back to my sister, niece and nephews, my mom insisted on buying me this necklace. Note also the warm red hoodie, and three layers of clothes. Skyping with Luke was the most cheering part of our evening. We miss him so much. It makes me happy to just see his face in his dorm room, hear about his Gospel choir concert and organic chemistry and plan to meet his RVA friends in NYC this weekend. His news: winter arrived. New Haven is COLD. The seniors working together is another fun sight. I spent last evening with Julia's class, but snapped this as I looked for Caleb to hand him a sandwich because he missed dinner. The girls have given him a note of encouragement with his number (8) for the tournament today. He worked for about four hours after his game last night, then got up at 615 to work two more before the tournament today, all on the food that the seniors sell to raise money for their end-of-the-year class trip. Not sure when college apps fit into all this, he's exhausted. This bright knobs always make me happy, when the roaches are running off the kitchen counter I try to focus on this little spot of beauty. My mom sent these months ago, but these remind me to be thankful that she made it back safely to the USA after a month in Kenya.

Two views

Some evenings I can wrest a half hour or more in between work, scrambling to see games, a quick check of email, preparing to cook dinner, folding laundry, clean up. So when I can, I love to go for a short run or walk with Star. One of our favorite routes is directly across the field in front of our house, catching a path that leaves the station houses behind and meets a relatively flat old road or railroad cut, to the airstrip. It is a gravelish path, used lightly by foot traffic from the valley up to Kijabe. Yesterday as we jogged along, I was struck by the different views to my left and my right.

To the left of the road, the trash dump for the station. Heaps of garbage, columns of smoke rising from the attempt to burn the trash. An old man was picking through the pile, looking for anything useful. And between the road and the dump, a ditch filled with grey, bubbly, putrid water, the effects of sunless days and drenching rains. The stench is nauseating, the view distressing. A stray dog lopes through.

To the right of the road, however, eucalyptus bushes lend a balancing fragrance, with their silvery-green leaves and exotic scent. The valley falls away over boulders and acacias. In the distance, the sun filters through clouds, a golden light on the tops of mounts Suswa, Margaret, and Longonot. The horizon is endlessly far away, hazy and beautiful.

One path, but two views, both real.

And as I jogged along, it struck me that this is a picture of life. As we move along our path, we can look left or look right. We can see the putrid or the sublime, because both are there. Neither should be ignored, but there is some choice involved in which way we spend most of the time looking. And I've been looking left too much.

Looking left, my heart sinks when a kid misses a deadline for a school event, sits on the bench for a game, does not get invited to participate. But if I looked right I'd be thankful for school even if we are at times peripheral. Be thankful for a season without injuries, even if playing time has been disappointing.

Looking left, I feel inadequate and incompetent in my work and in most of life. Looking right, I'd be grateful for the blessing of being around people who are smarter and more experienced than I am. To the left, another baby with incurable complicated heart disease, who will die sooner rather than later. To the right, a child whose bone marrow aspirate showed his cancer was cured.

Looking left, my heart protests the way God allows suffering in the lives of people I love. Looking right, I see the privilege of walking through a hard and dark valley with friends this week.

Looking left, I am tired of the intestinal parasite that has wiped me out, as well as the toxicity of the cure. Looking right, I realize how great it is that no one else in the family got it.

Looking left, the tension of living in a country on the edge, tense, unstable, wondering when the next grenade will be launched. Looking right, the reality that life goes on almost normally.

This month started with an absolutely life-draining, mistakes-made, non-stop call weekend. I think I started looking left then, and now three weeks later I've hardly appreciated the view to the right. God sent my mom to organize my kitchen and play games with my kids and cheer us on. He sent two visiting doctors to allow a little breathing space in life, mentors, gift-bringers who have taught and supported in amazing ways. He sent friends to fix our car. He sent us a weekend break. Bethany reminded me that praise and thanks are instruments of war. That when we're under attack, the way to survive and emerge is by remembering thankfulness. By looking to the right. How many Psalms are written just this way? A lament of left-ward looking, true, painful, and then a transition to look rightward and remember that which is also true and beautiful, even if distant.

