A Hard Day

Today has been one of the rainiest days since I arrived at Tenwek. It was raining when I walked to work this morning, raining as I traveled home for lunch, and raining as the day came to a close. And did I mention that it was also raining in between? Fitting weather to match my mood after a tough week.

One of the reasons I love the field of urology is that there are many conditions which are very well treated, bringing about significant improvements in quality of life. In addition, most patients recover completely without major complications. But most medical specialties at one time or another have to deal with some difficult, incurable diseases. Urology is no different.

Today, for the second time this week, I crossed paths with a patient suffering from a very unfortunate illness. These two almost identical cases left me with a heavy heart from not having the answer to my own question of “why?” Both of these patients were young Kenyan men in their early fourties. Both had initially presented to outside medical facilities with pain in the side of the abdomen. As with many patients at Tenwek, both of them had come to this referral center for a second opinion, hoping for a more encouraging prognosis than they had been given previously. Sadly, both of them had unresectable, incurable, cancerous growths in the kidney.

Metastatic, inoperative diseases are not new to me. In my young career as I urologist, even before practicing in Kenya, I have cared for patients with disseminated cancers of almost every urologic type. The disease processes are not so different here. The circumstances are.

In the states, most patients are able to find exceptional care and seemingly unlimited resources within a short drive. And for patients who deem the closest facilities unsuitable (which would epitomize the term “relative”), there are a number of internationally renown centers that specialize in cancer management. Services for patients with metastatic cancer include hospice centers, access to the latest chemotherapeutic drugs and high-tech radiation therapies, free enrollment into clinical trials testing novel treatments, and myriad analgesic medications to ensure pain-free disease progression. Not so here.

To its credit, I will say that Tenwek Hospital does a wonderful job involving chaplains and hospice personnel in the care of terminally ill patients. And I really don’t think that there are many, if any, places in Kenya where patients can get the degree of surgical care that is provided here. But as a whole, palliative options for patients with metastatic cancers are limited.

So back to my patient today. A young man and his brother had made the four hour trip from Nairobi to the western highlands with a glimmer of hope. Before introducing me to these two gentlemen, my resident (PAACS general surgery trainee) sat me down to review the patient’s CT scan. What I had originally heard was that the patient simply had a tumor of the kidney, which I felt confident could be resected. But as we scrolled through the images, I saw the cancer in his lung and spine. Unresectable.

My medical tool box seemed so feeble compared to what I had known in the states – no chemotherapy to discuss, no contact information to provide on hospice centers, no clinical trials in which to enroll the patient, no specialized pain clinic to refer the patient to when his spinal tumor becomes symptomatic. Just a sinking feeling from being the one to extinguish his flame of hope.

Parenthetically, urologists in training in the states learn very early in residency about the “too late triad” (Google it if you’re interested). The “triad” portion of this phrase describes three symptoms that can accompany patients with kidney cancers: flank pain, blood in the urine, and a palpable abdominal mass. The “too late” part implies that if a patient presents with these three findings, it is almost always too late to provide a cure.

“How can anything good come out of this visit?” I thought to myself as I concluded my explanation of his disease and its prognosis. I inquired about his family, his social support, and his faith. The encouraging news was that he was a follower of Christ. The discouraging news was that he had a wife and young children who would soon learn the details of his prognosis.

I did the only thing that I know to do in a moment like this. I asked if I could pray for him. It’s difficult to describe the humility and deep dependence on the Lord that are felt when the eternal intersects the temporal in this way. I certainly don’t deserve to be part of such an encounter, but whatever His reasons, the Lord has given me these opportunities.

Asking God to do the communicating, I put my hand on his shoulder and began to pray. During my pauses, as I waited for the resident to translate to the patient in Swahili, I began to discern the subtle sniffles. Seeing tears on a Kenyan face is a very rare occurrence, and in this moment I realized that my patient was broken. Perhaps it was discouragement from his prognosis. Perhaps is was fear of the unknown symptoms yet to come. Perhaps it was the weight of having to convey the news to his wife and children. “Lord,” I thought, “in a people who are already broken from so many other challenges in life, why more breaking?” My hope is that his tears were overflowing emotion from knowing that “the Lord is close to the broken-hearted and saves those who are crushed in spirit.”

I reflected back on our encounter, where for a few minutes time seemed to stand still, and the Lord reminded me of Tenwek’s motto … “We treat, Jesus heals.” My patient will be healed. Not because he underwent extensive surgery and not because I could offer him some new chemotherapeutic agent. Rather, he will be healed because he knows Jesus. Whether on this side of eternity or the other, a cure lies ahead. Satan may hand us the “too late triad.” And to that I say Satan, here’s the “never too late triad” – Father, Son, and Holy Spirit.

