Strike two you're out

This is Malt. She arrived at Kijabe hospital at 11 pm last night, after a seven-hour ambulance ride from Isiolo, a rather remote Kenyan town far to our northeast. In those seven hours, as her post-c-section mom held on for life, they called EIGHT hospitals and were refused admission until they finally made it all the way to Kijabe.

Why? Because yesterday the public sector nurses, clinical officers, mortuary attendants, lab and pharmacy personnel, all went on strike, for a "hardship allowance" to be added to their salaries. The entire government health system was paralyzed, leaving only private and Christian hospitals like Kijabe to suddenly fill in the gap. This was much worse than the previous doctor strike. Proving we can limp along without doctors, but we can't manage without nurses!! There are many issues of injustice tied up in who controls health funds, and how they are distributed. However I suspect that Malt's parents live on less than the INCREMENT the Kenyan nurses are demanding in their monthly salary. And there are the people who suffer and die when the strikes begin.

Malt's mom had two children, then lost two who inexplicably died just before delivery. Finally someone in her remote village sent her for antenatal care on her 5th pregnancy. She was found to have the blood type A NEG. Malt is O positive like her dad. So her mom's body began sending antibodies to destroy Malt's "foreign" blood. Sensing impending disaster Malt's mom asked for a C-section. And sure enough, by 24 hours of life Malt was turning yellow from severe jaundice and dangerously anemic.

And so we began the delicate process of putting a line in through her umbilicus and gently removing her blood and replacing it with compatible blood. Two teaspoons at a time. Over and over until we had exchanged her entire blood volume twice over. I finished at 3:30 a.m..

Malt still has a long way to go. She may live, or she may succumb. She was a bit premature, and her jaundice was severe enough to cause brain damage. The delay in her care certainly makes her survival less certain. Malt's story of a seven-hour ambulance ride to reach the 9th hospital for help is only topped by Lucy. I have to tell you that in this picture Lucy looks peaceful. She had just died. Lucy''s mom only lived about 15 minutes from Kijabe. But she labored all day at a small cottage hospital in the small town she's from. When she broke her water and started pushing and was going nowhere for some HOURS (maybe five . . . ) she was put in a taxi with some sort of nurse and they drove FOUR HOURS (12:3o to 4:30 am) to THREE HOSPITALS trying to get a C-section. At 4:30 they finally came back near home to Kijabe, where the mom proceeded to deliver a dead baby.

Well, mostly dead. There was a slight slow heart rate, with nothing else. No breathing, no crying, no moving, no eye opening, no nothing. I was called and even though I intubated the baby right away, gave resuscitation drugs and CPR and revived a heart rate for a while, Lucy's brain was gone. She didn't more a millimeter, ever. Her pupils were fixed, her reflexes gone.

Because the whole hospital was getting inundated with transfers and desperate people (did I mention the 29 weeks pregnant seizing woman? Or the two kids with meningitis?) we had no ICU space to even consider pushing Lucy along in her brain-dead state, hoping for a miracle. So I had the agonizing responsibility of calling it quits. Pulling out the tube, which was filled with excrement from this baby's stressed pre-delivery deterioration, and waiting as the heart rate fell to zero. And then sitting with the mom to explain and console. Who said through her tears, "God is faithful."

Lucy's life was not important enough for several hospitals full of people to take note and take action. We must stand against injustice for nurses, but not at the cost of the lives of the innocent. I am profoundly weary this morning. Nothing is more wearing than acknowledging defeat and waiting for death. Particularly the death of a baby who, if managed properly a few hours earlier, would have been alive, well, normal.

Not much else to say other than pray for Kenya, for justice and mercy to flow down. Because they seem pretty dammed up right now. I am falling asleep typing (we happen to hit this strike in a bad stretch where we are each on call 5 of 9 days . . two weekends in a row and two non-matching days in between, so that means 6/9 nights with interrupted or very little sleep), so I leave the last picture one of my other anchors. A morning jog with my dog, clearing the weight of that night of terrible decisions and sorrowful outcomes.

Anchors

This week has had some difficult moments.

