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

Have You Considered My Son?

I have often wondered why God ordained that the story of Job be placed in the scripture.  The story of Job seems to stimulate more questions than answers.  My mind tends to go into loops of circular thinking when I consider how the God of love appears to conspire with Satan to bring down one of God's creation from earthly success to the depths of despair--to prove a point? to win a wager? Job is surrounded by "friends" who not only are wrong, but disagree among themselves in expressing their erroneous theories about his downfall.

In the end, Job is privileged to be both praised and challenged by the God of the Universe--"Have you considered my servant, Job?" God asks as He speaks near the end of the book.  After He has dispensed with Job's friends and their misguided interpretation of Job's life's tragedies, He proceeds to challenge Job's protest that he has any right to self-determination based on self-righteousness or a short-sighted human sense of fairness.  In the end, He restores Job to his former prominence materially and socially, even more so than before--with one vast difference--Job now has a much fuller understanding of life and His relationship to his God.

Jesus's story seems to have many parallels to Job's.  He was wealthy beyond our imagination before coming to earth--the King of all creation, worshiped by angels, feared by the evil one and his minions, who knew their eternal fate.  All of that wealth and joy and comfort came tumbling down to a manger filled with straw, surrounded by barn yard animals, with a blue collar daddy and a teenager mother who conceived out of wedlock.  Raised in a backwater town hours from Jerusalem, living under the dangerous circumstances that brutal Roman rule and local rebellions produced, His child hood was disrupted by a sudden departure to a foreign country to escape the murderous hand of Herod.  As we become aware of Him as an adult we find He has lost His earthly father; His mother places expectations upon Him that He is reluctant to meet; His brothers, lost as to who He is and what He is about, treat Him unkindly.

Like Job, He is surrounded by men whose resume's would not impress and whose wisdom is lacking; the best educated and most formally religious of the lot eventually betrays Jesus in an effort to manipulate his own earthly political purposes.  Jesus' efforts to redirect the misguided religious leaders of the day results in rejection followed by persecution and ultimately the most horrific execution imaginable in that era of history or any other.  Surely, after His death many must have decided, like Job's friends, that He got what He deserved--isn't that how life works, then and now?

Once again God has taken a prosperous life, that of His own Son, and allowed its devastation.  The greatest injustice in all of history--the perfect man murdered--and God stood by and let it happen.  But Jesus is restored--resurrected.  Quietly He goes about making Himself known to a few hundred people and then ascends to be with the Father who allowed Him to be cruelly murdered.  His restoration is complete with the  knowledge that He has provided a way for us to be with Him.

Periodically, to a lesser or greater extent, we are Job.  We may experience the seemingly premature death of loved ones like Job; the loss of property pales in comparison, but we also experience those kinds of downturns.  We may be like Issac--every time he digs a well someone else claims his work for their own--ever done work and had someone else take the credit?  Like Paul, we may have been on the non-Christian end of persecution, dishing it out at some point in our life, and now suffering under the same persecution. Though not physically exiled, we could be on our own Island of Patmos emotionally, isolated from former friends, family, or coworkers who no longer have anything to do with us.  And we are asked to be like Jesus--to act in faith that allows us to go beyond our circumstances and trust the One who is risen, who overcame.

We are not entitled to an answer or an outcome or to feel sorry for ourselves. We are shown the Cross and told that His grace is sufficient. I think God, upon hearing our grumbling over our circumstances, would say:  "Have you considered my Son, Jesus?" Nothing we have experienced or can ever experience can go beyond what Christ suffered for us.

Thanks be to God the Father that He knew the end before He began, that Jesus' death and resurrection was known to be coming before the creation of the universe, and that His love for His creation, for us, would be so great that He would allow His beloved Son to go through torment because He knew how it would all turn out. He asks us to stay the course but only in the light of His Son and His life and His suffering, and His redemptive acts.  The promise of restoration is ours, perhaps in this life-perhaps not; but the greater promise is eternal restoration and life on the New Earth with Jesus.

Thank you, Jesus, for what You did.  Thank you, Father, for being God and for your patience when we question your omniscience and omnipotence.  Help us to experience our resurrection in Jesus, to know restoration as Job did, whether here on earth or in the New Earth to come.  Amen.

