Two months home

It has now been a little over two months since coming back from Kenya and I have had a bit of time to reflect on the trip.  Those of you who follow my sister-in-law's blog will recognize some similarity in this post to one of hers.  Deedee went on a mission trip with ABWE to Liberia during part of the time we were in Kenya and returned with thoughts that were comparable to my own.

Many have asked questions about the trip that are kind of hard to answer.

How was the trip?  
Expected spiritual answer: Great!  God did amazing things.
Actual answer:  Challenging.  Hard.  Demanding.  God did amazing things.

Was it life-changing?
Expected spiritual answer:  Yes!  I will never be the same.  I can't wait to do it again!
Actual answer:  Umm...Yes....It certainly does change me...I wonder if I can do it again?  Repeatedly?

Will you go back?
Expected spiritual answer:  Yes!  I can't wait to do it again!
Actual answer:  I don't know.  It depends on where God leads us.  I am not sure if repeated short-term trips are what we should do.  The need is hard to ignore.

Are you glad to be home?
Expected spiritual answer:  Yes!  We are so fortunate here in the U.S.
Actual answer:  I am glad not to worry about rinsing my toothbrush from the faucet.  I am glad not to worry that the kids are going to get malaria or E. coli or visceral leishmaniasis or African trypanosomiasis or worms or ...  I am glad to be back to Jittery Joe's and Chick-fil-A.   I am glad to watch the Falcons and dismayed over the state of the Bulldogs.  I am not glad to be back to all the unnecessary things that consume our time and energy.  I am not glad to be back to worrying about people who make a fuss about driving 20 minutes in a warm car to come to the office to be seen when there are people who gladly travel for hours or days to get to a place where they can receive care.  I am not glad to be back to battling insurance companies to pay for the services that they promised to provide to their customers who paid them in good faith.  I am not glad to have what I have when there are so many who have nothing.

What's next?
Expected spiritual answer:  I am looking for our next trip.  I can't wait to do it again!
Actual answer: Many are the plans in a person’s heart, but it is the LORD’s purpose that prevails.
I don't know what's next.  I know that I have to get through the winter.  I know I have to continue to provide customer satisfaction to people who think they should be able to walk into my office and be seen immediately, whether or not the child actually needs to be seen immediately.  I know God has a purpose for me being here, in Athens, now, but I know my time is excessively consumed by my profession.  I know Moses spent 40 years in the wilderness of Midian before returning to Egypt to lead Israel out of captivity.  Is forty years in the wilderness part of God's plan for me or does he have something else for me to do sooner?  I don't know what's next.

I know that God's plan does not always follow our logic.  See my friend Lynn's blog for more on this.  Logically, I should have gotten a job with my undergraduate degree in business.  Logically, I never should have gone to medical school.  Logically, we should have gone to a Spanish-speaking country in this hemisphere for a medical mission trip.  Logically, we should have gone for a shorter time and not taken the kids with us, to protect them.  Logically, God would condemn all of us who rejected or betrayed Him.

But that was not what God had in mind for us.  He made a Way for us instead.

Final day in Kijabe

Final Day in Kijabe and travel home

I finished work just in time on Tuesday to get home and change in time to go to dinner with Rhett and Megan at Mama Chiku's.  Rhett, Megan and their kids drove to our apartment, then we all walked from there to the restaurant.  As usual, it was a pleasantly cool, breezy evening and we had a nice conversation as we walked.  With my clinical responsibilities behind me, the evening was nice and relaxing.  We arrived at the restaurant and worked on getting tables set up.  The ten of us took up about 2/3 of the space in the restaurant.

Mama Chiku's

We ordered a family style meal that included chipatis (thick tortilla-like bread), ugali, beef, potatoes, carrots, and something like collard greens or cabbage.  The kids mostly liked the chipatis and tasted a few of the other things.  We tried everything they brought and we liked the chipatis best, too.

Ugali with cabbage

Chipatis

We finished dinner and walked back to the apartment to pass on our leftover groceries to the Shirleys.  After a little more time of fellowship, we said our good-byes and returned to the apartment to work on packing to go.  It had been a great blessing to have the Shirleys there to help us get settled and involved in the Kijabe community.  I am still amazed by the greatness of their faith that led them to take their 3 small children halfway around the world to serve God in Kenya.  Megan and Rhett would soon be visiting the U.S. and Megan would have to travel from Atlanta to Amsterdam on her own with the children since Rhett had to return to Kijabe earlier.  They will continue to serve at Kijabe for another year, please keep them in your prayers.

