A shout-out of thanks from a few vulnerable kids

 This is Daniel, looking feisty on his final day with us.  When he was admitted 58 days ago, he was hours from death.  His mom had defaulted on her own care and seemed completely unable to deal with his AIDS.  I agreed to pay his hospitalization costs from our Needy Children Fund, never guessing how long he would stay or how expensive it would be.  He was so malnourished and had so many infections.  As we started to pull him out of the TB dwindles, he had a reaction to anti-retrovirals that meant we had to stop them. After nearly two months he is finally off oxygen and gaining weight.  But the real story is his mom.  Daniel saved his mom's life.  Because over these two months she slowly came to accept her diagnosis.  To allow herself to be helped.  To resume her own treatment.  In the last two weeks I hardly ever found her without her Bible open on her lap.  She found life.  I don't know how long Daniel will survive, but I do know his hospitalization was worth every shilling.  Two lives were impacted, and I'm grateful for that.

 Jonah continues to improve, very slowly.  His spine is now stable, and he can be wheeled out into the sunshine.  His mother came all the way from Samburu to this place where she knows no one and barely speaks the language of Swahili.  She is brave.  I am afraid Jonah is blind since his near-death in one of his operations.  But he definitely hears, and stops his restless moaning when I talk to him.  Jesus made the lame walk and the blind see.  Jonah needs that kind of miracle.  Kijabe and the Needy Funds have kept him alive and shown him love, putting him in the place where he can wait for the angel to stir the water, for the healer to pass by.

We've had a photography team at the hospital documenting stories like Daniel, Jonah, and this cute 4 year old who was brought to our outpatient Maternal and Child Health clinic Thursday. He is severely chronically malnourished, with very stunted growth due to his mother's inability to feed him enough every day.  But here he is having the time of his life seeing his face in the camera.  A kind pastor in his town brought him in for care.

Lastly, another vulnerable child, this one a refugee from the largest refugee camp in the world located in Dadaab, Kenya.  The NGO's that work there send kids like this to Kijabe for diagnosis and treatment.  I believe she has a genetic dwarfism syndome, something that is not easy for a family with seven other children to deal with in a refugee camp located in barbed wire fences in the desert.

So many children who live with too little care, space, food, medicine, opportunity.  So many who dwindle without resources or care for too long, and come to us too late.  But these four were helped, by our Needy Children's Fund, the Orthopedic Vulnerable Patient Fund, a local Kenyan church, and the UNHCR and other NGO's.

Thank you to all who have donated in the last month.  The income and expenditure when I checked on Thursday were almost exactly matched.  God knew our needs.  I just keep spending the donations on these kids as fast as they come in, knowing the more we help, the more will be provided.  THANKS.

Large Hearts, few hands

Our Paeds department had quite a week.  We are supposed to have 3 full time doctors, which includes one husband/wife pair who split the job 60/40.  One of the three dropped out with preterm labor and between that and her upcoming maternity leave will probably miss 6-7 months.  We are all terrified that work will push her to deliver early, and committed to going the extra mile to cover with just two instead of three.  So every day has a bit less margin, a bit more push.  December looks even more stressful because of the way leaves were planned, but I had hoped for a pretty stable November.  Then on Monday my remaining colleague was feeling sick, so he went home early with abdominal pain. I wondered with his wife about appendicitis, but he didn't think he was really that sick.  By Tuesday morning his appendix had ruptured and he was in emergency surgery.  Thankfully we have good surgeons and immediate attention and he will be fine, eventually.  But he's out for the indefinite future and so is his wife (mostly) to care for him, though she was able to work for the afternoon on Friday she will miss about a ten day stretch as well.  I was running around the hospital on Tuesday while they were in the theatre, just thinking about making it through the day post-call and Scott's Birthday with a small party planned for the evening, while trying to take care of all the patients on the general floor, the ICU, the NICU, delivery rooms, casualty, outpatient, private . . it gets a little crazy.

We watched part of the "Home Alone" movie at our last class night, and Julia surmised that evening that we should call Paeds "Work Alone".

