Saturday, August 24, 2013

Things handed down

It was a difficult night. A 20 year old had come in as a referral from an outside hospital with the following story: Several years ago she had had a cesarean section, and was now pregnant at approximately 22-24 weeks. She had gone to an outlying hospital where they diagnosed an intrauterine fetal demise, and started an induction. A week later, she still hadn’t delivered and was septic. By the time we saw her, she had "the look." ("The look" is how I have come to describe the appearance of a woman who is close to death and knows it. It is in her eyes. It is a brave look. And it is also a look of resignation and sadness. There are never any tears, and there is always a profound silence). Her abdomen was soft and she had some guarding, and the fundus of her uterus was not readily palpable. The ultrasound showed a fetus—but not clearly in a uterus. I took her to theatre and found her 24 week baby outside her uterus, and a placenta that was attached by adhesions to her small bowel. Her uterus had ruptured days before and was not viable. And so, at 10 o’clock at night, I found myself doing a hysterectomy on a 20 year old.

The next morning, I received a call from my intern. We had gotten another transfer—this time from a very remote area, with this story: She is a 32 year old mama with four children. She had delivered all of her other babies at home—but this last delivery did not go well. She labored for days, finally made it into a district hospital, and was diagnosed with obstructed labor and a fetal demise. She underwent a cesarean section. At the time of her operation the doctor thought her bladder was necrotic. They sent her home on post op day #3. She returned several days later with hemorrhage and purulent vaginal drainage, along with urinary incontinence. She got antibiotics, and a week later was transferred to us septic with a hemoglobin of 4. When I went to her bedside, she too had "the look." She was hypotensive, tachycardic, febrile, and breathing 40 times a minute. Her wound was pouring out huge amounts of foul drainage, and she was bleeding. Her exam was consistent with a dead uterus sitting in her abdomen, and also for possible early necrotizing fasciitis.

And so, a hard night devolved into a harder morning. An hour later, I was in the theatre—and this case was much, much worse, because the patient’s uterus and upper vagina, along with some fascia and muscle, were necrotic and gangrenous. The smell was horrific. After two hours, we had gotten her uterus out, her vagina resected, and her pelvis debrided.

Both of these women survived surgery. They both have a long way to go towards recovery.

This afternoon I am sitting beside an open door, listening to crows calling, looking out towards the Poinsettia and Jacaranda trees full of bright little birds, feeling the soft breeze blowing through my curtains and onto my skin—I am tired and I am thinking about my patients. I know about the anatomy, the surgery, the physiology. I know how to approach their care—in the operating room and postoperatively. I know they are both not out of the woods by any means —the human body is just not meant to undergo this type of prolonged insult. But I also know that they can survive, they now have a chance. So, I know a lot of things—but I have realized out here that it is not enough just to know a lot of things.

I grew up the daughter of a physician who was a general practitioner turned child psychiatrist. My childhood and early adult years were spent beside him, soaking up everything he could teach me about being a physician—but more than that, a physician who practices out of a call to help and minister to the body, soul and spirit of a person created in the image of God. Many times I find myself thinking, feeling and sensing with my patients, the way my father did, and sometimes the feelings can be so strong I have to step away.

Yesterday, standing beside that second patient who had suffered so much and had come from such a remote place—I became momentarily overwhelmed by her pain. But I could not step away. I was the Gynecologist who had to open her abdomen and try to begin to fix what was terribly broken. She needed a Gyn surgeon at that moment—but she also needed something more. She needed someone to see beyond her broken body, beyond the anatomy, the surgery, the physiology. She was alone, quite possibly facing her final moments of consciousness this side of eternity. No one spoke her tribal language. Her family was not around. Strange people in masks were standing over her. The lights were very bright.
It was at that moment I saw "the look" come into her eyes. But wasn’t I the surgeon? Could I feel with this woman and do the things I needed to do to save her life? At that critical time, it had to be about the anatomy, the surgery, and the physiology, didn’t it? Could I let myself become vulnerable, right before I started hacking away the gangrenous tissue filling her pelvis and abdomen?

She was looking at me then. I grabbed her hand and we stared into one another’s eyes. I tried to tell her without words that she was not alone. She held my hand tightly and I looked down to see our hands grasping one another: one hand freckled, pale fingers entangled with her beautiful, dark and work- worn fingers. In the next few minutes we induced anesthesia and began surgery.

As a missionary doctor in Africa, I confront many challenges —the surgery is difficult, the diagnoses can be illusive, and the suffering of my patients often extreme. The emotional and physical toll is great. Yet in the midst of this, I am rediscovering what it means to be the kind of physician that my father was. Yes it is about medical knowledge, technical proficiency, and experience. Yes, it is about empathy, even personal vulnerability. But it turns out that the whole is far greater than the sum of the parts. And knowing a lot of things does not make you a good physician—although it might make you a good technician. There is a sacredness about what the physician does: ministering to a hurting, perhaps profoundly damaged person, created in the image of God. And it calls for something that cannot be outcome measured in electronic health records, or counted off in shift hours or time cards. It cannot be defined in terms of patient safety acronyms, or equated with teams of administrators administrating. It is what my father knew after nearly a half century of the practice of medicine.