We spent our last night in the apartment with mixed feelings.  There were many things we were looking forward to about returning home: 

• not having to remember to turn on the hot water heater on before dinner, off before bed, on upon awakening, and off again after everyone had showered in the morning
• not having to shake our shoes to make sure no spiders had taken up residence during the night
• not having to remember not to wet our toothbrushes with water from the sink and to rinse our mouths with water bottles rather than sink water
• no longer dealing with very unreliable dial-up internet access
• not wondering what animal was the source of the meat in the rather tasty samoosas (we hoped it was beef, but who knows?)
• not wondering why the samoosas started turning red once they were in the fridge for a few days
• not having as many "OC!" moments while I take care of patients ("Oh, crud!")
• sleeping in my own bed with my own pillows
• we were all looking forward to having a little Chick-fil-A when we got back
• college football (never mind what was actually happening with UGA's season)
• worship services at WFBC

Samoosas

There were, however, many things we would miss about Kijabe.  There was a greater simplicity to life there, and I can't say that I really missed much of the electronic aspect of our lives here (Amy will be shocked by that statement since she likes to call me Mr. Technology).  I greatly enjoyed watching how the children played creatively with each other and how they really had a great time together.  We would certainly miss the graciousness of the Kenyan people.  I had greatly enjoyed going to chapel at the hospital and working with people at a place whose purpose was to glorify God in what they did.  It was fun to see Rhett singing at chapel as the only white face in the choir.  Despite the stress that came with taking care of much sicker kids than I take care of here, I would miss the expanded use of my training there.  The easy access to specialists here and time pressure of running the office here leads to earlier referral of patients than I would like.  Although I should be dependent on God on a daily basis in my work here, the fact is that the lower severity of most illnesses here does not often push me to depend on Him like I should.  I spent more time on medical reading in the 4 weeks there than I have in the last 3 years here in the U.S.  Nothing inspires you to read like a patient you can't figure out.  


I would also miss the opportunity to work with some of the most talented physicians I have ever been around.  I have not been more impressed by any two physicians I have ever worked with (and I have been blessed with the opportunity to learn from some of the best in their fields in the U.S.) than I was by Dr. Steve Letchford and  Dr. Paul Jaster.  The breadth and depth of their knowledge and skill is, in my opinion, unmatched by anyone I have ever worked with here in the U.S.  I had the pleasure also of working with Dr. Bert Lee, Dr. Leland Albright, and Dr. Joshua Tjong during my time at Kijabe Hospital.

Wednesday morning was spent finishing packing and distributing the remaining medical items we had brought with us.  We went to the nursery, pediatrics, and to the chaplain, Mercy, to say good-bye and then I stopped into the ICU to talk with Dr. Letchford and check on the girl who had surgery for her enormous encephalocele the day before.  I was pleased to find her doing well in the ICU without a ventilator and to find the other baby stable on the ventilator.

We returned to the apartment, finished packing, and waited for our driver to pick us up to go to the airport.  The trip to the airport took us through Nairobi at rush hour and included some portions that took us through some of the infamous Nairobi slums.  The poverty was really quite shocking, even though I have been exposed to extreme poverty in Mexico and Venezuela in the past.  We were instructed not to have our windows open (or even cracked) as we drove through these areas.  This was the only time during our trip that I felt any concerns about safety.

We arrived at the Nairobi airport and had to kill a couple of hours before boarding the plane to Amsterdam.  Personal space is apparently a concept that is lost when one is standing in line in Kenya and our progression through the security check was unpleasant for someone with a tendency to claustrophobia.  The kids nearly got arrested (joking, a little) for having scissors in their bags for crocheting.  The same scissors were perfectly acceptable in the U.S. airport and the Amsterdam airport.  The kids were made to throw the scissors away before they could enter the holding area at the gate.  The waiting area was packed full of passengers and we moved to an open area at the front so the kids could sit on the floor.  We chatted with a guy who was married to a Kenyan girl and visited periodically.  Though they were married, neither could get a permanent visa into the other's country and they were forced to make periodic trips to visit each other in each country.

The airport staff once again showed kindness to those of us with kids and allowed us to board the plane before other passengers.  I was happy to be out of the overcrowded gate and into the plane to begin the long journey home.

Last Two Working Days at Kijabe Hospital

My last call night ended Monday morning and I was off to round at the hospital again.  Overall, there were no terrible occurrences that day, for which I was thankful.  On pediatric rounds we learned that our girl with the huge encephalocele was going to get surgery the next morning.  Hallelujah!  Despite the concerns of the surgery resident over the weekend, the surgical team ended up agreeing that she was healthy enough to undergo the anesthesia and surgery risks.  I thanked God that she was finally get the intervention she needed and I looked forward to the final result.

