Hello, blog.  Sorry, blog.  Sorry…I haven’t forgotten about you, but I have intentionally ignored you.  I ignored you, not because there wasn’t anything to say, but because there was too much to say.  And for that, I am sorry.  I will try and catch you up.

2002 – (Woah…don’t start there, that was over 10 years ago…okay, fine…)

2006 – Our first trip to Africa, together.  It was after this trip we knew our calling was to work with PAACS.

2008 – Move to Ethiopia with our very cute, but very loud son.

2008-2013 – Live and work in Ethiopia; add one beautiful girl.  Realize the challenges to cross cultural living are just as hard as everyone warned about and we learn to strive for the dependence of the Lord for joy and sustenance.  But at a cost.

So, now we begin where we left off.  In November 2013, we returned to the states for a time of furlough or home assignment.  The previous 16 months in Ethiopia, had been Paul’s most difficult of them all.  He was experiencing the toll of stress.  Chronic stress from all angles…and as we would soon learn, stress is cumulative and residual.  We returned to the States, with the intentions of rest, reflection and seeking wise counsel.  We were thankful that the first few months would involve the comfort of celebrating the holidays with family.  In January 2014, we attended a debriefing and renewal week at Mission Training International in Colorado.  What a great week that was for us as a family.  Nathan still says his favorite place is Colorado. With the snow to play in and the view of Pike’s peak from our breakfast table, it truly was a week to be together with each other and with the Lord.

Here is Paul’s description of our week at MTI below:

“The experience at MTI was first class and we are very thankful to be have been able to attend. It was clear that the people running the show are highly experienced and have crafted a honed, professional experience over the years. It was a restful blessing to so clearly see that these people were knowledgeable and trustworthy.

Through the course of the week and in our counseling time, it became very clear that we have not been doing well in Ethiopia, that we are not on the bell curve, that we were already experiencing some of the consequences of chronic and poorly managed high levels of stress, and that something needs to be done.  And we feel that this has moved beyond a threshold where it would be appropriate to maintain the same direction while only trying to make adjustments. Though we plan to return to Ethiopia at the end of March, we are confident that we need to transition away from Ethiopia for a period of time. It seems clear that the issue isn’t an acute event, but the accumulation of trials over time. A good friend offered a useful African proverb that helps articulate it, “We will not march today. We will wait until our souls catch up to our bodies.” We need to take some time for our souls to catch up. Though we earnestly hope and pray that God still has later service for us in the setting of foreign missions, we know for certain that He has service for us somewhere. In any setting, though, we want to be in a condition to serve well. And we just aren’t there right now.

This has been and continues to be an extremely difficult decision. There has been a lot of sadness and mourning, and we know that that will continue for a long time. But at the same time there is a deep-seated peace in feeling confident that this is the right choice.”

So, we have realized that we need to take a break from the mission field.  This time includes a ton of transition. Coming off the field seems a hundred times more frightening than leaving for the field. And after talking to others who have also left the field, that seems to be a common assessment.  Moving back to America in some ways seems exciting…”You mean, we get to buy a house? We get to settle ourselves in a community where we don’t come and go? I get to drive a car and remain anonymous as we stroll through the mall or park?” But it is also very sad.  We are grieving the loss of not living in Ethiopia anymore.  We are grieving the loss of a dream to live here longer and to immerse deeper into the culture. We are grieving the loss of a community and daily relationships that go beyond surface level conversations.  We are grieving the loss of not working alongside the staff and PAACS residents at Soddo Christian Hospital.

And although this chapter of our lives together is coming to an end, I rest in the hope that it doesn’t end here.  I know that God has a plan for us to carry out and we will walk faithfully in His steps into the next chapter.  Maybe it is to return to the mission field someday. Maybe it is to support missions from the States, through prayer, giving, and emotional encouragement and care packages.  But ultimately it is to stay focused on the goal of living for the Lord with others in mind.

So, we are flying out of Ethiopia on June 7th.  We will be in the Dallas area for the next year and we will send an updated address once we settle.  Thank you for all of your support through the years.  We cannot thank each of you enough and we have felt well supported by your love, prayers and gifts.  It has truly been a blessing to walk this chapter of our lives alongside all of you.

The family visiting Lalibela, Ethiopia in July 2013

The family visiting Lalibela, Ethiopia in July 2013

I have so many blogs floating around in my head, but the days are flying by and we will leave for the states soon.  We will be on home assignment (aka family and friends time, cheddar cheese time, holiday time, time to see all of you time!) from December through March.

One of the hardest things about leaving for a few months is tying up loose ends.  Making sure all of the things we usually do are covered…which also includes making sure we have adequate surgery coverage.  God has provided surgeons for this time and we are very thankful!  There are 4 different surgeons coming from the US and Norway, some who have been here several times.  In addition, we are very blessed to have a PAACS graduate come and live here and teach the residents and work with them for the entire time we will be gone.  Dr. Arega is Ethiopian, but graduated from the PAACS program at Tenwek in Kenya.  He is on his way to start a new PAACS program in Malawi, but will graciously be able to be here while we are gone.  This is a huge blessing and answer to prayer.

Here is a small report about the great time we had last month at our PAACS retreat…

PAACS Ethiopia 2nd biannual retreat

On October 4th through 6th, the PAACS Ethiopia team met for their second retreat.  The retreat was held in Soddo on the Soddo Christian Hospital Campus.  The residents’ broke in the new PAACS apartment building as they all stayed there together for the weekend.  The staff from Myungsung Christian Medical Center (MCMC) arrived from Addis on Friday night and everyone enjoyed dinner together at a new restaurant in Soddo with an Ethiopian manager who lived in Texas for more than 30 years. All were gathered on Saturday morning with a time of getting to know each other better.  During the games we discovered that Dr. Moges was one of the only ones without corrective eye wear, only Paul Gray had ever experienced general anesthesia  (better yet his operation was completed by Chi Chung) and that no one in the group was an only child.

Saturday morning was filled with times of worship in both Amharic and English.  We received a word from a local pastor who is currently completing his masters from Fuller Seminary.  He spoke to us on John chapter 15, about the Vine and the branches.  He encouraged us that the “Father is the gardener” and just like any good gardener, He will help us along the way in hopes that we will produce fruit. After several sessions of studying the Bible and discussion, we had a time of prayer for the program and for each of the graduates as well as the current residents.

Group worship

Group worship

Saturday afternoon the staff and senior residents attended a Residency Review Committee Meeting.  They discussed plans for the future and requirements from the government to maintain accreditation within Ethiopia.

