Not the Christmas We Expected

We should have known better when the Sunday sermon emphasized interruption.  God interrupting plans.  Mary's, Joseph's, the Magi's, the Shepherd's, pretty much everyone in the story.  But especially Mary's, because everything she must have dreamed of before the angelic interruption (a happy marriage, a peaceful life) and even after the angelic interruption (victorious overthrow of the rich and proud in her lifetime by her son) was turned upside down.  Her heart was pierced when her son came into the world suffering, and a few decades later left it the same way, in blood and cries, seemingly at the mercy of cruel and indifferent authority and injustice.

We welcomed Caleb home on Friday.  Together at last, after six months.  Stories slowly eeking out about his first term at the USAFA and Luke's at Yale, good food, Christmas movies, too much rain, decorating cookies, puzzles, pizza, visitors, church.  

This is our second Christmas at Kijabe.  Last year we were both on call, and we missed out on most things, somehow on the outside of the season.  Yet this is my favorite time of year, steeped in patterns and traditions over two decades in Africa, welcoming Jesus anew.  So last year was a hard transition. I missed our home in Uganda, our team, our neighbors, the rhythms and patterns of community.  The predictable cow slaughter.  Visiting our neighbors.  Knowing the songs, the expectations.  The pace.  The hot dry wind blowing in, the cocoa drying.  Our own dairy cows, an every-ready real manger in our own yard.  This year I really wanted to anchor our family in the continuity of some of our old habits and grasp onto the Kijabe versions of some new ones.  We did advent Sundays, inviting different groups over, both missionaries and Kenyans.  And I tried really hard to sync the hospital needs where we're still working, the RVA we're-all-on-holiday cascade of events, the Myhre family traditions, our new WHM team mates, figuring out Kenyan culture, and the new realities of kids home from college who need space and rest.  Tried too hard, probably.  Planned, dropped, added, negotiated, re-evaluated.  Chose which services and events we'd do with the community, with RVA, with the hospital, with friends and neighbors.  Planned a big camping trip for four families of people who know each other well and often do things together, but with whom we've never been able to spend that time.

And almost none of it came to be.  We see pictures of our old team in Uganda and our sister team in Sudan doing the kinds of things we loved; we hear about all the great things people around us here managed (gift baskets to needy families, visiting rural churches, candlelight services, caroling).  But our Christmas was quite different.

On Christmas Eve morning I was in the hospital, catching up on the details of ICU patients from the weekend, checking in with our ward and nursery teams, examining patients.  There were contract issues for our new CO, and payment issues for some TB meds, notes to write, phone calls, prayer.  

The new 3-bed HDU (High Dependency Unit, a room with monitors and oxygen and a more intensive nurse-patient ratio than the general wards, but a step down from ICU) had finally been finished, so we gathered our surgical and nursing and chaplaincy colleagues in to dedicate it in prayer.  I was trying hard to be efficient so I could sign out early at 2 pm and take my kids to join the maternity and nursery nurses as we took gifts of food and clothes and crafts up to a children's home a couple miles away, something the Kenyan staff had arranged themselves.  Then we planned to do our traditional Norwegian Christmas Eve white dinner, and join the hospital staff once again for caroling in the hospital, concluding with an 11 pm candlelight service at RVA.

Instead, an interruption.  

"Mom, there's been an accident, it's Caleb, he's OK but his knee is swollen".  

After this it was hard to concentrate, but Scott was able to quickly leave in the car and go get him.  All the kids had gone down into the Rift Valley on pikis (motorcycles) for a picnic breakfast and just visiting time with friends.  They were on a road, but the road had been washed out, which they didn't know.  The first riders went right but Caleb was on the left side and suddenly the road emptied into a crater.  He swerved, the bike nosed into the hole, and stopped, throwing him.  It took Scott an hour to get there and another to get back, with Caleb's leg splinted using the car jack, in excruciating pain.  I met them in the casualty (ER), where Caleb's knee was terribly swollen, but his attitude was as usual calm and stoic and selfless.  An IV, morphine, exams, xrays, discussion.  Looks like 3 of the 4 ligaments which hold the lower leg on to the upper were torn:  ACL, PCL, and MCL.  Bad news.

In that first hour, all I wanted was a rewind.  We had discussed him not going.  Yes, it's part of this culture, it's the way to get around on these roads.  But the consequences of an accident for Caleb are potentially more than for most of us.  His life involves physical training.  LOTS of it.  His dreams involve things like jumping out of airplanes.  His days are full of stress and abuse that will only be worse on crutches.  Scott and I felt sick with sorrow.  He had to face calling into his commanding officers.  The Air Force doesn't always take kindly to disability, and will hold him responsible for taking this unnecessary risk on his vacation time.  He's looking at surgery, or several surgeries.  Months of crutches.  A year of rehab before he can do the things he loves, like run and play soccer and go for the parachute training and flight training he is pursuing.  If we had seen this unwanted, extremely interrupting moment, we would have done almost anything to change his path.

But we didn't see, didn't prevent.  And now a new hard road opens up before him.  We have a lot of decisions to make about travel and medical care, and I'm sure many things we haven't thought of.  But with 48 hours' perspective here are the lessons I've been tossing around again.

