On Triumphalism and Daddys

 

Palm trees wave their hands in the hot humid air.  Hosanna.  Lord save us.  Set us free.  See how your king comes to set his people free…

In the church I grew up in, we took communion every week.  It was the Lord’s Supper done in remembrance of his death, burial, and Resurrection.  If you missed Sunday morning for whatever mysterious reason, you could take it at the Sunday evening service.  For 14 years I felt terribly awkward around the Lord’s Supper because that was how old I was when I was baptized, as in issued a ticket.

Last Sunday we were at the Kenyan coast for an organizational retreat.  For the first time in seven months I got to take the Lord’s Supper.  Seven months.  After a practice that is central to my church experience once (or twice!) a week every Sunday for nearly 35 years, that’s a long dry spell.  It came following a message which I was eagerly devouring as well, but won’t re-hash completely, about the “Triumphal Procession” that is mentioned in 2 Corinthians 2:14 and Colossians 2:15. 

The image of the Greek word θριαμβεύω “triambuo” is actually the victory parade of a Roman army returning with the spoils of war, and there at the back of the line after the ticker tape and hurrahs, there comes the POW’s chained and destined for the arena to be killed by lions.   So St. Paul describes our station in life as that part of the triumphal procession.  The end.  The POW’s. Being lead out of the kingdom of darkness, into the Kingdom of the Son He Loves. 

And I was so happy to be marching slowly up the aisle at the end of that triumphant procession.  But I missed my church back in Tennessee too.  Then, I thought of them doing this exact same thing.  We process forward to receive into our bodies little bits of the Body of Jesus and little bits of the Life of Jesus.  And then my homesickness melted into something sweet and unifying.  There they are too- following the careful procedures of which aisle to take, which element and which manner to take it.  Looking around, who’s here today?  What are they going through today? How’s his chemo I wonder? When’s her baby coming? Look how they take the children with them! O- I love this song, if only I could remember the 2^nd verse… Jesus, this looks like a wedding and look at those wedding partiers processing up the aisle to meet you!  I loved being the bride!  And now, I receive you, Lord.  Not just your supper.  But You.  Your death and your Beautiful Life that chases it down.

And I remember.  I am part of you still.  Nothing will separate me from your love.

There were 6 missionary kids last week that gave a testimony- their story of faith.  (Ask somebody what that word means in Greek sometime!)  And then they were baptized in the crystal Indian Ocean.  And it was less dying as POWS at the end of line than it was Daddys loving their daughters.  They came, willing to be buried in the water and made Alive in Christ.  And their Daddys were there, like mine was for me when I was 14, saying to them: My daughter, I have always loved you.  Even before this day.  I love you and you make me so happy just being you.  I will do anything to rescue you from your darkness.  Anything.  

The out takes: 

little American Gothic

this guy was interested in baptism.  Mostly he was interested in how long they holdya under.  Good question for 6 yr olds.  And seminarians.

more than words

Month of March in pictures

March is a birthday month for us.  We have been practicing "whether at work or play, do your best".

Not many medical images here.  You can thank me later.

Daktari Wife has been facilitating some Sunday School Teacher training workshops.

Father-Son camp out at Mt. Suswa

Nairobi guest house for birthday respite

Kindergarten tea time for the 6 yr old's special day

This thing was actually moving on down the road. Amazing.

Solar system cupcakes for the party. I'm letting the kids decorate the cupcakes every time.

Little Miss and her brother's birthday drum.

Facilitating visitors in a gift cow for a widow.

Birthday safari.  Happy Birthday to me!

We were eating next to the Mara river watching a huge crocodile on the bank when this little killer buzzed by: the Tsetse Fly.

Pre-dawn game drives to wake up with the African plains

Mara River

Facilitating a visitor to buy a mud house for this widower and his 7 children

Our little friend Caleb and his birthday

A big part of the reason we are here.  These Medical Officers graduated the training program at Tenwek this March.

simple present tense

The kids are watching the preview for Toy Story 3 (Andy goes to college) and I'm tearing up. Somebody please.  Stop personifying kids toys and making my heart ache over these fleeting moments of little pleasures.  It’s a present tense nostalgia.  It's the fear of missing it. My friend Mary said she was so happy at her son’s high school graduation while all the other moms cried, she was really celebrating his accomplishments without regrets.  She just delights in the simple present tense.  I have so much to delight in our simple present tense too.  Like 20 people eating homemade missionary pizza in our house on Friday night, watching Toy Story.

