Sunday, December 23, 2012

Leaving Boone

We are sitting in the Charlotte airport, waiting for a flight.  This morning we locked the door and said goodbye to our house in Boone.  (Yes, we did turn off the iron and the oven).  The long journey began.  

This morning we read from Zecharaiah. One verse said, "Do not despise these small beginnings, for The Lord rejoices to see the work begin, to see the plumb line in Zerrubabel's hand."  Sometimes the work ahead of us seems like we're trying to build a temple. It seems like we're starting out with just a piece of string in our hands, but we're excited to start.  

Please pray for us.  We will spend Christmas in Switzerland.  By January 1, we should be in the Democratic Republic of Congo.  

Saturday, November 10, 2012

Pictures from Maban

Sabit.  Amazingly he survived a gunshot wound through the chest.

The face of malnutrition.


Cleft lip kid. 

A visitor.

Myself, Khadija's father and Dr. Atar

The pigs of Maban.  No garbage disposal service required!


Panorama of Maban Hospital

Look to the East and you will see Lindsey and Dr. Atar



So, Lindsey and I were recently in Maban, Sudan.  This is a little town along the border between South Sudan and Sudan.  It was a pretty sleepy place until a year ago, when fighting broke out in the Blue Nile State of Sudan.  This conflict epitomizes the heavy-handed approach that the Khartoum government has utilized against its own people in the marginalized border areas.  I can attest to the intensity of this war, as I personally experienced aerial bombardment while working at Kurmuk Hospital last year.  I helped to treat countless patients whose bodies were torn by sharp fragments of bullets and bombs.  I lived the struggle to flee from a war zone.  At one point I was forced to balance the desire to serve with the basic instinct for self-preservation.  I opted with the latter and fled.  Shortly after, the town of Kurmuk was captured by the Sudanese army.

The area around Maban has served as a location for refugee camps from the struggle in Blue Nile State.  Refugee camps in Doro, Gendressa, Batil, and Jamam have offered the chance of survival to the hundreds of thousands who have fled with scarcely a shirt on their backs.  The threat of bullets has given way to the less glamorous, but more potent threat of starvation.  When I visit these camps, I see the misery of people living in horrible conditions, with a sheet of torn plastic over their head, eating food that we wouldn't feed our pets.  I have to wonder how bad things would have to be to flee to a place like this.  

Maban County Hospital was established when Dr. Evan Atar, the indefatigable Sudanese doctor at Kurmuk Hospital finally fled across the border with a handful of staff.  He stayed longer than I did and barely got out in time.  They were allowed to set up medical services in a health center, and thus began the work of caring for the health needs of refugees.  The demands are overwhelming.  There is the business of caring for malnourished kids, treating diseases like malaria and typhoid fever, establishing programs for treatment of tuberculosis, dealing with obstetric emergencies, etc.  The work load is heavy and overwhelming.  Dr. Atar doesn't complain.  He just keeps plodding on, doing what he can to help people in need.  You would think that the cumulative burden of dealing with human suffering on this scale would get him down, but he just smiles and does what needs to be done.  

I've been at Maban Hospital a couple of times.  This last time I went with my wife Lindsey, a Pediatrician.  I helped out with the surgical problems.  This includes things like hernias, abdominal emergencies, trauma, abscesses.  There are also challenges like hydrocephalus, vesicovaginal fistulas, burn contractures, malignant tumors and many things that you just can't quite figure out.  In short, you deal with whatever comes in the door and needs a scalpel.  It is pretty exciting, as you have to be willing to do whatever needs to be done.  Lindsey took care of kids with pneumonia, meningitis, typhoid, tuberculosis, malnutrition, anemia and the ever-popular malaria.  During this particular period of time, we dealt with a lot of obstetric problems.  We had a run of caesarian sections, in particular.  These were mostly women from the refugee camps who were not able to safely deliver their babies.  They were generally referred by other NGO's who managed health care in the camps.  They did what they could, but when they needed surgery, they would load them in a Toyota Land Cruiser and bring them down a bumpy road and leave them on our doorstep.  During a ten day period, we did twelve of them.  This is a lot for such a little facility.  They mostly came at night.  