1.  We live by community.  When Caleb was wheeled into casualty our neighbors flocked to help.  One couple had accompanied Scott and held Caleb's head on the bumpy road back, providing comfort and advice.  The paeds surgeon did his head to toe trauma exam, the ortho surgeon evaluated his knee, the casualty doc checked in, the PT person came up with a brace and crutches, someone led us in prayer.  My paeds colleague covered the rest of the day for me, and Scott was relieved of call that night.  We were even given ice.  When you are in need, then you find out that great friends support us.

2.  It could have been worse.  This was one of the first things our friends said.  He could have injured his head or broken his neck.  He could be dead or paralyzed.  A knee can heal.  In our grief for all the suffering this interruption involves, it helps to remember that this is NOT the worst case scenario, no matter how sad it seems to us.  In the same 24 hours two women we know died in Uganda, one the wife of our pastor and translator from complications of pregnancy, the other a woman who suffered from HIV from complications of chicken pox.  A destroyed knee impacts life, but does not end it.

3.  Parents make mistakes.  Kids make mistakes.  Accidents which might have been prevented, aren't.  This is where GRACE is needed.  To save us from ourselves, even when we fail.  A washed out road can still be redeemed by God's purposes.  I don't feel that way right now, but I do know it is true.  I would not write the script this way.  Caleb has already had plenty of pain, already had three previous surgeries, already broken bones two other times.  He worked very very hard the last six months.  And now the next six, the next twelve, will be even harder.  I don't know why he has to face this, and how exactly our bad choice (to let him ride the piki) and God's providence work together.  But grace trumps.  Worse outcomes were prevented, and the hard one he got will be matched in some way by mercy.

4.  Parental love never rests.  With every milestone survived, new dangers open up, and our kids are always at risk.  A sword shall pierce through your own soul also.  Repeatedly.

5.  Our kids are amazing and resilient. Patient in suffering.  Remarkable in hope. 

Tomorrow instead of a camping trip we're heading into Nairobi to get an MRI (we hope) and begin to make more concrete plans.  Prayers appreciated for miraculous healing.  For sustaining courage to face all the implications.  For wisdom as we figure out how to support Caleb.  For our family to roll with the unexpected.

To accept interruptions in the spirit of Mary:  behold the servants of the Lord, let it be to us according to Your will.

On Christmas and Redemption (part 2)

I am going to tell a good story.  With a happy ending.  But you can't get to resurrection without death. The Christmas story itself drips in the slaughter of innocent children (see post below, part 1).  The context of Christmas is death. And you have to live in darkness to see the great light.

Three times this week I've seen children die.  That's the context.  But twice in the last 48 hours I've seen a miracle.

The first was on Tuesday evening.  It was a long day, and I was passing by my ICU patients about 6 pm thinking I would soon head home.  A 6-year-old girl (a theme this week it seems) lay in one bed, still groggy and on a ventilator after our neurosurgeons had removed a brain tumor the day before.  As I stood there, she became hypoxic, her monitors starting to flash red.  I moved in to examine her as her heart rate slowed dangerously.  Her skin turned to a deathly pallor.  She did not respond to deep pain, at all. The nurse and I began to increase her oxygen, sample her blood, call over her surgeons, push IV fluids.  The senior surgeon shook his head, acknowledging that there was not a lot we could do if she was bleeding into her brain as we suspected.  Niether of us expected her to live.  But an hour later she was back to her baseline, and I spent the night watching with bated breath.  By the next morning we were able to remove her from the ventilator.  Her eyes were open, she responded to us and was breathing on her own.  I can't explain what made her deteriorate, and then revive completely.  But I'm glad.

About 24 hours later I was finally home, and had put on my Christmas pajamas and settled in after a great dinner to watch the Princess Bride with the family.  When I got a desperate phone call from the nursery, the baby with whom I had spent the prior night slowly exchanging his blood, had been getting a second exchange transfusion with the on-call staff, and arrested.  Could I come?  I threw on clothes and tennis shoes and ran.  This was a cute and loved little newborn boy who had been very sick but was crying and active only hours before.  Now he was lifeless.  The doctor on call, Sarah, had intubated him and I confirmed her efforts were moving oxygen in and out of his lungs, which usually brings a newborn back if he's save-able, but not this one.  A nurse was doing CPR and another had drawn up medicine.  We gave adrenaline once.  Twice.  More CPR.  Blood glucose normal.  Three times.  No response at all.  His pupils didn't constrict to light, he didn't move, his heart was completely flat.  Sarah and I switched back and forth, giving breaths and pumping on his tiny chest.  I could see his mother over my shoulder, sitting in tears.  He'd been down for 10-15 minutes by now, and I would have given up, but we tried one more thing.  I had asked for calcium gluconate, but they were having to order it from pharmacy (!) and it was taking long, so finally I just looked at one trusted nurse and asked her to RUN not walk to ICU and bring back a vial. She returned and drew it up to push slowly as per protocol.  He's dead, I said, just shoot it in there now.  We followed it with a big push of IV fluid, not expecting it to really do anything, but wanting to give him one last chance.

It was the most amazing thing I've almost ever seen.  This dead baby opened his eyes. He looked up at us, and started to squirm.  His heart started beating.  He started fighting our breaths, and looked like he wanted to cry, only he couldn't with a tube down his airway.  His color returned.  He blinked under the bright lights of the nursery.  After a few disbelieving minutes, we pulled his tube out and he cried like any normal baby, as his teary-eyed family and doctors and nurses looked on.  We held a thanksgiving prayer.

