July 4th: Our Nation and the Parable of the Rich Fool

Someone in the crowd said to him, “Teacher, tell my brother to divide the inheritance with me.” But he said to him, “Man, who made me a judge or arbitrator over you?” And he said to them, “Take care, and be on your guard against all covetousness, for one’s life does not consist in the abundance of his possessions.” And he told them a parable, saying, “The land of a rich man produced plentifully, and he thought to himself, ‘What shall I do, for I have nowhere to store my crops?’ And he said, ‘I will do this: I will tear down my barns and build larger ones, and there I will store all my grain and my goods. And I will say to my soul, “Soul, you have ample goods laid up for many years; relax, eat, drink, be merry.”’ But God said to him, ‘Fool! This night your soul is required of you, and the things you have prepared, whose will they be?’ So is the one who lays up treasure for himself and is not rich toward God.” Luke 12:13-21 (English Standard Version)

As we celebrate the 240th anniversary of the Declaration of Independence and as we consider from what beginnings we came, what aspirations as a nation we had and have, and as we wind down a bitter season of campaigning for our next leader, I was struck by the parallel our nation has to the main character in Jesus' parable of the rich fool.

So what were the roots of that man's misguided thinking that resulted in his untimely (from his perspective) death?  Using a bit of historical literary license, not rewriting history but imagining how his history might have evolved, I will try to give you a synopsis of his life:

He was born into a family with some means--in the era in which Jesus lived, it is unlikely that he was from lowly beginnings if he became a wealthy land owner and producer of large crops.  He was gifted with the intelligence to conduct life in a productive manner and the resources to make a temporal, cultural success out of his life.  More than likely he had parents who gave him the education that was befitting of his social class and the practical training that allowed him to become an independent land owner and farmer.  From the quality of the productivity that led to his illusion of success it is apparent that he was blessed with adequate rain to grow his crops and the resources to collect and store them. 

So, where did he go wrong?  He could not control the circumstances of his birth.  If he was born into privilege, it was not of his doing.  He apparently used the advantages of his life to good effect when viewed from the standpoint of productivity, probably laboring long hours in overseeing the production of his crops.  There is no indication in the parable that he misused his position to harm others or to dishonor his parents or family.  His is not a story of a prodigal unrepentant. His is more the story of the elder brother, the one who stayed home and worked for Dad, who built his own business empire and was reaping the rewards of it.  Again, where did he go wrong in Jesus' eyes?

He looked upon himself as the source of his blessing, failing to acknowledge and be grateful for the blessings that were bestowed upon him in the form of family, intellectual ability, business acumen, and the natural blessings that God gave him in the form of seeds that grew, soil that was fertile, and rain caused the crops to grow.  The implication in the parable is that the rich fool ignored the underpinnings of his history and gloried in the gifts he was given without acknowledging the Giver. His rejoicing was over temporal circumstances and self-centered. He took no delight in nor made any effort to honor the Source of all of his success.  Had he done that would his efforts and success have been diminished?  No, they would have been placed in the perspective that all meaningful temporal success is placed--an eternal one of gratitude to the Creator who made it all possible, from the raw resources to the labor involved to the finished product. 

How does this have anything to do with our nation?  We as a nation have lost sight of the historical perspective of how we became a great nation. We have allowed the Founding Fathers to be treated as short-sighted men who could not possibly have envisioned the circumstances of today, and we discount the profound wisdom they wrote into our Constitution and the Bill of Rights.  We have failed to emphasize learning factual history as one of the most important means of planning for the future.  We have allowed popular, reactive opinion to create tidal waves of cultural change with no idea of what the consequences will be for the structure of our society. 

As a nation we take credit for "greatness" without any thought of the guiding of divine providence that even our non-Christian Founding Fathers acknowledged.  Like the rich fool, we are prosperous but blind, reveling in our wealth while ignoring its temporal nature, not willing to study the steps to our success in a manner that leads to humility, gratitude, surrender, seeking of divine guidance, obedience, and trust in God.  

We are a foolish nation, powerful in resources as was the rich fool.  We are an ungrateful nation, steeped in self-congratulatory praise as was the rich fool. We are a nation lacking in true humility, taking credit as a people for what God has provided, as did the rich fool.  

Things did not turn out well for the rich fool.  Things will not turn out well for us unless as a nation we:

Humble ourselves; ask for God's blessing and guidance; obey Him; trust Him above all else. 

Educate our young and provide them with a deep appreciation for the history of our beginnings, the struggles of our growth, the mistakes that required national repentance, and a recognition for a long-term perspective on all decisions of significance. 

