Dan, Heather, Jeremiah, Emma, Claire, Levi, Josie and baby Jane

Friday, February 10, 2017

A SIGN for a New Generation

 Orthopaedic residents and consultants from Tenwek and Kijabe.  Dr. John is on the far left.  We are demonstrating the "squat and smile" photo, which Dr. Lew Zirkle, the founder of SIGN, likes to see SIGN patients perform to show they are healed!
Dr. John and I.

AP view of Dr. John's tibial SIGN nail.  The nail goes in through the knee, and travels down the intramedullary canal of the bone, across the fracture to just shy of the ankle joint.  The two screws go through holes in the nail to stabilize and hold the fracture.   
Lateral view.

Teaching ex-fix principles using PCV pipes simulating bones.
The entire group at the PAACS Basic Science Course, Brackenhurst Conference Center, Limuru Kenya.

During one call night in December, two weeks into the national doctors’ strike in Kenya, and with cases stacking up for surgery, I received a phone call from one of the 3rd year orthopaedic residents.   “Dr. Galat,” he said, “you won’t believe this, but your resident, Dr. John Mandela, just injured his leg playing soccer.” “Really,” I said, somewhat concerned, as Dr. John was the only resident on my service at the time.   “He’s in casualty,” he said, “and it looks like he has an open (compound) tibia fracture.”  While heading to the hospital to see Dr. John, I chucked, musing at the irony of personally operating on my only resident.  “You just can’t make this stuff up,” I thought to myself, at the same time thankful for the opportunity to help.

I found John in casualty with a bloody splint on his leg, and, trying to lighten the mood, promptly informed him he was going to have to write all patient notes from his hospital bed.  Thankfully, we were able to take him to the operating room that same night to wash the open wound, and stabilize the fracture using a SIGN nail.  SIGN Fracture Care International is a not-for-profit company with a vision of “creating equality of fracture care throughout the world.”  They do this by providing nails to a network of SIGN surgeons in more than 300 SIGN programs in 53 developing nations.  To date, more than 180,000 patients have been healed using the SIGN intramedullary nail, and between Tenwek and Kijabe hospitals, we have treated more than 3,000 patients using this innovative nail.  Now, one of our own trainees has received the very nail he is learning to use to heal others. 

Recently, I saw Dr. John at the PAACS (Pan-African Academy of Christian Surgeons) Basic Science Conference, a two-week intensive course for 1st and 2nd year surgical residents from all over Africa.   I was amazed to see him walking without a limp, just 6 weeks from his date of surgery.   Without the SIGN nail, he would have still been in a heavy plaster cast, walking with crutches, and struggling to get around.  As I watched him interacting and learning with the other 50 residents, I thanked God for this new generation of surgical trainees who are dedicating their lives to helping others in need.  And the PAACS orthopaedic family is growing, as the Kijabe/CURE program will soon join Tenwek to make a total of 16 PAACS orthopaedic residents-in-training.  It is a privilege to be involved in the education of these young, bright, committed African trainees who will be part of the solution to the lack of surgical care in some of the most needy parts of the world. 

Dr. John will return to his training post at Kijabe next week, just two months from his injury.  I told him he failed his rotation on the Galat service, and will have to remediate!   Just kidding…we’ll all be glad to have him back.


Thanks for all your love and support over the years!

Sunday, December 11, 2016

Tragedy and Triumph

Not sure I have ever seen this type of injury.  Open proximal humerus fracture in a boy who fell from a height. 

Levi and Claire majorly stepped up to the plate while Heather was away.  

One of several open fractures admitted this weekend.  




With Heather being in the States for Emma’s graduation from Mercy, and me “moonlighting” as Mr. Mom, my one prayer for this weekend of call at Kijabe was, “God, please make it light” (although skeptical, because I am known as somewhat of a “black cloud”).   I find it interesting how our perceptions of personal “need” are often trumped by God’s higher purposes, as He may have something far greater than our convenience or comfort in mind.  

What started as a light Saturday call quickly vanished after being summoned to the ER to evaluate a woman with bilateral open tibia fractures.   At her bedside was a concerned-looking man with a bloody bandage on his head, holding a baby about Jane’s age.  Two other young children were standing next to him, crying.  “What happened?” I asked the man, as the little baby grabbed my fingers and cooed happily.  “I was traveling with my family and our car broke down last night,” he said.  “We slept in the car and early this morning, my wife and I were trying to push the car along the roadside when a speeding Mercedes Benz crashed into us,” he said in broken English.  His story touched an exposed nerve in my soul, as I considered the senseless injustice of these events in the life of an already poor family. 

While preparing this woman to go to theatre for a washout of her open fractures, I received a text from our medical director which read, “FYI, there’s been a bus accident in the flyover/Chicken Inn area.  We may get a mass casualty in about half an hour’s time.”    I quickly ran home to tell Levi and Claire (my very capable child care specialists) that I might not be of much help with Josie and Jane, and briefly relayed to them the poor family’s story.  Claire quickly responded, “Dad, can I make cookies for that family and the workers in the hospital?”  “Of course,” I responded, encouraged by her desire to participate in her own unique way. 