Pray that as we plod along this road, we'll balance the left-view of the trash dump by taking long right-views of the sun on the valley.

Kenya at War

Kenya invaded Somalia this week, and President Kibaki officially declared a state of war.  It is a peculiar war, waged by Kenyan military across their border in cooperation with the weak government in Mogadishu against the kidnapers and insurgents who control much of the territory in between.  The reality of this is pretty far removed from idyllic Kijabe.  Pretty far, but not completely.  Today as I walked to the market with Acacia, I saw police stopping and checking vehicles as they approached the hospital.  Our neighbor pointed out that  one was wearing blue flip-flops with his blue police uniform which cut into the intimidation factor a bit.  Emails are circulating about security awareness, because Al-Sha_bab has threatened to bring their campaign of terror and bombs to Nairobi in retaliation.  This station has a history of angelic protection from attack during the Mau Mau uprising decades ago (Mau Mau who were later captured reported turning back from attacking missionaries and children at the school, because of the strong perimeter of military they saw, when in fact there were none).  So one could look at it either way: a dangerous spot as the largest concentration of American missionaries in East Africa and the perfect target for anti-USA or anti-Christian terrorism . . . or a very safe spot protected by God Himself.

In other news today, Burundi was named as the most corrupt country in East Africa.  Our new team has their work cut out for them,  Every step of their work, from building houses to getting vehicles to approving curriculum to rehabbing the hospital to sourcing clean water . . will be met with the obstructing frustration of inefficiency and bribe-seeking.  Uganda has cracked down on anti-government protestors again, even as a hundred US military "advisors" landed to assist in the capture of Joseph Kony, murderous and deluded leader of the LRA.  Our Uganda team is back in business, with new team mates Josh Dickenson and Pamela Stephens.  Josh was an intern with us who went on to finish a PhD in Engineering in Florida.  And as soon as he landed he was swept up in trouble-shooting diminished water flow in the pipleline that provides tens of thousands of people with life-saving clean water.  As soon as the Johnsons landed they were sick, a key CSB donor landed unexpectedly early for a visit, and another team mate had an injury requiring stitches, so it's back to the usual push.  Pushing for the Kingdom, and being pushed back.

Please pray for peace in Kenya, for protection from terrorism.  Pray for courage in Uganda, and wisdom, and provision as our team puts their shoulder to the plow, as our CSB students and friends take their life-determining national exams.  Pray for vision and growth in Sudan as our team hosts 5 businessman interested in micro-development.  

Pray for our family too. One more week with Grammy, Caleb feeling the crunch of application deadlines, some disappointing grades and games, some very heart-rending patient stories, all felt more acutely by me because I'm muddling through an unpleasant case of dysentery for the first time in over a decade (just after I told a new missionary that I eat freely when we're out in Nairobi and never get sick . . . ).  

One can be lulled into the protected beauty of this place, of a structured hospital, of competent colleagues, of seemingly normal teen life and school, and forget that we are living in a war.  Right now, both spiritual and literal.