Teach our children that purpose in life is more important that privilege; that serving should be the ultimate goal of every person; that possessions and wealth are instruments of the Creation given by God to serve and glorify Him and to help our fellow man.

Protect the rights of minorities to live under umbrella of the Bill of Rights and the Constitution; we never know when we will be the minority. 

Return to a rule of law that governs with compassion but firmness; that recognizes that government exists to provide man with the freedom to succeed or fail, but does not exist to take from us the very purpose of living. 

Lord Jesus, help us to not be, as a nation, as the rich fool.  Help us to return to the humility that led to an ordered government that valued liberty over state but that led to heroic self-sacrifice for the good of others. Take not the life of our nation from us, but help us awaken to our folly and repent. Amen.

Simon Peter and the Rest of Us

And Peter remembered the saying of Jesus, "Before the rooster crows, you will deny me three times." And he went out and wept bitterly.  Matthew 26:75

When I read of Peter's remorseful response to his denial of Christ, I feel not just sympathy but empathy.  I identify with Peter--he was a guy prone to quick decisions.  Remember he also pulled a sword and relieved the High Priest's servant of an ear.  He was the one with the quick responses to Jesus' probing questions--not deeply contemplative answers--answers that came from an active mind, a passionate heart, but lacking the understanding and commitment that Jesus ultimately sought from Peter.  He is probably the guy who "dictated" the book that Mark transcribed--short, lacking a lot of detail, the Cliff Notes of the Gospels.
I wonder if Peter had an element of what is called bipolar disorder--he was on top of the world, all-in, full speed ahead; then he wasn't and he was in despair at his lack of courage.

I spend a lot of time evaluating medical students and residents for their performance in the care of newborns. If Peter showed up as an intern I would cringe.  I have had more than a few soul mates of Peter's come through the newborn nursery or the NICU over the years--eager, reactive, exuberant--similar to a young horse romping in the pasture with you in the saddle--unpredictable and dangerous if you let them have their head, but with patience (a lot of patience) from the faculty they became great physicians with their passion intact.

Isn't it amazing that Jesus chose this unpredictable personality to be the rock upon which he founded his church?  Jesus saw through Peter's shallow thoughts and saw a man who could develop a deep and penetrating understanding of Jesus' mission.  Jesus saw through Peter's unbridled enthusiasm and knew He had a man whose passion would carry the Gospel when bridled with the maturity of the Holy Spirit. Jesus saw a man whose desperation at his failings would be the catalyst for commitment after the resurrection.

I think Jesus sees us in a similar way: He knew before we were born we would have moments of deep regret in which we mightily failed Him.  We could view those failings as catastrophic and unforgivable.  Jesus does not; the Lie that we are tempted to believe is that we can do something to separate ourselves from Jesus. The Truth is His sacrificial death was a statement of His commitment to us and His resurrection was the proof of the power of God over sin and death.

Peter and Judas both denied Jesus in their own way.  Both men regretted their decisions. One repented and became a leader of the church; one thought himself beyond hope and hung himself without ever really believing the Truth. We are presented with the same choices that Peter and Judas were when we sin against our Savior.  The act of denial and betrayal can become a door opening to the work of the Holy Spirit through repentance. Or it can become a pit of prideful despair--"I am so bad even God cannot forgive me"--a statement which is a lie that causes us to hide from God just as Adam and Eve did in the Garden.

The more we live in His Presence in the present, the more He opens our eyes to our shortcomings, not for the purpose of condemnation, but to give us strength to restoration through the Holy Spirit; to remove our denial, to penetrate to our core and relieve us of the tension that comes through pretense.  Jesus was always at work healing when He was on earth, and He still is.  He healed Peter, He is actively healing our spirits as we live in the light of His Word.  Pray for me and I will pray for you that we gain the understanding He wills for us to have and that we receive His healing with an open heart.

Thank you, Jesus.

Thinking About Roe v. Wade

Recently I attended a delivery for an infant weighing under a pound whose gestational age was under 24 weeks.  After stabilization in the delivery room the infant was transported to the NICU where he remains stable on substantial but not extreme support.  That infant has a greater than 50% chance of going home with his mother and becoming, with his cooperation, the person that God intended him to be.

If, after his birth, I had taken steps to end his life or if I had just turned and walked out of the room and compelled those on my team not to intervene it is highly probable that today I would be facing a number of problems from both a civil and a criminal viewpoint.  Certainly I would be liable for a breach of duty, perhaps for wanton disregard for life.  I could even have been accused of premeditated murder since my plan to not support the baby would have precluded others with the necessary skills from being present. At the very least my medical license (and my law license) would be in jeopardy.

If the mother walks into the NICU and attacks and kills her baby, she will almost certainly be arrested and charged with voluntary manslaughter or even murder.