But over the course of the day, I realized how NOT alone I really am.  As soon as I heard about my colleague going into surgery I texted the three clinical officers whom I had given an admin day "off" and they got out of their car and came right back to work.  My RVA nurses rearranged that clinic.  My friend and colleague in Nairobi who usually comes out to work and take call about 3 days a month called to say she was clearing her schedule and would come from Weds to Friday morning.  A family medicine doc in casualty will help for three days next week, while his casualty work is done by another family medicine doc.  Ironically I had finagled a way to get Scott off for 24 hours so we could spend an overnight together at a nearby resort for his Birthday (a few days late) on Thursday night.  I wasn't sure until the last minute we could pull it off, but we did.  I ended up back in for an ICU admit almost as soon as I got home, but it was a good evening/morning respite, it really felt like a true rest.  

I confess I am tired. The sadness of some cases pulls my heart down, the endless press of work drains me, the feeling that there is no one to share the burden feels too hard.

But the truth is, my hope is not in my colleagues, in fairness or work, or in control of my schedule.

My hope is that I'm here serving a God who knew about the preterm labor, the appendix, leave schedules, and everything in between.  A God who allows Sabbath, a 1 in 7 rhythm of true rest that is more and more necessary, and does not require apology, the harder the other six days get.  It's November 15, and I've only had one full calendar day out of the hospital this month.  I'm hoping for a couple more towards the end, asking God to provide.

In the moment when illness strikes, when admissions roll in, when patients crash, when someone says they can't help with something, when unforeseen circumstances press down, I find out my heart-size.  A large heart absorbs the stressful circumstances and answers with grace.  A large heart listens to each new plans-fallen-through and does not despair.  A large heart is not self-protective, and always has room to pour love onto sadness.

My heart is not large enough for this task.  But this verse jumped out today from Psalm 119: 32 "I will run in the way of your commandments, when you enlarge my heart."  This is the same phrase used of Solomon, whose wisdom had to be accompanied by this character of large heartedness for his decisions to bless many.  Immersion in God's word, running in the way of His commandments leads to a largeness of life that is the way I want to live.  No counting the bitter hours of who does what, but a generous spirit of service with joy.

So that's my prayer this month, a prayer that the paucity of hands-on-deck will be compensated by a largeness of heart that lets me approach changes in plans with courage and peace.  That lets me react with grace to each new stress and push.  Please pray that for me.

Front Row seats to the Burning Bush

The burning bush represents the impossible presence of God, and when you see that, you have to take off your shoes.

And that happens in the grief, when a teenager meets Jesus, when a mother is comforted, when we bow in desperate prayer.

It also happens in awe.

So to complete the story of the week, I spent four hours in the hospital this morning in meetings.  Not the usual choice for holy ground.  The first was the Neurosurgery Audit, where we discussed the last two months of admissions, deaths, infections, new procedures.  The Albrights are inspiring people, working way too hard to care for ever increasing numbers of children.  Kijabe sees about 250 spina bifida patients a year, ten times more than even the busiest neurosurgical services in America, with a fraction of the resources.  And they are doing research on new surgical techniques, publishing scientific papers, and training Kenyan doctors.  Inspiring.

From there to a meeting with the Medical Director, Executive Director, Head of Engineering, Head of OB, and me.  To propose an expansion of our nursery and maternity space to meet demand.  Mardi had made a proposed drawing.  Only the Executive Director wanted to think bigger.  To have new construction, new space, better facilities, and double the capacity.  Again inspiring, because this has real potential to impact child survival.

And from there to a meeting of the BKKH (Bethany Kids) team, surgeons and nurses and administrators who care for children with birth defects and disabilities.  We discussed how to not just train surgeons and send them out to Madagascar, Ethiopia, Sierra Leone, Rwanda, Tanzania, Uganda . . but to also support all the other services needed for kids there, to multiply what is happening at Kijabe.  A lot of brainstorming and philosophy and really good stuff.  Holy ground.

So in the midst of the losses, it is good to see that we are ever improving services, ever increasing hope.  To be reminded of the 20 that go home cured for every one who dies.  Of the amazingly dedicated and talented people I work with who are pouring their lives out for kids and for Jesus.

