A view of Kapsowar

Dan here....
We have been in Africa for over 40 days now, and I realized that we have not posted very many pictures of the hospital, where we live, or the main town of Kapsowar.

Hospital Grounds

The nursing school on the hospital grounds

This will eventually be the new dorms for some nursing students.  All of the cement is mixed by hand and carried shovelful by shovelful from the ground to the top floor.  Apparently they have been working on this for about 2 years now.

Kristen outside of the maternity ward

A couple of the buildings where sick patients stay while they are being treated.  Each building has several beds, all right next to each other where the patients stay.  There isn't the privacy that we have in the US

Kristen just outside the theater.  This is where the 2 operating rooms are and where Kristen does a lot of her work

Billing office on the hospital grounds

Lab and X-ray building

The front of the hospital where all patients enter

Ambulance

Hospital gate at the front entrance.

Inside the theater looking at the ICU and 2 OR's at the end of the hallway.

Another picture of the front of the hospital

Inside the theater

Kristen's office/exam room inside the maternity ward

Nurse's station in the maternity ward

If you are planning on having a baby, this is the delivery room

 Where we live

Looking out our front door

In the background is our water tank.  As long as that has water, we have water in the house.  You can also see how they ran our electrical wire.  Since Kristen and I just sold our house in the States, we always are joking "that's not up to code!"

A view of the backyard

The basketball court on the mission compound.  Many kids come in the afternoon and play basketball here

A poinsettia tree in our front yard

More of our front yard

The front of our house

The back of our house

Our "garage"

Kristen's walk to work

More of the trail on her walk to work

The gate just outside the mission compound

A view on the walk to the hospital

A view on the walk to the hospital

A couple of water tanks and buildings on the hospital grounds

I took this pictures because it is very common to see pipes all over the place here.  They dont really bury their water pipes here

Our car

The town of Kapsowar

Main Street

One of the 3 gas stations here in Kapsowar

This is where Kristen and I get most of our produce.  Each little stand is managed by a different vendor.  I would be surprised if most vendors make more than a dollar a day.

The pickup truck in the middle of this picture shows one form of public transportation.  They will fit at least 20 people in the back of that truck

All of these mini-vans are for public transportation.  They wait until the van is full before they leave.  These are all sitting just outside the hospital.  

                                                    

                                                               Another view of main street

The local church that we have been attending

                                        

                                          Another church in the area

Inside the other church

   

No Santa in Kenya

Kristen here...

Dan and I celebrated our first Christmas as a married couple here in Kenya.  It was unlike any Christmas I have ever celebrated, but it was special, sweet and a wonderful time just to be together. Christmas in Kenya is different than back home. When you strip commercialism away from the holiday things really do change. The hub-bub of the stores playing endless Christmas music, the crowds of people, the Salvation Army Santas that ring bells in front of grocery stores are nowhere to be found here.  There are no Christmas cards or candy canes. There are no holiday commercials playing in the background on our non-existent television. Sure, we made Christmas cookies and decorated a small tree we brought from home, but all of the extra hustle and bustle just didn't exist this season.  There are no shopping malls and I am not even sure that Kenyans know about Santa. Most certainly don't have the money to buy presents.  After asking around it seems that most Kenyans celebrate the day by treating themselves to a bottle of soda and taking the day off from work.  It suddenly became really hard to find a Coke in our small town.

Ribbons and balloons hung in the doorways at the hospital. That is about the extent of the decorations here for Christmas.  Very Kenyan.

A view of main street in Kapsowar. All of the roof covered structures on the sides of the road are little shops.

It is so interesting to think about Christmas in the absence of Hallmark and all of the extras that come with the season back home. As I was walking down the main street of Kapsowar looking at all of the little shops, "restaurants" and "hotels" I kept thinking, "Lord, is this what you were born into?  Is this what it was sort of like in Bethlehem?"  We are slowly getting used to our downtown, but it is a far cry from home.  The dirt road is crowded with people, beat up cars and animals all jockeying for a place on the path.  Trash litters where sidewalk should be and goats are the main street sweepers as they walk along grazing on whatever someone has left behind.  The shops are more of run-down little shacks.  Each one has a name, but it doesn't necessarily pertain to what is inside.  Once you walk through the small doorway of the wooden walled, tin roofed shanty it takes a while for your eyes to adjust to the darkness inside.  There are no lights.  The floors are dirt and everything inside is dusty.  Humble might be an understatement when describing our main street.  There are a few hotels that dot the road of Kapsowar.  I have never ventured into one and cannot imagine what the accommodations would be like.  Certainly no running water or electricity.  Every once in a while you can see an outhouse of sorts out back through the broken fence with a tattered sheet over the entrance where a door should be.