If a nurse makes an egregious error--a wrong dose of a medication or a mistake in the management of the ventilator--and the infant dies as a result of that breach of her duty of care, she and the hospital would face the civil consequences of a law suit and the possibility of actions against the nurse's license.

Yet today much of America, along with our President, is celebrating the anniversary of Roe v. Wade (again).  Under Roe v. Wade, had this mother decided the day before her delivery to go to an abortion clinic and had she conspired with the staff at that clinic to end her fetus' life, she would be a free person, as would the entire staff of people who participated in that baby's death.  No one's civil liberties would be put at risk except the fetus who had been murdered.  No one would face a suit for civil breach of duty.  No one's license to practice nursing or medicine would have been put at risk.  According to the current thinking of our President and many of like mind, all the actions taken would have been praiseworthy because the rights of the mother to "reproductive control" had been preserved.

If someone shoots and kills you, do you think where you are standing at the moment really matters:  is indoors more acceptable than outdoors; would the fact you were ventilator dependent and in a hospital mean that the action of that person was legally acceptable?  Even if you were terminally ill, would a family member or a total stranger ending your life because you were an inconvenience to them or to "prevent you from suffering a miserable life" be considered an acceptable action, without legal consequences?  Of course not.

So, why does the location of the fetus whose birth I attended recently have implications about when I could legally have ended his life?  How are the uterus and the placenta functionally different from a bed and a ventilator? Both settings provide protected rest, nutrition, and life support until the individual can regain (or gain) the capability of independent function.  (Statistically, the fetus, left unharmed, has a substantially better chance of survival than an adult on life support, and meta analyses have shown that the predicted number of productive years of unborn fetuses far exceeds that of a population of adults on life support--so a utilitarian, faced with an either/or choice, would let the adult die and keep the fetus alive.)

On the day before that delivery, ending that little boy's life would have been "exercising a woman's right to privacy" with the full support and praise of most of our media, our politicians, and a very large minority of our population. At the moment the fetus moved out of the uterus, even before the cord was cut, ending the same child's life would have exposed the killer to severe civil, criminal, and career consequences, along with a firestorm of media criticism and almost certainly a comment by our President about the need to protect our children from senseless violence.

Abortion is legalized, senseless murder based on an arbitrary, totally manmade legal construct of when protected life begins.  If our politicians and courts decide, as some radical philosophers have suggested, that meaningful, protected life only begins when one is able to care for oneself, are we going to let parents decide that their six month old is too much trouble and take him to a euthanasia center to be rid of him?  Or if Grandma and Grandpa are bed ridden and can no longer care for themselve, do we condemn them to the same fate?

Ridiculous you say--that could never happen; we would never allow it!  But hundreds of years of slave trade happened; and Nazi Germany really is not a myth; a million people died in Rwanda 20 years ago this April; legally assisted suicide is a reality in this country.  Been to Amsterdam lately?  Be sure to be in good health if you go--especially if you are over 60.

The unthinkable is only impossible until our consciouses are so seared and insensitive that we no longer care enough to fight for what we know is right.

A Little Bit of Heaven

God destines us for an end beyond the grasp of reason. Thomas Aquinas, Summa Theologica

Joy is to be found in Heaven now by anticipation and later by realization. Joyful are those people who have two feet upon the earth, but who breathe Heaven’s air. Steven J. Lawson, Heaven Help Us!

I am certain that whatever my anticipatory picture of how life will be in Heaven, it is heavily flawed.   If it were fully known how life would be there perhaps, like the apostle Paul, we would be more anxious to go now than would serve God's purposes here on Earth.  As it stands, God gives moments of peace and pleasure and shared love here, I think, both as a reason to remain and as a foretaste of life to come. Last week Jason (my eldest son) and I were privileged to have one of those moments.

We traveled to North Carolina to visit with friends that we first met in 1977 during my fellowship at Duke. We were only in Durham for two years, but the bonds of friendship that grew from those years has been sustained for 36 years, through years of camping together in at least eight states, from attending weddings in Durham, Athens, and Birmingham, and through the constant contact that electronic means of communication provide.

I think one of the true measures of friendship is the ease of being in one another's presence.  Though I had not seen any of them in several years, there was an ease of renewal that defies explanation except on a supernatural basis--I believe that God gives us those kinds of friendships as a reminder of His charity to us in redeeming us for Heaven.  The inability to fully express the emotion of those times is a reflection of the inexpressible nature of gifts of God that go beyond our full comprehension--if we could fully express all that it means, the largeness of the time would be somewhat diminished.  Such will be Heaven.

