A Global Challenge

For the past two years through this blog we have shared many stories.  We have shared stories of individuals in Burundi who have benefited from the medical and surgical care delivered at Kibuye Hope Hospital. These are the personal stories of the patients who have made it to the hospital. What we have, however, neglected to talk about is a global problem we are currently facing. Today there are 5 billion people who do not have access to safe and affordable anesthesia and surgical care when needed, according to a recent Lancet Commission on Global Surgery.  If that number sounds like a lot, that is because it is a lot.  In fact the total population of the world is 7.125 billion.  That means the MAJORITY of the world does not have access to safe and affordable anesthesia and surgical care.  

This same commission estimated that 16.9 million people die every year for lack of access to safe and affordable anesthesia. This is more than twice the population of Washington state ... dying, every year.  This figure is four times higher than the number of people dying annually from malaria, HIV/AIDS and tuberculosis COMBINED!  

According to the World Federation of Societies of Anesthesiologists "a lack of training in anesthesia, along with a lack of vital anesthesia equipment in low and middle income countries, is a huge part of what is making this number so shockingly high.  In many countries anesthesia and surgery are simply not safe".

It is hard for people to wrap their minds around this. It is hard to make people care about numbers so large they are almost unfathomable.  I'm sure it would be more vivid if we were all looking at the problem from inside the circle with the other 5 billion people who simply have no way of getting a needed surgery. 

This is the crux of what we are doing. We can go to Burundi and train anesthetists and surgeons and treat patients with safe and affordable care.  What can you do?  You can support those who go and those who are laboring to change these statistics.  

We need a team of monthly supporters fueling the work we are doing in Burundi. If you would like to join our support team there is still plenty of room. We are currently at 41% of our monthly support goal with the aim to reach 100% by June so that we can deploy at the end of the summer. Will you partner with us to be a part of the solution to this global challenge?

Click here to join our support team

Heroic

This morning I was reflecting on our time last year in Burundi, and remembered a particular moment that I am not sure I ever shared in a blog post.  It was an afternoon during Reanimation (critical care) rounds, and I was seeing patients with my 6 medical students.  There was a patient, a middle aged man, who was very sick with tuberculosis.  We were seeing him together in the "isolation" ward.  I put "isolation" in quotation marks because if you have ever been in an isolation ward in an American hospital, this is nothing like that, but is rather a building separate from the rest of the hospital, with open windows to facilitate good ventilation.

The man we were seeing was sitting up in his bed gasping for air.  There was no oxygen in the hospital that week to give to him.  After discussion with the internal medicine team, it was thought that he might have a pericardial effusion (a collection of fluid compressing his heart) as a result of his tuberculosis.  It seemed to me that if we could do an echocardiogram with our ultrasound machine, we could decide if this was part of his problem and potentially remove some of this fluid.  This MIGHT help his breathing.  However, in order to do this test, I would need him to lie down.  He said if he was to lie down, he could not breath at all.  I told the students that if we could at least get him into a reclining position (maybe 45 degrees) I could do the exam.  However, the beds in Kibuye are not adjustable.  You are either sitting up or you are lying down.  I could not think of a solution to this problem, and so I looked at my group of students.  One of them had come up with a solution.

He took off his white coat.  He climbed into bed and seated himself behind the patient, then put his arms around this man's waist and gently leaned him back against his chest, so that I could do the echocardiogram.  It was hard for me to not let myself cry as I watched him do this.  This patient was sweating, he had likely not had a shower for weeks, he was HIGHLY infectious with tuberculosis.  And this student made himself into a human pillow, so that we could do the exam we thought needed to be done.

As I think about this afternoon, two thoughts keep churning in my head.

What this student did was so beautiful to me, because I saw in it a picture of the Gospel.  I saw in what he did a reflection of the work of Jesus Christ, who took off His kingly robe, and embraced those who would believe in Him.  He ate with sinners, he washed the filth covered feet of His disciples, He invited dirty little kids to come and sit on His lap.  He humbled Himself out of love and compassion for His people.

The second thought is this.  We are moving to Burundi to teach, train and disciple African medical students.  And as much as I like to think that one of things I am going there to teach is compassion, oftentimes, it is they who are teaching me compassion.  To be honest, I would not have done what this student did.  I am far too selfish and too concerned with my own health and my own cleanness.  I am grateful for the example he was to me.  I am grateful for the opportunity to work with students like this, who are bright and compassionate, students who are, in my eyes, heroic.

My Bad Dream

Have you ever had a dream where you realized you were back in college and it was final exam day, and you had forgotten to attend class or study or read for the entire semester?  Or perhaps you have had the dream where you showed up for a presentation in front of a class and after beginning realized you were naked?

