Kwaheri Tenwek!

Dear friends,

Our time here at Tenwek is coming to a close for another year.  It is always a bittersweet time as we say goodbye to new friends and old, and reflect back on the patients that we have helped care for while here.  It is with much joy that I can report back on a patient that I wrote about earlier this month (see posting 9/16/19, “Why am I here?”).  Her initials are E.O., and she is a 29-year-old mother of 4 young children.  She initially came in with severe mitral valve stenosis, tachycardia, severe right heart failure, hypotension, and respiratory failure.  I fully expected her to die within the first 24 hrs. of her presentation, but she miraculously survived with aggressive efforts at supportive care.  I wrote to you about how I felt that God had His hand upon her during that critical period, and how I was awed to be able to participate in His plan for her survival and care.  She remained very tenuous during the subsequent days while in the intensive care unit, and gradually was able to be weaned off of ventilatory support.  We were very pessimistic that once extubated, she would be able to support her own respiratory needs, but again she miraculously surpassed expectations, and was able to breathe on her own.  Despite this, she remained dependent on IV medication to support her blood pressure, due to the severity of her rheumatic valvular disease.  We were never able to stabilize her BP adequately, so that she could be moved out of the ICU.  In desperation, we reached out to the Cardiovascular team and informed them that we thought E.O. was as stable as we could get her with medication, and that she would likely die in the hospital, or shortly thereafter without surgical intervention for her valvular heart disease.  The long-term missionary in charge of the cardiovascular team here (Dr. Russ White), evaluated her with his team, and agreed that she had essentially no detectable blood flow past her severely narrowed mitral valve, and his statement to me was: “I don’t know how she is still alive”!  He was planning to operate on another patient the next day, but would then have a period of one week during which no surgeries were planned due to shortages of personnel, and vacation time for some of his critical staff.  He was willing to try to replace her diseased valve the following day, but reported that the patient was declining surgery because she was convinced that she had been placed under a curse, and would die if she sought medical help or hospitalization.  It was her belief that she would survive only if she left the hospital and abandoned efforts at medical care.  Many members of our team spent time with E.O. and her family explaining her disease and what was needed to help her.  They also prayed with her, and over her and informed her that our God was bigger and more powerful than any curse that might have been placed on her.  The hospital chaplain also came by and counseled her, and prayed with her and her family.  E.O. remained very ambivalent and indecisive.  She gave consent to proceed with surgery, then again revoked consent.  This pattern repeated itself several times, before her family finally intervened and gave consent on her behalf, claiming that she was not able to rationally make a decision for herself.  Finally, as she was being prepped for surgery on the afternoon of 9/25, with the consent of family, and ultimately of the patient herself, she was taken to the operating room for mitral valve replacement.  Dr. White had confided in me that he was uncertain what to expect.  He did not know if her right ventricle would recover from being chronically overstretched and dilated, or whether it would recover once the mitral valve obstruction was relieved.  He thought that there was a relatively high risk of death intraoperatively, or shortly thereafter.  E.O. was covered in prayer by our team and myself as she went through surgery.  On the last day of our time here at Tenwek (9/26/19), I awoke with some trepidation and anxiety.  I had not been called about E.O. overnight and presumed that this meant that she had survived the night, but was uncertain about her status.  Marilyn and I walked up to see her in the recovery room this morning, and I was greatly relieved to see E.O. sitting up in bed, extubated, and alert!  She looked as stable as I have seen her over the course of her hospital stay!!  I silently thanked God for bringing her through her ordeal safely, and expressed to E.O. my joy at seeing her on the road to recovery and wished her and her family a happy and blessed life.  I told her that I would be returning home later today, and asked permission to have my picture taken with her.  Once again, she refused,…then consented…  I am confident that one day she will be able to smile again, and will come to believe that the curse that she has believed to be her destiny has been lifted by the grace of our great God!!  Glory be to God on high…. and thank you for the life of E.O.  May she have a long and joy- filled life, and may she be a living testimony to the love and grace of God…both to her family, and to her community.