One case, in particular, stood out.  We had finished up a long day and were eating dinner under the plastic canopy that served as a dining area.  The food, though not gourmet fare, was plentiful.  Even rice and beans tastes pretty good after a long, hard day.  During these precious moments of down-time, the team enjoys a little humor and you find yourself laughing about the terrible things that took place that day.  This includes things like having to perform an amputation and finding that the hospital doesn't have a saw that is sharp enough to cut through the bone.  We laughed about the experience of having a live grasshopper land smack-dab in the middle an open wound during surgery.  We chuckled about the fact that there was only one set of sterile drapes available for an emergency and that they were burned on the charcoal fire used for sterilization.  At this point, the gates were opened and a vehicle from MSF drove in.  An unkempt Belgian field worker informed us that he had brought an emergency case for us.  It was a woman who was pregnant and had been bleeding for the past day.  She had no blood pressure for a while, but after pouring in some liters of fluid, they got a blood pressure of about 50.  This kind of qualifies as a bona fide emergency and we dropped our plates and ran.

Dr. Atar went off to find some OR staff.  Karen and Lindsey and myself opened up the OR and found the last remaining sterile drape set.  I went in search of the patient and found her lying on the ground in the maternity.  She was breathing and had a thready pulse.  We put her on a stretcher and carried her across the courtyard, stepping over pigs, goats and sleeping family members, and into the OR.  The presumed diagnosis was placenta previa.  This is a condition wherein the placenta implants over the cervix.  It basically closes the door of the uterus and makes natural birth impossible.  The bare area of the placenta is also prone to sudden and catastrophic bleeding, which is what had happened.  The body can tolerate a lot of blood loss, more than you might think.  At a certain point, however, there just aren't enough blood cells carrying oxygen to the tissues.  You lose consciousness because the brain isn't getting oxygen.  The chance of the fetus surviving in such a condition is low indeed, and the chance of the mother surviving isn't much better.  This woman was lying in a bloody pool and was on the verge of death.  I took a quick look with an ultrasound to confirm the location of the placenta.  I saw that the baby was still alive, but just barely.  The heartbeat was slow and it looked like it was just about to stop.  We didn't have much time.  

I put on some gloves and asked someone to pour betadine on the abdomen.  One good thing about this situation is that you don't need much anesthesia.  This patient was nearly unconscious.  We gave a little bit of ketamine, gave an abbreviated prayer, and I cut.  I've been in this situation before and I've learned to move pretty quick.  In about thirty seconds, I had cut open the uterus and pulled the baby out.  The other good thing about a patient who has no blood pressure is that they don't bleed.  The baby came out like a ragdoll and I handed it off the field to Lindsey.  

Doing surgery involves an element of focus.  You drape off a little corner of the body and this becomes your world.  Everything else disappears as you cut through the fascia and open up the uterus.  When my hand was pulling out that baby's head, that task was the only thing on my mind.  Total focus.  As soon as I had sewn up the uterus, I lifted my head to reevaluate the situation.  It was pandemonium.  There were about ten people in the room.  Lindsey and Jared were working on resuscitating the baby.  There were efforts to secure oxygen and to keep vital equipment plugged in.  Several people were working to secure additional IV access.  There was one nurse squeezing an IV bottle to push the fluids in faster.  Some people were trying to obtain vital signs and find appropriate resuscitation equipment.  Some people were handing gauze pads and sutures to the surgical team.  Several individuals simply did not know what to do and were standing around with a dazed look.  