The End of a Story, and Hope doesn't give up

I had just walked out of the morning's monthly staff meeting when my pager went off, and I hurried to the HDU knowing it would be Vincent.  He had been vomiting, cold, listless, with abdominal pain through the night I had heard from the on-call doctor, worse than I had left him, but in the early morning hours told the nurse he was hungry.  His mother called the staff over an hour later, alarmed, because he was no longer responding.  I walked in to find him gasping in the way that people do as they die, pulseless, with the large unmoving pupils of the brain dead.  He was gone.  That gasp was his last, and as I watched the heart monitor petered out to a flat line.  We had long before decided that we would put every effort into his fluids, medicines, oxygen, feeds, and wound care.  But we would not do CPR.  The low-likelihood of helping high-pain violence of it would have been grotesque in this circumstance.  Vincent's suffering was over, even as we gathered around his bed stunned, and then held on to his shaking, weeping mother, he was free.  Free of TB and pressure eroding his paralyzed body.  Free of the monitors and hospital.  Free of our failed help.

Two things made this morning bearable.  First, a conversation with the nurse a few minutes after he died, as we reviewed the course, his treatment, what could have gone wrong or been done better.  "Did you know that Vincent prayed to receive Jesus last week here, as did his mother?"  No, I didn't, but evidently another nurse had been sharing Jesus with them even as she cleaned his wounds.  Second, the assurance that we had done everything possible, there was no treatment we held back.  We didn't just move him to a corner to die, we kept open the possibility of a miraculous reversal right up to the last minute.

I wish we had seen the Fall-in-reverse, the resolution of disease that we long for.  I was reminded by others later that we were discharging 4 other kids who had been healed, and many more the week before.  Most kids do get better, most of the time we are witnesses to improvement.  But Vincent's body was so weak, so spindly, so ravaged, so destroyed, the path God chose for him to healing was through the valley of the shadow of death, straight to the table prepared.  I do not regret the all-out effort to keep him alive for two weeks, which enabled him to experience the hands and heart of Jesus in those who cared for him, to encounter the living Christ.  I wish he had not suffered such pain or his mom such loss, but I know that he met Jesus in his suffering, and pray she does too.

Still it was a hard day, moving through the ward, back and forth to clinic, with sorrow in my heart.

Then in the mid-afternoon I went to nursery where we were sending a baby for admission.  Simon, the little baby who was in ICU for weeks after multiple surgeries and chest tubes to repair his congenitally non-functional esophagus and trachea, was still there.  His faith-filled mom is always content, hopeful, patient.  She greeted me warmly.  We have spent more time together over Simon than most people in her life.  His last chest tube had come out a couple days ago, and he is finally doing well after weeks of nearly dying.  I think she could sense that I needed to touch hope today.  "Do you want to hold him?" she asked.  I'm not sure any mom has ever asked me that. She gently scooped him up in his blanket and handed him to me.  Not to evaluate, just to enjoy, mom to mom.  It was beautiful.  Nothing speaks hope more clearly than a one-month-old who has survived against extreme odds, and is only a short step away from cure.

I tried to get Simon to smile as he chomped his pacifier.  I'm sure I smiled.  A lot.  He was the perfect reminder that God is at work in healing at Kijabe, in spite of the morning with Vincent, there is much good we can still do.

A small dose of hope

Vincent (see post below) pulled through today, barely.  Overnight his breathing became labored and he was moved into our 3-bed High Dependency Unit (the level of care between the general ward and the ICU) for high flow oxygen and monitoring.  Alarmed by his sleepiness and cold skin this morning I asked the nurse to take his blood pressure:  60/20.  Yikes.  Fluids, pressors, warmth, antibiotics, prayer and by afternoon he was up to 85/55 and sipping some milk.  He just teeters on the edge of fighting the bacteria in his bloodstream and the despair in his soul.

The HDU is a 3-bed unit of excellent care too late.  Vincent with his paralysis, chunks of missing flesh, raging infection, all most likely from a disease that was curable for the first few years of gradual symptoms.  Little A in the middle whose minor skin pustule turned into a massive flesh-destroying infection, over a matter of a few months eating its way through his side, his kidney, his spleen, his intestines.  Perhaps if he wasn't an orphan, living in a remote corner of Kenya, he might have had definitive care in time to save his life.  His last surgery revealed we are losing this battle though, and his care is now designed to make him comfortable until his inevitable death.  And on the other side Jonah, still pulling for a miracle, fractionally more awake day by day.

