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.

Realities

 
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

 

 

 

                                                                                                                                            

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

 

 

 

 

 

Fly

In 1997, Sugar Ray came out with the song “Fly.”

All around the world statutes crumble for me

Who knows how long I’ve loved you

Everyone I know has been so good to me

Twenty five years old, my mother God bless her soul.

 

I just want to fly. . .

 

This is not the song that you would necessarily expect to pop into my head while I am working  out here in Kenya—but several weeks ago, as I watched one of my patients drag her leg into the delivery room, it is the song I heard.

 She was 25 years old. I ran into her on rounds as simply “This is a 25 year old G4P2 @ 26 weeks with PPROM.”  In other words, she was a young mom with kids at home who was 26 weeks pregnant and had broken her water way too early. And she had hypertension—the going thought was that it was chronic. And she had epilepsy. And she had had a stroke at some point. Her parents were gone and she was a widow: her husband had died last year. She wept when she shared that this baby was a product of a rape. I tried to take care of her and her baby—and part of this was doing an ultrasound. This is when I saw her walking down the hall. She walked with a terrible limp. Upon examining her, I saw that her left foot had been terribly scarred and deformed—my intern explained that epileptic patients in the developing world often have these injuries from falling into open fires during a seizure.

 Twenty five years old: when I was her age, I was a young and idealistic doctor, newly minted, and about to start my internship. I had nary a blemish (except for my freckles). I was well loved and loved well. I thought I might save the world one day. My life opened up before me and I was excited to see what it might hold.

 Flash forward to now: watching that young woman struggle with her reality and all of its grimness, all I could think about was her youth, her isolation, and her locked in, closed out world. Few people had been good to her it seemed. She had no mother to comfort her. And I think both of us would have flown away that afternoon if we had had wings. She did leave against medical advice several days later.

 I saw her again two weeks later in Casualty. We were called emergently to see her. She had come back to the hospital with severe pulmonary edema (presumably from severe preeclampsia). We intubated her and we threw every medical thing we had at her. I induced her labor in order to try and save her—and the baby did not make it. But against hope: she DID. After two weeks on a vent, she came out of it. She was neurologically and otherwise completely intact—she had RECOVERED. The OB and the Medicine teams rejoiced. She went home to be with her children. We thanked God for intervening. She was a miracle.

 Two weeks later on, I was in my Gyn clinic when the Medicine attending, a visiting American doctor who had been one of the docs who had worked so hard to help this young woman, came up to me fighting away tears. He stated without preamble: “She is gone—she came back in last night in pulmonary edema. And this time, we could not turn it around. I am devastated.” And I knew he was talking about my patient, our patient—the girl who was twenty five years old and not well loved.  

 

I just want to fly . . .

 

Tragedy.  Cruelty. Violence. Inexplicable loss. Injustice. Suffering and death. Orphaned children. Children gunned down in their classroom a week and a half before Christmas.

 “Why?” my heart shouts, and then the hard question comes again: “Where is your God in the midst of all of this pain?”  When I was twenty five, I think I had more answers—I may have even been arrogant enough to try and offer some of them to people whose shoes I had not walked in.

 But this I know: deep in my heart there is a faith in a man called Jesus. He was born in a filthy hovel to a poor, frightened unmarried girl two thousand years ago. He came to show us that God is love. He came to ultimately overcome the tragedy, the cruelty, and all of this terrible loss.  Early in his earthly ministry, he said as much to some incredulous religious leaders:

The spirit of the LORD is upon me, and because of this He has anointed me to preach the good news to the poor; He has sent me to heal broken hearts and proclaim liberty to the captives, vision to the blind, and to restore the crushed with forgiveness (see Luke 4:18).

And so I keep going. I keep walking even though I no longer can fly. And I trust that my God will ultimately restore all that is crushed: our hearts and His own heart, a heart that loved us so much that He came to suffer and die for us.

 I doubt that Sugar Ray had any of this in mind when they wrote those lyrics. Still, I love that old song.

 

 

 

 

24 hours . . .

On Call

0755 I make my way up the long hill that leads from our home to the Hospital Gate. Up along the broken road, red dirt and busted old pavement, motorbikes, overloaded with passengers, children in school uniforms, women in colorful African prints, stray dogs and scattered chickens, the smell of wood smoke and flowers, bright flashes of birds darting among the purple flowers of the Jacaranda trees.