"Elegence Hotel" one of the fine establishments of Kapsowar. 

I wonder, is this what the inn was like that Mary and Joseph were trying to stay at?  Was this the best option in town?  In staying at such a public place would lice or bedbugs be a concern?  In considering this over the past weeks I sort of wonder if this is a closer picture to the reality of that day than our modern day Hilton or Holiday Inn Express.  I am sure that the inn in Bethlehem didn't have room service or even accommodations with private bathrooms.  However, after watching the mangy animals roam the streets sorely in need of a vet I can imagine that an inn like the ones we have here in Kapsowar would have been a better option than a stable filled with stench and bugs and garbage.  Yet, God denied His son even one of these inns to make a point.  Humble beginnings. There was no special treatment for this baby born to an audience of shepherds. Even He was humbled to be among the least of these.

I have never seen this before

Entrance to Maternity Ward....my home sweet home at the hospital.

 

Kristen here…

“I have only read about this, but I have never seen this before.” That seemed to be the theme of my week at the hospital and the mantra I kept repeating day after day.  It started last Sunday night and continued with multiple patients culminating Thursday evening when a pregnant mother showed up with what I think was congestive heart failure and cardiomyopathy.  A deadly condition in pregnancy - one with a 50% mortality rate in the best of circumstances and these certainly weren’t the best of circumstances.  This dreaded condition is one that I have read about, one that shows up as an abstract question on a board exam, but not one that many will ever see in their career as an OBGYN.  I certainly never saw this is residency and even if I did, I would not be surprised at all if that patient would have been transferred to a bigger, more critical facility because the stakes are just that high.

 I took one look at this mother lying on the bed in front of me and knew I was in trouble. Her legs were swollen to the sizes of small tree trunks.  Her pulse bounding at 180 beats per minute.   Every beat of her heart caused her entire torso to shake because she was working so hard to stay alive.  She was talking in incomplete sentences in her native language to the nurses around me.  Breathless, we put a pulse ox on her and saw that she was only satting at 80%, a far cry from the near 100% that you and I are breathing right now.  A quick ultrasound put an estimation on the age of her unborn child….7 months gestation.  1.6kg.  2.4kg is the weight needed for a baby to thrive here.  Anything less and the baby may struggle or not even make it.  I called one of the other medical officers down to help me.  We had a tough decision to make.  She needed an echo to confirm my suspicions, but that is not available at our hospital.  The toll the increased stress this pregnancy was placing on her heart made me uncertain if she would even survive the night.  All of the text books would say to do an immediate delivery.  Mother’s in such a serious condition have a much better chance of survival if they are not pregnant, but what about her baby?  1.6kg.  It was a gamble.  I don’t know that I had the right answer.  I got another medical officer involved and the anesthesiologist.  They both came to examine her.  She was alone.  There was no family with her.  No one to discuss the grave choice we had in front of us.  Our option was to do a c-section within the hour, an operation in which she may not survive or to watch her struggle to breath the remaining few hours of her life as she surely wouldn’t make it until morning.  With heavy hearts we moved her to the operating room.  I placed my hand on her arm and prayed silently, choking back tears knowing that there very well could be one, if not two deaths on my watch that night and there was very little I could do to stop it.  Just before the spinal was placed the whole operating room stopped as she was prayed over in her native tongue. We all knew what the next minutes could bring.  We proceeded with a rapid c-section as she was not able to lay flat for very long and keep up her respiratory efforts. 

After the baby was born the room was silent.  This is one of the worst sounds in the world for an OBGYN as I tried to focus on finishing the surgery all the while praying to hear the sound of a cry from the life that had just been born.   The minutes seemed to drag on.  The mother’s heart rate plummeted.  I glanced at the anesthesiologist to get some sort of clue as to how he thought the patient was doing.  Nothing – I couldn’t read his face.  Just keep going Kristen, just keep going.  Finish the surgery so we can stabilize the patient. 

