Marilyn's Musings

 

Tenwek has been a unique experience for me this year. I have struggled to understand why it is so. Since the Ob-Gyn department now has three levels of our Ob-Gyn Residency in place, a lot of the minute-by-minute decisions are made by them. I now serve more as a consultant/staff person overseeing their decision-making and growing surgical skills. I rarely need to “scrub-in” to guide them through a gynecologic or obstetrical procedure, even though I am in the room.

I already have great respect for the nurse midwives who manage actively laboring patients. However, for the 40-50% of our patients who need cesarean sections, I will participate in the decision making by the clinical and medical officers (PA and Medicine interns)and the residents. I cannot decide if I am like a “fly on the wall” or some “guardian angel” viewing from above. Both are quite foreign to me.

This has allowed me to process patients and their clinical situations on a bigger scale. I miss the intimate relationships I had developed with patients in the past. But I appreciate more the challenges these patients bring to their primary caregivers from this new perspective.

I see the trust that the patient/mother has for them as she deals with a pregnancy loss-either early or later in gestation. I see the fear of life-threatening diagnoses to herself and her baby. Examples include severe hypertension, uncontrolled diabetes, an enormous number of serious blood clots and strokes, advanced cervical  and other gyn cancers, heart failure (in a 17 year old after delivering a premature baby that didn’t survive), overwhelming infections and an unbelievably high number of twin pregnancies (1/20 pregnancies are twins in Kenya), and on…and on….

It takes a special patience to try to educate our patients about their diagnoses. Most patients are poorly educated, and medical jargon has to be translated very simply. I see the interns and residents sitting for long  periods with the patients who do not even know what questions to ask.

I have seen vast improvements over the past 12 years in the resources available to treat patients. The Blood Bank is not as dependent on missionaries and visiting staff to donate blood as in the past. It is customary for surgical patients to have family members donate almost without exception, and if un-used, the blood can be used for other patients (which is better than in the US!).

We all need success stories. Here is mine (ours!). (JC) is a 25-year-old 8-month pregnant woman who was in a motorcycle accident. She underwent an emergency cesarean delivery at another facility, but the baby was stillborn. 5 days later she was transferred to Tenwek Hospital with an overwhelming infection. We did an exploratory surgery only to find a tear in her small bowel! This was directly related to the blunt trauma to her abdomen sustained during the accident! General surgeons were called in to repair it and to take over the care of the patient. She has now  had seven (7!!) more surgeries to ‘clean out’ the problems resulting from the infection and damage to the bowel. We thank God that she will almost assuredly survive. She will need prayerful care as she struggles with the loss of her baby, AND the physical demands on her body. We strongly lean on “We Treat….Jesus Heals.”

We all need time to escape, recover, and be reminded of God’s sovereignty. This weekend Randy, Madison (U.S. ObGyn resident visiting here with us) and I went of several safari rides. God’s creativity was on full display with the variety of animals we saw and the beauty of His physical world. We were humbled. We thank God for allowing us to be here and to experience the broad array of emotions that we always experience in Kenya and at Tenwek specifically.

I thank you for sharing this experience with me/us.

 

Love, Marilyn (Randy and Madison)

Sunset on the Mara...

Jonathon and Chelsea Swanson - a Samaritan's Purse missionary couple

Dinner with Madison Chapman and Jonathon and Chelsea Swanson - beautiful friendships courtesy of the Tenwek Community

 

Another Teen, Another Near-Death Experience.

 

 

 

 