The Garden and the Cross

And he withdrew from them about a stone's throw, and  knelt down and prayed, saying,   “Father, if you are willing, remove  this cup from me. Nevertheless, not my will, but yours, be done.” And there appeared to him  an angel from heaven, strengthening him. And being in an agony he prayed more earnestly; and his sweat became like great drops of blood falling down to the ground.  Luke 22:41-44

I am prone to overlook the humanity of Jesus.  In doing so, I discount the struggle He encountered in remaining obedient to His Father's will.  To forget His agony in the Garden allows me to attribute His willingness to go to the cross as merely "a God thing"--He was divine and could endure anything through His divine nature. Tacitly I am saying, "My cross is too heavy for a human to bear--He could do it because He was God, but those same expectations should not be placed upon me."

If I see the cross without considering the Garden, I fail to learn the complete message of the crucifixion.  He dreaded the events that were about to transpire and, in His humanity, He asked God for another way.  When another way was not provided, He showed the humility of an obedient Son and went to the cross.

What do I learn from Jesus in the Garden?  First, I learn that painful circumstances occur in everyone's life, even the life of God's Son.  Through that I know He can commiserate with my own painful times in life.  I learn that it is okay not to just stuff my feelings and "grin and bear it"--its okay to ask for relief, to seek a way out of the pain by asking God for circumstances to change.  I learn that when His answer is "stay the course", constrained obedience, not angry rebellion or sullen passiveness is the proper response.  And, eventually, I learn that the reward for obedience is a new perspective on the experience-- in retrospect, perhaps in this life or perhaps not until in the next, I learn why my prayer for relief was not met with the response I sought.

Oswald Chambers repeatedly exhorted his readers to "remember the Cross".  Paul, in his letters, frequently plead with his gentile churches in Asia and Europe, to focus on Christ crucified.  They both knew the power of the crucifixion to change each life that focuses there.  God came to earth, suffered and died; and then He overcame death.  That power can only be divine, and I am prone to see only the divine power, not the human suffering and the anticipatory dread that lead up to the cross. The lesson from the Garden restores the balance of "fully human, fully divine" in my view of Jesus, and gives me the courage to persevere, to humbly ask for relief, and in an equally humble spirit to ask for the constraint to be obedient through circumstances of life that are painful and temporarily unabated.

Jesus loves us and He knows what we are feeling, not only because He is omniscient but because He was in the Garden.

Lord, help us to see it is okay to ask "for this cup to pass from us" and then, if it does not, to bear our crosses obediently.  Amen.

A Letter to the Rebellioius

You may wonder, "Why?"  Why address a letter to the rebellious? Because we are fallen, and our fall resulted from our rebellion.  This letter is to me and to you.  

He gave us instructions: The Ten Commandments.  Can you recite them?  And "Judge not that you be not judged" is not one of them, lol, though our post-Christian culture would have you believe it is the first and greatest commandment--"leave me alone, let me do what I wish, and I will do the same for you, so long as what you do does not interfere with my selfish desires."

We unknowingly seek God in all of our wants, thinking that we can replace the true first commandment by worshiping the creation, by seeking pleasure as our god as though it will replace the joy of knowing and honoring and worshiping Him.  As G. K. Chesterton said:  "Every man who knocks on the door of a brothel is looking for God.” "We seek our satisfaction from that which was intended for our delight--only He was meant to satisfy." (Bruce Johnston, JH Ranch).

We defeat the first two commandments in one fell swoop: not putting Him first and worshiping creation.  Then we deceive ourselves: we think we are not committing blasphemy simply because we do not use profanity (or maybe we do).  But we ascribe to God things that are not of Him; we credit/blame Him for things of our own doing and assuage our conscious by attributing our action to His leading.

I will not go through all the remainder of the 10.  You get the picture.  We don't keep the Sabbath Holy consistently; we dishonor our parents; we steal, cheat, lie, covet, commit adultery (against God, if not against our mate), and kill in our hearts, and all of this is defined in the one word: rebellion.

Is it not amazing that God did not just burn it down and start over?  He could have, and would have been justified, even in our human terms of justice.  We would have no leg on which to stand legally; we would not even have legal standing to defend ourselves, for slaves do not have legal standing in their realm of service.  

But, of course, He knew of our rebellion before He created the first man.  His love balances His justice. Without love, there is just the legal consequence--death.  Without justice, there is no freedom, without freedom to choose, there is no love--there is no obedience, no opportunity for rebellion, no freedom to choose Him, or not.