To our Tenwek family ….Kwaheri!  To our U.S. family and friends…see you soon!  To Peter and Petra…see you in Lisbon!!

E.O. in recovery following mitral valve replacement!

A message from Marilyn

Dear Blog Aficionados,

Randy has again offered me an opportunity to post on our blog. One of the many blessings that Tenwek offers to us as a couple is the time to share deeply our joys and concerns from our daily experiences  (limited access to the distractions of TV, the internet,  and our phones help immensely). He senses perhaps an opportunity for me to understand better, and to share with you, what Tenwek has come to mean to me.

When I left Tenwek last year in October 2018, I entered into an incredibly tumultuous year. I retired from my Ob/Gyn practice which had enriched my life for 33 years. I had anticipated an upheaval of emotions and had put into place the chance to thank so many people for the joys and blessings of those years. God presented an idea to me (thru a casual conversation with a patient’s husband) to develop an outward and visible sign to those people who shaped those years. Rob Grimes used his Godly hands to create Women Partners mugs, and also a special set of mugs with a heart logo on them. I spent the year leading up to retirement handing out those mugs to the people who had become symbolic of what I loved. Those cups overflow with love and gratitude to so many patients and peers and co-workers who graced me with their trust. So many of my patients have become life-long friends and essentially have become extended family. You know who you are and how you have enriched my life. My partners, and the new young doctors who have joined our growing practice, know the depth of my commitment to those relationships. I learned from them, and was humbled by all of them.  I am eternally grateful to God for these people and years.

And now He has blessed me again with a similar opportunity at Tenwek.  He sent such an obvious sign when, on my first day of retirement, I was invited to help with the development of an accredited Ob/Gyn Residency program at Tenwek.  PAACS (Pan-African  Academy  of Christian Surgeons) is our governing body.  My retirement date had been set long before this opportunity presented itself. Only God could have orchestrated my transition from retirement directly into an effort to help further the development of the Ob/Gyn program at Tenwek. It was wonderful to meet up with other Tenwek Ob/Gyn ‘addicts’! Now I have a new cache of co-workers that I have the opportunity to learn from, be humbled by, blessed by,  and hopefully,  to help. What I didn’t anticipate was the joy of recurrent encounters with former patients here at Tenwek!  This year I was performing ultrasound studies one morning.   One of the many women that came in looked familiar –I said to her: “Don’t I know you from last year”?  She said:  “No, you delivered my child in 2015”.  Her husband even breached Kenyan etiquette by giving me a hug when he saw me! (Kenyans do not typically show open expressions of affection between men and women). She is now in her 4^th pregnancy, and only one of her children is still alive and well---the one born in 2015!  She is now 7 months pregnant with twins, has had 3 previous cesarean sections, currently has a placenta previa, as well as chronic hypertension (every Ob/Gyn doctor reading that has now undoubtedly broken into a cold sweat). At present her babies are starting to lag in their growth and her placenta previa is starting to be problematic. Selfishly, I would love to participate in the ultimate birth of these babies, but they will benefit from staying in the womb far more than the 4 days that I have left on this trip. God will set their delivery date and my role with them.  My love and prayers will be with Rehema and her care-givers whether I am here, or 9,000 miles away in San Antonio.

I now have a new group of peers, co-workers, and relationships here in Kenya. They will never replace my previous practice family. I no longer have the freedom of a single spoken  language, but have the opportunity to expand my means of communicating-God is SO big-I pray that His Holy Spirit is manifested  through me by eye contact, a gentle touch, a smile of encouragement, or shared tears of sadness.  I witness depths of compassion deeper than I have ever seen from the people who have chosen to dedicate their professional lives to caring for patients here at Tenwek.  I participate in prayers in other languages without knowing, or needing to know,  the meaning of the words themselves.  It is obvious when the corporate “AMEN” comes from all participants at exactly the same time that the words themselves are unimportant…that what IS important, is the corporate talking with God on the patient’s behalf. It is a sweet, repetitive occurrence shared many times throughout the day. The Christian music and singing that fills the halls during morning shift change throughout the hospital is also language independent.

