Habari rafiki,

June 26, 2011

Leland assures me that the pleural of rafiki (friend in Swahili) is rafiki (friends). I asked if he was sure like a neurosurgeon (sometimes wrong but never in doubt) or sure like Leland. He assured me that it was the latter. I’ll confirm it with our Swahili teacher, Edward Amalu, at tomorrow’s lesson—not that I doubt Leland or anything….

We decided we both needed help in talking with the patients more effectively, so Leland arranged for private lessons 2 evenings per week. Each time, we start with Leland’s questions—how do we ask if the child is vomiting, passing stool, etc. For that reason, we don’t have the ability to have pleasant dinner conversation—but we can find out important information about the patients. We’ll work on the more socially acceptable dialogue later. In the process, Edward tells us fascinating things about the Kenyan culture and customs. It is fun to pick up a few recognizable words as the patients or staff talk around us. And the staff seem to be very appreciative of our efforts to learn Swahili—though my pitiful attempts at pronunciation still send them into peals of laughter.

An amazing thing happened at our church this past week. Four years ago, the church started a construction project on the existing church building and moved into a tent. The tent was to have been used for 6-9 months. As I explained in an earlier post, some renegade council members not only stopped construction but bribed the authorities to rescind the construction permit and had the caretaker arrested at gunpoint. On this past Thursday, the pastor was told he could finish construction—many church members worked feverishly until the early hours this morning (Sunday) to ready the church for worship today. Late last evening, a ferocious storm moved through Nairobi and shredded the tent roof, making it an even “hole-ier” place. We worshiped this morning for the first time in the new building—but Pastor Sam led us into the tent at the close of the service, and with tears in his eyes, thanked God for providing a dry place of worship, not for 9 months, but for 4 years. He spoke about Elijah and the widow of Sidon during the famine—who had flour and oil for only one cake—but God made it last “until the rain came.”

Work at the hospital has been emotionally draining this past month. Thursday a week ago, we had a week old baby boy brought to OPD with a temperature of 35.4 degrees (normal is 37), a slow heart beat, abnormal respirations, a high myelomeningocele and severe hydrocephalus. I asked the nurses to quickly get a heater and start an IV so that we could stabilize this baby who probably had a neonatal infection. After 10 minutes and no heater and no IV, I looked to see what they were doing and they were cleaning out the infamous supply drawer that has been the bane of my existence since we arrived last September. Now, I do appreciate that they recognized the need for organization—but I had to seriously question their timing and prioritization. I decided that we wouldn’t get very far in OPD so carried the baby to the nursery where he was stabilized. Later that very afternoon, another baby, 9 day old Agnes, was brought by her mother from Lodwar (“veddy far”) which is in northwestern Kenya and is quite remote. The baby’s temperature was 41, and a nauseating smell permeated the room when she arrived. She was covered with dried birth fluids and stool. I quickly cleaned her and drew fluid from her head for analysis—it was pure pus. She had the most horribly infected myelomeningocele that I’ve yet seen—leaking foul-smelling fluid. It was obvious that she could not survive. After Pastor Mercy and I told the baby’s mother, she disappeared. A little later, the OPD nurse came to me and said that the baby was gasping. I went down to find this baby girl alone in the exam room. I could not stand the thought of this child dying alone, so I held her in my arms until she died. Afterward, my lab coat was saturated with the infected spinal fluid. Mercy saw great benefit in having the baby brought to us to die—the custom of the people of this baby’s tribe is to put dead bodies out in the bush for the hyenas. By bringing the baby to us, we had the child buried in our church cemetery in Kijabe.

Several days later, a 6 year old very malnourished boy was brought to OPD with pus draining from a hole in his scalp. It had been draining for over a year. Humphrey, our pediatric neurosurgery fellow, took the boy to theatre to drain the abcess—and it grew every kind of bacteria as well as amoebas. The child will be on 4 antibiotics for at least a month—if he survives. Unlike the US, there is no Child Protection Service to call—the most that might be done is to have his mother put in jail for a few days—which would accomplish nothing. So, if we can heal this boy, he will return to his home. So, what is the right thing to do? These are the questions we face every day.

Habari again—it is one week later—this week I had little time or energy to complete the posting I began above. Another eventful week—the 6 year old boy mentioned above developed very severe pneumonia despite 4 antibiotics. Of course, we had the usual problems of having the nurses change times that the antibiotics were given (one was supposed to be every 6 hours; they didn’t like that so they gave it at 6am, 10 am, 6 pm and 10 pm). The IV access was poor so he didn’t get all the doses no matter when they would have been given. His white blood count was 31,000 (normal is 4.5-11,000). When Mercy and I talked with his aunt, she called his father who said to bring the boy home immediately so he would die at home. So, we took off the oxygen and removed his IVs and sent him home on a matatu (about a 12 hour journey). It was hard for me to remove the oxygen, though after talking with our pediatrician, Dan Entwhistle, I agreed with him that the child was not likely to suffer more off the oxygen than he was with it.

I very often have trouble deciding what to share in the blog. I don’t mean to demean or denigrate the Kenyan staff—many are quite dedicated to their professions and really feel that their work is a ministry. But it is hard to see poor quality nursing care given and to not address the issues with those responsible. We have routinely had orders not carried out, medications not given or given incorrectly, dressings not done properly. To be fair, though, each nurse takes care of 8-15 patients; these are very sick children. I’m not sure how well I’d be able to do under those circumstances.