Both of these children will die again some day, whether this week or in one year or seventy.  But for this moment death was defeated.

Because Christmas ushered in a new reality, a deeper truth than the existence of evil.  Christmas began a redemption that is still pushing out through the world, rescuing and reviving, renewing and resuscitating.  Babies and water systems and economies and families and minds and bodies.  After the Matthew 2 slaughter, read the Isaiah 35 blossoming.  Fear not, God saves.  Springs arise in the desert and life returns to children and the recompense of God arrives.  Evil undone.  In the world, and even in me.

On Christmas and Slaughter (part 1)

Having spent 17 of the last 20 Christmases in Africa, the wind which blows in a drier hotter season now feels familiar, and the flashing spastic lights we bought in our capital a couple years back (our first electrified season) feel appropriately chaotic.  Last year was our first in Kijabe, and I remember the church Christmas pageant which included a band of skinny little camouflage-clad Kenyan boys as Herod's soldiers marching in like a rebel resistance army, and Jesus' parents fleeing before them like any other refugees. I don't recall much focus on this part of the story in America as I grew up.  Our plays ended half-way through Matthew 2, with the gifs of the magi, while the scene was still serenely beautiful and triumphant.  The slaughter of innocent children gives the story a jarring, uncomfortable ending, dangling, unresolved, and terrible.  Rachel weeping for her children, because they are no more.

Five years ago on this day I had just flown from Bundibugyo to Kampala to see my own children for whom I had wept, thinking that Scott and I might be no more, after surviving a 3-week ebola-exposure incubation.  Many innocents had died all around us.  That Christmas was awash in grief, much like Christmas in Connecticut this year.  The 20 first-graders who died, and their six heroic teachers and administrators, are a modern-day slaughter of the innocents.  Angry evil lashing out at those who are defenseless.

We should not have dropped this part of the Christmas story all these years.  Because slaughter is the context of Christmas.  The whole story hinges on the presence of rampant evil.  When masses of children are violently killed, it becomes hard to deny the reality of injustice and suffering, the horrible brokeness of our world.  And in Revelation 12, we see the evil pictured as a great serpent, seeking to devour God's holy child.

Christianity is not about a moral standard, who is right and who is wrong, winning arguments or elections.  It's not about the right songs or the right politics, or power or influence.  It's not about an intangible inward assurance of a distantly future eternal location.

Christmas and Christianity are about redemption of a real evil in our real world.  This is a serious business.  People get hurt.  The evil that made Adam Lanza mentally ill, that tortured his life, that deprived him of treatment or cure, that deceived him into believing this last act of horror was something he needed to do.  The evil that split up his family, that lured his mother into buying assault weapons capable of firing hundreds of rounds of deadly ammunition in a matter of minutes, the evil that insinuates that limiting this sort of weapon to the military is an infringement of human rights.  The evil that kills twenty African children every three minutes of every hour of every day of every year, over and over.  The evil manifest in viruses that turn love and motherhood into death, in greedy dictators who steal from their own people and ruthless terrorists who throw grenades into neighborhoods, in failed crops, hunger, ill-equipped hospitals, careless drivers, floods and droughts.

On this continent it would be absurd to deny the horror and heartache of evil, just as absurd as it would be to do so in Newtown.  Or in Bethlehem, when the bloodied bodies of baby boys were being buried.

The birth of the child who is God ushers in a turning point in the story.  A foe capable of meeting evil, and defeating it.  Disguised and humbled in human flesh.  The incarnation sets in motion a complete reversal of all that is wrong, all that is sorrowful, all that is painful, and in the course of this battle, a lot of people die.  The baby survives and becomes the man who will refuse to ride against Roman powers as a King, that is a victory too small, a territory too temporary.  This King will choose a path of suffering, voluntarily taking on all that evil could throw at him, in his own body, nailed to a tree.  Like the teachers at Sandy Hook who put their bodies in the path of bullets, trying to protect the children.  This King will defeat evil.  He will walk out of a tomb, so that every 6 and 7 year old gunned down, every starving baby, and even the Adam Lanzas of the world, can be redeemed.

We saw the Hobbit movie a few days ago.  The filmakers inserted a scene at Rivendell in which Gandalf muses that it is not so much the power of armies that keeps evil at bay, but the ordinary acts of courage and kindness that preserve our world.  The community outpouring of love which will heal hearts in Newtown.  The tenacious pushing of a teenage girl who gave birth to a baby, and the steady painful walk he took towards death.  The daily self-sacrifice of his followers who sweep streets and teach children and suture wounds and defend the fatherless.

Evil is real.  Innocents suffer.  But the story does not end there.

DOGS

Some things I love about my dogs:
They'll try new paths on wandering jogs
They wait for me when my pace slogs
They never complain about my blogs.

Some things I love about my kids:
EVERYTHING.

Luke's HOME! Day One

I'm typing this as I eat dinner at midnight, which is also lunch, which gives some overview of the wonderful chaos and energy that has always seemed to swirl around this boy.  If Day One of his Christmas Vacation Visit is any predictor, we may not survive.