0805 I reach the doctor’s meeting room for morning report. Consultants, residents, interns and students— flurry of white coats—the sound of English softly accented in a lovely Kenyan lilt, mixed with Swahili and Kipsigis. The phone rings—“Good morning Daktari—they need you right now in Maternity.”

Strange. A senior Medical Officer, who is actually an apprenticed (if unofficial) Ob/Gyn, was on call last night. I wonder what could be happening. I soon find out.

0815 Picture to stay with you the rest of your life: A young mom, lying on the delivery table, a 24 week fetus (I guess the age) who was stillborn, lies on the cart beside her, and the mother’s small bowel has eviscerated out from her vagina—it delivered after the fetus instead of the expected placenta. She does not cry. She does not moan. Like a bird caught in a trap, she is utterly still.

0900 In Theatre. We pray with the mother. We open up her belly. There is a 4 cm laceration on the posterior aspect of her uterus. We pull the small bowel back up through the hole. I figure out the best way the deliver the placenta—the surgical resident undermines it from above and I pull it out from below. I give misoprostol. Pitocin is running. I scrub again and fix the uterus, and learn how to do a small bowel reanastomosis. *

1100 Rounds can finally begin. Forty patients, two hours behind in the day.

1105 Chai time.

1120 We begin in the labor ward. Preeclampsia, trials of labor after C-section, twins.

1130 Stat call to the delivery room: the WORST shoulder dystocia I have ever seen: older mama, grand multip, hypertension, intrauterine fetal demise. I finally deliver the baby by grabbing the posterior arm. I do mediolateral episiotomies out here. Dislodging the baby was pretty awful, but the mom was alright, and we avoided a fourth degree laceration. Fleeting thought—if this baby had not already been dead, would it have survived this delivery?

1145 Rounds start again. Labor room. Room 100 where our immediate post op and post op day #1 patients stay. Our one “private” room. Then the back wards—post ops, Gyn patients, and our antepartum patients. The acuity level here never ceases to amaze me.

1300 I am lecturing on (ironically) “Obstetric Emergencies.” The team is running late. Fortunately, time is a little different out here—it is more or less expected that we will not start on the hour.

1400 I run home to eat a late lunch. Lunch out here is the main meal of the day, and I look forward to seeing my family. I sit down and the pager goes off. Bad strip on the labor ward: the young preeclampic G1 has spontaneous late decels. We do not have continuous monitoring out here—I had requested a NST before we started an induction on this young preeclamptic patient at 34 weeks. We prepare for a C-section.

1500 There is no “thirty minute rule” here. Urgent means ASAP—find the OR team, find an anesthetist. Get the patient prepped. It takes “time and patience” as my son says. Try to rush it. Go on—use words like emergent. Get assertive. Move the patient by yourself. Fuss a little. Fuss a lot. And everything slows down a little more. And you regret not playing by these unspoken rules. Time and patience.

1600 The baby is covered in thick mec—but cries and pinks up.

1700 Finishing the day at MCH (“Maternal Child Health”). Our interns have already handled most of the issues—so perhaps and I can get home. [MCH is an ongoing, M-F, 9-5 walk-in maternity clinic. Run by nursing and a regular clinical officer (equivalent to a physician’s assistant), we help staff it with our clinical officer and medical officer interns. And I serve as the consultant.  I am impressed at how knowledgeable our junior staff is—truthfully, these interns work harder than I have seen interns work in a long time. They see huge volumes of patients, handle tough cases, teach students, study and attend lectures—on call every other to every fourth night working 36 hours straight (oops—you cannot go home post call). And they become really good really fast.  Go figure.]

1800 There are two women with previous scars (this is how we describe previous C-sections) who may be laboring. One has had successful vaginal births before, but she has polyhydramnios and the baby is literally floating. Her random blood sugar was normal but I still suspect she is diabetic. The other has a history of 2 previous sections and was admitted late from MCH.

1830 Up at Theatre. There are three cases from general surgery waiting to go—numbered 1-2-3 on the board. Below, like an unnumbered footnote, are our two patients. Umm. . . I speak with anesthesia—there is only one anesthetist on—we can only run one room right now. OK—but we cannot be fifth as the mom with 2 previous sections is laboring and the baby, and her uterus, will not wait. General surgery weighs in and says we can have the next room.

2100 Home at last after another section. A lot of adhesions—again—but mom and baby are ok. The other lady is not laboring right now. We can wait and do an elective case in the morning.