Something happened to that woman after we got the baby out.  She stopped breathing and the monitor couldn't find a blood pressure.  When I looked at the head of the table, she looked like she was dead.  It was one of those situations where you have to make a difficult choice.  In the most commanding voice I could muster, I gave the command for everyone on the team to stop working on the baby and to concentrate on trying to save the mother.  We had to make a decision between the child or the mother.  We chose the mother.  If we hadn't we would have lost both of them.  I broke scrub and we started ventilating the woman with a bag.  We poured in fluids, drew up medications, and after a couple of frantic moments we got a weak pulse.  After a few more minutes she resumed spontaneous respirations.  This was a huge relief.  In the back of my mind, I had a terrible vision of carrying two dead bodies out of the operating room.  Only when we had a decent pulse on the mother, did I ask whether the child had ever started breathing.  It hadn't.  There was a feeble pulse for a while, but by this time it had stopped.  It was a beautiful little body, perfectly formed and still warm.  

By this time Dr. Atar was sewing up the woman's abdomen and we turned to the next urgent task; getting blood.  Unless we got a few red blood cells in her, this woman wouldn't last long.  Karen had gone to the lab and gotten some blood typing reagents.  They were tucked in her armpit, as they had been stored in a freezer and were frozen solid.  We had a short debate as to whether blood typing reagents will still work if they are frozen.  I stuck a needle in her neck and obtained a small amount of watery blood.  It had the appearance and consistency of very weak cherry Koolaid.  I'm not a lab technician, but there are a couple of vital skills that you learn in the field.  One is to do a blood type.  I took one slide and put three drops of thin blood on it.  Then I added the slightly defrosted reagents; Anti-A, Anti-B and Anti-RH.  The first two did not agglutinate, but the last one did.  O+!  Good for me, as I'm B+.  Bad for Karen, as that happens to be her blood type.  No time for other tests.  I didn't have to ask her.  Karen sat down with a blood bag, put a tourniquet on herself and swabbed her arm.  I found a nice vein and poked it.  In about a minute we had a plump unit of blood.  

There are a lot of nice liquids in this world.  Milk is a good one.  Water is nice.  Oil has its advantages.  Coke is great.  At this point of my life, my favorite liquid was fresh, warm, whole blood.  The Bible is right when it says in Leviticus, that "the life of a creature is in the blood."  We poured in that unit and the life started coming back in this woman.  It is such a simple thing, but the effect of giving a unit of blood in such a situation is profound.  This woman started to focus her eyes and to respond to questions.  She still needed more blood.

Getting blood in Sudan can be a real challenge.  There is a genuine fear of donating blood, even for loved ones.  People think that they will die if they give blood.  We asked the family.  One tall man in a filthy clothes, with nappy hair immediately said he would give.  He said he was the girls father.  Amazingly, he was the same blood type.  He looked at me, and peered in the open door at the chaos within.  He asked if his daughter was still alive, and we said yes.  He never asked about the baby.  I think he knew.  

The father lay down and we drew his blood.  It took three sticks with a huge needle to get a sufficient quantity of blood.  He endured this without complaint and without flinching.  Afterwards I thanked him and told him that he had done a good thing.  This man smiled at me and thanked me for helping his daughter.  He said something in Arabic to Dr. Atar, who also smiled.  I asked him for a translation, and he said, "He says that he is prepared to even give every drop of his blood for his daughter.  He says he is old, and has lived his life.  He loves his daughter.  He says that she is the future and she means everything."  

We explained that mother was doing OK and that she would probably survive, but that the baby had died.  They said that it was the will of God and that they accepted it.  The dead baby was wrapped in a cloth and given to the grandmother.  She cradled it and looked at it lovingly.  She did not shed a tear.  I left them there, two thin characters in filthy clothes, holding a sad little bundle.

The next morning, she actually looked petty good.  We asked her how she was doing, and she responded "Great."  Her hemoglobin was 3.2!  The normal is 13.  She was hungry and wanted to eat something.  Sudanese women are tough!

I've been doing this work for a while.  I've seen more than my share of suffering and death.  Sometimes I get a bit callused.  The work that I do is a drop in the bucket.  I can help a person or two here or there, but sometimes the work can seem a bit futile.  Occasionally I have an experience like this.  You do the very best you can, and you can actually save a life, in the literal sense of the word.  This woman was dying and she came back to life.  Her name was Khadija.  It is grueling work, sweaty and dirty.  You can't do it without getting blood on your hands.  You might even lose a little of your own blood.  Even the victories are bittersweet.  I can't get out of my head the vision of the grandmother cradling that perfect little body.  What sticks with me, however, is the incredible nobility of the human spirit, even in the face of suffering.  I remember the smile on this man's face, as he told me he was ready to give every drop of blood he had for his daughter.  There was something redemptive in that, something that reminded me of One who gave every drop of his, just because he loved us.  

