Eric's Book: Promises in the Dark

(from Eric)

Several years ago, I drafted a series of stories and reflections from my life as a missionary doctor.  The stories center around the theme of "Walking with Those in Need Without Losing Heart".

Jesus calls his followers to enter into the broken places of the world.  That much is clear.  This may be on a personal level, like a family member dealing with a divorce or a chronic illness.  This may be on a vocational level, as a social worker or an inner city teacher or a missionary doctor.

We are called to walk with those in need.  And it takes its toll on us.  How do we avoid burn-out on the one hand and cynicism on the other?  How do we remain faithful in the midst of the tension that is our broken world, where the promises of God are not yet fully realized, and where even their smallest glimpse can be hard to find?

My hope is that this book has something valuable to add to these questions.  I'm excited to say that, after several years of refining, Promises in the Dark: Walking with Those in Need Without Losing Heart will be available October 14, 2019 (less than 8 weeks away!) from New Growth Press.

It's already available for pre-order on Amazon at this link.

Here are a couple endorsements that I've been glad to see:

“Eric McLaughlin brought me to tears with this honest look at the difficulties of the life of a compassionate caregiver. When dealing with this broken world, there are no simple answers. But there can be hope. Promises in the Dark is essential reading for anyone who walks with others through suffering and questions how to keep on going.”
- Dr. Kent Brantly, Ebola survivor; coauthor of Called for Life

“Why do we love lawyer and doctor shows? We know both worlds bear extremity, suffering, and passion, and that is at the core of what intrigues and terrifies us. Eric McLaughlin, a missionary physician, engages the raw and compelling questions of what it means to be human and trust God in the face of a world that is stark and at times cruel. Eric offers no simple answers or trite truisms. Instead, he invites us to engage the questions with the confidence that there is nothing we face that Jesus has not first entered. The song sung in this brilliant book is that death is real and horrible, far more so than our antiseptic Western world can bear, but death never gets the final word. There is something about life and love that lingers far longer than heartache, and it is this story that enables us to enter all other losses with hope. This book will intensify your passion and encourage you to live the best story ever told.”
- Dan B. Allender, Professor of Counseling Psychology and Founding President, The Seattle School of Theology and Psychology

“What does a lived-out faith look like in the throes of an African field hospital? In a world of disease, death, and brokenness—of broken promises—how does one live as a light to the world? The answers to these questions are to be found in the pages of this honest book.”
- Michael Card, Songwriter, Bible teacher

COTW: Hip Dislocation

By Jason
We have not posted any "Cases of the Week" (COTW) lately, despite the fact that every week we are all presented with something that expands our minds and keeps our noses in the books.  So much of what we see are common diseases/injuries that present long after they started, for one reason or another, which makes them more difficult to treat.
This case is no exception. It was a young man in a car accident who had a posterior hip dislocation.

We see these once every month or two.  But this one had occurred several weeks before he came to the hospital.  I remember years ago when I treated my first patient with a hip fracture, I looked in a great book called Primary Surgery, which gives incredibly poignant advice on most anything a surgeon would encounter in a developing world hospital and how to treat it with limited resources.  The picture that accompanies hip dislocations is below:

This seems to imply that putting the hip back in the socket takes about as much force as patting a dog on the head.   I have found that this picture grossly under estimates the amount of force necessary, especially for a hip that has been dislocated for a few weeks.  For our patient we gave a spinal for complete relaxation (sometimes we can do it with just sedation).  Then we tried pulling up on the patient's leg while he was on his back (this often works, but requires a pretty strong back on the part of the healthcare provider it requires moving the patient to the floor, so that no one would fall off the bed.  See poor example below.). 

When that didn't work we flopped the patient back up on the OR table and progressed to the maneuver in the first picture, but we couldn't generate enough force.  So finally we had a medical student sit on the patient's calf while another held the ankle and then did some gentle rotations, swinging the patient's leg back and forth and then we heard it - the wonderful clunk of a reducing joint.  Maybe this can be named the "Kibuye Method for Reducing Hips" in the next edition of Primary Surgery!  The patient did well and was eventually able to walk again without any difficulties.

Zigama Mama

Zigama Mama logo, designed by Carlan

by Rachel

I've always been interested in the idea of public health.  People have likened the idea of medicine in the developing world (or elsewhere) to pulling drowning people of of a raging river.  Public health is going upstream to figure out why so many people are falling into the river in the first place.  Of course, if all your time is spent saving the drowning, it's pretty hard to find the time to pull yourself away to take a walk upstream.  Important and necessary, but challenging to prioritize none the less.