And it is what I am coming to know, and perhaps beginning to understand, in the middle these difficult nights, in this hard place, holding onto the hand of my patient.

Saturday, February 16, 2013


My faith is grounded in a person who cares passionately for women and children. This faith led me to become a missionary and move across the world to care for women and children in East Africa. My ministry draws me into daily encounters with hurting people, and sometimes their pain overwhelms me. I then turn to the one person who knows their pain better than I ever could—and who understands, loves and forgives in the midst of our human sorrow.

Abortion and its awful consequences is one such sad and heartrending circumstance that I am encountering almost daily now. * When I came to Tenwek Hospital as a missionary doctor, I thought I would be able to distance myself from the abortion debate that I struggled over in my work in America.  I am a follower of Jesus. In my mission hospital, I practice in accordance with my Christian worldview—and am privileged to work with other doctors who share my worldview and my belief that abortion takes a person’s life.

But I am discovering that the practice of medicine in Africa is less about debates with clean lines and predictable consequences; rather, it is about the realities of caring for people whose lives are often broken in ways that are difficult for someone like me to understand:  lives who have always been lived in poverty, helplessness and at the margins.  And these realities are often so brutal that it takes my breath away. I am discovering that here in rural Kenya, abortion is widely practiced in back rooms and alleys—and it continues to take lives—but here it is destroying the lives of both the baby and the mother. And it is breaking my heart.

She is a teenager and in high school. She is home for break from boarding school. She has a secret that she is terrified will get out: she is pregnant, and although her loose clothing and has allowed her to cover it up until now, people are going to find out. The baby is moving around a lot and she can no longer deny it. Soon everyone will know. Why did this have to happen to her? She cries when she thinks of herself just last year—a top student, full of dreams, waiting for that special boy who would talk to her parents, negotiate cows for her dowry, and marry her. Perhaps they would move to Nairobi. She could go to college. She could get a job. They would live in a pretty apartment and have a big family. Her mother and sisters would be so proud of the eldest girl.

 Then she met him. He was older and married. He drew her in, complimented her, gave her gifts. She wanted to please him. She never thought it would end with her becoming pregnant and him moving back to Nairobi.

Alone. That was what she was. And so afraid.

Day #1. The abortion really hurt. She had contacted an older woman outside of Bomet whose name she had been given by another girl at her school. She went to the woman’s house, and had special green sticks pushed up into her uterus while she lay in a dirty little bed. She went back to her home and lay in her own bed. She did not feel well. Her baby was really moving around. She cried herself to sleep.

Day#2. She awoke in wetness. She had broken her water. She started to cramp severely. She waited.

Day#3.  Just pain. The baby was no longer moving. She felt hot and sick.

Day #4. Blood, and a really bad odor.

Day #5. A lot of blood. She was weak and vomiting. She could not stop shaking. Her mother had figured it out. She spoke to the relatives. They would help with the hospital fees. They piled into the car and drove to Tenwek.

Once in Casualty, she felt calmer—she would get some help. She got an IV and an ultrasound. The baby was dead. She was infected. The doctors and nurses questioned her—she told them it had happened on its own. She had wanted this baby. Would they believe her? She was taken to the operating theatre. The baby delivered, and it was macerated and infected. The baby came out with a long green stick. Now everyone would know.

Something was wrong. Other people came into the room. She felt a large amount of wetness between her legs. She heard the word for hemorrhage. The anesthetist told her she would have to go to sleep now.

Day #6/POD #1 D&C/TAH.** She is in a special unit for very sick people. She has a line in her neck with blood going into it. Another IV with medicine is in her arm. She hurts. She asks the nurse what happened, and is told something about losing her uterus. Her uterus? No man will ever have her now.

A new doctor comes in. Two new doctors come in. She does not feel right. She can’t catch her breath. She thinks she is bleeding again. Her arm hurts when they draw blood. Why is her skin bleeding?

Three doctors are standing beside her now. They talk to her about Jesus. She remembers Him. They ask her to take Him into her heart—to accept him as her Savior. Yes—yes—she wants Him. She prays and asks Jesus to save her. She asks Him to save her life too—here on this earth. She has so many dreams. She misses her mama. It occurs to her that she is falling away. She wants to sleep.

The story of this young girl ends here. She was buried along with her baby. I stood with her as she accepted Christ. She was awake and cognizant only for about 10 minutes after this. We pumped in whole blood and fluid and antibiotics. She was septic and in DIC.*** My post call intern gave her his freshly donated blood to try and turn the process of DIC around (we do not have blood components here—just whole blood and sometimes fresh blood—which has all of our clotting factors). She was intubated. The family arrived. They gave blood too—wanting to help her, and if this were not possible, perhaps some other patient.  In the end, her young heart just stopped. And we could not bring her back.

I hesitated to publish this essay because I know about the gut level response that abortion creates.  I have many respected colleagues who will read this and respond with one kind of anger, directed at laws and worldviews that do not support abortion. I have also sat with other respected colleagues who respond with anger directed toward the providers of the abortions and sometimes, at the women who attempt to procure them.