Two vignettes:

A baby with spina bifida and hydrocephalus spent a month in BKKH having various complications. Finally she was ready to go home. During the hospitalization, I remarked about how many visitors her mum had—often several friends/relatives per day—it was unusual because many of the mums have no visitors until they are ready to go home—many have no visitors at all. The day after the baby was discharged, she was still in the bed and her mother was in tears. The mum and baby had been disowned by her entire family—they did not want a disabled child in the house—and not one of her relatives wanted to take responsibility for paying her bill. Unfortunately, this is not a rare circumstance. Leland and I paid part of her bill; BKKH forgave part of it (though BKKH will pay the amount of the entire bill to Kijabe Hospital). Your donations go toward paying the bills of these babies.

You may remember the saga of the disappearing infrared thermometer. One morning last month, a security guard and one of the experienced neuro nurses appeared in front of me—the guard was holding the missing infrared thermometer. I was overjoyed and said something about rejoicing for what was lost had been found. It took me a few minutes to realize that he had found it in her purse—the guards routinely search the belongings of staff members of the hospital as they leave work because there is so much theft of hospital property. The nurse said she had used it for mobile clinics—in later versions, she said that the in-charge nurse had given it to her (clearly not true), that each nurse had one—her testimony changed even during her disciplinary hearing. The committee was unconvinced—or rather, they were convinced of her guilt so gave her the option of resigning (and retaining her benefits) or being discharged. After she had continued to work for 2 more weeks, she finally refused to resign so was dismissed. As painful as this incident was, it was very important for the nursing staff to see that there are consequences to theft, lying, etc. What was particularly upsetting, though, was learning that most if not all of the other nurses knew that she had it for the two months that it was missing. Not only did no one turn it in, or report her, but also no one thought enough of the nurse to encourage her to return it anonymously so that she could retain her job.

We are enjoying the winter here—July is like January in Wisconsin (well, relatively speaking). Even though we are just 2 degrees south of the equator, we see a real difference in weather. The afternoon sun no longer streams in the living room window; when we sit out on the balcony we almost always need sweaters. The long rains are past; we still have rain occasionally but it is often cloudy and foggy. Since there is no heat in the hospital, the staff wear parkas, hats, and scarfs. Being from Wisconsin most recently, we wear regular clothes under our labcoats, but I do have to admit that on foggy days, my hands never get warm.

Last Friday marked the beginning of our eleventh month here—time has flown. We feel much more settled here—and are feeling that we belong here in Kijabe. Making friends is still a slow process but our growing involvement with the Nairobi International Lutheran Church has helped us feel at home in Kenya. Leland has been asked to preach two sermons during the pastor’s leave. We were “greeters” this morning and both of us have been scheduled to read the scripture.

If anyone would like to see a presentation of a video about our work in Kijabe that Leland and I made at Luther Memorial Churchon May 1, please go to http://gallery.me.com/leeapowell#100069

Here is a link to a BKKH newsletter: https://app.e2ma.net/app/view:Join/signupId:1418122/accId:1408519

Thank you all for your prayers. It has been so good to hear from friends—some who were “lost to follow up” for many years. We pray that God will be glorified in all that we do—I am not just talking about our work here in Kijabe, but in the lives that all of you lead as well. I am increasingly convinced that it is not so important what work we do; what is important is that we follow our Savior so that His work is done here on earth.

Take care, God bless.

Susan

Habari Friends,

It is Saturday; I am taking a few minutes to write while the clothes are drying. We have a renewable energy clothes dryer—it is called a clothesline. Because it is so windy today, the clothes dry in about 75 minutes. I have discovered that “permanent press” doesn’t work well without an automatic dryer…amazing the things we Westerners take for granted.

Although it is still “the rainy season,” we have mostly sunny days with rain sometimes at night. There is great concern in Kenya because the “long rains” during April and May have not delivered the rainfall that was expected. Many are predicting continued food shortages and rising prices for food and gas. Food prices for Kenyan staples (maize flour, milk, rice, potatoes) have risen between 15 and 33% since January. Many of our patients live on the edge of starvation in the best of times; we fear that we’ll see even more malnourished children and mums.

The rise in the cost of living is causing anxiety among the Kenyan politicians; they fear that people will become desperate—and politicians aren’t very good at controlling desperate people. Here in Kijabe we are not isolated from this—two weeks ago an armed gang of men invaded the Casualty (Emergency) Department, beat the security guard, and robbed the people there (staff and patients). All the hospital staff were quite shaken by that—it has never happened before at Kijabe Hospital. Here in our Quadplex, the contractors have installed security gates at the two entrances to the building. However, there is no lock on either gate as yet—and from the way the gates are constructed, I’m not sure anything other than a padlock will work—so we’ll either be locked in or out. Not ideal. Maybe the appearance of the gates will be a deterrent. It will also deter visitors—there is no intercom to alert us that someone wants to come up. So some yelling may be in order.

In April, we started worshiping at Nairobi International Lutheran Church. It is a wonderful group of people—most are from countries in Africa. Sam Wolfe, a pastor who worked for 30 years in Tanzania and 7 years in Frankfurt, was called to minister to the church. On Good Friday, he preached about the Last Supper, when Jesus told the disciples that one of them would betray him—and each one asked, “Is it I, Lord?” Pastor Wolfe then applied that to us today—am I the one who passes by a hungry child, am I the one who fails to visit the sick and those in prison, am I the one who doesn’t clothe the poor? His Easter sermon was from Mark 16: 1-8 where the women discovered the empty tomb and left “trembling and bewildered.” We tend to see the joy of the Easter story and forget how terrifying the empty tomb was to the women and the disciples. While we are in the midst of circumstances, they can cause us to tremble. In hindsight, we can see God’s hand leading us through those times.