I know that in time we will be brought together again, perhaps for another wedding as the third generation matures and begins adult life, more likely for a funeral as our first generation ages into the reality of that eventuality.  But whether in joy of a new beginning or in sorrow for a separation (for a while), there is a comfort in the reminder that these visits bring:  that these moments, full of love and laughter, feasting and play, are brief glimpses of what eternity, in part, will hold.

C. S. Lewis comments (in Mere Christianity) that a three year old would have a very hard time being convinced that anything could be better than chocolate and that adults wonder how anything could be more pleasurable than that provided by sexual relations.  I find myself wondering how anything in Heaven could be more warming and satisfying than being with old friends in a beautiful location, but I have faith that all of us, the three year old, we adults in general and those who gathered this past weekend at Hyco Lake will be astounded at what God has in store that will cause all of these pleasures to pale by comparison.

So, the final reminder for myself: enjoy the momentary joys that are a foretaste.  But do not grasp them in a manner that makes an idol of the creation.  Like daily manna in the wilderness that was replaced by the milk and honey of the Promised Land, the momentary joys of the present are not to be grasped as a means of sustaining them but released so that our hands can reach for the final prize--being in the eternal presence of God the Father and His Son--Heaven.

Come now, Lord.

It becomes us to spend this life only as a journey toward heaven . . . to which we should subordinate all other concerns of life. Why should we labor for or set our hearts on anything else, but that which is our proper end and true happiness? Jonathan Edwards, “The Christian Pilgrim”

For three things I thank God every day of my life: thanks that he has vouchsafed me knowledge of his works; deep thanks that he has set in my darkness the lamp of faith; deep, deepest thanks that I have another life to look forward to—a life joyous with light and flowers and heavenly song. Helen Keller

Kibogora 2013: Where is Home?

We really did not leave Kibogora this year--at least not completely.

Kibogora came back to Mobile, in our hearts, in our minds, in the thought processes that dominate daily life.  To reinvest in the daily life here while remembering what we left behind is difficult--knowing that Valentine will probably never get the cardiac evaluation she needs, and will probably die a young death from the congenital structural problem that was so obvious on her exam. Her story is representative of many other patients.  Identifying the need for care is just the start in Africa--finding a way to supply the need is often beyond the capability of the hospital or the infrastructure of care within the country as a whole.  This is especially true for medical disorders or highly specialized surgical problems without local solutions.

Micki and Valentine

We are thankful for the group of USA (as in University of South Alabama) surgeons, Jon Simmons, Andrew Bright, and Kristen Hummel, who, along with J. C. Bataneni from the Congo, performed many procedures while at Kibogora.  They gave Tim Berg, a general surgeon from Texas who is spending a year with his family at Kibogora, a much needed break.  Laura Jelf, who will be doing her internship in Baltimore in a trauma surgery unit, worked with them, and when they departed, she carried on care for patients they had seen and assisted Drs. Albertson and Berg in their work.

Drs. Andrew Bright, Jon Simmons, J. C. Bataneni, and Kristen Hummel

Andrew, Laura, Kristen, Jon, and Duane in OR

Laura Jelf, Kristen Hummel, and Jon Simmons at work in the OR at Kibogora:

Laura and the African Mutts, Salt and Pepper

Joseph Sewell, Meagan Pate, and Carter Edwards, joined later by Anna Foust, were the Internal Medicine team, a unique experience for 4th year students who team with Congolese and Rwandan generalists to run the medicine wards at Kibogora.  In a manner similar to last year, their abilities prompted the local physicians to rely heavily upon their knowledge and understanding of the problems their patients faced.  

Anna Foust, Joseph Sewell, Meagan Pate, and Carter Edwards--The Medicine Mean Team

Meagan and Anna on Medicine Ward

Carter contemplating the view from Kibogora

Joseph pondering a diagnosis

The Pediatric team rounded in the Neonatology Unit, on the "well baby/maternal" area, and in general pediatrics.  The time was one of significant loss of life due primarily to the complications of preterm birth and the difficulties of managing infants without the necessary equipment and technology.  Duane asked us to think of one word to summarize the trip and, being ambivalent, I thought of two:  persistence--Kibogora will become better and better at caring for newborns with the persistence of people like Julie Yerger, who is in the first year of her second four year commitment to sharing the love of Christ through her nursing care and overall leadership;  and risk--when you go to Kibogora and see the need, you cannot "unring" the bell--the needs and the people become part of the fabric of your life and you cannot leave that behind no matter where you go geographically.