During my last week in Kibuye in November, I had the privilege of having my own "bad dream" come true.  I got up to present at our hospital's grand rounds, in French ... and quickly realized that ... I don't actually speak French.  Okay, I speak a little French.  

Shortly before my arrival in November, the team at Kibuye decided it would benefit the medical students, national doctors and the rest of the hospital staff to hold a weekly grand rounds, an hour lecture on a specific topic, usually given by one of the missionary doctors (although we hope soon the national doctors will be able to participate in this as well).  My first two weeks in Kibuye I learned a lot about cranial nerve palsies (from John) as well as evaluation and treatment of abdominal pain (by Jason).  On my third week, Jason asked me if I would present.  I chose to present on the topic of "Anesthesia for the Pregnant Patient".  Jason offered to find someone to translate for me, but in my foolishness, I declined, thinking it would be a good opportunity for me to practice my limited French ... in front of the entire hospital staff.  Sometimes I make poor decisions.

Through the use of my broken French, a lot of hand waving, and a bit of interpretive dance, I got through it, and hopefully my next presentation will be a bit more polished.



If I smile long enough, perhaps they won't notice I forgot what I was supposed to say.

I think this photo really captures the joy and laughter my French brought to the room.

Click Here To Get Rich Quick

If you are reading this and you live in the U.S. or Canada, I have good news for you.  You are already rich!  I know you don’t feel rich, but if you could just take a step back and see your life and your wealth on a global perspective, I am sure you would agree with me … you are rich.

As we head into the Christmas season, you will undoubtedly be inundated with letters, e-mails, advertisements asking you to give to any number of charities.  I am writing this blog post to implore you to consider giving and to consider giving generously.   I have heard people argue against the idea of giving to charity for several reasons:

“Charity does not make a difference” - I could tell you hundreds of stories of lives that were massively impacted by even small amounts of giving.  I could tell you stories of lives that were saved by even small amounts of giving.  Charity does make a difference.

“Charity does more harm than it does good” - Historically, there have been charities that no doubt did more harm than good.  Even 10 or 20 years ago, this was true.  Thankfully today, we stand on a mountain of research and experience which most charitable groups use to guide them in doing development and relief work that is both empowering and sustainable for the people they serve.

“I won’t give money to a group that is going to take out 10 or 20% ‘overhead’.  I want my entire donation to go toward the cause”. - Let me ask you a question.  Let’s say you want to donate $100 to the charity of your choice.  You have 2 options.  You can have the entire donation go directly toward the beneficiaries, and then your money ends.  Or you can allow the charity to take 20% of your money and invest it in hiring talented leadership, marketing and further fundraising, which will increase your $100 over the next 5 years to $1,000.  Which would you choose?  We would never buy stock in a company that paid their employees nothing, did nothing to market their product, and did nothing to grow their company, so why do we hold NGOs to this impossible standard?  For an excellent TED talk on this subject, click  HERE

So, in my attempt to help you wade through the mountain of letters, emails and ads you are going to receive this month, I would like to suggest, implore, beg you, to consider giving to one of the following three causes.  These are all groups which I have been directly involved with, which are having a massive impact in what they are doing, and which you will likely not receive a single solicitation for this month (aside from this one … from me).

1.  Lifebox is a UK based charity whose goal is to provide every hospital in the developing world with high quality, durable pulse oximeters.  These small hand-held devices are used all over the hospital, but are especially valuable in the O.R. where they give you continuous measurement of a patient’s heart rate and oxygen levels.  With very little effort on my part, Lifebox has provided me with a total of 8 pulse oximeters which I have distributed to Kibuye hospital as well as 2 other hospitals in Burundi which were greatly in need of these life-saving tools.  They are eager for me to identify and make contact with other hospitals in Burundi who are in need of these machines. They rely on donations to continue this. This is truly life-saving work.

Lifebox

2.  Yezelalam Minch was founded by Birtukan, who grew up a World Vision sponsor child.  This entirely Ethiopian-run NGO provides food, education and healthcare for 1500 orphans in and around Addis Ababa.  I have served for several years on the U.S. Advisory Board for YZM and have been able to follow the amazing work they are doing.  They rely heavily on families in the US or Canada who are willing to sponsor a child in need as well as one time donations to sustain their operations.  This is a project very dear to the hearts of Stephanie and I.

Yezelalem Minch

3.  Kibuye Hope Hospital - If you have been following our blog or our story for any length of time, you probably guessed that Kibuye Hope Hospital would make my “top 3” list of giving options this year.  This is an amazing hospital and an amazing ministry, which continues to have great financial needs, which you can help with.  Here is a link to their giving catalog.  Donations can be made through Paypal:

Kibuye Hope Hospital

Stretched

One of the things I both fear and love about working in a place like Kibuye is that you are constantly stretched beyond your skill level.  Stretched because of lack of resources, lack of specialists, language barriers and a million other reasons. 

