Goodbyes

In the past 24 hours, we've had to say "goodbye" to two very dear couples -- John's parents and the Roberts family (fellow ophthalmologist).  It was wonderful to have a week with John's parents and the kids had some great time with Grandma & Pops.  The Roberts are headed back to the States for a year-long furlough after 4 years of service at Tenwek.  They were the first to welcome us in Kenya and have since been tremendous mentors, both spiritually and professionally.  Their daily encouragement and company will be greatly missed!

These goodbyes were difficult for obvious reasons, but mostly because we were the ones being "left behind" this time.  I have come to the conclusion that being apart from family is probably going to be my biggest challenge here at Tenwek.  It makes me very grateful for the community we have here, both with the McCropders and the other missionaries.  Please pray for all of us as we adjust to the realities of being apart from family and friends for such an extended period of time.

Fortunately, all the McCropders have some "hellos" to look forward to in the next few months.  If you're interested in seeing a beautiful part of Africa and enjoying a real safari, let us know.  We'd love to add you to our "hello" list!

When it Rains, it Pours

And in other news, the McCropders were just today featured in ANOTHER news article! This was in the Ann Arbor news online, and the link can be found here. Good thing, since we were all getting jealous of John's publicity. :)

Philly Inquirer, Part II

Some of you may remember that John was featured in an article in the 2008 Philadelphia Inquirer, written by one of his fellow ophthalmology residents. Just today, the same paper ran a follow-up article on his experiences here at Tenwek. Here's the link.

COTW: Cord Prolapse

Doctors go into OB-GYN for a variety of reasons. Usually people cite things like an interest in womens' health, variety of care/procedures, surgery (without being a general surgeon), and overall happy outcomes. And sometimes the adrenaline rush that comes from critical situations. :) But here, one of the Kenyan medical officers rotating on our service said candidly, "I don't like OB. It's such a sad service." I had never heard that said about OB before, but she's right. When things go well, it's the happiest service in the hospital. When things go wrong, it's devastating--losing small babies and young mothers is one of the hardest things to deal with in medicine. So I wanted to share one of our victories with you, that should have been a terrible outcome, but was nothing less than a miracle.

Last week I was on call, performing a C-section with one of my interns in the early evening. The mom was pregnant with twins (kids #8 and 9), both in the breech position. Other than some increased bleeding from the uterine incision that we were trying to control, things were going fine. And then a nurse walked into the OR and called to the team, "C-section for cord prolapse coming down the hallway!" For those of you who have never heard the term, let me explain. An unborn baby's total oxygen supply comes from the umbilical cord, attached to the mom through the placenta. Usually when a woman's water breaks, the baby's head is pushing against the open cervix, acting as a cork or barrier so that the umbilical cord stays inside the uterus. Very rarely, however, a loop of cord will slide past the baby's head, through the cervix. It is a critical situation because the baby's head will then compress the cord against the cervix or vaginal wall, cutting off blood flow and oxygen to the baby. When this happens in the hospital, it is an emergency and the baby needs to be delivered via C-section immediately to protect against severe brain damage or death due to lack of oxygen...immediately meaning within 5-10 minutes.

So, without other options, I left my brand-new intern to finish up the first C-section (we were almost done by this point) and ran to the other room. The only history I had on this patient was that she had just arrived at the hospital with the cord already hanging out, and was close to her due date. I did a quick exam to feel the cord and it was still pulsating with the baby's heartbeat, a good sign, although it was on the slow side. We put the mother to sleep and I started the C-section. When I opened the uterus, I found that instead of being head down or breech, the baby was lying sideways in the uterus. It was difficult to maneuver the baby out of the uterus, but as soon as it (he!) was delivered, he started crying. Praise God!

After finishing the surgery, I was looking through some paperwork that had come with the mom and found a note from a referring clinic. She had come in to the clinic at 3pm and had been diagnosed with a cord prolapse at that time. I started her surgery at 8pm, FIVE HOURS LATER. Reflecting on why this baby hadn't died, as it very probably should have, I think his "malpresentation" was what saved him. Because he was lying sideways, neither his head, feet, or butt were compressing the cord. Well, let me change that statement. I think a miracle saved this little boy, with all odds stacked against him.

I wish I had a picture of this little kiddo to show. After many calls with babies and moms dying, it was so refreshing and uplifting to have delivered three beautiful, alive baby boys in the span of an hour. Things like this are why I went into OB.