Finally, there was a squawk from the corner of the room.  It wasn’t the sound of a healthy cry, but it was something.  Something resembling life in that newborn.   One small victory.  The resuscitation team continued to work on the baby.  My job was the mother.   I placed the last stitch and the mother was still alive.  Praise God!  Tearing off my surgical gown I walked over to the baby.  There was respiratory effort – though strained, the baby was at least trying to breath.  A good sign.  Shortly thereafter one of the nurses took the baby to our NICU for further care.  It seemed like this baby might have a chance.  The mother’s heart rate had come back up and her blood pressure was stabilizing.  She was still a long ways from recovery, but she had survived the surgery and her body seemed to be responding well to not having the stress of pregnancy straining her heart.  Still tachycardic and requiring oxygen, I knew that she was in critical condition.  I talked with the medical officer about the best course of treatment for her.  My text books listed off a bunch of cardiac drugs to give a patient in her situation, but none of them listed the doses nor had I ever given a patient these drugs before.  Back home, this would have been under the care of a cardiologist.  We don’t have one.  I knew I was way out of my league, but there wasn’t anyone else to care for her. 

I stayed up most of the night at her bedside watching her vital signs fluctuate and praying over this patient.  We didn’t have the equipment or exact medication that she needed, but we were giving her what we had.  Our human medicine is so imperfect.  The next bigger hospital that may possibly have more in the way of resources than us is a good 2-3 hours away on treacherous roads.  Sending her in the middle of the night in the back of a pickup truck to that hospital without the ability to monitor her just wasn’t a good idea. 

The patient’s family showed up late that night.  How do I explain to them what has happened?  How do I convey that I did an emergency c-section and possibly jeopardized the life of her child to save the life of the mother who may not make it through the night?  How do I explain something as complicated as congestive heart failure to those that still go to the witch doctor when they are sick to get rid of evil spirits?  With the help of some of the OR staff I bumbled through what had happened and my concerns for the patient.  The family graciously accepted what had been done and the situation at hand.  I am always amazed.

I walked back into the “ICU” where she was laying.   My prayers continued, “God show me what to do.  I am so lost.”  In residency you always have the comfort of knowing that though you might be managing a patient there is always an attending, a senior doctor looking over your shoulder.  You have someone to turn to and ask a question when you are unsure, someone to bounce ideas off of, someone to go over a patient with you to make sure you are not overlooking any details.  It is much different here.   There isn’t anyone else to ask.  I am alone.  A good friend of mine who is also a physician recently told me that feeling of grave responsibility and aloneness hit her too when she was first out of residency and it taught her a lot about prayer.  She learned that though she doesn’t have a physical attending looking over her shoulder any more she does have the Lord.  Her words, “Kristen, let God be your attending now,” just kept echoing through my mind during those early morning hours sitting at her bedside.  I definitely needed a senior doctor to give me guidance.  This was the cry of my heart as I prayed.

The patient was so sick that she wasn’t able to keep down any of the medications we gave her.  She needed these desperately.  Our hospital does not have the IV forms of these medications so the only way to give them was orally.  My heart sank with each failed attempt.  Her heart rate started to climb. 

As the first light of dawn broke over the ridge of the nearby mountains the patient was still alive.  She had made it through the night.   I watched her the next day as she finally began to be able to keep down some medications.  I wrote to several colleagues and talked to some missionary doctors on the phone in other parts of Kenya to get their input.  Every idea they had we were not capable of at this hospital.  We began again to talk to the family about trying to transfer her to another hospital.  This might be her only hope and if it can be done in the daylight it would be much safer.  After long negotiations over the cost of transport and hospital bills it was settled and I walked with the gurney and watched as the patient was lifted into the “ambulance” – more of a glorified truck with a covering over the bed.  I prayed as the vehicle pulled away.  It would take a miracle to save the life of this new mother. 

I learned a lot from this one patient.  Her name and face will forever be ingrained on my heart.  Holding life so delicately in your hands comes with a weight of responsibility I cannot begin to describe.  I have never seen a case like this before and hope in my deepest being that I never do again.  I do know though, that God is my attending.  My short comings are many, but my senior physician is never wrong.  That is where my hope must always remain even in the most dire of circumstances.   I may have never seen this before, but He has seen it all. 