After six years here, Eric and I decided to take that walk.  Ever since the first months here at Kibuye, I have been noticing a huge amount of uterine rupture (UR) cases.  They are very rare in the US, but we have about 20 cases per year here (Side note for the medical folks: I looked at cases of UR from 2015-2017 and found 55, which is over 1% of our deliveries. !!??  Only about 50% of there are on uteri with previous scar.  So we have a huge amount of UR on unscarred uteri, which is pretty rare in the medical literature.  Harder to prevent for sure...).  A big risk factor for UR is labor after a previous Cesarean section.  Everyone in the health community "knows" this, but given broken systems and difficulty in education, many women who are at risk for UR continue to labor at home, in their villages, way after their due dates, instead of receiving a scheduled C-section or coming in to the hospital to deliver under surveillance.  Some show up with three previous C-sections, in labor, and don't even know their due date.  If only we could find a way to get these ladies to come in sooner, to decide if a C-section is the best decision, and to choose a date for that C-section, maybe we could prevent some of these cases of UR.  At the very least, we can decrease complication rates of infection, hemorrhage, fetal distress, etc, which are all higher in women with emergent vs scheduled C-sections.

Enter, Zigama Mama.  This is technically Kirundi for "protect the mother."  Our Burundian friends say that's not exactly the way they would say it...but we decided to use the phrase anyway given its catchy nature! :)  Our hospital is the referral site for 17 health centers in our district.  Any woman needing a C/S or increased surveillance would get sent from them to us, which also explains why our C/S rate is about 30% of our deliveries each year (instead of the national average of 6%).  The idea of Zigama Mama was to look at all of our C/S data from the health centers for one year, then do a training session for the nurses at the health centers.  The intervention is simple:  every woman with a previous C/S, even one, gets identified by the nurses, written into a register, and then she gets a "coupon" for a free ultrasound at Kibuye.  While ultrasounds are recommended in pregnancy, they are cash pay ($5) and most women can't afford them.  So, the free ultrasound is the incentive to come to Kibuye, where I can confirm their due date and decide if a C/S is indicated or not.  If yes, I schedule it.  If no, I encourage the women to come to the hospital (not the health center) for monitoring as soon as labor starts.  That's it.  We'll look over the next year to see if our rates of emergent C/S and UR decrease.

Training on Postpartum Hemorrhage, using resources from Laerdal Global Health

We had the initial training session last week.  Honestly, I wasn't sure how it was going to go.  Eric made up a schedule that involved a start time of 8:30.  At 8:30 on Thursday morning, only one person (out of the possible 35) was there.  However, people trickled in over the next hour and in the end, 16/17 health centers were represented!  We presented the rationale for the program, the nuts and bolts, and then had several hours to do some training for the nurses on post-partum hemorrhage and neonatal resuscitation, as well as share a meal together in the canteen.  It was great to see our Burundian doctors coming in to help out with the hands-on training programs.

We divided up into groups to practice techniques on a uterine model for treating PPH

Dr Ladislas, one of the Burundian docs on my service, also did a great job leading one of the groups

On Monday morning, I actually already had four ladies show up with their Zigama Mama coupons!  I'm excited to see how this intervention can have a positive impact on the health of women in our district.  There remain so many barriers to access to care, but hopefully, little by little, we can chip away at them.

The Zigama Mama ultrasound coupon

Kibuye Couture

By Julie Banks

Zeke, Julie, and Liam

When you come to Burundi, one of the first things you will notice are the colorful clothes.  Especially in our rural village of Kibuye, it’s quite rare to see a woman dressed in “western clothing.”  Women normally have two pieces of fabric that make up their daily clothes.  They wrap one piece around their waist as a skirt and the other serves multiple purposes: a shawl, a baby carrier, a towel to clean messes, a make shift sack to carry potatoes, and more. 

The fabrics are absolutely mesmerising! Bright statements of joy radiate against a sometimes dry and dusty background. 

It didn’t take long for us to want to join in with these beautiful people and try on these bright colors!

Greg, Anna, Alyssa, Heather, Keza, George, Abi, Madeline, Micah, and Susan

Fabric is sold in pieces that are 1x4 meters.  It's a wax-covered cotton which has a slight stiffness and a nice sheen.  The fabric supplies are constantly changing, so if you find one you like, you better buy it quick or you may never see it in the shops again! 

These little shops are found in the town of Gitega and in the city of Bujumbura.  Each shop is maybe 2x5 meters large where they sell fabric and sew on a few machines that sit outside.

Selecting your favorite pattern and colors is no small task – so many choices! 