Icelandic Ash Comes to Kenya

We're not sure how this is affecting most of our US friends and readers, but this bizarre story (yes, it is quite bizarre for a volcano in Iceland to close air traffic all across continental Europe) is probably affecting life in Kenya more than you might think. There are 2 primary ways:

1. There are few ways to get to Kenya from outside the continent of Africa, without going through Europe, most notably Dubai, and I think there are direct flights to Accra, Ghana, and Johannesburg, South Africa, from which one could then get to Kenya. Nevertheless, almost everyone coming to or going from Tenwek goes through Europe, most frequently London or Amsterdam. Thus, since the Icelandic blast, several of our visitors have been stuck in Kenya, unable to leave. And some have cancelled their trips to Tenwek, if they were of a relatively short duration, and the delay makes them less worthwhile.

Also, this just happens to be the week when family members from both the Faders and Cropseys come to Tenwek. That's right, via Europe. Not great timing, but we're praying that these much-anticipated reunions will go forward as planned.

2. Every day plane traffic to Europe is closed, Kenya loses up to $2 million dollars from a single export: Flowers. Who knew? According to the BBC, flowers are the top export earner for Kenya (I thought it was tea). And the time delay in the reopening of airports means that the quality of the blooms is diminished, and thus this is money lost for good.

Chameleon Fun

This weekend while feeding one of Anna's chameleons (Gertrude), I got some "action shots." Their speed is almost as amazing as their accuracy. Since I have been helping Anna feed these chameleons for quite some time, I found myself thinking "Hmm, that looks like a real juicy one," the other day when a fly landed near me.

Case of the Week (COTW) - Graphic Pictures

As we all know, HIV is a terrible disease, especially untreated.  One of the tough things in the eye unit is diagnosing lots of people with HIV for the first time.  The eyes can often harbor the first hints that someone has HIV/AIDS.  One such clue is a particular type of eye cancer, Squamous Cell Carcinoma (SCC) of the conjunctiva (thin layer of tissue covering the white part of the eye).  Often this can be treated successfully with early removal.  Unfortunately, the woman who is this COTW presented very late in the course of her disease.  She initially had to have her eye removed a year before at an outside facility due to the cancer.  This is usually not necessary if caught early.  Sadly, they did not have clean margins (the tumor extended beyond the edge of what they removed).  The tumor re-grew and had the appearance seen in the first two photos when I saw her.  She was quite poor and had very little social support.  HIV often has this painful repercussion, especially in Africa.  In fact, she had still not begun anti-retrovirals a year after diagnosis despite treatment being free in Kenya.

A somewhat unique fact about SCC is that it likes to travel along nerves.  Thus, a "small" tumor can send off fronds and have much further spread than one might imagine.  Because our patient's tumor now involved the orbit (the eye socket) and her lids, I decided it best to do an orbital exenteration (everything in the orbit is removed down to the bone) including the eyelids in this case.  If we didn't get it all, it's next target would be inside the skull, where all the nerves of the orbit come from.  It would then prove to be inoperable and slowly fatal.  The pictures to the left show my incision going down to bone.  The dissection was then carried to the back of the orbit between the bony orbit and its covering, the periosteum.  The optic nerve was then cut as the last remaining attachment.  This is the largest of the cranial nerves, and it took a bit of force to cut.  I then packed the orbit with gauze to stop bleeding (big nerves tend to have big vessels as partners).

As we waited for hemostasis, I turned my attention to harvesting a skin graft from the leg to cover the empty orbit.  If you hadn't guessed, this is not the usual work of an ophthalmologist.  We like to keep it above nose level if at all possible.  Thankfully, I had done a few skin grafts with my dad as a kid growing-up at a mission hospital in Togo, West Africa.  

As we returned to the orbit and unpacked it, things got interesting.  It didn't bleed, but it did fill up with a clear fluid.  Not good, CSF (central spinal fluid that bathes the brain and spinal cord)!!!  In my attempt to get as much optic nerve as possible, I had made a hairline fracture in the thin roof of the orbit (which happens to be the floor of the brain!).  Having never encountered this particular problem in training, I was open to suggestions, preferably ASAP.  My Kenyan assistant brilliantly suggested bone wax.  We tried, but it just wouldn't stick well enough.  The leak at this point had become pulsatile (the brain creates significant fluctuations in pressure as it fills and empties blood with each heart beat).  Not good.  I decided to consult the nearest non-eye surgeon who happened to be an orthopedist.  Dr. Galat said, "When I get CSF leaks, I plug it with fat."  Good enough for me.  So, with the assistance of a passing general surgery resident, we harvested a fat graft from the abdomen.  It seemed big, but then again, the orbit is a big hole, and we literally needed it to be water tight.  Thankfully, it seemed to do the trick, but we knew it only had a few days before the fat would die and need to be removed.  Our hope was that the leak would be sealed by then.  

Abdominal fat graft with its overlying skin being placed in the orbit.  

The next day, she states, "Daktari, my eye socket feels pretty good, but I've got a stitch in my side and a pain in the leg like you can't believe.  Aren't you an eye doctor?"  (slight translational liberty taken).    