Whenever my kids were little, if we were lost or if things were a little unsettling, I’d tell them we were having an adventure. Well, we had an adventure this month. On two occasions the week before Palm Sunday, I’d awakened during the night with a gripping (really excruciating) pain that almost made me pass out both nights—but the pain lasted only 10-15 minutes, so I just went back to sleep. On Palm Sunday, I awoke with right upper quadrant abdominal aching pain that grew during the day—by midnight, we decided to go to Casualty where the Australian surgeon, Peter Bird, met me, diagnosed cholecystitis (gall bladder attack) and gave me a shot of pethidine (Demerol in the States) that caused me to not remember the walk back to the Quadplex (LOVELY medicine). Early the next morning I had an ultrasound confirming the diagnosis and by 10:30 am was in theatre (alas, not acting) having a laparascopic cholecystectomy. Much to the nurses’ amazement, I went home that evening (Kenyans aren’t acquainted with same day surgery). The bill for the entire adventure was $500. Paying the bill was yet another adventure; they lost my “file” (medical record) twice in the same day.

Avoiding an “open” operation allowed us to leave for the States on 4/27/11 as planned. We spent 2 days of rest with our dear friends, Deb and Barry McLeish in Madison, then worshipped on Cantata Sunday at Luther Memorial (fantastic music with organ, strings, brass, and tympany). Leland and I gave a presentation in the adult Sunday school—I realized afterward that I’d just given a missionary talk at my church just like the lady who inspired me as a child--Miss Emma Snyder, a missionary nurse who worked in the 1950’s with lepers in Nigeria! That was a “wow” for me. The rest of the week was spent in Chicago—we rested and visited with my family, all of whom were present for Michael and Marisa’s engagement party hosted by her parents.

Leland spent some time reviewing the operations done since we have come to Kijabe and BKKH. In the first 7 months, 869 pediatric neurosurgical cases were done with an average of 124/month. Two thirds of the cases are related to spina bifida and hydrocephalus; the other third is a mixture of tumors (brain and spinal cord), encephaloceles, lipomyelomeningoceles and others. Our work is exceeding the amount budgeted by BKKH by about $10,000/month. While in Chicago, we met with Scott Ward of the Medtronic Foundation who visited us in Kijabe in November and has been instrumental in arranging funding of a wireless internet system to be installed in Kijabe in June as well as that for our neurosurgery fellow, Humphrey Okechi. Scott calculated that each operation and hospitalization costs an average of $228. Remarkably, the Sunday School children of Luther Memorial Church dedicated their weekly offerings for this past year to the children of BKKH—they raised $228.42. Others who have been incredibly generous have been nurses and staff of American Family Children’s Hospital OR who have donated proceeds from “Dog Bones For CAT Scans”, gathered outdated medical supplies, and given sacrificially from personal funds. Luther Memorial Foundation awarded the Neurosurgery Patient Subsidy Fund of BKKH a generous grant. We feel quite grateful to all who support the children and are praying for God’s guidance in finding ways to make up the monthly deficit.

We were blessed with visitors this past month. Sandi Lam, who just completed her pediatric neurosurgery fellowship at Children’s in Pittsburgh, spent 4 days here and did 17 operations. John and Maggie Tarpley, close longtime friends of Leland’s, visited Kijabe to facilitate an international outreach option for general surgery residents at Vanderbilt. Tom Steineke and the physican’s assistant who works with him, Peter Parcells, covered for us during our absence—though we were able to visit with them briefly the day they arrived (the same day we left). We cannot describe how wonderful it is for us visit here with people from the States. I have come to realize how important it is for people to come here and see for themselves not only what we do here, but the patients and families that we treat. Most people who visit and see the needs have described that their lives have been changed by what they see here. So, we invite people to come visit us—but, expect your life to be changed.

People have asked if it was hard to come back—and, yes, it was hard for me to leave my children. My granddaughter really doesn’t understand who IS this lady who looks a little like her mom and is called “Shosho”? But when we arrived back in Kijabe, both Leland and I felt that we had come home. We are energized by our work here. We feel that we are exactly where God has led us. In my devotions each morning, I read a portion of M. Craig Barnes’ An Extravagant Mercy. In his essay on Mark 1: 16-20, he talks about how the story of the Bible has been about people on the move—whether that means a change in relationships, job, aging, or relocating. He says, “…the point of following Jesus [is] not to get to a new place. The point of following Jesus is to follow Jesus. Along the way, we come to understand that our identity is found not in where we are but in the Savior who is leading the way.”

Thank you for your prayers, your support, your friendship.

Susan

Jambo! (yet another way of saying hello)

On St. Patrick’s Day, March 17, 2011, the Long Rains began. It was a day of tremendous excitement among the hospital staff because it meant that the crops just planted will survive. There were torrential downpours (which meant soggy ceilings in our third floor apartment—but that’s another story)—5” in 2 hours…dirt rivers the color of Burnt Sienna (always my favorite crayon) flowing downhill. The silence that night—the complete ABSENCE of wind—was stunning. We could hardly sleep for the silence. J I had expected that the long rains would be like living in Portland in January—rain all day every day. That isn’t the case at all—there have been days with an hour or two of rather light rain, sunny days without any rain, and days like today which are overcast most of the day with occasional showers. But, my, how green is our valley! The tan/brown parched earth has been transformed to lush green. I hope the pictures I’ve included give you some idea of the beauty.