Some stories have a nice little conclusion, but I can't really come up with one.  Two days later we flew out of Maban.  We'll probably never see Khadija again.  The fighting is picking up again as the rainy season ends.  This means a new influx of refugees will flood the area.  With them will come their diseases, their emergencies, their suffering.  Unsung heroes like Dr. Atar, Jared, Karen and Loralee will care for them in the best way they can.  They will give their time, their effort, their tears and their blood.  There will be some successes, but also many failures.  They will struggle, like Sissyphus, wrestling to deal with one emergency, only to have another one show up on the doorstep. It is hard work, but it is good to see this stuff.  It is good to put our hands to the work, and to share, on some level, with the suffering of this world.  It is the work of the Good Samaritan and I think it is what we are called to do.  

Saturday, October 27, 2012

A bilateral cleft lip means more room for fingers!
This patient was the last cleft lip of the project.

A happy reunion.  This is me with Moses (right) and Joseph (left), both nurses from Lui Hospital.  I operated on Joseph over 10 years ago.  He came as close to death as I have seen anyone ever come and survive.  By God's grace he is doing well and working as a medical assistant.  He might be the reason that I ever came to Sudan in the first place.  
Lindsey with a cute one.
In surgery.
One of the many Nyancheks.
Me with the boss-man checking my work.
It has been an interesting time here in Juba.  We finished up the cleft lip camp.  78 patients were operated on.  It was a good chance for me to scrub on a bunch of these cases.  I mostly assisted, but I did more and more of them as the time went on.  It is so different from the cases that I usually do.  Only about an inch or so of the body is involved, but it is in such a visible area that it changes everything.  The surgery is technically exacting, as you want to do everything in your power to make things look as nice as possible.  There is also a lot of art in it.  You are workin on someone's face, and the face is your identity!

Many or these patients were named "Nyanchek" (or some variant). This word means something like "deformity".  Imagine what life would be like to named Deformity.  In many of their eyes we could see the shame and misery that they had suffered.  The most exciting part of the camp was watching these patients as they looked at their new faces for the very first time.  Some of them just seemed stunned, like suddenly looking in a mirror and not recognizing yourself.  Others were so full of joy and burst into spontaneous songs and praise to God.  I operated on the oldest patient, a woman of 60 or so.  At that age, I would think, "why bother?"  When she was asked why she wanted surgery, she said that she just wanted to be able to hold her head up and not be ashamed.  

Many of the patients chose new names for themselves.  The chaplains spent a lot of time with these folks, explaining that their physical change was only a part of the real spiritual change that they could be theirs by following Jesus.  One of them changed her name to Grace.  Another changed hers to "Amore."  She said it was the name of a beautiful cow that she remembered.  "Beautiful Cow" might not be the name we would all choose, but it is pretty amazing to think that someone could get a new face, a new name, a new identity.  It is even more amazing to think that someone could even be born again.

The cleft lip camp coincided with the Franklin Graham Festival which took place over the last two days in Juba.  The place was packed and you could feel the excitement in the crowd.  The message given was the same simple gospel message that is preached around the world. We are all sinners, but Christ died to save us.  This message is delivered in a straightforward, no frills manner.  There was no persuasive arguments and no promises of any kind.  It was the simple gospel message, but when it was over and the invitation was given, the people rushed forward to receive it.  It was so powerful to see this in action.  

So it has been a time of change.  We have seen changing faces, changing names and changing lives.  It has been a thrill to see it and to play a small part.  Tomorrow morning, Lindsey and I will leave for Maban.  We will be working in a small hospital near the border with (North) Sudan.  Samaritan's Purse is working there to care for refugees who have fled from the conflict across the border.  Please continue to pray for us as we serve in this difficult situation.  