I usually think of our man-cub as more like Buzz Light-Year than Andy, the boy that grows up.   But he is changing.  People do that, you know?  He went and turned six this week. 

I wasn’t planning this to be any big deal.  In fact, I wasn’t planning much celebration because I got lost under the stress of waiting for a work permit to come through for Daktari, which it did.  Hallelujah and happy birthday to us from the Government of Kenya! Thankfully we live in a mission community that is somewhat like living in a yellow submarine and a friend offered to plan a party for us to have together with their son turning 2 years old.  It was quoted as being “An awesome birthday party” too.

Missionary kid birthday parties are so great and so simple.  No Pintrest pressure to perform, no need to collect clout with cute cupcake presentation, no pressure on kids even to give presents really.  Mostly we dig in our little closets for something that would be a nice up-cycled gift, or maybe find something local like a stone carved animal or goat skin drum.  The little things really mean a lot to us at six. 

We don't mind at all if you wear tie dye and plaid on the same day. In Africa you are judged not by the color of clothes you wear, but by the content of your character. 

Man-cub, you are my big Kindergartener who can bound out the kitchen door at lightning speed yelling to the world “I love you mom!” as you take yourself to school every morning.  Or to infinity and beyond, whichever.

There are little joys we share here like a dad coming home for lunch every day to take an intermission from the dramatic realities of intensive care medicine in rural sub-Saharan Africa.  You are starting to get it a little at a time.  And when we see you show compassion in your own way to your kittens or the neighbor kids, my heart wells up to overflow.  It's in the here and now for you too.

You beg for tickle time and you love it even though you let me in on your secret the other day about losing your ticklishness. But we both pretend it never happened cause I can’t handle that kind of change so suddenly.  Let’s just enjoy you today.

Just a simple little five years of present tense moments have gone by building for us the two best accomplishments of my life.  You and your little sis. You make me proud.

And now you are six.  

TB or not TB; That is the Question

Welcome back to Daktari Cases.

This case comes complete with a soundtrack courtesy of Merle Haggard, as well as an existential reference from Hamlet Act 3 Scene 1; so the recommended gameplan, start Merle out and have him playing in the background while you read the story.

The story of Charles goes like this: he is a young man of 25 years, a local guy from Bomet who grew up in the burgeoning Kenyan middle class.  He has lived the good life for our area: always had food on the table and school fees keep him on the track to success: education is the way out of poverty here, and Kenyans take it very seriously.

Then three years ago he started to get a cough.  He shrugged it off for a few weeks, until people started to notice.  Then he went to the clinic and told them his story: he'd had a chronic cough, and was an otherwise healthy young man.  In our part of the world, that means he has pulmonary tuberculosis (TB), plus or minus HIV.  His chest x-ray showed the abnormalities on the left upper lobe, and a sputum culture was sent.  Sensitivity for sputum culture in our setting is @ 50%, so most clinical decisions are made based on clinical evaluation.  For Charles, the clinical evaluation said, "TB" and he was started on TB treatment.

He felt better over a couple of weeks, but kept taking his treatment for the full prescribed 6-month course.  4 drugs x 3 times per day.

Nothing happened for a few months after he finished his initial treatment.  He returned to work and led a normal successful life for another quarter of a year.  Then his cough came back...same symptoms as before, and he returned to the clinic.  This time the exam and the x-ray showed the abnormality on the right side of the chest.  This was deeply concerning to the clinical staff, at the back of our minds there is always the question of evolving drug resistance in tuberculosis, and when we see these HIV-negative patients returning to clinic with a relapse or recurrence, there is a fear that they are in the 2-4% of patients with drug-resistant TB in our area.  Another sputum sample is taken and is negative.