Shopping for fabric can be a little overwhelming as you have to negotiate the price (normal in this culture) and we often draw a crowd of curious onlookers eager to see what we are buying.

After we buy our bright fabrics, it's time to talk to our favorite seamstress, Mama Mugisha.

This sweet woman is Dina, but everyone calls her "Mama Mugisha" (moo-ghee-shah).  She is an atelier or seamstress/tailor.   Incredibly talented.

Mama Mugisha is so fun to work with.  She is creative, confident, and highly skilled!  I love scrolling through Pinterest with her asking, "Est-ce que vous pouvez faire ça?"   “Can you make this?  Can you do that?”  She always says, "Oui!  Je vais essayer!"   “Yes!  I will try!”

There are, of course, no thin paper patterns sold in nice little envelopes here.  But Mama Mugisha can simply look at a photo or drawing, take our measurements, and then come back a week later with a finished product really close to, if not exactly, what we ordered!

Kayla designs the cutest clothes!

No patterns.  No electricity necessary.  Mama Mugisha's team works with sewing machines that are powered by a foot pedal – maybe like one you could find in an antique shop in the States.

Logan and I recently asked Mama Mugisha to make scrub tops for our physician supporters in the Missouri Association of Osteopathic Physicians & Surgeons.  They wore them with pride while Logan spoke at their annual conference in April.

Missouri Association of Osteopathic Physicians & Surgeons

When I asked Mama Mugisha to make a large order of shirts for us, she clapped her hands in laughter and hugged me saying, “Now you are my little sister.  You are family.  Because of you at Kibuye my children can have an education and the people who work for me can send their children to school.”

So it’s a win-win!  We and our friends get to wear these beautiful Burundian clothes, and she and her family (and her workers' families) are blessed in the process!

Me showing pictures of people wearing Mama Mugisha's creations to her husband.  He was so thankful for us, and impressed with his wife's work!

From Kibuye kids to adults, we all love incorporating the local fabrics into our wardrobe!  We try to have fun with what we wear and not take ourselves too seriously.  Here are a few snapshots of us in our finest Kibuye Couture!

Burundi Day at KHA

Zeke, Biniyam, Sam, Liam, Ben

Jonah bringing Kibuye Couture to RVA's Spring Banquet (with Ella & Matea)

Stephanie made graduation caps out of this beautiful fabric for our 8th grade grads and for Scott who completed his Masters degree.

Anna, Scott, Ella

We love twinning!

Alyssa and Alma 

Logan and Julie

Matea and Ella

Susan and Alma

Team Triplets!  Alyssa, George, and Abi

One Sunday I showed up at church matching two friends from the village!

So, whenever you come to Kibuye, we will take you fabric shopping and let you meet the marvellous Mama Mugisha!

Wilderness Medicine Club

(by Greg)

The children on our team get a great deal of exposure to the practice of medicine.  Many of them have physicians or nurses for parents.  Their neighbors (and therefore "aunts and uncles") are healthcare providers.  They get regular opportunities to visit the hospital, and occasionally to do a bit of light wound care.  And now, thanks to Wilderness Medicine Club, some of them know how to suture, how to evaluate for cervical spinal cord injuries and what to do in case of a snake bite, grenade attack, tornados and bear encounters, among other things.  Because you can never be too careful.

Alyssa and I signed up to lead a twice a month Wilderness Medicine Club over the past several months for three of the middle schoolers.  It was a lot of fun, using a combination of didactic teaching, workshops, clinical scenarios and YouTube videos.

This was day one of their training.  They wandered upon this poor victim who had apparently just experienced a head trauma .... while opening a bottle of ketchup.

On the final day we held a "mega-code" creating the perfect storm of disasters to which the students had to respond.  Jimmy the mannequin (who normally lives in our closet but occasionally makes an appearance to frighten team children or our house helper) was minding his own business, walking along the edge of a wall (which his parents had told him not to do), when he took a nasty tumble, had a head injury, then went into cardiac arrest, then (after being successfully resuscitated) was found to have an open tibia fracture.  And then, wouldn't you know it, a snake came out of nowhere and bit him.  We opted out of adding in a tornado scenario, as they are quite rare in Burundi.  

Some of the smaller children came across this traumatic scene and were very curious.

No scar revision will be needed for this banana!