Warren (for the both of us)

Tuesday, October 23, 2012

Panoramas from Juba!

 It has been fun to be part of the cleft lip thing here in Juba. I feel like I am getting better at doing them. It is a nit-picking sort of operation. A matter of a millimeter here or there makes a big difference. This is very different from my general surgical approach.  In one way the operations is fairly simple, but whole textbooks have been written about how to do it properly.

I am attaching below two links for panorama views. The first is from the top of a mountain near Juba.  The second  is in the courtyard of Juba Teaching Hospital. 


Cleft Lip Camp: South Sudan (October 23, 2012)

Warren and Youssef
It has been about a month since our last blog from DRC….now we join you from South Sudan!  We are here for the Samaritan’s Purse’s second annual cleft lip camp in the capital of South Sudan called Juba.  Some amazing things are happening in the lives of these people born with facial deformities!  To give you an idea of how significant this problem is, many of the people are named “deformity,” meaning that this is their identity.  It takes a lot of courage for people to even believe  that they can and even should be healed of their deformities.  I have been told that one of our patients, Youssef, ran away from the hospital several times.  Both Warren and I were involved in his surgery…he was the only man with a moustache.  I remember praying specifically for this man during the case.  He was so happy afterwards, wanting to shake hands with everyone.  He returned to his village by air today to his wife and children a changed man. 
Warren, Youssef, and Dr. Jim
There have been patients who have said that no one has ever loved them like this before, evidence that our God must be real.  This is so powerful and so true.  A large group of patients burned their amulets, having tangibly experienced that Jesus is more powerful than the spirits.  Some people have professed faith in Christ.  We pray that these people will grow in their relationship with Jesus as they return to their homes.

It has been great for Warren to work on his surgical approach to cleft lips, alongside ENT surgeons.  He has great technique already, but this is refining his skills and giving him confidence.  I have been helping to provide deep sedation (anesthesia) and working with an anesthesiologist.  This has been fun and kept me on my toes…a new realization that during a case I am responsible for a patient’s survival.  During critical care fellowship I have learned so many useful things for this setting.  I have provided anesthesia for many of Warren’s cases…adjusted his surgical loupes, scratched his back, and the list goes on-and-on….you know those surgeons need lots of assistance! 

I often say, “It is hot!”  Warren tells me that he is trying to break me of this phrase by coming to Sudan.  So far it is still hot and one sweats without doing anything.

On Friday and Saturday we will participate in a festival with Franklin Graham here in Juba, South Sudan, called “Hope for a Nation.”  Really looking forward to this!  We have been told that there will be choirs from throughout the country singing together.  After this we will travel to a place called Maban in South Sudan to work in a local hospital with lots of refugees from North.  I have been told that there are many malnourished children there and I am sure we will have our hands full.

Intake from Nuba Mountains
Overlooking Juba

Can you find my (Lindsey's) feet?
Goodnight from South Sudan!
Warren and Lindsey

Monday, September 17, 2012

Title 1

Panorama from the water tower at Nyankunde. How can such a beautiful country be such a mess?

We made it!

We made it back to the USA. Entebbe, Addis, Washington DC, Charlotte then back up the misty mountains to Boone. I think that international travel must take years off your life. Still everything worked out well and for that we thank God. Below are a few pictures taken around Entebbe. The Botannical Gardens are stunningly beautiful.

Friday, September 14, 2012

Waiting for the boat...

Well, we have said "goodbye for now" to our future home in DRC.  Warren keeps talking about the "cultural adjustment" that I am experiencing.  The concept of time in Africa is simply different and revolves around value and relationships.  I have "known" this.  It is one thing to "know" this and another to "experience" it.

We took the long way back to Uganda from DRC, actually a 2.5day trip by road and boat.  It is possible to simply fly (1.5hours) from Bunia, DRC, to the airport in Uganda but we wanted to "experience" life a bit.  We have wanted to understand how people get around and the landscape a bit.  It may not always be possible to take the ground route into and out of DRC, but it is fun.