 On rounds in the "NICU" with Jamie Partain, Mary Margaret Clapp (nearest), Julie Yerger (center), Katy Lalor, and Keith Peevy

Jamie Partain, who took a month of her vacation to go to Kibogora

Her input in the NICU will have lasting benefit

Peds team:  Mary Margaret Clapp (with friend), Anna Foust, Jamie Partain, Katy Lalor, and Micki Peevy

Katy Lalor and Dr. Nathaneal, a Rwandan doc with whom we rounded on Pediatrics....hmmmmm....his favorite expression!!

Mary Margaret

Carl and Francie Albertson are still in Kibogora, having committed to a two month stay.  Carl is an orthopedic surgeon who has gone, often with Francie and family, to Africa many times and to several places.  He and Duane Baxter "checked out" Kibogora in October of 2011 before we committed our group to go there last year. They flew a 5 day round trip to spend 30 hours at Kibogora--that is commitment to an idea!!

Francie and Carl Albertson

Carl, along with Daniel Smith, a fourth year student headed to Jacksonville for an orthopedic residency, worked the longest hours of anyone.  They performed many procedures to repair old injuries, congenital problems in children, and new problems that presented to the hospital while we were there.  Carl also conducted spiritual rounds on Sunday afternoons, taking time to pray and visit with his patients.

Carl and Daniel at work

Daniel before the beard

and afterwards, always aware of where the food was!! He burned all the calories working on orthopedics.

Sarah Beaver, a Duke trained physical therapist who works in Fairhope, traveled with us and used her expertise to help patients and to educate the local therapist.  She is picture below with Micki after the Nyugen Forest Canopy Trail trip as we had tea and coffee at the Nyugen Lodge:

Leadership came from Duane Baxter, who planned this entire trip and who is the spiritual leader of our group.  

Duane (white shirt) with Dr. Jon Simmons.  This trip is a product of God placing a vision in Duane's heart.

Duane preparing to do dental surgery (not!)

When Duane left to return to the States, Joseph Sewell became the leader for devotionals and did a great job of facilitating discussions as we studied Phillipians.  

A few pictures and words cannot adequately summarize weeks of travel, adventure, medical care, and relationship building that occurs on a trip like ours. Perhaps one picture can do a better job:

Faith is involved when taking adventurous walks, whether a mission trip or a stroll across a suspension bridge hundreds of feet in the air.  Unseen planning and support are required--dependence on those things that humans can do; but ultimately, before we take the first steps, we have to trust that God has ordained the steps and that he knows the end even when we cannot see it.

And it helps to take a friend:

Thanks to all who supported this trip and for all who took pictures that have been shared here.  I had a hard time finding pictures of Carter because he was usually the one behind the camera.

Kibogora 2013 Week 3

Easter at Kibogora brought a new experience to the group as we traveled for the first time on Lake Kivu in route to a rural Free Methodist Church for Easter services there. We boarded a local homemade vessel and set out for a nearby peninsula, changing a long walk into a 20 minute boat ride with spectacular scenery.  The boat had a gasoline powered motor which died within a couple of hundred yards of our destination, leaving us adrift on the placid lake for a few minutes as the owner tinkered with the motor.

Thankfully the motor restarted and we puttered on in to shore in time for church.  The pastor from Kibogora led us in a brief hymn of thanks as we docked--I was struck by his practice of gratitude for a small success--how often do I thank God for arriving home for work each day?

To board the boat we hiked down a mile long mountain path to the lake and had a shorter walk up to the rural church that sat atop the ridge of the peninsula. The brick church had walls and a roof but, like many of the churches in Rwanda, had windows without glass, doorways but no doors, and red dirt floors.

The service began at 9.  There was much singing, both congregationally and by choirs. Members of our group were seated in specially prepared seats behind the pulpit (a wooden desk covered in a sheet and decorated with colorful banners.)  Our seats were a wooden bench covered in green cloth. The sun shining through the colored overhead cloth cast a strange pastel glow on the pulpit area.

Almost all of the singing was accompanied by dancing, some choreographed in the various choir performances , but joyful dancing occurred during the congregational hymns as well,  and many of our group joined in, much to the delight of the children.

The service lasted over four hours and included a new member ceremony, a baby dedication ritual, a brief homily by one pastor, a longer sermon by the senior pastor, and, at the end, communion.
Afterwards we were ushered to a classroom in the school next door and given a lunch of goat meat, goat liver, beans, rice and gravy, and soft drinks.  Meat here is scarce with many families only having it on major holidays so the meal was a real gift to us from the local church.

Afterwards we slipped and walked down the steep red dirt embankment to our boat and returned to Kibogora.  We got our exercise for the day by climbing from the boat landing back up to the housing compound, a walk of about a mile with a 1000 foot change in elevation.