12 MN Pager goes off. Drat. My clinical officer explains: G7P6 patient with remote history of a C-section followed by successful vaginal deliveries, came in spontaneously laboring at term—heart tones lost, station lost, fetal parts palpated in abdomen, mom tachy.

0030 In theatre, massive hemoperitoneum, beautiful still baby up around liver, uterus ruptured with huge arterial bleeders. Get fluids, get blood. BP dropping. Hands work faster. A lot of prayer. She has six young kids at home. Hands work faster. A lot of prayer.

0200 Patient is stable and going to our recovery room. Adrenaline surge is wearing off—boy I am really tired.

0230 “Daktari, there is that patient with previous scar and polyhydramnios—she is in a lot of pain . . .”

0500 Back home after another C-section. Baby was huge, by the way.

0755 I make my way up the long hill that leads from our home to the Hospital Gate. Up along the broken road . . .

*This lady ultimately did well physically—but her heart was broken.  Abortion is actually illegal here, but  patients obtain them anyway from people in the community who get misoprostol or various herbs for the early pregnancies, and attempt instrumentation in advanced pregnancies. Many come in with hemorrhage that can be fixed with a D&C and blood products. But one presented with renal failure—we think from some herb—and we transferred her for dialysis—but we fear she ultimately died. She was 16. Another had uterine and large bowel perforation—she will live with a colostomy for the rest of her life. She is 17. Family Planning is not readily available to unmarried girls and women in rural areas, and married women cannot use birth control without their husband’s permission. Sadly, whether single, married, or widowed, females in this part of the world do not have a lot of control over when or with whom they have sex, when they marry, who they marry, or what choices their husband makes on their behalf after they marry.

SETTLING IN

    We are now well into our second month here at Tenwek Hospital.  Some days it doesn't seem like it has been that long, and others days we feel like well seasoned missionaries.  Like any move, whether across town, across country or across the globe, there have been moments when we are invigorated by our new surroundings and new challenges, and other times when we are terribly homesick for our friends and familiar surroundings.  However we are comforted by the peace we have in knowing that we are exactly where the Lord wants us to be.

    Joy is very busy with the OB/GYN service.  The need of the women in this part of Kenya is amazing.  In addition to the large number of births this hospital handles annually, she is also seeing women with various forms of cancer on a daily basis, and Joy has also participated in several fistula repairs in her first month.  Joy has been blessed to work with a very experienced OB/GYN surgeon from Vanderbilt University who spent many years working in Nigeria.  Andy, and his wife Judy, really took us under their wing during their stay here and helped us get settled.  Joy is also working with two excellent residents, one of whom is currently training in Greenville, SC.  Jill and I have enjoyed swapping stories about the upstate, but I don't think she has ventured to the Beacon yet.

    Life at Tenwek continues to be busy and fulfilling.  There are children playing everyday and dogs running around, including one very big Great Dane named Zeus. We are very lucky to have a  comfortable apartment with a nice view of the countryside.  We even had a nice big brown slug come in to greet us our second night here!  After several minutes of discomfort/paranoia/disgust, one of the mks (missionary kids) just told us to put on a pair of gloves and put it outside.

  A big part of life at Tenwek is having dinner with friends.  We have hosted two dinners so far.  The first was with a fellow OB/GYN and his wife, one of the long serving nurses, and a family who are adopting two Kenyan girls from a village where they are working to set up a clinic.  The second was a dinner for the hospital staff working on the OB/GYN service.  Joy and I prepared spaghetti, and the Kenyan guests made mandazis (fried donuts) and Chai.

    While Tenwek Hospital is not a town, there are several dukas surrounded the hospital.  The dukas are where we can get sandwich bread, juice, milk, and fresh fruits and vegetables.  There are butchers, salons, and even a place to make copies.  On the other side of the street from the dukas is a hillside field where people harvest vegetables and graze cows.

We hope that these pictures have given you a little bit of an idea of what our lives are like in Kenya.  We both feel very blessed to be in a place with a strong sense of Christian community, both among the missionaries and the Kenyans.  We would ask that you continue to pray for the people in the community and the people who treat and are treated in the hospital.  Finally, we want to thank everyone who has reached out to us through email or facebook.  We love our new friends, but we also miss our friends and family back in the states.  Contact with those who love, care and support us back home helps us to remember that we are merely the tip of an iceberg that is our team serving at Tenwek Hospital.