I thank each and every one of you who read our missives about Tenwek, and God’s work here, and in our lives.  I write this while looking at birthday cards from friends and family in America, and from Kenya as well. Words seem to jump off the page… Joy, Hope, Peace, Love, Faith, Smiles, Laughter, Hugs and Surprises. May those words also resonate in your lives.

….and from my sister:  “Most of all, may your (birth)day be the beginning of a beautiful year…the kind you (and ALL OF YOU as well) deserve”.

I pray it is so until I return to Tenwek in September 2020.

Love to you all,

Marilyn

Marilyn's 6th Kenyan birthday!

A little cross-stitching to start the day!

Enjoying birthday cards from friends and family....

Cake and ice cream with our new visiting staff friends

Why am I here?

Greetings from Kenya to all our friends and family. 

Most years when we come to Tenwek there is that one special patient (or sometimes several patients) that seems to answer the recurring question:  “God, have you really intended for me to be here”?  I have spent much of the last week feeling like I wasn’t being particularly useful to the medical team, and again found myself wondering anew, “Why am I here”?  While on call last night, I met the “reason” for this year’s trip.  Her name is E.O. (to preserve her privacy).  She is a 28-year-old Kenyan woman who had been healthy (to her knowledge) all of her life.  She had never been under the care of a physician and had no significant past medical problems.  Her family brought her into Tenwek last night (Tuesday) with the story that she had begun having difficulty with her breathing when she would try to do anything strenuous.  This reportedly started about a year ago and gradually worsened, but she had never sought attention for these symptoms.  About 2 weeks ago, she began to have more difficulty breathing, and had been rapidly worsening since that time. They reported that she was now having difficulty breathing even when sitting and resting, and was no longer able to lie flat at night to sleep.  They also noted that her feet had begun to swell and that she was fatigued, weak, and lethargic.  The family became concerned, and brought E.O. into Tenwek for evaluation…they had to carry her into Casualty (the emergency dept.) because she was no longer able to walk.  On arrival, she was assessed by one of our visiting Emergency Medicine fellows from the U.S.  Dr. Swanson was alarmed by her appearance, and noted that her BP was quite low at 70/40; he was able to perform a bedside ultrasound evaluation of her heart and found massive enlargement, as well as evidence of rheumatic valvular disease (severe mitral stenosis and mitral regurgitation for those of you in medicine, or for those just curious!).  She also had a rapid heart rate and an irregular rhythm, which was aggravating her rheumatic valvular disease (atrial flutter with variable block to be precise).  The mitral valve narrowing was making it difficult for blood to flow into her left ventricle, and the rapid heart rate meant that the time between contractions, during which filling of the ventricle could occur, was shortened.  In all likelihood, this rhythm change may have occurred a couple of weeks prior, and “tipped her over” into fulminant heart failure with a reduced cardiac output.  This is a very tenuous and critical situation for a patient with these valve lesions, with death occurring in a significant number of these patients.  To complicate matters, there were no ICU beds, and no ventilators available in the hospital.  My intern for the night had not previously dealt with this particular set of circumstances (nor had I, at this level of severity) and was having difficulty prioritizing the various aspects of her urgent needs.  I found myself whispering a silent prayer (and not for the last time over the course of the night!) ….”Lord, now would be a good time to show up if you intend for E.O. to survive”.  We set about attending to her most urgent needs, and trying to stabilize her blood pressure.  While we were doing so, 2 of our other patients became unstable, arrested, and required our efforts at attempted resuscitation.  Sadly, these resuscitative efforts failed, and there were grieving families to console.  Meanwhile, E.O. had been teetering on the brink of cardiopulmonary arrest herself, but amazingly, had not done so while we were occupied with others.  As a result of these patient deaths, one of the much- needed ICU beds had become available, and we were able to reserve it for E.O.   A few hours after getting her into this ICU bed, she began to have more restlessness and more difficulty keeping her oxygen levels up.  