My mentor, transgenders and beautiful people

Vandersteen and I have been at it now for three operative days. Each has been filled with cases morning to night with interesting and sometimes difficult operations.

The people once governed by the great Chinggis Khan have been incredible. The Mongols have these beautiful ("hoorhon" in Mongolian) children whom David and I have absolutely fallen in love with. They are very joyful children with high pain tolerance and a quiet toughness not seen in American children. The adults are warm, unassuming and accepting.

Working with David and these children has regenerated my passion for medicine. I really love kids. Sometimes I forget but they are such a joy and Vandersteen is unbelievably good with them. Even in Mongolia where he doesn’t speak a single word completely correctly, the children love him. David does medicine how we should all do medicine: no pretenses, no bitterness toward his patients, out of a desire to improve circumstances of lives otherwise pushed aside. It may sound like he is naïve, but after almost 15 years of practice, this is truly who he is as a person, doctor and friend. It’s been inspiring to work with him again. He certainly lifts my spirits and has re-sparked that fire to really help people.

We’ve done a number of transgender cases. These people often have chromosome or hormone receptor abnormalities causing severe malformation of their genitalia. These problems are really tough in any culture. However, the Mongolian families handle the issue with exceptional grace. We took care of a true hermaphrodite (which means “he” literally has male and female parts). (Pic below)

He noticed his breast starting to grow and already knew his genitalia was not right. His mother and him were so grateful for a diagnosis and for the reconstructive surgery to make him finally look like a male. Many cultures shun and humiliate transgenders, including Americans, but the Mongolians have handled it with care. The families are accepting and appreciate our efforts to make them feel "normal". The smile on this boys face the day after surgery said a thousand words and anticipated a life without torment or uncertainty.

Yesterday, David and I took on a 4 month old with probable Wilms tumor of the left kidney. It was taking up more than half of her abdomen and was visible from across the room.

We were the talk of the hospital for taking on such a large tumor in such a small child. In the US, she would certainly have gotten chemotherapy before surgery to shrink the tumor. However, for Mongols from the countryside, chemotherapy is not a reality. And, honestly, it sounds like the most appropriate chemotherapy drugs are not always available even in UB. So, David and I knew that resection may be this child's only chance at survival. She would likely be dead within weeks without surgery.

The surgery went very well and she is doing great. We had to move all the intestines, the spleen and literally peel the pancreas off the tumor. She started low on blood (anemic) and we gave blood during the operating - though there was almost no blood loss, pat on our own backs :). It is important to check if the patient's blood reacts with the blood we are transfusing, but they can't really do that here. Nori, an anesthesiologist on our team, mixed some blood samples together on the back table in a coffee saucer. Yep, a coffee saucer.

One song that has been part of my morning devotional time has been especially influential on my outlook this week:

"Other side of the world
She is just a few days old
A helpless little girl
With nothing of her own

She is not to blame
for the journey she is on
Her life is no mistake
Won't you lead her to my cross

Won't you be my voice calling
Won't you be my hands healing
Won't you be my feet walking
Into a broken world

Won't you be my chainbreaker
Won't you be my peacemaker
Won't you be my hope and joy
Won't you be my love"
-- Mercy Me

There are so many other stories to tell about traditions, food, Mongolian medicine and friends. I will try to get more of them out sooner than later. We move toward our final day of operating tomorrow. Say a prayer for all the families and children we've had the privilege of serving. I saw Kevin and Pam Block as well today. In fact, we had dinner and it was so great to see them.



If everything we do is absent of Jesus, then this so called love is in vain.

First day in Mongolia

So, I have finally completed a full day in Asia. I need to stop coming to these continents for work :)

Vandersteen in Customs with our surgical gear. Took 2 hours and an act of congress to get these things through congress.