We were consulted by surgery on a wheezing baby who turned out to have too high a dose of ceftriaxone going. We reduced the dose to the weight-appropriate levels and the patient's wheezing improved by the next day.  Wheezing is a little known and rarely occuring side effect of ceftriaxone and that appeared to be what was going on with this child.

I was consulted on a child in the clinic who was having some issues with possible syncope (fainting).  A chest x-ray was done and was unremarkable.  An EKG was done to evaluate this as well.  In the U.S., I have the luxury of having all the EKGs I order being read by a pediatric cardiologist.  No such luxury at Kijabe.  I then had to read the EKG from scratch, which I haven't done since my last pediatric cardiology rotation in residency.  It was a nice refresher on EKGs.

Tuesday would be my last pediatric conference with the interns and residents, so I spent most of the rest of the afternoon and evening preparing my talk.  I decided to hit a variety of topics that I felt would be important for family medicine interns and residents to know about pediatrics.  Among the topics was IV fluids, which is one of my least favorite topics, but I felt it was something I should review with them.  The overriding theme was that you have to make most of your medication and fluid decisions for kids based on their weight, not just their age.

Tuesday also brought no major disasters, but still kept me busy.  I was thankful to see that a pediatric resident had arrived the night before and would be taking over the supervision of the nursery.  One of the family medicine residents who was there for a month would be taking over the pediatric wards once I left, so both the nursery and pediatrics would be covered.  I recognized in the pediatric resident the same sense of both excitement and inadequacy that I had experienced at my arrival.  Knowing that she had done her Neonatal ICU rotations much more recently than I had, I was confident that she would do fine.

The boy we had intubated over the weekend remained stable on the ventilator and, as I had resolved, I did not extubate him prior to my departure.  The girl with the encephalocele was recovering from surgery and spent the night in the ICU, though not on a ventilator.  The blood sugars on the diabetic girl finally stabilized and she was transferred from the ICU.  God had answered my prayer that no one else would die before I left, and I was thankful for that.

Although there were only a few deaths in my short time there, it quadrupled the number of deaths I have had in my practice in 6 years in the U.S.  If that rate continues over the next 6 years (the amount of time I have been practicing and out of residency), that would equate to over 300 pediatric deaths in the same time span that produced 1 death here in the U.S.  By no means is that a scientific statistic, but it does illustrate the difference in pediatric health here and there.  What a great need there is for quality health care in the developing world!

One of the things Amy has pointed out when we show our pictures from out trip is the sign at the entrance to Kijabe Hospital that includes an arrow guiding the way to the morgue.  Death, tragedy, and poverty are a part of life to the Kenyan people, yet they maintain such a joyful attitude.  We could learn some lessons from the Kenyans.  I am reminded of the verse in Proverbs that states:

Proverbs 30:8b     give me neither poverty nor riches; feed me with the food that is needful for me,

⁹ lest I be full and deny you and say, “Who is the Lord?” or lest I be poor and steal and profane the name of my God. The Holy Bible : English Standard Version. Wheaton : Standard Bible Society, 2001, S. Pr 30:8-9  

We have reached the point in the U.S. where we congratulate ourselves on our wealth and accomplishments and deny God as the source of our prosperity.  We use "the American dream" and "retirement planning" as justification for the hoarding of our wealth.  When compared to the rest of the world, there are few (some, though) in the U.S. who are not wealthy.  May we recognize God as the source of this prosperity and understand that God gives us this prosperity to use for His glory, not to guarantee that we will not have to earn a living past the standard retirement age.  In fact, I think we should expect to labor throughout our living days.

Gen 3:17  And to Adam he said,

     “     Because you have listened to the voice of your wife

                    and have eaten of the tree

     ^l     of which I commanded you,

               ‘     You shall not eat of it,’

     ^m     cursed is the ground because of you;

               ^n     in pain you shall eat of it all the days of your life;

¹⁸           thorns and thistles it shall bring forth for you;

                    and you shall eat the plants of the field.

¹⁹           By the sweat of your face

                    you shall eat bread,

          till you return to the ground,

                    for out of it you were taken;

     ^o     for you are dust,

                    and ^pto dust you shall return.”