The week at the hospital was the busiest and most tragic of either year here.  Monday Hope, the seven month old with  unresolved  respiratory distress continued to do poorly and a staff meeting resulted in a decision to send her to the children's hospital in Kigali.  She arrived without incident on Tuesday and is being evaluated there.  Tuesday began normally with rounds in the NICU and then the pediatric building.  Around 11 o'clock we received a request to attend a term c/section, so Jamie Partain,  a trained neonatal nurse practitioner and Katy Lalor, soon to be a pediatric neurology resident, volunteered to go while we continued to help see the 40 or so peds patients.

Shortly I received an urgent call from Katy asking for assistance with the undiagnosed preterm triplet delivery that the term c/section had become. We (Micki, Mary Margaret Clapp, soon to be a family medicine resident, and I) climbed the two ramps leading from the peds ward two levels up the hill to the OB resusitation area.  The triplets weighed 1 kg, 1.15 kg, and 1.47kg and all three had respiratory distress.  We transferred them to the NICU and added the support available but the two largest died of respiratory failure within hours, leaving only Sunshine (our name for her since mothers refuse to give names to their newborns for the first few weeks in Rwanda) to struggle for survival.

Wednesday night about 10:25 we were called to the NICU for twins weighing 1500 grams each plus a baby weighing 1600+ grams whose bowel was outside the abdomen (called gastroschisis).  The twins had mild respiratory distress and were quickly situated with oxygen cannulas and placed in incubators.  The baby with the gastroschisis presented a decision that is too common here--enter into care that is almost certainly futile but will prolong life for a few hours or a day, or provide palliative care and do nothing else.  This infant's problem in the US is very difficult to manage and requires extended ventilator care, so in conjunction with the missionary general surgeon, Dr. Tim Berg, we decided to not pursue anything but comfort care--the infant died Thursday morning in Micki's arms as the mother and grandmother looked on, unwilling to hold the baby.

Thursday morning, we were called to a c/section for a preterm baby.  While we were stabilizing that 1640 gm baby, Dr. Ngoy rushed in from the c/section with the twin that they had been surprised to find when trying to evacuate the placenta of the first baby. Baby 2 weighed only 880 grams and had been hiding out!!  Both had respiratory distress and were placed on nasal oxygen, but are now off oxygen at this time.

We went to a late lunch, but were called back down for a deterioration in Sunshine (the surviving triplet from Tuesday, who had suddenly become difficult to oxygenate.  She never improved and died later that day in Mary Margaret's arms, probably from a brain hemorrhage. Frequently here mothers refuse to see or hold their dying babies, a cultural habit that seems to go hand in hand with their refusal to name them until they have survived for weeks.

The same day, while waiting for another c/section a woman walked in off the road and approached Micki, who was setting up the resuscitation area for the delivery we were attending.  The woman patted her abdomen--Micki, not understanding the gesture asked her what was wrong. The woman proceeded to unwrap a 1200 gram little girl from a blanket, apparently having delivered at home or in route.  Micki sent someone for me and we evaluated the baby who, though very cold, was in otherwise good shape.

Soon afterwards the OB team delivered a 27 week pregnancy by c/section (weight 900 gm) and we had our 10th premmy in just over 48 hours.  We settled that one on nasal cannula cpap and drug ourselves off to the houses for dinner.  Ten babies, four deaths--in the US perhaps one death or none--the lack of technology impedes the obviously better nursing and physician care that is evolving here.  The lack of ventilator support or surfactant to treat respiratory distress, the lack of IV nutrition, the absence of pumps which can accurately deliver IV volumes, and the lack of routine blood gases and electrolytes make management of all sick neonates more of a guessing art than a scientific endeavor.

Friday Mary Margaret, Micki, and I, along with Julie Yerger, the Free Methodist missionary nurse from Washington, and Esphrosine, the Rwandan charge nurse and our primary English--Kinyarwandan translator, had to tell mom and dad that their three week old who has never fed except by tube, should be taken home so that they could, have time with him before he goes to Heaven.  Esphrosine, whose soft heart shows with every new death, struggled to keep her own composure as she translated our words.  The parents were sad yet glad to be going home which, though only about 12 miles away, was a 4 hour walk and a 1.5 hour car ride over very poor roads.

The mother of that infant had her money stolen earlier that day. In Africa one has to,pay the bill after discharge or become a boarder at the hospital until the family or the village of origin sends the funds. The entire hospital bill for 18 days was just over $150 USD and after insurance the parents 10 % was about $15, so our group gave the money to the social worker somthatntheyncould go on home.

Though this year has been much busier than last year, we have been blessed to have Julie Yerger here.  She is an amazing person of great perseverance and optimism in the face of very difficult circumstances.  She is the "go to" person for the nursing staff and has made significant improvements in care since she returned in June, having taken a year furlough after four years here prior to that.  Her balanced, realistic approach to the realities of what can be done here have made an otherwise unbearable few days no less sad but easier by far on our team.