Wedding Bells and a Church Service

Saturday’s are the day for marriage here in Kenya.  Kristen and I were enjoying a nice Saturday morning out on our back porch when we noticed several cars coming up towards our house.  We do not have very many cars around our house usually as we are on a “road” that goes to nowhere and is mainly just used for those of us missionaries living in this area.  We got up to see what was going on and found a huge wedding party standing in our front yard taking wedding pictures!  We do have a beautiful front and backyard and apparently it is good enough for wedding photos.  So of course we got our camera out and started acting as photographers ourselves.  As I mentioned in another post, they like to decorate their cars with wedding decorations and parade through town on their way to church.  I am not sure if this was a standard wedding or if these people were a little wealthier.  They were dressed as if they could have been having a wedding anywhere in America.  They had a huge wedding party though.  Much larger than any wedding party I have ever seen.  Kristen counted 20 bridesmaids!  I saw about 10 groomsmen and there were probably about 5 ring bearers and 10 flower girls.  They seemed to encourage us taking pictures of them.  I even heard one of the guys say “mzungu” to his girlfriend.  What he wanted was for her to move a little to the left so she would appear to be in a picture with Kristen and I (mzungu’s) who were standing in the background.  We were not really dressed for a wedding.  Kristen was in hospital scrubs and I was wearing shorts and a T-shirt, but I guess we were dressed ok for the wedding album!

Cars getting ready for the parade

Some of the bridesmaids

ring bearers

flower girls

Notice the photographer wearing a coat.  It is in the mid 70's

The next day was Sunday and church in the morning.  We normally go to the 9:30 service which is an “English” service.  It tends to be just about half and half English and Swahili.   We were running about 20 minutes late this Sunday however as Kristen was on call and finishing up a procedure at the hospital.  We got there at about 9:50 and found that the service was just starting.  Apparently, they had decided to have one joint service today instead of the English and Swahili services.  African services are not so much like American services.  For starters, a start time of 9:30 is just a suggestion.  There were still people arriving at noon.  Which brings me to my second observance, African services are much, much longer than any American service.  By noon, we were 2.5 hours into the service and they had not even started preaching yet.  The service was kind of hard for Kristen and I to follow since it was 90% in Swahili and neither of us really know much Swahili yet.  There is a lot of singing where it seems like they sing the same few verses over and over again.  They also like “dance” and their singing tends to be much livelier then what you will find in the States.  I believe the pastor also invites people in the audience to come up and share a special song or passage in the Bible with the congregation.  I think this is somewhat normal for at least this church.  Several people will go up throughout the service.  They will just stand up where they are sitting and start singing as they head to the front of the church.  Occasionally, others will join them in song at the front.  We could not figure out if they were invited to come up or if there was any order to what was going on in the service.  We American’s like our bulletin which will tell us the order of the service and what’s coming next.  This does not exist here.  Another thing that we have been advised on is that it is not uncommon for the Pastor to ask you the morning of when he sees you at church if you would like to speak at church (and by speak, I mean give the sermon).  I have been told to always have something prepared as they like to have mzungu’s get up and talk as if we have something better to say than anyone else.  Luckily, I have been able to download podcast from Northridge Church.  I have been listening to Brad Powells talks to prepare my future sermon!  About 2.5 hours into the service, the church was finally jam packed.  There were no seats to be had.  I leaned over to Kristen and said I felt like I was in a motatu as they just seemed to put more and more people on each bench.  I was just sitting there minding my own business when two young Kenyan kids of about 3 -5 years of age walked down our row, passing all the Kenyans sitting in our row, purposely seeking out me.  They stopped in front of me, turned around, and waiting for me to pick them up and have them sit on my lap.  The little girl began to snuggle into my chest like she was going to take a nap while the young boy just sat on my lap staring at me and taking it all in.  Kristen and I just started laughing so hard that tears came to our eyes.  There were a bunch of Kenyan teenage girls in our row sitting next to me, and they all starting laughing too.  

Every seat was taken.  This picture was taken early in the service

a short video of the church singing