FINAL REPORT

Dear Friends, Yet again God has richly blessed me beyond all imagination during my time at Kapsowar. He blessed me in fulfilling my educational goals, my spiritual goals, and He led me in further maturity and intimacy in my relationship with Him. The educational goal of my time in Kapsowar was to learn to take care of pediatric and NICU patients in a resource limited hospital. This goal was met in full. I cared for preterms (as young as 24 wga and 600 grams), hydrocephalus, myelomeningeocele, severe dehydration, malaria, bruciolosis, dysentery, parasites, typhoid, pneumonia, milliary TB, AIDs, cutaneous larva migrans, bacterial meningitis, respiratory distress, respiratory failure, constipation, nephritic syndrome, rheumatic heart disease. I spent time counseling and talking to 6-12 graders on drugs, alcohol, premarital sex, health, purpose/life direction, a relationship with Christ, how to stay pure as a Christian, and other concerns they had. My spiritual goals were to be Christ to my patients and the hospital staff, and to encourage and strengthen the missionaries who I’d be working with and learning from. I at least tried to do all of these, and my hope is that God uses even my feeble efforts to have accomplishes all of these things during my time in Kapsowar. Because of the language barrier my ability to have the meaningful spiritual conversations I desired was hindered. So I committed to at least praying with each of my patients instead, so that at least they would sense God’s love and involvement in their care. And God blessed even this simple offering. Niger was definitely more resource limited, but not by that much. And the patients were just as sick at Kapsowar. All of the patients I took care of on the pediatric ward improved and went home (except for the ones still admitted when I left). None were transferred (One with new onset seizures we referred to a neurologist in Eldoret for brain CT and EEG , and another we recommended follow up in Eldoret if his hepatosplenomegaly didn’t resolve in a month since he had improved from his acute illness and symptoms) . None died (just NICU patients, and many of them wouldn’t have survived in the US either). Many cases I had at least a guess of what I was treating, but I was rarely as sure as in the US where I can order a million tests, yet we were able to put them on some sort of therapy, and they all improved. God was able to reveal His power and greatness to both me and the patients, by my simple willingness to involve him in the physical health of the patients by pleading with Him individually, cases by case that we’d know what we were treating, that the medicines would work and that the child’s health would improve. The remainder of this letter is my testimony of what God has been doing in my life (both in Kenya and in the months leading up to Kenya) and how He was been maturing my relationship and trust in Him, in preparation for the next season of my life: God put overseas medicine for the purpose of increasing his kingdom, on my heart in the ninth grade. Since then I’ve been focusing on both serving him today and preparing for His calling on my live. Now I’m 6 months away from the completion of my training, nearly 15 years later. God’s provided numerous opportunities for me to serve him as well as to grow and mature in my faith and my ability to serve him as a physician. You grow a lot overseas while serving in a foreign culture. Resources are different. Names of medicines/types of medicines available are different. Labs and imaging are limited. The food is different. Religion is different. Acceptable dress/ clothing/ attire is different. Relationships between people and gender are different. Relationships between people and gender are different. Gender roles are different. Outlook/perspective on life is different. Work ethic is different. Values are different. “Strength” is men may be valued in two different cultures---but what that looks like/means varies from one culture to the next. Language is different--- even when it may still be English: accent, word order, and meaning of word phrases are different. Political system is different. Security is different. Corruption is seen in different areas of the national/ political system/ government--- in different ways. Travel is different. Technology is different. Response to death and life is different. Through all these differences you have to find yourself and the one uniting factor--- Christ. But even an intimate relationship with Christ may look different across cultural lines. Now I’m in Kenya. Most recently I was in Niger (in June 2012). Niger has probably been the most challenging place I’ve been because there was a double language barrier as well between me and the locals. The full impact of that month hit me probably 3-4 months ago. I had a really hard day, at the end of which I was doubting God’s goodness. I knew God was there and that He’d sacrificed everything so that we could be united with Him, but I felt like since I told him I’d do whatever he wanted to help Him increase his Kingdom--- then he was asking me to give up everything—all my desires, hopes and deep longings. The next day I allowed Him to remind me that that was all a lie. Part of the problem was that at some point during residency and life in the Bible belt I’d caught Entitlement syndrome. He says all you who are weary and heavy laden, come follow me and learn the unforced rhythm of grace. For my burden is light. That means that though we give up everything and every moment of the day we are “full”: we have joy and an unexplainable energy and strength surges from the depths of ourselves. In that moment I gave up everything and gave Him my all, striving for balance, sustainability and life---And found it. I realized the key was in fulfilling our purpose. Doing what we were created to do. I was not created to heal people physically (only God can). As a follower of Christ I was created to help lead people into spiritual healing and an intimate relationship with God. Fortunately, as a physician I realized that spiritual healing is actually the true source of physical healing in many ways, due to the way God created the human body, mind, and spirit. I started noticing the clinic and hospital encounters where I’d both had and taken the opportunity to address the underlying spiritual issue of their medical condition left me feeling more energized, rather than emotionally and physically drained—as just treating the physical aspects of the sick and dying did. What does this have to do with Kenya?....I’m almost there. So reflecting back on Makunda, India (Feb 2011, Jan 2012)--- it’s a very busy hospital. It’s a very poor area. Workers burn out fast. The Indian physicians who started it and have run it for the last 18 years have given their entire lives to God’s work there. Yet how many have come to know Christ personally due to all the believers sacrifice’s—I’m not sure. And how sustainable is that intensity of work--- I’m not sure…But the thought of myself continuing to work that much brings upon me an overwhelming sense of dread. Niger was the same. A lot of people to see. Not many resources. A lot of death. (In defense of the workers both in India and Niger is that Islam has such a hold on the hearts of the people the Christians are trying to reach there as compared to the people in Kenya. The spiritual work of Kenya is more like that in the Bible belt in US, mostly challenging nominal Christians into a more mature faith and a personal relationship with Christ. Whereas the spiritual fertility of the people hearts in Niger and north India is more like the US West coast or the East coast. You’re trying to till up the soil and plant seeds in concrete). In that moment 2-3 months ago, when I doubted God’s goodness, all the dread of an unsustainable life of sacrifice was overwhelming me and crushing me. But through Kapsowar Hospital in Kenya I’ve seen life and sustainability. The hours are the same. But the individual patient load is less—and has allowed for a deeper relationship with the patients and more opportunities for speaking truth into their lives. And these encounters energize rather than drain, enabling more strength to passionately seek more opportunities to love the people I serve and help them find life, truth, and Christ. I have hope for the future, I’m excited for where God leads me next year, and I’m eager to help more hurting people know the fullness of life God intended for us all.