So, Charles gets second-line treatment for the new set of symptoms and radiographic findings.  This time he gets 4 drugs 3 times per day, and a daily shot of a drug called Streptomycin, a very painful and inconvenient everyday experience for 9 months.

Once again, he gets better for a few months, and then has a recurrence of his symptoms.  He gets treated again with another course of intramuscular Streptomycin.

On the fourth recurrence of his symtoms, I get involved in his care.  He is admitted to the Tenwek Medicine Teaching Service, and we go back through his story.  He has had 4 treatment courses for sputum-negative TB that seems to move around from one side of his chest to the other.  Maybe there is something else going on here?  Some of the dangers of working in Africa amidst so much TB is that you start to call everything TB.

And for this case, I wasn't convinced.  I spoke with my surgeon colleagues, and asked them to do a biopsy of his lung.  At Tenwek we can do a procedure called a video-assisted thoracoscopic surgery (VATS), illustrated here.  This gave us a piece of tissue to examine: is this TB or something else?

And it turns out this case was of something else: Bronchiolitis Obliterans Organizing Pneumonia (more handily named BOOP).  It's an inflammatory lung disease that responds to a short course of steroids, something as simple as a week of prednisone like you get for poison ivy.

Charles doesn't have TB, nor does he need the stigma and fear associated with it.

That takes us back to the existential question that we on the medicine service ask ourselves daily: TB or not TB; that is the question.

Power Surges

On Power Surges

The hospital’s hydro-electric dam is not steadily running the local power source until a 3^rd turbine is built.  How one inserts a new turbine into an already built hydro-electric dam I could not tell you.  I can’t help but imagining a little Dutch boy is down there sticking his finger in it though.  Bet he’s tired too.

Hence we have power outages frequently and irregularly.

Our little Miss cannot cope when the power goes out at bedtime and the little princess night light in her room goes black.  So we light candles and flashlights and wonder if all the overhead lights are switched off in case we are asleep when the power surges back on in the night.

Today the power was out when Michael went to play racquetball.  Yes, there is a racquetball court at Tenwek. And yes, he did try to play racquetball in the dark. 

Brown outs: warn us of the pending darkness and surge of electricity when it ends.  They are actually worse than black outs (unless one is playing racquetball) because the power will fluctuate up and down and destroy electronics.  And I ain’t talking about my hairdryer.

Hospital CT scanner: burnt out.  The $100,000 light bulb couldn’t withstand the surge of electrical ups and downs from power surges.  For Daktari, it means he has to guess what is going on inside the patient’s heads (which he’s pretty good at, at least for me).  But these patients come in with embolisms and blood clots and abscesses left and right.  Not knowing for certain from an image is risky business too. 

Burnt out: what happens when people get too tired from 6 months in living cross culturally with no break nearby.

Even my indiglo watch light is burnt out. Not like I need to actually know what time it is after dark anyway.  It’s time to be asleep is all I know.

So here is the little story of some ups and downs that came in our life recently leaving us feeling dizzy, shocked, and thankful.

Last September, we entered Kenya on a visitor visa and had applied for a work permit.  We were told that having applied for the work permit was good enough to begin work.  Due to many factors, Kenyan immigration has slowed some things down lately on issuing work permits and apparently our name was not at the top of the stack for any of the meetings leaving us in a 3month + backlog. On March the 3^rd our visitor visa would expire and we would need to leave the East African community to the nearest, cheapest, safest place in order to exit, re-enter, and get a new visitor visa.  We were prepared to head north to the Land of the Giles: Ethiopia.  We even have good friends there in the capital city- Travis, Emily, and baby Clare Weeks.  However, the US Embassy in Nairobi notified us that to be working under any circumstance in Kenya (even unpaid) on a tourist visa was ill advised, illegal, and potentially hazardous to your health.  Hmm hmm.

Wow.  We are undocumented workers.  What were we to do?  We found out about a special work pass that could take a month or more to process but would cover us until the long-term work permit was cleared.  Well, for a month or more what were we to do?  Brown out.