As a doctor on the mission field, it helps to remind myself that when the dust settles at the end of the day or at the end of a life, Jesus heals those who have put their faith in him. Please pray that as we direct our efforts toward curing earthly diseases, we will always remind patients of the hope that can be found in the one who offers eternal healing, and that those who do not yet know the Healer will know Him soon and know Him well.

Blessings,

Paul

Bumps in the Road

“Be flexible.” That was one of the exhortations most emphatically conveyed when I was preparing to go on my first short-term mission trip some years ago. In fact, I still remember vividly how a few of the team members and I were asked to ad lib a short skit demonstrating the importance of flexibility. After six months on the mission field, I would say that this admonition has served me as well as any.

Not every day requires back-breaking degrees of pliability, but at any moment I have to be able to handle a change in plans. The realities of third world medicine demand it. Let me give an example. There was one recent Thursday, which for me meant a 7-8 am surgery meeting, an 8-9 am academic meeting, and on this day three surgical cases. About 8:00 am, I received a phone call from a missionary in a nearby town who was having a urologic problem. He asked that I evaluate him and informed me that he would soon be en route to Tenwek.

After getting a brief history, I realized that managing his condition would require a small procedure and that he and his wife would need a place to stay. Tenwek has an abundance of visitors, so this request was easier said than done. But I promised to help find a room at the guest house. Still having the morning conference to finish and surgeries awaiting, I enlisted the help of my wife to investigate whether Tenwek could accommodate our visitors for a few days. Not that she had a lot of free time, being busy with homeschooling and getting kids out the door to class.

Once the missionary arrived at the hospital, I had to find a few minutes before my first case to help him get registered. Tenwek is now, believe it or not, live with an electronic medical record system, which means that I couldn’t order any tests until the registration process had been completed. Unfortunately, I was not yet facile with the system, so I had to ask yet another person to assist me with getting him registered.

Now on this morning I was hoping to start my first case a little early because I needed a special piece of equipment (a C-arm for fluoroscopy for those interested) which is generally utilized all day long by the orthopedic team. The fact that I had been granted this early start was in and of itself no small feat. But I knew I had to work quickly so that the orthopedic team could have the equipment back in time for their case. I certainly didn’t need anything else on my plate at the time.

My first case unfortunately went longer than I’d hoped, leaving me a little stressed about causing a delay for the orthopedic team. Following the case, I turned my attention toward helping the missionary get the tests done that I felt he needed. Because these tests had to be ordered on the electronic record system, I quickly found a clinical officer (similar to a physician’s assistant in the US) to put in a brief note for the patient and order the lab work and ultrasound.

Not wanting the missionary and his wife to wait around too long, I located a visiting radiologist and asked him to perform the ultrasound, which he was able to do right away. Anxiously listening for my pager to signal that the next surgical case was ready, I was thankful that it continued to remain silent. Following the ultrasound, I gave the patient a specimen cup to produce a urine sample, which needed to be evaluated. I informed him that I could drop off the sample in the lab for him, since that would actually be easier than giving directions (urologists don’t mind handling urine).

Before I could make it to the lab to drop off the sample, one of the residents tracked me down and requested that I go examine a patient in the general surgery clinic with a urologic complaint. No problem, the pager was still quiet. It turns out that this particular patient would need surgery that day, so I coordinated with the resident exactly what would have to be done and asked him to call me when the patient was in the operating room. Still no pager activity, but what about that urine sample I needed to get to the lab … I’d better head that way.

But before I could exit the general surgery clinic, another resident asked for some advice about a different patient with a urologic problem. Ok, sure. In the meantime I heard back from my wife that the guest house had a room available for the missionary and his wife. Thank goodness. Oh yea, I almost forgot about that urine sample sitting on the counter. I finally dropped it off with a sigh of relief and a feeling that I’d actually accomplished something.

As I left the lab and headed back toward the operating room to investigate the delay with my second case, I heard a voice call from behind … “Daktari!” (doctor). I turned around to see a Kenyan in a white coat that I vaguely recognized but had not officially met. He informed me that his father was in casualty (emergency department) with a urologic problem and asked me to come to evaluate him. I obliged with the permission of my still silent pager. Fortunately it was nothing too urgent, and I advised his father to come and see me in the urology clinic in two weeks.