Here is an outline of our day leaving DRC...the stops and all.  We woke up early in hopes of catching a public boat across Lake Albert at 9am to reach Uganda.

  • 5:45am-Warren wakes up
  • 6:00am-Lindsey wakes up (usual pattern)
  • 6:30am-Drinking coffee & waiting for the taxi

  • 7am-Still drinking coffee....
  • 7:30am-Still drinking coffee.  Our friend arrives to say that the arranged taxi is "not going out today."  He leaves to find another taxi.
  • 9am-Taxi arrives to depart for Lake Albert (2.5hours later than anticipated)

  • 11am-Arrive on the shores of Lake Albert after quite possibly the roughest road I have ever been on.  It would have been difficult to mountain bike on this road!  
    • Immigration officer told us the boat "just left."  He says that we might be able to get a pirogue across the lake; he cannot stamp our passports until we have plans to leave.
    • We see a motor boat approaching in the distance.  We both think: "This might be the way across the lake."
    • We descend the hill to check it out.
  • 11:30am-We makes plans to get on the motor boat $20/person.  We are thrilled!  Our bags are loaded.  We are told that they will simply have to offload a part of a crane before we can leave.  We talk to a health inspector and various other people, then sit down to wait.  We watch some young boys fishing in their underwear.
  • 12pm Back to the Customs Office to have our passport stamped.  Warren deflects a request for money by saying that he will be a doctor at Nyankunde in a few months if the border patrol has any medical problems.  The border patrol asks to see Warren in private about a health concern and forgets about the request for money.  The exam is conducted behind closed doors and results in a little smirking afterwards, also the use of hand-sanitizer.  Also an explanation of how diseases are transmitted from one person to another.  
  • 12:30pm-Other boats arriving.  Unloading of boats.  Men from our boat are nowhere to be seen.  We are told they are waiting for a battery to run the crane, in order to unload the boat we will take.
  • 1pm-Waiting for the battery to arrive.  Warren takes a nap with the guys.  Lindsey talking a young Congolese about the "Big Fishing Season" on Lake Albert in September.  The boy asks Lindsey about "Big Fishing" in America.  Lindsey struggles to explain why we don't eat big fish, due to toxins in the lakes.  Warren tells Lindsey NOT to try to explain how Americans prefer to hang their game fish on the walls (this would not be understood and thought to be ridiculous).  

  • 1:30pm-Someone starts up the crane.  This looks promising....
  • 1:40pm-Unload complete.  Men disappear again.  What is next?
  • 2:15pm-Men reappear and we load the boat to cross Lake Albert (about 3 hours later).
  • 2:15-6:15pm-Crossing Lake Albert.  Stunning sunset.  Warren drives the boat for a bit, resulting in a serpentine course across the lake.  Pirogues are still crossing the lake.

  • 6:30pm-Customs on the Uganda side.  Phone calls to the border patrol who has gone home for the night.
  • 7pm-Taxiing across Similiki National Park for Fort Portal.  There are warthogs, antelope, and baboons crossing the road.
  • 715 pm.  Stop to fix a tire.  Lindsey uses the facilities (bushes) and is nearly left behind. 
  • 9pm-Arrival in Fort Portal for the night.  We stayed at the Raja Excelsior Hotel.  Not quite as fancy as the name, but adequate. 

We crossed Lake Albert about 5 hours later than I "thought" we would.  I found myself frustrated by this and reflecting on why.  I concluded that I simply like to know what the plans are, to have some certainty.  Rather, the "certainty" was that we were on a journey.

After all that, we still don't really know when the public boat departs on Lake Albert.  Is it 7am, 8am, 9am, 10am?  Is it everyday or only Mon/Wed/Fri?  No one could really give a concrete answer.  The answer was simply that the boat does not leave everyday and that the boat usually waits until it is full.  This is Africa isn't it?  We both concluded that this is a fun adventure, just as long as there is not a flight to catch!

Well, we leave tomorrow for the US.  We hope you have enjoyed our little adventures.  Many more to come....especially as Lindsey gets "culturally adjusted."