The above picture was taken about 9 am at Jomo Kenyatta Airport.  If we all look a little weary, realize Luke had been on the plane two straight nights, and the rest of us had arisen early to arrive at 6:30 ahead of the traffic, for his 7 am flight.  Only KLM seemed to have stashed his bags so deeply in the bowels of the aircraft it took them two hours to locate and unload.  Nevertheless we were all thrilled to hug him.  We stopped for coffee on the way back through driving rain and traffic and didn't reach Kijabe until almost noon.  At which point Scott and I guiltily ran into the hospital to relieve our friends who had held down the ship all morning; and the kids were enveloped by a happy noisy Letchford/Rabenold/Kinzer crowd.  I didn't know it would be the last time I saw them all day.

While I was catching up on dying patients, putting my 10 month old malnourished baby B on not just dopamine but epinphrine AND dobutamine drips, panicking over my 6 year old post-brain-tumor surgery girl, and helping a colleague find referral numbers for another 6 year old with leukemia and matching hemoglobin and platelet counts (2), plus working on policies for newborn resuscitation . . . Luke and Jack decided to go on a piki ride.  First day home, first priority.  They were joined by several other boys and headed for the highest point around, Kijabe Hill.  When I finally finished work at 7 and walked in, I was surprised to find out I hadn't missed any time with them.  They were still gone.

In fact I found our neighbors, ever kind and patient, coming for tools to take to Luke and Jack who were stranded by a flat tire.  Luke had gallantly stayed with his little brother when the puncture occurred, in spite of the cold and rain.  Tyler K rode back to the rescue in the dark while I finished cooking dinner, though as it turned out they had to seek help from a random mechanic who fixed the tube with what looked to me like a bolt through a patch of rubber . . .  Only before any of that could actually get finished, Scott was called back to admit and ICU patient and I was called back to nursery. Rachel S happened to be stopping by at that moment, so she gamely followed along.  And spent the next three bloody (literally) hours with me putting an umbilical venous line into a 2 1/2-day old baby with a bilirubin of 28 and then pulling his blood out and putting fresh blood in, 10 cc at a time (2 teaspoons), 44 times, to completely exchange is blood volume twice.  Rachel is in a nursing program at Calvin so she claimed to be happy to monitor and record the baby's vital signs every minute or two, while I carefully did the exchange.  This baby would have been severely brain damaged if we did nothing, and hopefully now he can recover and possibly be OK.  We prayed with his anxious mom.

Thankfully Luke and Jack survived darkness, rain, and a detour on a dangerous highway, to make it home. with only one low-speed sand-induced spill that resulted in seven stitches, but a mere flesh wound.

So dinner at midnight, while the Christmas lights sparkle, thankful for all these fun college kids and their enthusiasm for Africa and each other, thankful for survival, thankful for getting a line in the baby and making it through the procedure, thankful Caleb is packing right now having finished chemistry exam, and hoping for a bit less eventful of a day tomorrow.

Intensive Daring

This month I'm working in the Intensive Care Unit, the ward in our hospital with five beds for the five sickest patients.  Over the last year we've been admitting more and more children there, so that our adult/kid ratio now is about even. The adults get a real live board-certified academic intensivist (part time) and a dedicated medical officer.  The kids get me, and thankfully my colleagues.

Intense:  "1) existing in a high degree; forceful or extreme; 2) highly concentrated, strong or deep; 3) feeling strong emotion; extremely ernest or serious."

The ICU has the highest degree of medical care possible in our hospital, and pretty much on our continent.  Monitors that read the electrical waveforms of a heart rhythm, and oscillate with breaths, and even sense critical oxygen levels.  Machines, which I grant you are outdated in 2012 but would have been state of the art twenty years ago, with dozens of knobs and tubes and cords, that mechanically ventilate a patient's lungs.  Pumps that calibrate fluid rates to the tenth of a cc per hour.  A nurse for every patient, or at most two.  Good lighting, phones and a desk, space, supplies, physical therapy.

And ICU care is strong, deep, and concentrated.  Most of my medical practice up to now has been more of the inch deep/mile wide variety.  Overwhelming numbers, do what you can for as many as possible.  I'm finding that I like the focus on only one, two, or three patients (for a brief moment we had all five beds once, but generally only a couple).  There is no student, intern, or resident between me and the child, so I'm the one examining, measuring, pondering, head to toe.  Every drop of fluid in and out, every medicine, every change.  Intensive investment.

But I am also finding ICU medicine to be a seriously risky business.  This is the spot of last resort on this earth.  The likely-to-be-fine types don't come here.  The happily curables don't need it.  So it is a service on which one faces death, over and over.  Strong feeling and emotion, yes.

Friday was a 1 for 3 sort of day, where the strongest emotion was sickening grief.

My first patient, baby F, came through the day saved.  He was born with mengingomyelocele and developed a dangerous form of hydrocephalus.  It was my job to recognize that and advocate and keep him alive until our neurosurgeons could operate; to advise his mother to consent to the risky procedure; to get his body ready and manage every detail afterwards.  He is emerging from nearly-dead to potentially-saved. Very satisfying.