RRC meeting from back L  around to back R- Paul Gray, Jon Pollock, Wendy Willmore, Wayne Koch, Jodi Ross, Netsanet, Seigni, Daniel Chang, Chi Chung

RRC meeting from back L around to back R- Paul Gray, Jon Pollock (General Surgeon at MCMC), Wendy Willmore (PAACS faculty at new site in Tanzania), Wayne Koch (ENT on PAACS Commission), Jodi Ross (admin), Netsanet (administrative assistant), Seigni (3rd year), Daniel Chang (PAACS faculty at MCMC), Chi Chung (PAACS faculty at MCMC)

While some were at the meeting… a football (soccer) game was organized with all of the PAACS residents playing against the OR staff.  (It was a rematch; the PAACS residents won the game last year.)  It was a close game, with the OR staff winning by a few goals.

Moges and Ebenezer running the ball down the field

Moges and Ebenezer running the ball down the field

the winning OR staff

the winning OR staff

On Sunday morning, everyone participated in an English church service.  There was an encouraging podcasted message on sacrifice by John Piper.  And Mark and Allison Karnes served everyone communion.  After the service, the Addis team parted ways for the 5 hour drive back to Addis.

Group shot.  It was a great time to be together and encourage one another and grow closer in our relationships.

Back row: Dr. Wayne Koch (visiting ENT, PAACS Comission), Dr. Efason(2nd year), Dr. Seigni (4th year)  Paul Gray (PAACS Ethiopia program director), Dr. Chi Chung (MCMC Site Director) Middle row: Pastor Zodie (retreat speaker), Dr. Moges (3rd year), Dr. Ebenezer (1st year), Dr. Ronald (3rd year), Dr.  Jon Pollock (MCMC faculty), Dr. Bob Greene (visiting ortho sugeon), Dr. Ben Martin (visiting Emory 4th year resident) Front row: Yerusalem (wife of worship leader), Pastor Muller (worship leader), Netsanet (PAACS administrative assistant), Dr. Gezahegn (1st year),Dr. Surafel (2nd year), Cissy (Ronald’s wife), Jodi Ross (administrative assistant), Becca Gray, Dr. Chang (vascular surgeon and faculty at MCMC)

Back row: Dr. Wayne Koch (visiting ENT, PAACS Comission), Dr. Efason(2nd year), Dr. Seigni (4th year) Paul Gray (PAACS Ethiopia program director), Dr. Chi Chung (MCMC Site Director)
Middle row: Pastor Zodie (retreat speaker), Dr. Moges (3rd year), Dr. Ebenezer (1st year), Dr. Ronald (3rd year), Dr. Jon Pollock (MCMC faculty), Dr. Bob Greene (visiting ortho sugeon), Dr. Ben Martin (visiting Emory 4th year resident)
Front row: Yerusalem (wife of worship leader), Pastor Muller (worship leader), Netsanet (PAACS administrative assistant), Dr. Gezahegn (1st year),Dr. Surafel (2nd year), Cissy (Ronald’s wife), Jodi Ross (administrative assistant), Becca Gray, Dr. Chang (vascular surgeon and faculty at MCMC)

Hi all, This is Becca.  I thought I would re-publish a few stories this week.  Recently, I have written several stories for the Soddo blog and PAACS website.  But I realize some of you may not have seen them (You can sign up to receive both newsletters on the websites linked).  Even the post Paul wrote below this was featured on the hospital website and circulated on Facebook throughout the country.  We have heard several reported stories of children who have died, in other regions of the country, because of this toy. Please pray that we can get the word out and eliminate the toy.

The following story comes after 5 years of prayer and fundraising….We have finally finished the PAACS apartment building.  After everything Paul and I have gone through with this building, I’m not sure we will ever build a building or house again.  It was a lot of work…work we are not experts in and work that is tedious.  But God provided the man power, others’ expertise and the money…and it is finished and we are thankful! We are thankful to each of you who have given faithfully and have persevered as we continued to talk about this need year after year! Read below.

 

Move in Day!

After many years of prayer and preparation, the new Soddo PAACS apartment
building has been completed!   The finished building has 7 apartments (1
three-bedroom, 3 two-bedrooms and 3 one-bedroom apartments). These new
apartments will allow the surgical residents to have a reliable source of
power and water. And, since they are on the hospital’s campus, it will
significantly improve their home security, including that of their families.
From an educational standpoint, this will also allow us to improve the
residents’ experience with night call. This will allow senior residents to
take back-up call in the night and gain experience in teaching junior
residents under faculty supervision in the night hours.

We want to extend our deep appreciation to everyone who has given so
graciously to make this happen. We have been encouraged by everyone’s
support and gifts even in the end as we raised money to furnish each
apartment. A big thank you goes to Africa Mission Healthcare Foundation for
their donation that funded over 1/3 of the project costs.

The residents are enjoying living in the same building and often eat
together, sing praise music together and enjoy holidays together since they
are away from their extended families.  Dr. Surafel said, “Living on-campus
together gives us lots of time for fellowship and we eat many meals
together.  It is also easier to see patients more quickly.”

Inside an apartment living area. Thank you for helping provide the furniture to make a comfortable living space for each family!

Inside an apartment living area. Thank you for helping provide the furniture to make a comfortable living space for each family!

Helping Dr. Gezahegn and his family move into their new home.

Helping Dr. Gezahegn and his family move into their new home.

The residents’ kids and missionary kids all enjoying the same playground.

The residents’ kids and missionary kids all enjoying the same playground.

The finished apartments! We are still working on some landscaping, but have hired a gardener and cleaner to keep up with the grounds and inside.

The finished apartments! We are still working on some landscaping, but have hired a gardener and cleaner to keep up with the grounds and inside.

A lot of what we do here is reactionary. Bad things happen and we do our best to deal with the problem. There is no question that it is better to prevent the problem in the first place. As good as the trauma care in the developed world is compared to the developing world, the greatest contributor to outcomes has been in prevention. Americans, for instance, are often unaware of the blessings they have in the all the injuries that never happen because of good public health measures. It makes me pause and thank God for all the merciful and good gifts He has given me of which I am completely unaware, including the unknown good things given and the unknown bad things averted.

But knowing that prevention is good and actually making it happen are two very different things. There is a saying about being too busy fighting the alligators to drain the swamp. It is a real dilemma and there are no easy answers.

We have been blessed to participate in a little swamp draining in the last few weeks. Some of the most terrifying situations we encounter here are aspirated foreign bodies in children. Sometimes it is a coffee bean or a peanut or a piece of corn or a toy piece, but it is always terrifying. You have to get the thing out, or the child is very likely to spiral and die. But getting it out involves manipulation of an often very small airway in an already sick kid. And if oxygenation goes south, you often have only moments before the child goes into cardiopulmonary arrest and dies.