Some days, the burden of sorrow just weighs too much.  My tough can-do wavers at a kind face bringing tears.  The stress of complicated ICU patients, these three heartbreaking HDU patients, the myriad of the malnourished and seizing on the general floor, and the steady flow of outpatients needing assessment or reassurance or more wisdom and insight than I can muster, drains me.

But in the midst of all this a few doses of hope.  

First, we had a lovely graduation ceremony yesterday for two Paediatric Surgeons completing their fellowship.  Dr. Situma will return to Uganda where the ratio of surgeons to patients is even lower than Kenya . . note that all three boys who got too little care too late had problems that were partially surgical . . . and Dr. Lebbie to Sierra Leone where he will be the first and so far ONLY paediatric surgeon in the country.

The spiritual as well as the medical maturity and excellence of these two men was evident in their speeches, and in contrast to so much of what passes for success in Africa.  Really inspiring.

And then I found Acacia and a classmate volunteering to serve meals on the Paeds ward in the evening, and came home to dinner with Jack and three friends from his soccer team, great guys.  These are the next generation of hope, and they lifted my spirits.

On TB and Two BOYS and Hope

I am going to be politically incorrect and use real names, because these are real people.

Jonah is an 8 year old from Samburu country, who came here on a mission flight in a desperate attempt to save his life.  He has tuberculosis of the spine.  TB is treatable, and his caretaker who came coughing out the disease is much better.  But Jonah's spine was perilously bent, his nerves stretched, his blood vessels compromised. Drs. Muchiri and Mara planned his surgery while our team initiated TB treatment and nutritional support.  His first surgery was aborted when his blood pressure dropped, his second allowed most of the infection to be drained out but was aborted when his heart stopped temporarily, and the third finally allowed him to have his spine stabilized.  His little brain took a hit, but over the last week he's been opening his eyes and moving his hands.  Today I transferred him out of the ICU.  Small victories.  A recovery would be a miracle.  But we can ask for a miracle.  I have learned only one word of Samburu:  "Suba!" which I say loudly many times a day hoping for a response.

Dr. Mike Mara is pulling for this kid with skills, funds, and prayer, and his hope is inspiring.  Here he is greeting Jonah last week in ICU post-op, along with Jonah's little Samburu friend with a hip infection who came on the same plane.

Back home, the village women held a fundraiser to contribute to his care.

Please pray for Jonah.









And please pray for Vincent, who we believe has the same disease.  Only he is 15, and his was even more advanced than Jonah's by the time he came.  This is his spine MRI courtesy of Dr. Sarah Gessner.  Note the folding bend in the top right.  It should not be there.  His spinal cord is crimped, and he is paralyzed.

Vincent was a normal kid for many years.  He had some prolonged illness when he was 4, but eventually ended up on TB meds.  Within two months he was so much better that his parents thought that was enough.  But TB requires prolonged treatment.  It wasn't enough.  Vincent's mother began to notice a hump in his back when he was in 6th grade.  By 7th grade, his legs were getting weaker.  By 8th grade, he could only walk with a stick to prop up his dragging limbs. By 9th grade, he had to go to school in a wheel chair.  By August this year, his paralysis and time in the wheel chair forced him to drop out of school.  By October, his hips and legs were eroding as he stayed too long unable to move.  His mother took him to the best hospital around, which said there was nothing to be done, unless she wanted to try coming to Kijabe.  She went home for two days to organize and ponder her terrible choice:  let her son die, or travel across the country with him leaving her other four younger kids to depend upon the kindness of neighbors for survival.

She came to Kijabe, where Vincent's horrific wounds were assessed by two surgical services and found to be incurable, particularly in view of his sullen withdrawal.  We found him on our ward, reeking, with thick wool blankets pulled over his head.  What teenager wouldn't be depressed to be paralyzed, with his body decaying around him?  My colleague and I are both mothers of boys this age.  We decided to ask for another miracle.  To treat his depression and malnutrition, to clean his wounds and see if there was any spark of hope left in his heart.  Today he nearly died.  His wounds are so infected we had to put him on a course of antibiotics that will cost about $600.  The odds of his survival are slim.

But just when it seemed prudent to give up, to not prolong suffering . . a flock of Australian nurses appeared in his room today.  Teaching wound care.  Thoroughly debriding and cleaning.