Theses

by Rachel

Janvier, my very first thesis student, at his graduation

One of the most painful and yet ultimately enjoyable tasks that we as doctors do at Kibuye is supervising thesis projects.  Just as a recap of the Burundian medical education proces, students attend medical school as a university degree right out of secondary school.  They typically spend 6 years in the program—3 as basic science/classroom learners, and 3 as clinical learners.  This is where we interact the most with them.  They do clinical rotations at Kibuye and we lecture and provide more bedside-type teaching.  At the end of all their clinical rotations, students have to sit for a type of oral exam, and then they develop and present a thesis project.  This is probably styled like a US PhD sort of setup (albeit at a lower academic level), where the student presents their research and then defends it to a jury of 3 doctors.  

Now, some of us doctors are more academically inclined that others in terms of research, but every student needs an advisor for their project, and when there are 50 students and about 10 doctors in the Hope Africa University system, well, we get called upon quite a bit to act as directors.  Funny enough, it’s been a steep learning curve.  I did some (ok, a) research projects in residency, but there was a team of people to help me out—statisticians, epidemiologists, research interns, and sub-specialized attending doctors.  They told me how to design the study, ran all my stats, and helped me interpret the results.  I just had to help collect the data, do some background research, and then present the work.

So I’ve now been the thesis director for about 13 students who have graduated, with several more in the works.  The process typically begins something like a student approaching me and we have a conversation like,

Student: “Hello doctor.  I would like to do a project in Obstetrics and I was hoping you would be my advisor.” 

Me: “OK.  What did you have in mind?”

Student: “Maybe something with C-sections.”

Me:  “That’s very broad.  How about something more specific?”

Student: “Maybe indications for C-sections.”

Which, as any researcher out there would know, is not really a research project.  Many discussions and emails later, we usually land on a project which may or may not be valid (how would I know? I’m not a researcher).  Then the student spends months combing through (or looking for) old charts, reading textbooks and journal articles, and formulating a usually quite large (90-100 page) book.  We revise, I ask for p values and then can’t remember how to actually calculate a p value (but I know it’s important) and back and forth we go until the presentation day.  This is the more fun part.

One of our students, Innocent, presenting his data

What we didn’t realize at the beginning was that after a student defends their thesis project, they actually become a doctor.  They take their oath by holding the Burundian flag and from that moment forward, they can practice medicine.  It’s not after graduation, like we initially thought.  So this presentation day is extremely important (it is understood that the student will pass…if the project would not yet receive a passing score, they would not be allowed to present).  Many many friends and family come.  Fancy clothes are worn.  The room is decorated with flowers and special table cloths and water bottles are set out for the jury.  

Really, we are totally engaged and attentive during the presentation!

The student presents, the jury asks questions, and then deliberates on the score for 10 minutes or so.  Then the student returns and the score is read aloud amidst much clapping.  Then the Geneva Declaration is recited by the student as they hold the flag (and sometimes the Bible) and there is much more clapping and many more pictures.  And voila.  There is another doctor to care for the sick in Burundi.

Aimable gives his oath

Nadia reading the oath

So after all the work and difficulties and misunderstandings and time, getting to participate in these thesis projects is a culmination of what we have come here to do.  Training African medical professionals.  Many years ago we started here with the premise “We’re not the best people for this job.  Our students are.”  On thesis presentation days we start to realize that dream.  Hearing a student, no, doctor, recite the oath for the first time is always a little emotional for me.  I remember the day I took my own oath, “many years ago” now, on a cloudy May day in California, and remember the privilege and weight of responsibility given to us.

Christiane, one of our current stage professionels. 

Our student Bertrand, after finishing his thesis.

I solemnly pledge to dedicate my life to the service of humanity…

I will maintain the utmost respect for human life…

I will practice my profession with conscience and dignity and in accordance with good medical practice…

I will not use my medical knowledge to violate human rights and civil liberties, even under threat…

I make these promises solemnly, freely, and upon my honor.

"Family"

“Family”

My brother and his wife and their four kids were here over Christmas and we had a fantastic 3-weeks together. It’s the second time we’ve seen them since 2014, the third time since 2010. Yet we feel so close to them.  The same day they left our two older kids flew back to Kenya for their second term of school at Rift Valley Academy. Our house suddenly got a lot quieter as we dropped from 12 people to 4. (and to understand fully you would have to know some of those 8 who left)

Once again we have a shift in our family, these bonds that tie us to those closest to us. Two of our kids won’t be home for three months, and I won’t see my brother for who knows how long. 

Family relations are an odd thing at the best of times, but being on the other side of the world from parents and siblings, and cousins and everyone else makes these bonds more peculiar.

A few months ago in our team bible study, we were discussing how true community has the same characteristics of a family, including non-selectivity. You don’t choose what family to be born into, you don’t choose what children to have, and even though you chose your spouse, the family that you will end up becoming is not the direct result of precise decisions along the way.