ACUTE VIRAL GASTROENTERITIS VERSUS DYSENTARY VERSUS TYPHOID VERSUS BRUCIELLOSIS

Diarrhea, vomiting and GI symptoms overwhelm me overseas in developing countries. In the US I know the most common is acute viral gastroenteritis and we never really have to worry about anything else. People’s farm animals don’t live in their homes in the US. Raw eggs and milk are pasteurized. Meat is well cooked for the most part. Drinking water is clean for the most part. But abroad, nearly-half of the children complain of diarrhea, vomiting, bloody stools or abdominal pain. I freeze u inside unsure of what to do. This month has been good for me and I highly recommend the book “handbook of Medicine in Developing Countries” for those trying to make the transition to resource limited situations and hospitals. Shortly after arriving in Kenya I was on call and admitted a 4 year old girl with 3 days of bloody, mucous stool, vomiting, and fevers. No urine output since earlier that day. Very lethargic and ill appearing dysentery. Dysentery is a bacterial infection and unique to it is a couple day history of blood/mucous in the stools. Antibiotics are indicated for moderate to severe cases. Pretty much anyone who is admitted to the hospital is in the moderate to severe category. She was pretty severely dehydrated (as noted by the lethargy), so we treated with antibiotics and lots of IV fluids. That night I admitted another 4 year old with one day history of multiple watery stools. NO blood. And fever. He was ill appearing but not lethargic or as dry looking as the first girl - Acute viral gastroenteritis: identified based on the watery stool and no blood. I treated him with IV fluids as well, but no antibiotics were needed and he improved. Earlier that day I’d rounded on a 10 year boy who had been admitted from Out patient department with severe low back pain and constipation for a month. He was now unable to walk. I asked Aaron to review the case with me, because I was stumped. The clinical officer (i.e. the Kenyan version of a PA) admitted him was concerned for Potts Dz. But Aaron ordered a test looking for Bruciolosis (a bacteria from raw milk or under cooked poultry). The test ended up being positive, so we sent him home with 6 weeks of appropriate antibiotics Bruciolosis is suspected based on fever without source, +/- diarrhea or constipation. About 20% of cases have joint pain or low back pain. Typhoid is the other GI illness seen a lot here. It’s suspected with more than 2 weeks of diarrhea +/- fever. In Niger we’d see it all the time after it was too late and the bacteria had already caused perforations in the bowel walls. The test they had in Niger wasn’t very helpful, so they nearly never tested. I never saw a typhoid perforation while at Kapsowar. They used that same test at Kapsowar, so they probably prevented perforation by over treating falsely positive Widel tests.