What are the odds that these angels would miraculously materialize at this moment?

So we have not yet given up hope.  But hope is ethereal, easily vaporized in the hard reality of Vincent's life.  Please pray for him to choose to live.  Please pray for us to witness the power of God bringing impossible healing in this boy.

Sometimes I have to admit that I hesitate to hope.  Hesitate to ask for prayer for two boys who may not be able to breathe much longer, let alone sit, or walk.  Hesitate to draw attention to two cases that will most likely end in sorrow, as if that would make God look bad.  So I can only say that while they are in my care we will do our best to give space for God to work, to speak words of truth about their worth, to trust that whether God heals them on earth or in death they will be eternally running in glory.  

Thanks for board exam prayers...

For seven hours yesterday, I stared at a computer screen, squirmed in my chair, tried to block out the incessant clicking of neighboring keyboards - and answered medical questions at the incessant rate of one per minute.  I know a lot of medicine.  I answered questions ranging from rabies to rashes to radiology, from newborns to geriatrics, from psychiatry to sarcoidosis.  And by the end, I was spent.

But today, I want to take a moment to give thanks.
I'm thankful I was healthy, focused, rested, well-fed.
I'm thankful there is an international computerized testing center in Nairobi.
I'm thankful for the prayers of many friends.

And on the way home I saw a spectacular rainbow, reminding me of God's covenant promises, of His love and faithfulness.  And it made this little exam pale in comparison...

Ten Facts on a Tuesday

A few emails and comments have alerted me to the fact that I often fail to give follow-ups after asking for prayer.  So here are the answers to a couple questions today, and some bonus points as well:

1.  Scott lived through the strenuous and stressful exam.  He won't know if he passed for two more months.  It was exhausting.  Thanks for praying.
2.  More importantly, Dr. Travis Johnson finished all his chemo and last week he had the great news of a clear CT scan.  We are so thankful for the flood of prayers that carried his family through the last six months of nausea, weakness, and the stark reality of risk.  He is now a cancer survivor, which means for the next five years he will be closely monitored.  But all is well.
3.  Our Burundi Team finally arrived in Kibuye last weekend.  After two years working together in Kenya, meeting with WHM and deciding on Burundi, applying, raising support, packing containers, speaking, traveling, then nearly a year together in France for French study and three months in another area of Burundi for Kirundi study . . . drumroll . . . they have moved into the village where they will staff a hospital and teach medical students.  Do pray for them to establish strong relationships and healthy boundaries as they work on house construction supervision, and plan to begin full time medical work in January.  Meanwhile the Bonds are studying French and recruiting for the Bujumbura branch of this work.
4.  Caleb continues to need healing for his knee injury, but with admirable spirit plows on.  He has to pass a swimming exam today which with enough tape and pain tolerance he hopes he can do.  Luke has applications in to about a dozen or more med schools, so you can pray for God's provision and guidance in that process.
5.  Our South Sudan Team is dispersing for rest and home ministry soon, and we continue to pray that the Massos will have the support they need to return in January, and that God will raise up new leaders and new team members to bless the people of Mundri.
6.  New team members on the Bundi team have survived a disease-ridden first couple of months, and eagerly await the next influx of colleagues.  The spiritual and physical battles there never let up.  Pat in Fort Portal could not get travel visas to the US for the two young orphan girls she has guardianship of so needs prayer for wisdom and perseverance as she faithfully continues to serve without the benefit of that break.
7.  Josh and Anna Dickenson were wed, and true love is in the air elsewhere, so keep tuned for more announcements.
8.  Bethany agreed to RVA's request that she extend her counseling ministry from 3 months to 2 years, hooray.  The Maras are hosting a team of photographers to connect the church to the work of Kijabe hospital, and working through difficult issues with inadequate staff in the orthopedic department.
9.  In Nairobi, our team continues to reach out to the community accused of the Westgate attack and the community of the victims.  This team is focused on language learning right now and could use prayer for Swahili to flow.
10.  To make a complete top ten, we thank God for the spiritual hunger among students here at RVA and especially our own.  And we are thankful for fellowship and community in spite of demanding, challenging, unending work at Kijabe Hospital.

PRAYING TO PASS

Perhaps the best analogy would be the Red Sea blocking one's exit, with murderous armies behind and the Promised Land distant and inaccessible.

