Making Virtual a Reality

While a good understanding of anatomy is important for the practice of medicine, it's foundational for the practice of surgery.  Knowing the relationships between structures can be the difference between curing the patient and causing irreparable harm.  Because of its foundational nature, in the U.S. anatomy and physiology is one of the courses taught early in medical school.  Around 90% of U.S. medical schools include cadaver dissection as a part of their curriculum.[1] Even as the pedagogy for medical education is transitioning to a flipped classroom model, the importance of in person time studying cadaveric anatomy is not lost on educators.  In fact, according to anatomy course directors, one of the most common weaknesses in anatomy curriculum was insufficient dissection time, a problem which was only exacerbated by COVID. [1] 

There are many factors that prevent us from maintaining and using an anatomy lab as a part of our medical curriculum here in Burundi.  Both the formaldehyde and refrigeration options for preserving cadavers are very expensive.  Then comes the practicalities of maintaining constant electrical supply or the safe handling and disposing of large quantities of hazardous chemicals.  All this says nothing of the cultural and ethical implications of obtaining cadavers on a regular basis...

So, what are we to do?  

Well, 11% of U.S. medical schools also utilize virtual software to enhance, and in some cases replace, the cadaver dissection portion of their anatomy courses.  In the post COVID era, a full 23% more plan to incorporate Virtual Reality in their anatomy curricula.  [1] While the data is a little old at this point, a 2015 meta-analysis of the educational effectiveness of 3D visualization technologies in teaching anatomy showed that it 1) improved factual knowledge, 2) improved spatial knowledge acquisition, and 3) improved user (aka student) satisfaction as compared to all teaching methods. [2]

Visiting resident Yves Yankunze having some one-on-one teaching time.  We had recently discussed hiatal hernias, so I was pointing out the relationship between the esophagus, vagus nerve, diaphragmatic hiatus and aorta/aortic hiatus.

Since I had the headset and anatomic models ready to go in our (mostly) unused OR 1, I was able to have an impromptu teaching session for the nurse anesthetist students rotating at our hospital.  It was a chance to show them the relationship between the upper airway, the trachea and the esophagus.  A critical understanding for successful and safe intubation of patients. 

When set up in the classroom, other residents are able to follow along with the teaching as I guide the student wearing the headset toward the relevant and important anatomy.

After a few back-and-forth emails, the medical director for The Standford Virtual Heart program graciously provided me with a copy of the software.  So after we finished our chapter on congenital heart defects, our residents had a chance to explore the defects and their associated flow patterns and murmurs in virtual reality.

For now, I'm focusing this virtual experience on our current batch of surgical residents.  Their need for recalling and understanding anatomy is the most pressing.  But the trial run has been well received and quite helpful.  I'm excited about the possibility of significantly expanding our use of VR into the anatomy course taught at Hope Africa University.  

Afterall, it's hard to build a solid house without a solid foundation...

[1] Shin M, Prasad A, Sabo G, Macnow ASR, Sheth NP, Cross MB, Premkumar A. Anatomy education in US Medical Schools: before, during, and beyond COVID-19. BMC Med Educ. 2022 Feb 16;22(1):103. doi: 10.1186/s12909-022-03177-1. PMID: 35172819; PMCID: PMC8851737.

[2] Yammine K, Violato C. A meta-analysis of the educational effectiveness of three-dimensional visualization technologies in teaching anatomy. Anat Sci Educ. 2015 Nov-Dec;8(6):525-38. doi: 10.1002/ase.1510. Epub 2014 Dec 31. PMID: 25557582.

Doesn't Mean You're Doing It Wrong

 Where no oxen are, the manger is clean.

But much increase comes from the strength of an ox.

-Proverbs 14:4

I read this proverb this morning.  It does what proverbs do best, namely to pithily state something that is universally accepted, and then leave you to connect the dots.

Generally, I'm a fan of order.  Unapologetically, in fact.  There is something about bringing order out of chaos that rings of creation by the God in whose image the Bible says I am made.  In the hospital, and outside the hospital, I spend a lot of time trying to solve problems.  And oftentimes, those solutions take the form of trying to develop a good system.  A system that documents medicine doses given.  A system for determining how our construction projects will be funded.  A system for approving student thesis research projects.  These are all good things, and what's more, I think they are one of the significant contributions that I and my teammates make to various situations we encounter here.  I see a well-functioning system in place and it feels so right.

In other words, I like a clean manger.  Quite a lot.