THE POKOT

There are two major people group that Kapsowar hospital serves: The Maroquet and the Pokot. The hospital is in the mountains where the Maroquet live. The Maroquet are farmers and consequently pretty nourished appearing in physique because the mountains have rain and are green. The Pokot on the other hand are herders in the valley, which is drier and has less access to water. One part of the Valley has a river that runs through it. On the opposite side of the Valley is a community, Lodengo, that God has put on Kyle’s heart. Whereas the Maroquets are Christians and nominal Chrisitians, the Pokot are still largely animistic. Part of the native Kenyan culture is the circumcision which marks the coming of age. Boys are circumcised among both the Maroquet and Pokot between 12-16 years of age. At Kapsowar the Christians have organized essentially a leadership training camp associated with the circumcision at the hospital, so that the procedure is controlled and the boys are monitored at the hospital, and also it lets them put the emphasis on becoming a man of God (instead of them going around and beating women after the ceremony as it has been in the past). Among the Pokot the boys have to kill some animal and then they all dance around the corpse chanting to their ancestors. Female circumcision is still very common among the Pokot, and less so among the maroquet. After the female’s rite of passage, she can be married. Sometimes as young as 13 years old. God has really placed the Pokot on Kyle’s heart. They have great need for both the Lord and the basic needs as well. Kapsowar is the nearest hospital to them, being about 3 hours away. Because they live off animals they’re all very thin and malnourished. And they have little access to water. Responding to the burden that God put on Kyle’s heart for these people he began driving down to the Valley every month or so to have a clinic and speak truth into the lives of the people. Kyle talked with the people and pursued the Lord’s direction for helping this people to improve their health and ability to meet their basic needs. Consequently, they began seeking a way to access sustainable fresh water, so that they could then open a health center there in Ladengo. It’s over 1.5 years later, and they’ve been through an overwhelming amount of frustration and discouragement. Several wells they dug ended up not having any water after all. They’ve used several different geologists to help find water, several different drillers. The first driller had equipment that took a year to drill and kept breaking. But the conviction that God desires health and water for these people is still alive! Maybe God is teaching the Pokot and the missionaries alike faithfulness and persistence in prayer. But love for the loss people of the Pokot fuels the flame of hope as the people of Kapsowar pray for the well. Yesterday the drill reached 136 feet and ran out of gas. Based on the calculations of a geologist from MIT who’s a believer, the water should be at about 160 feet. Be praying for the well and for the Pokot, that they see God in all his glory, and that they cannot deny his love for them. A sustainable water source is necessary for the health center being built there to be able to care for the people and be sustainable as well. Currently they only hold clinic in Ladengo once every 4-6 weeks. With the health center there, the people will have daily access to health care. They will be able to deliver uncomplicated labor in the hospital there. They will have access to basic medicines and vitamins. Last Friday when I was on call, Kyle called me to due a c-section with him. A Pokot woman had just arrived from the Valley. She’d been laboring for several days, but she still had not delivered the baby. It was concerning because she’d had 5 normal vaginal deliveries in the past. When I put my hand in her uterus to deliver the baby the head felt bigger than normal (usually during a c/s you deliver the head first). As I tried to pull the head up towards our incision to deliver it, it kept floating away. Kyle helped, but ended up delivering the butt first. As it came out we saw on the child’s spine a myelomeningiocele. The rest of the body came out except the head got suck and couldn’t fit through the uterine incision. As we struggled to deliver the head, base on the spina bifida Kyle guessed the kid had hydrocephalous…and he was right. The head was as big as the rest of the baby’s entire body. The child also had clubbed foot on the right and an extra appendage of the gum in its mouth. She wasn’t breathing but had a heart rate. As we closed up the mom, the nurses worked on resuscitating the kid. Finally she started breathing and her tone came back. She was placed in NICU and did well overnight. If she survived she could go to the Christian hospital at Kijabe where they had specialists and have her spina bifida repaired, and hydrocephalus drained. The next night she stopped breathing and they were unable to resuscitate her. Spina bifida has been significantly decreased in the USA because most pregnant women are given prenatal vitamins which have folic acid. Because this lady didn’t have easy access to prenatal care she wasn’t given prenatal vitamins. The Pokot’s diet is probably low in folic acid as well because they drink goat’s milk, which is deficient of folic acid. Even very basic medical services can significantly improve the overall health of the Pokot. But Kyle was still able to use the tragedy as an opportunity to comfort and share truth with the baby’s parents. Please be praying for the Pokot, that they come to know and worship God.