If justice is a necessity of meaningful love, then the Answer to our rebellion had to incorporate justice and love--the justice we deserved, death, had to be delivered upon someone.  No created human could be that someone unless we all died an eternal death--justice would have been served, but Love would have not.  Only Someone who did not deserve death could balance the scale of justice.  Only Someone who loved humanity could have been willing to sacrifice themselves for that justice; only Someone who was obedient to the Father even unto death could have been willing to die in our place.

"Jesus is the Answer"--an often used quote, but often taken for granted.  He chose to come and live and die and submit Himself to the power and love of the Father.  He would not have been any less God had He decided not to come.  He may have been compelled by love, but He was not coerced, just as He will not coerce us to be obedient, to set aside our rebellious ways.  

We either lay down our own wills out of love or we rebel.  Receive our daily bread or forfeit peace; pray or prey; be lead from temptation or yield to it--yielding sounds passive but it is active and rebellious.

The blind men in the ninth chapter of Matthew knew they could not heal their blindness but they had faith that Jesus could, and He did.  We cannot heal our rebellion, our spiritual blindness, either. Like the blind men of Jesus' earthly days, we have to ask in faith for Him to change our hearts, place in us the will and desire to be obedient, to yield to the only One in all the universe worth yielding to--Jesus.  And He will intercede with the Father for our healing.  There is no other Way.

Leaving Kibogora

The last days at Kibogora were a game of emotional twister--we were simultaneously wrapping up clinical cases (Dr. Albertson was still operating the night before we left), mourning relationships that would either end or become distant due to time and distance, dreading another 30 hours of travel, and longing for home with its emotional and physical comforts--seeing our friends and family, back to our familiar work and school environments, a bed with back support, AND            

                                                                        
                                                                      The Obsession of Certain Members
                                                                    


Things we will miss (not a complete list):

Our group--Carl and Franciie, Duane, Leanna, JC, Britni, Liz, Shannon, Melissa, Bryan (aka Duane), Luke, Cody, William, Brannon, Becky, Caroline (aka Carolina, Carolin), Micki and me--the meals together, Bible study led by Duane, Carl, and Becky at the Black House, lots of laughter and a few tears, sharing of frustrations, losses and victories;

                                                Gathering at the Black House

Games of Catch Phrase (spectator here), less than dignified dancing to Lion King (spectator again), watching nine people who had shared four difficult years work and play together; church at Kibogora Free Methodist with a 1000 of our closest friends,

                                                 Kibogora Free Methodist Church


JC Bataneni, our Congolese surgeon and friend, who is back at Nebobonga in the Congo, and Leanna, who is headed back to the northwest U.S. to continue training for her July marathon--she ran every day, using her GPS watch to measure distance.

                                                             JC and Leanna


 a day in Amsterdam;

                                            The Ladies at Grand Centraal in Amsterdam


Rounds on Destin and "Buddha Belly":

                                                                   Buddha Belly and Mom


sitting in the "internet breezeway" after rounds while being stalked by a local psych patient;

                                              Britni, Liz, and Caroline in The Internet Breezeway (with "friend")



early mornings looking out over Lake Kivu,

                                                      The View from Our Compound
                                                         
the walk to Kumbya Retreat,

                                                         The Road to Kumbya Retreat

The View from Kumbya

                                                       Micki at Kumbya Retreat

time at Good News Guest House in Kigali

                                                 Good News International Guest House

                             Back yard of Good News Guest House overlooking Kigali



Our night at Kinigi Guest House at Volcanoes National Park, gorillas trek stories, bus rides complete with "one lane chicken" provided by our driver** (see ** below)

The Congolese, Rwandan, and European staff members that befriended us and helped us feel welcome upon our arrival, and with whom we worked side by side for three weeks; especially Edi, our German friend who helped us "learn the ropes" even if "the sky was falling"; Jeanne Paul, the head nurse who always seemed to be able to get someone shipped to Kigali or Butare when they REALLY needed to go; Dr. Ngoy, our Congolese "pediatrician" with whom we shared three weeks of patient care and good humor, and Madeline, the Head Nurse on Peds, who "did not have good Eeeenglish" but always knew what we needed and provided it.

                                            Dr. Ngoy with Britni Bradshaw and Liz Donahue

                                          On the Pediatric Deck with Madeline, the Head Nurse

The patience of our patients--their most demanding moments were when they asked to go home; they were cooperative, accepting, and appreciative.