On Monday, I met with the parents of baby J. He was born two weeks prior and came to us with jaundice and cataracts, and we later diagnosed severe hearing loss. His liver, eyes, brain, and lungs were damaged by a viral infection (CMV= cytomegalovirus) his mother contracted probably early in pregnancy. A negligible disease unless you are an unborn baby or immune compromised, and then it can be catastrophic. Baby J seemed to rebound early in his second week of life, and for a couple of days I hoped he'd just be a hearing-impaired but possibly relatively normal kid post-cataract surgery some day. But then he developed progressive respiratory distress. By Thursday night last week he was teetering on the brink of death, and was rescued by the ICU. I kept him all weekend on the ventilator, once doing CPR for a couple of minutes when his heart was faltering down to zero, once re-intubating him, and often adjusting and evaluating. We had started a new antiviral medication and hoped that 24 to 48 hours would make a difference. By Monday I could not see much improvement, and had already turned away another child who needed an ICU admission because we had no beds. So I had a long, gut-twisting, heart-wrenching conference with baby J's parents. I told them that I thought we were not helping him, and were possibly causing him more pain and more problems with this tube that was in his airway, for no real benefit, and I wanted to bring up the possibility of taking him off the breathing machine. In a country with extremely limited resources, this is a conversation we sometimes have to have.

I wanted to give them a day to adjust and think and pray. But an hour or so later they called me in to say they were ready. They stood by his incubator and put their hands on him and said goodbye. They cried. I cried.

I pulled out the breathing tube and suctioned and put him on nasal CPAP, a less invasive delivery of oxygen and air under pressure through the nose. I didn't know if he would even try to breathe. But he did. Fairly well. After an hour it was clear that he was going to fight on. He was actively moving, whimpering a bit, and pulling hard but keeping his blood oxygenated. I was cautious but slightly optimistic again. We moved him down to the nursery.

Tuesday morning I was nervous walking in, but there he was, yellow skin and bruised IV sites, fluttering eyelids, breathing away. Not great, but alive.

I still didn't think his long term prognosis was very hopeful, I'd seen him too close to the edge too many times. But these parents really got to my heart. I think English-speaking parents, without the barrier of translation, are more difficult to protect one's heart from. This mom was so completely dedicated, attentive, anxious, invested. And the dad was amazing. So caring. He came in his suit from work, and listened, and put his arms around her. I was really pulling for them.

Tuesday afternoon, I was teaching a group of a half-dozen nursing students how to resuscitate a newborn using the materials (model baby) we got at our conference. They were taking turns, putting breaths into the baby with the bag and mask. When I noticed the nurse carrying a REAL baby to the other resuscitation table, and Bob walking towards them. I left my students to check what was happening. It was baby J, with no pulse, no breathing, milk spilling out over his face. The nurse had been moving him from one bed to another, after a feeding through his nasal-gastric tube, and he vomited. He had absolutely no reserve. All those periods of marginal oxygen, all that infection in his brain, it was the final straw. So I moved from pretend CPR to the real deal, for about ten minutes we tried to revive him, with no success.

His parents came in at the very end. When they realized what had happened, they broke down. We got them into chair in a side room, where we talked and comforted and prayed again. They held his body. They said thank you. I said what I could, probably not very profound, but I hope they knew I cared.

And from there, I walked out to cook a birthday dinner.

Which brings us to the title topic, anchors. Sometimes I can't bring myself to think of another meal to prepare. Keeping the house stocked with limited time and resources, keeping kids fed, keeping laundry moving. All that lillies-of-the-field stuff we aren't supposed to worry about feels like a challenge. But this week as I took a couple of hours in the middle of a long weekend of call to make funnel cakes and play UNO with my "caring community" of 10th graders, or spent hours on Caleb's birthday cake, I realized these concrete wholesome tasks are anchors.

Stirring and kneading, measuring and washing, sorting and straightening. These daily solid tasks of life hold me. When I think about another dying infant, or the sadness of the parents, or the vast things I can't do and don't know how to help, I can despair. So I'm thankful for the necessity that anchors me to earth, that gives me a wholesome alternative to the world of the hospital. As much as I stress over coming up with another dinner, that incarnate reality steadies me

God put our souls into these bodies for many reasons. One is sanity.