The Holy Bible : English Standard Version. Wheaton : Standard Bible Society, 2001, S. Ge 3:17-19

Don't misunderstand the above.  I don't particularly hope to continue working through my 70s and 80s; in fact, I am rather lazy by nature.  I prefer not to work even now in my 30s, at least not as hard as I must.  I like the idea of retiring and would love to do so someday.  I am just not sure that saving for retirement should prevent us from using our resources for God's glory now.  How many BILLIONS of dollars are tied up in the 401K accounts of Christians (including me)?

Last Night of Call in Kenya

After the night of a thousand blood sugars, I was looking forward to attending the AIC church in Kijabe, though I knew I would have to do another greeting ("Hello, my names are David Sprayberry.  I am saved.  I am visiting Kijabe for this month with my wife Amy, and my children, Madeline, Abby, and John.  We bring you greetings from Watkinsville First Baptist Church in the United States."  or something like that).  

Prior to leaving for church, however, I was paged to Casualty (the ER) to admit a baby with a temp of 42 degrees Celsius.  If you are like me, you don't know exactly how high that is, but you know it is higher than it should be.  I pulled out the trusty Blackberry and discovered that 42 degrees Celsius is equivalent to 107.6 degrees Fahrenheit. (!!!!!)  I rushed down the hill to Casualty with only a nod toward the security guards instead of the usual brief conversation that Kenyan courtesy dictates.  I arrive in Casualty to find one of the new ER docs already working on getting blood, urine, and spinal fluid, leaving me to obtain the history from the parents and get admission orders and notes done.  Being just a few days old, the baby would be admitted to the nursery for further management after the labs were obtained.  Unfortunately, by the time this was all done, it was too late to make it to church, so Amy and the kids went on their own (which left Amy to give the greeting).

Upon my arrival to the nursery, I found that one of the babies we had previously intubated and ventilated was having difficulty again.  He had been doing well with CPAP since he was extubated the last time.  We had been working on gradually increasing his feed volume and he apparently had another aspiration event, which resulted in respiratory distress.  He had deep subcostal and intercostal retractions despite a CPAP of 5 cm H20.  I REALLY did not want to intubate him again and put him back on the ventilator.  I decided to check his venous carbon dioxide level to confirm respiratory failure (blood gases are not available at Kijabe).  The level was quite elevated, supporting my assessment.  I decided to reintubate him, and he proved to be even more difficult to intubate this time.  Fortunately, the ER doc had decided to come by the nursery to help with the intubation and we finally succeeded in intubating this baby for the second time in this admission.  

In a previous post, I mentioned that this was a 28 week infant who had made it through his first 10 weeks or so without any surfactant, intubation, or ventilation.  This was now my second intubation of him in my 3 weeks at Kijabe.  I resolved that I would not extubate him before I left Kijabe in a couple of days; I was not going to intubate him a third time.  After intubation, we decided to carry the baby to the ICU while bagging him, rather than try to maneuver an incubator through the halls and bagging at the same time.  We set the baby up on the ventilator and he remained quite stable the rest of the time I was there (but I did NOT take him off the ventilator before leaving).  HIs mother, the one who had said "please help my baby" before the first intubation, was understandably quite upset by the need for reintubation.  I attempted to comfort her and assured her that I would be praying for her baby.

Much of the rest of my day and night were spent managing blood sugars on the diabetic child.  There was a little disagreement between the surgery resident and the intern on pediatrics about whether the child with the huge encephalocele was septic or not and I was paged that night to try to settle the dispute.  The pediatric opinion was that the child was not septic, but that the only way the erosions on her encephalocele would resolve would be for the surgeons to remove the whole thing.  The pediatric intern proved to be correct, but the surgical resident was nowhere to be found to inform of this, so my involvement in the dispute was unnecessary.  I will confess that I was thankful that I was not on call Monday night, so that I could finally have some uninterrupted sleep.   

Next to Last Call Night at Kijabe Hospital

Saturday, the 2nd of October:

On Saturday, I arrived to round on pediatrics and in the nursery.  I was saddened to learn that, during the night, the baby with the encephalocele who was just extubated on Friday was unable to respire adequately and passed away.  Although this was not a surprise, it was still difficult to hear.  I can't imagine the sorrow that parents experience when they lose a child.

On pediatric rounds we found that the child with extreme cholestasis had begun to improve.  This was an answer to prayer because I did not have much to offer this child in the way of medical treatment.  The child with the huge encephalocele had begun to develop erosions on the encephalocele.  These erosions were being treated, but I doubted that topical or systemic antibiotics would do much good.  The cure for these erosions would have to be surgical removal of the encephalocele, but surgery was apparently not ready to take her to the OR.  I could only hope and pray that they would take her to surgery before the erosions caused sepsis and, ultimately, death.