But the other two children I was called for the same morning, and tried to revive enough to admit, both died.  The first was a 2-week old infant whose mother had come for her own routine post-partum check.  She didn't even realize that her baby was dehydrated, starving, septic, unable to feed for a day or two but probably sick much longer.  When she asked a nurse to just take a look the infant was not even breathing, and her heart had slowed down.  The nurse rushed the baby to nursery, the nursery team sprang to action, but when I arrived they were doing full CPR with no response.  After ten minutes we knew we would not get this mottled, dusky, limp baby back to life.  Her name was Princess.  First and only child.  I spent a good while just patting the wailing devastated mother, praying for her.  Wrenching.

A couple of hours later, another call, this one from the ward, where a 4 month old with malnutrition and anemia and dehydration whom I had seen that morning crying and with normal vital signs, was now not breathing at all.  She was unresponsive to pain, her pupils did not react to light, but she still had a reasonably strong heartbeat.  As we gathered emergency equipment and waited for the ICU to be ready, we knew it was unlikely that her brain would survive this.  Still it seemed worth a try, and I decided it would be safer to go ahead and intubate her, which I did.  But as I adjusted the position of the tube and a colleague connected a bag for pushing in breaths, there was a catastrophic event.  Our attempt to breath for her ended in a horrible pop, her entire body inexplicably filling with air, and blood suffusing her face and head.  I've gone over the whole thing with everyone involved, and can't really explain how the small pediatric-sized bag breath could result in such an immediate, irreversible demise.  I've cried.  Nothing compared to how her mom cried, holding on to me, undone.  It was awful.

Part of me knows that these deaths, whether from a disease process that has reached a point of no return, or a final complication of trying to help, are part of the territory of intensive care.  That a successful intubation or line or diagnosis or comfort does not mean I'm a good doctor or good person any more than a bad outcome means I'm finally revealed as useless.  But a larger part of me feels deeply the devastation of failure.   I read a good blog (http://www.alifeoverseas.com/pianos-arent-in-the-bible/) where failure is equated with innovation and learning.  Sounds great until the learning experience of trying and failing comes at the expense of an innocent life.  Some days, like today, the idea of stepping back in to a weekend of call after the Friday of Failure makes me want to quit, or wonder if I should find something safer to do.

But I went back this morning, habit or hope I'm not sure.  Perhaps because insulation from death is not a luxury easily obtained in Kenya.  Perhaps because someone is praying and I'm reminded that it is good to be humbled and reminded of my mistakes and limits, even when death is involved, because death is not the final reality.  Perhaps because I resonate with this famous quote used in the intro to a book I'd like to read (http://www.brenebrown.com/books/2012/5/15/daring-greatly.html), that life is not fully lived in the unmarred safety of the spectator seats, but calls for intensive daring:

"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better.  The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly;  . . . who at best knows in the end the triumph of high achievement, and who at worst, if he fails, at least fails while daring greatly."  --Theodore Roosevelt

Merry Christmas to Me

Remember Baby L?  She was born with a chest full of fluid and a swollen body, and at one point in the ICU we had run out of chest tube options and prayerfully and sadly used the last one, thinking we were at the end of her life.  She's a miracle survivor.  Today she came back for a normal 2-month check-up.  Gaining weight, smiling even.  But not as widely as her two happy parents, who showed her off in the ICU and nursery at my request, to encourage the nurses who work so hard where so many die.  This is what Christmas is all about, babies in danger, rescued by the baby who entered our world dangerously. And moments of joy.

Merry Christmas!

It's that time of the year... Advent candles and calendars and year-end prayer letters...

Click here for a Christmas devotion from Jennifer and for the Myhre family update (complete with color photos from Scott)...

Merry Christmas from us to you...

Blindsided by Homesicknesss

These pre-Christmas days are full of hospital work and cookie-baking and lights and carols, and the wind of a drier season sweeping away the clouds for radiant days.  Jack reads, watches cooking shows, plays basketball and soccer, and goes on long piki (motorcycle) rides with friends.  Julia crochets and bakes and hikes and plays soccer and runs and reads some more.  Last night they pitched in together to make pasta from scratch (as in dough rolled out, cut in strips, dried a bit, then boiled) with a spicy bacon and tomato and wine sauce they found on the internet.  I've not been home that much, the responsibilities of ICU care and the Paeds department weighing a bit this month.  In the late evenings though we've been watching Lord of the Rings together, one disc of the extended version each night.  Tomorrow will be our last.  Then we'll be ready for the Hobbit, whenever it opens in Kenya.  We celebrated our first Advent Sunday with two neighboring families who are good friends.  And today Scott and I were able to leave the hospital early and drive into the Nairobi suburbs to enjoy a few hours of food and creative gift-exchanging with the World Harvest team there.  It was a lovely gathering with decorations and a tree and laughter and stories of family.

So I'm still processing why a wave of something like grief nearly knocked me over as we pulled away. A physical chest-tightening numbing sorrow without a clear antecedent cause, tears springing up as we walked into the mall on the way home to quickly gather fresh fruits and vegetables and a few bags of bread and staples.  It felt like homesickness, but I really couldn't think of what home I was sick for.  The tasteful house we had just left with a bit of southern flair perhaps brought to mind my childhood home in Virginia. The team gathering perhaps brought to mind our 17-year home in Bundibugyo.  And the familiar faces perhaps made the absence of half our kids more acute.  All in the context of what is usually my favorite holiday, which has left me on edge this year.  I just feel profoundly tired.  I really like our little house in Kijabe, the fireplace hung with stockings and the bright yellow kitchen walls.  I love this work, and my colleagues.