TONNY

Probably about 1.5 weeks into my time at Kapsowar a 10 year old boy Tonny was admitted for low back pain. The Kenyan physician who admitted him was concerned for Pott’s disease (TB infection in the spine). The xrays were negative, he had no sign of infection (no elevated white count or fever). He lay in his bed and moaned. I was worry so Aaron and I ordered the test for Bruceolosis, which came back border line positive. He’d definitely been exposed to it and may or may not be having an active bout of the infection. About 20-30% of the time patients with bruceolosis developed low back pain and require up to 3 months of antibiotics instead of the normal 6 weeks. He was improving so we discharged him home on Doxycycline and Rifampin. Maybe a week later when I was on call, I was called in during the evening to evaluate a new admission…Tonny. According to his father the back pain hadn’t improved and starting that morning he had been confused, not knowing who his parents where and not about to answer questions or follow commands. On exam he was moaning in severe pain and his neck was so stiff that I wasn’t able to bend it forward. He also screamed out in pain with flexion of his hip. I became very worried for meningitis. I called Aaron, who was on call with me, to come in as well to evaluate Tonny and do the Lumbar puncture (LP the test were we stick a needle into the back between the vertebrae in to the spinal column and collect some cerebral spinal fluid [CSF] to send for studies to see if WBC’s, RBCs, bacteria or fungus is present) with me. Aaron agreed with my concern and we waited for the nurses to set up the LP. They were unable to find a LP tube (evidently the hospital was out and they were waiting for the newly ordered tubes to arrive). So Aaron and I went up to the lab to look for a LP tube. He found only one (usually you collect fluid in 3-4 vials in the USA so that you can do various studies and decrease the chance of contaminating the fluid with blood from the skin as you inserted the needle). We made it work. We called the lab in and waited as they ran all the studies on the CSF. Protein was high, glucose was normal, WBC was very high, bacteria was numerous. They did a Gram stain on the bacteria and it came back Gram positive cocci single and in pairs. They didn’t have the ability to culture the CSF. So we had to guess based on the Gram stain that he had Strep Pneumonia Bacterial Meningitis, so started him on Ceftriaxone. (There’s no Vancomycin here). The next morning he was very little better (sometimes knowing who people were) if at all. His dad was concerned and wanted him transferred 2 hours away to Eldoret where they could do a CT scan. We had discussed it before the LP results, but now we knew the diagnosis and could give the appropriate treatment at Kapsowar, and he wasn’t stable to transfer. Aaron helped me consol the boy’s father, and he agreed to wait another day. The next day the boy knew who he was, where he was, the month, the year, and why he was there. But he still had neck pain which was worse with eating, drinking and any movement. Because he wasn’t drinking or moving his family felt he was the same. Again Aaron and I talked with his father, saying they could transfer if they wanted, but he was improving. Personally I was still concerned that he was still too unstable to transfer. Aaron explained that the improvement from meningitis was very slow, and was the same no matter if he was at Kapsowar, Eldoret, Nairobi or in the USA. Aaron told the father that the boy was improving impart due to the antibiotics, but mostly due to God and his response to our daily supplications. His father agreed to stay. The next morning we found out the boy had eaten some the day before, and I found him sitting up with his legs hanging off the side of the bed as his father fed him. Finally he was stable enough for transfer if they wanted. The father wanted to think about it, but we had community clinic so we discussed the case with the Kenyan doctor who was covering the hospital while we were out. He’d arrange physician to physician transfer to a neurologist in Eldoret if the family decided. The next morning I started rounds not sure if Tonny would still be there…. He was. He continued to improve day by day. Yesterday was my last day and he was eating, up in a wheelchair, and laying out in the grass on his side during the day. Today is day 8 out of 14 days of IV antibiotics. His father’s smile testifies that he had seen the glory of God.