As expected, the fat graft died and had to be removed about a week after placement.  We were quite thankful she did not get a CSF infection nor did she leak upon removal of the graft.  Some of the fat actually was alive and covering the bony orbit which provided a nice substrate for her to granulate the orbit.

At her last follow-up, she continued to heal well, but still had not gotten on anti-retrovirals.  It was explained to me that she was unable to meet the commitment level needed by the HIV clinic to be on anti-retrovirals responsibly, largely due to her lack of social support.   

Trees of Tenwek

In a continuing effort to give you a look around our surroundings, and enable you to "see" where we live our lives here, we present a tour of the trees of Tenwek. These are the "I know what they are and they are interesting" sampling. There are others, but I'm sure you would agree that this sampling is sufficient.

1. The Jacarandas outside the front doors of McCropder-plex. The aforementioned treehouse is in one of these, and apparently later this year, they will drop some mad purple blossoms.

2. The Acacia is the quintessential African tree, known for being the trees that giraffes prefer. Anna has taken to calling them "The Giraffe Tree" or "The Thorn Tree". Both fitting names.

3. The banana tree. We transplanted a few saplings into our shamba (garden). They are doing OK, but we might not get any fruit by the end of our two years.

4. The Eucalyptus is not native here, but there are tons of them, presumably because they produce timber faster than almost anything else. However, they suck up lots of water, and the government is trying to clamp down on the planting of them.

5. I'm told the Loquat trees (which we have a lot of) will produce their yummy goodness within the next couple months, but that we'll have to be quick in gathering any, if we're to beat the climbing Kenyan children to them. (Not that we would try to...)

6. We have 3 Avocado trees within 50 yards of our home, and they are starting to produce in a big way. Apparently, you pick them, and then they ripen. Hmm. The experiment on this issue sitting in our window-sill casts it somewhat into question.

7. There aren't any tea trees on Tenwek land, but the hillsides within a 10 minute walk are carpeted with them, Kenya being the 3rd largest tea-producing country in the world, after India and Sri Lanka. They are only about waist-high, and the mature plant gets its leaves picked every 17 days. Prolific!

8. Though not quite a tree, we're quite proud of the ginger plants in our shamba.

9. Not a tree or especially exotic, but I have never dreamed Rosemary could grow into such a big bush as lives in our shamba. You are welcome to come and help yourself.

Internet Woes and an Analogy

Some of you might be wondering why you haven't heard from us in awhile. And as I'm typing this message on a day when the internet isn't working, you might still not hear from us in awhile (until I'm able to actually post it)! There are things that we need to adjust to as we settle into African/Kenyan culture. Internet seems to be a familiar taste of home, but too often we forget that it's a Western phenomenon in an African setting. What I mean to say by all this is basically that the internet has been extremely unreliable since our arrival. It probably wouldn't be so bad if we hadn't come in with expectations of routinely video-Skyping our family and friends. We have been able to do this sometimes, but with decreasing frequency as the internet has been “upgraded” these past months.

About 2 days out of 7, the internet is just not working at all. No one can connect. We're not sure why this happens. Sometimes as the systems gets “upgraded” a feature gets changed and someone has to physically come to each of our homes and reset some parameter on our computer. Sometimes the Tenwek system can't connect to the larger Internet body, somewhere out there. About 4 days out of 7, the internet is exceedingly slow. We can check our gmail in basic html, maybe update a blog and load a photo if we're willing to wait a few hours. And then about 1 day out of 7, everything is lined up perfectly for good, moderately fast internet...and then this happens:
The power was out last week for over 24 hours, and that brought the network down, too, so no emails. And it's not just that a line went down, but the transformer actually blew up during a storm, and needed to be replaced. All this to say, sorry if you don't hear from us. We're trying! And since the internet continues to get “upgraded” and with each change, gets slower...we might look into other options soon, like the personal McCropder satellite uplink. Details on how to contribute to come. :)

But seriously, I think our internet is an analogy for the issues that we face in the hospital on a daily basis. In order for the internet to work, we usually just think about our own personal connection. Instead, many different things have to happen in order for us to connect. Our computer needs to be functional, the Tenwek server needs to be functional, we need to connect to the server, the server needs to connect to its internet provider, which needs to be working...and then we have to have power to be able to work the system too, which is another matter entirely. There has to be water over the dam, the hydroelectric turbines need to be functional, all the wires need to be working, there's apparently a transformer that needs to work, etc. Many factors we don't even think about.

