Dan, Heather, Jeremiah, Tory, Emma, Tye, Claire, Levi, Josie, Jane and Ethan

Saturday, November 14, 2015

Sweeter than Honey

Mr. Joseph's pressure sore, in the operating room, prior to sharp debridement. 

After a few days of honey dressings.  Note the wet, white fibrous tissue is completely gone, and the wound beginning to heal with nice red granulation tissue. 

The honey is obtained raw and first strained with a sieve to remove all solids (but not enzymes). Then the honey is diluted with normal saline to make it more manageable.  

Gauze, soaked in honey, used to pack the open wound.  Mr. Joseph's grandson is packing the wound himself after expert training from our wound care nurses.

Mr. Joseph and his grandson, on the day of discharge.  Oh, happy day for all. 

Every once in a while, we care for a patient at Tenwek who defies the “natural order of the expected,” and demonstrates that we serve a God who intervenes and heals according to his sovereign plan.   Mr. Joseph (name changed), an unfortunate man in his 70s, was admitted to Tenwek after a horrible road traffic accident in which he suffered injuries a 20 year old would have difficulty surviving.  In addition to an open left ankle fracture, his left hemipelvis was completely crushed, injuries in an elderly man which would spell almost certain death in our environment.  After thorough washout of the open ankle fracture, given his age and co-morbidities, the decision was made to treat these very severe injuries non-operatively with bed rest.  Due to scarcity of bed space, he was placed on a ward far from orthopaedics, and unfortunately (because of his non-operative status) far from the top of our daily “tyranny of the urgent” list. 

Famous for my overly keen sense of smell, one morning during 7am report, I noted a scent quite different from the normal stench of the wards in the morning (a potpourri of smells too challenging to put to words – more than one visitor has had to sit down during rounds secondary the dizziness).  “What is that horrible (new) smell?” I asked the intern on orthopaedics.  “Do you remember Mr. Joseph?” he asked, looking somewhat forlorn.  The name jogged my memory, and I said “Oh yes…the old man with that terrible acetabular fracture we were treating with bed rest.”  The intern replied, "Yes, that’s right.”  “Somehow he developed a huge pressure ulcer on his sacrum and we transferred him to orthopaedics so we could keep a better eye on him.”  My heart sank as I said, “Let’s go take a look.”

Upon entering his room, my nostrils were completely assaulted with the foul smell of rotting flesh mixed with other unmentionables.  Overall, Mr. Joseph looked ill, on the verge of sepsis, as did his helpless roommates who were themselves enduring the smell in that crowded, warmish room.   Rolling him on his side, a huge pressure sore covering his entire rear-end was revealed, skin eroded all the way down to bone with wet, white fibrous tissue covering the gaping holes.  Only twice in my medical career have I ever gagged…the first was as a na├»ve medical student when the chief resident in general surgery told me to go smell the stomach wound of a patient “so that I would know the scent of pseudomonas infection.”  This was the second time.

The first thought that went through my mind was that Mr. Joseph would never survive this massive pressure sore, and my inclination was to let the family take him home to die.  However, his oldest son completely refused, saying that his father would live, and be completely healed from both his injuries and complications.  After explaining the details to the family, and the length of time it would take to clean up and heal this sore, the first step was to take Mr. Joseph to the operating room for a sharp debridement.  So, later that day, after our normal queue of trauma cases, Dr. Lando and I explored and debrided the wound in the operating room, finding it much deeper and more severe than we had originally thought.  We cleaned it the best we could.  “Now, let’s start thrice daily wet-to-dry dressing changes and hope for the best,” I told Dr. Lando, still with significant doubt that the patient would survive. 

After a few days of dressing changes, the wound looked only marginally better - less smelly, but still with necrotic margins, and lacking healthy granulation tissue (the beefy-red tissue the body forms to heal and close wounds).  One morning on rounds, Dr. Louis Carter, a seasoned plastic surgeon himself in his 70s, who visits Tenwek regularly to teach the residents (and consultants) about wound coverage and care, said, to my interest and surprise, “What that wound needs is a little honey.”  I’m sure my face entirely revealed what my mind was incredulously thinking: “Honey...you’ve got to be kidding!?”  Dr. Carter explained that God made honey not just for gastronomic pleasure and biblical imagery, but also for wounds - that the enzymes and sugar in honey fight harmful bacteria and fungus, and encourage the formation of healthy granulation tissue.  “But it can’t be the highly processed honey like you find in the supermarket,” he said.  “It has to be completely raw, with the comb and bees and everything else in it.”   “Well, what do we have to loose?” I said. 

