out of orbit

Do you remember motorcycle carnival rides where all the motorcycles ride around and around making lots of noise and lots of little children feel so happy and tough at the same time?

Bomet, our town, looks about like that except the ride spun out of orbit and all the colorful pleather and chrome scattered everywhere.

Motorbike taxis are a main source of income for young men these days.  They are also the main source of orthopedic patients at the hospital.  Driving a car on the highway amongst them can feel like a bird flying in a swarm of bees.

Sometimes the wind here is so strong that I feel like the whole planet is being flung out of orbit on one of those carnival rides.  Or maybe it’s just on the far reaches of a seasonal eclipse around the sun.

You know, we are just right below the equator so when seasons change we are the reverse of you “northerners”  (Did you ever think you’d be called that? Don’t worry I would never call Georgians and Tennesseans and Alabamians by that northerner term usually affixed to a prefix).

Yes, things are often the reverse of “normal” here.  And we are in the southern half of the world now where People are people through people.  That is, Africa is to relationships as North America is to individualism.  Mother T. used to say “loneliness is the leprosy of the West”.  Poverty of relationships is indeed true poverty. 

So I am indeed blessed and thankful in this upside down place.  While nothing good comes in the news out of Africa these days let me tell you, people here are people because of relationships with people.  I can stay holed up in isolation of the different house we’ve just moved into and try to locate where the heck is the scotch tape in this place- or I can walk 50 yards (45 meters), to the shops and shake hands with 10 people who all ask how I’m doing, how is my home, how are my kids, and where am I going. 

I am thankful for the wildness of an African rain that commands such respect all humanity stops together in our tracks until she passes by.  I am thankful for the beauty of obtrusively orange honeysuckle vines climbing over an otherwise gray stone building. It’s like Tennessee orange wisteria, ya’ll.  And I’m thankful for the stark rainbow of colors that African women wear like a kaleidoscope of beautiful black, brown, and boldness.  I like to see their reactions when I try to wear some of that funkytown.  We could say it’s good for building relationships perhaps.

So wild and out of control, that’s kinda what you hear about Africa isn’t it?  The idol of control is not worshipped here anyways.  Maybe that’s why I like it so much.  Maybe I find comfort in the ambiguity of plans as long as everyone is happy.

Can I ask you a favor?  Will you speak kindly and sincerely to someone in the store or on your street today?  Can you alleviate the loneliness of your neighbor by just showing up in your humanness too?  It might be off your normal orbit, but that could be truly a beautiful and wild ride.

To our readers, please pray for our friend Kent Brantley, a physician living and working in Liberia amidst the Ebola virus outbreak.  He has contracted this deadly virus.  He is a husband and father.

These are stories of tragedies.

Joseph was a young man of 28, a husband and father as well.  He suffered a motorcycle accident and a fractured femur (long bone in your thigh), an everyday story here.  His leg got infected, and when we first saw him, he was hanging on to life by a thin thread.

"There is a stat consult from ortho" I heard walking through the ICU on a Thursday morning.  And then he lost his pulse.  We coded him intermittently for about four hours, buffering in boluses the overwhelming death that was coming.  This young man was a fighter, and despite the failure of almost all his organs, he pulled through the day.

Like clockwork, the organs that failed him returned: he awoke (brain) started breathing on his own (lungs) maintaining his blood pressure (heart) making urine (kidneys) and blood cells (bone marrow).  It was a marvel of the created human body, like a re-do Garden of Eden.  We took this picture to illustrate this moment.

Because we knew he would never walk, the femur was gone, we found this wheelchair, complete with the hand crank, and the tires to handle the African village life.  We put it together in anticipation.

But this isn't the Garden and I warned you that these are stories of tragedies.  After four weeks in the ICU, Joseph was unable to get enough nutrition to rebuild his strength.  Over the course of about a week he wasted away, the will was gone, or was it his strength?  He died on my weekend off.






This is a man named Richard, and his children (all 7 of them).  The setting for this story is about 2 hours' drive off the paved road, a road I got to take because of the work that Katie does with a women's group called Tabitha Ministry.  The backstory is one that I'm all-too-familiar-with from Tenwek.  His wife suffered complications in pregnancy and died giving birth to these twins 2 years ago.  He is a widower, and with his community and with his mother-in-law he cares for these children.




We got invited to a ceremony to dedicate a house given to him by some donors from the US.  Mud and sticks and tin roof and all.  That's me (the white guy) in a somewhat-ridiculous African shirt that the Tabitha ladies gave to me.

The weight of tragedy that we see in everyday life at the hospital is the greatest challenge of living here.  Often I wonder, "what's going to happen to these people?" and without an answer I move on to the next patient in line.  Here's a community, a church, that has joined together to support this man in his tragedy.  We have a great deal to learn about community, about suffering, and endurance, and about hoping in the resurrection.  And these are our teachers.