She began to struggle and fight against efforts to keep her oxygen mask in place.  She began to exhibit “air hunger”… a frantic effort to keep breathing…and during this time, pulled out the IV catheter that was providing her with medications to support her blood pressure and to treat her rhythm disturbance.  It was now obvious that she was going to require sedation, placement of an endotracheal tube, and support from a ventilator if she was to survive…but there were still no available ventilators in the hospital.  As we were furiously calling around to different units in the hospital, we discovered that the operating theater was holding 2 ventilators for planned cardiovascular surgery patients who were scheduled for surgery the following day!  We decided to push ahead and to intubate E.O, and to delay worrying about how we were going to support her till directly faced with the problem…at worst, we could “bag her” (use a compressible bag to force oxygen into her lungs through the endotracheal tube) until a ventilator became available.  This generated yet another urgent prayer on E.O.’s behalf…. “Lord, I am only going to get one chance to get this tube into her airway, or she is going to arrest…please guide my hands, and spare her life…and, please make a ventilator available for her”….needless to say it has been years (thankfully!) since I have been in a similar situation, and I was feeling the stress acutely.  My own heart was threatening to escape my chest, and yet, I felt with some certainty, that God was there with E.O. (and me), and did not intend for her to perish.  During the intubation, I was not able to see her airway well, but the tube went into proper position with a single effort.  Thanks be to God!!  We now had control of her airway, and she was very relaxed after the IV sedation.  Now what!?  We had an intubated patient, but no ventilator!!  The night nursing staff in the ICU began to rotate turns  “bagging” E.O. This effort went on for about an hour, while we started making some calls and begging for release of one the reserved ventilators.  In order to obtain release, I had to directly appeal to one of the on-call Kenyan cardiovascular surgeons.  He was very gracious and listened to my patient’s story with great interest.  He made a personal visit to the ICU (now about 4 a.m. local time) and not only approved release of the ventilator for her stabilization, but also promised to review her case with his cardiovascular team the next day.  For E.O. to survive for any extended period of time, she was going to need surgical replacement of her diseased mitral valve.  In the meantime, it was our job to “tune her up” to the best of our ability with medications and other forms of support.  After securing a ventilator for her, and getting a central venous catheter placed (another long story which I won’t go into now!), we were able to administer her critically needed medications, and safely administer her much needed supplemental oxygen.  She has been steadily improving into the early morning hours, and now looks as if she may continue to stabilize.  The cardiovascular team has seen her, and will be putting her on their waiting list for a much needed valve replacement sometime in the future…I’m confident that it will happen if God wills it….I’m betting that He does.  I don’t know what God has planned for E.O.’s life, and certainly she has a long way to go before she can be thought of as stable.  I only know that I am thankful to have been led here… to have an opportunity to join God in the work that He is doing in E.O.’s young life.  On Wednesdays (today) at Tenwek, all the medical and surgical staff gathers for morning devotionals.  Here, a member of the hospital’s staff is asked to speak.  Today’s topic turned out to be “Why does God allow suffering”?   We were taken through the story of Jacob’s son Joseph, and how he was sold into slavery, imprisoned, and seemingly hopeless, only to emerge years later as a trusted advisor to Pharaoh, and ultimately a savior to the nation of Israel during a period of drought and hunger throughout the land.  The speaker’s message was: “that which man intends for evil, God can use for own His good purposes.”   The message that I heard was:  “ we don’t always understand why God allows suffering to occur, but He often uses suffering for His own good purposes”.   I trust and hope that E.O.’s suffering (as well as that of many other patients here at Tenwek) will only bring some future “divine good” into their often difficult lives.  May that be true for us as well.

With love,

Randy.

E.O.'s Chest x-ray...yes that large white blob filling her chest cavity is her heart!!

E.O.'s ECG...for those interested!