Mr. Joseph was transferred to the Wound Ward, the finest raw honey was sourced from the local Mau Forrest, and the unconventional honey dressing changes initiated.  Amazingly, in just a few short days, the wound completely turned the corner – the smell completely left, the fibrous margins disappeared, and the most beautiful beefy-red granulation tissue appeared.  Excitedly, we continued the daily changes, and when we ran out of the first bottle of honey, we all exclaimed, “Get honey with even more bees in it!”  Soon, the wound was closing well and the patient was being mobilized to a wheelchair (by now, the fractures totally healed).   Even Mr. Joseph’s grandson, who wants to become a nurse, was trained to perform the daily honey dressing changes. 

After several months with us at Tenwek, wound still open but much smaller and healing nicely, Mr. Joseph was discharged from the hospital.  I saw his oldest son that day with a veritable smirk on his face.  He reminded me of his faith - that God would heal his father as we had together prayed.  A flood of paradoxical emotions washed over me: guilt for indirectly playing a role as consultant in the neglect that caused the wound, thankfulness for Dr. Carter’s inside knowledge of the medicinal value of honey, and marvel that God has the final say on life and death.  

Scripture is full of imagery related to honey, and the parallels with Mr. Joseph's story are astounding.  God’s just decrees, when believed and obeyed, are said to be sweeter than honey (Psalms 19:10).   Gracious words are said to be like “a honeycomb, sweetness to the soul and health to the body” (Proverbs 16:24).  God's gracious decrees, His promises, bring healing and life to foul wounds.  And, at the end of time, those who put their hope and trust in God will enter the ultimate Promised Land, a Land flowing with milk and honey - perfect healing for our wounds, and victory over death - purchased by the precious blood of Christ shed for us on the cross.  Grace, forgiveness, healing, hope, life…sweeter than honey.

Thanks for all your prayers and support for our family!

Saturday, October 3, 2015

Meet the Nugents

The Nugent Family: Dr. Dylan and Jessica and their four boys, Eugene, Darby, Asher and Tobey

Josie was enamored with Asher, although it was not reciprocated.  "Stop looking at my puzzle." 

Jane was a hit.

Dylan is a self-proclaimed "baby whisperer."  Actually, he is...

During their tour of the western U.S.  

Tobey and Jane.  Is it culturally appropriate in the U.S. to still arrange a marriage?  

In February 2013, I received a random email from a 3rd year orthopaedic resident from the University of Florida in Jacksonville whom I had never met.  The email entitled “The Road to Medical Missions” from Dr. Dylan Nugent, explained that, through a series of interesting events, his wife Jessica found our blog and together they read through it in the evenings.  They were amazed at the similarities between our families, and Dylan conveyed how God had been developing their sense of calling to medical missions.  Long story short, that initial email led to phone calls, meetings, and finally a 1-month visit to Tenwek in October 2013.  During that time, God fully confirmed Dylan and Jessica’s call to long-term orthopaedic missions with us at Tenwek.  Dylan recently finished his residency training, passed part 1 of the Boards, and they are now in their final preparations to leave for Tenwek next month under a dual appointment with World Gospel Mission and Samaritan’s Purse.   

Dylan and Jessica, their 4 boys, and Jessica’s mother recently visited us in Phoenix for a week (as part of a several week post-mission-training tour of the Western U.S.) during which time we “talked shop,” ate well, planned for the future, and prayed.  Our mutual, prevailing, strong sense was that God ordained this partnership as the direct result of prayers long prayed before we ever met.   Now, along with our Kenyan partner Dr. Kiprono, we are a “threesome,” one short of what I would call the Tenwek Orthopaedic “Dream Team.”  Any other readers interested?!

Please pray for the Nugent’s as they pack, say their goodbyes and leave for Kenya on November 16th.   Pray for grace to adjust to a new culture, a new practice, a new home (essentially, a new life) and that God would preserve them for many years to come! 