That was Friday last week.  Saturday I helped lead a seminar for about 30 Sunday School leaders and teachers out in a village where a pastor and his wife have a children’s home with about 50 orphaned kids living.  It is a lovely place with glossy concrete walls of manilla and sky blue trim.  Standard issue rust colored concrete floors.  I find myself oddly attracted to these typical paint schemes and I think “ah that is mid-century chic” (my enculturation rate may be febrile).  There were panorama vistas in the chapel overlooking the green hills that are quilted with tea farms, fallow fields of failed maize crop, trees, and nice wooden stitching of fences.  The window looking up the hill lures with a flowerbed of cosmos.  Oh yeah, I was teaching too, sure.  T

rying to encourage a room full of Sunday School teachers who are young teens and old men, and they each have about 50 kids each week sitting under a tree, struggling to convey the message of the gospel without props when some of them don’t even have a Bible of their own to start with! (Something we will be working on soon.)  But there I was, lost in the cosmos.  Gloriously delighted to be lost in green pastures, beside still waters, at the place of songs.  At this moment, I think, this is what I’m here for!  Power surge.

But I do miss home.  We miss our family.  We miss our times at the Mexican restaurant by Kroger, we miss stability, we miss anonymity, and so much more.  So maybe this will be time for us to go back to the States for a few weeks.  Or more.  So we sent out an urgent prayer request on Sunday morning, seeking wisdom, grace, favor, etc.  And we concluded that indeed for far too many years have far too many white people put themselves above the Kenyan law and created a cycle of symbiotic disdain.  But we are here to be whole Gospel people, not indispensible medical saviors or missionary super saints who would go to jail for our right to treat people and not submit to authorities.  Because this story is bigger than what we can see- this story that goes back to a long, long time ago, when a man looked up in the pitch dark of an ancient near eastern night sky and seeing the stars burn from billions of miles away with the beacon of light that still reaches my eyes today.  They echo to me: live by faith.  And we put our dream on the altar.  We would submit to the authorities and leave those 50+ patients to be unseen by Mr. Daktari Monday morning.  We will live by faith, even though fear knocks at the door.  The fear started to tell me “you may be gone for a long time before your work permission is granted”.  And I cried to think of our kids missing this dreamy life they have.

Sunday morning I was watching a banana leave wave in the wind and its chartreuse reflection on the polished wood floors.  I listened to Andrew Peterson sing “Hosanna.  See the long awaited King come to set His people free.  We cry Oh Hosanna.  Come and tear the temple down, raise it up on holy ground.  Hosanna”.  The Gospel is lifting up the lowly and bringing down the haughty. 

Monday morning there was a pre-scheduled executive board meeting at the hospital.  Michael was getting dressed to go to work because he is a creature of habit and loves going to work.   But he didn’t go.  Back and forth.  Up and down.  Emotions were on the same power grid as our house.  Then we got word.

The medical superintendant told the board we had this problem and would not come to work until it was legal to do so.

 Within minutes someone was on the phone with someone else and deciding that there would be a special pass for work issued tomorrow!  The immigrations office would also renew our visa to be here tomorrow!  It was a battle of our hearts over right and wrong and hubris v. humility. Someone else was able to fight it for us, thanks to the many prayers from you all.

So now we are still here at Tenwek, keeping calm and carrying on after all the surges of emotions.  And left dizzy by the goodness of our God.

And we have a one-month extension on our visas now, in hopes that the long term permit comes through by March 26.

And the CT scanner has a new bulb being installed too.  So when Daktari gets back to work tomorrow, (legally) he can really see what’s going on inside people’s heads. Light in the darkness.  Dazzling light.

Daktari Mother-In-Law

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When I look at my daughter, who says she is “freeee” years old in every sense of the word, I think of my mom and how she has loved me for all my thirty free years.

Our internet has been inoperable for a few days now so I will send my mom a birthday blog.  Although disconnected from the web and facetime and skype, I feel more connected to her when I see Annie and me together.

My mom pinned wings on my soul before I was born.  She was a flight attendant who set out to see the world and she met a handsome and humble former fighter pilot who was settling down for the domesticity of commercial flying.  She told him she was going to marry him and within six months they did. 