Afterwards, I walked to the ER to see if this “mass casualty” would materialize, and indeed the ER was already full of first arrivers from this bus accident…and equally full of doctors and nurses ready to help.  Outside, a minivan driven by a very well dressed woman arrived.  She jumped out of her car and shouted “I have an injured man in the back!”  As we opened the sliding door, we saw a man crumpled on the floor of the minivan.  His limbs were twisted and garments soaked with blood from the multiple open fractures sustained just a few minutes prior.  As the team of residents and nurses placed the man on a stretcher, I asked the driver what happened.   “A large bus was overtaking another car, when it collided with a matatu (smaller passenger van),” she said.  “Several people are dead, and this man was the driver.”  The nerve in my soul felt a little more raw as I wondered why such a tragedy even needed to occur.   But, as I walked back into the ER, I was encouraged to see my friend Isaac, the housing manager at Kijabe, with a pair of latex gloves on his hands, helping in whatever way he could as a non-medic. 

After a full day of operating, while trying to exit the theatre to sneak home, the junior resident-on-call met me in the corridor.  “There is another patient for you; an 11 year old boy who fell from a height,” he said, “ and his humerus is sticking out of the skin at his shoulder.”  “Are you kidding?” I answered incredulously, now growing a little tired of the “non-answer” to my earlier prayer for a "light" day.  Before tackling this case, I decided to walk home to grab a quick bite.  On my way, I meet one of the senior ortho residents (who was not officially on call) walking into the hospital.  “What are you doing here?” I asked him.   “Helping with the other ortho cases for the evening,” he said.  “I’ll call you when the next patient is ready to go.” 

Thankful for a little opportunity to recharge, I continued my walk home and pondered two thoughts: (1) there is too much tragedy in the world, and much of it appears senseless, beyond my ability to understand (aka. the exposed nerve).  But maybe my responsibility is not to understand, nor question God’s purposes, but just to be available to help alleviate some suffering in this little part of the world. (2) in the midst of the tragedy, there is also the triumph of people pushed to “pull together” (Swahili word “harambe”) as a team with multivariate giftings, for a cause greater than our comfort…to help the poor and suffering in Jesus’ name, who came to suffer and triumph on our behalf.  These ponderings were solidified as I walked into our well-ordered home to the smell of freshly-baked snickerdoodles.   Levi and Claire clearly didn’t need me all that badly after all!

Thank you for partnering with our family though your prayers and support!


Let us keep hanging onto Psalm 41:1: “Blessed is the one who considers the poor! In the day of trouble, the Lord delivers him.”    

Friday, November 4, 2016

Divine Surgery



My second week at Kijabe, a clinical officer came for advice on a perplexing case of a young, 12-year-old boy with multiple joint pains and fevers.  “I think it’s a case of juvenile rheumatoid arthritis,” he said, “but it could also be infection.”  “Let’s go take a took,” I said curiously, as his lab work showed a markedly elevated white count and ESR, findings more consistent with a diagnosis of septic arthritis.  However, this condition is rarely seen in multiple joints simultaneously, unless the patient also had some hidden source of infection, showering the bloodstream with bacteria. 

When we came to Adan’s bedside, his body was burning with fever, and he looked rather ill.  Everywhere I touched hurt, but the slightest movement of his right shoulder, right elbow and left ankle caused excruciating pain.   A quick aspiration of his shoulder joint with a large-bore needle confirmed what we suspected: pus.  Thus, plans were made to take him to the operating room for urgent washout of these multiple joints. 

In theatre, Dr. John Deng (general surgery resident) and I started with the shoulder as Dr. John Weston (a visiting resident from Mayo) worked on the ankle.  As the capsule of the shoulder joint was pierced, pus under pressure oozed copiously and continued as we "milked" the arm upwards.  After opening the elbow joint, we found the same.  The entire fibrous covering (periosteum) of the humerus was elevated off the bone and a large pocket of pus communicated with both joints above and below.  Dr. Weston also found pus in the ankle, less than the shoulder and elbow, but still present.  Cultures were taken, and antibiotics were started.  Although we weren’t certain why multiple joints were infected, after these thorough washouts, we expected the pain and fevers to quickly diminish.

However, this was not the case.  Over the next 48 hours, this fevers climbed even higher, and his white count was not dropping, despite being on strong antibiotics.  Cultures eventually grew staphylococcus aureus, a common bug for musculoskeletal infections, which was sensitive to the antibiotics he was receiving.  Daily, on morning rounds, I kept hoping to find him better.  However, he continued to spike fevers, and still looked quite ill.  “What are we missing?” I asked the team, as we examined him daily.  Finally, after about a week, one of the nurses noticed a small amount of pus oozing from a wound on the lateral side of his leg, opposite the original incision made to wash the ankle.  “Let’s just take him back to theatre and wash all these joints again” I said, still not convinced we were on to the true source of his ongoing fevers.