I was talking to my friend Christina, an OB at a nearby hospital, about a patient recently and all the issues that played into her care. She had lost six babies all at the end of the second trimester, before birth. This is a complicated case, even for the US, but Christina started her on medication and things seemed to be going well. The lady was put into the hospital and given steroids to help the baby's lungs develop in case it came early. But then Christina left for a few weeks and the woman went home, not seen again until she presented to the hospital at her due date with a dead baby. The last hospitalization had cost her too much money, and she was indebted to another family member. She couldn't afford transportation back to the hospital for more care. She said she wasn't told to come back. She had visited another clinic instead where the nurse didn't pick up on warning signs that the baby was not doing well. So many breakdowns in the system. We tend to think about the medical process only, but here there are financial concerns, communication issues, and outside medical systems that we can't count on to be reliable. There is a huge web of exacerbating factors that play into every patient we meet.

So pray for us, that our internet issues would get resolved, but on a larger level that God gives us grace and wisdom and insight into each patient that we treat, uncovering their true needs and giving us guidance on how to meet those needs.

Easter Egg Hunt

How is Easter celebrated in Kenya? We're not really sure about the country at large, but here at Tenwek we had a very festive weekend! Our last post detailed the church services on Sunday, which were fantastic and celebratory, but we also wanted to share some pictures of the more secular party as well.

Prior to the hunt, all the kids gathered on one end of the compound to hear a story, giving the adults and teens a chance to hide eggs. None of the eggs were “hidden,” per se, but some were easier to get to than others. There are two eggs in the treehouse picture. Can you find them? Hint: look high (the red one is hard to see, but was placed on the third branch up from the bottom in the picture—yikes!). And also demonstrated is John trying his best to make things challenging for the kiddos.



The “release” of the kids was quite entertaining. From ages 3 to 12, the kids went wild trying to find eggs. Here's Anna finding one of her allotted 11 eggs (for fairness' sake) and then a picture of just a small number of the hoard of kids participating.
Finally, the event concluded with the opening and dedication of the new Tenwek tree fortress, built by Jeremiah Galat and his grandpa. Lots of fun going on up there. Just a few more ways that make Tenwek seem like a small taste of America.

Happy Easter from Tenwek!

Christ is risen indeed! Today we celebrated our first Tenwek Easter. And as you can see, we were able to jump right into the mix. After a rockin' Christian Passover meal last night, hosted by the Cropseys, we had a sunrise service outside, as the sun came up over the nearby ridgeline. Eric played guitar, and John led the service, and gave a short devotional for the 100+ people in attendance.

In accordance with past tradition, the service ended with some music being played, while people placed the various flowers they had brought upon the wooden cross. The result was quite beautiful, and is seen below.
Later, at the main service, Eric joined another post-resident physician, Dan Galat, on the church worship team. Below also are Dr. Agneta (surgery), Dr. Wanjalla (outpatient), and Mr. Musyoka (statistics). Musyoka's son Asante always stands up with him on the worship team and strums a little plastic telephone like a guitar, which is about the cutest thing ever.

We pray you are blessed as you celebrate and remember the resurrection of Jesus, and the incredible difference that it makes everyday.

The Jolly Green Giant

Buying a used car is often an interesting process no matter which country you live in, and Kenya is no exception. Within weeks of our arrival to Kenya, it was evident that getting a vehicle would be necessary. We batted around various options and decided that a lightly used van which could fit all of us would be ideal. Since most of our travel is on asphalt or decent dirt roads, we decided that an SUV would not be necessary to get us where we needed to go. So a while back, the three families went into Nairobi to search for a suitable van that we could all share for the next 2 years. The boys kicked some tires in a variety of used car lots without much success. The type of vehicle we were looking for is very commonly used as a matatu, or a van for public transport, and so they are in high demand. We almost decided to try and make the trek back to Nairobi some other time.

We then got a recommendation and called “Jolly,” who promptly found 5 of the exact type of van we were looking for. Jolly has connections, apparently. One of the five was looked a little better than the rest. It had been used as a cargo transport van in Japan for 7 years and then imported to Kenya. There were therefore no seats (except the 3 front ones) and lots of evidence that the driver of the cargo van had been a chain smoker. Jolly assured us that he could take care of the smoke smell and get us some good seats. We took it for a test drive (with me sitting on the floor in the back of the van) and were quite pleased. So we asked Jolly to make a few additions, like a rack on the top, and putting “PRIVATE” on the front so that police don’t stop us all the time thinking we are a matatu. We then agreed to pick it up when we were returning to Nairobi in 3 weeks.

The finished product is a 2003 Toyota Hiace Diesel Van with 11 seats (there are 11 of us). We are very pleased with it. We have taken it on a number of trips already, and it has performed flawlessly (even when I got stuck in the mud last week). We have named it “The Jolly Green Giant”, and call it “Jolly” for short, in honor of the car salesman we bought it from. We are very thankful to those of you who have donated to the purchase this van. We know that it will allow us to be more effective in our work here over the next two years – and maybe we’ll take it to where we go next (road trip anyone?).