Ephesians 3:20-21: “Now to him who is able to do far more abundantly than all that we ask or think, according to the power at work within us, to him be glory in the church and in Christ Jesus throughout all generations, forever and ever. Amen”

Tuesday, September 8, 2015

Newness and Renewal

Heather was induced because she was diagnosed with Intrauterine Growth Restriction (IUGR) and her OB did not want to going past her due date (because of increased risk of still birth).  Here, I am helping Heather through a contraction (or sleeping...can't remember).  The interns and residents thought her water had broken, but in reality, it hadn't.  So after "laboring" for almost 24 hours, her OB "broke" the water, and real labor began...Jane was born 45 minutes later.  Ahh, teaching hospitals!!

Jane was predicted to weigh less than 5-1/2 lb.   God answered our prayers and she came in at 6 lbs, 14 oz. and perfectly healthy!!  So much for this diagnosis of IUGR!

Levi, although he wanted a little brother, was so happy to meet Jane. 

Poor Josie's face communicates the fact that she is no longer the queen.  I love my girls!!   Lord help me!

Two sets of grandparents.  Thankful my parents were able to come and meet their 28th grandchild!

Levi, Emma and Claire on the first day of school at Veritas Preparatory Academy.  I cannot tell you how thankful I am that my two teenage daughters have to wear uniforms!!!  It curtails so much potential drama!

Jane is pretty much held all the time.  I'm hoping she'll be quite well adjusted as an adult with all this love!

Fully content...

One of the unexpected blessings of this year will be more time with Jeremiah before his next phase of life (and because he is an awesome chef).  He has applied to the US Naval Academy, and is currently working towards his congressional nominations.  I am sure he would appreciate your prayers for God's provision and direction!

This picture captures Josie and her expressions around Jane ALL THE TIME.  She continually giggles and shouts "Jane loves me!"

The recent Galat family events could surely be described in one word: “newness.”  In the last few months, we transitioned Stateside for several months of Homeland Ministry Assignment (HMA), graduated our oldest, Jeremiah, from RVA and got him settled into classes at Arizona State University, had our 6th child, beautifully healthy baby Jane Kathyrn Galat (her name meaning God’s pure and gracious gift), and started our three middle children (Emma, Claire and Levi) in a new school in Phoenix.   Heather and I feel like we live between two worlds (…or five) with our kids spanning such varied ages and life experiences: college, high school, middle school, toddler and newborn!  This, all the while living literally between two worlds: Kenya and the U.S.  There are times when I wake in the middle of the night, and it takes me a few seconds to recall exactly where (and even who) I am.   I remember my mentor at Trinity Evangelical Divinity School, Dr. Paul Hiebert, a long time missionary to India, saying that the call to missions is like a call to cultural schizophrenia.  We can relate on multiple levels!

But even in all this blessed “newness,” God has been leading us to pray for one thing for our family: “renewal.”  Why? Because we came back from Kenya feeling tired, disheartened, and worn, in large part because of all these major family changes/stressors, but also secondary to the major events of the last two years at Tenwek.  God heard these prayers and, as he often does, began to answer in mysterious and miraculous ways, drawing us to drink more deeply from His word and seek Him more earnestly in prayer.   When Heather returned to the States in June, concerned about homeschooling our kids during this time of HMA, she made applications for Emma, Claire and Levi to attend a relatively new classical charter school here in Phoenix, just a few blocks from where we live.  All summer long, all three kids were way high on the wait list (more than 100), until (of course) the day Jane was born, when we received an email that Claire had been accepted.  The following day, we received a second email that the school's offer had been rescinded because we did not respond in a timely fashion.  You can imagine our surprise when we finally got around to checking our email again after returning from the hospital!

Not wanting to miss a possible opportunity for our kids, I called the school, and told them the reason we didn’t respond in a timely fashion was because…well…we were having a baby (akin to “the dog ate my homework”).  They believed my story and graciously reopened their offer for Claire.  Long story short, after Claire was accepted, Levi and Emma jumped to number one on their respective class wait lists, and within a few days of having a baby, all three were in school.   These events happened so quickly (and around other major life events), that I struggled to process what all this would mean for us as a family, and for our lives and ministry at Tenwek.  But what God made clear though this unexpected gift (especially for Heather having a new baby) was that we would need to extend our HMA by a few months so that our kids could (at least) finish this school year before heading back to Kenya.  Could be this the beginning of our prayers for renewal?