FRIEDA cont.

Frieda improved on her medications and was finally able to go home after being at the hospital for several weeks. During that time period her mom was able to experience Christ’s love, and I was able to watch her heart soften day by day. All our conversations were through a translator or broken English but sensing a person’s heart doesn’t depend upon language, and she seemed aware of Christ’s precious love and acceptance of her and her children by the time Frieda was ready to go home.

Solomon

I walked in to the pediatric ward to start rounds and saw the nurses trying to start an IV on a new patient. Solomon is a 7 year boy who looked very ill. He was tachypneic (breathing fast), hypoxic (oxygen saturation less than 90 percent on room air), tachycardic (fast heart rate), and lethargic (not very responsive). I quickly gathered a history through a translator. The clinical officer who had admitted him had obtained from the history that he’d had bizarre behavior prior to presenting to a different health center which sent him to us. Now he was complaining of full body aches, fever, and a cough. His lungs were clear to auscultation. He complained of neck pain and had an expression of pain on his face with neck flexion and hip flexion. Aaron Jones and I did a lumbar puncture. The LP came back negative. I reevaluated Solomon and now he had abdominal pain. He had guarding and rebound on physical exam. So we discussed the case with the surgeon. Dr. Rhodes (the surgeon who’s American train but been here for 15+ years) recommended an Xray to evaluate the hypoxia even though his lungs sounded clear. (We order xrays less often here than in the states because the patient has to pay for everything we order, and so if the study isn’t going to change my management then there’s no point in ordering one). There isn’t portable oxygen at the hospital, so they quickly transferred him to the surgery building where there’s oxygen and also a portable x ray machine, because he was too unstable to go to xray without oxygen. The xray showed his upper lobe of his right lung was completely whited out. It was an odd presentation. We decided to treat it like pneumonia, and he was already on Rocephin. But it could have been atelectatis. Or the other thought was that TB usually is seen in the upper lobe of the right lung, but usually it’s a cavitary lesion and not a whited out lobe. That was late Friday afternoon, and I was off the entire weekend….. …I returned Monday morning to find him off oxygen and clinically improved. He’d been afebrile for 36 hours, sitting up at the side of the bed and looked much better! Praise the LORD 

Weekend Off :)

So I had the entire weekend off. It’s the only weekend I’m not on call while I’m here (I did have last Sunday mostly off except for rounding). Saturday was glorious. Up until last Tuesday the weather had been beautiful: Sunny, not humid, and in the 70-80’s during the day. Tuesday it was gray, overcast, cold and rained off and on through out the day. That continued Wednesday, thurdays, Friday morning and finally around noon the sun came out and stayed out the entire weekend. I slept in Saturday morning, and lounged around the house in my PJ’s until noon for the first time since early to mid November ! Then since everyone except the Kenyan doctor was off, we all went on a picnic down to the river for lunch. Both Jones families, myself, Mim (a medical student for Buffallo who arrived last Monday), and Ces. When we got down to the river there were a bunch of Kenyans washing their cloths and cows out grazing. We drove on an off round path around a small hill and found an isolated place to hang out. They turned the music on and had it blaring from the SUV speakers as we set up a picnic on the hillside in the glorious sun. But before long we saw a host of dark faces standing at the top of the hill looking down at us. It’s so crazy. We weren’t even doing anything that exciting. Eating, talking and relaxing. But some how we managed to have an audience for a very long time. Adults and kids alike. Sonya (Aaron Jones’ wife) joked that they found it entertaining and strange that we were at the river and not washing clothes. I don’t notice people staring as much anymore since it’s so common every time I go overseas. But I do always feel bad for and send up a prayer for the movie stars who can never get a moment of peace when they go out in public.