The beauty of our surroundings--every part of Rwanda we saw could have been made into a postcard for a tropical paradise (except for the road construction).  Lake Kivu and its environs were gorgeous--its too bad schisto kept us from being able to enjoy the Lake fully.

The national attitude toward a clean environment--Rwanda has a national clean up day ONCE A MONTH where markets are closed and everyone is expected to help make their surroundings more beautiful.  Litter was virtually absent--I saw one plastic bottle loose on the road and a couple of slips of paper in several hundred miles of driving.

Home made soccer balls:  children will find a way to play ball, and ball in Rwanda is football (soccer).  They tightly wrap dozens of plastic bags together and bind them with twine to create a functional, though slightly less than spherical, soccer ball.  Some of the guys on our team swapped them a real soccer ball for one of the local creations--wonder which one will last the longest?

Little kids with plastic water jugs perched on their heads--children in Rwanda are brought into the family work force early, helping to cart the daily water needs from source to home in dingy yellow jugs that they balance on their heads hands free.  The work ethic here is a necessity of survival.

Missionary midnight:  9 p.m.  The older ones of us were asleep by 9 each night or shortly thereafter.  We learned from the U.S. missionaries in Kigali that 9 p. was "missionary midnight".

Things we probably won't miss:

9 hour plane rides (x2) and (x2)

8 hour bus rides with a driver whose first two names must have been Kinyarwandan for Richard Petty.**

90 degree neonatology units

mosquitoes and the risk of malaria

patients for whom we had no answers

attack rats in our houses

houseflies and horseflies in the OR and L and D

tuna soup

power outages with a 15 minute generator delay

apathy and fatalism

stories of grenade attacks

reminders of the genocide

"Mazunga!! Give me some money!"

no portable xrays for babies

no ventilators for babies or adults


Both lists could go on.

God gives each of us unique opportunities in life.  We either avail ourselves of them or they pass us by.  They do not generally come again.  For that reason, I regret that I waited until age 62 to join a mission group.  At the same time, I am so grateful that circumstances brought us all together and gave each of us the opportunity to go to Kibogora.  Each of us might go again, but not on this trip with this group of individuals.  Part of the recovery from travel is jet lag, part is missing the group and adjusting to "normal" life back home.  I'm glad the most important member of the group for me (Micki) came home with me!!

                                                                             Micki
                                            On the Path from Compound to Hospital Kibogora

Kibogora Week Three

6 April 2012

--see also http://teamrwanda2012.blogspot.com

On Saturday most of the group walked to Kumbya Retreat, a beautiful, quiet spot on Lake Kivu owned by the Free Methodist Church since 1944.  While most went in the morning, Micki and I decided to go after lunch. By that time a large thunderstorm had covered the area, rattling windows with powerful explosions of thunder that followed closely on the heals of brilliant flashes of lightening over the lake.  Storms here come up quickly in this rainy season, often with an accompanying light and sound show, but most last only a short time and roll quickly on over the next mountain.  Those who did go to Kumbya either walked back early and were soaked or sought shelter on the porch of the house there and waited it out. All seemed to have been glad they went.

Sunday was not a day of rest. Just as we were preparing to leave for church, my local cell rang with a call for help--a small preterm infant with respiratory distress had been found in its incubator  with cyanosis and a dangerously low heart rate. There are no heart monitors, so infants often are in extremis by the time anyone realizes there is a problem. Dr. Ngoy (our Congolese friend) had bagged the baby back to viability by the time we arrived, but the infant could not  be sustained without intubation and ongoing positive pressure ventilation.  I intubated him to give all of us time to consider our options--continue bagging for days with only a glimmer of hope of success or stop right then and accept the limitations of life where we were (this infant has a 98-99% survival in our NICU's in the States). The group of students (really doctors for all intents and purposes except for a piece of paper) quickly committed to setting up a schedule to bag the infant during the evening and night, with the nurses to carry on during the day.  The latter part of our plan proved to be the undoing of the baby's chances, as just as the first folks from our team arrived the baby was discovered to be without pulse, a nurse sitting beside the baby, her hand not on the Ambu bag--she was unaware of what had just happened. William Perez gives a moving account of that afternoon in the group blog, teamrwanda2012.blogspot.com.