More Photos, Grammy and Julia at Kembu Cottages and Farm

Celebrating Cultural Diversity

Today was a Kenyan national holiday, Mashugaa Day, formerly Kenyatta Day, for remembering the heroes who fought for independence and established this country. RVA takes the opportunity to celebrate "Multicultural Day", which is the 4th of July and Halloween and Thanksgiving all sort of rolled into one. Probably the highlight of the program was a traditional Korean Fan dance, performed by twenty or so young elementary-aged girls, only a fraction of whom were actually Korean. Imagine butterflies dancing ballet. The Parade of Flags: the students of RVA carry passports from over 30 countries. The student who has been at RVA the longest from each one is honored by carrying that country's flag to the front of the auditorium, and giving a greeting in the local language, while the audience cheers. It was pretty amazing to see the students transformed by their national costumes and languages, and to realize the richness of this place. USA, South Korea, and Kenya pretty much brought the house down. The language classes also come forward in groups and present a song, skit, reading, etc. in their language. Above you can see Acacia, Julia, and Caleb all looking quite animated while singing in Swahili. Caleb and his good friend Titus performed a humorous song, about being a "Mujungu" (foreigner) in Kenya. They sounded really good together, and the song was hilarious. If you use your imagination, you can see Jack in the back row far right with all the French classes singing "Blessed be the Name of the Lord" in French. After the program, the students divided into four teams (red, white, green, black the colors of the Kenyan flag) for relay-type games. Somehow the amazing food service coordinator Mrs. Janet Adkins manages a feast for all after the games, chicken and ribs and corn bread, eaten on the lawn in front of the school. Chatting after lunch. Grammy and Caleb in front of Kiambogo, the original RVA building. The entire student body lined up in the gym, mimicking the arrangement of colored stripes on the Kenyan flag. Not pictured: there was a girls' basketball game, where the jazz band played in all the intermissions and time outs, which felt very much like the pep rallies and games of my high school days. And the evening ended with fireworks as the stars came out over Upper Field. Real fireworks. Impressive popping sizzling exploding bursting colors. The entire school community was sitting in the bleachers, a boom box was blaring Souza marches amplified by a bull horn, and we oohed and ahhhed as the fireworks lit the sky. The theme of the day was God's Kingdom is here and includes all of us . . . it truly was a day to realize that in Heaven we'll be standing next to kids from Ethiopia and Brazil and China and the Netherlands, just like we were today.

A Tale of Two Hospitals

In the massive, sprawling, congested city of Nairobi there are two hospitals.  There are actually many hospitals, but these are two of the most well-known, and since they host he only two paediatric residency training programs around (there is a third program in Eldoret at Moi University) they are the two that I've wanted to visit.  Since we have a visiting paediatrician in October as well as back-up from another visiting med-paeds ICU doctor, we came up with the grand plan for the three long-term Kijabe paediatricians as well as our colleague who runs the Neonatal community health program here, to take a field trip.  Together. 

So yesterday Mardi and I set out in the mist at 7:30 to drive into the city, where we met Immaculate and Mary (who live in Nairobi). It was an 11-hour eye-opening day.

Our first stop was AKU, as upscale and private as it gets in Africa.  This is a hospital where one needs a culture-shock debrief to leave the doors and re-enter the rest of the world.  It was established by a wealthy Persian hereditary prince, as part of the world-wide foundation that promotes development in the name of that particular branch of that particular religion.  We were treated royally as well:  greeted by the department chair, hosted to tea and sandwiches, invited to interact with all available faculty (all Kenyan, young to middle-aged, professionally styled, friendly), then given an extensive tour highlighting such technological wonders as the completely digital radiology department, nuclear medicine scans, well-equipped intensive care, state-of-the-art linear accelerator radiation therapy, carpeted luxurious hotel-like super-private wing where all the diplomats stay.  The Paediatric ward is new, bright, sunny, clean, creative, calm.  They have about 25 beds, with probably 20 kids.  The neonatal ventilators and monitors were state-of-the-art, and only two babies had the full-time attention of a nurse and a doctor.   The clinic has huge exam rooms, and a handful of well-dressed babies waited to see the consultant.  I felt like I could have been in any suburban high-quality American hospital.  This program takes 3 or 4 residents per year, who are paid to work there.  The only drawback for them is that the patients are all private so they are superseded by the private consultants to care for them, and the spectrum of disease can not include much that is common and poverty-related, because only the wealthiest Kenyans (or best-insured) can get in.  These residents already rotate at Kijabe for their surgical month, and we will now be on the lookout for improving their general paediatric experience while they are there as well.  We've referred a couple of patients back and forth, and it was good to find out about the wealth of subspecialty consultants there.  But few in our population would afford care at AKU.