It is hard to convey how different life is here. Take road construction, for instance. You all know what that means in the US—heavy machinery, hard hats, safety signs. Here, everything is done by hand—men push wheelbarrows up and down the hill to bring the medium sized rocks that form the base covering for the old dirt road. Then, they cover that layer with load after load of red dirt. Finally, the cars driving over the road pack it down—which means that now that the rains have come, the middle of the one lane is a muddy mire—we have some missionaries who cannot negotiate the new road even with 4-wheel drive SUVs.

Another group of workers dug deep trenches (about 3 feet deep) so that telephone wire could be laid to the houses further down the hill from the hospital—the physicians living there had to rely on cell phones to call the hospital. The reason that the lines couldn’t be strung on the existing telephone poles is that the wire had repeatedly been stolen for the copper. In the course of digging the trench, rocks and other assorted things were unearthed. One day we saw an ovoid “rock”—which on closer inspection was a human skull. We named him Yorick and were a bit concerned until the medical director informed us that we live on a former cemetery so that bones were always being discovered during the course of construction of the Quadplex. He suggested we just rebury the skull. Alas, poor Yorick disappeared before we could reinter him. Gone too soon to have known him well….

I’ve mentioned before about some of the hard ethical dilemmas that we have here—Leland asked that I give you several vignettes:

1. A 6 day old boy came to OPD yesterday from East Pokot—a very poor area in northwest Kenya. His father was older and had moderate tremor—one side worse than the other. The baby was the eleventh child and had had no medical attention since birth. I don’t think I’ve ever seen a dirtier baby in my life—the clothes were covered with dried stool and urine, he had never been bathed since birth. He had a huge myelomeningocele that was infected. He had no movement below his hips and had a very small head. As I examined him and tried cleaning his back, I realized that he had significant apneas—pauses in breathing—during which his heart rate dropped precipitously and he became ashen. After a pause, he would gasp and then start to cry. Leland examined the baby and saw that his prognosis was rather grim—if his breathing and heart rate could be stabilized, he could have an operation to close the spina bifida, then probably a shunt to treat the developing hydrocephalus. However, the chance that he had the beginning of a bad infection because of the open spinal cord was huge—which would be likely to infect his brain. Also, treating the spina bifida would require that the family do good wound care, observe him for complications (shunt malfunction, skin ulcers) as well as do catheterization to help him urinate regularly. We consulted with Pastor Mercy and she had real concerns that this family would not be able to handle all these medical issues. She recommended though that we give the family the choice of treating the baby or taking him home. That discussion (always a hard one) took place with translation from English to Swahili to the local language of the Pokot. The father seemed to vacillate—but the mother said that if the baby couldn’t be normal, she wanted to take him home without surgery—and that is what they did.

2. A 50 year old man rode via matatu for several hours and presented to Casualty (Emergency Department in British/Kenyan English) with a chronic subdural hematoma causing severe headaches and an impressive right-sided weakness. He had no money to pay for an operation. There were no beds available in the hospital. With a simple operation, he could resume a normal life—without one he would be incapacitated. The operation and hospitalization would cost 26,400 Kenyan shillings--$330 in American dollars (can you imagine how far $330 would go in the US?). One of our wonderful OPD nurses, Jane Mutinda, offered to house him and his wife with her family overnight until a bed became available. Leland paid for his operation and hospitalization—he had a remarkable recovery and is a very happy and grateful man.

3. In December, an 18 year old young man had resection of a medulloblastoma—a brain cancer. His family was able to pay for his surgery and hospitalization. Afterward, he needed an MRI of his spine to make sure he had no sign of cancer there. He could afford only the cervical MRI—we made arrangements to pay for the rest of the spine MRI through funds from BKKH. The MRI was clear of any signs of cancer. But, he needed radiation therapy to make sure the cancer cells were killed. Arrangements were begun to send him to the University of Wisconsin—but then we became aware of a facility in Nairobi which could do the radiation therapy (the usual place, Kenyatta National Hospital has a waiting list of 400 patients—people usually die before they can start therapy). The cost for 6 weeks of daily radiation treatments for this bright young man was KSh 200,000 or $2500. Leland and I felt so strongly that he should have the therapy (which is potentially curative) that we split the cost from our personal funds. The young man just completed the 6 week course and has started back to school.

These are just a few of the many dilemmas we encounter here—whether to treat babies with severe brain damage with expensive medicines and long hospitalizations, whether we should try treating children with massive hydrocephalus, malnutrition, and scalp bedsores, whether children with brain tumors should undergo the risk of surgery (with no ability to do scans here at Kijabe) or face death from the tumor without surgery.

Added to these often heart-wrenching concerns, we daily have incidents where ordered meds (including antibiotics for severe spinal fluid infections) are not given—or are charted as given but have not been, lab tests are not done or the results have been lost, equipment goes “missing” (the donated infrared thermometer that I brought from UW “walked off” last Friday). From time to time we have no running water anywhere in the hospital--washing hands between procedures on patients can be an adventure. It can sometimes be difficult to maintain a cheerful demeanor during the course of the day.

