Linda

This week Sharon and I are operating on a 14 year old with an congenital anomaly I don't think has been reported. She has distal vaginal agenesis with absence of the posterior urethra. She is unable to menstruate and has a large volume of blood "trapped" inside with urinary leakage.   We had planned for the operation on Wednesday, but she came tonight in severe pain and will need surgery tomorrow. Speaking with her mother tonight she asked, "How many surgeries like this have you done?" I had to tell her I couldn't find any other girls with this combination of anomalies, and so we've been studying about what to do. We prayed together for wisdom and I would ask you to pray as well for this child. Pray that we can construct a functional vagina and that we will be able to repair the urethra as well.

Parched

Kijabe has been unusually dry.  It is dusty, the few creek beds are empty, and the hillsides are brown.  

The dryness came to be a reality in our house this morning. We turned on the faucet this morning to find nothing.   Not even a few drips of water. We're not sure if the tank is empty, faulty plumbing, or something else.  Futhermore, we have not been told when to expect water in our house again.   

Fortunately up the hill at the Waring house the spigot produces water.

Tight Squeeze!

Doing My Own Thing.

When Meredith dresses herself.  I can't quite place the style....

BOH

There are many unique medical abbreviations in Kenya and probably in every country, common things get shortened. However, sometimes these abbreviations can be a bit mind boggling. Some of my personal favorites ISS (immune sero status-HIV), 1PS (one previous scar), PMTCT (perinatal mother to child transmission), and BOH (bad obstetrical history). BOH took me a while to figure out and remember, and indeed many histories here are simply "bad." So today there was a C/S for a BOH. This mother had 2 babies die during prolonged 2nd stages (pushing) and I advised a C/S this time. Showing her, the vigorous baby boy was a delight. 2 weeks ago I delivered another mom who had lost 3 babies during or immediately after delivery. Above are the pictures of these little ones.  I think a new abbreviation can be added to these charts: BOH BPG BL (bad obstetrical history but praise God baby lives).

Treehouse

Nancy

She came to the clinic by herself with chart in hand to be evaluated for a jaw fracture.  The cause of such trauma is usually motor vehicle accident or assault.  Sadly her trauma was due to the latter at the hands of her husband.

"He hit me with a piece of wood.  The long stick smashed under my chin and my mouth began to bleed.  Then he raised the wood up and brought it down on the back of my shoulders. He then grabbed my neck with both hands and choked me again and again."

Nancy rested uncomfortably in the dental chair supporting her neck with the palm of her hand.  Her front lower teeth were displaced, bloody, and painful to the touch.  No jaw fracture was present.  We numbed her mouth and extracted her front 3 hopelessly mobile teeth, placed gauze in her mouth, and prescribed the appropriate antibiotics and pain medicine. I guess that is all we can do for you.  I left to attend to the next patient.

After a break I asked Hannah one of our assistants, "What will happen to Nancy? Will she go back to her husband? Will she prosecute him?  Will he face justice?"

"You see the problem in Kenya, and most of Africa is that when you are a victim first you have to hire a lawyer.  That takes a lot of money.  And if the other person has more money, their lawyer will win due to bribes, or just because they have more money." 

"Do you think Nancy will return to her husband."  

"She has family in Nairobi, but the problem is that of course in Kenya the women are responsible for the children.  She has three children.  Her husband has the land and house.  She has no way to provide for the children.  Also, getting a divorce in Kenya is very hard.  Culturally when we marry we see it as you stick together no matter what. Legally, if you are married in a church in can take over 4 years to receive the divorce papers."  

At that moment I returned to see Nancy.  Of course there is more we can do for her.  God expects more of us. Thankfully she had not left the chair.  "Why are you still here?"

"I feel weak and I don't know if anyone will come to pick me up?"  

"Can I pray with you?"

"Yes."

"We prayed that God would heal her mouth and back, that the pain would be relieved.  We prayed that her children would be safe.  We prayed that justice would be done and that her husband would face consequences of his actions.   We prayed that God would rescue her from this violent social situation."

"Will you go back? Will you forgive him?  Are your kids safe?" I asked in succesion.

"My firstborn daughter is in University.  My other children are with my mother.  My husband, he is a wealthy man. He has his own business and land.  He is crazy in the head.  I have already forgiven him.  But, I will not go back.''

My youngest patient ever.

At just under 1 month old this baby was by far the youngest patient I had ever seen.  Although the American Academy of Pediatric Dentistry recommends that the first dental exam be either when the first primary tooth erupts or by one year of age, even in the United States I rarely saw children under the age of 4.  I'll be honest I can treat fractures, infections, root canals, but this baby really intimidates me!    

From the expression on the babies face you can tell he was not happy but not because he was in pain thankfully.  He was not happy to have me prying around inside his mouth!   You can see in the above picture (if you look closely) bilateral solitary white lesions attached to the gingiva on his lower ridge.  Mom said he was breast feeding normally and growing as expected. 