Ulaanbaatar, Mongolia has been as advertised: gracious and graceful people, modern culture meets nomadic traditional Mongol life, poverty versus extravagant, crazy driving, terrible smog, and a Russian hospital. We saw over 50 patients in clinic today (can somebody say "shotgun") and documented each one in pictures.

Here are a couple beautiful kids from "countryside" with their mothers:

Most the pictures are medical (and meaningless to the none urologist) so I will spare you the enjoyment. We saw these children like a factory: they would come in, we would "hear their story" in 30-45 seconds via a translator, look at available x-rays, do a physical exam, and then triage to either surgery, no surgery, or needs surgery but we don't have time this week. After the long day, all the patients and their families were waiting in this dirty hospital to see if we would "pick" them. They were lined up in this hallway and we were passing between them - back and forth - while they watched us, hoping and praying that we would help them.

After much discussion, Vadersteen and I felt the same way: we had to help as many as we could. We put everyone of them on the schedule and turned none away. It will be an extremely busy week, but likely one the most rewarding of my young career.

Some interesting, some not interesting and some silly highlights:

View of city from our hotel.

Vandersteen and I got in a 7 mile run (or as he calls it "jog"). It was just a run. The smog and traffic make running in this city anything but fun - not to mention dangerous. But we survived, saw some monuments and got in some miles.

The "list" of surgeries broken into days for Vandersteen, Hurlee (Mongol urologist) and myself to accomplish this week:

Our operative theater and team. Note, that there are two beds in one room. Yep, we do two surgeries and two different patients in one room. Surgeon dream, but not the safest.

The whole team:

Left to right: Tomoko (anesthesiologist - Japan), Adam Childs (urology resident - Mayo, Minnesota) Yoki (anesthesia resident - Japan), me, David Vandersteen (pediatric urologist - Minneapolis, Minnesota), Keira (recovery nurse - Vancouver, BC), Jeremy Myers (urologist reconstruction/trauma specialist - Salt Lake City, Utah), Nori (pediatric anesthesiologist - Japan)



On a silly note. Vandersteen and Childs going down to visit the underground families. People literally live down in the sewer system of the city and these manhole covers are missing at times. Trouble is, at night you can literally walk right into them.

THE APPLE CORE

An apple core is the center part of an apple. When an apple is consumed, often the core is not eaten as it is woodier, contains seeds, and is sometimes less sweet. In the Venezuelan culture, the core is believed to be poisonous. This remaining part is usually discarded. Evan certainly knows how to discard an apple core and last week he thought the toilet was "the" perfect place to accomplish that. Then he pooped on top of it and flushed.

After days of battling a clogged toilet with every reasonable device, I too, like the Venezualan people, believe the core to be poisonous. The struggle continues...

An Amazing Day Starts with a...

(JOURNAL DATE 3/17/2010)

...run! What else could I have said. And today, unlike any other day in Kenya so far, started in an amazing fashion. Awoke around 5:30 AM and met Karanu (the young surgeon hosting me) to go for a 12 km run. What I didn't know was how amazing those 7 miles would be. We started out the gate of the hospital, through the area of Otiende (in Langata) and into Nairobi national park, which is a mere 3K from the hospital. As we ran on the paths of the national park I was amazed to see the African sunrise over an almost picture perfect safari setting - herds of cape buffalo, warthogs, antelope, zebra and even a few giraffe. And to top it off, one rhino spotted around 7 km. As we came back through the Otiende area, the school children were gathered and were quite excited to see a mazungu (translation: white person, pronouncation: ma-zune-gu). So excited, that they ran with me for stretches yelling to all their buddies "Mbio mazungu" (T: running white person, P: m-bee-o). It was the most amazing run I've ever been on and one I will never forget.

Above are pictures of the bridges over the safari land we ran on when I went back - trouble is, during the afternoon the animals were sparse. I did catch another rhino!