The other notable event on Saturday was that a child with diabetes had been admitted the night before with severe hypoglycemia.  As this was treated during the night, the blood sugars began to rise and she needed to be restarted on her maintenance insulin regimen.  This regimen was ordered correctly by the intern, but the nurse, being unfamiliar with insulin administration, gave the child 24 units of regular insulin instead of 24 units of 70/30 insulin.  That was a HUGE dose of regular insulin for a pretty small child (4 years old if I remember correctly).  Regular insulin is fast-acting and its effects last a few hours; 70/30 insulin is a combination of regular insulin and long-acting insulin. The net result of this error is that the child received over 3 times as much regular insulin as she should have.  Because this error put the child at risk for severe blood sugar problems and seizures, we had to admit the child to the ICU.  Blood sugars would have to be followed very frequently until they stabilized, which meant I would be called with blood sugars very frequently for the rest of the weekend.  The calls aren't so bad during the day, but you just can't get decent rest when you are awakened every couple of hours.

Just a few more days until our time at Kijabe would be over.  Hoping for no more deaths before we leave.

Friday, October 1 - extubation

So, after the overly eventful Thursday, my last few days at Kijabe hospital arrived.  I would work a regular day Friday, be on call Saturday and Sunday, and then finish with two regular work days on Monday and Tuesday.  I arrived Friday and went to the ICU to check on the child we had intubated on Thursday.  He was doing "well" on the ventilator, meaning that oxygen was going in adequately, carbon dioxide was coming out adequately, and his lungs were not requiring high pressures to achieve this.  This is not truly good news because it means that his breathing problems from the day before were not caused by a lung problem, they were caused by a brain problem: his brain was not telling his diaphragm to breathe sufficiently.  On my examination, he would withdraw from pain but had very little else that was positive from neurologic standpoint.

We had talked with neurosurgery prior to intubation the day before, and they said they would give him a trial of a few hours on a ventilator to see if he would recover respiratory function.  We had decided to give him longer than a few hours and allowed him to spend the night on the ventilator in order to be certain that he was not going to recover adequate respiratory function.  After another round of discussions with Dr. Letchford (ICU/med/peds), Dr. Lee (ICU), and Dr. Albright (neurosurgery), the consensus was that if the child was going to recover, he would have resumed spontaneous respirations and started to "overbreathe" the vent, which he had not done.  

The prognosis was discussed in depth with the parents and they were given the choice to transfer to Kenyatta Hospital in Nairobi for further ventilation care or he would need to be extubated and allowed to try to breathe on his own.  Kijabe Hospital did not have the resources to perform prolonged ventilatory care on a baby that would most likely never recover.  We advised the parents that if the child was extubated, he most likely would not breathe adequately and would likely pass away.  The parents decided against transfer for continued ventilation and chose extubation, with the understanding that the child would not be reintubated if he began to have respiratory failure again.  We extubated Friday afternoon to CPAP (continuous positive airway pressure) to give him the best chance to make it and the child initially did breathe some on his own with the assistance of CPAP.  Prior to extubation, the chaplain came up and we prayed with the family before stopping the ventilator.  At the end of the day he was still breathing spontaneously, though somewhat irregularly, and there was a glimmer of hope that he might make it.

Interesting Day at Kijabe Hospital - Thursday, September 30

This post was originally written on Thursday, September 30, the day that these events happened.

There is a lot of medical mumbo-jumbo in here, so I will include a little glossary at the end. 

I was awakened today with a "999" page to the nursery.  "999" here means come immediately, do not call first.  I had slept in scrubs since I was on call, so I jumped up, threw on socks and shoes and hurried to the nursery.  I found one of our patients, a child born with encephalocele, had stopped breathing and the nurses were giving bag/mask ventilation.  The child had ventilated easily with the bag and mask, and sats and HR were good with bagging.  The problem was that when you stopped bagging, there was NO respiratory effort at all.  Not a gasp, nothing.  Because the encephalocele implies that there is a good chance of a brain abnormality, it is debatable here whether you would intubate this child or not, because the child might never make an attempt to breathe again.  I checked quickly to see if ICU had a bed and a ventilator available, and they did.  Next I had to talk with one of the main docs here and also the pediatric neurosurgeon.   The opinion was that this child should be given the opportunity to be ventilated, at least for a few hours, to see if he would begin to breathe on his own again.