Unfortunately, the death of that infant was not an exceptional event. Infants with respiratory distress are placed on a nasal oxygen cannula with no means of assessing oxygen levels in the delivered gas or in the babies blood.  Without heart rate monitors and with inadequately functioning saturation monitors, no ventilators and inadequate numbers of staff to watch the babies, unattended deaths are not uncommon. There have been at least four since our arrival.

 On Monday afternoon we attended a stat c/section for a mother with a bleeding placenta previa (a dangerously low lying placenta) at 29-30 weeks gestation. We intubated the infant in the delivery room and then extubated the infant and placed her on a cannula with oxygen in the "nicu".   She weighed 1300 grams (about 2 pounds 14 ounces).  She did reasonably well until Tuesday night when a power outage stopped her oxygen concentrator from working--we went down to find her blue but breathing, with a saturation below 50 (acceptable is greater than 88 in a baby her age). Her father was at bedside and used his cell phone light to help us assess her.  After 10-15 minutes the auxiliary generator came on and she recovered her color.  We said goodbye to her dad and left, praying that the power, which goes out almost daily here, would be sustained until her oxygen needs were gone.  Early the next morning she was found without pulse or any sign of life.  Another infant with a 95+% chance of survival in our country had succumbed to the lack of support here. Lack of artificial surfactant, no mechanical ventilato, no monitors, and an unpredictable power supply were obstacles she and this delivery system could not overcome.

Early in the week, Carl Albertson, the orthopedic surgeon and our group leader after Duane's departure, was asked to see a one year old whose hand had been severely cut by a machete wielded by an slightly older sibling. The injury will require several hours of restorative surgery by Carl and his team, and months of recovery and rehabilitation will follow.  The injury was preventable merely by keeping dangerous tools out of the hands of children.  As I write this, Carl and his team are laboring to return that boy's hand to usefulness-- a critical determinor of his eventual ability to earn a living in this agrarian culture.

Children here are often left unattended at very small ages, something we noted while walking through local villages.  While driving here from Kigali it was common to see three and four year old children walking right beside the road unattended by an adult as buses and cars drove by at 50 mph. Life's value here, to many, is discounted.  The costs of risks are often not clearly counted except in the retrospective agony of injury or death. This rather pervasive attitude appears to be part and parcel of the apathetic and fatalistic view of life that an animistic culture produces.

On Wednesday Micki and I, with an afternoon free of medical activities, decided to walk to Kumbya Retreat with the hope of some quiet rest by the lake. The road to Kumbya is a dirt and rock road (mud and rock with heavy rain) that descends steeply from Kibogora, winding through the countryside, an occasional village, across one field of coffee beans, and down to an inlet to Lake Kivu, where Kumbya sits on a small peninsula.  The walk is about 3 miles, or in Rwandan distance, one to two hours, depending on how fast one walks and how many pictures of the beautiful countryside you choose to take.  No walking trek in Rwanda is taken alone, for children follow everywhere, often shouting "mazuka" and asking for money.   Somber adults speak if spoken to, and smile if they see you smile, some saying "good morning", no matter the time of day.  Children here are now learning English as the new official language so they tend to know more English than the rural adults, but everyone seems to know some form of greeting in English and/ or French.

At the retreat we watched the local boats going to and fro across the lake. They are dugouts, hollowed tree trunks that natives use for travel and fishing. Some came within a few yards of our waterside perch, their occupants waving and speaking if we acknowledged their presence, and laughing if we took their picture.  We did not swim, though the water is quite inviting-- the thought of contracting schistosomiasis, a common pathogen in lake soil and water with serious consequences for the liver, dampened any enthusiasm we had.

After a peaceful hour at Kumbya it was 4 o'clock and we headed back in order to return before dark; traveling at night on foot on the rural roads is not recommended for expatriates-- for all manner of reasons.  We decided to take the local's short cut across a field to shorten the more laborious trip back up to Kibogora.  We did not know that path involved walking across a rapidly flowing, muddy stream on two flattened logs with nothing to hold onto. Micki hesitated a moment and calmly walked across. I didn't.  I stood paralyzed, knowing a muddy dunking would make travel back very uncomfortable and would almost certainly kill Carl's cellphone, which he had loaned us for the walk  (we had excellent cell coverage the whole time).  A Rwandan woman, quietly amused at my indecision, walked over, took my hand, and without a word led me across.  When I thanked her she smiled shyly and walked on, her good deed done and my ego only slightly dinged.  What she did for me--taking my hand and showing me the way with quiet confidence and humility--is a template for all believers.