My mom sacrificially left her work aside in order to raise little girls at home.  But the wings were still there on her heart.  So she took us all around the world.  She taught us how to see the world. One day in Clayton County she helped out a lady who was walking home from prison.  My mom established mercy and justice in my heart.

My mom would give of herself to care for another, though it cost her dearly.  That, and she likes to dance.  She likes to have fun and water ski and laugh so loud she snorts.  My mom and her mom and my little girl, they all are passionate and wholehearted about what or who they care for.  They don’t do things half way.  You should hear Annie singing in the yard.  You should feel her tiny forceful running hug.

My mom’s mom was a World War II nurse in training who married a handsome and humble service man named Mr. Jolley who would take her dancing and stay faithful his whole life.  My mom found one just like that; minus the dancing.  My dad just took mom flying.  We have some purty lucky ladies in my family.  I pray Annie finds one like her daddy too.

And these women in my line all stand up for what they believe in.  Like it or not.  I don’t know if it’s Southern or just who we are, but at least I know my mom believed in me.  And she never asked me to be someone I was not even when I marched to the beat of my own drum.  Even when I was a typically bad attitude teenager, she didn’t give up on me and persisted in love.  Oh, mom I hope to be strong like you when Annie is stubborn like me.

Once in my year after college I went to Switzerland to try to figure out life before I moved to Africa (the first time).  What I figured out was that I missed home and my mom came to rescue me.  We dipped our little bread in a Swiss fondue in that Alpine village and went back home where everything was all right.

Back to that Georgia dirt in the garden where she stood like an angel in her nightgown among the white blooming spirea of our home as I drove out to meet my next destiny.   That Georgia dirt from which I grew up too.  Sometimes it is just clay but sometimes it is sweet Georgia brown dirt. You planted us with deep roots and a firm foundation.  And you taught me how to see the beauty that comes out of what was once just dirt.  Potential is what my mom looks for.

So last month she and my dad flew around the world to come visit me and my hero husband and their grandchildren.  My baby girl she says, is so much like me.  And we take her out on adventures too.  As we drive through Kenyan farm land, a man as black as the dirt he is hoeing stands bare chested in the field.  I think of Adam, of the ancestor of us all here in Africa.  And how many generations have treated him like the dirt from which God grew him.  But how my mom taught me to see the Image of God breathed into the Adam like life of that black man.  Even when history is wrong, even when the systems of generations is wrong, she helped me to stand tall for what is right.

My mom gives so much of herself to others.  Now I am starting to see it in the mirror and in Annie.  It’s her image poured into us.  She pinned the wings on my soul after all.   

Happy Birthday Mom.

Heart Reconstruction

Welcome back to Daktari Cases.  It’s been a few weeks since I’ve posted a case; not because there has been a dearth of interesting medicine, but really because there has been a surplus.  In addition to the usual holiday busyness (and we do have a less commercialized version of that here), there was a nationwide strike of healthcare workers in government institutions.  The details and causes of which I’ll omit (because I’m sure I don’t understand them).  The result was a very full hospital and outpatient department at Tenwek, which always runs at full capacity, over the past few weeks has approached “two-to-a-bed.”  With the New Year has come a settlement, and the reopening of the government hospitals, good for the patients and a breath of air for Tenwek.

So, I’ll start 2014 with a story.  The young lady’s name is Soi.  She is a 20 year-old woman from a village about 15 kilometers away who was married last year and is expecting her first child.  She finds herself getting tired and short of breath as she enters her 4th month, and when she asks her mother, she learns that this is a part of bearing a child.  Reassured, she continues to go about her day as a young wife and mother-to-be, working in the garden, carrying firewood, cooking and cleaning.  She lives beyond the reach of the electrical lines and water system, and beyond the reach of our prenatal care.  She carries on with life in the cool lush dirt-floor equatorial sun until one day she can’t walk to the river.  Then everyone notices that something is really wrong.  And they find a driver with a car and take her to Tenwek.