I only remember this girl. She was not a debate. She was not a consequence. She was not a criminal. She was a beautiful person, made in the image of God, who  felt trapped and hopeless and made decisions that eventually led to death. I believe both she and her child are with Jesus now. And He has wiped away every tear from their eyes.

*Abortion is illegal in Kenya and in most countries in Africa. Attempts to procure abortions illegally contribute to the overall high maternal mortality rate in the developing world. 

**Post-Operative Day #1; Total Abdominal Hysterectomy

***Disseminated Intravascular Coagulation





Saturday, January 26, 2013

The Road to Umoja

The Road to Umoja*


The road to Umoja is dirt and rock and potholes. We were driven there by Joseph, the man who, along with his wife and family, had founded this children’s home for orphans ten years ago. He picked us up on a Saturday morning in his old white pickup truck.  Along with about ten other people, we crowded into the front and back of the cab and the truck bed—and bounced our way along for a twenty minute ride from Tenwek. When we reached our destination, we encountered a gate with the name Umoja written across it in colorful paint. We pulled into a quiet little shamba and immediately were surrounded by fifty smiling kids, several house parents and teachers, a few cows and a ton of chickens. Our visit to Umoja had begun.

We were welcomed—the kids were excited to meet the new Tenwek missionaries and say hello to some returning visitors. We had come to help a visiting missionary seamstress measure the children for school uniforms. Now this is a big job—it involved getting each child’s name, taking their picture, and recording about twelve measurements on each one. 

Before this event began, we were given a tour of their home. There was a very large building like a gym with wooden benches, a couple of long tables, a kitchen at the back, and a tin roof on top. This is where the kids ate and played and studied. Then we saw the two dorms, one for girls and one for boys—large cement houses with rows and rows of bunk beds, and tin roofs. What I noticed was the heat—tin on top of cement equals very hot during the day and cold at night. I was also struck by the numbers of beds. The littlest children (about three years old) sleep on the lower bunks. I thought about how much our son loves to snuggle with us at night in our bed at home. Home. What a word.

Our son loved meeting the cows and the chickens. Umoja is actually a small farm, and part of the money that helps support this endeavor comes from the sale of eggs from their huge chicken coop. There is also a field out back filled with sukuma wiki (a local staple food—think mustard greens), and some banana trees.

Our tour done, we filed into the main meeting room to begin assigning numbers, taking pictures and recording measurements. And it was a long, tedious process. And the sun was hot under that tin roof. Our four year old did not understand why he could not have his apple juice box (warm water and chai is all that our hosts have to drink—a fruit juice mini box with its tiny straw is a luxury and out of reach).  It became very noisy too (tin roofs and cavernous cement buildings also equal LOUD). As the sweat began to run off my body, as the noise began to crescendo, as I found myself explaining in a conspiratorial whisper for the one hundredth time about the apple juice box, I began to look at that long line of kids as a burdensome project that was standing between  me and a nice cold coke in the cool quiet little apartment that has become our home at Tenwek.

And that is when I saw him.

Something about him stood out to me. I do not know exactly what it was. He was dressed literally in rags—the collar of his shirt had been partially ripped away from the main body of fabric—and his pants were too big. There was a bit of dirt wiped across his cheek. He was barefooted.  Our gazes kept meeting across the busy gym. His eyes were bright. Out of dozens of beautiful boys and girls—I kept looking out for this little one. Who was he I wondered?

Hot. Hotter. Hottest.  “Why am I here, Lord?” “Can this be over now?”

I looked down, and there he was. He was staring up at me with eyes that seemed to be filled with—laughter. In the heat, in the dirt, in the sweat, in the crowd—

“What is your name?” I asked. He looked at me full in the face and said softly,

“I am Emmanuel.”

I saw the face of Jesus
In a little orphan girl
She was standing in the corner
On the other side of the world
And I heard the voice of Jesus
Gently whisper to my heart
Didn't you say you wanted to find Me
Well, here I am, here you are
So what now
What will you do now that you've found Me?
What now
What will you do with this treasure you've found
I know I may not look like what you expected
But if you'll remember
This is right where I said I would be
You found me, what now?

And I saw the face of Jesus
Down on Sixteenth Avenue
He was sleeping in an old car
While his mom went looking for food
And I heard the voice of Jesus
Gently whisper to my soul
Didn't you say you wanted to know me
Well, here I am
And it's getting cold

So what now
What will you do now that you've found Me?
What now
What will you do with this treasure you've found
I know I may not look like what you expected
But if you'll remember
This is right where I said I would be
You found me, what now?

So come and know
Come and know, know me now**


The road back from Umoja was still the same road that I had traveled upon in the morning. But somehow, I was no longer thinking about the dirt, rocks, or potholes. I was remembering a person who had found me earlier in the day, and the words of my favorite song were going round and round in my head.  What now?

*Umoja means “unity” in Kiswahili

**Steven Curtis Chapman, “What Now?” from his album All Things New