Julia's Baby

When I arrived the youngest and smallest baby in the NICU was Julia’s baby. He was born early at 22-24 wga due to placental abruption. He weighed 600 grams at birth. By the time I arrived he was slowly but surely gaining weight. He was still on oxygen. We given Aminophylin here to stimulate respiratory drive (in the states they use caffeine). He was transitioning from IVF to NG tube feeds. I continued to advance his daily intake until he was taking in 180 kcal/kg/day. He was gaining weight at a slow but appropriate rate (goal is 15-30 g/d). He was the smallest baby that Kapsowar had every cared for and managed to keep alive. Even for the states he’s a miracle. After 3+ weeks he was at 810 grams on Wednesday. Then in the morning he aspirated and stopped breathing. They resuscitated him and he started breathing again. He stopped breathing to more times around midday. And then 2-3 more times that evening. Finally the nurses called the on call doc at 8:30p that he’d stopped breathing for 2-3 minutes. He ran to the hospital. They coded the child, gave chest compressions, rescue breaths and iv epi, but never the less he passed. It was a great loss for his mother. She’d been expressing breast milk every two hours for weeks and feeding him through his NGT, every patient and hopeful. Please pray for her healing.

Frieda

HIV/AIDS is common here due to a number of reasons, one of which is the break-down of the family unit. Many families live apart because the husband may find work in a city several hours away, and consequently adultery is more common. It’s a shame to be associated with the diagnosis so many people are in denial of their diagnosis as well. I admitted a 5 year old 15kg female about a week ago who presented with fevers, abdominal pain, tachypnea (rapid breathing), and tachycardia (rapid heart rate). Her HIV test came back positive. We started her on prophylactic dose of Bactrim for PCP, but otherwise waited for CCC to see the patient. CCC is a department of the hospital that manages informing the patient and family of the diagnosis, investigates the social situation, and arranges medications and further follow up and management. They kept deferring to discuss with the patient because the woman with her was claiming to be her aunt and not her mother. Finally they found out that the woman was in fact the patient’s mother, and she was 7 months pregnant. They tested mom and she was HIV positive too. She had another small child at home as well. We suspect that the mom was already aware of the child’s diagnosis and that she’d been trying to hide the child and not seek medical attention because then everyone would know her AIDS status as well. We treated her for dysentery and pneumonia but she continued to have high fevers to 104 at night. So we treated for Malaria even though the test had been negative. She was very thin though she had a large abdomen so we treated her for worms. The fevers began to come down and she improved clinically, but she continued to be tachypneic and hypoxic. An abdominal xray had been performed on admission and Ces (one of the surgeons) had seen it and said bilateral lung fields looked whited out, but we could never find the film. The child’s lungs sounded clear on auscultation but due to the tachypnea and hypoxia I kept trying to reorder an Xray. But the staff and the family continued to refuse because they didn’t want to pay for the second film. Finally they accepted because they were told the hospital would cover the cost since they’d lost the first film. The films were a classic example of miliary TB. So we started her on TB medications. This story hasn’t ended yet….