From there we fought traffic (actually it was surprisingly not bad) across town to Kenyatta Hospital, the massive historic public institution and main teaching hospital for the University of Nairobi (medical school, nursing school, clinical officer school, public health).   Multi-storied, with dark stair wells, marginal cleanliness, obscure arrangements, a bit of a prison/institutional atmosphere, and CROWDS of patients.  The architecture was reminiscent of Mulago and Mwanza, I wonder if they were all constructed in the peri-independence colonial days of the early 60's, with open-air halls and central courtyards, unpainted grey-yellow stone stucco, formidable.  We sat in on the weekly Paediatric teaching conference, which was amazing, led by a personal hero of mine Ruth Nduati who proved that bottle-feeding HIV-affected infants was MORE DANGEROUS than exposing them to potential HIV infection through breast milk.  She is the department chair, and brilliant.  Here they take 25 or more residents per year, who sat in a steep lecture-hall with it's old furniture and peeling paint.  After the rounds we met a neonatologist (both she, the chair, and another lecturer were 50-something sorts of well-established academicians) who took us to see the newborn nursery and intensive care.  The space was brighter than I expected, and reasonably well equipped, with again the same amazing modern ventilators (only 3 of 7 functional) and monitors.  But 75 babies were crowded into what should have been space for less than half that many.  In the incubator room for the preemies, the babies were turned sideways to fit two or even three in each plastic box.  Mothers stood shoulder to shoulder with their hands through the little doors doing feedings.  Every inch of the other rooms was cluttered with cots, chairs, parents, files, etc.  Sometimes there are up to 20 students as well.  We had a good talk with the charge-nurse about the challenges she faces.  From there we toured one of the four Paediatric general wards, each with about 50 beds but bursting with a hundred or more patients.  Again the bright yellow paint, oxygen, IV tubing, etc showed a fairly functional and active system, but the place was packed, room after room with more than one patient in each bed, milling parents.  One lady ran up to me smiling and at fist I thought she was mentally a bit off, but then I realized she was the mom of a patient we referred a couple of months ago who was still languishing in a forgotten corner.  My guess is that the over-taxed residents focus on the sickest handful, and the vast majority get little attention after admission.  The consultants round only two mornings per week and then they only see 5 or 10 or 20 of the hundred inpatients.  The emergency room was lined with waiting patients, but there seemed to be an excellent triage system in place, and a very sick child was receiving oxygen by face mask with a paediatric resident attending to him.  Patients pay small fees at Kenyatta, but for EVERYTHING, from a bed to a dressing to an injection to a medicine.  Overall the costs probably end up similar to Kijabe or a bit lower.  If you have a competent aggressive parent who can advocate and navigate and has a bit of cash on hand, Kenyatta has the expertise and resources for some of the best care in Kenya.  But for the masses of the bewildered poor, it probably turns out to be a frustrating and overwhelming place, easy to slip through the cracks.

I don't think there could be two more different hospitals in the same city offering such similar services. One is all about money, modernity, efficiency, customer satisfaction, excellence.  One is all about inclusion, the public good, stretching resources, making do, thinking nationally.  Both fill an important niche.  But you can probably tell my heart is with the latter.  It would require a strong heart to work there, because I'm certain that death is common.

Week in Review, Part 3--the Big Picture

If you've persevered through all the family happenings and medical crises of the last week, bless you for reading. The last thread of the week though was a national level meeting of the Kenya Health Task Force, convened by our American Ambassador Scott Gration, in order to cut mortality in Kenya by HALF. By the end of NEXT YEAR. Which does not sound very possible, but I have to say his opening speech was both inspiring and impressive. This ambassador grew up in Kenya with missionary parents and even went to RVA for a while, and his wife spent most of her childhood at Kijabe. They are ideally placed as Americans who know Kenya, the language, the people, the issues, the dreams, and can connect Kenya's community with both the American government (i.e. money and power and influence) and with outside charitable organizations (i.e. skills and dedication). This is the same effective triangle of action that our famous Hopkins public health professor, Carl Taylor, wrote and taught about. A cooperation between local communities, government, and NGO's, driven by actual data and need, taking advantage of the unique gifts of all three.

