Abundant grain on the hilltops

April 8, 2013

Nyankunde Mountain

On top of Nyankunde mountain looking down at the village

“May there be abundant grain throughout the land, flourishing even on the hilltops.  May the fruit trees flourish like the trees of Lebanon, and may the people thrive like grass in a field.  May the king’s name endure forever; may it continue as long as the sun shines.” Psalm 72:16

It is planting season here at Nyankunde.  I have been marveling at the hillsides and how much of the land on the hillsides has been cultivated this year.  Compared to last year I would say that much more of the land is being farmed.  I believe this is a sign of community development and prosperity.  I also think it is a sign that this is a sign of security, of people feeling that this is their home once again.  After the many lives that were lost here in such a tragic way, it is a beautiful thing to see.  New life has come to Nyankunde.

In the evening it is a common scene to see people climbing the hillsides to their fields with sickle in hand to work/harvest grain in the fields.  You can’t help but see the dependence of people on the land “May there be abundant grain throughout the land.”  Every time it rains I feel thankful.  We have a medium-sized vegetable garden and a large plot of beans/peanuts, so I only experience “dependence” on the land in a small way.  We are certainly not eating only what we grow, unlike many of the people here.

Planting rows

Re-feeding a child

I think Congolese people understand many things as it relates to the soil and agriculture.  I have started to use the analogy of a seed growing up to be a small seedling to a child’s progress in the feeding program.  Progress is slow and lots of work in the beginning.  The kids refuse food over and over.  They have no appetite, no energy whatsoever.  All they do is sleep and eat, eat then sleep.  It seems like nothing is happening.  The beginning of re-feeding is like placing a seed in the ground and then waiting over it…is there enough sun?  Are the conditions right, enough fertilizer, enough rain?  This is when parent’s get discouraged and it is really important that they understand this process and to get support of the extended families (especially the fathers).  We don’t focus very much on weight, rather on behavior and frequent feedings.  So the child refuses again….not to worry.  Try hard not to show frustration…offer the same thing again in a hour.

Then parents start to notice small changes such as the child asking for food, or waking up to eat.  They

A recent graduate of the nutrition program

may be less clingy and fearful and generally happier.  This is when we can introduce new foods.  This can be likened to the small sprout beginning to appear.  It is fun to watch!  This is usually the sign that we will succeed, even if progress is slow.  Now we start talking more about weight and developmental goals.

The last thing we notice is a child’s activity picks up.  He curiously explores his environment again and maybe starts standing and walking again (or for the first time).  This is the flowering/fruit stage.   

Some children progress through these stages rapidly, but for many it takes literally weeks.  Some succumb to infection and complications of their energy deficits, but most succeed.  I would say it is the most rewarding thing I get to witness.  Generally parents are thankful for the time to recover in the hospital. 

I have one little 12year-old boy with cerebral palsy who came in to the hospital completely emaciated with signs of both protein and calorie malnutrition.  He weighed 8kg, what you would expect a 1year-old to weigh.  During the initial few weeks he slept a lot and lost his edema (a normal process), decreasing his weight to 6kg (his real weight).  Now he is on the rebound and is approaching 8kg once again.  We have placed a g-tube and are using this for therapeutic milk and protein-rich porridge, while he takes many of his calories by mouth.  A 20% increase in body mass is substantial over a period of 6weeks!  He remains very developmentally delayed and non-verbal, but he is genuinely happy and smiles most of the time.  Will his life ever be truly normal?  No, but he is greatly loved by his family and gives them much encouragement.  This is often the case with children who have special needs.  Perhaps some day we will have him up in a wheelchair and able to explore his world.  It is a blessing to be part of his recovery.

Who are the Poor and Needy?