Spent the rest of my day in the surgical theater today and it was "prostate" day. They reserve Wednesday to do most of their open prostate surgery. Basically, make a small incision in the lower abdomen, open the bladder and use their finger to remove the prostate. These surgeries are almost extint in the US as we are capable of the exact same operation with a scope which requires no surgical incisions. Additionally, our patients generally go home the same day or the next. These poor men are in the hospital for 5-7 days. We did 7 prostate surgeries today and they let me do them all after I assisted the first two. It's a simple operation really and nothing compared to the complexity of radical prostate surgery or transurethral prostate surgery (something I am much more accustomed to). By the end of the day, I was completing these in 25-30 minutes skin-to-skin. I really enjoyed it.

Above is Dr. Nyagah and Lydia (scrub RN) completing an appendectomy in a 12-year-old boy.

But that was only part of the day: finished up the day with a couple c.sections, ruptured ectopic pregnancy, torsed ovary, appendix and I was provided the opportunity to teach them an alternative way to divert urine following bladder removal. This was largely successful and the surgeons felt this is something that they could add to their treatment options. However, some of them (there are 3 surgeons here) showed more interest than others. I've already been placed in a box by one of them, who sees my time here as nothing more than lightening the workload. He really isn't interested in practice change, even if it is teachable and applicable. The thing is, as a urologist, I have a very specific area in which I study and can provide them with more insight than their general surgery training. I guess I shouldn't worry about it. I'll let everyone get what they want out of my time here.

As if this wasn't enough for one day, that evening Karanu and I went to Kibera. I had been near it but this was the first time I would travel into the famous "shantytown." My view of life would never be the same. As we entered via a side alley, we were surrounded by children chanting "mazungu! mazungu!" As a mazungu in the slums, I represent many things, but to the children I represent hope. They see white people and foreigners as evidence that their is life outside their sad existence. That people outside of Kibera care and are willing to help. Most of all though, the kids see me as a zoo animal - we are more rare than elephants in these parts and the kids love catching a glimpse. They all know one phase in English - How are you? - and they repeat it over and over no matter where you walk. This is a very unsafe place to be as a foreigner and even for a Kenyan not living in the slums, so Karanu and I walked briskly and I did not bring a camera (this time - I did later). On this trip, I did not speak much to the residents (although I did the next time) but I did meet an artist named Joseph, who was quite amazing. I told him how good he was and that he should paint more of his tribe, the Maasai people, to sell to tourist. (Remember this part because I will see him again in a few days).

The location at which we entered Kibera.

Let me orient you to Kibera. This place is no stranger to tribal/gang violence, riots, drugs, alcohol, sexual immorality, disease and a lot of petty crime. The conditions, in short, were atrocious. Two million people packed into 2 square km with no electricity, no plumbing, no city resources. The residents of Kibera are written off by the country of Kenya and the city of Nairobi. They have nobody to defend them, nobody to stand up for them and absolutely nobody of power that cares about them enough to claim them. So how did it all begin? Well, we can thank the British for that. The British colonized much of the world, including Kenya and the more centrally located Uganda. In an effort to "open up" the interior of Africa in the late 19th century, the redcoats started building a railroad from Mombasa (the coast of Kenya and previous capital) toward Kampala, Uganda (the present capital of Uganda). In the interim, the city of Nairobi was created out of thin air to support this effort and people were "transferred" from northern Kenya and Sudan to build the railroad. When the efforts were completed the Sudanese and displaced Kenyan were given land outside of Niarobi. These individuals have been called nubians and, under the British colony rule, were the rightful owners of the land - their reward for a life of slavery and displacement. As Nairobi industrialized and grew, it became obvious that more and more rural Kenyans would move to the city and the nubians started to offer their land for rent. Many poor rural Kenyans started moving in and building "structures" to live in. The city never brought power, plumbing or amenities and drew the area on the map as a green blob outside the city - funny thing is, the slums are still a green blob on the map today, except the blob is now inside the city. As the structures grew and more people moved in, the Nubins continued to divide the land up, affording each member of the slum less and less space to live in. Today, the average family of 4 sleeps in a 6 x 6 foot room, which may be built from mud, sticks, aluminum or a combination of and the floor is dirt/garbage or concrete (for the lucky ones). And, yes, they sleep on the floor. The British treated this area like Americans treat Native American reservations - do what you want with the land, but we don't feel like providing anything. This worked okay because the Nubins were the rightful owners and even had paperwork to prove it. Eventually, the slum was so large, that it was divided into villages, each with its own "governments" of nubians and many times governed by tribal law (still the case today).