Friday morning, Joseph, our Burundian anesthetist, came to tell me that there was an urgent Cesarean section.  This is not unusual.  It seems that people in Burundi do not travel at night, even when experiencing life threatening emergencies.  Therefore, women in obstructed labor often present for C section first thing in the morning, once the sun rises.  Joseph then told me that the woman’s blood pressure was 190/120.  Well, yes that is a problem.  He then explained to me that she was also alternating between seizing and unconscious.  She had full blown eclampsia.  

Now, as a practicing anesthesiologist in the US, I have read about eclampsia many times, such as during medical school and while studying for my board exams 10 years ago.  But I have never actually seen a patient with full blown eclampsia.  That is because patients with PRE eclampsia are identified early with good prenatal care and if things show even a hint of progressing to eclampsia, they are transferred to a center which specializes in this life threatening problem, such as the University of Washington, where they are managed by a team of specialized anesthesiologists, intensive care doctors and OB/GYNs.  

So, as my mind is racing trying to retrieve any bit of memory about management of eclampsia, I follow Joseph to the Maternity ward.  When we find her she is unconscious, and within 2 minutes starts convulsing.  They cannot find any fetal heart tones (they use a small wooden tube which they place on her belly and hold the other end to their own ear).  Their best guess, she might be 20 weeks pregnant.  I remember that we need to give magnesium.  But first we need an IV.  We spend about 7 or 8 minutes trying to find a vein, but find nothing.  I decide we can’t wait.  I ask them to take her to the OR as fast as they can.  I run to Jason’s office to retrieve his ultrasound machine.  When she gets to the OR I ask them to hold her head still while I put an 18 gauge IV catheter in her internal jugular vein under ultrasound guidance.  It works, we have IV access.  Now, how much magnesium do I give?  I can’t remember if it is 2 or 4 grams.  No one else seems to know.  There is no high speed internet to look this one up, and since we seem to only have a few vials left, we give 2 (it turns out the correct answer was 4, but thankfully 2 seemed to work).  

On weeks when I am not here, there are 2 options for anesthesia for cesarean.  Spinal or Ketamine.  Problem is, her platelet count is dangerously low (26K), so spinal could cause bleeding around the spinal cord which could paralyze her.  Ketamine will make her blood pressure even higher, which could cause heart failure or a stroke.  But thankfully, this week, we have compressed oxygen and so we can do a real general anesthetic.  We get her off to sleep, the national doctor performs the C section, while Jason is performing another urgent C section in the other OR.  As we suspect, the baby is stillborn.  

During the surgery we continue to give more magnesium and clonidine to lower her blood pressure.  We find another peripheral IV (much easier while she is not having seizures).  She wakes up and we remove the endotracheal tube.  Now after most C sections the women return immediately to maternity where they are checked on by a nurse once in the morning and once at night.  I suspected she would not survive without more intensive monitoring.  So, we brought her to our “recovery room” right next to the OR, so that we (Joseph and I) could continue to watch her vital signs and continue to give her magnesium for the next 24 hours.  Now that we are post-op, I finally look at her pre-op labs.  She has both renal failure and liver failure.  Her urine catheter is putting out what looks like mostly blood.  And there are still a line-up of scheduled surgeries to get through, including our next patient a 6 month old with cleft lip who has been waiting for me to arrive so he could have this done.  

Joseph goes to maternity and finds a nursing student who can sit with the patient.  I take a blank piece of paper and make a graph where she can chart vital signs and urine output every hour.  I don’t have the experience to know what this woman’s chances of surviving at this point are, but I suspect they are low.  I pray for her.  

Throughout the day, by God’s grace, her blood pressure remained stable.  She had one more seizure a couple hours after the C section which we treated successfully with more magnesium and valium.  

This morning I found her wide awake. The family tells me she had no seizures overnight.  Her blood pressure is normal.  Her urine now looks like urine. The nursing student had stayed with her all night and completed my vital sign chart, filling in every hour except 3 AM.  I am shocked with delight.  I now believe that this woman is actually going to survive.  

This case stretched me.  This is not the only case that stretched me yesterday, but this is the one that stretched me the most.  I am grateful for the intensive and compassionate care that was given to this woman, especially by Joseph and this nursing student.  I have heard health care professionals in the US say they could not come and work in a place like Burundi because they are not “good enough”.  Many of them are much better than me.  They are smarter than me, more skilled at performing procedures, and better looking than me.  All that you really need to come and work in a place like this is the willingness to be uncomfortable and the willingness to be stretched.  