But something is missing, something that Christmas and lights and icing and music cannot fully veil.  Luke and Caleb are most obviously missing, and I can't even let myself think about decorating and baking one day without Julia, and eventually even Jack.   But something bigger is missing.  Home.  This life of pilgrimage just becomes too much sometimes.


The Christmas story is about home, in a reflective longing way.  Elizabeth longed for a child, with a physical emptiness even while in her ancestral village.  Mary had to shelter in a cave.  Joseph ran across borders at night with his young family into the unknown.  The magi traveled long and far, which in those days carried a significant chance of no return.  The Israelites were shaken up by an occupying power that pushed them into countable quantums in temporary towns.  And Jesus left the home of the Trinity in some way, loosening his due grasp on equality and power and love, to experience abandonment and darkness.

For a holiday that two thousand years later is symbolized by a happy hearth, the original reality involved an awful lot of pilgrimage.

Bethany wrote on her blog that Advent carries a necessary element of restlessness.  The shadow of discontent with the current state of things gives birth to the longing for a real home, real fellowship, real belonging.  Lord of the Rings is a Christmas trilogy; the King returns in obscurity, small faithful people plod on against the odds, the serpent of Evil battles the faithful, sacrifice and courage finally allow good to prevail.  And even the characters that go home never ever feel at home again, their souls have seen too much to fit into the old life, and they carry that longing for a fully restored earth.

So in hard moments of the weight of loneliness, remember these characters, and hold on.  Here is a closing line from an on-line Advent devotion (Joy! To Your World! A Countdown to Christmas, on YouVersion):

"I hope that the first lesson you will learn in the Christmas story is to be patient with God. Trust God even when your circumstances are challenging. Continue to live a righteous life through days of disappointment. Pray fervently and believe that God is listening to your prayers. Continue to embrace a positive heart attitude when you don’t get your own way.

Allow the loveliness of Elizabeth to remind you that true believers walk by faith and not by sight."

A Bundibugyo Love Story

In the theme of "Love at the Speed of Email" (2 posts below .. .  we had our own story last week.  We usually miss all the weddings and fun, so we were thrilled (!!!!) to be part of this engagement.


The emails, texts, and phone calls had been slipping back and forth over months.  Josh finished his PhD in engineering at the University of Florida just in time to join the Bundi team before Anna left to teach at Kijabe.  They fell in love.  And over the course of the last few months he plotted how to get a family ring re-set for Anna, and how to surprise her with a proposal.  

We invited her to an overnight in Naivasha with our family, and let her right into the trap:  surprise, Josh had flown from Uganda and met her with roses and an embrace. 

 He took her down by the lakeside while we waited in front of the simple, elegant bandas at Elsamere, the historic home of Joy and George Adamson, conservationists famous for the story Born Free.  Soon they came back with the good news:  she said yes. Here they are minutes after engagement, with the ring on Anna's finger.

Below they are calling Anna's family, and later Josh's, to share the good news.

Since we had drawn Anna (and our kids) in with the promise of a walking safari on Crescent Island, the next morning we did wander among the giraffe and wildebeest.  

This is only the beginning of the story.  These two met in a very difficult environment.  I have my money on a love that will last, and will bless the world.

Dec 4, Five Years Later

On December 4, 2007, our best Ugandan friend and colleague Dr. Jonah Kule died of ebola hemorrhagic fever, in a tent at Mulago Hospital in Kampala.  He died because he was a compassionate person, brave in the face of the unknown, dedicated to the community, serious about his role and responsibility, and committed to Jesus.  He had a dream of being a doctor since he was a young boy, and after many years of work with us as a clinical officer and then five years of med school, and one year of internship, he was finally on the ground at the center of his dream.  His story is a long one with many unbelievable twists and turns, but none of us could have foreseen it ending only a few months after he began working as a qualified doctor in our extremely underserved district.  On December 4th five years ago we wept ourselves into stunned numbness.  His family's loss and ours, magnified by thousands of people who looked to him with hope. 

Ebola has struck Uganda four more times since then, not the same strain, but popping up with a few scattered cases here and there every year or so.  In our epidemic 39 people died; there were 116 confirmed and probable cases, 147 listed in the newspapers, and 192 suspected cases.  Scott, Scott Will, and I were all exposed but not infected, and the only other doctor in the district besides Jonah and us was infected but survived.

Jonah left his wife Melen, who was six months pregnant at the time with their only son, and five daughters.  

Those were dark days, the kind that put my stomach in a knot even now, though they were still pierced with light.  The sobbing desperation of loss, the beautiful community of friendship.  The inexplicable end to our plans, the beginning of redemption along other paths. 

Melen has weathered much work and disappointment, betrayal and jealousy by those who should have supported her.  But she remains rooted in faith and forges ahead with her nursery and primary school project, caring for her children as mother and father to them all.  The tottering health care system that could not afford gloves to protect us back then still limps forward, but with Dr. Travis and Dr. Jessica and renewed interest in nutrition and sickle cell disease.  I still find myself occasionally seeing someone on a motorcycle with just the sort of stance, or yellow helmet, that I begin to believe is Jonah, then remember.  I know Melen does too.