A known orphan in the Kianda village of Kibera. He is taken care of by multiple "mamas" in the nearby housing.

When Kenya gained its independence in 1963, the new government stripped the nubians of their claim on the land but did not really do anything. In fact, the nubians still claim the land, still claim rent from the inhabitants (about Ksh300-700 per month for above described "complex" - $4-7 USD), still govern amongst themselves within the villages and still lobby for the city to acknowledge the area. They want acknowledgement because the fact now is this land is valuable. They can build 5 story apartment buildings here and make a lot more money - of course this would displace millions of people as well. So, why hasn't this happened? Funny thing, because of the years of living here with no city amenities, the people of Kibera merely throw their garbage on the ground. Over time this has led to incredible instability of the hills and ground onto which the buildings would be placed. In fact, Kibera is literally built on a landfill now. Wherever you walk, you are literally standing on garbage and the smell doesn't lie. It is so bad, that during raining season landslides will literally bring down 25 houses at a time and kill hundreds.

It's "cute", but this is the railroad the original nubians help build and it goes right through Kibera and is still active today. Notice the garbage, structures and 13 or 14 year old girl with an infant of her back.

Well, where do you stop...I could go on for days about the place and people I served, but the reality is this, the conditions are worse than you can probably imagine, 50% of 16-25 year-old girls are pregnant, 40% HIV rate, 60% of the children you see are orphaned and rely on a kind stranger or older sibling, the avg resident lives on 45 cents per day, 60% of Nairobi's population lives here and they occupy a mere 6% of the city's land... without clean water...without electricity...without plumbing... and many without hope, vulnerable, becoming prey of radical Islam and sitting on the frontlines of a spiritual battlefield they I didn't know existed before today...

Me in Kibera.

HAPPY EASTER

When Africans get sick...

(JOURNAL DATE 3/16/2010)

...they really get sick. I did rounds, clinic and theater today and noticed just how bad and advanced these disease processes are. Of course, this is likely secondary to lack of finances and access to care for the Kenyans. For one, none of these people have anything close to insurance. In fact, almost 80-90% of Kenyans are uninsured and pay for health care entirely out of their pocket. Second, the majority of Kenyans have limited access to care. They do have public hospitals here, but they are slow, inefficient, and frankly provide substandard care. Most of the Kibera residents we serve at St. Mary's Mission Hospital understand that they will get better care here than at the larger public hospital, Kenyatta Memorial in Nairobi.

Back to the diseases. They see a lot of advanced cancer and most of the medical care provided for this is palliative. Esophageal, gastric and breast cancer is common and often terminal at diagnosis here. Interesting that I've seen so many gastric (stomach) cancers, the incidence in the US getting lower each decade. Also, they often don't stage the esophageal cancer. Unless the patient is very young, they almost make no effort to determine whether or not the patient could be saved with radical therapy. Additionally, there is extremely limited access to medical oncologist in Kenya, with the wait for chemotherapy often extended beyond the anticipated lifespan.

All of this without even mentioning HIV and tuberculosis. The rate of HIV in Kibera is around 40% and growing. This puts a tremendous burden on mission hospitals but also on the communities in which it is spreading. Many children in Kibera are orphaned (literally or metaphorically) and grow up with little adult influence. This has lead to elevated levels of sexual immorality and spread of disease - not only among the teenagers but vertical transmission to their offspring. Kibera has multiple generations of HIV positive families and then the problem becomes cyclic. Doesn't take a huge stretch of the imagination to realize that cycle won't break soon.