 

The diagnosis made was gingival cyst of the newborn or Bohn's nodules.  These cysts are a result of degeneration of the epithelial rests of the dental lamina.   

The cyst is lined by odontogenic epithelium which is covered by a thick layer of keratin. Keratin gives the cyst its yellow color. Generally they rupture on their own with in the first two months of birth.  

I have seen him since the picture was taken and they had not burst as of yet. I'll continue to follow him week to week. 

  

Kenyan Census

Last tuesday at 8 AM I received a knock on my door from these two visitors.  They were official Kenyan census takers who along with perhaps thousand of other workers have 1 week to knock on doors of every house, apartment, shamba, and hut in Kenya.

       I invited them in to our duplex and proceeded to be part of a Kenyan census.  The questions were quite interesting ranging from level of education, religion, number of children, possession of phone, radio, tv, vehicle, and pets, and my most favorite question; how many wives do you have?  

I think our wazungu family skewed the census in many different ways, but it got me thinking about what does the typical Kenyan household consist of?

These statistics were pulled from the care international website (http://www.careinternational.org.uk/3235/kenya/kenya-statistics.html).  

Kenya is striving to meet the needs of its population of over 30 million, but as you can see it has a long way to go in regards to availability of clean water, maternal mortality rate (1/100 mothers die during child birth) and HIV care.   No surprises to see that nearly one quarter of Kenyans live on less than one dollar per day.

Kenya Statistics

Population	31.9 million
Urban population	35%
Major ethnic and linguistic groups	Kikuyu 22%, Luo 13%, Luhya 14%, Kamba 11%, Kalenjin 12% and others.
Languages	Swahili, English (both official), Kikuyu, Luhya, Luo, Meru and others.
Religion	Protestantism 45%, Roman Catholicism 33%, Islam 10% and Traditional Beliefs 12%.
Life expectancy (at birth)	45.5 years
Infant mortality (under one)	78 per 1000 live births
Under five mortality	123 per 1000 live births
Maternal mortality rate	1000 per 100,000 live births
Adult HIV prevalence rate (ages 15-49)	6.7%
Percentage population with access to safe drinking water	62%
Adult literacy rate	84%
Proportion of population living on below $1 a day	23%

Gum Boots

All of Kijabe has been praying for rain to grow the maize, fill the Ken-tanks, and turn the fields green.   It has been two years since this area has received significant rainfall.  This drought naturally adversely affects crop production and the ability to dig wells and find water aquafers.

    Just yesterday it drizzled all night long and into the afternoon.  Not nearly enough as can be seen in the parched, yellow grass in our yard.  But it was enough to settle the dust and give the girls a chance to wear there gum boots and rain jackets to school.

1st day of 1st Grade

Amelia woke-up earlier, got dressed and then had to wait to walk to school. She had her new outfit on (courtesy of Nana) and a new backpack (thanks to Grammie). Meredith also put on her coat and backpack and thought she would be going to school as well. 

I think the day was a success. Amelia's been talking about school since coming home, and looks forward to collecting the "four things to share about me" for Friday. I think the biggest problem is going to be settling on only 4 things! 

This was also an exciting day for me as Dr. Sharon Morad (OB) began working and we will be together the next year. We've got a busy day lined-up for tomorrow and I'm grateful for her help!

Iatrogenic Dentistry

(This blog is mostly for dental nerds)

The terms iatrogenesis and iatrogenic artifact refer to adverse effects or complications caused by or resulting from medical treatment or advice.  Examples are a wrong dose medicine, surgical instrument left inside the body cavity, or wrong leg amputation.  Thankfully in dentistry iatrogenic events are far less spectacular but still cause plenty of headaches and unplanned outcomes.

The specialty of endodontics presents many opportunities for "misadventures" as a professor once told me.    Indeed this occurred to me as I was completing RCT on a staff member at Kijabe Hospital.  For no apparent reason on a non-curved canal, with straight-line access, a Tulsa Rotary 40X.08 separated.  

The radiograph shows the file trapped and short 4 mm of the apex (and with obvious periapical pathosis).  Leaving the file is not a preferred option as it is short, does not provide seal, and there is a RL at the apex.  Apicoectomy (surgically removing the last 5 mm of the root tip) is a possibility, but unfortunate and somewhat invasive  Extraction is another option yet terrible.  The last option was to attempt to retrieve the file--something I had never been successful in accomplishing.

The Tulsa Dental Piezo Ultrasonic came in handy again (thanks for the donation)!  After 30 minutes of using multiple non-surgical tips and different ultrasonic levels (5-15), water and no water, stil the file failed to come loose.  All I knew about operating this instrument was to circle the file (which was not visible) in a counter-clockwise fashion.  It didn't seem to be working.  All that seemed to be happening was the removal of intracanal cementum and possibility of perforation.  