CALEB, Numbers 13

The boys get bigger, the toys more complex, but Caleb's birthday gift reminded me of all those years when a new lego was the ultimate fun. Be on the lookout for some awesome gopro videos. On a more serious note, this child has worked 17-plus years of faith challenge into our hearts, as we held him with open hands even before he was born. Perhaps the decision to stay in Bundibugyo with a strong history of preterm labor and loss (and realizing that faith did not equal an outcome of my choosing) was the hardest, but only the beginning, of a process that will leap forward as he leaves home this year. In my chronological Bible-reading plan for the year, February 28 takes one to Numbers 13. Yes, on Caleb's birthday, the story of Caleb. Really.

And so once again the reminder that this young man is very much like his namesake. Tough. Quiet leader. Can-do. Brave. The type that would go into enemy territory if asked. And mostly the type that would not be influenced by the majority opinion. Caleb stands on his own, and has no qualms to make his own way apart from the crowd. Tonight was a small gift, a fire, good food, a fun gift, time together. In the light of impending graduation and continental separation, we all pause to soak in the goodness of a birthday, and the wonder of a great young man.

Caleb 17th Birthday Surprise Pizza Party

Late, tired, and slow internet, so here is an unfiltered bunch of pictures. Kids, flour, music, laughter, teasing, blue silly string, a guitar cake, balloons, pizza, more pizza, fire, sodas, stories, memories, pictures, candles, singing, the torrential downpour of the afternoon stopping just in time, mud. Caleb turns 17 tomorrow, but we surprised him tonight. No small feat. And all the dorm kids got back for mandatory study hall at 7. Yeahh.

I am going to call her Little Miss Red Shoes, because she reminded me so much of the young girl Heidi dubbed Little Miss Polkadots. I'm sure I'll get some flak because I am posting her picture here, and I do so soberly and with thought. I could black out her eyes or distort her face in some way. But I want her to be seen as she is: a diminutive nine year old, looking alone on a stool in the casualty department, brave, patient. Not something other, something veiled. A real little girl who bravely told her story today. It is not a happy story, and so feel free to stop reading here. Many lives are not rated G. Little Miss Red Shoes goes to school with her friends. She's in second grade. She lives with her mother and an aunt. Her father left the family years ago, though she thinks she saw him sometime in the last year. Her mom is HIV positive on treatment, sells little bits of beans and corn for a living, and often turns to the local church for assistance. Little Miss Red Shoes lives about a kilometer from me, in a community full of hospital workers and dedicated Christians. But that did not protect her, or at least five friends she could name including one girl in nursery school, from being raped three times in the last year by two teenage neighbor boys.

One of whom was her cousin. She's been lured into a home to run an errand, locked in a room when her mom was away, grabbed and forced. The boys gave her 20 shillings once, and 5 shillings another time (a few pennies), which probably made her feel even more violated. She sits kicking her red shoes back and forth, fingering a muffin into crumbs, quietly telling her story, restlessly, slowly. She and her friends have all been beaten by parents for reporting such stories. Last night, though, when she told her mom again, her mother saw the soiled clothes and heard her sobbing, and believed her, and stormed out to confront her sister's teenage son. Who did not deny it. And shorty afterward the mom's sister, the perpetrator's mother, the victim's aunt . . . showed up at Little Miss Red Shoe's house and beat her again. To keep her quiet.

But this time she was not quiet. She and her mother reported to the police, and then the hospital. The MO, who is a gentle, careful young woman, and I coaxed enough of the story out to be outraged, and then got a pastoral counselor, a community pillar, a respected grandmotherly type from the church to come and listen. Just the person we needed, who will mobilize reaction even if the police do not. We sent off tests and filled out reports. We listed the names and classes of the other girls, so they can all be drawn in by this lady for counseling.

The raping 15-year-old boy is in custody, but his family is well off, and likely to sway the police in their favor. They followed Little Miss Red Shoes and her mother to the hospital and tried to convince the senior nurse not to pursue the case. Instead he helped me arrange for a security escort to bring the report safely back to the police.