By now it had been a while since I finished my last surgery and I was becoming concerned about why the next patient was not in the operating room yet. I tracked down the resident working with me, and to my chagrin found out that the anesthetist assigned to my room was only “scheduled” to work a half day and was now gone. What? This would have been good to know before the day began (if not earlier). With no hope for anesthesia, a rightfully upset patient who arrived the night before for today’s surgery was told that his case had to be rescheduled (since I was not available the next day for surgery and would then be out of town for the weekend). Unlike in the states, most of the patients at Tenwek don’t just come from “around the corner,” so you can understand his and my frustration.

Luckily, my third case of the day was a minor procedure and did not require anesthesia, so we would be able to do it without an anesthetist on hand. But not right now. As I’ve mentioned once before, Kenyans rarely miss lunch, and by now it was about 1:30 pm. Knowing my next case would likely start shortly after 2:00 pm, I trotted home to enjoy a quick bite to eat with my family.

I then learned that the driver who had just brought the missionary couple to Tenwek to see me was someone we had gotten to know recently. My wife, being the sensitive lady that she is, realized that he had probably not had any lunch, and so I gave him a call and asked him to join us at our place for a meal. He informed me that he’d be right down. If by “right down” he meant 30 minutes, then he was right down.  Those who know Kenyan culture know that he probably did come right away, but the cordial and sometimes lengthy greetings that inevitably occur when walking more than ten yards amongst other Kenyans likely accounted for his delay.

At this point, my family and I were already done eating because the kids had class and I needed to return to the hospital any minute to finish my last scheduled case. As I was preparing to walk out the door, our driver friend arrived, ready for some food and fellowship.  So I sat back down at the table and suppressed my “American” urge to race back to the hospital before I was late.  We talked about his recent transport of several missionaries to the Ugandan border and the great things that they were able to see the Lord accomplish during the trip.  As I walked back to the hospital I lamented at how I had almost let my “busy” schedule steal this ordained meal.

After completing my last case and pausing to catch my breath, I began my end of the day walk down the windy and rocky road that leads homeward. Only Ashleigh and Ivey were home, as the older three were on another part of the compound playing with friends. Ashleigh informed me shortly thereafter that she and Ivey were heading out to pick up our other three children before dinner time.

I decided to lie down for a brief rest, but just as quickly as deep sleep fell upon me, I was brusquely awakened by my pager. I had completely forgotten about the case that had been added on from the general surgery clinic. Pushing through my tired fog, I called Ashleigh’s cell phone to let her know that I needed to head back to the hospital. Disappointed by her ringing phone in the next room, I accepted that I would have to go on a hasty search around the compound to track her down (since I had the key to the house), inform her about my case, and quickly make it to the operating room. Thankfully, I found her at the first home I looked in and was off to surgery. After finishing the case and wondering what could possibly happen next, God’s grace allowed the urologic demands to fade away into the Tenwek sunset and I was able to call it a day.

While I wouldn’t say that this represents my “typical” day at Tenwek, these types of unexpected events do occur with surprising regularity. I’m not sure that I can offer any deep spiritual insights from my day of being flexible. But I think that flexibility can at least on some level be seen as a type of spiritual discipline. Sort of a sister fruit of the spirit to patience. After all, how many times did Jesus have to deal with interruptions? Perhaps more importantly, how did He respond? And how does the Lord use us during times of bending? What kind of witness do we offer when things don’t go the way we plan or take much longer than we hope?

It’s easy to get comfortable with the routine and anticipated patterns of life. My prayer for myself, and perhaps for you, is to embrace a posture of flexibility, realizing that God’s purposes are often found in the unanticipated more than in the expected.

“For my thoughts are not your thoughts, neither are your ways my ways,” declares the Lord. – Isaiah 55:8

Blessings,

Paul

 

 

Living the Paradox

As Ashleigh and I mentioned in our May newsletter, perhaps one of the most valuable lessons we learned during our time at Mission Training International (MTI) was dealing with the paradoxes that are an inescapable part of life on the mission field … good times interspersed with hard times, spiritual growth met by spiritual resistance, a longing to interact with family and friends in the states right alongside a deepening love for the Kenyan people we have come to serve. These inevitable and inseparable forces are what we refer to as the “yays” and “yucks” of daily life.