So in the middle of this wild week of intubating babies and baking birthday cakes, I found myself as Kijabe Hospital's Paediatrics representative to the Let's Live campaign, sitting around a table with Kenyan professors and ministers brainstorming on how to improve immunization coverage, or new ideas for training doctors, or innovations in the treatment of malnutrition. We focused a good bit on the neonatal (birth to age 1 month) mortality rate which has barely budged in the last decade (33 to 31 per thousand births) and accounts for almost half of under-five deaths. It was stimulating to sit in lectures once again, to ask questions, to meet interesting people at tea and lunch from all areas of Kenya's health system. And in a week in which one of those 31 per thousand was not a mere number but a gut-churning reality, it was also a relief to look at the big picture view of where this country is going in health, and feel encouraged that bright and ambitious and capable people are dedicating their lives to see change.

Week in Review, part 2 - Challenges

Because life is always that way. A celebratory week can not just be savored, it has to be wrested from the thorns. From the Fall, the curse meant that we could live under the vine and fig tree, but only at the cost of the sweat of the brow. We could commemorate the joy of 15 years since bringing forth a particular child, but only in the context of mourning for others.

Last weekend, the first two days of October, and by the end of them I thought I might need the rest of the month to recover. There are call days, and there are call days. This one did not start off too badly, rounds were reasonably efficient, and I ran up the hill to the school to watch the boys play soccer. At the very moment that Caleb scored the opening goal of the match, my phone rang from the ICU asking me to come for a little neurosurgical baby who had "coded" on the floor and been temporarily revived and transferred up to intensive care. And that was pretty much the last free and happy moment of the weekend, and beyond. It all runs together now, but I will tell you a few stories.

"Baby of Carolyn" lived her whole life in this week I'm reviewing. I was with her at the moment of her birth Saturday, and the moment of her death at 4:40 this morning. It all started when her mom was transferred into Kijabe from a smaller clinic, bleeding and leaking amniotic fluid, with a supposed 30-week pregnancy whose fetus measured smaller than that and with a dangerously falling heart rate. Her husband did not feel he could afford an emergency C-section or intensive care that might be needed for the baby, nor did he think the baby could survive, so they refused at first to sign consents. Which left Scott, on OB call, and me, on Paeds, standing in the labor room calling our medical director and executive director for ethical advice. Within a few minutes we got permission to insist on trying to save the baby, even if the hospital would be left with the bill. And within a few minutes after that Scott was extracting the baby girl surgically and I was coaching the intern through a resuscitation of her tiny limp blue not-even-gasping form. She began to breathe with help, pinked up, moved. She weighed 840 grams. Things were going as well as one could hope with such a distressed preemie until I intubated her for the first dose of surfactant, a soapy coating that preemies lack in their lungs. I put the tube in too far (easy to do in such tiny babies) so that it lodged in her right mainstem bronchus, and the intern assisting me gave the first few breaths with nervous vigor (also easy to do in this stressful situation). I was listening for breath sounds and watching the monitor, and neither looked good, and then I looked back down at the baby and nearly died of shock and dismay when I saw that I had given her such a severe pneumothorax that air tracked up and ballooned under the skin of her neck. I called our excellent anesthesia and surgical attendings for rescue, certain that I had killed the baby. It was a terrible hour, but they were able to place a chest tube and re-intubate and stabilize. I took her to the ICU (my second newly ventilated patient of the day). It was a long weekend with her, trying to keep the tube in place, following xrays, managing her fluids and tiny initial feedings, comforting her mom. And throughout the week, I had hope. Even when I happened to be the one who found her when her tube was out, who set her up on CPAP, and who ended up with her all night the last day of the struggle, when her heart was failing, her kidneys were failing, and we ultimately failed to save her life. On Saturday we had made the difficult decision to choose to go all out to give her a chance; by early Friday morning I had to make the much more difficult decision that we had done everything, and lost this battle. She had not taken a breath, moved, opened her eyes, made a drop of urine, all day, and even intubated and pushing in the breaths we could not get her saturations over 50% (normal is 90-100%). I stopped pushing and just put her back on oxygen and within two minutes she was dead. Her mom, achingly, thanked our team for trying, and said this was God's plan. Which is on a certain level true (Job says the Lord gives and the Lord takes away, blessed be the name of the Lord) but on another level is not, the cosmic struggle of good defeating evil means that babies like Carolyn's should linger into a full earthly life as eternity reaches down into their time.