THE IRWIN’S ARE IN KENYA

     It has been a while since we have been able to update everyone, but we have a good reason.  WE HAVE BEEN BUSY.  In the weeks before flying out, there was scarcely a minute that was not being put to good use.  We were making daily trips to the dump and Goodwill trying to get our house ready for departure, and those trips were accompanied by the also daily trips to Wal-mart, BJ’s Wholesale and the Dollar Store in order to supply ourselves.  In the previous 40 years of my life I never thought I would have to try and figure out how much deodorant I would need for two years.

      At this point I will also offer a bit of advice, in case any of you are thinking of leaving your home for two years: do not try and have your house exterior painted the last week you are in town.  The people working on our home did a wonderful job, but it was an added amount of chaos we didn’t need.  I really wish we had pulled the trigger on that home improvement job about two months earlier. 

      Right now all of you are probably thinking: ‘Joy and Bill are organized professionals, I am sure they were packed and ready to go at least a week ahead of time.’  Oh were it so.  The night before we flew out, we were up to the wee hours of the morning trying to pack our 13 bags plus carry ons.  The interesting thing was there was plenty of space in all the bags, but we kept running up against the weight allowances. In the end, we managed to get most everything packed, and we were ready to go when our ride to Dulles arrived.

     While international flights are never fun (and on a side note, why do they make you troop past the people who get to stretch out on those nice comfy reclining chairs/beds on the way to your cattle car?) our flights went well.  We arrived in the Nairobi airport about 28 hours after we left our home in Richmond.  We were met by one of our neighbors in Tenwek, Dino Crognale,  along with two drivers who were needed to get our stuff and us to the guest house.  Needless to say, we were exhausted.

      The following day, with the help of the Crognales, we went shopping at the Nakamat.  The Nakamat is Kenya’s version of Walmart.  It was an interesting experience shopping to equip a home from scratch, especially a home we had never seen.  In the end, we broke our shopping up into a morning session and an afternoon session, and we probably filled up close to six shopping carts.  We should have tried to get a few pictures of this, but the truth is we were dead on our feet.  After our first day in Nairobi, I think shopping to set up a new home with jet lag and extreme exhaustion should now be considered for status as an Olympic sport, and we never would have medaled without the help of our new friends.

     After another sleepless night in the guest house, it was time to travel to Tenwek.  The last time Joy and I made this trip, it took about five hours over very poorly maintained roads.  I am happy to say that the roads are in much better shape, and the trip only took about 3 ½ hours.  It is a beautiful drive through the Escarpment - think Simba being introduced to all the other animals in the Lion King - and the Rift Valley.  When we last made this trip we saw giraffes walking beside the highway, but this time we only saw a few baboons. Upon our arrival in Tenwek, we were greeted by many of our neighbors, and we had lots of help unloading our new and old possessions.  We were also invited over to various homes for the first several days for meals.  The Tenwek community has truly welcomed us with open arms.

     We have a very nice apartment that we are working hard to make a home.  We have brought lots of pictures of our friends and family that we are going to be hanging everywhere.  It is also nice to be surrounded by our new friends.  It reminds me very much of being back on the Hampden-Sydney campus, where no one was a stranger.  When we walk out of our home, we have two banana trees on either side of the walk, and we look out over the mountain ranges in which Tenwek is nestled.   We are currently in one of the area’s rainy seasons, and there is usually a thunderstorm every afternoon.  However, we have yet to wake up to anything but a beautiful morning.

     Our first full week has gone extremely well.  Joy has been busy at the Hospital.  The OB/GYN service is incredibly busy with all types of cases.  However, she has been blessed with an exceptional Kenyan doctor who has helped her to get her footing and several family doctors, one from New Zealand, who have helped to cover this exceptionally busy service.  The good news is that Joy has been able to come home everyday for lunch to spend time with the family, and she has not been held up at the hospital too late any night.  We would ask you to continue praying for the women of Kenya who Joy is treating, and also to pray that additional doctors will come to provide for these women and their babies.

      In the coming weeks, we will return to Nairobi to obtain our work permits.  Please pray that this does not result in an entire day spent in a government office.  We will also pick up a few things that we only realized we needed after we arrived.  That will be our only excitement for the near future.  We would ask you to pray that Tenwek continues to become more and more like a home to us.  Also pray that we can be good neighbors to those who have already been so good to us, and we can be a good witnesses to each person we encounter along our way.  We have been very blessed by the Lord upon our arrival, and we hope that He is as present in each of your lives.

Until next time,
The Irwins