Last month we were informed that the “nurses” were very upset with us; we were given a list of our infractions. Both Leland and I were a bit surprised—we had seen some real improvements in our relationships with the nurses on morning rounds. Many of the formerly reticent nurses had started to actively participate in sharing information about the mums and babies—some had started to ask good questions and were showing interest in learning new techniques. So, we did some reality checking—talked to several Kenyans, other missionaries, and each other—also spent a good amount of time in prayer. We each decided that, despite what had been shared with us, we felt like we were heading in the right direction with our relationships with nurses and other staff in the hospital. We realize that building relationships takes time, and we are committed to doing that over the next 4-5 years. We also realize that cultural differences interfere with understanding—my doing the ventricular taps to be more efficient was seen as being critical of the nurses’ abilities. Our writing daily progress notes was seen as critical of the nurses’ charting. There is real reluctance among some (but not all) Kenyans to directly share information and concerns—we tend to be direct which is seen as quite rude. I feel very confident that we will sort these difficulties out—already the discussions that we’ve initiated with the unhappy nurses have soothed some of the hurt feelings. But, I also became aware of a very important truth. We did not come here to please people. We came because we both felt called by God—we not only want to be obedient to that call, but out of the gratitude we have for God’s love and mercy toward us, we want others to see Christ through us. We are here to bring glory to God, so that through us, people see, come to know and love God.

So, I want you all to know that we are very happy here; we feel an incredible sense of peace. We don’t downplay the difficulties but also don’t dwell on them. We are not discouraged. We look forward to continuing to get to know the Kenyan staff; we love working with the patients and families. Most of all, it is supreme joy to be serving God in this place every day.

We ask that you continue to pray for us—for wisdom, patience, cheerfulness, discernment. Thank you for your prayers and encouragement.

We have confirmation from Paul Buford, the bookkeeper for Bethany Kids, that the Neurosurgery Patient Subsidy Fund has been established. To access the website, go to www.bethanykids.org. If anyone feels led to contribute specifically toward care of indigent patients, you can designate gifts to that fund under “Other.”

Take care, God bless.

Susan

Habari Friends,

Impunity: exemption from punishment or loss or escape from fines…the impossibility of bringing the perpetrators of violations to account—whether in criminal, civil, administrative or disciplinary proceedings. (Wikipedia) In other words, No Consequences.

Impunity…a central word here in Kenya. One sees that word on nearly every page in the daily newspaper; impunity is rampant not only in high administrative circles but also among interactions with nurses on the ward. Several weeks ago, the Kenyan public was bombarded with the video of policemen summarily executing alleged criminals lying in surrender on Lang’ata Road in Nairobi (just hours before we drove along the same road). Just this week, a child in respiratory distress was ordered to have a chest xray at 11:45 am. The order was not “noted and handed over” until 9pm that day—the child did not have the xray until the next morning. Neither of these incidents is unusual. Neither provokes sustained or generalized outrage among the people here. It was very disturbing, in fact, to read so many letters to the editor praising the action of the police who shot the men lying face down on the tarmac through the head. I’m told that so many people have been brutalized by gangs of men who have broken into their homes, raped their wives and daughters and have escaped—with impunity. So people accept the brutality of the police, having no confidence in the justice of the courts. What they don’t think about is the possibility that one of them will be judged and executed by the police in a circumstance of mistaken identity. There is a move afoot to arm the traffic police—which also has prompted supportive letters to the editor. Yet nearly every time we drive, we see or hear of people who have been pulled over by the traffic police who have demanded bribes to avoid fines. One nurse anesthetist described refusing twice to pay bribes—she and her husband lost two days of work going to court to fight the tickets they were given (for speeding or not having the appropriate paperwork in the car)—both times having to pay a fine imposed by a court that supports the police. I drove to Nairobi on Thursday while Leland operated at Kijabe—though driving here is daunting, I am much more afraid of being stopped by the police checkpoints than of having a matatu plow into me—at least I have some control of where my car is on the road—I have no control over those policemen and their nightsticks. But God heard my cry, and spared me from being stopped. Quite honestly, that was serious prayer being sent up for two hours.

The nurses at Kijabe Hospital are very upset because the pay scale has been reconfigured to make it more “equitable.” Those nurses who have been working the longest have seen a decrease in their base pay with “allowances” for housing, education, etc that at least equal what the pay had been before restructuring. However, many of the longterm nurses are threatening to quit because they say they have taken a substantial cut in pay. It was explained to me by the Matron that the base pay is what banks consider when a person applies for a loan; it is also the basis for calculation of the pensions. Until this week, I had no idea how many Kenyans live on loaned money—the debts they accumulate are astounding—and are spread among family, friends, the hospital, and banks. It is also remarkable how freely hospital workers and patients ask us for loans—about two weeks ago, a patient’s mom stopped me in the hallway saying that her child had a cardiac defect and needed Ksh 14,000 for surgery—and could I give her that. When I said I could not give her the money, she looked incredulous and, laughing, asked, “Why not?” Quite honestly, the verse: “Ask and you shall receive” came to mind. There is a totally different philosophy here about asking for money, help, etc—and I’m coming to understand that people often don’t expect someone to give all that they’ve asked for—but the asker feels that he/she has nothing to lose by asking. Quite honestly, it takes a good deal of cultural awareness, understanding and wisdom to know what to do with all the requests for money, loans. Leland and I have responded to several requests—but obviously cannot help everyone who asks. It also can be quite disruptive to the local economy if missionaries overpay their help—it was explained that when that occurs, the Kenyans can’t afford to hire people to clean, cook, watch their children while they work.