Cynthia C. is a 19-year-old Kenyan female who came into our outpatient clinic about 5 days prior to admission, complaining of feeling dizzy, with nausea, headaches, and chills. Her exam at that time was fairly unremarkable and she had some blood work done which was also within acceptable limits. Her white blood cell count was checked and was low -normal, her hemoglobin was slightly low (not unusual for a healthy young female), and her platelet count was normal. She was sent home with the equivalent of Tylenol to take as needed and was told to return should she begin to feel worse. On 1/14/24 she came back into casualty (the equivalent of our “emergency room”) with recurrent headaches, subjective fever and chills, body aches, fatigue, nausea, and some upper abdominal discomfort. Her lab tests were again drawn and over the five day interval since being seen in the outpatient clinic, she had developed an acute injury to her kidneys with declining function, a low normal white blood cell count (arguing against a severe bacterial infection), a worsening anemia, though still relatively mild, and a severe drop in her platelet count from 150, 000 to 20,000 (with platelet counts of 10,000 or lower one worries about the risk of spontaneous hemorrhages).  She did not look particularly ill or unstable at that time, but given the rapid decline in her platelets, and the associated decline in white blood cells, and red blood cells, we were worried about the possibility of some sort of bone marrow failure of production. We made the decision to send her to a local teaching hospital about 2 hours away, where she would have access to hematology and oncology services and the opportunity for a more rapid evaluation of her bone marrow. Before the transfer could be arranged, she spiked a fever to 39 degrees Celsius (or 102.2 degrees Fahrenheit). She began to have shaking chills, lethargy, and confusion, dropping blood pressure, difficulty breathing, and a rapid heart rate. She required initiation of medication and fluids to support her blood pressure, oxygen to supplement her breathing, and rapid re-evaluation to try to assess what was happening to her. She was literally threatening to die in front of us. My intern and resident re-examined her and thought that she had developed some right upper abdominal tenderness, but nothing else had changed. The decision was made to cover her for the possibility of septic shock (a bacterial infection extending to the blood stream), and also to check her for the possibility of malaria ( a protozoal infection of the red blood cells, obtained when bitten by an infected mosquito.)  Malaria is not common in or around Tenwek, because the elevation here is about 6800 feet, and it is too cold at night for mosquitoes to survive. To test for malaria, a sample of blood is taken,  some of the blood is smeared onto a glass slide, and the red blood cells are examined under the microscope for the presence of protozoal organisms within the red blood cell. This was done by the hospital laboratory and was reported as negative. Both the intern and the resident physician remained suspicious of severe malaria because a few cases had recently been seen in the Bomet area. Our patient had not travelled out of the Bomet area, and specifically had not visited areas of Kenya known to have a high incidence of malaria. They contacted me and asked permission to initiate empiric therapy for malaria while repeating another blood smear for microscopic examination. Having never seen a case of malaria in all of my career as a physician, it seemed quite ironic to me that I should be called upon to make that decision. Since the patient was deteriorating so rapidly, and we did not yet know what was wrong with her, I agreed with their request to initiate malaria therapy while pursuing re-evaluation. She was started on therapy, her blood smear was repeated, and this time was reported as positive! This disease is almost always fatal when severe and untreated (though most cases are usually not “severe”). With treatment, the mortality drops to about 5-7%. While this disease is almost never seen in the United States, in Kenya about four million cases occur annually! I am so thankful to be working along side these young Kenyan physicians here at Tenwek. This patient almost certainly would have died without their tenacious pursuit of the correct diagnosis, and their decision to treat for what they suspected, even though there was no firm evidence to support it. As a result of their care, the patient has begun to improve. She is now off blood pressure supporting medications, her fever is down, her alertness is improving, and her blood cell count abnormalities have not worsened further. Her kidney function is also beginning to improve. She remains quite ill but looks like she should make a full recovery. Each night when the team on- call takes over, the rest of the team prays over them. A common request is that God grant them endurance, strength, wisdom, and good decision making. I cannot help but think that God, “the great physician,” was present with us on this particular night. Another day in Kenya…another disease process I have never personally seen or treated. It is a very humbling experience to work here…another example of how my “weakness” allows for God’s glory to be more clearly manifest. (2 Corinthians 12:9-10).

Malaria Infected Red Blood Cells

The Medical Service team (left to right): Dr. Tony Ochala, MO Mutai, MO Lee, "Dr Randy", MS "Jay" (from S.Korea), Dr. Gogo, Dr. Lily, MO Rachel, MO Yegon, and MO Mupa.

 

Thoughts on Suffering

 

 

During our first week here at Tenwek, I have been encouraged by my friend Madison to read a book entitled “The Insanity of God; A True Story of Faith Resurrected,” by Nik Ripken. The general theme of the book is that persecution and suffering are to be expected as part of the Christian life, and where suffering is greatest, one often sees remarkably deep faith and miraculous results from obedience to God and His leadings. At Tenwek there is no shortage of human suffering, and despite this (or perhaps because of it), I have encountered many people with deep, rich, faith-filled lives. One example from this past week:

Sharon C. is a 17-year-old Kenyan female who recently suffered the death of her child during birth. While still grieving, she herself became increasingly ill and short of breath. Her heart size was enlarged on chest x-ray, and her lungs began to fill with fluid. She had an echocardiogram (ultrasound of the heart) which showed post-partum cardiomyopathy (weakening of the heart muscle following delivery of a child, which leads to symptoms of heart failure and shortness of breath). She progressed to respiratory failure and had to be intubated and mechanically ventilated. She was aggressively treated with medications to improve her cardiac function and to clear the fluid from her lungs. After several days of aggressive support, she was improving and was weaned off the ventilator. She was extubated and seemed to be doing well but remained incredibly sad and emotionally flat. Her family rallied around her and provided love and support. The intern (Alice) taking care of Sharon, was also very attentive and emotionally invested in her care. Typically, Alice would earnestly pray over Sharon at every encounter, and ask God to heal her body, to comfort her spirit, and to give peace and comfort to her family members. After a few days of improvement, Sharon was again noted to be getting increasingly short of breath and tachycardic ( having a fast heart rate). Her chest x-ray showed what looked like a large fluid collection in the right chest, and two attempts were made to aspirate and remove this “fluid” to help her breathing and oxygenation. These attempts were unsuccessful, and Sharon’s condition continued to deteriorate. She again required intubation and mechanical ventilation. Follow-up chest x-ray showed a progressive “whiting out” of the entire right lung field, and it became clear that she was developing a severe pneumonia rather than a pleural fluid collection.  After several days of ventilation and broad-spectrum antibiotics, she again was improving, and extubated herself (pulled her breathing tube out) during one of her more agitated periods. She was re-intubated because of her decreased level of alertness and concerns about her ability to protect her airway. She remained on sedation while intubated, but despite this was able to “self-extubate” two additional times. After the last episode, her chest x-ray demonstrated a pneumothorax (a collapse of the right lung). She required re-intubation and also the placement of a chest tube to re-expand the right lung. Each of these procedures has undoubtedly produced much pain and suffering for Sharon and her family. Currently, she has been weaned off the ventilator and continues to slowly clear the pneumonia in her right lung. We are all praying that she will eventually be healed. Suffice it to say,  she and her family have had “more than their fair share” of suffering during the course of her hospital stay.

I find myself asking God:  “how much more must she and her family endure?”  I have not been able to talk with Sharon directly (yet) to know how these events might be impacting her faith (or lack of it?), but I can certainly see the effect that it is having on her intern, and her family members. They all continue to exhibit a deep faith that God is present in Sharon’s suffering, and that He is sovereign. The family trusts that we are doing our absolute best to care for her but note that we are also reliant on God for the outcome. In addition to teaching us empathy, resilience, and compassion for others, suffering  “…produces endurance, and endurance produces character, and character produces hope, and hope does not put us to shame, because God’s love has been poured into our hearts through the Holy Spirit who has been given to us.”  (Romans 5: 3-5). As Nik Ripken puts it:  “suffering is one of God’s ordained means for growth of his church. He brought salvation to the world through Christ, our suffering savior, and he now spreads salvation in the world through Christians as suffering saints”  (Nik Ripken, “The Insanity of God; A True Story of Faith Resurrected”).

Other than suffering vicariously for Sharon, and patients like her, I cannot say that serving here at Tenwek involves much discomfort for me personally.  I have a comfortable apartment to provide shelter, the climate is temperate, the food is plentiful and good, and the fellowship provides me with a buffer against loneliness and insecurity. Seeing God at work here among the patients and staff, and having the opportunity to serve alongside them, continues to deepen my personal faith and my determination to follow Jesus to the best of my ability. Watching others suffer and experiencing that suffering along with them is always difficult ….but then, “when everything seems like crucifixion, remember – there is always resurrection in Jesus” (Nik Ripken).

La Pieta - by Michelangelo, St Peter's Basilica, Vatican City

Teach me your paths

Dear friends and family, 

Marilyn and I arrived safely in Kenya a few days ago, and are getting settled into our positions here at Tenwek Hospital. This year, we are accompanied by one of our mentees from San Antonio who is now in his 3d year of his OB/GYN residency. We have known Madison and his wife Savannah since their first year in San Antonio, when Madison arrived at UTHSCSA as a new first year medical student. During that year, they attended a CMDA marriage retreat at our home in Fredericksburg, and have subsequently  become close friends and mentees. It has been fun watching him grow and mature from new medical student, to nearly fully trained OB/GYN physician. It has also been exciting and rewarding to be able to accompany him on his first international mission trip to Africa. He and Marilyn have been less busy than usual, but have already been involved with some C-sections and surgeries. I look forward to hearing and writing about the experiences that await them here. The medical service where I will be working, is again overflowing with the very ill, and the very unusual (at least compared with US inpatient services). As has been the case on previous trips, I have been struggling with doubts and uncertainty about the call to serve here. The last few months have been somewhat of a “spiritual desert” for me, and as a result I have not felt the usual “pull” or “tug” on my heart that I have experienced in the past. I’m again questioning if this is where I’m supposed to be despite prayers for guidance and discernment. Consequently, I am following the advice given to me by one of my previous pastors: “when not certain about what God is calling you to, just keep doing the last thing that you felt clearly called to do, and continue to prayerfully await the next clear leading”. I guess time will tell if this is wise counsel…I’m hopeful that it is. In the meantime, I feel woefully inadequate to the task at hand. I can certainly relate to the feelings described by the apostle Paul: “For the sake of Christ, then, I am content with weaknesses, insults, hardships, persecutions, and calamities. For when I am weak, then I am strong.” (2 Corinthians 12:9-10). Fortunately, I have had very little in the way of insults, hardships, or persecutions thus far.  Weakness and calamities on the other hand, I’m no stranger to.  Feeling strength through Christ…I’m looking forward to. Please be in prayer for us again this coming month – particularly for wisdom, discernment, good clinical judgement, health and endurance. Stories and experiences will be forthcoming…till then… 