For the last several years we have been greatly blessed to have the proper tool to get these things out – a rigid bronchoscope. Wayne Koch, a visiting surgeon who has repeatedly come to Soddo, graciously provided it. It enables us to grab the offending item under direct vision from the inside of the airway without having to cut the neck open. Before receiving the bronchoscope, we had to do just that – cut an opening in the trachea and try to fish it out. Barbaric though it was, God was gracious to us during the pre-rigid scope days and we were able to successfully treat the kids that came in. God was further gracious in his timing of the rigid scope, however.

Since receiving the scope, a new culprit has proven increasingly common at our hospital. There is a cheaply made party toy widely available on the market that has caused a lot of problems. It is produced in a fairly populated country to the far east of here… It is a party noisemaker toy that consists of a tube with a balloon attached to one end. Inside the end of the tube with the balloon is a hollow plastic piece with a small tongue-shaped rubber diaphragm. The intended (I assume) concept is that someone blows into the opposite end of the tube, inflating the balloon. Then the balloon deflates, blowing air back down the tube, through the plastic piece and over the diaphragm, making a frankly annoying sound. The cost-benefit analysis of this thing utterly astounds me.

 

IMG_2383

IMG_2342

 

Anyway, here is the unintended (I assume) concept. The kid blows down the tube and partially inflates the balloon. Then, in an attempt to amp up the fun, he/she then sucks in a big breath with the tube still in his/her mouth to get a second blow into the balloon. Having not personally observed the event, I assume it goes something like this: this works for a few times, maybe a bunch; but eventually whatever adhesives are holding the plastic piece in place weakens. Then, when the kid is in maximal inspiration for that second awesome breath, and the vocal cords are maximally open, the positive pressure from the deflating balloon knocks the plastic piece loose. Between the positive pressure from the balloon and negative pressure from the child, the piece rockets down and through the vocal cords into the airway.

We have now cared for at least nine such children here at Soddo Christian Hospital. The last two cases have been particularly heart-rending in that the thing was stuck just below their vocal cords, so that it made the intended noise with every gasping breath. The timing of the rigid bronchoscope is such a blessing because I’m not sure how successful we would have been trying to get these out through a blind hole in the trachea. Because they are designed to pass air through them, the pieces often lodge down in the airways to one of the lungs (usually the right) and coughing doesn’t necessarily knock them up into the main airway. Thankfully, we have been able to get them all out thus far, with healthy children at the end.

The last one (two days ago) was a beating. I always come home and tell Becca that each of these cases takes around six months off my lifespan. It is a weird emotional response each time. I start the case with a deep sense of trepidation and fear, praying fervently for God’s help. By God’s grace, I am able to keep focused on the situation while we’re doing it. But once the foreign body comes out, I get light-headed and tachycardic (racing heart beat) and develop a temporary tremor in my hands. Major adrenaline rush – but not the fun skydiving kind.

The last one however took about six years off my lifespan. It was a small, four-year-old little boy. His cords were so small I have no idea how he managed to fire it down there. He must have huffing up for a mammoth breath. I could barely get the rigid scope through. It was a dicey several moments, but I finally got a hold of it and tried to pull it out. But it literally would not fit back through the cords. The piece popped off the graspers and back into the airway. Unfortunately, I couldn’t get the scope back into his airway and his oxygen level began to plummet. We always have a tracheostomy set open and available for this possibility. So I grabbed a knife and slashed in. Emergency airways are absolutely terrifying. I remember it being described in residency as ‘operating with Elvis’ because when you’re leaning over trying to get it in, you usually have most of your weight on one foot – and the other one is spasmodically bouncing up and down in a frantic version of the King’s trademark move. Anyway, Elvis and I got into the airway OK and we were able to get his oxygen back up. Several more moments of improvisation ensued and we were able to confirm that the thing wasn’t downstream, in the lower airways. So it must be above the tracheostomy tube. By putting enough blankets under his shoulders to really hang his head back and aggressively tilting the bed down, I was able to peak upstream through the hole in his airway after removing the tracheostomy tube. Sure enough, it was there and I was able to grab it with a clamp and remove it. At this rate, I figure I’ve only got about 12 more years of life…

One of our residents has now written up an abstract on this situation for presentation at the Surgical Society of Ethiopia and has drafted and submitted a formal letter to the Zonal Health Department to seek official action on this toy. I don’t know what will come of it. But we pray that the importation of this toy will be stopped and that public announcements on mass media will help deter people from buying and using this toy. Please pray for a resolution to this serious problem. I don’t know if there are any other hospitals in the country that have a rigid bronchoscope for this problem. By God’s grace, we have had good outcomes for the kids who have been brought here. But I have no idea how many children have died because of this toy. Lord knows, there are plenty of problems at baseline around here. Please pray that this pointless one would go away.

Paul

Many of you know that when we arrived in Ethiopia over 5 years ago, that we were the only young family.  I was the only “non-working” adult on the compound and Nathan was 7 months old.  And although we had a lot of support from the rest of the community as we adjusted, many days were hard for this mother.  I was used to getting in my car with my baby every day.  I would drive to the park to walk around, to meet a friend for lunch or just drive…hoping my little boy would get some sleep.  Well, then we packed up our baby, left my 4 wheeled symbol of independence and left the big city.  We landed in Soddo, on a small compound and all of a sudden I was very dependent.  Dependent on advice from others. Dependent on food from my own garden.  Dependent on the Lord…to provide and teach us a new way of life.

Nathan at 7 months sitting below our 6 bags headed to Ethiopia

Nathan at 7 months sitting below our 6 bags headed to Ethiopia

I began finding my own rhythm.  I learned the language.  I broke up the days by letting Nathan play in the grass and dirt outside.  I would strap him on Etagainu’s back and we would take trips into town, for coffee and popcorn.  Eventually, Bajaj’s came to town and I had a mode of transportation again!  One that didn’t include staring at the back of an emaciated horse wondering if he was going to collapse at any moment and we would all go flying.

the dreaded horse cart....poor little horse

the dreaded horse cart….poor little horse

I loved the freedom that a Bajaj brought for me.  Funny, I know.  But it was a glimpse of independence.  Being able to call a driver and have him show up and take me to visit friends in town or easily go and get a few things I needed for dinner.

The upgrade...the bajaj...my new 3 wheeled symbol of independence.

The upgrade…the bajaj…my new 3 wheeled symbol of independence.

But still I struggled with community life, the fact that my kids needed friends and I longed for other young moms to talk things through with.  I invited some kids from the community for regular play dates, but several times the kids moved on to bigger cities in Ethiopia and we were back to where we started.  I met several other great families who were living here, but all living in very different places within Ethiopia.  And at the most I may see one of them every few months.