Someone offered us a hand in our walk of faith, perhaps knowing we were having a difficult time taking that first critical step.  Our vertical relationship with our heavenly Father  and our human relationships both involve a hand reaching out in humility and a hand grasped in gratitude. St. Paul said that the greatest attribute in life is love (1st Corinthians 13). No other accomplishment can take the place of love; all of our best put efforts added together are a "clanging (worthless) cymbal" if we lack love.  Agape' love, unselfish, other-motivated, selfless love begins with the hand of Jesus reaching to us, and continues as we reach out and share Him and His love with others.

Everyone on this trip has been frustrated by inadequacies--sometimes by the facility, sometimes by the attitudes, sometimes by our own shortcomings, sometimes by the obstacles put before us here.  But, as Oswald Chambers said so eloquently in My Utmost for His Highest, God does not give us overcoming life, he gives us life as we overcome--the struggle is part of the process of maturation and without it we would not grow closer to Him or to each other.  Gratitude, Obedience, Dependence is the acronym of a whole and holy life--taking His hand, offering our hands to others, and letting Him be responsible for the results.  Kibogora--the hard working Rwandan and Congolese physicians, the staff who labor under unfavorable work circumstances, the patients who wait in stoic patience for their care, the limitations of the hospital's infrastructure, the very remoteness of its location--is a lesson in offering what is possible and letting God be in charge of the outcome.

Kibogora Week Two

Saturday, the 24th, was a day of exploration for many as most of our team went to the National Forest to see a colony of Colobus monkeys and then lunched on a Rwandan island in a river that forms the boundary between Rwanda and the Congo.  The Congo is visible across Lake Kivu from our compound at Kibogora.

Micki and I decided to stay behind to rest up and I had a chance to write some, which is my way of recharging and decompressing the emotions of these days.  We made morning rounds in the "nicu" for Dr. Ngoy, who had a mandatory meeting off site.  We discovered a baby girl who was eating poorly at breast--a real problem in a culture where formula is unaffordable and carries a much greater risk of infection due to unsafe water and the removal of Mom's immune system as the final milk purifier.  More below on this little infant girl.

Sunday began with church at the Kibogora Church located a few yards outside of our compound, a large brick structure which could seat over a thousand.  The second service began at 9 a.m. (the first was a youth service--no late sleepers among Rwandan Christian teens, who came in their school uniforms) and was complete with electric keyboard and guitars that accompanied five different choirs, all of whom had clearly put effort into preparation both of the music and the choreography. Each choir, from children's to adult and all those in between, sang with a rhythmic to and fro side step. They were all quite good. After congregational singing--familiar melodies with Kinyarwandran lyrics--we were formally welcomed, and Duane went before the congregation to express our thanks.  Since the sermon was also in Kinyarwandran we left as it began and had our own worship time at the "black house" (our houses are designated by colors).

The new week began with a busy schedule, including the addition of "health center" visits by two students each day. The nearest center is a 20 minute walk*. There are 11 others throughout the countryside, and they provide much of the outpatient care as well as performing many uncomplicated deliveries. Kibogora Hospital serves as the referral center for all of them for problems that exceed the clinic's level of care.

*(It is notable that distances as measured by miles or kilometers are seldom expressed. In a country where most walk everywhere and even a 90 mile trip by car can take 5 to 7 hours, time becomes the currency of distance.)

Paradoxes abound here.  In a place where McDonald's has not yet sold a happy meal, where Starbuck's is outstripped by the coffee grown down the road and CVS and Walmart are unknowns, where paved roads and air conditioning, mowers and electric dishwashers and elevators are absent, 25 yards from the hospital gate sits a computer store. Cell minutes are sold in 90 cent increments (roughly 550 R. Francs); minutes for your wireless Internet access can also be purchased, or, if you have no computer, you can purchase time on theirs, all in a 10x10 building. Cell coverage here is better than at USA Children's Hospital, and texting to the U.S. is as instantaneous as being in the next room. Our bus driver on the way here, when not actively risking the lives of pedestrians in an uneven game of chicken, entertained himself by texting and talking on his cell, all the while negotiating curves and construction zones. Some behaviors appear to be universal. :)