Jamie Partain has worked tirelessly while not feeling all that well and is helping Julie review nursing policy to try to improve care while also being a care giver on our team in both the NICU and the peds ward (not her comfort zone).  Katy and Mary Margaret have never complained and dove into patient care like seasoned residents, helping to stabilize babies, attend c/sections and do whatever had to be done to provide the best care we can here.  Micki has returned to her respiratory care roots, added some nursing care, and is a provider of gifts to moms through her compassion in end of life situations and her provision of knitted caps for all the NICU babies.

On the weekend the "old folks" rested while the nine younger of the group split into either going back for another hike in the rain forest or a boat ride to Kumbya, the missionary retreat nearby.  Sunday, April 7, is the day Rwanda marks the beginning of the genocide mourning period so we stayed home for our own church service. Later the pediatric group went up to the house of Dr. Ngoy and his wife to see their seven month old twin girls, Gabriel and Gabriella, who were born here late last August.  We had dinner with them and then headed to our compound before the beginning of the evening genocide recognition service.

It was a full week.  We leave Wednesday for Kigali and Friday for home.

Kibogora 2013: The first two weeks.

Kibogora 2013

From Grace Community Church to Mobile Regional Airport to Houston' Texas to Washington, D.C. to Addis Abbaba, Ethiopia to Entebbe, Uganda to Kigali, Rwanda to Kibogora Hospital on Lake Kivu in southwestern Rwanda--Saturday morning to Tuesday evening--eighteen souls from the Mobile area and one from Nebobongo in the Congo who joined us in Kigali--arrived to share medical care and nursing care and physical therapy and respiratory therapy and English skills and, most importantly, share and experience  the love of God with the patients and staff of the Kibogora community and with each other.

The flight from Washington to Addis Abbaba, a long thirteen hours regardless of the conditions, was not one for someone who did not like children--directly behind us and audible to everyone on the plane was an 18 month old whose shrieking began with boarding and recurred periodically until we landed the next morning. Fortunately, he was occasionally distracted by his three year old sibling, who with another couple of toddler travelers made the two aisles of the plane a full circuit track, laughing with delight as they completed their mid air marathon while the Ethiopian attendants turned a blind eye and a very deaf ear.  No sleep was to be had.

There was a little excitement in Addis as six of us found that our status was "standby" shortly before leaving Washington, and initial attempts in Addis to change to an assigned seat were met with a lack of urgency only achievable in Africa.  But, we had prayed about it at Carl's suggestion and about an hour before boarding the gate attendant assigned us seats.

We spent the night in Kigali after visiting the currency exchange and a grocery store, staying at the Good News Guest House, a remarkable improvement over last year's Eden (after the Fall) Motel.  Tuesday morning we boarded a big yellow Canary Buslines vehicle and were off for the eight hour ride to Kibogora--the road was much better this year, much of the mud and rock roads from last year having been paved by the Chinese who are draining the natural resources of Rwanda in exchange for the improvements in infrastructure.  Last year's driver (Mario Andretti Nugashami) would probably have made the trip in under six hours, but we would have all aged years in the process, as we did last year.

We began our first day at the hospital on Wednesday, the 20th, and were delighted to find that the "neonatology" unit was under the guidance of Julie Yerger, a native of Washington state who is serving her second four year tour at Kibogora.  Julie is the "go to" person this trip for everything from housing and food provision to laundry services and travel, but her job as a nurse trying to improve neonatal outcomes via improvements in OB care and newborn services makes her an invaluable asset to Kibogora; and her cheerful, matter of fact approach to each new question has been great.  Edi, a nurse from Germany who spends months here every year and was a great asset last year arrived about the time we did.

Just after we began work we were asked to evaluate a three year old whose name is Valentine (pronounced with the last syllable "teen") whose surgery to relieve post burn contractures at the elbow had been postponed because of a heart murmur and low oxygen saturations (80's).  After examining her we are convinced she has a form of congenital structural heart malformation--probably Tetrealogy of Fallot.  Her surgery has been indefinitely postponed while we try to get her heart evaluated by the pediatric cardiologist in Kigali.  Valentine, meanwhile, is the life of the pediatric ward and has captured Micki's heart.  She has a ready smile and is a ham as soon as a camera appears.  Please pray that she can be properly evaluated and get the surgery she needs, which if it occurs, will be done by a team of Belgiun surgeons who visit twice a year in Kigali.