And then we got several emails and visits from families who said they were interested in moving and serving at Soddo.  Paul and I thought it would be a dream come true.  Can you imagine if the community grew and we all lived here together?

And it was amazing to see how it all played out over the years.  We would pray and pray that God would send more to serve here.  And he did, more than we could have imagined.  We now have a compound filled with 17 kids and one on the way.  We have grandparents who have left their grandkids and serve our kids…I mean spoil our kids, as if they were their own.  We have parents who are willing to take on extra kids for a few hours or for a weekend. We live every day with people who know us through our best and our worst…and they still love us.  And it is such a blessing!  I love serving with everyone who has made their home in Soddo.  It really is a picture of the church.  People drawn together by a common bond, unified by the Holy Spirit and the mission given to each of us to serve and live together.  People who grow together through colliding daily.  The church is a beautiful and messy blessing.

Kids hanging out

Kids hanging out

The kids enjoying a movie night with the Ayers, while Paul and I were out of town.

The kids enjoying a movie night with the Ayers, while Paul and I were out of town.

 

My neighbors!  How lucky am I? We are all currently home schooling together, keeping our husbands going and yes, even our favorite time of the day is recess too! Quality time on the playground does everyone some good.

My neighbors! How lucky am I? We are all currently home schooling together, keeping our husbands going and yes, even our favorite time of the day is recess too! Quality time on the playground does everyone some good.

 

This weekend Ethiopia added one surgeon to its country of almost 85 million people. 

Plus one!

Dr. Daniel our 6th graduate from PAACS Ethiopia since 2009, will return to his home town as an accredited and certified surgeon. 

How will the plus one make a difference?…

Plus one will average 10 to 20 major operations each week.  Plus one will treat each patient with compassion and care.  Plus one who share the gospel of Jesus with countless patients and their families.  Plus one will be a leader in his home and in his community.  Many will travel days to reach the hospital, not to be turned away because there is no surgeon, but to be taken in and treated by that plus one.

This is what we are here for, to train and disciple these doctors who will go out and change the statistics of a nation, one at a time.  

Congratulations, Dr. Daniel!

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Paul and I with Daniel and his wife Chaltu.

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Dr. Daniel with the faculty that trained him, (from left to right) Dr. Chi Chung (General surgery MCM in Addis), Dr. Mark Karnes (OB/GYN Soddo), Dr. Jon Pollock (General surgery MCM), Dr. Chang (vascular MCM), Dr. Daniel, Dr.Kim (OB/GYN MCM), Paul Gray and Dr. David Hardin (General surgery Soddo)

A few weeks ago, all of the PAACS residents across the 6 programs in Africa took their annual end of the year exam.  After the test, Paul and I stayed up late inserting letters into the score sheet to try and get a peak at how the guys did.  It was evident that they did well, but I didn’t know how well they did until we got the PAACS bulletin and saw the following article highlighting many of our PAACS Ethiopia residents….  

PAACS WRITTEN EXAM GIVEN
“The annual PAACS in-service exam for the PAACS residents was held the first weekend of July. Forty residents sat the exam. The overall passage rate was 15 of 20 on the senior level and 15 of 20 on the junior level. All but one of the substandard scores were close to the benchmark and it is expected that they will perform adequately on the remediation exam scheduled for the last Saturday of August.

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Residents at Soddo Christian Hospital, part of PAACS-Ethiopia, prepare to take their written PAACS exam.

The highest score on the senior exam was Elijah Mwaura, a fourth year resident of Tenwek, followed closely by Dejene Desalegn, a third year resident of PAACS-Ethiopia. The highest score on the junior exam was Moges Mulu of PAACS-Ethiopia just ahead of John Kanyi of Tenwek. For the first year residents, Efeson Thomas and Surafel Mulatu, both of PAACS Ethiopia, tied for the highest score.

The KR-20 score, a measure of reliability for examinations, was .90 for the junior exam and .79 for the senior exam. The test was written to a pre-established blueprint to assure validity.”  ~ PAACS Bulletin August 2013

We are so proud of the guys because of all the hard work they took to prepare for the exam.  There were several Saturday afternoons where I found them all in the library studying together.  If you would like to sign up for the PAACS Bulletin emails click here!

This blog post began a week ago and then got pushed aside in the busy-ness of the past week. I will try to finish something to share this weekend. There is a lot on my heart, and I confess that writing it is not in small part about catharsis. There will be some medical items at the end. And I will warn those who don’t like it that there are some graphic pictures. In honor of my mother-in-law, there is a ‘bunny buffer’ for those who don’t want to see it. When you see the bunnies, beware. Blood is coming.

Part I – Spirituality

God gave us a really encouraging morning yesterday. It was a strong reminder of our strong and sovereign God’s activities, even when we’re unaware of them.

We have a patient who has been with us for a long time named M. M is from a rough area and showed up with a seven-day-old AK-47 wound to the shoulder and jaw. It seems the bullet punched through the top of shoulder from the back, exited the shoulder, and then caught him under his left jaw, exiting out his mouth near his chin. It had completely blown away a segment of his left mandible, including teeth and the soft tissues around it. After a week of no care, it was an infected mess with a huge, gaping hole between the floor of his mouth and the hole in his neck below his jawbone. The then unstable mandible was just sort of hanging there, and he was leaned on his side in bed, drooling out of it.

He has been with us for a long time. We initially took him to the operating room to try to clean out his wounds and figure out some way to stabilize his airway. It took a couple of iterations of attempts, but we were finally able to put an external fixator on his mandible. Like much of the medical descriptions in this post, it reminded me of a mad scientist’s experiment. But it worked and we were able to stabilize the situation and give wound care to clean up the infections. Because the floor of his mouth was pretty well ripped off from the front, he has some difficulty swallowing. But we were able to use some suction tubing as a straw so that he was able to eat porridge and build his nutrition.

We have been blessed to have a plastic surgeon with us for the last week and a half, Joe Woods. We had been waiting for him to come to tackle M’s reconstruction – creativity was needed. By the time Joe arrived, the infection was under control and the communication between his mouth and neck had scarred shut. The trick now was putting him back together. In addition to reconstructing his jawbone, we had to put some good soft tissue in there to fill in what was lost. We ultimately took him for a full-day operation and opened everything up again. We used reconstruction bars to span the bony defect and placed bone graft from his hip. We then borrowed some muscle, fat and skin from his chest (pectoralis major myocutaneous flap) and tunneled it up his neck to drape it over the bars and reconstruct the floor of his mouth. It really went well, in a mad scientist sort of way.