African Worship Night

A short video from African Worship night at Tenwek.  Enjoy!!

A day in our life at Tenwek

Greetings friends.  Some have asked what a typical day here is like, so I thought I would take you with me on my Thursday journey!  Unfortunately, my day begins about 1:30- 2:00 a.m…this is the time I typically awaken for the first week or so after arrival…a nasty “jetlag” effect that seems to affect me more so than Marilyn.  I manage to fall back to sleep a while later, and am then re-awakened about 5:30 by roosters crowing, and the sound of boda bodas (Kenyan motorcycle taxis) and trucks coming to life outside our guest house on the rocky dirt road adjacent to our property.  After disentangling myself from the mosquito netting which hangs over our bed here (and seems to do a fine job of trapping 1-2 pesky mosquitos INSIDE the netting), I carefully descend the steep and shallow staircase to the living area below.  The coffee maker has been prepped the night before, and after the switch is flipped, I begin to hear the water boiling and the smell of coffee begins to fill the our snug and comfortable, but somewhat chilly apartment.  The nights here are cool…usually in the 50’s- 60’s.  The days are mostly sunny and warm, sometimes getting up into the mid 80’s.  Afternoon showers are common and usually brief. This year we are very fortunate to be staying in the “Galat Guest House”, a two story, two bedroom furnished apartment named after the long-term missionary family that originally obtained funding for the construction of this group of houses.  The Galat complex consists of a large home which now houses a family of 8, (soon to be 9), with adjacent guest housing for 2 additional visiting families.  In addition, there is a large meeting room over one of the apartments, which is locally known as “the upper room”.  Here the long-term missionaries and their visiting guests gather on Sunday evenings for an hour of prayer and sharing of concerns/joys.  The Galat family no longer occupies the house that bears their name…that honor goes to the Copeland family who are currently awaiting the arrival of their seventh child!  Will Copeland is a neurosurgeon who has been working at Tenwek now for the last several years.  After a breakfast of corn flakes, yogurt, and locally made bagels, Marilyn and I sit down for our morning devotional time.  The scripture for today is Romans 15:13 -   “May the God of hope fill you with all joy and peace in believing, so that by the power of the Holy Spirit you may abound in hope”.  The day in the hospital begins at 7:30.  The critically ill patients in the HDU (high dependency unit) and ICU (intensive care unit) are seen first.  Today we are caring for a woman who has been admitted the night before with new onset diabetes, and a potentially life threatening condition called “diabetic ketoacidosis” – she is responding slowly to treatment, but appears to be gradually getting better.  We are fortunate today, and only have one patient to be seen in the HDU/ICU.  Following this, we head up to morning report, which begins at 8 am.  This is a time when all the medical and surgical staff gathers for a case presentation, followed by a discussion of a medical topic related to that particular patient.  Today, one of the surgical residents presents a summary of brachial plexus injuries with discussion limited to adult patients with trauma-related injuries.  This apparently is a relatively common injury around here with all of the boda boda accidents!  Today, I am called out of report to assist with care of a post-partum mother who has a blood pressure of 220/140 and has not been responding to IV blood pressure medications.  After morning report, the medical team gathers to discuss patients on the service before making rounds.  The time begins with a prayer for wisdom and discernment in caring for the patients that we will encounter that day.  This is followed by a brief period of scripture review and life application led by one of the Family Practice interns.  Next we review deaths from the last 24 hr. period and discuss what we believe to have happened with each case, and what we might have done differently to improve care.  Today we discuss 3 cases from the night before.  During our discussion, a patient on the female ward has arrested and we are called to attempt resuscitation.  This patient has been admitted with an unexplained anemia, a hemoglobin of 3.6, and high output congestive heart failure.  She is in the hospital to be transfused, and to have a bone marrow evaluation performed.  Her resuscitation is unsuccessful, and her family is gathered to have the news broken to them as gently as possible – this responsibility falls to my intern and myself – I have seen the patient only once, the day before, and the family has not been expecting her death – this is always a difficult discussion…in any language or place.  