And so, when we don't know what to do, or what to say, we speak the Good News, that God rescues sinners from death.  We treat the sick with compassion and thus fight an insurrection against the powers of this world: sickness and suffering,  and we plant a little bit of that news in this African soil.

a view from driving by

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 Hiking up a dirt road with motorbikes whizzing by, their loud music flattens out with space.  So to, time and distance make my stories feel flattened like that.  They were too sharp, too dangerous to publish earlier.  So today we have invited some guest bloggers to give you a glimpse of what it looks like to visit Daktari life.  Here's what they have to say:

A few years ago at our beloved home church in Birmingham, Alabama we had the privilege of meeting Mike and Katie Davis—connecting immediately because we both have strong family ties to Kingston, Tennessee—we worshipped together, celebrated welcoming Annie to the world and were sad when they moved to Jonesboro, TN but kept in touch as we could via Facebook.  As our family made a big decision last January to spend a month in Kenya, we reached out to Katie to ask for advice, guidance and prayers as we navigated this mission trip with 3 teenage girls.  Katie was 100% joyous in her response…in fact, her very response was “My first time to Africa was when I was 13, just be ready for them to fall in love with this place!”  Midway through our trip, our family descended into Tenwek—smack on top of this amazing, dear family.  Mike is changing lives, touching families and stretching his heart and brain to negotiate the medical needs, wants, challenges and successes at Tenwek Hospital.  Katie is changing lives, touching families and stretching her heart and brain to negotiate cross cultural dynamics, kids’ lives and now…our unwieldy family.  With grace, calm and welcome, the Davis family absorbed us into their mission lives here.  I’ve posted some on facebook (Rachel Estes)about this rhythm but want to share some here.  To a family with constantly hungry teenagers, I’m noticing Mike and Katie anticipate, savor and celebrate food.  Each bit of food is deeply and intimately connected to someone’s life here.  Joseph is selling eggs to have funds for an orphanage…Amos walks two hours to sell carrots on Sundays for his school fees…every piece of food is a story.  That translates into this family.  If you finish all the eggs on Friday, you need to wait until Tuesday for Joseph to come…what a concept for our American-paced family.  Meals are about relationships and connecting…savored and enjoyed.  If there is something from this whole mission that we bring home to our house, I pray it will be this anticipating, savoring and celebrating of food.  I’m watching Katie connect in the community through ministries that have her driving far away on bumpy dirt roads…bringing the Bible story (yes, the WHOLE BIBLE) to a gathering of women on a Saturday morning-she helps connect the neighborhood kids with activities, she weaves people together to strengthen the community and she does it with beauty and God’s love.  Driving us out to an orphanage today, Katie spent her own time and energy making sure that our family had a very Kenyan experience.  Mike comes home for lunch with prayers of joy and of sorrow for those whom he serves at the hospital.  He knows their stories, their families and despite many sad moments, he sees miracles. 

Mike and Katie, Josiah and Annie are having their hearts broken and widened by all they are experiencing here…they are changing lives…those they serve and their own.  What a blessing for this community and all future communities in which they serve this family will bring.  Below are three reflections from my daughters:

We went to the hospital to check out what is going on there, there were many sick people there and we saw all the doctors and nurses working diligently to help each person.  Every day Mike comes home and tells us what happy, crazy, or sad thing that happened that day. While Mike is working day AND night to help the residents of Tenwek hospital, Katie is working to keep the kids happy. Yesterday the whole neighborhood was over at her house and she managed to keep all the kids engaged (which did not look easy!) and she seemed calm the whole time. They both work really hard at their VERY different demanding jobs and still come home to their kids with a big smile on their face.

-       Lydia Estes (12)

I have loved getting the amazing opportunity to spend time here in Tenwek. Learning their amazing way of life, from their great relationships with their community, to their always-helping hearts and hands. I have loved getting to help many parts of Kenya, so it was fun to see another side of Kenya in a more day-to-day lifestyle. It was really cool just to see what its like to live in Kenya. I am truly blessed to have gotten this experience with this great family.

-        Isabel Estes (14)

Today my family and I went to an orphanage in rural Bomet. When we first got there some of the kids were lined up to shake our hands and greet us. We then got a tour of the place and almost everywhere you looked you had an amazing view of the land and mountains. My two sisters and I each shared a scripture verse with the kids. After all this we went outside and played with them for almost two hours. I played volleyball with some of the older kids which was really fun while my parents were turning the jumprope for some of the younger kids. We then went down the road a ways and had chai with the pastor who ran the orphanage and his family and we talked about the joys and challenges of running an orphanage. He then invited us to go back tomorrow and play volleyball at the high school where he taught.

                                                              -      Virginia Estes (16)

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.