As Warren and I were reading through Scripture and praying last week, I started to weep over the passage in Psalm 72.  Warren just stared at me as my voice cracked.  Maybe it’s pregnancy making me more sensitive in general, but this Psalm describes the heart of God for those in need.  It was as if the Lord were saying to me personally, “Help him to defend the poor, to rescue the children of the needy, and to crush their oppressors” (74:4) and “Help him judge your people in the right way; let the poor always be treated fairly.”  It is the heart of God that people are treated fairly, that they have an advocate, and the opportunity to prosper.  Why?  As the Psalm says, “for their lives are precious to him” (72:14).  God wants us to have an active part in the process of caring for people, looking for those with special needs.  Most of the time you don’t have to look very far.  This is part of living out the Gospel, “true fasting” in the words of Isaiah 58:6-7:

“Is not this the kind of fasting I have chosen: to loose the chains of injustice and untie the cords of the yoke, to set the oppressed free and break every yoke?  Is it not to share your food with the hungry and to provide the poor wanderer with shelter-when you see the naked to clothe him, and not to turn away from your own flesh and blood.”

The question is, who are these people in our lives?  Who are we asked to defend and treat fairly?  I don’t think this is simply charity work, but rather standing in someone’s place and advocating for them.  Is it simply about giving money?  It seems like Isaiah is telling the reader to share his own food and resources (time, energy, etc).  This Lenten season, may the Lord show you how to turn your lives outwards to embrace the needs of others.  May this be part of our sacrifice to Him.

Blessings and love,

Lindsey

April showers will bring May flowers

Looking back at this past year, April was my favorite month.  Everything is green and lush and it rains almost everyday.  Fields are being planted all around us and people are hard at work.  When it rains here, it really rains!  Our garden is flourishing and we are harvesting vegetables on a daily basis for dinner.  We plan to plant peanuts in the the field behind our house this week...rather with our hospital work we will pay a group of people to prepare the ground for planting.  

Our newest Warren-designed oven

Pregnancy

March finds me more than halfway through my pregnancy (22 weeks)!  It is such a

My little baby bump

miracle to watch a baby growing and developing inside of you.  It is such a slow but certain process.   I am finally certain when the baby is kicking and moving about.  I am incredibly thankful for my good health and plenty of fresh

foods to eat.  All I have experienced is fatigue; it is more difficult to work all day long without sitting down.  I plan to slowly reduce my hours as the pregnancy progresses. 

I often wonder what kind of parents will we be.   I know how to take care of a child’s medical and emotional needs, but I have never had my own child. There are so many unknowns. Who will this little person be?  What will they be good at?  We're getting more and more excited about what the future holds.  I can identify a bit with Mary when she says "My soul magnifies the Lord...may it be onto me as you have said. ". We want to be good parents who point to the Lord in all we do and say.  We leave the rest up to Him.  He already knows who this child will be and is our job to trust Him and not worry too much.

Being pregnant in a different culture that my own is an interesting experience.  Overall I would say that pregnancy is a private affair here....in fact most people do not announce their pregnancies.  I have told a few people, but I know the word spreads rapidly.  This is so different than American culture where

everyone celebrates upcoming babies with showers, gender revelation parties, and excitement.  Maybe pregnancy is such a regular part of life here.  Most women here spent most of their adult lives raising children and having babies.  Babies come and babies go with infant mortality as high as it is.  Maybe women don't want to set their hopes too high.  I do miss being able to rejoice and wait in expectation

alongside family and friends.  In a funny way, I miss being able to announce something to a group of people.  Warren and I share much of this together as we look at weekly ultrasounds and see the baby's physique taking shape.

Pediatrics

Pediatrics is as busy as ever.  Most days I am responsible for about 50 patients.  I care for more patients on a daily basis than I would ever have in the states.  This past week I diagnosed two children with tuberculosis, one of the spine and yet another case with meningeal involvement.  Our nutrition program

is "hopping!"  This month Samaritan's Purse is starting up community nutrition care groups for at-risk children and their families.  We are hoping to provide community follow-up to those being discharged from the hospital nutrition program.  This will involve community gardening and hopefully engage the fathers in field preparation. Last week the SP team was doing a community assessment in a nearby

community and was led to the home of a new mom and her twins struggling to survive.  The woman was too weak to stand and needed to be transported to the road for emergency evacuation.  I am convinced that this little family would have died.  Pray for them.  The babies

are gaining weight and looking stronger everyday.  They are not out of the woods yet.