The spiritual issue is that M. holds to a different religion than us and none of our hospital people, residents included, can speak his language. Our only communication with him was through his son, also an attendant of the same religion. We had another patient at the same time from the same region, involved in the same fighting and a member of the same religion. After treating his chest injury and putting his arm back together, we tried to talk with him about Christ, but were firmly rebuffed. I confess that I had little hope of success with M, between his age and the fact that we would have to share the good news of Jesus through an interpreter completely disinterested in doing so.

Yesterday, it was finally time to send M. home. Additionally, we had another young man who was ready to go home. This other man was involved in a fight and, as the on-call resident described it, was “hit on the head with a metallic object”. He had a neat circular fracture in his skull and bone was shoved down into his brain. We had opened him up and removed the brain fragments. He was doing well and also ready to go home.

I felt conviction in my heart to share the gospel with both of them, despite my frank lack of faith. Compounding the problem was the huge gaggle of people we now have on morning rounds, between nurses, residents, staff, and emergency surgery students. It is awfully hard to have a meaningful spiritual discussion with so many people. So we decided to split off. After finishing in that ward, Dave Hardin stayed behind with two of our residents, a more experienced senior resident and one of the junior guys. They were going to try to initiate a spiritual discussion with both of these men. The rest of us moved on to complete rounds and get the day going.

It was later, as I was starting the big case for that day, that Dave came in to share the good news. Apparently M. had been thinking a lot about Christianity during his stay with us. He said that someone in their area had been sharing with them about Jesus for a while now. As the guys were talking with him, it was evident that he had already decided to become a Christian! They prayed together and shared further. Apparently there was a church in the area that he could attend to grow as a believer. The translator son was not quite ready to profess faith, but wanted to talk further with the believer in their hometown about it. He was definitely considering.

Furthermore, the young man with the brain injury was a similar story. He was of the same faith but also wanted to follow Jesus. He was fearful of how his community would respond to the change, so our resident exchanged phone numbers with him and tried to set up some time to stay in touch to help disciple him. The young man accepted a Bible and discretely wrapped it up in a newspaper to take it home.

Amazing! All the while I’m feeling doubtful about any chance of success, and God has already brought the fruit to such ripeness that it’s about to fall off on its own accord. All we had to do was reach out and take it. It was very fitting that my Bible reading this morning included this passage from the book of John:

(Jesus) “Look, I tell you, lift up your eyes, and see that the fields are white for harvest. Already the one who reaps is receiving wages and gathering fruit for eternal life, so that the sower and reaper may rejoice together. For here the saying holds true, ‘One sows and another reaps.’ I sent you to reap that for which you did not labor. Others have labored, and you have entered into their labor.” John 4:35-38.

Part II – My family is awesome

God has deeply blessed me with an incredible family. I love them so much. I just want to brag a little. Becca is an amazing woman. I can’t believe how much she accomplishes, all while being a fantastic mother and dear wife. To a “T”, she is the so-called Proverbs 31 woman. There are so many areas where she is taking care of business that I can’t get to. In addition to being a lover and friend, she is a heck of a partner. God willing, our residents will have a great new apartment building to move into in a month or so. And it will be in no small part to Becca’s work.

We had a fun date night last weekend. The Hardin’s graciously took the kids and we went to the best eating establishment in town – our house! We locked the door and turned off the porch light. I actually drew up a great sign that said “Go Away” in both English and Amharic, including a reasonable drawing of an upturned hand blocking the way. Becca, always the wise one, wouldn’t let me actually post it outside the door. We used the money we saved by not going anywhere to buy a new album on iTunes and enjoyed the music while cooking/eating dinner together. Very yummy and great atmosphere!

I am also awfully proud of my kids. Lydia has such a vibrant personality. I have so enjoyed getting to play with her, having “tea” together and playing “Sweetie”. Sweetie is when she and usually Nathan pretend they are the mom and dad at home. Lydia assigns the roles and off they go. When we play together, it is precious, albeit a little odd. Usually, I get assigned the role of dad while she and Nathan are assigned the roles of sister and brother… I’m still trying to figure out which part is “pretend” but they get very strict if I stray off role – such as to become “Scottish accent dad” or some other fun accent. “No, daddy! Talk like you normally do!”

And with Nathan, I’ve nearly become a bone fide crack dealer. I have my boy firmly hooked on Minecraft, the video game. But we have so much fun playing together in the evenings before he goes to bed. We also like to occasionally watch a YouTube Minecraft tutorial from a guy who drives Becca crazy. This past weekend, I also introduced him to a new drug when I gathered Nathan and Lydia together for a late Saturday night showing of Star Wars, A New Hope. Ah, Star Wars is truly timeless. Especially with all the new kids on campus who are already hooked on Star Wars, I felt it was important for his social development to understand the storyline. He’s hooked.

Part III – Creativity Required (written last week)

It never ceases to amaze me how much happens in any given amount of time here. Previously I shared about a six-year-old little girl we operated on for a skull fracture and herniated brain.  She survived her hospitalization and has since been discharged from the hospital. Like a lot of severe head trauma, I’m not sure how she is actually going to do; but she is alive. It took a few days but she woke up and began feeding. But she still isn’t moving the affected side of her body much and she isn’t able to communicate or engage her environment. Dave and I received advice from one the neurosurgeons at Baylor and we will plan to reoperate on her in three months (assuming she returns). We will need to reconstruct her dura (tough lining around the brain) and perform a cranioplasty (give her something hard where there is currently no bone). He gave us a few options since we don’t have titanium mesh. The most creative was to harvest rib bone and weave it together like a piecrust. I’ll never look at apple pie the same again…

Dave and I have had several difficult situations where we have had to rely on God for grace and creativity. A few weeks ago we had a man come to clinic with a long history of right upper quadrant abdominal pain and jaundice. His bilirubin was elevated and it appeared that he had stones in the area of his gallbladder. Additionally, the biliary ducts in his liver were dilated. It looked like his gallstones had fallen into the main bile duct coming from his liver and had blocked the system, usually near the duct’s entrance into the small intestines. This represents a problem that has seen a huge evolution in the United States. These days, gastroenterologists are usually able to fish these stones out with a scope and it is quite uncommon to have to do it surgically. As it turns out, I never saw a single common bile duct exploration as a resident, with exception of a few times where we flushed some tiny stones out during laparoscopy. But I was certainly never involved in some of the cases like I’ve seen here.

This one turned out to be one for the books. We knew we were going to have to use the C-arm (x-ray in the OR), so we talked with orthopedics about using the room with the x-ray. Dave got the case started and found a very angry abdomen. The man had a long-standing, chronic state of inflammation in the area, with dense and difficult adhesions. His pancreas had also been made chronically ill from this as well. It was abnormally firm and had further contributed to the difficult inflammation, complicating the dissection. It took a long time to just whittle the gallbladder down until we could find the main bile duct. Even then, the anatomy was shot. We finally were able to remove the gallbladder and open the bile duct. He was full of various sized stones, and we were able to milk several out of the common bile duct. There were some large, palpable stones down behind the pancreas and near the intestines. And we were able to extract the ones we could feel. It took a combination of milking and gentle use of stone forceps. Finally, we were able to pass a urine catheter down the duct and into the intestines. As far as we could tell, it was clear.