It was a week for complex patients. Another baby, Samuel, was admitted over the weekend, transferred from another hospital where he'd been treated for pneumonia and had not really healed. HIs chest xray showed a discreet pulmonary mass, which by CT was later confirmed to be a rare congenital malformation. But that did not explain his extreme cyanosis; he was BLUE, and not that uncomfortable about it. So we got an echo in Nairobi which showed complete transposition of the main blood vessels leaving his heart. The blood which should flow to his lungs for oxygen flows to his body without much, and the blood which comes from his lungs just keeps going back there, two parallel independent loops. Needless to say he can't live long like this, but we hope that he'll qualify for surgery with a visiting team in November. I snapped his photo when his mom dressed him in a shirt labeled "Special" to remind us that his anatomy is not a mistake, God can take this problem and turn it to good.

Then there was the little girl with pneumonia who got worse and worse, as her infection spread into empyema, pus in the lining of her lungs. As well as the neurosurgical patient whose wound may have been infected with tetanus, she lies in constant spasm. Or the previously normal 8 year old boy whose week of fever and headache progressed to intractable seizures, whom I found admitted to our service with classic signs that his swelling brain was about to push down through his spinal cord into his neck. Another trip to the ICU. Or the infant we had sent home from the ICU a few weeks ago who returned with a big mass in his abdomen, which turned out to be his bladder, obstructed and damaging his kidneys. Or the HIV-exposed baby who was dwindling not from the infection but from hunger. Or the Maasai boy whose bizarre symptoms Mardi linked to sampling local mushrooms. And on and on.

Somewhere in there we also had a visit from a family from Germany, whose adoption of two Haitian children led them to establish a charitable foundation to fund projects for needy children. Though we had never met we bonded quickly over the stories of these patients, and it was a privilege to connect Simone with our Paeds ward chaplain Mercy. Mercy meets with and prays with every family on the ward, and through her loving care hundreds if not thousands of people have encountered Jesus in life-changing ways. She'll be able to help identify patients who truly can not pay even the nominal fees charged by Kijabe, and connect them to Simone's group in hopes of allowing more children with anomalies to access surgery, more families being crippled by expensive bills to break out of the cycle of poverty.

And I haven't even mentioned the national meeting for health in Kenya, which will have to have a separate post.

Birthdays, grandparents, donors, visits, meetings, severely ill patients, calls in the middle of the night, tubes and blood, oxygen and labs, cooking and more cooking, travel and hosting and plans, dishes and dirt, recoveries and tragedies. And not a lot of sleep. In the context of a minor cold and just not feeling very physically well myself, I think this was one of the most challenging weeks since we arrived in Kenya. I end it tonight, tired, and sad about Baby of Carolyn, relieved to take a weekend away from the craziness, and a bit drained of optimism.

Week in Review, Part 1 - Celebrations

In the theme of thankfulness, let's start with a couple of family highlights.