I returned to the nursery, and with the help of the intern and the nurses, we intubated the baby and transported him to ICU for ventilation.  I received a crash course in the little ventilators we have here shortly after arrival, and have previously had to change ventilators once since I have been here, so I was able to grab the ventilator and get it ready to go for this child (no respiratory therapists here to set eveything up).  We settled him into ICU and ordered a chest x-ray for tube placement.  Side note: the parents later asked if the child could breastfeed while on the ventilator.  This was not the first time I have heard the question asked since I have been here.

I then returned to nursery to grab the things I had left there.  I walked in to find a 3 day old who was just being admitted after driving all night in an ambulance from Somalia.  This child had bilious vomiting and an incredibly distended abdomen.  The child had not stooled once since birth.  Examination turned up a good reason for no poop: no anus.  We ordered some preliminary labs and films and called the pediatric surgeons to come see him.  They came and agreed to operate on him today.  Fortunately, the rectum was very close to the skin surface, so they were able to just open up an exit for him.

No Anus = No Poop and a Really Distended Tummy

After that baby was admitted, I went back up the hill to the apartment and finally showered, changed, and ate breakfast.  I returned to the hospital and went about the usual daily activities, which led to me seeing a 7 year-old boy with significant direct hyperbilirubinemia (total 19, direct 11), fever, and proteinuria.  I was also called to the clinic to see a child with a positive Gower's sign, which suggests Duchenne Muscular Dystrophy.  I am hoping that maybe he has a spinal cord lesion instead, but we found out that there was a family history of DMD, so DMD is the likely diagnosis.

And, earlier this week, we had a girl with carpopedal spasm and a positive Chvostek's sign, which I have never seen before.  She ended up passing away, so please feel free to pray for her family, as they are undoubtedly mourning her loss.

Glossary:

Encephalocele - a "neural tube defect" in which there is an external sac at the base of the skull which may contain membranes and fluid only or may contain brain tissue.  Related to spina bifida.

Gower's sign - when a child uses his arms to help straighten/strengthen the legs as he stands up.

Carpopedal spasm - spasm of the hands and feet associated with low calcium

Chvostek's sign - twitching of the mouth when the facial nerve is tapped or percussed.  Also associated with low calcium.

Reflections on the Safari and Return to Kijabe.

We returned from the safari on Sunday with an awe of what we had just seen of God's creation.   I have had the blessing of seeing many beautiful places on this earth, both near and far.  I think one of the ways God's rewards those who rise early is by allowing them to see terrific sunrises periodically. Here in Oconee County we also have some fantastic sunsets that I get to watch while I drive home (I guess God gives the gift of his beautiful creation to those who don't have to get up early, too).  I have always enjoyed our trips to the mountains and to Lake Rabun because of the great beauty of those places.  Growing up near Clark's Hill Lake, I have fond memories of skiing at sunset on a surface of glass.  I love driving to the Lowcountry of South Carolina and driving under the oaks draped in Spanish moss on the way to the beach.

Madeline jumping from the boat dock at Lake Rabun

Lake Rabun

Despite the natural beauty all around us in the southeast, there are a few places that I have been in this world that are almost overwhelming and are certainly a testimony to the greatness of the Creator. Oahu and Maui, though more than 20 years have passed since our visit, are among these awe-inspiring places. Parts of Bermuda, where Amy and I went for our honeymoon, were fantastic, as well. Much of the Caribbean is similarly spectacular. The coast of central and northern California provides one incredible view after another, and standing at the base of a redwood is an experience encourages humility regarding our own importance.  Our family road trip to Arizona two years ago led us to the Painted Desert, the Petrified Forest, and the Grand Canyon. The varied hues of the Painted Desert were phenomenal, the bizarreness of the Petrified Forest was amazing, and the beauty and absolute vastness of the Grand Canyon was overwhelming and inspired worship of the One who created it all.

California Coast

At the Foot of a Giant

The Painted Desert

Between the Painted Desert and the Petrified Forest

Petrified Forest

Grand Canyon at Dawn

Grand Canyon in the Morning

    

Grand Canyon with Clouds Rolling In

The Maasai Mara savanna was one of those places which inspired such awe. The landscape was extremely beautiful and quite vast (see sunset pics on the previous post), but here it was the wildlife that triggered such captivation. Our photos (see the last post), though quite amazing to me, still do not do justice to what we actually saw. I couldn't help but wonder what this must have been like 100 years ago or so, before these lands were disturbed by overhunting and tourism. Teddy Roosevelt came to Kenya to hunt (and laid the cornerstone at Rift Valley Academy while on one such trip) nearly a century ago. What must it have been like back then, before the endangered "big five" (lion, leopard, elephant, cape buffalo, and rhino) became endangered? It is difficult to fathom how much more impressive it might possibly have been.