I grieve deeply that any nine-year-old girl should live in fear of her own relatives and neighbors. Should have her tiny innocent body violated. She wanted us to give her medicine that she could take so the boys would leave her alone. Her world is not safe. Her mother is thinking of sending her away to live with another relative, so she won't have to see this boy at school.

It is easy to think that such stories are rare, or exaggerated, or distant. But this one was real, and matter-of-fact, and right in our neighborhood.

So tonight please pray for JUSTICE, for Little Miss Red Shoes and the countless little African girls (and others all over the world) who are raped, beaten, blamed, sold. Lord have mercy on them.

BACK TO THE NURSERY

Introducing . . . After two weeks of the CMDA conference and a field trip to Naivasha's maternity and neonatal programs . . it was time to return "home" to the Special Care Nursery. Here are a few of the babies. Naomi is well on the way to becoming the SECOND gastroschisis survivor. Hannah Wangari went home at the end of last week, and Naomi has had a miraculously straightforward course, her protruding intestines quickly fit back into her tiny abdomen. Little Samuel has a spinal cord open-to-the-air defect on his back and no opening to his anus, not to mention a very very small head and un-find-able testicles. I find him cute in his own unique way. Can't seem to find a clear syndrome that combines all his problems, so maybe he really is unique. Amazingly Kijabe has some of the best surgeons in the world for these malformations. This baby's mother was infected with a virus called CMV, relatively benign for her but devastating for the baby. He has cataracts, and severe hearing loss, jaundice from a liver that doesn't work normally, and he needs oxygen to breathe. However he's much better over the course of the week with supportive care, and he'll get good audiologic follow-up from our neighbor and eye care from the nearby Kikuyu eye hospital. I had little hope when I was pitching in two weekends ago to help a visiting doctor cover that baby Paul would live. His mom died in the ICU that weekend, and I was second-guessing my decision to intubate Paul. But he's a champ, and it looks like he might make it, all three pounds of him. This baby, sadly, died this morning, after I had snapped this photo yesterday. He was born in an ambulance on his way here to a mother who had no prenatal care, at 27 weeks (out of 40) gestation and weighed 830 grams yesterday. That's small. He had a rough night, and when our team tried to help him all morning we just kept losing ground. Finally we gathered around him, holding his tearful mom's hand, and prayed. But God did not do the miracle we asked for. An hour later he died in his mother's arms. Satan always attacks the weakest. So sorry for Lucy, the mom. This little pumpkin is my vote for the cutest baby in the nursery. He's close to being big enough to go home. Lastly, our newest baby, NEONATALIE. She is a very realistic baby model made for teaching. After our excellent conference I was able to go through a "Helping Babies Breathe" curriculum with the staff, and have them practice ventilating and caring for little NeoNatalie. The instructor can make the baby breathe, cry, and have a pulse. Or not. So that the student has to really react and take action.

I loved sitting in class, absorbing. But it is also nice to be back in the real world with Paul and Naomi and Samuel and the others, fighting for life instead of just talking about it. Even though we don't always win.

Thoughts on rainbows, sacrifice, transition, and hope

Early morning darkness, a faint smattering of rain staccatos on our plastic mbati roof then peters out. After two weeks of daily all-day commutes to our continuing medical education conference at Brackenhurst, there is finally time to squeeze in a short run with Star before the day begins. The dust of a nearly two-month drought has been dampened by the scattered drops. By the time I reach turn across the escarpment the clouds are breaking and glowing pink with a new sun. I'm thinking about Leviticus, my current waypoint in the year's chronological Bible read, about the difference between burnt offerings and peace offerings, waves and heaves. And remembering the clear message in late Exodus: the point of the sacrifices was presence.