This last month I said "goodbye" to a little girl named Anifa.  She had been under my care for much of the year for her advanced skin condition pemphigus vulgaris.  She experienced many complications related to the side effects of steroids and was more and more debilitated.  The family could see that it was time to shift gears and go home.  She spent five days out of the hospital before going to her

eternal home.  Her mother visited us today in pediatrics and told us the last thing Anifa said before she died was that she could hear children singing.  She said that she wanted to join them.  I love the thought of children welcoming Anifa to heaven, it brings tears to my eyes every time.  DR Congo was not Anifa's home, she was only passing through.  I am thankful for the healing that took place within her family as they rallied around her during her last months.  May the Lord give us the eyes to see the significance of our lives and cherish our days.

Nyankunde Hospital is undergoing a rebirth.  It is a Congolese mission hospital 

once again, this time run by nationals and the local church and not ex-pats as

it once was.  Many buildings in the area are still in shambles from the war but 

many have been re-built.  People who once lived here come back to see the

renewal and life starting again.  People cry, they reminisce..."I used to live

here, " or "I was born here."  For many there still is a significant fear

factor, some do not want to live here again because of the memories, but overall

life abounds once again.  Nyankunde is a prospering village again, the people

continue to struggle with food security but they have plans for the future. 

There are more fields being cultivated this year than last and we have to fight

to keep our small garden plots.  Now displaced peoples take shelter in

Nyankunde.  It is exciting to be part of the changes happening here, the

training of Congolese doctors and nurses again.  We see people from all over

eastern DRC for a diagnosis and treatment.  We see our share of heartaches and

many with advanced disease.  It is my prayer this next year that the spiritual

ministry here continues to grow, and that we would be known for this.

Rosie

We have a beautiful young pup named Rosie, a bull mastiff.  She is growing by leaps and bounds and

Rosie at about 9 weeks old

is 12 weeks old.  She doubled her weight this past month and is about 12kg!  She was so small at first that I insisted we keep her enclosed from the threat of owls at night.  I no longer fear the owls!  She is lots of fun and already knows “sit” and is learning “come.”  She has no fear of goats or pigs and approaches everything with a curious spirit.  Most passer-bys pass to the other side of the road when they see us coming with one phrase: “mama wey.”  We are spending lots of time with her and exposing her to lots of new things.  She loves picking everything up, eating bugs, chewing shoes, and eating fish and Goma cheese rind.  We are thankful to have a dog again.  We hope that we can train her well before the baby comes in August. 

Rosie now at 12weeks of age

We are grateful for your support and interest in our lives.  It is a privilege to serve here and see God at work. 

Some prayer requests:

 1) Pray for the health of our baby we wait with anticipation.  Pray that God would continue to give us joy in this season of preparation.

2)   Pray for our future plans to serve in Congo to become clear.  This is a logistically challenging place to live and work.

3)   Pray for a profitable time at an upcoming medical conference in Greece at the end of April/beginning of May and for the week following that we will spend with Warren’s parents.  Greece here we come!

4)   Pray for the many medical challenges we face daily and for insight into the spiritual needs of patients and families.  Pray that Jesus would be known here at Centre Medical Nyankunde.

5)   Pray for humility of spirit and service as we treat and work alongside our Congolese colleagues.

Blessings,

Lindsey and Warren Cooper

Pediatrics team
A night with Dr. Chantal before her departure to Bunia.  We miss her.

Interesting Cases - an account by Warren Cooper

I am officially sick of interesting cases. It seems like we have had nothing but, in the last week or so. I wouldn't mind a couple of straightforward hernias. It keeps me from getting bored, I guess, but sometimes it's a little much. A few examples...