In the operating room, after Adan received general anesthesia, I was able to do a more thorough exam.  I noticed that the left thigh was slightly larger than the right…subtle, but notable.  To confirm my suspicion, I stuck a needle in his distal thigh and pus rolled into the syringe.  “This must be the problem,” I thought as I prepared to again wash out the joints and make new incisions to wash the lateral leg and thigh.  As I opened the thigh, I was shocked to find about a liter of pus that tracked in a pocket up to the level of his hip.   “How can so much hidden pus escape the examining eye of so many providers?”  I thought to myself, now fully convinced I had found the culprit of the ongoing fevers.  As expected, over the next few days, Adan’s temperature and white count finally normalized, and he slowly gained strength as he was transferred out of the ICU onto the general peds ward.  We never found the exact cause for his polyarticular septic arthritis and osteomyelitis, but we are thankful that he is on the mend.

The spiritual parallels to Adan’s story are salient.  Hidden sins of the heart, when left un-confessed and un-addressed, continue to fester and cause soul-sickness.   Perhaps even more deadly than the “spectacular” sins, the “small” sins of jealousy, greed, pride, anger, selfish ambition, and unbelief are more easily hidden and, as such, are commonly left untreated.  As a result, they can grow into an ugly abscess, jeopardizing our very life and faith.  Let’s be honest with each other.  We are all sinners and that is why we so desperately need a Savior – Jesus, the great physician.  Only He can perform divine surgery to open the hidden areas and place us on the path to healing.

Thanks for all your prayers and support!

Mark 2:17  “On hearing this, Jesus said to them, ‘It is not the healthy who need a doctor, but the sick.  I have not come to call the righteous, but sinners.’”

Friday, September 30, 2016

Miracle at Kijabe

Samuel, now all smiles!


Original CT scan of the fracture of T7 vertebra. Bone fragments are pressing into the spinal canal, compressing the spinal cord.


Dr. Muchiri did excellent work stabilizing his spine. 



On my first day of work at Kijabe Hospital, I met a 20-year-old patient named Samuel, who had been involved in a terrible motorcycle accident resulting in a burst fracture of his T7 thoracic vertebra.  When he first presented to Kijabe (one week after the accident), Samuel was completely paralyzed from the abdomen down, without any motor and minimal sensory function in his lower extremities.  One of my new partners, Dr. Muchiri, had performed a decompression with posterior instrumented fusion from T4-T10 so that the patient could at least mobilize to a wheelchair.  Now, when I first met him, more than two weeks from his initial injury, Samuel was recovering from his surgery, and physiotherapy was beginning to work with him, teaching him how to live as a person with a new, permanent spinal cord injury.

Samuel’s affect was quite flat when I first met him, no doubt secondary to the realization that he would never walk again.  Spinal cord injuries in Kenya are at best, significantly challenging (as there are no disability provisions or laws in Kenya) and at worst, a “death sentence” (as patients, neglected by family and friends, often succumb to pneumonia, infected bedsores, or urinary tract infections).  My heart went out to Samuel as I was examined his legs, confirming that he was indeed paralyzed.  After my examination, I offered to pray for him, and he readily accepted.  I prayed simply that God would meet him in a meaningful way, and that he would be able to function well with his new condition.

Upon returning from a 3-day trip to Singapore for an orthopaedic training course, while rounding on patients in the morning, the team came to Samuel’s beside, and he was beaming.  “Anything new with Samuel,” I asked, hoping that he had gotten his wheelchair, and was progressing on schedule with therapy.  “Yes,” said Dr. Otido, rather dispassionately.  “He started walking about three days ago."  “What?” I said, looking searchingly at the team, entirely puzzled, as I had never seen, nor heard of a patient who made a complete recovery more than two weeks after such a spinal cord injury.   “Come again…you said he’s walking?!” I asked with emphasis.  “Yes,” said Dr. Okello, the orthopaedic resident.  “He’s been walking with crutches.”  Bewildered, I went to Samuel’s bedside to examine him myself.  I couldn’t believe what I was seeing… he had full sensation in both extremities, and was moving his legs, feet and toes as if he had never been injured (all the while smiling broadly).  I looked back at the team, and said, “This is a complete miracle!  There is no other way to explain this medically!”  Now Dr. Okello was the one looking puzzled.  “Daktari, you know…these things happen at mission hospitals,” he replied.   “Indeed,” I said, still amazed that I had witnessed a modern day miracle.  Later, I came to Samuel, and encouraged him with the truth that Jesus had heard our prayers and healed him.  He fully agreed and affirmed that he was a believer, a member of the Presbyterian Church in Kenya.   

As I have processed Samuel’s case (myself and with other physicians), I am convinced that we have been privileged to witness a true miracle.  There is absolutely no way to explain it medically.  While recovery after such spinal cord injuries can occur, it is usually minimal (e.g. slight improvement in sensation by a level or two), especially in those who have demonstrated almost complete neurologic deficit for an extended period of time after initial injury.  But should I be so surprised?  Is anything too difficult for the One who in perfect wisdom created something as complex as the spinal cord?  Surely, “Who is like you, Lord God Almighty? You Lord, are mighty, and your faithfulness surrounds you.” Psalm 89:8. 

Thanks for all your prayers and support which has sustained us over the years, and enables us to continue partnering with you in Kenya!