Which is a good thing to remember this moment. Because the whole two-week conference was another milestone of closure and grieving and moving on. For the first time, we were FROM Kijbabe not Bundibugyo. Our kids were in school, and living at home, rather than missing school in Uganda. We were listening to lectures and pursuing workshops to improve health care in Kenya, not Uganda. Heidi and Jessica graciously came for an overnight to connect with the kids and our life here and talk about Bundibugyo, which is good and home-sick-inducing all at once. And though it never worked out to have the Johnsons connect with us and our new colleagues the Steeres (we figured they'd become great friends so we really did try) we did get to at least have a lunch with Travis and Amy, and take them to a soccer game, and visit the kids and grandparents at their lovely nearby tea-estate location. So once again our present reality intersected with our past, which can be both good and unsettling.

Ruth VanReken reminded us of the hidden losses, the discordance between how you think you SHOULD feel and how you DO. Ahh, so familiar. In the two weeks I can't count how many times people asked us "how do you like Kijabe" or "what made you leave Uganda" or "are you glad to be with your kids" or some such evaluation of the last year. These are the same brave souls we hug and chat with and compare notes with every two or four years. And every time I am asked I summon up cheer and confidence and repeat the list of ways God opened this door and told us to walk through it, and the list of ways that we are thankful He did. Only every time I still feel like I'm convincing myself. Repeatedly hoping that God really DID lead us. Guilty for not being completely ecstatic that I'm here in this great hospital with a home full of kids and pleasant weather. So it was helpful to hear Ruth say that this is normal. Many losses are hidden. They don't make sense to others, particularly not those who are feeling the weight of their own loss to BE in the place that I miss.

Then there was the medical education workshop I mainly went to in order to support the speaker who was covering for me in the hospital these two weeks. And by the end I was floored with the realization that the Spirit was speaking. He talked about leaving a program he had set up, and seeing it discontinued and changed. But then seeing that what mattered were the people whom he invested in over the years. Education as discipleship. The programs may come and go but the individuals and the community persist. And that is still true for us, as we read the notes sent our way from Bundi, as we get the texts and emails.

Back to the rainbow. Sacrifice is cost. But not destruction. The rainbow symbolizes that what is lost (the whole world) is, in God's mystery, redeemed. Genesis and Leviticus are telling one story. This is a messed-up world, and we are called to sacrifice if we would approach the One who is Holy and Other. But the sacrifices are ways of inviting, of cleansing, of preparing, of approaching. They are not wanton wipe-outs.

So this morning I was reminded that it is OK to feel the loss, and in some mysterious way it is perhaps necessary to clear the space for the cloud of glory that comes and fills and guides. That what goes on God's altar is transformed and redeemed to bring relationship. That it's not just about counting the cost, but seeing the hope of what it brings. For most people that probably means leaving their kids, and going to a hard, hard place. For me that has meant leaving the hard, hard place and coming to my kids.

And I did see that, in some concrete ways these weeks. The heart ache was there, of not being in harmony with our old life in the same way. But then the gradual permission blossoms, to become rooted in this new life. In the middle of the conference two of our interns came over one late evening for dinner to bring us a thank you gift for being part of their lives this past year. We brought our old friends to the soccer game, and were reminded of all the new friendships that are deepening here. Perhaps it is the magic milestone of passing one year and entering the cycle for the second time, but as I hug and chat and cheer, I am with some women who have shared deep pains in prayer this year, I am with some kids who have been in and out of our house, I'm with people who are walking our same path. I'm with people whom I am growing to care about and feel part of. And best of all the evening that one set of friends needed to spend on an alone date, we ended up with new friends having a real time of fellowship and celebration.

This transition started exactly two years ago, when our replacements arrived in Africa at this very conference. It took a major step a year ago when we moved to Kijabe. And I think I feel more at peace now, in February 2012, about actually living here, not just temporarily serving, but living, than I have since we arrived.

The rainbow painted that truth, that our God does not delight in destruction. That if He wounds He also binds. That the tears have meaning and water the new harvest.

As the colors disappeared this morning, ephemeral in the mist, I'm sure this sense of moving through a milestone will also evaporate. Reminders will be necessary. But for today I am embracing this new life.

Pictures from Hell's Gate

Hell's Gate, Kenya

As Americans we take the phrase "gates of hell" (Job 38, Matthew 16) comfortably symbolically, invisible and unreal.

