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  Machines, which I grant you are outdated in 2012 but would have been state of the art twenty years ago, with dozens of knobs and tubes and cords, that mechanically ventilate a patient's lungs.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