Bed 2 came into the hospital nearly dead. Not like the cute "Princess Bride" version, but the real thing. He had been vomiting massive quantities of blood for the previous day. He was in shock, with a barely perceptible blood pressure. By my estimation he had one or two red blood cells left in his blood vessels and they were working overtime. I put in a femoral line and we started pouring in fluids. This is a reasonable thing to do, but it really solves nothing. What he needed was red cells, and to stop the bleeding. A quick ultrasound confirmed the diagnosis: liver disease, probably resulting from schistosomiasis (a parasitic disease that you really don't want). We rushed him to the endoscopy suite, where we saved his life with...a couple of tiny rubber bands!  No kidding, that's all it took.  Actually getting them in the right place is little bit tricky.  He was bleeding from what is called esophageal varices.  These are dilated blood vessels in the esophagus which result from scarring in the liver.  I loaded the little rubber bands on a little tube that fits over the scope.  I sucked up the bleeding vessels into the scope and fired off the rubber bands using a nifty system involving tiny strings and beads, if you can believe that.  This whole procedure was complicated by blood which was literally pouring out like an open faucet.  Also the patient had by this time received enough fluids and blood to become agitated and combative.  Imagine the goriest bloodfest movie you've seen, multiply by two and you've got a pretty good idea of how things were.  It was not pretty, but we saved his life!  ...only to have him promptly lapse into a coma.  It was probably the big protein load which pushed him over the edge into hepatic encephalopathy.  Folks with liver disease do not tolerate lots of protein and this guy was essential drinking his own blood (a very high protein beverage!)  Anyway, that's where we stand now.  It may have been something of a Pyrrhic victory, but you have to try.  Maybe he'll wake up.  What a tragic disease!  This guy is in his early 30's and this disease is going to kill him.  If not this time around, then probably the next one.  Solution?  Don't bathe in contaminated water.  

Bed 3 is a man in his 60's who came in with jaundice.  He had something obstructing his bile ducts and pancreatic duct.  This is most commonly a malignant tumor in the head of the pancreas.  We discussed the options and scheduled him for surgery.  What commonly occurs is what (in the surgical realm) we call a "peek and shriek".  You open, you find a tumor that has spread, and you close.  The best I was hoping for was a biliary bypass, in which the bile duct is sewn to the bowel to treat the jaundice.  I opened him up and discovered a small tumor in the head of the pancreas, as predicted.  What I did not expect was that...that was it.  No appreciable lymph nodes, no spread to adjacent organs, no signs of liver metastasis.  In the scenario, the appropriate operation is what is known as a Whipple.  This is a huge operation which consists of removing the head of the pancreas and the duodenum.  In the US, this operation is generally performed in designated "centers of excellence."  Well, I saw one of these operations in my residency.  That doesn't exactly make us a center of excellence.  Anyway, we got started and things went fairly well.  I asked someone to open up a copy of Zollinger's Surgical Atlas to help refresh my memory on the general steps of the operation.  We got the tumor out, completed the necessary anastomoses (pancreas, common bile duct and stomach), and closed.  All things considered, it went fairly well.  We finished in about 4 hours.  This is a long operation for me, as I generally lose interest after about 2 hours.  One hesitates to talk of a "cure" when dealing with pancreatic cancer...but this may well be.  We're still not out of the woods.  Recovery can be a bit of a rocky road, but so far so good.

Bed 5 was injured in a vehicle accident.  It was the usual Congo scenario: a truck full of cement which was also carrying a bunch of people on top.  I'm not sure what happened, but it was bad.  Supposedly the driver fled the scene and hasn't been seen since.  There were one or two killed at the scene.  Four patients arrived at the hospital and it was up to us to figure out who was really injured.  Bed 5 had an obvious fracture of the humerus (no, it's not funny!) and a pelvic fracture.  He was also very, very drunk.  This gave me a little insight into how people tolerate the abysmal conditions of travel in Congo.  You get liquored up and the whole trip seems like fun!  Anyway, over the next couple of days this guy went nuts, probably from alcohol withdrawal.  He was getting up, harassing the nurses, flailing his broken arm in an alarming fashion and wetting the bed.  We gave everything we had to keep him down; valium, thorazine, haldol.  Nothing seemed to do much good.  Eventually we operated on his arm, and it was mess.  I pieced it together as best I could with screws and a plate.  It was an exercise in creative orthopedic surgery, but it actually came our looking pretty good.  After the operation, he kind of woke up and appeared "clothed and in his right mind" (as the Biblical passage relates).  Since that time he's been quite pleasant.  He has been talking with the chaplains and is keen to start reading the Bible.  