A chaplain assists in comforting the family, and offering prayers for them and their loved one.  We finish our medical team meeting with mendazis (deep fried lumps of dough) and chai (sweetened milk tea)…I know what you are thinking!!...and yes, I am ashamed!!...then head out to the wards to round on our patients.  Today’s rounds are relatively brief and the patients are relatively stable (by Kenyan standards)…we only have about 20 patients to see, and I am responsible for seeing 4 of the 20 (with my intern).  After rounding, I leave the interns to finish their work and their charting, and head over to one of the long-term missionary homes.  Several of us visiting staff members, have been invited to have lunch with Dr. Russ White (cardiovascular surgery) and his wife Beth.  As I am preparing to sit down to lunch, I am paged by one of my interns… a patient has arrived in casualty (the equivalent or our emergency room) in complete heart block and needs placement of a temporary pacemaker for stabilization… she has never done this procedure before and is requesting assistance.  After the temporary pacemaker is in place and functioning, I head back to the White’s home where I catch the end of the lunchtime conversation, and am treated to a delicious meal of pasta, topped with chicken and vegetables, and green beans.  Ginger cookies complete the meal, and it’s time to head back to the hospital to check on the patient in casualty.  While there, I am asked to see another patient who has come in with altered mental status, a recent witnessed generalized seizure, nausea, vomiting, and hyponatremia (low sodium level) of 113.  He has a hx of alcohol abuse and is suspected to be experiencing DT’s (Delirium Tremens).  While evaluating him, the patient in the next bed suddenly stops breathing and resuscitative efforts are begun (this time successfully)…one bed over is our patient in complete heart block with her temporary pacemaker…she is now sustaining a HR of 80 and a BP of 90/70.  Now she is in need of a permanent pacemaker, but we are told that none will be available for 2-3 weeks…such is the activity of an average day in casualty…it will only get crazier as the evening approaches.  As I return home to our apartment to get ready for dinner, I find a group of young children on my porch swing.  They are sweet, energetic, and charming.  Norah (a 4 year old Copeland daughter) engages me in a game of “I spy with my little eye”….others soon join in.  I pass an enjoyable ½ hr. to an hour before I realize it is time to go to dinner.  This evening, we have a dinner meeting with the “Friends of Tenwek” to honor all the short term volunteers and there families, and to connect them with representatives of Tenwek once they return home…we are treated to the personal story of the Copeland family mentioned above, and how Will felt his calling to mission work during the final years of his training in neurosurgery at Mayo Clinic.  The family is now entering their third year of full time service at Tenwek, and have no definite plans to return to practice in the U.S….Will’s loans from his medical school training are being paid by his sponsoring mission agency, freeing him to continue his volunteer service.  After dinner, it is time to head over to the hospital grounds for an evening of African Worship in the local chapel of the African Gospel Church.  Leading worship is a Kenyan cardiovascular surgeon…also participating is a Kenyan general surgeon, several nursing staff members, various other hospital personnel, and my medical intern, who has earlier today placed her first temporary pacemaker!  Today is the first day I have managed to make it through the entire day without falling asleep in the afternoon!  Perhaps my jetlag is coming to an end (with assistance from Norah and friends)? Tonight, as I reflect on the day, I am reminded of the scripture passage from our devotional time this morning…in retrospect, it HAS been a day filled with hope, joy and peace… a peace which passes ALL understanding given the events of the day.  It’s now approaching the end of another day…it’s again getting cool, the mosquito netting is coming down, the coffee is being prepared for the morning, and I am looking forward, with hope, for my first full night of uninterrupted sleep (perhaps)!  Tomorrow promises to be another interesting day here in rural Kenya.

With love,

Randy and Marilyn.

Our Galat Guest House Accomodations

View off our front porch

Entrance to our apartment

Our local produce vendor

Norah Copeland

Norah's friends ....and my porch companions

Friends of Tenwek dinner...Dr. Hong and family