We are again at Malu—the place of refuge and rest that we have found east of Lake Naivasha. There was a lull in workload following the holidays but the past two weeks we have again been inundated with patients—we had three mattresses on the floor in OPD and took out beds in one area so that more mattresses could be placed on the floor (we had one patient in “bed 11X” meaning 11 Extra). We had 8 emergency admissions last Friday and 4 new babies with spina bifida admitted on Tuesday. For the past two weeks, every patient who has arrived and is not emergent has been sent home (sometimes a 6-8 hour matatu ride) and rescheduled as an elective admission —including babies with hydrocephalus who are symptomatic but still feeding well. We had wondered if we had scheduled our R&R a bit too early, but after the past two weeks, we both needed the break. So here I sit on the wooden porch floor, writing and looking up at Tanga, the Rhodesian Ridgeback who alternates sleeping on the floor with chomping noisily on her toenails. The herd of horses just grazed through the “front yard.”

For the first time since we have been here, I have seen Leland grow angry with circumstances in the hospital as well as concerning the new apartment. Last week, during a craniotomy, he requested the microscissors to cut the arachnoid lining of the brain. Each of the three pairs of scissors that he brought had bent tips (from mishandling) and could not be used. Two of three cautery wires had damaged insulation, causing them to short out. The endoscope camera also malfunctioned and several cases of endoscopic third ventriculotomies had to be converted to shunts. Then, in our new apartment, an inspection by the architect, the contractor, the BKKH administrator (who will take “ownership” of the building once it is officially “done”) and the inhabitants revealed some deficiencies—like electric plugs that did not work, wet spots in the ceiling from defective roofing, pipes under the sink that leaked, windows with huge gaps allowing red dust to blow through the apartment). I’m afraid that our priorities (leaks, plugs,) are quite different from theirs (painting, smooth doors); I think this is one of those times where we will look at each other, shrug, and say, “TIA.” (This is Africa). We have requested that the resident from Vanderbilt who arrives next week bring more duct tape and weatherstripping to keep out the wind and dust.

In our work here, we continue to struggle with how best to treat the children with complex congenital brain deformities or those children who arrive at the OPD barely clinging to life. A 2 year old girl, Jebet, arrived in OPD from northwestern Kenya about a month ago with a history of one week of vomiting and diarrhea. She was severely dehydrated with a temperature of 41.7 C (107 F), heart rate of 200, respiratory rate of 68 and having a seizure of undetermined duration. She was blue; I left her to get oxygen (there was no one in OPD to help me); the tubing wasn’t available—once it was found, it wouldn’t fit on the adapter to the oxygen tank—which turned out to be empty anyway. Because she had had a shunt operation in November, I quickly aspirated fluid from her shunt for analysis and to prove that her shunt was working (her pupils were pinpoint so it didn’t look like a shunt malfunction problem). Then I called the pediatric service and they assumed management. However, because of her severe and prolonged dehydration, she clotted a major vein in her brain and sustained substantial brain damage. Leland examined her a few days later; she was still febrile and her condition was very grave. He recommended not aggressively treating her. However, she was aggressively treated and just yesterday, I was asked to explain to her very young and very poor mother why we could not “fix” Jebet. Once again, Pastor Mercy and I talked with her, explained that Jebet could not see, probably would never walk and talk. After the explanation, the mother asked if the paperwork could be completed that day so that she could pay the bill and take Jebet home—the complicating factor is that Jebet’s father told his wife, “Don’t bring her home; I don’t want a disabled child in my home.” So, now that we have salvaged this very ill child, she and her mother have no home to which to return. So, when Pastor Mercy asked me to lead the prayer, my request was for God to provide a home for Mama Jebet and Jebet. I am not sure that Jebet wouldn’t be better off now if she were in the arms of Jesus. We have at least two babies right now with very severe brain deformities in addition to severe spina bifida and hydrocephalus. It is hard to have the family spend precious resources on these babies who are unlikely to see their first birthdays with the best, most aggressive care.

We were told on Thursday that we are ordering “too many scans” on the children. Since we treat children with brain tumors, complex hydrocephalus, severe spinal deformities, it is exasperating to hear that we have ordered “too many scans”—especially when the vast majority of children go to surgery with only an ultrasound, not a CT or MRI. Ultrasound is readily available at Kijabe and is relatively inexpensive. CTs and MRIs are available only in Nairobi. Often, we order a CT without contrast when in the US, the child would get an MRI with contrast. The concern about “too many scans” reflects a lack of understanding of the kinds of abnormalities we are treating. However the concern also reflects the limited budget for the neurosurgical program

So that brings me to my requests. I’ll list them in no special order but I’ll ask you to prayerfully consider how you might be able to help. I think of that mama asking me for money—if she keeps asking, someone may feel led to help.

1. We ask that you pray for us to have strength, compassion, and wisdom so that we make good decisions in giving care in a place of very limited resources.

2. Pray for us to maintain a good sense of humor, flexibility, and reasonable expectations so that we are better at rolling with the punches.

3. Please prayerfully consider contributing to the BKKH fund that is established to pay for scans that children need for surgical planning. Many parents cannot afford the $200-400 cost of a scan here.

4. Pray for the leadership of Kijabe Hospital and BKKH. There have been and are soon to be complete changes of leadership at both entities. Change is always difficult and threatening—even when it is positive.