Bed 6 was in an altercation and got his hand sliced.  We had a couple of busy days and I was looking forward to a slow day in the OR.  When I saw this guy, I realized it was not going to be the case.  He had a deep gash over the palm of his right hand and his fingers (3,4,5) were extended.  He could not flex them.  Flexor tendon injuries to Zone 3 of the right hand do not make for an easy day.  I was informed by one of our trainees that they generally approached these injuries by simply sewing the skin back together.  That is well and good, but it means your fingers will never work again.  I did an ultrasound-guided block of the median and ulnar nerves, put on my surgical loupes and prepared myself for a tedious operation and a splitting headache.      The patient had a moment of panic when I instructed the team to cut off a black rubber bracelet he was wearing.  He misunderstood and thought I was telling them to cut his hand off at the wrist.  It may have something to do with my reputation.  My local name is "Chinjachinja".  This means something like "The Cutter" or "The Slasher".  Anyway, it was a tedious and difficult operation, which did indeed result in a splitting headache.  The tendons in this area, as it turns out are a very complicated mechanism.  There is both a deep and superficial flexor tendon.  Unfortunately this guy had been closing his hand when he was slashed (grabbing the attackers blade?) and the severed tendons had retracted way up into their sheathes.  It took a long time to find them and get them sutured back together.  It went fairly well, I think, but it's a nitpicking operation, and a region of complicated anatomy, if you're not used to being there.

Anyway, I could go on.  I could tell you about the lady with a nonunion of the tibia, the man with a tumor causing his eye to pop out, the kid who cant stop vomiting, the lady who cannot swallow, the boy whose hips have both died, the man who thrombosed both femoral arteries resulting in bilateral above-knee amputations, the lady whose placenta grew into the uterus, the lady with a huge recurrent tumor of her chest wall........but I won't.  It would take too much time and no one is really that interested to read it all.  

That is my life and my burden to bear.  Too many interesting cases!  In a way it is good.  It means that the hospital is known for taking care of difficult cases.  It means that people are coming here for training and they're seeing techniques that may help them as they serve in other places.  It also means that I come home exhausted and wondering what it would be like to have a "normal job."  I'd probably be bored.  

To anyone who actually made it this far in this gruesome account, congratulations.  Thanks to everyone for your support and your belief that God is doing a wonderful work here at Nyankunde Hospital.

Warren Cooper

Big changes and Grace

Time is flying by.  I can't remember the last time I updated this blog. Seems like it is my turn (Warren).

So, what's new?  A whole lot!  The big news is that (drumroll please....) we're having a baby!  Even as I write these words, it seems surrealistic. Lindsey is due in August. What a mysterious process!  We have been following the progress with ultrasound and it is so amazing to watch this new life progress from tiny blob to a little creature with hands and feet!  Who knows how this happens, how the cells migrate, the organs develop, and the fantastic architecture of a human being develops?  Anyway, there are lots of changes ahead for both of us and we look forward to this grand new adventure. Lindsey is well into her second trimester and is developing a little bump.  She is starting to feel something like butterfly wings moving inside.  God has been so good to us and we have both been in excellent health. I had a little touch of morning sickness, but I'm ok now!

On a slightly similar note, we took the plunge and got a new puppy in Kampala.  It is a sister of our late beloved dog Peterson. Same mother and father. Her name is Rosie. I was going to go with something more ferocious, but Lindsey vetoed all my suggestions. Even at 2 months, you can see the instinct to guard her territory.  I think she will be a great family dog. We drove all the way back from Kampala with her. She even drove for a bit. 

We've had the luxury of having two other doctors here. Kimiko Sugimoto is a surgeon who actually grew up in Congo. She has been here for a month and has been a great help. We also have Laura Foudy, a family practitioner who has an interest in surgery. Having this help has allowed me to work on some other projects. This includes things like constructing a charcoal oven, planting trees, watering the garden, responding to some neglected email.  We were able to travel to Beni, and spend a couple of days working at the hospital there. 

We had a great time in Uganda. We spent several days at Mulago Hospital, observing cardiac echo for congenital heart disease. This was a chance to get some experience.  It was interesting to see how things work in large hospital in the big city. It made me so thankful for our situation in Nyankunde. Maybe we cannot do open-heart surgery, but I feel like we are doing what we can to help. Plus, Nyankunde is just so much more pleasant than Kampala. 