The state of orthopaedics at Tenwek is such that the team needs me back yesterday, not next summer.  And I struggle wanting to faithfully balance the needs of my family with these huge needs at Tenwek.  However, we believe that God is leading us into what we have been praying - a season of renewal - so that we can go back to Kenya stronger, more compassionate, and better equipped to love deeply.  There are still several unknowns.  I would like to work while I am in the states to keep current with orthopaedic technology and skills, and I am still praying for God to miraculously provide a way for me to finish my board certification process.  He knows the importance of such things.  Would you please join us in praying for renewal for our entire family, for strength and wisdom for Dr. Kiprono and Dr. Dylan (who will be joining the team soon) and for God to provide the means by which I can work and finish the board certification process?  Thanks, and God bless you for your ongoing prayers and support!

Monday, June 1, 2015

Word and Deed

In the operating room, the right shoulder with bone-destroying mass which fungated through the skin and became a large, pus-draining wound. 

The incision for a forequarter amputation.

The day after surgery still sick, but feeling better. 

The second day after surgery, Andrew felt significantly better, as the source of pain and blood infection had been removed.  We are praying that the cancer margins are clear and that it will not recur.  

Last weekend, while enjoying some time off with my family, I received an unexpected page from a visiting surgeon.  “I have an odd case I want to run by you,” he said apologetically, knowing I was not on call that night.  “An 18 year old boy presented to the emergency room tonight with a huge mass and an open wound on his right shoulder,” he said.  “He appeared very sick, with a white count of more than 20,000, so I took him to the operating room for a debridement, thinking this mass was secondary to an untreated infection…but we encountered significant bleeding which was very hard to control,” he continued.  Hearing this history, my mind went immediately to a condition we see frequently here, but only very rarely in the US: a highly aggressive bone cancer called osteosarcoma.   After explaining my opinion to the surgeon, he admitted that not once in his 25+ years of practice in the U.S. had he even seen an osteosarcoma, let alone one so advanced that it had fungated through the skin.

The following morning on rounds, I met Andrew and was surprised to find a young and handsome (yet sick appearing) man with excellent English.  He relayed that he was a college student studying computer science.  However, this mass has grown so aggressively painful that he found it difficult to attend classes.  Finally, when the cancer broke through the skin and became foul-smelling, the instructors asked him to leave and seek treatment.  I explained to Andrew that his x-rays showed the entire shoulder joint had been destroyed and that with the superimposed infection, with increased white blood count and high fevers, (really to save his life) the only solution was to remove the entire arm, including the shoulder blade, to the level of the chest wall, a surgery I had never desired to perform.  

After obtaining consent, we took Andrew to theatre and gave him general anesthesia.  Upon removing the packing, which had been placed in his shoulder to control the bleeding, a bolus of bloody, and very foul-smelling pus gushed from the wound, filling the operating room with a sickening smell.  The arm was prepped and draped, and with the help of Dr. Heath Many (who isolated the large vessels to the right arm), we performed the first forequarter amputation at Tenwek.  While we did not see any tumor during surgery, we did find pus which had tracked all the way to his chest wall.  After washing well with a mixture of bleach and normal saline, I closed the wound loosely over a drain. 

The following day, Andrew looked markedly better and no longer septic, the source of pain and massive infection having been removed.  I sat and talked with him, and he relayed a deep faith in God and a desire to trust Him no matter how his future would unfold.  I prayed for Andrew, and that his heart would be encouraged and that God would completely heal him of this cancer.  The results of the biopsy will be available in approximately two weeks, and if our suspicion is confirmed, he will still need chemotherapy, as a tumor of this size most certainly has metastasized to other areas of his body (although not immediately evident on our workup). 

Even after seven years at Tenwek, I am still routinely amazed at the level of orthopaedic pathology we encounter here.  In the past two weeks, we have seen not one, but four cases of the same type of massive osteosarcoma.  Patients come daily with multi-trauma and open fractures that would rival the busiest centers in the U.S.  And just last week, we recorded our 1500th patient having received a SIGN nail.  But what amazes me more so, is the opportunity this busy service provides to share the love of Christ with our patients.  Yesterday on rounds, after seeing the young men in our open 10-bed ortho ward, I took a few minutes to encourage these men to follow Christ.  While turning to leave, one man said out loud, “If we want to follow Jesus, can we raise our hands while you pray for us?”  Before I knew it, 8 men had their hands high in the air as I prayed for spiritual and physical healing.  Later in the day, I saw 4 of these men outside, basking in the sun, and they pulled me over to enquire about bibles.  The opportunities of both word and deed at Tenwek are unending.   

Thanks for your ongoing prayers and support for this ministry here at Tenwek.  We love and appreciate you all!