Enter September 1st and October 7th – two days that have stood out in my mind since we boarded a plane with one-way tickets to Kenya. Even before we departed, my parents had planned a five week visit, made possible by my father’s part time work schedule and his willingness to log extra days ahead of time to make up for his absence.

mom and dad and mdWe were richly blessed and humbled to experience their deep love for their children and grandchildren. This unstoppable, unconditional, unwavering love was certainly the supernatural strength which pushed aside the obstacles of jetlag, lost hearing aids, aching feet and knees from these rugged hills, fatigue from existing nearly 7000 feet above sea level, and the struggle to establish a routine in the third world while living out of a very simple one room guest house apartment. All to say “you guys are worth it.” Only the love of Christ can do that.

Van awaySo yesterday, after a wonderful five week visit from Mimi and Papa, my family watched as their van pulled off hospital grounds and faded into the distance en route to Kenyatta International Airport. Another yuck to swallow. But could it be that God allows yucks in order that we might appreciate the yays that much more? After all, it’s hard to fully comprehend just how bright the sunlight is unless you’ve experienced the dark of night. And doesn’t a glass of cold water taste best after you’ve been parched by the summer heat?

All of UsWhile we tolerate and learn from the yucks, which are a natural consequence of living in a broken world, we choose to focus on and give thanks for the yays that the Lord allows. Will I embrace more September 1sts knowing that October 7ths are waiting around every corner? Absolutely. And such is life, accepting the paradoxes but encouraged that in the not too distant future ALL yucks will be a thing of the past.

Blessings,

Paul

Unaware

While there is much to write about my first three months at Tenwek Hospital, I would like to reflect back on the road leading here …

Just the other day I was communicating with a friend back in the states who was deeply impacted by recent life events demonstrating the Lord’s omniscience and faithfullness even in the things we don’t realize.  Probably all of us have either experienced first hand or heard inspiring stories of how God reveals his character through answered prayers.  But I think it is also important, as my friend had pointed out, to recognize that God is in the business of making the paths straight for his children even when they are unaware.

A few months before I left my urology practice in the states, I remembered my need to have malpractice tail coverage.  For those who may not be familiar with this legal matter, any physician who ceases to work is still liable for malpractice claims for a number of years, which varies from state to state.  In Georgia, where I practiced, this time period is two years.

My assumption was that my malpractice coverage would be paid by the group, but to my dismay I discovered that I was incorrect.  An oversight on my part, I admit, and not an easy mistake for a diligent planner like myself to swallow.  This created a potentially major obstacle, as our mission budget had already been established.  The possibility of adding a line item for monthly malpractice premiums would be a significant burden and could even delay our departure to the field.  After mentally preparing myself for the staggering cost I expected to pay, I mustered the courage to call my malpractice carrier for a quote.  It should be noted that in my short-sighted, task-oriented mindset, I had failed to prayerfully leave the issue in God’s hands, at least consciously.

The first question asked by the insurance agent was how long I had been with the group, which was just over five years. Already a little confused about the relevance of her inquiry, I nearly fell out of my chair with her next statement – “Well, any physician that we have been covering for at least five years gets FREE tail coverage upon retirement.” Impossible. Nothing is free.  But despite my disbelief and repeated interrogation, her position could not be swayed.  So free it was.  The only caveat was that I would not be able to practice (in the U.S.) for the next two years or else I would be liable for those premiums. No coincidence that my first term on the mission field would be for two years. Also no coincidence that God had allowed me work just the right length of time to receive this unexpected blessing.

Free.  Like the unmerited gift of forgiveness that I’ve been given.  Free.  Like the feeling of having a thousand pounds lifted from my shoulders.  Free to walk through this life without having all the solutions because I can trust in a loving Creator who does.

Perhaps what amazes me the most is that as children of God, even in our complete unawareness of the struggles and roadblocks that await us around the corner, the Lord, in His omniscience and faithfulness, goes before us to make our paths straight.

From “Amazed” by Lincoln Brewster:

You dance over me while I am unaware
You sing all around but I never hear the sound

Lord I’m amazed by You
Lord I’m amazed by You
Lord I’m amazed by You
And how You love me

2 Timothy 2:13 – “if we are faithless, he remains faithful, for he cannot disown himself.”

Blessings,

Paul

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A Day In The Life

Now that I have about a month of hospital experience under my belt, I thought it would be a good time to give a quick glimpse into a day in the life of a Tenwek urologist …

roosterOn most days I am awakened by my alarm clock, assuming it goes off by 6 am.  After that time, it’s a bit challenging to sleep through the roosters crowing from the hillsides – God’s reminder for those without alarms that it’s time to start a new day.  I love the consistency of sunrise and sunset on the equator, which is maintained with a perfect rhythm.  The morning begins with a cup of Kenyan coffee and some quiet time for study of scripture, usually alongside my bride.  Gauging for distance, and free from the limitations of automobile travel, I’m out the door a good minute or two before I need to arrive at the hospital!