Generally speaking, though, we do not live in a world of clean mangers.  And by the way, this proverb is being ridiculously polite, and I think we all know it.  I mean, yes, it's true that the oxen will leave the manger dirty, and there is a nice parallelism between the manger void of food and the harvest of food that the oxen produce.  But we all know that the manger is not where the real mess is.  Oxen leave quite a bit more in the stables before they go out to their work.  The stable is not clean.

I can relate to that.  For all fires I try and put out, or all the systems I try to put into place to prevent the next fire, things fall apart.  The day feels like whack-a-mole.  Even 60% feels super great sometimes.  This world is good and fallen and messy.  Our efforts at creative order in this world are good and fallen and... messy.  Actually it can be quite dispiriting.

I like a clean manger.

Proverbs' personification of Wisdom walks in the door and retorts, "but do you like an abundant harvest?"   I see where she is going with this.  I glance up at her as if to ask "do I really need to answer that?"  She looks back as if to say the same thing.  

"Yes, I do," I say begrudgingly, but still appreciating the back-and-forth. 

"Then it's going to be messy," Wisdom replies, "but that doesn't mean you're doing it wrong."

***

Aside from the oxen argument from the natural order, why is this mess necessary?  Couldn't we be free to create order without it.  Last year, I read these words from the late, great Eugene Peterson in his Under the Unpredictable Plant:

A group of seminarians I was leading on retreat once asked me what I like best about being a pastor.  I answered, "The mess."  I had never said that before; I don't think I had even thought it before.  The answer surprised me as much as it did them...Actually I don't like the mess at all.  I hate the mess.  I hate the uncertainty.  I hate not knowing how long this is going to last, hate the unanswered questions, the limbo of confused and indecisive lives, the tangle of motives and emotions.  What I love is the creativity.  And what I know is that I can never be involved in creativity except by entering the mess.

I think this is quite true, and I can relate to it.  Thus, to act in imitation of my Creator, I will enter the mess.

Even more so, I think that I am (very slowly) learning that this is how we grow in trust.  How should things be in this world?  It's a good question, and part of the answer is that we are to be trusting God.  And how would we learn to trust without things happening in a way that is other than what makes sense to us?  

The manger is not clean.  We need the mess.

***

One Kibuye way of expressing this over the years has been to reference "thorns and thistles".  In Keller's Every Good Endeavor, he references these words in Genesis 3:  "Cursed is the ground because of you; through painful toil you will eat food from it all the days of your life.  It will produce thorns and thistles for you, and you will eat the plants of the field."  

Keller's point is that sometimes our work in this world is full of hardships and brokenness, the "thorns and thistles".  Why?  Because the world is broken with sin.  Why is that important?  Because, though it means that the presence of such difficulties is a sign of something wrong (we know this intuitively), it does not mean that we are doing something wrong.

Yes, we have days like that.  So you do, I imagine.  We walk home and catch the eye of an old friend who happens to also be a teammate.

"How's the day?"

"Thorns and thistles."

A nod of understanding.  Sometimes, it's a mess.  But that's not a sign necessarily that you're doing something wrong.  It may be an opportunity for creativity.  An opportunity for trust.  Maybe it means that the oxen are hard at work.  We await the harvest.  Courage as you wait.

2020 in Kibuye: A journey towards flourishing?

(by Matt)

If you have ever been to Kibuye and attended family worship on Saturday evening, you have probably said the following words as part of the liturgy: “Thank you (Lord) for leading our steps even when we do not understand.” Lately, every time I read and speak these words they resonate with me a lot. I guess it is because there is a lot I do not understand about life in Burundi, the world, 2020 and its series of crises.

The year 2020 has been a very challenging year. It has showcased the vulnerability of mankind, our exposure to risks and the possibility to lose the things that give us a sense of security and safety such as democracy, economic stability, health, freedom, and fellowship with others…

While the impact of these challenges has been gentle in Burundi this year, I am still struggling with the sense of vulnerability that this uncertainty has revealed. I would like to shield myself against the possibility of losing anything I possess.

My work in Kibuye as the construction manager generally puts me in a position of authority. By default I am called to take actions and to make decisions that are executed immediately by those who are under my authority. My natural tendency in this position is to suppress any kind of vulnerability. But as Andy Crouch puts it in his book Strong and Weak, whenever authority and vulnerability are not held together, the result is withdrawal (no authority and no vulnerability), exploitation (authority without vulnerability) and suffering (vulnerability without authority).