Persistence proved successful and the separated file in a swift movement was loosened and removed.  The canal was shaped (somewhat overshaped in the coronal third).  The canal was irrigated with NaOCL, dried, sealed with therma-seal, and obturated with thermafil GP.  Decent fill with a "puff" of sealer extruded past the apex confirming patentcy.

I'm grateful for an understanding patient and the chance to correct an iatrogenic event.

The same Word

I found interest in a recent podcast and wanted to share with you the introduction.  Take a moment in your mind and answer the following questions.  

1) Who is the living person who has had the greatest influence on your life?

2) Who are you?

3) What is God like?

4) What is "The Church"?

5) What is "The Church's" Gospel?

6) What is Truth?

7) What is the meaning of life?

Answers:  All can be answered with the same word.

1)Who is the living person who has had the greatest influence on your life? Christ.  We have a God who is living today.   "I am with you always to the end of the age."  Matthew 28:20

2) Who are you?  We are in Christ.  "if anyone is in Christ he is a new creation." 2 Corinthians 5:17 

3) What is God like? God is like Christ.  "in Christ all the fullness of God dwells" Colossians 2:9

4) What is "The Church"?  The church is Christ.  "the church is His body" Colossians 1:24

5) What is "The Churches" Gospel? The Gospel is Christ.  "I decided to know nothing among you but Christ crucified." 1 Corinthians 2:2

6) What is Truth? Christ claims He is Truth.  "I am the way the truth." John 14:6

7) What is the meaning of life? Christ is the meaning of life.    "I am the life." John 14:6

  (Shared from Podcast Peter Kreeft "The Word" 28/2/2007

Amelia's Pottery

Amelia and Meredith have learned on their own how to make pottery here in Kenya.  

Inside their "bush fort" they mix mud and water together on a piece of lumber.  They form the bowl with their hands and other made up tools to their correct shape.  Then they allow the mud to bake under the sun.  Finally, adding some paint to finish their creation.  One each for Mom & Dad.

Encouraging

Proverbs 12:25 (Amplified Bible)

²⁵Anxiety in a man's heart weighs it down, but an encouraging word makes it glad.

This proverb is particularly fitting for my heart which is often filled with anxiety. Our visit to Tenwek last weekend was more than a celebration it was encouragement. Being able to visit and pray with friends over work challenges, hearing thoughtful words from a general surgeon, getting 8 ounces of Tilamook Cheese as a gift, eating with other families, and spending time together as a family made my heart glad.  

But anxiety so easily creeps back as I returned to busy wards, sick patients, 2 babies dying during labor, trying to resolve interpersonal conflicts, complex surgeries.... but as I'm leaving today the main OR coordinator encouraged me.  And yet, I know her day is filled with many demands as well.  So I wonder, perhaps an anxious heart is also eased by encouraging others? After all if we can focus on others, rather than ourselves, then there should be less time for anxious thoughts and worry. 

Borios and Tillamook

The "borio" cookies we found at Nakumat despite being jumbo size just didn't compare to the real thing.  Nevertheless, Meredith licked out the frosting in the middle.

Friends from Tenwek that returned to Oregon recently thought of us and returned with Tillamook cheese straight from the factory.  Thanks this little slice of Oregon is delicious!

A day with Dad

In an unexpected last minute move a holiday in Kenya was declared by the president today. A national census is occurring and census takers work late in the evening knocking on doors; hence people may need to rest the next day due to the late night interference.

Non-emergent outpatient service were closed at Kijabe; so that meant some time extra time with Amelia & Meredith.

Amelia would say, "I had a rough day. Daddy & Mommy gave Z the cat away again.  I was at the park climbing the tree when they came to get him. This time I did not even get to say goodbye.  Then I tripped and fell down the stairs."  We don't expect Z to come back this time as they have taken him to the Kakamega Forest (roughly 400 km away).

This is what Kenya (and a day with Dad) does to Meredith.  I think under the yoghurt on her face you would find dirt, then perhaps marker, and who knows what else. 

50th Anniversary Celebration at Tenwek Hospital

Sara and I and the girls made the 180 kilometer dusty drive to Tenwek Hospital to mark the 50th Anniversary of Compassionate Health Care, Spiritual Ministry and Training for Service.  Although Tenwek Hospital has existed for nearly a century, it was only after 20 years of prayer by a dedicated nurse that in 1959 Dr. Ernie Steury the first full time physician arrived.

My how Tenwek Hospital has changed in the last century (Tenwek received its name because it took the first missionaries "Ten-weeks" to arrive from Mombassa).  Now drivers go To Tenwek and back in 1 day.  