So we went with the x-ray. The only type of x-ray dye available here that is safe in this setting is a type of dye normally used for urology tests. But it works. The patient’s family had to purchase the vial from the pharmacy before surgery – and we only had one vial. We just don’t have anyone who really knows how to operate a C-arm so this procedure (and anything else like it) is always a beating. We also don’t have the proper catheters, three-way stopcocks, etc., to do it easily. So after what felt like an extended Abbott and Costello skit, we finally felt sure there was a big stone still down there. But we were almost out of dye. And when we sent someone off to the pharmacy for another, we were informed that the hospital was all out.

At this point, Duane came into the room to heckle us since we had been at it for such a long time. He mentioned that it would be helpful to have a scope to look down there. Too bad we don’t have a choledochoscope. But, we do have a reasonable quality flexible laryngoscope…. Dr. Wayne Koch, ENT surgeon, had sent it to us. I think he would be mortified to realize that our first real use of it was to stick in some guy’s bile duct. But, we were desperate. I broke out and fetched the scope. The problem is the scope doesn’t have any working channel. If you just stick a scope by itself down there, you’re not going to see anything without some irrigation, and there is nothing on the scope to allow irrigation. So we decided to go side-by-side. We wiped the scope down with a disinfectant and I handed it to Dave. We took some sterile IV tubing and asked anesthesia to plug in a bag of saline. Through the hole in the bile duct we slipped in the scope and the IV tubing, running fluid in. Amazingly, it worked. Dave was able to guide the scope down and into the bowel. As he backed out, he finally saw the stone. Now we had to get it out.

We tried unsuccessfully to milk it out, grab it with forceps, or dredge it out with a catheter balloon. Nothing was working. Finally, I walked down the hall with a scrub nurse to fetch a stone basket normally used for urinary stones. It is a small wire-looking thing that, when deployed, extends a four-wire little hoop basket that will grab a stone. Again, the challenge was how to safely get the thing down where we needed. Normally you would guide it down a channel in the scope, but no doing. We first tried to gently feed the basket beside the IV tubing and scope. But it was too sharp and we were afraid of perforating something. Finally, we took a needle and jabbed a hole in the side of the IV tubing and were able to feed the stone basked inside the IV tubing. With Dave guiding through the scope, we fed the IV catheter down and deployed the basket. It grabbed the stone and we were able to pull it out, albeit with a fearful tug to deliver the beast through our hole. Dave confirmed via the scope that we were clear. The guy did well and we will see him back, hopefully in a week or so, to pull the drainage tube from his bile duct. 

We’ve had several other “bush league” shenanigans here at Soddo. Last Tuesday morning, Dave called me at 0330 about an 18-month-old girl who was in respiratory distress with an aspirated bean. Apparently she had aspirated the bean almost a week ago, but had been languishing in another hospital while be unsuccessfully treated for bronchitis. The kid was now nearly obtunded and struggling to breathe in the ICU. We rushed her over the OR with the video scope equipment and pulled out our rigid pediatric bronchoscope. Actually, come to think of it, Wayne Koch donated this as well. That guy has saved a lot of people here! This thing is a true lifesaver. Basically, it is a metal tube that can be placed in the child’s trachea through which a scope somewhat like that used in laparoscopy can be passed. Additionally, you can attach a ventilator to the tube as well to deliver oxygen and anesthesia. There is also a grasping forceps that slides over the scope and can be passed down the tube and used to grab offending items for removal.

We gave some light anesthesia to the child, but allowed her to keep breathing for herself. Using the same technique to intubate someone, we placed the bronchoscope into the child’s trachea. It was challenging due to the voluminous pus in her throat and gasping, but it slipped in, thank God. I’ve had some babies that are so small the tube almost didn’t fit. Inside, we had to suction out a lot more pus and were finally able to slip the scope down the tube. It was a mess and hard to see, but we finally saw what looked like a bean in the bronchus heading to the right lung. Unfortunately, for reasons we still haven’t ferretted out, the scope wasn’t working well and the vision was really foggy – couldn’t fix it. It took several near-blind grabs, but we finally pulled out most of the bean and the husk. But the bean had been there long enough that it was falling apart. A small little piece was still down there, now in the bronchus heading to the right lower lung. The bronchus was just too small to admit the forceps. We weren’t sure how to get it out.

In a similar desperate grab, we decided to try the stone basket thing again. Except now, there was no room for the IV tubing gig. And we were afraid that the same type of basket was just too big for this space. So we found another stone basket that worked a little different. When deployed, this one extended four little tines that spread away from each other and had tiny little hooks on the end. With it open, you could hug it up next to a stone and, as you close it, pulling the tines back in, it grabs the stone. It might work. Getting it down there was, again, the problem. So we took some suture and tied it onto the scope, so that the stone basket would go down right next to the scope. Unfortunately, the dang thing was so foggy, we couldn’t see.

So Dave suggested our old friend, the laryngoscope. He ran off and brought it in. We lashed it up with the stone basket, the two things tied together, and we attached a camera head to the eyepiece, letting us watch on a monitor. It worked like a charm. I’m telling you, this thing is golden. With a nice, clear picture, we were able to get down there next to the chunk of bean and carefully deploy the stone basket tines under direct vision. One of the little hooks managed to beautifully snare the fragment (which was actually three little bits barely held together by vegetable fibers), and we pulled everything out together. The little girl had a roaring pneumonia, but she responded great to antibiotics and went home about four days later. God was so gracious.

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Here’s your bunny buffer warning. Venture forward at your own risk.

Part IV – Wild and crazy operations

We have had some challenging operations lately. Most are related to having a visiting plastic surgeon and tackling things I wouldn’t normally do.

First is a young woman who came to the hospital with a terrible tumor involving her entire right cheek, half of her upper lip, and most of her lower lip. It was terrible and disfiguring. With Joe’s help, we were able to remove the tumor, including several teeth and a rim of bone from her mandible. The real challenge was putting her back together. Again, we took skin, fat and muscle from her chest (pec flap) and brought it up to her face. This time, we flipped the skin inwards and used it to recreate the lining of her mouth/cheek. We were also able to fold part of the chest skin outwards and somewhat recreate the corner of her mouth. I won’t pretend she looks great (still think mad scientist), but it is a lot better than before. We initially planned to bring up a flap from her shoulder to reconstruct the outside skin of her cheek. But in the OR, it was evident that it wasn’t going to work. With the pec flap in place, the outside of her cheek was now the underside meat of her chest flap. So we harvested a full-thickness skin graft and put that in place. We took the dressing down the day before yesterday and it looks good. Again, not good per se, but better than before. 