Whenever I am awed by creation, I am reminded that this is one of the ways that God reveals Himself to man:
Romans 1:20     For since the creation of the world His invisible attributes, His eternal power and divine nature, have been clearly seen, being understood through what has been made, so that they are without excuse.  New American Standard Bible : 1995 Update. LaHabra, CA : The Lockman Foundation, 1995, S. Ro 1:20

After our return from the safari, I was apparently rather busy the next three days, because I did not have the opportunity to jot too many notes on the events of Monday through Wednesday.  I made a few notes about Wednesday, but I was apparently a bit sleepy when I wrote them, because they are largely indecipherable.  There was a preterm baby who was admitted after a home delivery.  This child had an encephalocele (a fluid sac at the base of the skull, which may or may not contain brain) and apparently never cried after delivery.  The baby presumably had birth asphyxia and was to be treated for possible sepsis, as well.  One of the other babies in the nursery finally got an echo because of a persistent murmur (actually, two murmurs: a contiuous machinery murmur and a loud systolic murmur) and turned out to have a large patent ductus arterious (a persistent fetal blood vessel that is supposed to close after birth) and pulmonic stenosis (narrowing of the valve that leads from the right heart to the lungs).  Another baby had an echo late the previous week and was found to have an atrial septal defect and pulmonary hypertension, which contributed to a persistent oxygen requirement.  One of our preterm "feeder-grower" babies was reported by the lab to have a bilirubin of 23 (possibly dangerous) but did not appear jaundiced at all.  A stat repeat bili was performed and turned out to be 2.  Doesn't instill a lot of confidence in the reliability of the lab.

Over on pediatrics, a Somali patient was admitted with spina bifida and a massive encephalocele.  This poor 9-month-old had an encephalocele that was roughly 3/4 the size of the rest of her body.  Just turning her from one side to the other was at least a two person job.  How this mother managed to take care of this child for 9 months is beyond me.  We were consulted by surgery on a child with massive hydrocephalus who was going to eventually get a shunt to decrease the fluid and pressure in his head.  I was saddened to hear that our girl with the low calcium had passed the previous night, presumably from sepsis (severe infection).  The cause of death will never be known for sure because no post-mortem labs or autopsy was done.  We crowded about 10 people into a rather small hospital room the next morning to talk with the family.  The conversation was translated from Swahili to Somali, so I truly did not understand a word of the conversation.  I did the only thing I could, which was to stand there and pray for this family to be comforted and to come to know the Comforter personally.  Fortunately, or rather, providentially, there is a missionary couple in Kijabe that had spent several years working with Muslims in Somalia.  They were present for the conversation and remained with the family after our discussion.  Feel free to pray for the family of this Somali girl.


As Wednesday drew to a close, less than a week remained for us in Kijabe, but it would be a challenging and memorable week.

Safari Days 2 & 3

The Fairmont Mara Safari Club has 2 game drives each day for its guests, one in the morning and one in the afternoon.  The morning game drive starts at 6:30, so your room waiter brings coffee, hot chocolate, and tea to your tent at 6:00 to help make sure you are up in time for the game drive.  Now I don't usually like to get up at 6:00 a.m. on my vacation or weekend days, but this would undoubtedly be worth getting up for.  Amy and I got up a bit before 6:00 and began to rouse the kids from their slumber so we could make the drive.  I elected not to have coffee since we would be in a land rover in the middle of the Maasai Mara for several hours.  We had been advised not to hang our hands out the windows while on the drives, so I gathered that it would not be advisable to get out of the land rover for a code brown.

The morning drive was also fantastic.  It was quite exciting to watch the king of the jungle meander from the trees to the grassy brush to meet two lionesses, coming within about two feet of our vehicle as he walked.  He clearly did not feel threatened by our presence.  As we continued on our drive, we encountered many more zebras, gazelles, wildebeests and topis.  The Great Migration is said to involve about 1.3 million wildebeests, 500,000 Thompson's gazelles and 200,000 zebras, as well of tens of thousands of topis, elands, and other game.  Given the huge numbers of these animals we saw personally, I must say that I believe those numbers to be correct.

Thompson's Gazelle

Abby was thrilled later in the drive when we came upon a herd of giraffes.  As someone else has stated, I think God was expressing His sense of humor when he made these things.  When we approached the herd in the land rover, they all turned their heads to stare at us.  Most of the other animals on the safari ignored the vehicle, but the giraffes all took notice.  Although I cannot attest to the veracity of this, giraffes can supposedly outrun most of their predators and have been known to kill lions with a kick.