First, on Monday, Grammy arrived in Africa. This is her sixth visit to the continent in the 18 years we've lived here, 3 alone and 3 with my Dad. Scott and I took a taxi ( a separate story, but due to a mishap while changing the oil, we were without a vehicle, until a servant-hearted and capable friend at RVA fixed it on Wednesday; I would mention his name but he's very humble about it, and he might get inundated with mechanical problems if we make him famous . . . ) down into the city Monday night, and waited for her flight. Which was a bit delayed, and then waiting for her handy walker to be unloaded delayed her further, until we were beginning to worry. Never fear, she had befriended multiple people on the flight and got a Kenyan airport worker to help her with her bags, talked her way through customs with two humongous pieces of luggage stuffed fully of goodies for us, and briskly made her way out into the waiting crowds in her bright pink sweater, more-slender-than-years figure, and trademark sliver-white hair. She'll be with us for the month of October.

Secondly, on Tuesday, Julia turned 15! What a lovely young lady she is, smart, capable, helpful, willing, determined, loyal, loving. She sets her own pace and has her own style, athlete and scholar, loving dogs and crochet, books and flowers and cows and bugs, friends and soccer and piano and choir. She decided to invite her JV soccer team (from 2nd term) to come for pizza, so in the less-than-two-hours between the end of Basketball practice and the mandatory study hall time for dorm girls (no exceptions for Bday parties I'm finding), we had to squeeze in 14 girls making and eating dozens of pizzas. Lots of laughter, creative toppings, hot fingers, excited conversation. We all called out our top 15 things we love about Julia as we baked and ate. As darkness fell the girls poured inside for a 4-layer cake and ice cream, then we sent them back to their dorms with bags of goodies. Julia, a blessing in our life and family that none of us deserve, yet none of us would want to live without!

Thirdly, on Wednesday, because our friend fixed the car, and because I was able to get out of a meeting an hour early, we converged upon Rosslyn (another international school in Nairobi) to cheer on the teams. It was a privilege to watch Acacia in her first-ever-in-her-life athletic competition, first team event, in her uniform, giving her all. Though her team does have a long way to go. . . Jack's team also lost Wednesday, though by a narrow margin. Julia was the only winner but her team played at a different school, so we didn't get to hear that until later (and in the week-in-review theme, her team also won a whole JV tournament last Saturday, they have really come together as a team and are doing quite well). Caleb's team was resting until Thursday when they played the Prison Guards. No, that's not a euphemistic name for a school team. It is literally the young adult men who have jobs guarding at the maximum security prison in Naivasha. His team had previously gone TO the prison and played the prisoners themselves, so I guess the guards wanted their shot. In spite of being much younger and not quite as strong or fast, the RVA boys endured and emerged victorious, 3 to 1. Caleb sent in the corner kick that resulted in one of those scores, and played hard and well the whole game. With every game we get to see I remember that it is a privilege not a right, that I never saw Luke play a high school sport, that these hours are the most focused live-in-the-moment hours of our life. When we stand and cheer, it is all about the kids and the day, the sun and the breeze, the excitement and encouragement. We're not on the way to something else, we are THERE.

Which brings us to today, when the family spun off in several directions for the long weekend. Julia's birthday wish was to take Grammy to see our favorite Kenyan spot, Sunrise Acres, near Eldama Ravine, the cozy basic camp-like cabins on a dairy farm in the highlands. Acacia went to visit her aunt, uncle, and cousins who work at a Christian University in Nairobi. Jack and Caleb flew to the coast to visit a family there whom we have been friends with over many years. This was planned long before the recent kidnappings, travel warnings and restrictions in that region, so we let them go ahead on faith, but deep down wish they were at arm's reach. And as we take a short weekend break we miss Luke all the more, this is a setting which should include him.

By any measure a full week, with the comings and goings, games and tests, celebrations and meals. But this was only half of the week, or less. On to part 2.