I do not understand everything about 2020, but in my role as construction manager I have been learning that it is good to embrace both authority and vulnerability, because that is the way to flourishing. Here are some examples of how this principle has played out in my work:

1. When the temptation is to withdraw, remember you are part of the body. I have been learning that I am not a mercenary or expert sent to save/help Kibuye but rather part of the body of Christ sent to be with my brothers and sisters in Burundi so that together we can serve and take care of the part of the body that is hurting or needs my gifts. Being then doing. Being for me has come with personal and emotional involvement; I have been trying to be more deeply embedded in relationship and mutual dependence with the construction crew which makes me vulnerable in a way. For this reason the team has welcomed me as one of them but also as their leader. They started trusting me more than they did before.
   When we were finishing the kindergarten building, the director of the school approached me and told me that the school had decided to paint all exterior beams and columns of the kindergarten in a cream color. He did not expect any pushback from me but compliance. It was a simple request from the director who runs the school, a request that had no structural implication I needed to be worried about. It would have been easy to just paint the building and move on. But that would have been withdrawal. As a member of the community I was aware of the challenges we had with maintenance because of the lack of training, human resources and funds. It was my responsibility as an architect and a member of the community with authority to deliver a building that will serve the school and the community for years to come. I told the director that we were not going to paint exterior beams and columns because it would require regular maintenance, which the school could not afford. Instead I had designed it to be aesthetically pleasing and low maintenance. He was very disappointed in me but I thought it was worth pushing for. Now after two months of rain and mud the building still looks clean
   
   
   

   

   Kindergarten building

   
   

   

   View from the access road

   
   
2. When the temptation is to act without vulnerability (exploit), find ways to stay in relationships. Dependence on my team exposes me to the risk of failure and disappointment but it also empowers my team with the authority to take actions that could affect me directly. At times the authority given is misused, but most of the time it is used in a meaningful way. If my team or the project fails, I fail; if they succeed, their success is also mine. I do not always like this kind of vulnerability but God has been teaching me to embrace it.
   A few weeks ago, I had to get 4 self-contained rooms at the Octaplex ready for 4 new doctors to move in. I relied on and trusted a local contractor to make all the furniture for the rooms but in the end, they let me down because they couldn’t meet our deadline. I felt vulnerable and suffered because of their actions. If I had not trusted them in the first place maybe I would not have felt disappointed and hurt, but I would have reinforced a negative bias about Burundian culture and contractors. Maybe I trusted them because I started to learn the meaning of being, accepting the other who is different as my brother or sister; or maybe I was learning that change, transformation and healing come when we are together in a relationship. We trust and get hurt but we also use the authority we do have (authority is our “capacity for meaningful action” according to Crouch) to try again; and we hope that the power of love that comes from being together will change the other and us. Although I ended up doing the work with my team to meet the deadline, we kept the relationship with the local contractor and contracted him for other work hoping that they will be more reliable in the future.
   
   
   

   

   The Octaplex

   
   
3. When the temptation is to suffer out of fear of shame, take action together. I am learning that to be culturally appropriate does not mean to withdraw from taking meaningful action in order to avoid the possibility of loss or hurt. Instead, I think it means to communicate clearly in a respectful manner about the action that needs to be taken, while acknowledging that something valuable might be lost in the process.
   Last year, concrete test results for the paediatric building ramp were very bad. As a consequence, part of the ramp had to be demolished and recast. This was a very sensitive matter for leaders and members of the construction team. In this context, to demolish part of the ramp meant to accuse someone publicly of being incompetent at his or her work, a shameful rebuke in a shame-honour culture. I remember being asked several times if there was another course of action that would not require any demolition, but there was none. We had to demolish the ramp but we also were exposed to the possibility of hurt and a broken relationship with some leaders and members of the construction team. We decided to wait and demolish at a later date when everyone had come to peace with the decision. It was clear that no one wanted the ramp to endanger people’s lives by not taking care of the issue. Instead of using culture as an obstacle to good decision making and an excuse for inaction, we took action together and overcame shame and potential suffering.
   
   

   

   Paediatric Ward with the whole team
   

   
   

   

   View of the ramp

Now that I am at the end of my time in Kibuye as construction manager I can say thank you Lord for leading my steps to places of vulnerability where your spirit empowers me to take action in community and flourish.

I hope that in my journey I will gain more understanding of these words “I take pleasure in my weaknesses, and in the insults, hardships, persecutions, and troubles that I suffer for (the body of) Christ. For when I am vulnerable, then I am strong,” 2 Corinthians 12:10

Heroes Come In All Sizes, or, How Guinea Pigs Exemplify Christ

by Carlan

[Trigger warning: this post involves a story about experimentation using animals. To skip to the spiritual lessons learned, skip down to "Heroines #1".]