What does it mean to have non-selective compassion, concern, empathy for those around you? 

It's is hard.

It is hard in Kibuye, it’s hard in urban Chicago, it's hard in rural Texas, and suburban Edmonton. 

While it may look very different, there is nothing unique about God’s call to all who could claim to be his people to love those around them. 

There have been many times in my life where I just feel like walking away from someone, or some situation entirely because it seems like the easiest thing to do. 

And yes, while it is possible to walk away from family, most everyone has a stronger sense of tie to family than any other relations. Even as a child, you know that you don’t really have a choice. No matter how much your siblings aggravate you, there’s really nothing you can do about it. That’s why as a child the almost mythological option of running away is so huge. How many of us didn’t at least once in our childhood think / dream /threaten/attempt to run away? ( If you say ‘no' - you probably either don’t remember well, had no siblings, or are some kind of freakishly forgiving person)

I guess that’s why there’s a saying "you don’t get to choose your family" (at least I think that’s a saying, if not…it should be)

This is probably why in such independent and individualist societies, we’ve reduced the entire concept of ‘family’ down to it’s smallest possible division. Only your immediate, nuclear family, which have statistically become smaller and smaller.  Fine, I’ll love my ‘family’ - but let’s make that word include as few people as possible. 

The divorce rates we are all impacted by must be a sign of our refusal to accept this non-selectivity, this non-negotiable set of relationships.  If a marriage turns south or gets too hard, we leave because “it’s not what I signed up for”.  But isn’t that the whole idea of non-selectivity, that we may get something we didn’t choose? 

Our kids will turn out the way they do - and for many parents, that will bring heartache, even disappointment at decisions made.  But does that mean you ask them to leave the family? That you decide what they’ve done makes them no longer worthy of being a part of the family? 

Non-selectively loving others is hard. It’s hard in extended family, it’s hard in your neighbourhood, it’s hard in all of our jobs, and it’s hard on this team. (Except you Greg - clearly)

Having kids travel two countries away to attend 9th grade seems strange to me, even though we’ve now done it two times. Does that make our family weaker?  A few years ago I would have replied with an unqualified ‘yes.’  Now that we’ve experienced it, however,   I have a very different viewpoint. 

There are (by my count) 21 kids here in Kibuye who call me ‘Uncle George’ on an essentially daily basis - yet some of the children of my biological family really don’t know me that well, some I’ve never met. 

I think the problem is made worse by my pathetic communication. There are many people who I care about, and think about often, but never get around to calling or writing.

Family is vitally important. The kind that we immediately think of when we say ‘family’ - our siblings, our parents, our kids. So is extended family.  So is community.  So is everyone else.

I guess what I’ve come to realize even more clearly regarding these kind of tight communal relations is that they go both ways.

We have to be open to seeing how we can show grace, compassion, kindness to those around us.  Reducing ‘family’ down to the smallest possible definition is exactly what the bible scholar who was questioning Jesus was trying to do when Jesus responded with the story we call the Good Samaritan.

“Fine," the man seemed to be saying, "I should love ‘my neighbour’ - but let’s be clear who exactly is in and who is out when we say that.  I need a clear line in the sand of how many people I need to be kind to - because it’s hard and I sure to want to show grace to too many people.”

The other thing is that not only do these bonds need to extend out, but we need them to come back towards us.

What is clear is that you can’t thrive without a group of people around you. This life does not work out so well as a solo gig.  There are plenty of people who can accomplish certain things without a strong support network (accumulating financial security, personal goals, etc.) -but to really have a full, engaged, rich life like I believe God designed us to have you simply must have people around you who are more than just co-workers, neighbours, or people you spend holidays with because you share some biological bond. 

We need each other. 

The other needs us.

If being part of this team has taught me anything (and it has taught me A LOT - especially Greg) is that doing life with others in an almost completely integrated way (friends=neighbors=colleagues=church=school=etc) is that it’s hard - but it is such a full, rich way to live. 

It is probably the most obvious when there is some acute problem, an emergency of some kind.  Someone suddenly finds out a family member has died, someone needs a medical evacuation, someone gets very sick. As a team we've gone through a lot of really hard things over the last few years - deaths of parents, sickness, and many other really, really hard things. 

However, that is only the most obvious.  When you look closer you see that through all the mundane, the small hurts, the kind words, the grace, the tension, the loss of personal freedom, the gain of communal joy -that this is how God has made us.

To live - in some way - in communion with others. 

To be part of a family, no matter what that looks like.