My current schedule includes two days of clinic and three days of theatre (no popcorn at this theatre … “theatre” is the term used here for the operating rooms).  Starting in July, I will have my own separate urology clinic day.  Until then, I wait patiently for urology patients to sift through those in the general surgery clinic.  One of my favorite parts of clinic is chai time.  About mid-morning, without fail, it’s a short break for hot chai and maandazis (a fried pastry similar to the New Orleans beignets) … no excuses or exceptions.

chai time I knew the Kenyans loved chai, but I was unaware that this tradition permeated even the medical clinics.  On my first day of clinic, I had entered an exam room to see a patient.  At the time, the clinic was a bustle with residents going here and there, in and out of rooms.  I must have only been in the room for five minutes or so.  But when I exited the patient’s room, to my surprise, were five or six residents sipping chai, eating maandazis, and jovially conversing with one another.  Now, a month later, I often find myself checking my watch for chai time.  Such an activity would seem unthinkable in the midst of a hectic clinic schedule back in the states.  More than just an opportunity for refreshment, chai time epitomizes the Kenyan belief that we should never be too busy to stop, rest, and relate.  Something to consider.

On a practical note, there are a few interesting differences in the clinic here versus in the states.  For starters, I am now taking care of pediatric patients.  This has been a bit of a stretch, as my practice in the states was limited to adults, and my last pediatric urology cases were over six years ago during residency.  This is compounded by the fact that many of these cases are not exactly straight forward.  In fact, in one short month I have already encountered several cases that I’ve never before seen and only read about in the textbooks. One month.  I can only imagine what my case files will look like after two years here.

The second variation is that the vast majority of patients in clinic are here for surgically treated problems.  In the states, we generally see a mix of both surgical and non-surgical urologic disorders.  This is not a complaint, because I love to operate.  Also, the potential to bring about a dramatic improvement in a patient’s quality of life with surgical intervention is very high (I can hear it now from the gallery – another surgeon with his “heal with steel” mantra).  Like the pediatric cases, the complexity of the adult cases frequently stretches my confidence level.  I  have learned that it is not enough to come to theatre armed with plan A, but plans B and C should also be well thought out before the gloves go on.

ORIn the theatre, I have been assigned my “own” room, #6, which the Tenwek staff have been extremely helpful in organizing and stocking to accommodate urologic procedures.  When I arrived at Tenwek, there were two surgical teams, the red and blue teams, with their respective faculty and resident members.  Though I usually round with the blue team, I have affectionately been assigned my own “yellow” team :).  One of the greatest blessings of operating at Tenwek is the opportunity to help train general surgery residents through the PAACS program.  They are exceptional not only in their clinical and surgical skills, but more importantly in the quality of their character.

When I heard from the missionary doctors here that there would be time for breakfast, lunch, and dinner with the family, I admit that I was a bit skeptical.  Of course, I’m coming from a work setting where I could probably count on one hand the number of times I’d had lunch with my family during the work week over the last ten years.  But just like chai time, the Kenyans are serious about their lunch break.  There’s no “working through lunch” just because it’s a busy day (unless your surgery just happens to run through the lunch hour).  So, the family has to put up with a mid-day meal with dad, pretty much every day.  I can’t tell you how much it has lifted my spirit to have these times with my family after a decade in the rat race.

I do take call, but only for urologic patients/emergencies.  The bad news is that technically speaking, I am on call every day, unless I’m away from Tenwek.  The good news is that the general surgery residents here cover the urology patients and consults, and their competency in doing so is very good.  That’s not to say that my evenings aren’t busy.  Facing new and unfamiliar urologic disorders has brought me back to my residency habits of consistent reading and researching.  My best estimate is that it will probably take a year or two to get into a good routine and to feel comfortable with the new urologic milieu in which I find myself. But it’s actually very refreshing.

You may be thinking that everything sounds pretty rosy as a urologist Tenwek Hospital.  Yet there are plenty of challenges and struggles.  We’ll save those for another day.  Of course they are all relative, and I can look around at the difficulties faced by the nationals in the area and feel almost embarrassed about what I thought were “trials” .

DSC_0232At the end of the day, when its all said and done, the real fulfillment here is borne out of the relationships … relationships with other missionary families, relationships with the residents, relationships with patients, relationships with our Kenyan neighbors, relationships in my own family, and most importantly the relationship with my Lord, who has so graciously granted me peace and purpose in the highlands of western Kenya.

Blessings,

Paul