Back In The Saddle

This past weekend I got the opportunity to return to Burundi.  I am here for three weeks to help out with teaching and also to help Jason with a few more complicated surgeries.  My route here took me through Dubai on Emirates.  It was a very comfortable flight.  It is  my hope that by mentioning how comfortable this Emirates flight was, that they will somehow stumble across this blog post and be so flattered that they will upgrade me to business class on the way home (Emirates ... are you listening?).

At the airport I was greeted by Caleb Fader (Jason’s brother and our newest Kibuye team member and engineer) and my friend George Watts (PhD in business, teaching at the Hope Africa University campus in Bujumbura).  It was great to catch up with them, their wives (Krista and Susan) as well as Randy and Carolyn Bond before heading up to Kibuye Saturday afternoon.  

It has been great to be back here, to see the team again and to see the progress being made at the hospital.  Monday we did 5 cases in the OR.  For any of my nerdy anesthesia friends reading who might be curious, Jason performed the following surgeries:

• inguinal hernia repair on a 2 year old (under Ketamine)
• palmar cyst removal (under axillary block)
• epigastric hernia (also ketamine)
• intramedullary nailing of a femur fracture (under spinal) - yep, without intra-operative X ray
• urethroplasty (under spinal)

We do have a handful of cases lined up while I am here that will require general endotracheal anesthesia, and thankfully we have a few full cylinders of oxygen!

This morning, before morning report, I went for a 4 mile run with Jason, Caleb and Joel Miller.  We ran on paths I had never explored during our previous time here which were beautiful.  We were greeted at every turn by Burundian women with hoes over their shoulders and children with notebooks in hand for school, often staring at me, sometimes laughing, probably wondering why that pasty muzungu in the back is having so much trouble breathing.  

Today, I was asked to sit on a board of 3 physicians for the thesis defense of one of the graduating medical students.  I was chosen for this because I am a specialist ... and because I have a pulse.  This was my first thesis defense, but I am told there will be many more in my future.  The student presented his research on Burn Injuries at Kibuye hospital, a very common problem all over Africa due to cooking methods using open fires around small children (no, that is not some sort of advocacy for all you helicopter parents out there).

I am excited to see what the next 3 weeks will bring.  As much as the pace of life here is slower than that in the US, it is never boring.  Although to be honest, I actually enjoy boring once in a while.  

Jason and Joel in our seats of judgement

A selfie of me with the church and hospital in the background ... and a chicken

The Monster Inside of Me

Lately I have been thinking a lot about money, probably too much.  I suspect this preoccupation has been triggered by the large pay cut I am about to get as we transition to becoming missionaries.  

It has come to my attention that money is very important to people (that’s right captain obvious).  However, it is not the money itself that I think reveals so much about us as people, but rather what we do with that money, why it gives us so much satisfaction, and why we spend so much energy laboring for it, and then worrying about it once we get it.  

Tim Keller once asked the following question: Five people are sitting around a table drinking wine.  How do you tell which one is the alcoholic?  The answer is, it is not the one who drinks the most wine.  No, you take the wine away from them and see which one starts to melt down.  Which one becomes angry and agitated?  That is the alcoholic. 

It is the same with money.  I think most of us have come to believe the lie that money will make us happy.  For some of us, it is what we can buy with that money.  For some of us, it is the security (or rather, the false security) that money gives us.  For some of us, it is the feeling of superiority that having a larger bank account than our neighbor, gives us.  But if you want to find out what someone’s heart is truly set upon, take that money away … and watch them squirm.

We saw this most tragically when the stock market crashed in 2008.   One study in the British Medical Journal suggested that the money lost in this crash resulted in approximately 5,000 suicides.  I suspect the emotional impact on many families was much more wide spread.  There is a monster living inside us.  Most of us do not even know that he is there.  But he is there, and he is eating away at our souls.  

You might think that since I am giving up the “American anesthesiologist lifestyle” and the salary that accompanies it, I am immune from this idolatry.  I am not.  I have spent far too much time “counting the cost” of what we are going to do.  Now, I know, with my head, that more money will not give us satisfaction in this life.  I know this in my head, but yet the monster inside me continues to wage war in my heart.  

It has been said that Jesus talked more about money than about heaven and hell combined.  He did this not because money was so important to Him, but because He understood the destructive effect it has upon us (even 2000 years ago).  And He talked about it because He loves us, and He wants us to let go of this clenched grip that we have on money before it destroys us completely.  God Himself gave up the riches of heaven, and entered into the poverty and filth of life among us, so that by His substitutionary atonement for our sins, we might be made rich, forever.  It is my hope in this alone which will ultimately defeat the monster.

For you know the grace of our Lord Jesus Christ, that though He was rich, yet for your sake He became poor, so that you by His poverty you might become rich. - 2 Corinthians 8:9