Lindsey (for both of us)

Wednesday, September 12, 2012

Almost done

Almost done!

It is our last night at Nyankunde. The last week has been tiring. Lindsey caught some horrible virus which caused her nose to run like a faucet.  I had to give blood to a lady who was bleeding to death.  Normally I don't even notice it, but it seems like I've been huffing and puffing to get up the hill. The running has been on hiatus, while I try regenerate some red cells.

Lindsey and Dr. Chantal
OR #1
We've been working hard in the new building. We brought over a whole bunch of boxes from the old store room where an army of small critters was having their way with precious medical supplies. We found some great stuff, as well as a lot of things that we'll never use. The challenge has been to go though these boxes and separate the wheat from the proverbial chaff.  The chaff includes materials for open heart surgery, some chest tubes which expired in 1968 and an implant designed for surgery on the super-obese (not many of those around here.)  It has been tedious to go through all of this stuff, but it's simply something that has to be done.  Lindsey and I have different organizational styles.  Sometimes I need to find her a job like organizing the suture.  It is mystifying and a bit frightening to see how much she enjoys this.
Lots of suture to organize!

The new OR/ICU building is not exactly ready for prime time, but it's come a long way.  My pride and joy is the Endoscopy room.  We actually have a pretty decent collection of scopes and I have carefully arranged the room with the necessary instrument to peer into the various dark places in the body.  I also found an old table that we were able to salvage and repair.  I have named the table "Lazarus".  We have materials in the other rooms and equipment that is ready to be used.  When we return to the US, we'll be trying to assemble the material that is still needed.
Omviti and me clowning around!

We'll also be putting together some supplies that we will need in the next couple of years.  We will be hosting visitors in our house, so we're looking to purchase bulk food items.  Packaged food is quite expensive to buy locally.  As an example, a small can of oatmeal costs about $5.00.  I went online and purchased a 50lb bag of oats.
"Sir Leaksalot"

In addition to organizing the new building, we continue to deal with clinical challenges.  Today I re-operated on a patient on whom I'd done an ileostomy when I first arrived. His ostomy was putting out so much fluid that we just couldn't keep him hydrated.  I ended up calling him "Sir Leaksalot."  He was getting so malnourished that I feared we were just going down the slippery slope.  I sewed his intestines back together today.  Hopefully he will make it.  I also operated on a poor little girl who fell in the fire after having a seizure.  This is a tragic, but all-too-common story.  I did a skin graft on her face.  Lindsey has been dealing with sick patient and continues to struggle with kids who die from diseases that should be treatable.  They just come in too late.  It is heartbreaking to have a child die of malaria right in front of your eyes, but this happens.  It is a difficult transition to come from an ICU setting where everything is available, to a place where you often can't even get blood.  It will be a great challenge to see what is possible with the limited means available.
On the water tank

My guys
Last week was the 10th year anniversary of the massacre and destruction of Nyankunde.  Not much was said to commemorate the event.  It may be that it is too hard for people to think about it.  Still, it seems like a new day is dawning here.  There is a spirit of a renewal and a hope that things will be better.  The new building is a huge encouragement.  For Lindsey and myself, we are just happy to be a part of what God is doing here.  It is pretty clear that He has chosen this time for the hospital to grow and to strengthen its spiritual ministry.  It has been a tremendous privilege for us to be here and we are excited to return in January.

Tomorrow we will begin an adventurous return to Kampala.  We will take a vehicle to Bunia and then to Kasenyi.  We are planning to take a local boat across Lake Albert, then find a bus back to Kampala.  We're not sure how long this will take.  We have allotted a couple of days for the journey.  We could just fly, but I think it will be more interesting to travel using local transportation.  More on this later, if we survive.
Lindsey with a preemie
Obligatory sunset picture. 

We will return to the US for a bit.  I will be attending an orthopedic conference in Washington.  In mid-October, we will travel to South Sudan to assist with a medical project there.

As always, thanks for your prayers and your encouragement.

Warren (for both of us)