All in all, rounds this morning with nothing short of depressing. It's amazing how poor the conditions are and how little hope many of these people have. They are eager to hear about Jesus (and America) but they have trouble grasping why He would provide such acceptance of them with grace and mercy. I just want them to understand ... "To hang between two thieves in darkness, love thought you were worth it". (Nicole Nordeman)

ON THE LIGHTER SIDE OF EVAN

Today (yes, really today) Evan and I went for an inaugural 1-mile run. He begged me to take him running today, so finally I gave in. He was so proud (and so was I) that he actually ran a full mile with me. And not so slow: 12 min and 33 sec. Way to go Evan!!! Guess I'll be signing him up for the kids 1-mile runs now :0

First day...

(JOURNAL DATE 3/15/2010)

...at the hospital and I didn't sleep well. More than a little anxious for the day. Landed at 10 PM last night and off to work at 6 AM today. Met one of the keepers of the guest house, Leah, and she made me an egg to go with some sort of cornflake cereal - which I proceeded to eat with cream instead of milk. Awesome.

The hospital is a REALLY BUSY place. The patients show up at 5 AM and start getting numbers. Patients come all day and go through a triage system, which sends them to the appropriate doctor, nurse or provider. It's basically the busiest ER I've ever seen. The acute care and surgical clinics see no less than 300 patients per day. The hospital is situated on the outskirts of Nairobi (to the SW) in the suburb of Langata and adjacent to one of the largest "shantytowns" or "slums" in the world called Kibera (google it, it is impressive).



Got a tour of the hospital and met most of the staff. There are 300 beds divided up into maternity, pediatrics, womens and mens wards. The hospital has the bare bones needed to provide decent care to an impoverished population: a basic lab, basic pharmacy, x-ray and ultrasound. The wards have 1 nurse for 25-40 patients - guess our nurses have little to complain about. They are not only understaffed, but they have no ability to regulate fluid rates, ins and outs, and maintain dosing schedules. This was most obvious on the pediatric wards, where IV medication rates were impossible to regulate. So much for weight based dosing. The operating room (to be called the theater from now on) consists of three "major" rooms, outpatient surgery room and a "scope" room. I got started in the theater right away. Minimal urology today, just a meatal stenosis and hypospadias revision. Spent most of the day doing ortho, general surgery and cesarean sections. This hospital does 900 deliveries per month and 300 are via C. section. I assisted 2, then was observed doing 2 and then did 2 c.sections on my own. Jet lag was terrible and I had to scrub out and go take a nap at 3 pm. It was embarrassing but going halfway around the world takes an adjustment. Not to mention, an overwhelming sense of being out of place.

The day certainly has made an impression on me. I'm in absolute awe that these people have any hope at all, that they find any reason to carry on, and that they have not been completed corrupted by the horrid conditions in which they live. The slum of Kibera is one of the most awful places I've seen. I'm just overwhelmed today...I'm having trouble understanding how God expects me to reach these people from my "ivory tower"... I can feel the prayers of those at home and will continue to do my own...

Just got...

...here. Wow do I feel out of place. I've been to a few places in this world but never have I felt so far from home. Getting through customs was hardly security and thankfully my ride was there to pick me up. Kenyan roads are 1) backwards (ex-British colony) and 2) treacherous. People line the roads everywhere you go and there are basically zero traffic laws enforced. We got to the hospital grounds (gated community near the Kibera slum, Kenyan prison and a big police station) and the guest house is really nice. However, it is very different than home - open windows with comfortable temps at the equator, cold showers and a huge hairy spider to greet me in the closet.

Well, time for bed under the mosquito net. Super nervous to start tomorrow. Hope God knows what He threw me into...


(picture of my room and bed)