Sherlock Holmes statue in London (courtesy: Wikimedia Commons)

I read the adventures and further adventures of Sir Arthur Conan Doyle's most famous character when I was in elementary school. If I learned one thing from Sherlock Holmes it was to be observant. So when we lost three patients in two days, only one of which I expected to die, I wanted to know why. Often we do not have enough information to accurately diagnose our patients' diseases and causes of death are no different. These cases were no exception. One presented very late with miliary tuberculosis (pretty sure of that diagnosis based on the X-ray), one had terminal renal failure and heart failure, and another had passed out after drinking too much on Christmas and started complaining of back and abdominal pain. Disparate cases, to be sure. But all had received Ceftriaxone within 6 hrs of dying (for concurrent pneumonia, urinary tract infection, and febrile diarrhea in the setting of leukopenia, respectively).

Could the Ceftriaxone injections be implicated in the timing of these patient deaths? A bad batch? A problem of labelling in the factory? Some toxic transformation while in transit or sitting on our pharmacy shelves? The imagination can run wild, but we needed data. One cannot make bricks without clay.

At my hospital in California, I could talk to the pharmacy committee and we might send a sample to be confirmed in a reference lab with mass spectroscopy and other advanced chemistry. In a land where 90% of the population farms without tractors or plows, that won't work. What would Sherlock Holmes do?

We could inject a healthy volunteer with Ceftriaxone and watch what happens. I could never ask a patient or colleague to consent to this, given that there is a risk that the Ceftriaxone was contaminated with a fatal poison, so I would need to be the volunteer. But wait...could a goat stand in the place of the volunteer? I would ask Silas, our chaplain who is also a veterinarian and pig farmer.

An experiment must have documentation.

Silas recommended we choose a more diminutive species. Could we find some "cobayes" to use? I did not know that word in French, so I asked about rabbits while looking it up in my dictionary. We have some rabbits on campus. That would be OK, according to my friend Silas, but we could probably find some cobayes even in the community around Kibuye. Alors! I found that word in the dictionary: guinea pigs. We have guinea pigs on campus too. I would need the permission from some kids before using their pets as guinea pigs for a science experiment.

Our multi-talented chaplain, missionary kid, and guinea pig "volunteers."

Heroines #1: our team kids. With a healthy amount of trepidation, a surgeon's daughter agreed that she could furnish three guinea pigs for this experiment knowing that it could save patients' lives. This pre-adolescent girl already had internalized the central ethical tenet that allows me to support animal research for healthcare - human life, as bearing the image of God, is more precious than animal life.

Heroines #2: those guinea pigs. As I was talking with this heroine, we both realized the connection between Christmas and these research subjects. They were risking their lives to save others. It might be a stretch to say that the guinea pigs were willing to die to save others, but they were standing in the place of myself and my patients so that we would not be exposed to a certain risk.

In any case, I'm glad to report that all three guinea pigs came through the process fine and dandy. Eliminating the impossible, I'm concluding that these patients died of their diseases and not our treatments. Thanks guinea pigs! Thanks intrepid missionary kids! But most of all, thank you Jesus, for absorbing not only risk, but wrath rightly deserved, for me and so many of our patients and colleagues.

Alive and well after 100 mg/kg of Ceftriaxone. Yay for guinea pigs!

The Brick Factory

by Jess Cropsey

Our faithful readers will know that there’s been a LOT of construction happening at Kibuye over the last 3 years.  Brick is one of the main “ingredients” that is used for beautiful buildings such as this newly completed local school building.  You will often see stacks of bricks cooking in a field or sitting by the side of the road waiting to be sold (for about 1 cent a piece).  

For Kirundi class at Kibuye Hope Academy, we recently took a field trip (literally walked through a field to get there!) to a local “brick factory” to find out more about this process.  We met Irakoze who graciously explained how you mix some dirt but mostly clay (ibumba) together and then put it into a wooden mold (iforoma).  

After sprinkling a little dirt on top (to keep it from being too sticky I assume), you pull it out of the mold and set it in neat rows in the sun to dry for 2 days.  Irakoze was kind enough to allow the kids to mix the clay with their feet (gukata ibumba) and make bricks using the mold.  Not sure if he’ll end up keeping them!  

After the bricks (amatafari) have hardened and dried in the sun a couple of days, they are stacked to the side until there are enough to make an ifuru (shown below).