I meet her in casualty (the ER), and she is clearly in distress.  Her initial vital signs are a heart rate of 164, BP 94/68, RR 30, pulse oximetry 82% on room air.  These are her initial chest x-ray and electrocardiogram.  Her heart is beating faster than it can fill up with blood and she is going into heart failure.  We have to slow her heart down or this downward spiral will get out of control.  We have to decide to try to use medicine to slow her rate down, or to cardiovert her with the electric shock of a defibrillator (it’s not a good idea to shock a patient when you don’t know how long she’s been in this rhythm (foreshadowing: it could cause a stroke), not to mention that I don’t want to shock a mom and baby).  After some calling around, we locate some drugs that were left from the last cardiac surgery team at Tenwek that will ease her heart rate down, and give her some diuretics to pull off some of the fluid that has collected in her lungs.  This happens over the course of the first night, and so as the beautiful African equatorial sun rises on the next morning, we start to ask “Why?”

Nothing in my medical education to date gave me an explanation of why an otherwise healthy 20-year-old woman would have this tachyarrhythmia as she enters her second trimester.  But the first storm has passed, and it’s time to get to the thinking part.  As I repeat her exam, and now that her heart rate is down around 100, I can hear new sounds: the “whoosh-thump-whoo” of a mixed systolic and diastolic heart murmur.  We are blessed at Tenwek to have echocardiography capability and this is what her echo looked like.  It shows an extraordinarily scarred and narrowed mitral valve with just a teeny jet of blood flowing through it, along with a very large blood clot in her left atrium.  This is a picture of severe mitral valve stenosis from longstanding rheumatic heart disease.  RHD is a disease of poverty from repetitive bouts of untreated strep throat.  She has been living, miraculously, with this severe heart disease, likely since her childhood.  Yet in pregnancy, her blood volume increases by about 50%, to accommodate the baby.  The way her body changes to nurture the baby has overwhelmed her damaged heart.  And the strain on her body will accelerate over the next few weeks; she won’t survive pregnancy without open heart surgery, and having that large clot in her left atrium gives her the added risk of a major stroke.

This is one of those times when I’m thinking about what it would be like to work in a walk-in clinic in Tennessee: “Oh, you have a backache, I’m sorry; here are some painkillers.” or “Is that a sniffly nose?  Should I give you some antibiotics (editorial note: NO!)” 

Anyway, I snap out of that daydream after about 1.4 seconds and call in a lifeline: Dr. Russ White, cardiothoracic surgeon extraordinaire.  I am SO thankful to work in a place like Tenwek with such awesome colleagues.  Yes, he’s seen this before. Yes, it’s a tough case with a lot of risks no matter what we do.  And Yes, we can do open heart surgery, replace her valve, remove that dastardly blood clot, and give her a chance to live.  The downsides: there’s very little or no chance that the baby will survive being on cardiopulmonary bypass, and there’s a fair chance that clot will travel up into her brain during the operation and cause a stroke, and the family will likely have to go bankrupt to pay for the operation and ICU care (even though it’s the cheapest open heart surgery in Africa).  We have a few days to weigh the risks/benefits while we try to optimize her health, and the family involves their community in a fundraising drive and all-night prayer meetings. 

At this point, we decide to go ahead with the surgery, and this is the point in the story where you come in.  Because many of you are our supporters, and I told the hospital finance department that we will pay to make this surgery happen.  The community in their village gave, the family sacrificed greatly, and we filled in what was lacking.  To the Operating Room…

The procedure was long and complicated.  The valve was deeply scarred into the surround heart muscle, the clot was hardened and calcified, making it difficult to remove (but able to be removed intact).  The baby didn’t make it through the procedure, and there were times when the survival of the mother was in doubt.  But this time when they shocked her to restart her heart, it beat in a smooth, healthy, regular 88 beats per minute.  Several days of recovery later, she walked out of the hospital and caught a ride back to her village, with a story of a miracle.  Reminds me of a story that the prophet Ezekiel told
-->: “I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh.” (Ezekiel 26:36).  And to those of you who are our supporters, this is your story too.  Thank you for giving and praying, so that we can be here, and giving so that people like Soi can be healed.  A piece of her new heart comes from you.