We thank you for your prayers, your monetary support of the neurosurgical program through BKKH, and for keeping in touch through email. We are grateful for each one of you—you sustain us.

As I’ve written this sitting on a chair under a tree in the open area in front of the cottage, I’ve watched several birds come to drink out of a concrete bird bath on the ground. The water level is quite low; each bird has perched on the side and carefully, tentatively tried to dip down to reach the water—but each has been unable to drink. It has been fascinating to watch each one finally “take the plunge” and get its feet wet by hopping off the the side to the floor—there drinking deeply and being refreshed. It teaches me that we all will come up dry unless we commit our entire beings to God’s purpose—that committing to the unknown can refresh us and give us sustenance. As Craig Barnes says in An Extravagant Mercy, “Receiving God’s grace shakes the very foundation of our carefully constructed lives…We even have to lose our interest in carefully constructed lives because, well, that may be the greatest sin of all.”

Take care, God bless.

Susan

Neurosurgery Patient Subsidy Fund

Bethany Kids @ Kijabe Hospital

PO Box 1297

Abingdon VA 24212-1297

Christmas in Kijabe

Dear Friends and Family,

I wrote a blog posting on 12/13/10 but an electrical surge blew my surge protector strip for the American plugs on the computers. The battery on my computer died and could not be resurrected until we had purchased new strips. Then, the internet connection failed so I could not post the blog even with a fully charged computer. Perhaps that is “providential” as my Dad would have said—the blog I wrote then was a bit down.

As I explained in the last blog, I had reached the end of my rope so I flew to Vienna on 12/2/10 (at 12:25 am) to meet Kelly, Joe, and my granddaughter Evelyn. My temporary Kenyan visa expired on 12/1/10 which was duly noted by the customs agent in Nairobi; he said it is fairly easy to renew—I told him, No! I HAD to leave Kenya!! Upon reaching Vienna I found a winter wonderland—it snowed for two days. It was good to be back where traffic signals are strictly obeyed, no one leaps from barriers between lanes and matatus are not heading directly toward you at breakneck speeds IN YOUR LANE! Crossing the street was so...pedestrian—no suspense at all. I gained 4 pounds in 5 days (schnitzel will do that). What was really helpful (besides playing with my granddaughter) was to talk with Joe and Kelly about their experiences in Syria. Joe has spent a good deal of time working with the Syrian guards who patrol the outside of the embassy. Over his 15 months there, he has significantly improved morale among them—mostly by treating them with respect and having clear directives about performance. Although his and my roles are dissimilar, he had some ideas that I will try since morale and performance are important issues here in Kijabe.

I have to admit that I had trouble returning--not simply because I missed my connecting flight to Nairobi in Zurich, had to detour through Istanbul arriving in Nairobi at 02:10 am—and did not find the driver hired to meet my plane until 05:45 am. The sidetrip gave me the opportunity to see Istanbul from the air and to cross off another country on my mental map of the world. My attitude remained less than stellar—until one of the moms approached me for help—then my heart melted with love for these women and their babies. I realized then that it has always been the patients that have saved me, fed me, ministered to me at least as much as I have to them. It is the Erics and Megans and Chanons, and Mr. Moseleys, and Sarahs and Marks and Davids, and Danelles of Madison, Portland, Pittsburgh who have been my best teachers, my strongest supports, and sources of greatest joy in my work. So, as in the past, these Kenyans ladies and their babies drew me back to the place where God has most certainly brought me.

We’ve continued to be busy at work. In November, Leland did 72 operations (his previous all time high was 30/month in Pittsburgh; so far in December he has done 81). Our Pediatric Neurosurgery fellow, Humphrey Okechi, has been a wonderful addition to our team. Humphrey has a gift for organization as well as technical skill in the operating room, so our rounds are concise and mercifully shorter each morning. He also has learned a good deal of Swahili during his first 6 weeks (I guess if one can learn Chinese, as he did in a year, one can learn any language) so is able to have more than rudimentary conversations with the moms. Leland and I are consigned to saying “nyumbani, kesho” which means “home, tomorrow.” We do cause some giggles among the moms as we try to properly pronounce words—asking the staff to spell the word causes some consternation, as the spelling is fluid and depends on one’s native tribal language. Babies admitted as Fatih Jepkemoi become Faith Chepkemoi sometime during the hospitalization. Athan becomes Aden, Iynoam becomes Ahinoam. Also, people don’t get caught up in such things as spelling: our clinic secretary Veronicah sometimes leaves the “h” off her name—she says she doesn’t much care how it is spelled. It reminds me of Ellis Island where names of immigrants were changed because the staff processing them didn’t understand the language and assigned phonetic spelling.

Leland and I spent one afternoon reviewing the complications of the past 20 children treated for myelomeningocele. We are dismayed at the number of spinal fluid leaks, wound infections, instances of incisions falling apart (up to 20 days after surgery). We talked recently with two of the pediatric surgeons here—there are so many factors that impede healing here—intraoperative temperature (the babies get cold during surgery), nutritional status and vitamin/mineral deficiency, skin preparation (we don’t have chlorhexidine prep here—it has been shown to significantly decrease surgical site infections), even oxygen supply to the tissues. At altitude, the air is “thinner.” Most people here increase their hemoglobin levels in compensation—that happens within 120 days of acclimating. However, so many of our babies are significantly anemic—they arrive preoperatively with hemoglobins of 7-9 (normal at sea level is 11-16). We have decided on some interventions that we can fairly easily institute; Leland will change the way he prepares the skin before surgery; we will start each child on multivitamins when they are admitted and send them home with a one month supply. Intraoperatively, the temperature will be monitored and recorded every 15 minutes. I need to talk with a nutritionist in the States of ways to supplement the mom’s nutrition so that the breastmilk is of better quality. Long term, we’ll need to work with the Kenyan staff to teach moms to cook more nutritious foods, refrain from feeding cows milk before the age of one year (one 3 week old baby was being fed cow’s milk last week).