On the day Dr. Jonah was buried, Scott read the passage about the seed falling into the ground from John 12.  Today seven young men are in med school to become doctors and public health practitioners from Bundibugyo.  Six of them are sponsored through the Dr. Jonah Memorial Leadership Fund (and the seventh through another ebola-connected sponsor) of WHM.  They should have been the generation to learn from working alongside Jonah, instead they are the generation who only exist because his blood poured out.

Today please take time to pray for Melen, for courage and strength and God's mercy on her and her children.  Please pray for these seven to return and transform Bundibugyo in the ways that Dr. Jonah began, by working with absolute integrity in hard places.  Pray for God's provision for them as our sponsorship fund (http://www.whm.org/project/details?ID=11129) has been drained by rising tuition costs and adding on new students.  Pray for our team still laboring in that place that has known too much death.  Pray for Scott Will in South Sudan, and Scott and I here in Kenya, to wholeheartedly live the bounty of years that could have been lost, for the Kingdom.

But mostly thank God for Jonah Kule, his life, his friendship, his unflagging cheerfulness, his ramrod insistence on honesty, his easy encouragement to communities, his listening ear and wise counsel, his vision, his love for God and God's people.  His death does not make any more sense five years later than it did then, but we acknowledge that we see through a glass darkly, and look forward to knowing face to face.

of Love and Long Distance and Writing

I'm not sure how I found this book, but it was a good read, the tale of humanitarian/missionary 30-somethings who find each other by blogs and emails and fall in love.  One of my favorite real-life stories, which has been repeated a handful of times even in Bundibugyo.  Here is the author's site.    Enjoy.

And here is my favorite quote:
". . That I started writing the essays largely because it was fun, but I kept writing them even when it wasn't nearly as much fun because I sensed that it was an important discipline for me to cultivate-that in the face of a constant kaleidoscope of airports and faces it would serve me well to learn to narrow my focus to a moment.  To take that moment for what it was and to think carefully about what else it could be.
  That over time, without my even really noticing, writing had become a spiritual discipline -one way for me to snatch breaths from beneath the waterfall of life.
  That now, like the chemicals on a photographic negative, it is the keyboard that helps me define my experiences.  On my best days, a jumble of moments, like so many bright pixels, coalesce into something vibrant and evocative as I type.   Often I feel as if I have not understood anything of waht an experience has really meant to me until I have anchored it in text.  "

Yes.  That's writing.

And as a person who anchors in text, and who spent four years in a long-distance writing relationship with the love of my life before we got married, I resonated with this book.

The End of the Road, or a Tale of Two Viruses

The end of the road:  this was the literal translation we were given for Bundibugyo.  So you'd think I'd be used to living there.

But I'm not.

Because the end of the road where I've been camping out lately is called the ICU.  This is a 5-bed unit shared by adult and paediatric medicine, with the most directed nursing care in the hospital, the best monitors, the only ventilators, the most space, and the smartest doctors.  Well, on the medicine side anyway.  I am a bit of a stretch, an intensivist-imposter.  Which is rather tricky because lately the paeds patients have outnumbered the adults.  One day this week I had 4 of the 5 beds and had a baby waiting to move into the 5th.  This is a room that beeps and bustles, where lights flash and IV pumps smoothly push and ventilators sigh, where we rally to the emergency and ponder the best plans.  But it is also a room where a lot of people die.

The problem with the end of the road is this:  100% of the people we bring in would die in the next few minutes, hours, or at most days, without this care.  We generally can achieve at least a 50% survival, which is really a remarkable thing.  But that's hard to remember when half your patients die.  That much death gets pretty discouraging.

The last couple weeks I've had two girls in side-by-side beds with very similar presentations:  high fevers, seizures, incoherent speech, weakness, and rapid deterioration.  The 11 year old girl in bed 3 we think has Herpes Simplex Encephalitis, a viral inflammation of the brain.  And she's the happy side of that 50% story.  After an initial touch-and-go period, she responded to acyclovir which we have to give in a tube to her stomach since we don't have an IV form.  She's waking up, following me with her eyes, lifting her fingers when I tell her to.  The excellent physical therapy and nursing care just may carry her through.  

But the 3 year old in bed 4 came to the real end of her road on this earth on Tuesday.  "S" was a little Maasai girl, who suddenly developed fevers and seizures, an inexplicable downward course.  Her grandmother and I tried to communicate in Swahili which neither of us speak well, this wizened lady with her stretched beaded earlobes and bald head, me with my white coat and desperate questions.  The night she was admitted I was frantically reading about viral encephalitis because of her neighbor in bed 3, when the word "rabies" jumped out at me. "S" was hyper-salivating, foaming at the mouth.  She was hot, hypertensive, smiling and singing inappropriately at first, incomprehensible, and going downhill fast.  The next morning her father came in.  Had "S" ever been bit by a dog, I asked?  Oh, yes, he replied, about 3 months ago.  What happened to the dog?  They killed it, because it was a stray, aggressive, behaving strangely, and they feared it would bite others.  Oh dear.  Over the next ten days we watched "S" get worse and worse.  When she couldn't breathe on her own anymore we intubated her.  We tried to find a way to make a diagnosis, and sent samples out that will take weeks to be analyzed, hoped that it was something else, something survivable, something temporary.