Not so the Maasai, who noted the steam hissing and boiling from thermal vents in the Rift Valley and concluded that a spiritual underworld literally broke through the earth in this area.  

Friday Caleb left with three classmates on a cross-country trek, sleeping under the stars on the ridge of the Rift near Kijabe Hill then descending into the dusty valley. Saturday by noon we had loaded up the rest of the family and the usual camping paraphernalia (which is similar if you go for one night or one week, pans and a skillet and tents and tarps, firewood and axe and water and binoculars, food and more food and flashlights and books) and set out to catch up with the boys.  We found them waiting in the shade where the railroad track they had followed intersects the highway, and they all crammed into our car and we made our way to Naivasha for lunch.  Where we happened upon half of RVA and found out where the "under-five" crowd goes on midterm weekend, to a resort with a pool where they can pay a reasonable day rate and swim!  Thankfully the two boys who wanted to go back to RVA got a ride with them, and we proceeded on to the nearby national park with our family of five plus one senior boy (which comfortably brought us back to our family of six).

Ironically, we typed "Hell" in the GPS to find the park gate.  Probably the first and only time we've set our destination for Hell, though biblically it is "Hades" or "Death" and certainly a place where Jesus would go for a rescue raid.

This is a tiny park, and as we set up camp and watched the sunset, glows of Naivasha and Mai Mahu and Narok were discernible on the horizons of the hills all around.  But in the crater-like plain which is protected we could see, from our campsite on a ridge, zebra (MANY), impala, Thompson gazelle, eland, warthogs, giraffe, Cape buffalo.  And after dark, we heard the eerie laughing wail of hyenas.  It reminded us of Ngorongoro in TZ, a pocket of wildlife and serenity.  

Unfortunately, just at sunset, it reminded us of Ngorongoro even more.  We had seen no campers anywhere, just lots of day visitors. We were gathered around our campfire cooking Naan over the coals and spooning up a hot rich Indian chicken and vegetable curry.  We had hiked to the top of the ridge and scrambled over rocks, we had watched animals and talked.  We were content.  When suddenly a group of ten American college students arrived.  In force.  In volume.  Though there was a wide area available for camping, they pitched their tents within ten feet of us and proceeded to giggle and shout and carry on as if they were the only people in the world.  Sigh.  At nine, feeling rather old, we asked them to tone down a bit . . . I cringe to think of this group blazing their way across Africa as if they were at a frat party . . 

But besides the noisy neighbors, the park was great.  Mostly we felt that "Hell's Gate" was an unfair rap, a focus on the exception rather than the rule.  After a leisurely camp breakfast we went to the gorge to hike, and though we tried to look what we were doing we didn't find the right path until we were rescued.  We had successfully avoided the 20-ish hustlers at the park headquarters who wanted to be our guides, but when a middle-aged Maasai man in a DQ shirt, plastic sandals, and well-worn walking stick with greying hair offered we gave in.  And were glad we did.  Caleb's classmate won his friendship with his excellent Swahili, and he took us well past the end of the normal gorge hike to see the "talking water", a larger thermal vent further down a wide valley.  He painted our faces with the ochre clay in warrior patterns, and found a local plant to treat Jack's cut finger he got collecting shards of obsidian.  We ended the afternoon with a picnic at a high lookout over Lake Naivasha.  

So where are the gates of Hell?  An idyllic park with grazing animals and rough beauty, yet punctuated by steaming sulfurous vents.  A wonderful 36 hours away with the kids in the restoration of wilderness, yet the peace was broken into by obnoxious revelers.  Place is important, everywhere in Scripture.  But rather than turning the passage between earth and hell into an abstract unreality, this park reminded me that the portals of problems are concrete and frequent, reaching everywhere.  The unseen breaks into the seen, evil breaks in on love, loss bubbles up through the shell of stability.  

Let us live then, in the real world, absorbing the beauty and not fearing the intermittent gates of hell that we encounter.  Let us not run away from the bubbling vents or think we can ignore or avoid them.  And let us remember that at least one portal opens in our own hearts, and the first battle is there.