We have so many discouraging stories—Leland asked that I tell you about a different outcome. Early this week, he saw a 26 year old Somali lady who had been struck by a stray bullet—which lodged at the end of her spinal cord causing complete paralysis of her legs. She had sustained the wound December 2nd; Leland told her that he thought there was a 20% chance of improvement after surgery. The surgical procedure went well; the following day, she had movement in one leg. Two days later, she had normal movement of her right leg and antigravity movement of some muscles in her left leg. We have seen many Somali patients; Dick Bransford says that arguments will never sway them, but caring for them compassionately in Christ’s name is the best way to minister to them. One Somali mom told the translator that she wanted to hear about this Jesus because she saw Him in Leland and me. That, quite honestly, is why we are here.

Two weeks ago I gave a 15 minute talk to the nursing staff on how to do wet to dry dressings—despite our telling and showing many of the nurses, we found every morning that the dressings were done incorrectly. After the talk, we were astounded to find that the dressings were correctly done….for the next 5 days—then a lapse back to the old way. When I asked about that, the nurse said that they’d been doing the dressings their way for years and she didn’t understand why we should change. Another thing I’ve recently discovered is that the nurses have as much trouble understanding our accents as we do theirs. So, they “seem” to understand what we say but really don’t. Other nurses are really not fluent in either spoken or written English—so once again, they say they understand but don’t follow the order that has been written. Today a very sick child was not given antibiotics for 24 hours--the nurses didn't see the new order until during the night (it was written yesterday at 0645 am) and then the antibiotics were locked in a cupboard, so could not be given until the person with the keys arrived for work this morning.

We are thrilled to report that we moved into our new home—a 768 square foot apartment on the third (gasp!!) floor of the new building on the downside of the mountain from the hospital. We have the furniture that we ordered (delivered 5 days early—that’s when they were delivering to Kijabe—take it or leave it). We have drapes that I chose and were made to order on Biashara Street in Nairobi—they were done in two days!! I finally have a stove that doesn’t make bread into nuclear waste—we feel like we are in heaven. There are a few glitches—they made ventilation screens at the top of each window—so each night a roof rattling gale blows through our apartment, flapping the draperies, showering that wonderful red dust on everything. Believe it or not, the wind wakes ME up at night!! (I’m deaf!!) The showers are remarkable—we love them; but in every other tap the water comes out in a pitiful trickle. And we have solar hot water—which so far has been solar tepid water. Every time I think about complaining, though, I remember that most of the staff at the hospital—and nearly all the patients—bathe in basins with cold water or water heated over a charcoal stove. Even with the imperfections, we both feel like we are now at home.

It was a strange Christmas in Kenya. The chaplain decorated the ward 3 days before Christmas. By Christmas day, each area had a small tree. But, there was no celebration of Advent (the sermons were from the book of Esther), and other than in mid-November, no carols or advent songs were sung. Leland and I finally went to the Uhuru Highway Lutheran Cathedral in Nairobi on the Sunday before Christmas—both of us remarked that we were able to worship for the first time since leaving Madison. We had dearly missed the liturgy, the readings, the recitation of the Creed, the Lord’s Prayer—as well as the hymns. I think that we will try hard to drive to Nairobi each Sunday to worship there. Despite the identification as a “cathedral”, the church is small so should allow us to get to know the members. It has a good mix of Kenyans and wuzunga—and has both a German and a Kenyan pastor. Otherwise, Christmas was quite low key here—a few of the staff exchanged gifts—like cabbage, etc. In a way, it was good to see a lack of commercialism and greed. It is a little disorienting to see life-sized replicas of Frosty the snowman and Rudolph in the Nairobi mall—2 degrees south of the equator.

In the last blog, we asked for ideas for how to ship the operating microscope. Eric Hanson, the new pediatric surgeon who arrived, told us he has room in his crate in Boone, NC for the microscope. So, we will need to ship it to Boone, but then the problem is solved. We hear that people are passing the blog along to fellow coworkers, etc, and welcome any new followers. If anyone has thoughts about ways we can improve nutrition, please send them.

Most of all, we ask for and thank you for your prayers for us. Even when we have very hard days, we remember that so many people are lifting us up to the Lord in prayer. We are part of a very large community—not just here in Kijabe but extending all over the world—people who care deeply about the poor, the sick, the helpless. “..for I was hungry and you gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me, I was naked and you gave me clothing, I was sick and you took care of me, I was in prison and you visited me. Then the righteous will answer him, “Lord, when was it that we saw you hungry and gave you food, or thirsty and gave you something to drink? And when was it that we saw you a stranger and welcomed you, or naked and gave you clothing? And when was it that we saw you sick or in prison and visited you.” And the king will answer them, ‘Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.’”

Take care, God bless.
We wish you a Merry Christmas and a new year full of joy, peace, and health.
Susan