And over those days, as we reluctantly drew closer and closer to the end of the road, I spoke often with "S"'s father.  Unlike many parents, he was unfazed by the ICU atmosphere.  He stood tall, like a man who was used to planning things, to being heard.  He asked questions, really good insightful ones.  He wanted data.  He remembered what I said.  He sat and stroked his daughter, talked, looked for signs of life. (His wife with her regal green beaded necklaces was sent home after a brief visit, to care for the baby.)  I could imagine this father unbowed by the challenges of fighting a lion with a spear.  On the last day of her life, we held a conference in our side room, with this father, his brother, the chaplains, the nurses, and me.  "S" was no longer responding to pain, no longer taking breaths at all.  She was gone, I believed, and it was time to withdraw the ventilator.  We talked and prayed and agreed, and then all stood around "S"'s bedside.  I removed the tube and held her hand, while the pastor prayed.  Children's hearts can sometimes beat on for a long time without oxygen, but "S" died quickly, without a flicker of motion or struggle.  I let go of that little palm.

Then there was the flurry of papers to sign, and questions about the body, about the bill.  But before they walked out, I shook hands with this Maasai father, and said sorry.  He gripped my hand so tightly, and started to cry.  Thank you, he said in Swahili, I know you did everything you could.  

There was something so poignant and real in that moment.  This tall thin man of the savannah, defeated by a disease we could not treat, grieving, struggling, the first crack in his authoritative control.  Yet in his moment of sorrow, holding on across a chasm of culture and education and everything, to say thanks for our effort in spite of our failure.

The end of the road is like that.  An emotional journey up hills and through quagmires, sometimes an unexpected turn, and then the abrupt, inevitable end.  Emotionally exhausting.  After two patients this week for whom I had to have those "this is the end of the road" conversations with their families, and one more who came abruptly from the theatre where he had bled profusely and arrested and was pulseless and unrevivalbe, well, that's a lot of death in a few days.  I'm spent.  

But the gripping hand of a parent who knows that we were in the struggle with them, the walking-alongside that occurs at the end of the road, is still a beautiful moment.  I suppose that's why I'll go back tomorrow, and the next day and the next, and keep beating my head against the end of this road, with a glimmer of hope that the path stretches on into eternity.

Two pictures of community

This is the Paediatric team at Kijabe, or at least those we could gather Thursday for Thanksgiving.  Paeds surgery, neurosurgery, orthopedic surgery, and Paeds medicine, doctors and clinical officers, spouses and kids.  Plus a pathologist and a teacher for good measure, 41 souls whose existence here serves to bring excellent care to the marginalized.  And they can cook to boot.  Very thankful to be part of this team.

And this is baby C being shy for the camera, a few minutes old, one of the great pleasures (and terrors) of being missionaries at Kijabe.  13 months ago Scott and I stood in this room trying to save the life of his mother, who was going into shock after his tiny precious fetal sister had died.  Today there was great redemption and rejoicing as he was born, strapping and healthy, wailing and moving and sucking his fingers.  We've both been up half the night here but we're smiling with relief and gladness.

Two pictures of community, sharing lives, rejoicing and weeping, eating and praying.  

There and back...again!

On short notice (just having returned from Uganda), I (Scott) was invited and agreed to attend the Planning Retreat of the South Sudan Team on the shores of Lake Victoria near Kampala.  One flight, four taxi rides, and an outboard motorboat ride later (next time I'll try to work in the camel), I found the South Sudan Team, hard at work - thinking through complicated questions of strategic planning for the coming year(s).  Again, I came to listen, observe, represent, and chime in on issues of policy and experience.    This is a team which living in a remote, harsh, and hot (!) place striving to serve a new nation with a fantastic diversity of skills.  Engineers dominate the team, but they are engineers adept at teaching the Bible, playing the guitar, or discussing ethics in addition to their obvious skills in making stuff work.  Others are investing their lives in health, education, and agriculture.  The challenges of living in South Sudan (Mundri) boggle the mind.  No grid electricity.  Only solar.  So, no air conditioning despite the consistent temps over 100 F.  Drinking water from a water bottle left on the kitchen table tastes like it has come out of the hot water tap.  It's not uncommon to hear any of five languages spoken in the market: Arabic, Moru, Swahili, English, or Somali.  Most of the men on the team study Arabic, while a few of the women study Moru.  

This team has been on the ground in Mundri for just under four years and what progress they've made.  They have a fruitful trusting relationship with their host denomination, the Episcopal Church of Sudan (ECS). They have tasteful housing, welcoming friends, vibrant church homes, appreciative partner schools (primary, secondary, theological), many new and refurbished water sources developed for the community…and a thriving volleyball league!   But they want more.  They want to develop public health interventions,  develop computer science centers, train more teachers, provide more medicine, raise up and sponsor students for professional training….it's exciting.  And it's very, very hard.

The South Sudan Team 

They need much more money.  For more housing (the Sudan Housing Fund) - currently in a puddle of red ink.  For infrastructure (like Internet service - the Sudan Operation Fund) - currently in a LAKE of red ink.  For a vehicle for the Bishop of the Mundri Diocese of the ECS…for computer training, sponsorship of students, short-term loans for small business start-ups, for drilling more water boreholes…there is so much which needs to be done….

And while one could feel despair at the enormity of the need, I feel thankful for this amazing team 

our dorm at the retreat

dinner with the team