Community Health Project

So we have to wear skirts in the villages and even spouces are discouraged from publically showing affection, yet premarital sex and teenage pregnancy seems to be just as common here in Kapsowar as back in Tulsa. This along with several other issues are what motivated Kyle Jones and the Kenyan social workers, Ruth and Zef to start the community health programs. At the primary school Kyle and Zef first talked to the entire school of about 400 on the hillside. They talked about health, hygiene and safety until they were cut off by the rain. They then crammed 120 6th, 7th, and 8th graders into one room and talked to them about alcohol, drugs, premarital sex, teenage pregnancy, STDS, and the gospel. Kyle talked for a while in English. Then Zef, who is a native Kenyan and is familiar with the local culture, began talking to them very animatedly. He switched back and forth between English and Swahili and had all the students laughing. He was quoting all the lame pickup lines and exposing the selfish intentions of the guys. I watched the girls’ eyes as Zef spoke, and they reflected the pure yearnings of their female hearts--- to be loved, cared for, and called beautiful--- as they soaked in all of Zef’s words. We talked to Zef and Ruth afterwards about the frequency of sexual activity in this age group. They said maybe some was common in 6-8th and a lot more in the 9-12th grade age. We then went to the all girls secondary boarding school in the afternoon. Kyle was planning to talk, and he also asked Zef, a nursing student who had come with us, and myself to give a little testimony about the topics he planned to cover. He talked to the girls about alcohol, teenage pregnancy, premarital sex and STD’s. He related it all to the Christian faith and God’s will for our lives. Kyle then turned and asked me to share next. We were inside a class room but the building had a tin roof and the rain on the roof had been periodically drowning Kyle’s voice out. From learning Spanish I know that the best chance of understanding a foreign tongue is loud and clear, where as your native tongue you can understand even when muttered under someone’s breath. Many of the Kenyans speak English but their accent is difficult for me to understand and mine is difficult for them to understand. So I knew that the students would definitely not be able to understand me if it was raining. Right when Kyle asked me to talk it began to rain. I deferred to Zef, who went dancing around the room, enchanting the girls and causing them to laugh--- especially when he counseled them on not selling themselves to their boyfriends for French fries, which he made sound like a common occurrence. While he spoke the rain began pouring and pounding on the roof until even we couldn’t hear. But he ran to the middle of the room and the girls continued to listen enraptured. I sent up a prayer to the Lord that the rain would stop for me so that I could profess His truth to the girls and they could understand. Then came my turn. The rain had completely stopped when I started and didn’t start again until the next speaker. I shared the testimony of various patients I’ve cared for over the years, and the truth they’d realized too late. I’d asked Ruth why sexual activity was so common in these communities, and she said due to peer pressure (both from friends and boyfriends). I asked the girls and they agreed with Ruth’s answer, but then I told them that wasn’t the real reason because they could just say no. The true reason is their innate desire to be loved, valued and desired. I shared the testimonies of my patients who had tried unsuccessfully to fill that desire with boyfriends and popularity, and then spoke true fulfillment in a relationship with Christ and in living to love and care for others for Christ. I gave examples why God’s ways is better in the current moment than the worlds, and focused on less on long term rewards and blessings. At the beginning of the day I’d thought that all this was kind of boring, especially during the group session at the primary school. But the smaller group settings where we could see into the students eyes and heart was such a precious precious reward. Kyle asked Zef whether he thought these talks would have long term effects. Zef responded that already he would visit the villages near the schools they’d already visited and asked them if they remembered what they’d told them. And the children would reply “yes,” and proceeded to reiterate a lot of what had been spoken to them. The greatest strength and value of these talks was it allowed the team a chance to speak the gospel to the students, offer them the opportunity to accept Christ, and encourage them in a more mature faith and relationship with Christ.