Mrs. Ernie Steury escorted by family.  It was moving to see her greeted and thanked by Kipsigis patients of Dr. Steury (Mosonik) years ago. 

President Hubert of WGM, President David Stephens of CMDA, and former President of Kenya Daniel arap Moi were honored speakers at the celebration at nearby Tenwek secondary school.  Several thousand people filled the soccer field to be a part of the celebration.    Dr. Stephens reminded us that Tenwek was founded on principals of 1) prayer 2) striving for excellence 3) humility and 4)  "keep the main thing, the main thing." (sharing the gospel).

Tenwek's new fountain in the courtyard with clean water!

The Kipaganga as you have never seen it before with a catered dinner.

Tenwek Hospital's new sign.

Various things I've removed

THIS BLOG HAS VIVID MEDICAL PICTURES 

With sometimes limited tests I'm not always sure what I'm getting into when a patient needs surgery. While this pushes my physical examination skills particularly since sometimes history is vague, I'm always amazed at the depth of pathology. So, if you want to look below is a small capture of some of the things I've been treating. 

What's more amazing though is the healing given by God to these lives. God's care and provision is revealed to these women through the healing and restoration of their health through surgery. I feel so privileged to work here!

ovarian torsion
fibroids from the uterus
Ovarian serous cystadenoma

Desmoid tumor of the abdominal wall and small bowel mesentery

Hydrosalpinx

Pelvic kidney with severe hydronephrosis

Ovarian dermoid cyst (yes, this has hair, a tooth and fat inside)

So, next time I post medical pictures I'll try to capture some of the adorable babies I also get to "remove" through C-sections! 

A place to find help.

After receiving positive feedback from other health care professionals its seems appropriate and uplifting to share Simon's story of healing (Simon was welcoming of photographs).  The best stories are that of our patients and their experiences at Kijabe.

Simon came to Kijabe dental six weeks ago from a place just 20 km up the road.    He is 29 years old, Kikuyu, and in good health.  

The painless swelling in his right cheek had grown steadily for 8 years to its present size.   Beyond the obvious disfigurement it does not prevent Simon from eating or holding a normal job.  It is firm to the touch.  Intra-orally the mass had malpositioned, or avulsed or mobilized teeth #19-32.  This intrabony swelling extended from the alveolar crest to the inferior border of the mandible.  The swelling has pushed into the floor of the mouth pushing the tongue upwards. 

A natural question for myself and most any observer is, "How did Simon let this get this big?"  Simon has been proactive about receiving treatment for the past two years.   The process of receiving surgical care in Kenya can be long and convoluted starting at a small dispensary where you might see a nurse, referred to a sub-district hospital where you might see a clinical officer, to a district hospital where if you come the right day you might see a dentist, to a national hospital where you would find and oral maxillofacial surgeon.  

Eventually Simon was able to attain an OPG (x-ray) of his mandible and maxilla at a National Hospital.  At this time he was given a prescription for a titanium mandibular replacement (much as you or I would be given a prescription for medicine).  In Kenya it is common to receive a prescription and buy your artificial hip, or knee, or in this case mandible before surgery is allowed.  

Simon saved and raised nearly 80,000 (1,000 USD) to purchase the titanium replacement. His surgery was finally scheduled at a National Hospital. It was cancelled.  It was rescheduled, and cancelled again.  He was not rescheduled.  At that time Simon came to Kijabe.

The incisional biopsy was  completed at Kijabe and as we expected it came back positive for Ameloblastoma.  Ameloblastoma is a benign slow growing neoplasm that typically presents in the mandible in the third to fifth decade of life more commonly in men.  Fortunately Ameloblastomas are treatable, but require aggressive surgical approach of partial mandibulectomy establishing clean margin of 1.0 cm past the radiographic extent of the lesion.

This treatment is beyond the scope of my training and profession, but one of the benefits of missionary medicine is the chance to work alongside dedicated and talented Christian surgeons.   

The 6 hour surgery involved a split lip incision extending below the chin and to the angle of the mandible.  After this the tumor was disected away from the viable soft tissue.  Finally the mandible was sectioned in the ramus on the right side and medial to the 3rd molar on the left side. 

Then a 10 inch segment of the fibula from the patient's left leg was harvest as a graft to replace the missing segment of the mandible.  The fibular bone was sectioned 3 times to approximate the form of the mandibular ridge.  Mini plates and bicortical screws were used to attach the fibular bone segments together and to the vital mandible.  The periosteum, facial layers, and skin was closed and a drain was sutured into place.

Simon was in the ICU several days after surgery mostly for access to urgent care if any airway issues arose.  Unfortunately, since the surgery the wound in his mouth has dehisced twice exposing the graft.  It has since been resutured.  He is just recently discharged. 

We are happy Simon found Kijabe, and that Kijabe was able to help him.  We pray he continues to heal and the mandibular graft takes.