Both the neonatology unit and the pediatric wards are busier than last year.  We have already seen children with malaria, many xray proven pneumonias, severe thrombocytopenia (as in zero platelets), and a variety of other respiratory and neurological disorders. There are no platelet transfusions available and no IVIG so treatment for thrombocytopenia, a life threatening disorder readily treatable in the States, is limited to steroids, prayer, and patience.  Leukemia is part of the differential, but we pray that this is a post viral syndrome that will be self limited.  

One little boy with malaria had a hematocrit of 13.  He was considerably more active after a transfusion that raised his hematocrit to 20, a level that would leave most of us unable to do much but sit.  We are also evaluating him for sickle cell disease, but Rwandans seldom have that problem, unlike many other African groups.  

Another boy about 12 years old is bed bound for reasons that are unclear.  He was beaten by his parents and has clear neurological deficits. His older brother lovingly cares for him-- his parents have not been permanently incarcerated because to do so would make orphans of all the children.

We are caring for a newborn whose mother threw him down a toilet pit after birth. A neighbor discovered what had happened and helped to retrieve the infant from the sewage and get it to Kibogora. 

The baby appears okay in spite of worms crawling from its ears and eye lids.  The mother was arrested, but brought to the nursery so that she can nourish the baby with feeding.  When the baby is discharged it will go to the jail with the mother so that she can continue to feed it.

On our first Saturday we traveled to the Nyungen Forest and hiked a 1.5 hour trail in an African rain forest--aptly named that day--and traversed three suspension foot bridges over deep valleys hundreds of feet below--not a trek best suited for the acrophobic.  After our hike we drove through a several hundred acre tea plantation to the Nyungen Lodge, an exclusive tourist lodge catering to expats who study the chimpanzee population of the area.  We had tea, coffee, and hot chocolate served with tea biscuits.

Sunday we attended Kibogora Free Methodist Church and then retreated as a group to the gathering house where we listened to a great Tim Keller sermon on the first chapter of Phillipians.   That afternoon the three volcanoes on the north end of Lake Kivu were clearly visible, and the active one in the Congo could be seen emitting smoke as the sun set and glowing as night fell. I have seen few thigs as beautiful as that view.

Returning here is a blessing mixed with the same sorrow and sadness that life can be so cruel and unfair to the "least of these".  The blessing of American and Western medicine is never more apparent than when we see easily diagnosable and treatable disorders here that go without adequate management because of the poverty and the limited technology and training.  People like Julie Yerger and Edi and Janet Stewart (the head of the new nursing school) live out their faith in trying to change the course of care and the quality of the training of the care-takers---the turns in direction are often analogous to turning the Titanic only to find a larger obstruction dead ahead--but they are resilient, dedicated individuals who are sharing God's love and their expertise each day of their service.

Drs. Carl Albertson, J. C. Bataneni, John Simmons, Kristen Hummel, and Andrew Bright all are contributing their surgical skills, and though our time here is limited, they change lives one person at a time and give Dr.Tim Berg, the resident expat surgeon, a chance for a much needed break from the unending cascade of orthopedic and general surgery cases that flow onto this "hill far away".  Others working in our group are Dr. Sarah Beaver, physical therapist and (importantly!) a fellow Duke Blue Devil, Jamie Partain, a nurse from our NICU in Mobile, Francie Albertson, who is the warm and loving wife of Carl, and Micki, my sweet wife and the Ipad Piper of Kibogora for all the children (same as last year).  

Eight senior medical students gave up Match Day weekend celebrations with their families and a much easier last rotation of medical school to serve as internists (Meagan Pate, Joseph Sewell, and Carter Edwards), surgeons (Laura Jelf, Daniel Smith), and pediatricians (Anna Foust, Mary Margaret Clapp, Katy Lalor) to the Rwandan people of Kibogora.  Like last year, my confidence in the future of American medicine is greatly increased by observing the skills and love displayed by these individuals, who will only continue to grow as physicians as they enter their last years of preparation.  Already they have made a quick study of the system here and have plunged into caring for their patients with enthusiasm and thoughtfulness.  I have done my best to overlook the fact that almost to a person they are die hard Alabama fans.  Everyone has flaws.

Duane Baxter put it all together. He leads the Christian Medical Ministry, coordinates all of our travel plans, leads us to Rwanda and leads the spiritual emphasis of our group in the morning and evening gatherings, all the while keeping it real with a good sense of humor and many rewarding discussions.  The trip last year was his vision, and with Carl Albertson, Duane traveled three days in October 2011 to see Kibogora for 30 hours to be assured that the site could accommodate our group. 

Please pray for our health and energy, for safe travel for those already returning, and for continued opportunities to see God's hand on these children of His.

28 March 2013

See the team blog: teamrwanda2013.blogspot.com