We spent a couple of days in Kampala, taking care of things. I had to go the US embassy to get my passport renewed.  We bought a lot of groceries. We also bought a lawn mower and a washing machine.  A lawn mower sounds like a luxury, but I really want our garden-keeper to focus on the garden.  It takes him about three days to cut the grass with a slasher. Now I can do it in 40 minutes, and it's therapeutic for me. 

None of this was especially relaxing, so we drove to Jinja and spent two days there. It was wonderful to just relax on the shores of the Nile, watch the birds, enjoy some nice food and appreciate how calm and peaceful our life is (but not for long). It wasn't exactly the "babymoon" but it is important for us to just escape the medical world for a bit. 

 We are well into our second year at Nyankunde. We really feel like we are home here. We feel like we are becoming part of the society here. We still have our share of cultural challenges, but we are making progress. The hospital has come a long way in this short time. This morning we had our weekly doctors' meeting. I looked around at the mix of foreign and national doctors, united in their desire to serve God by caring for the sick and suffering. I was so proud to be part of the process of medical education. I have been thrilled to see the ways that the hospital has progressed. I am excited to see these Congolese doctors advance in their care of complicated patients. Ten years ago this hospital was reduced to ruins. Today it is a beacon of care and training. Only God could do this, and it has been wonderful to be a part of it. We don't know if it will be possible to continue on with our present organization, but we feel like we have been called here and we are committed to this project. Lot of questions need to be answered and I'd be lying if I said I didn't have some anxiety, but we sincerely believe that God can work out all the details. 

Every day has it's share of little miracles, and we need to remind ourselves of that. One recent one was a 14 year old girl named Neema.  This word means "Grace" in Swahili.  She had stepped on a dirty tin can and cut her foot. She did the rounds of various care-givers and received the usual inadequate treatment. By the time we saw her she had a swollen right leg and she was in excruciating pain.  When I saw the patient, I did an ultrasound and discovered that she had a blood clot that was blocking her femoral vein. We started a heparin drip, but her condition was deteriorating rapidly. The next morning she was hypoxic and had a feeling of impending doom. This is a bad sign. We surmised that a part of the blood clot had broken off and traveled to her lungs; a pulmonary embolus. She was also having high fevers. What to do?  I found myself looking a girl who looked like she was about to die. I made the decision to amputate the leg. This is not the usual treatment of a blood clot, but I had the feeling that something else was going on in that leg. Few of you have had to amputate the leg of a 14 year old girl. It's a tough decision, especially when the leg itself doesn't look so bad.  It was just swollen. I was prepared for a tough conversation with the family.  Thankfully they realized the gravity of the situation and consented immediately. We took her to the OR and performed a very high amputation in order to stay above the clot. 

As I was closing the muscle, I asked Lindsey to open the vein and see what was there. She discovered that there was not only a huge blood clot, but that the femoral vein itself was full of pus. This pus had showered into her blood stream causing the sepsis.  The next couple of days were a bit rocky, but the fevers immediately resolved.  In another day she was off of oxygen and after about 10 days, she went home...minus one leg, but alive and healthy. 

There are lots of moving parts in a story like this one. First of all, how crazy to nearly die from stepping on a tin can!  A 14 year old girl usually does not get a blood clot.  Generally a high amputation is not the treatment of a clot, but there is absolutely no doubt in my mind that she would have died if we had not intervened as we did.  Without an ICU and a proper OR, we could have not have cared for this patient.  Without an ultrasound machine, we would have never even had made the diagnosis.  There were so many levels at which the story comes together, but I believe that every turn, God's grace was present.  "Neema".  Maybe this makes me a bad scientist, but when I look at the work we did and the people we treat, what I see is Grace, over and over again.  God heals people, but he lets us be a part of it, and it's exciting stuff.  

So, now we have a little girl with one leg.  The stump is probably too short to even fit her with a prosthetic limb.  She is maimed for life.  It is horrible and tragic, but it is also something of a miracle.  This is the paradox of the work we do.  I also know that God's grace will continue to work in her life.  

Thanks so much for being interested and for being a part of the work at Nyankunde. 

Warren (for the three of us...four if you count the dog)