ICU and Pressors

Last week we admitted a patient to the ICU which recently built at the hospital. It was the first time I'd ever used Pressors in a Developing country (ie. anywhere other than the USA). (Pressors are medicine that you give through an IV drop by drop in order to keep the blood pressure up in the normal range so that blood can still get to the brain, kidneys, and heart (you vital organs needed to survive). People dieing from heart failure, infection, or blood loss will have blood pressures that get lower and lower until they die-- usually of an arrhythmia due to the heart not getting enough blood supply. In the US we're able to keep very sick people alive and allow them a chance to get better with Pressors). We we're caring for a 26 year old female who had end stage (meaning about to die, probably within 6-12 months) heart failure secondary to rhematic heart disease. Earlier that year the workers/staff in the hospital had raised enough money to send her to Tenwick (a larger mission hospital in Kenya) to have her heart valve (which was damaged by the rheumatic heart disease and causing her heart to fail because it was working extra hard pumping blood to make up for the valve) repaired--- unfortunately see was sent back without the surgery because it was too late and her heart was too damaged. During morning devotion Kyle was called and told that she had coded (her heart had stopped) and the nurses were doing CPR on her. I went with Kyle up to the hospital. The nurses had brought her back to life--- had a faint pulse (ie low BP) and was breathing. Kyle told them to shift her to the ICU. Then we went up to the pharmacy. Kyle had heard a rumour that they may have received some pressors--- though they weren't on formulary (ie the meds that a pharmacy aims to always have in stock). We searched the shelves and found a small box of 5-6 vials of dopamine. Down to the ICU we went where we sat down with pen, paper, and calculator trying to figure out if we mixed one vial into 500mL of IV fluids how many drops per minute the fluids needed to run at in order to give the minumum and maximum amount of medicine. A "drip" is a medicine given drop by drop. Drips for the most part are given only in ICU's in the US because they're labor intensive--- you can go up and down on the dose minute to minute. Drips in the US are easy because each medicine has an electronic box that you can program how many mg/min or mg/hr of a medicine you want and it will adminsister it. The dose of dopamine is between 1-50 mcg/kg/min. In developing countries you have to compress the IVF tubing just enough that however many drops per minute you want are released. Because the dose of many of these meds are so small and our set ups in developing countries aren't as precise as in the US, we have to dilute it first and then calculate from mcg/min to ml/min to drops/min. The goal BP needed to make sure adequate blood gets to the kidneys, brain, and heart is measured as a MAP of 60. MAP= mean arterial pressure. Meaning 1/3 of the time BP is equal to the systolic number and 2/3 of the time BP is equal to the diastolic number, so the MAP is [SBP + (2 x DBP)] / 3. For instance for a BP = 90/60, MAP = 70. The goal MAP is >60. So that was the target with our pressors. With max dose of dopamine she was maintaining MAP 40 - 60. Then we ran out of the dopamine. So we calculated a drip of epinephrine (adrenaline), which I maybe saw used once at JPS during med school, but they don't use it much in the US to my knowledge (I guess because they have better pressors. We used it anyways because she was going to die anyways if we didn't. And it was working pretty well initially anyways. The other major thing going on was she was in renal failure though. She was fluid overloaded due to the heart failure, but her kidneys weren't responding to Lasix (a "water pill", ie a diuretic) and she wasn't making urine in 3 days. She needed dialysis but her sister refused transport --- she probably would have died in route anyways (the next large hospital was 2 1/2 - 3 hrs away). Kyle had spoken to her about her faith over the last several years, and he talked with her again. Earlier she had asked him in Swahili if she was going to see the Lord today. Kyle responded, "Not yet." But now it looked like death was winning. He comforted her and prayed with her and her sister. Over their heads through the window a double rainbow decorated the sky we went out and looked at them. They were very strong. You could see the entire bow across the sky reaching from hilltop top hilltop. With the promise of the double rainbow like a banner through the window over her bed we left her --- and she went to be with the Lord that night.

Justice

Its easy to complain able politics and police in the US until you realize how corrupt the government is around the world. On the way driving from Eldoret to Kapsowar the missionaries who where driving me in their vehicle were stopped by the police at a check point. The police comes to the window and asks Kyle (one of the doctors I'm working with who trained at my residency program) if he can arrest him. Kyle replied that he'd rather not be arrested. This went on for an hour. We weren't sure if they wanted a bribe initially, but they were trying to arrest him and then trying to confinscate the vehicle because the license plates weren't right. Evidently a lot of strict traffic rules were just passed this year. In that moment there was a feeling of not being in control and not being able to expect justice. WHile Kyle was nagociating with the police outside the car, Aaron, one of the other American doctors here told me a story about Ces an american surgeon who is also serving in kenya through samaritan's purse post residency. Ces had been pulled over a couple months ago and the police told her he wanted to arrest her for speeding (though she wasn't sure she was). She ended up spending a couple days in jail. After alot of phone calls they were able to get her out and all charges were dropped. Kyle ended up paying a fine (his "bail") and had to return the next week for a court hearing. He did his research and took a bunch of Kenyans with him. God provided a god fearing judge who returned his fine and told him that he could press charges against the police if he wanted, since the police handled the situation inappropriately. The whole thing makes you thankful for justice in America.

Arrival

Hey I've arrived in Kapsowar and hit the ground running! I flew from tulsa to atlanta to amsterdam to nairobe to eldoret and then drove to kapsowar a couple hours. We arrived at Kapsowar late thursday. I worked in the hospital friday and today. Friday we did 3 c-sections, rounded on maternity and newborn nursey/nicu, and admitted a bunch of medicine patients. Today I rounded on the whole hospital except for surgical patients with Kyle Jones. It's been a busy but very educational and fun 2 days. The weather is beautiful. Sunny, blue skies, green, and about 70 degrees. I've got my running route set. We're at 8000 feet elevation and its up hill, then down hill and then uphill again. PART OF the route is asfault but most is dirt. I'll post more stories later. Having internet issues so just wanted to give a quick update. God bless!

Off

Hey friends! And I'm off. I left the USA yesterday the 1st and should reach niarobe, kenya later tonight. Tomorrow I'll fly to Eldoret and then drive to Kapsowar, where the hospital is.