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.