On Monday Scott has to sit for an all-day 8 to 5 Family Medicine recertification exam.  He'll drive into Nairobi today to stay at a hotel near the Prometrics computerized testing center.  The last one he took was ten years ago.  He is a fantastic physician, can save your life and cure your malaria, manage your ventilator and life support, treat your diabetes or hypertension, deliver your baby by Caesarean section or suture your wounds.  But he hasn't ever touched the last fifteen new variations of diabetes medicines, and he thinks in tropical medicine differentials more than in obesity and over-indulgent lifestyle differentials.  After two decades practicing medicine where most of the world's needs occur, our skills sets have diverged from the US standards.  For the last few days he's been at his desk, working through a practice test that is designed for fresh-out-of-residency young doctors, and trying to read up and prepare.  Family Medicine is a fantastically broad area of expertise, and ten years is a long time since taking this test.  The questions are intensely specific and tricky.  He is sensing the impassable sea.

Would you please pray for him in your congregations on Sunday, and as you think of it on Monday?  Pray that he would not fear defeat, that a way would open, that he would call to mind the thousands of facts that are in his brain, that he would see God's mercy leading him to pass.

Pray that God's glory would be shown in allowing him (and soon me in Paeds) to maintain licensure as we serve here in Kijabe, Kenya.

(And you can pray for us too, I'm on call today and tomorrow and working pretty intensely these days, so a ripple of single-parent-time is not without stress too.)

Thousand Dollar Baby

What would you pay to save this baby's life?  A thousand dollars sounds pretty steep in Kenya, more than the annual per capita GDP, but a drop in the bucket many places.  She was born prematurely, and survived for a couple weeks in a local hospital.  But as the days wore on she became sicker and sicker, and when her twin died, her distraught parents scooped her up and got in a taxi to Kijabe.  She arrived on death's doorstep.  I got the call in nursery as I was walking out the door that there was a baby in MCH clinic, did we have an incubator?  No, I said, we'll have to send her on to Kenyatta.  We were running at 150% or more of capacity and taking on another baby would compromise the survival of those we already had.  

But as the visiting resident who was staffing the clinic worked on carrying out the plan we had made over the phone, she called back to ask some questions about the logistics of an ambulance.  These parents had nothing with which to pay for one.  I was at the end of a stressful day and scrambling to get dinner for guests.  THANK GOD it was one of those times the Spirit just kept me unsettled.  I had no peace about the decision to send this baby on to the national hospital.  It sounded like she would die on the way.  So I called the resident back with a plan to squeeze her in without an isolette, using a crib and a heater, and hope for the best.  I can't explain the internal battle but I knew we were supposed to keep this baby. 

That weekend she became much worse, and my colleagues took her to the ICU.  I thought it was hopeless.  She was on life support for six days, battling a nearly fatal and overwhelming infection.  We fought back with the strongest antibiotics, and the kind of medicine and monitoring only available a few places in Africa.  This little twin, a deep green color of jaundice, skinny and losing her grip on life, pale and with barely the strength to keep her heart going even when we took over the breathing, teetered on the brink for a week.  But day by day her vital signs became more stable.  My team was fighting to save this one, particularly as a twin when the other had died.  They had more hope than I did.

Eventually she came back down to the nursery, and we gently helped her get to the point of feeding, and then of breathing without any oxygen.  Today she's going home, having reached normal newborn size after almost a month of life.  

She is cured.

Her parents' national insurance card payed about a third of the bill, and they were able to bring about $250 which is 3-4 months' salary for the average citizen.  That left about $1000 still to be paid.  

Thanks to several recent generous donations, our Kijabe Hospital Needy Children's Fund was able to step in and pay the bill.  Which means that baby M can go home with her mother, who was a hair's breadth away from total bereavement.  Which means that we can sustain low cost care and offer the same services to the next baby.  

Though this is only a thousandth of the million-dollar-baby story . . the themes are similar, only our story has a happier ending:  a fight against the odds, an initial reluctance, a growing wonder, the beauty of strangers growing in relationship, victories, redemption, dilemmas, and loss.  Thanks to all who helped baby M survive, and pray that we can stay in the ring for the next one and the one after that.  We get beat up pretty often.  But today we're celebrating a victory.