By Tuesday, the baby mentioned above was no better, and with a persistent heart murmur since Saturday, we had ordered a chest X-ray, which along with auscultation and an EKG constitute the extent of available cardiac evaluation. The murmur had been louder on the right, and as it turned out, so was the heart. About the time we viewed the X-ray the infant's color deteriorated rapidly and we spent some time trying to achieve viable oxygenation, hampered by poorly functioning equipment, an oxygen concentrator as the only source of oxygen, and poor lighting and thermal support. Mom had no resources for transport or evaluation in Kigali, 7 hours away, but the hospital administration okayed the transport anyway and the next morning the babe was off to Kigali with her Mom. No report on her status as of yet, but the ultimate fate of infant's with complex congenital heart disease here is not good.


The entire week we have been treating Destin, a four year old with a major pneumonia and empyema (basically a left chest full of pus).  We needled his chest on Monday, and after the minimal test we can do on the fluid suggested a staph infection and not tuberculosis, Shannon Burgess, on Wednesday, inserted a chest tube, draining about 200 cc's of milk chocolate colored fluid with an odor that made one wretch. We have drained an additional 200 hundred cc's over the last two days, and Friday his fever was beginning to diminish.  Please pray for him--he has a long way to go if he is to recover.


Both of these patients' care have driven home how blessed we are to have simple things like wall suction, portable X-rays (when an X-ray is ordered the mother carts her child, paper in hand to X-ray), blood gases, oxygen with analyzers and saturation monitors, echocardiagrams, and, oh yeah, basic electrolytes.  For those in medicine you will perhaps be amused to know that neonatal bilirubins are reported as positive or negative, making them of use only to those dependent on Braille.  Physical exam is enormously more important when all of the tools (spelled c-r-u-t-c-h-e-s) we lean upon are absent. I think we will all be better doctors, certainly more appreciative doctors, upon returning to our technologically dependent medical worlds.


Thursday was a sad day as two of our team members and another U.S. physician headed to Kigali and on to their homes.  Richard Ellingstad is a family doc from Wisconsin who was here for two months without his wife, who had contracted severe malaria on a previous trip to Tanzania.  He was very gracious and helpful in getting us oriented to Kibogora. We will miss his presence at our group meals. Jeanne Claude Bataneni, a Congolese surgeon who traveled with us from Kigali to Kibogora, returned to his mission hospital in the eastern Congo's jungle. JC, as we know him, has returned to his birth village as the only surgeon, passing up much more lucrative and prestigious positions because he and his wife, also from the village and also a physician, have felt God calling them to serve His Kingdom there in Nebogongo Hospital. He is a kind and gentle man with a great testimony of persistence in the face of major obstacles to the practice of medicine.  Please pray for him and his family.


Our spiritual leader, Duane, also headed home to Kim and the kids.  He did a magnificent job of organizing this trip and in leading the group both in terms of logistical support, spiritual stimulation, and sensitivity to the emotions of a group far from home in a strange culture.  His calm in the face of his own fatigue and a sharp witted bunch of tired travelers has been a lighthouse emotionally. He will be missed.


Comment on week two After two weeks in this land, where Christianity is more of a palpably present influence than in Alabama, we are struck by the fatalistic approach to illness, death, and dying that an animistic cultural inflence produces. Tradional medicine practitioners (think "medicine men") discourage allopathic medicine and value their own power base and influence mor than human life. Compare that to our home culture, where a secular utilitarian view of life also erodes the Christian's high value on the sanctity of life, and deluded influence peddlers (think "politician") sell their souls on the alter of public opinion at the expense of the unborn and unprotected. Both are evils that medical providers who follow Christ will battle throughout their careers.

Here in Rwanda the battle is one on one, a relational effort to change people's hearts through the establishment of trust in our skills, our love and our faith in Christ. In the U.S. the battle is no less intense on the personal, relational front, but is compounded by the increasingly aggressive attack by the government on our rights as providers and patients to determine our own attitudes and actions in protecting all human life. Unless we are firmly founded in what AND why we believe what we do in regards to human dignity and sanctity of life, we risk having our resolve eroded.  On this issue the daily renewing of our minds in Christ through the leading of the Holy Spirit is an indispensable habit of life.  Please pray that these weeks "on a hill far away"** will be a time of formation and strengthening of values that will last a lifetime, however long those lives may be.

**see: On a Hill Far Away by Dr. Al Snyder, who gave his life to serve Christ at Kibogora