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Pre-operative

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Post-operative

We also tackled a poor lady with a huge, fungating tumor on her scalp, in the back right of her head. It was a horrible thing to live with. By God’s grace, it was not invading her skull and we were able to remove it without too much trouble. Again, the challenge was putting her back together. Joe performed a complicated set of flap rotations developed by a guy named Orticochea and was able to get things closed with appropriate coverage. She is doing so well and it is humbling and heart-rending to see how happy she is.

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Pre-operative

 

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After resection and a few days of wound care. Must have coverage of exposed bone.

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Scalp flaps raised to reconstruct defect

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After suturing in flaps and skin grafts

The last I will mention was an absolute beast of a case. This poor woman came with a huge abdominal mass, and was malnourished and miserable. She couldn’t afford to go for a CT scan so all we had for pre-op imaging was the portable ultrasound in our office. All I could ascertain was that it was… well, huge. It didn’t seem to be liver or kidney. But other than that, all bets were off. We explained that we probably weren’t going to be able to remove it safely and that in all likelihood all we could do is biopsy it. But she was desperate and wanted to try.

This is a tough area where I admittedly go back and forth. I don’t want to give up on people too early, but I don’t want to just hurt people either. Sometimes, especially with such poor pre-op work-ups, it is hard to know where to draw the line. But I felt like a biopsy wouldn’t be unreasonable.

We took her to the operating room the day before yesterday and started with a small incision. The mass seemed to be in the retroperitoneum on the left side (back part of the abdomen, behind all the bowel). Feeling around, it was evident that it hadn’t spread throughout the abdomen and seemed somewhat mobile. It felt kind of fatty and there were several other smaller fatty tumors. My initial hunch was that it was a malignant fat tumor. If we could get it out, it probably wouldn’t cure her, but it would certainly palliate her due to its large size. The question was whether or not we could safely get it out. There are lots of dangerous things back there in the back part of the abdomen. I called Dave out of the other room where he was working with Joe on a child with burn contractures to get his advice. Sometimes courage needs a little help. Dave encouraged me to just try, so long as it came easily.

So we started dancing around the edge of it. We started by rotating the left colon and its blood supply off. It took close attention, but it gave way easily enough. Bit by bit, we kept working at it, slowly circling around the thing when one area became tough. Dave eventually came over and scrubbed in to help. At one point, it was dicey that the blood supply to the small bowel was involved, but we were able to clear it off. Eventually, we found what looked like the left renal vein going into it – a very big, very fat, very short renal vein. We moved back over to the outside and felt the kidney. I tried to find a plane between the tumor and the kidney – but it wasn’t happening. Further work revealed that the kidney was definitely abnormal and it felt like hard cancer. So much for my so-called ultrasound skills.

At this point, we felt like full disclosure was needed. Something we could probably never do in the U.S., we asked one of the nurses to go get the family. A few minutes later, one of the family members came into the room wearing OR clothes, hat and mask. We showed him the huge thing sticking out of her open abdomen and explained that we were nearing a crossroads. We felt like we had a chance to get it out, but it was about to get really dangerous. There was a real chance we could get into something terrible and she could die on the table. He affirmed that she did not want to go home with that tumor, even if it killed her. He asked us to try.

I have to be honest with you. Even when you have permission to murder someone, it doesn’t make it any easier to do so. I haven’t been as scared as I was in that operation for a long, long time. And lest anyone think I’m being melodramatic, this stuff happens. I am still haunted by the death of our house worker’s sister after a complication at my hands while trying to remove a huge tumor of her carotid artery.

But God was very gracious. We were able to safely take the renal vessels and avoid other dangerous things. In the end there was gaping cavity where her tumor and kidney used to be and she was missing a fist-sized chunk of muscle in the back, with exposed ribs and spinal column. It took seven hours, but the beast was out. She is doing well so far. Please remember her in your prayers.

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Tumor held by scrub nurse

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Tumor with scalpel handle on top for size comparison

As ever, thank you all for your love and support. God bless you and may Jesus return speedily.

Paul

I was recently given two glimpses of how God may feel.  The glimpses came from my children.  Image

I told you recently that Nathan is a recovering minecraft addict.  Well, I started the weaning process a few weeks ago and he handled it very well.  He can now play in the mornings before his alarm goes off at 7:45 (yes, my children stay in their room until the alarm goes off and yes, I am spoiled) and he can play either at rest time or in the evening, but not both.  The other day he was in his room for rest time and he told me he wasn’t going to play because he wanted to play that evening with his daddy.  When I came into his room after rest time was over, he told me, “I’m sorry mom, I didn’t want to play minecraft, but I did.”  

Ah, Temptation.  

He then said, “Mommy, Next time, I am in rest time and don’t want to play minecraft, will you take the ipod out of my room?”  

In that instance, I felt proud.  Not at something I had done, but at something my child was figuring out.  A life lesson that he would surely learn over and over again – the hard way.  But he figured out that he could beat sin, by removing temptation. 

Temptation. Flee. Every tiny victory counts. 

 “…But as for you, O man of God, flee these things. Pursue righteousness, godliness, faith, love, steadfastness, gentleness. Fight the good fight of the faith. Take hold of the eternal life to which you were called and about which you made the good confession in the presence of many witnesses.” (1 Timothy 6:11, 12 ESV)

The other example, made me sad.  And it came from Lydia.  

She was outside playing with a friend. I passed by them and saw that they had done something they shouldn’t have done.  They picked a cilantro plant out of the garden.  I looked at them and asked about it, they made an excuse.  They lied.  I told them very matter-of-factly do not pull anything out of the garden! Not a flower, not a plant, not a vegetable.  They said okay.  And I believed them.  

About 10 minutes later, I walked back outside and saw them walking by with 10 carrots in their hands, with the roots fresh from the ground.  Really?  Didn’t we just talk about this? And it made me sad.  I was sad, that I had trusted that Lydia would obey, but lied.  I was sad that she knew it was wrong, but did it anyway.  

I saw a glimpse of how God must feel grieved by our sins.  How he is perfectly loving and perfectly just all at the same time I do not understand.  How he has forgiven all of our sins, past, present and future, how it is finished once and for all, I believe, but he must feel a tinge of sadness over sin.

But so often, I do the same thing.  Promise to have more patience.  Promise to focus on God throughout the day and then forget He is here.  And it made me realize God must feel similar when we disobey, break promises.  Sure he forgives us, has forgiven us.  And He certainly doesn’t love us any less.    