 “Show me your ways Lord, teach me your paths. Guide me in your truth and teach me, for you are God my Savior, and my hope is in you all day long.” (Psalm 25:4-5).

Leaving is hard, but the memories are forever

Dear Friends,

We have again reached that point in our trip when it is time to say goodbye. This is always such a bittersweet time for us…we are tired and ready to come home, but simultaneously realize that some our recent acquaintances will not be seen again. One thing has become apparent to us  over the years however:  our circle of “Tenwek friends” is ever enlarging, and one never knows when these connections may someday “intersect.”  For example, we first met Jonathon and Chelsea Swanson when Jonathon was an emergency medicine physician doing a fellowship in ultrasound in 2019. Three years later, we unexpectedly meet up again at Tenwek where they are now serving a 2-year commitment through the Samaritan’s Purse postgraduate program…such a sweet reunion it was! Many of the Kenyan doctors that we are now working with, we first met when they were medical students rotating through Tenwek Hospital. Dr Mike Chupp who is now the head of CMDA in the US,  we first met while he was serving as a surgeon/orthopedist at Tenwek. We recently had the pleasure of reconnecting with an old acquaintance from many years ago – Dilley (see photo below), who is a lifelong missionary to Kenya (along with his wife Ruth). Dilley has now become a patient at Tenwek and is travelling 8-9 hours from his home to receive regular care in the eye clinic. In the past, we have spent many hours listening with pleasure to Dilley recount stories of his time in Kenya, but never expected to see him or Ruth again. On our last night at the guesthouse this year, Dilley turned up to have dinner with us, and the reunion time was an unexpected joyous occasion! Of course, no trip to Kenya would be complete without a visit to our dear sister-in-Christ, Matilda Ongondi (see photos). I met Matilda on my first trip to Tenwek when she was serving as the head of the medical team that I was assigned to. She was my “lifeline” to the foreign world of Kenyan medicine, and was so sweet, faith-filled, and kind, that she has since become a forever friend. As many of you know, we also had the pleasure of hosting her at our home in San Antonio some years later when she just happened to being going there to study hematology/oncology at the UT Health Science Center SA. She is now a part of our extended Tenwek Family. Lastly, we are now headed out to reconnect with our dear friends – Peter and Petra Axt. We first connected with the Axts when they were serving together on a medical/surgical team in Guatemala. At that time, they were living in the Netherlands, and we never anticipated seeing them again. As Marilyn and I began making annual trips to Kenya, our journey often took us via connecting flights through Amsterdam. On one of these occasions, we decided to attempt to meet up with Peter and Petra on our way home. We met in Amsterdam and had a lovely reunion with them. Subsequently, we have tried to meet up with them annually on our way home from Tenwek. We have had some memorable times together in Prague, Bruges, Athens, and Lisbon…this year we are planning to visit them in their new retirement residence in Faro, Portugal. As we make plans to depart for Portugal this evening, we reflect back on all the wonderful blessings that we have encountered on our various times of service in Central America, and more recently in Kenya. Some of the biggest blessings have been the friendships that we have made along the way!

Kwaheri Kenya and Tenwek…till we meet again!

Jonathon and Chelsea Swanson

With Joshua - a medical student from Ghana, serving on the pediatric team

The OB Team - Sharon, Gideon, Brian, Cheryl, Albert, Jackie, Zapporah, Patricia, Marilyn, Monique, and Tabitha

The medical team 2022 - Dr. Obala, CO Joram, CO Wanyonyi, MO Lily, Dr Rwamba, CO Hillary, MO Rachel, and me.

Game night with the Cowles - Dean Cowles, Dr. Amanda McCoy, Dr. Monique Wubbenhorst, Marilyn, Me, and Dr. Cheryl Cowles

Reconnecting with old friends - Marilyn, Dilley, and Me.  Dilley and wife Ruth are lifelong missionaries to Kenya.

A visit with Dr. Matilda Ongondi in Nairobi.

Matilda and Marilyn

Such a sweet long-term friendship - Dr. Matilda Ongondi 💞💞