The holes at the bottom are filled with wood to make a fire.  The holes are then covered up and the outside of the brick oven is covered in mud or leftover clay to keep the smoke & flames inside.  

The bricks cook for about 3-4 days and after that time the color will change from the original gray to a reddish color.  Once the bricks are cooled, the mud is removed and bricks are taken from the top.  The final step is probably the most labor intensive of them all -- getting the bricks from the field to the side of the road in order to sell them...without a vehicle, a couple at a time.  It gives me a new appreciation for all the work that went into making our own homes, not to mention the many other hospital & community buildings that have been built at Kibuye by many Burundian craftsmen (and women).  Murakoze (thank you) Irakoze and our Kirundi teachers for such a wonderful learning opportunity.   

  

Learn by Drawing

by Carlan

Those of you who are educators no doubt recognize the subtle homage to John Dewey's quintessential quote "Learn by doing" in the title of this post. While I cannot endorse the consequences of his secular humanist & reductionist/mechanist philosophy of instruction, I can affirm the accuracy of his observation. Some paths only become apparent as you walk them, some lessons can only be learned by trial & revision.

Following on the tails of Jason's post about the EMI trip, I'd like to share a brief example of incredible blessing I have received during the process of designing an Emergency Department with Jason, the EMI folks, and some special guest consultants from Grace Community Church and LAC+USC Medical Center. It started with thinking...and dreaming. "What would an ideal ER look like? What are the critical pieces and how would we arrange them? How much space do I need? How much space do I have?"

If you enjoy design as much as I do, you know the intoxicating allure of opportunity. I was asked in July for a list of my top 20 favorite things. I listed a new notebook/journal as one of them -- so many blank pages of opportunity. But even before I began drafting blueprints, I realized I did not know the answers to many questions about how to design an ER. Cue the first round of learning by drawing - pre-sketch learning. The very process of dreaming about a real ER for real patients occupied by real students, nurses, and doctors changes the level of precision and detail needed. "How many ER beds are required to serve a 300-bed hospital? How many patient visits do we expect through the ER? etc., etc."

Draft #3.2 of the ER at Kibuye Hope Hospital (18 Mar 2013)

And then you draw something...only to realize halfway through the assignment of space that you needed an area where private conversations and evaluations could take place. Scratch draft #1; on to draft #2. Each time you draw it out, you refine your design and deepen your understanding of the space. "How big exactly is a patient bed? Are they fixed or mobile? Will we be able to wheel the X-ray machine in here?" One thus enters the second round of learning by drawing - inter-sketch learning. Certain relationships simply do not become apparent until all the elements are on the page. Then the glaring absence of bathrooms becomes obvious.

But you're not done yet. Once you've researched all your answers, revised all your sketches (I switched to little paper cutouts of patient rooms, trauma bays, bathrooms, nursing stations, etc so that I could just rearrange them on the floor without redrawing everything all the time), and reassembled all your various elements, you draw a "final" draft. Satisfied that you have considered everything to be considered, you run it by your friends and team. They like it. Yes! So you ship it off to your architect friends for some sort of rendering process whereby it becomes AutoCAD files. Wham! Round three of learning by drawing - post-sketch learning.

"Final Draft" of the ER at Kibuye Hope Hospital (27 Mar 2013)

"What building materials are you using? How wide are the walls? What building codes/standards are you using?" One finds that he has indeed not considered all the salient features of this construction when designing the ER, and a tug-of-war commences in his heart. "How much of the 'final' design can be saved while correcting for these highly relevant issues?" In my case, this dilemma didn't last long as Jason and the EMI team quickly identified the footprint available as too small for the "final" draft. But what happened next was a beautiful gift straight from the Lord.

John Hixson, one of two architects who volunteered to help me in this process, responded thus when I reluctantly told him to scratch whatever work he had already done on the project as we'd be going back to the drawing board:

"P.s. I love the work God has called me to! I have redesigned things 6 times and loved every moment of it! This is truly a pleasure!!!"

And I find that there is even a fourth round of learning by drawing - supra-sketch learning. To embrace being subject to process, to discovering en route what needs to be known to move forward, to trust in One with grander plans than a big building in a small village in a tiny little country without enough doctors. It reminds me of one of my favorite scenes in all of cinema - where Jesus checks his lines while working as a carpenter. Couldn't He have cut that table leg perfect on the first pass? Nope, He made Himself subject to process too. It was part of being with us. And getting to be with Him and His people every step of the way through this process has been a genuine joy.