Just as these experiences as a parent don’t change my love for my children, even more so, God’s love is unending and unconditional.

“The Lord is merciful and gracious, slow to anger and abounding in steadfast love. He does not deal with us according to our sins, nor repay us according to our iniquities. For as high as the heavens are above the earth, so great is his steadfast love toward those who fear him; as far as the east is from the west, so far does he remove our transgressions from us.” (Psalms 103:8, 10-12 ESV)

Thank you, God for your unending, abounding steadfast love! For sending your Son, to take our punishment. For sending us your Spirit to help us along the way. 

This is Paul; trying to get back into sharing something… anything… with our friends, family, and supporters back home. Becca’s advice is to not worry about writing anything big, but just start with small things.

Though it isn’t small, I want to share how thankful I am for the growing community here in Soddo. It is really amazing how much God has changed the landscape in the last few years. I remember when we first came to Ethiopia; we were supposed to fly over with the Anderson’s, who were in the US at the time. It turned out that Duane was struggling to control his hypertension and had to delay coming by a few months. So when Becca, Nathan, and I landed in Addis, it was a pretty empty scene at Soddo Christian Hospital. The hospital driver met us at the airport and we hung out a few days in Addis with no clue whatsoever about the country, exploring with a few remarkably unsuccessful shopping trips to get essentials. A few days later, Harry Bowers, an optometrist who was serving at the hospital at the time, landed from a trip to Zimbabwe (I think). We were so happy to see him and had a much more productive supply run before heading down to Soddo. For the next few months, it was pretty much just as and the Bowers in Soddo. And Harry didn’t even work in the hospital, doing his work in the separate eye clinic on the hospital grounds.

To look at it now is pretty amazing. Though there are plenty of challenges at the hospital, it is encouraging to see growth and development. And the community has grown so much. I am so thankful for the new families. The Karnes’ aren’t so new now, but I deeply appreciate them both and all they bring. The Gabrysch’s have been a joy. I remarked to Becca this morning while doing dishes how much I miss them (they are in the US right now). Both Jeremy and Christina have been great friends as well as bringing a truckload of needed skills to the work here. The Ayer’s are just plain wonderful. David Ayer’s gentleness, kindness, and godliness convict and inspire me constantly. And Julie and the kids are such a blessing to our community. They are one of the most generous families I’ve ever encountered. And now, after many years of anticipation, the Hardin’s have arrived.

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I am so thankful to have Dave Hardin here, both as a friend and another general surgeon. He and his family are really precious to us. I still remember being hosted by Dave and Karisa when I came to interview for the BUMC residency program while a senior in medical school. The work is still awfully hard and challenging here, but it makes a world of difference to have a friend and partner to walk with. My heart longs for Duane Anderson to get a full-time orthopedic partner for the same benefits and encouragement.

By the way, if there are any orthopedic surgeons reading this – I implore you to pause and consider if this is where your practice ought to be. In addition to satisfying, meaningful work, it is a surgeon’s paradise here. Seriously, honestly ask God if He wants you here.

Anyway, small things. Let me tell you a little about last week. We are in the midst of yet another round of work with national accreditation. Now we have to put together a comprehensive document outlining and analyzing our quality assurance processes (from top to bottom) from an educational standpoint in the program. All told, it will end up being a 50+ page document and will require creating quite a bit of brand new policies and procedures de novo. I do think it will make us better and it is addressing deficiencies that are legitimate. But as ever, it’s a lot of work. This document will then serve as a template for a four to five day audit visit from the authorities. Please pray for all of this. There are elements of this that I can’t articulate in a public place that could be game-enders.

As always! This is one of the incredible aspects of life here that I just never anticipated. For five years now, it has felt like a perpetual dance along an icy precipice, always gazing into the abyss and wondering how long this will last. My greatest consolation is that this seems to be God’s normal modus operandi, stacking the deck so heavily that success can only be attributed to Him.

That isn’t to say, however, that everything is going to work out; at least not how I would define “work out”. This is what keeps the dance so terrifying and exhilarating. God will win, but it might involve our taking a big fall. He is far too big to be boxed in by our expectations or definitions of a win. I’ve noticed that Americans in particular, me included, tend to lean heavily on circumstances and coincidences as a litmus test for what God is going. I’ve listened to dozens of stories in which people have described how God revealed His direction and will to them through a series of coincidences. We tell the stories with a twinkle in our eyes: “I had been praying about this and then I just happened to sit next to so-and-so on a plane who just happened to be reading a book about this. Then a week later this opportunity just happened to come available after…” You get the picture. It’s really kind of weird. You line up a series of what-are-the-odds coincidences and we’re convinced we’ve seen a vision. Never mind how significantly our personal desires affect how readily we notice which coincidences we see…

In this case, I’ve seen what seems to be real growth and development of the PAACS program here in Ethiopia. God really seems to be building something. So my tendency is say, “What are the odds that He could be building all this up to let it fall?” That may well be true, but it might not. God knows, not me. It wouldn’t be the first time that everything looked so right for something, only for it to then crump. I’m certainly not saying I’m hopeless. But it does keep the game interesting! My prayer is that we will keep putting one foot in front of the other in obedience, confident of the final result and victory in Christ, but frankly uncertain of how that will look in the immediate future.

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Ok, I’m not going so well with small things. One advantage of having a couple of gung-ho soldier boys here is that I’m having some positive peer pressure towards physical fitness. My brother Dave and my other brother Dave pitched in and built a PT torture device beside the playground. Hardin has been pulling us into some self-mutilation activities specifically designed to cause global body pain and nausea. What doesn’t kill you…? Yesterday (Saturday afternoon) we were doing some exercises when Ronald, the on-call resident, called me about an emergency case. I could barely breathe to talk with him on the phone. I have no idea what he thought about it. The case was horrible, but it got me an early release from our constitutionals.

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We had a six-year-old little girl who was struck on the head by a tree that had been cut down. She had a closed skull fracture and had significantly diminished neurological function, with lateralizing signs. We took her to the operating room and raised a craniotomy flap and found a large fracture fragment lifted up with brain herniating out of the hole. It was terrible. We removed the bone and cleared away some surrounding bone to allow more space for the release of pressure (which meant more brain pushing out). We tried to carefully remove dead brain with irrigation and suction. Finally we had to just close the skin flap and leave the brain decompressed. We are emailing for advice about further management if she manages to survive. She is still alive this morning, but not much better. Please pray for her and her family. Please also pray for our wisdom and that we would make the right decisions. Hardin and I kind of marveled the other day that, in the final analysis, surgery is actually the easy part of being here!

Love you all,

Paul

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