After the morning drive, we had breakfast at the club and then went to a Maasai village.  The Maasai villagers were very welcoming, especially once you pay the $20 entry fee (U.S. dollars).  The female villagers sang as we entered and the men demonstrated their jumping ability, which is how they prove they are ready for marriage.  If you jump high enough, you qualify to marry.  Good thing that's not the case here, because I have quite a few buddies who would be destined for singleness.  (I am not going to single out anyone specific, like Jamie Wolfgram or Chris Strickland).  We were then invited to join them as they sang and danced. 

The chief's son then led us around the village and was quite proud to show us their homes and inform us that the walls are made of cow dung.  I've got to say, the pediatrician in me just kept thinking "E. coli, E. coli, E.coli".  Each home had a room for the calves to sleep in at night.  That's right.  The calves slept in the home with the people.  Medical note: one of the big problems in Africa which can lead to blindness is trachoma.  This eye disease can be spread by the flies which are forever surrounding cattle.  It would be a good thing if the calves did not sleep in the home with the people.  After the "tour" of their typical home, which clearly indicates that the Maasai are not a claustrophobic people, we were invited to go to their market.  Each family had their own little stall in this market, and we were expected to visit each stall.  Somehow Amy and the kids got way ahead of me, so I got the hard sell at each and every stall I visited.  I am not real good at saying "no", so I now have two pieces of wood that theoretically can start a fire.  Maybe I will try them next time I fire up the grill.

Proud of the dung walls

After escaping the market, we returned to the club for lunch and a little relaxation before the afternoon game drive.  The kids ventured to the pool, but only John was able to handle the cold water.  After a short time at the pool, we met our driver, Cosmas, for the afternoon drive.  The afternoon drive again presented things to us that we had not yet seen.  As we left the compound, we saw a little flock of guinea fowl, which resemble the peacock, but without the distinctive tail plumage.  We then saw a group of impalas, which were quite graceful in appearance.  Interspersed with the impalas were a number of topis, an antelope species which I found to be quite beautiful.  We made our way to the foothills to find the rhinos known to inhabit the area and along the way had our first encounter with a jackal, which looks remarkably similar to our own dog, Dottie.

Guinea fowl

An impala (foreground) and a topi

Dottie, I mean, a jackal

 As we approached the rhino habitat, we were met by a group of rangers that informed us that this is where we were to get out of the vehicle for a short walk.  Surprised that we were asked to exit the vehicle, with kids (!), we climbed out and followed the ranger up the path.  He led us to an area where a group of 4 rhinos were grazing.  We began to take photos in front of these apparently docile behemoths, until the ranger motioned for us to move away.  He then informed us, "That one is aggressive...sometimes we run."  It was quite reassuring to know that the ranger was there to protect us with the rather small stick he was carrying.  We proceeded back to the land rover and then had the opportunity to watch one of the greatest sunsets I have seen.  The hymn, "How Great Thou Art", sprung to my mind and "How Great is Our God" to Amy's.  Absolutely breathtaking.

We returned to the club for another excellent dinner and a great night of sleep.  We were again greeted with coffee, tea, and hot chocolate on Sunday morning prior to our final game drive.  The girls and I headed to meet our driver at 6:30 as Amy prodded John along to get ready for the drive.  As Amy and John left the tent, they met a baboon helping himself to the tray of coffee and tea.  My return to see what was taking so long apparently scared the little guy off, but Amy was able to get a couple of photos of the event. The Sunday morning drive provided another opportunity to observe the great cats.  We then drove on to find some hyenas finishing off a wildebeest.  Along the way we saw a little vulture, a tawny eagle, and several jackals.  It was fun to see the jackals try to sneak in among the hyenas and still some breakfast.  John had a potty emergency and got to contribute some fluid to an acacia tree in the middle of the savanna.  How many 6-year-olds can say they urinated among a bunch of wild African animals?  John's kind parents decided not to take any pictures to use for future blackmail.  We then had another giraffe encounter and our driver found an ostrich egg (I don't know how he found it) for us to see.  We returned to the club and prepared to leave.  We said good-bye to the staff, who had been quite taken with the kids, and began the long drive back to Kijabe, still overwhelmed by the vastness, diversity, and creativity of God's handiwork.

What do you get when you cross a baboon with caffeine?

Tawny eagle

Hyena breakfast

A dik-dik

Secretary bird