Little Black Book

The Little Black Book, a log of all orthopedic surgical cases at Tenwek.

A two year old boy with rhabdomyosarcoma of the hand: one of the sad cases in the book.

An example of "MacGyver orthopedics." A periprosthetic femur fracture fixed with a long plate, screws hand-cut to length and cerclage wires.

The book also contains more conventional cases such as this ulnar shortening for ulnar impaction syndrome.



For those who are familiar with John Piper, one of his books succinctly entitled “Don’t Waste Your Life” is a personal favorite. When we left for Kenya eight months ago, Heather’s parents gave us several items they purchased from John Piper’s Desiring God Conference, including the “Don’t Waste Your Life Field Journal,” a little black book intended for…journaling. I use mine to catalogue all the surgical cases I do here at Tenwek, and the daily reminder to “not waste my life” helps keep the daily challenges in perspective. So far I have filled one book and am now on my second. I lost count at 300 about halfway through the first book.

Most other medical specialties allow for board certification of physicians while doing full-time missions: OB-Gyn, General Surgery, Family Practice, etc. However, this is not the case with orthopedic surgery. The American Board of Orthopedic Surgery bylaws currently state that it is a requirement for prospective fellows to work in the United States for two years before allowing them to sit for the oral boards. Thus, although I passed the written boards last summer, as it currently stands, I cannot be fully board certified working as a busy orthopedic medical missionary in Africa.

However, I also believe God is able to do a miracle, and that is the reason I am keeping my “little black book” of Tenwek cases, in the hopes that some day, the policy may change, and I may be able to sit for my oral boards with cases that I have done while following the call of God here in Kenya. The book is not perfect, including a “few” cases treated in ways non-conventional, what I like to call “MacGyver orthopedics” (the show from the late 80s/early 90 in which MacGyver could create anything out of the most elementary supplies). We do what we can with what we have. On the other hand, we are very blessed at Tenwek to have, what I have been told, the best orthopedic inventory in Kenya, thanks to our friends in the US who are so faithful, behind the scenes, working to secure supplies for Tenwek.

How our culture defines a successful life (i.e. wealth, power, status, education ) may actually be a wasted life. On the other hand, what is viewed as a “wasted life” may actually be the most fulfilling, meaningful, and eternal. Paradoxically, in God’s economy, the path to a life not wasted is by the very act of losing it. The challenge is for me, you, all of us. Thankfully, I have a daily reminder of this every time I write a case in my little black book. Let us encourage each other to not waste our lives.

Matt. 16:25-28 Then Jesus said to his disciples, "If anyone would come after me, he must deny himself and take up his cross and follow me. For whoever wants to save his life will lose it, but whoever loses his life for me will find it. What good will it be for a man if he gains the whole world, yet forfeits his soul? Or what can a man give in exchange for his soul? For the Son of Man is going to come in his Father's glory with his angels, and then he will reward each person according to what he has done.

Harvest Time

Kenya, being a climate which I would classify as “perpetual springtime in Ohio,” enjoys a year round growing season. And although July is the peak of summer fun in the Midwest, in Kenya, it is actually the “coldest” month, with highs in the upper 60s and lows in the upper 40s. Thus, this is the time of year for harvesting maize. And, after a busy week of moving into our new “temporary” housing, and a caseload of almost thirty surgeries, what better way to relax and spend a free Saturday than harvesting maize?

Maize is a critical crop for Kenya, because it supplies the brunt of the caloric energy for daily living in rural Africa in the form of a pasty, tasteless starch called “ugali.” Maize (or corn) is planted, harvested, dried, and ground into a fine meal, then boiled in water, without salt, until it becomes a firm, starchy mass of pure carbohydrates, and the perfect accompaniment for every Kenyan meal. After tasting ugali and out of curiosity, I have asked many Kenyans what, in their opinion, is so special about ugali. Answers vary, but the common underlying thread is that “ugali fills the belly.”

So when Peter Ronoh, our outstanding maintenance man, invited us to his “chamba” (farm) to harvest maize, we were honored. Sarah Galat (our new niece-in-law) and her mother Cindy (a nurse anesthetist), who are currently visiting from Ohio, came as well, and we all had a ball, hand picking and shucking corn and tossing the ears into large piles. It was actually therapeutic, and downright fun. Afterwards, we all enjoyed a cup of hot chai with a large scoop of sugar.

Two thoughts went through my head as I was working in the field. First is the scripture from Matthew 9:37-8: "The harvest is plentiful but the workers are few. Ask the Lord of the harvest, therefore, to send out workers into his harvest field." In addition to our family, about 20 or so of Peter’s neighbors came to help harvest his maize, out of their own free will, without even being asked, or expecting anything in return. They just showed up. With all the help, in less than three hours, almost an entire acre of corn had been handpicked, the job complete. The spiritual harvest is not so, however. According to Jesus, the harvest is plentiful but the laborers are few. If more were willing to just “show up,” would the spiritual work be done?

Second, I asked Peter what he was going to do with all this harvested maize (incidentally a “bumper crop”). “Are you going to sell it?” I asked, in my mind, thinking what the income could buy: schooling for his kids, an addition onto his miniscule two room house, maybe a new dress for his wife, or a few other luxury items. “I would,” Peter answered, “but I get afraid of my kids going hungry if I don’t save enough.” How many of us actually worry that we won’t have enough to eat, even with the downturn of the economy? Incredibly humbling words as we drove back to Tenwek, and prepared a supper of BBQ beef sandwiches for a visiting work team. No room for plain old, bland ugali in our house...

Thanks for your recent prayers and email encouragements. We really depend on your support of the work here at Tenwek. Please let us know how we can be praying for you as well. And please keep Alex (our nephew, and Sarah’s husband) in your prayers, as he is on tour with the Air National Guard in Afghanistan for the next six weeks.

New Family Addition and Other News

New Family Addition

Poor Emma has been begging for a dog since she was 4 years old. Her persistent requests have always been met with my standard, deflecting answer: “Keep praying and asking God for the right dog.” Well, it seems as if God heard Emma’s prayers, and at the same time, desired to teach me a lesson in giving pat answers. On Sunday, we brought home “Samson,” an extremely malnourished, flea-infested, and likely mistreated puppy, from one of the local orphanages. After three baths and several flea-dips he is finally cleaned up, and becoming more animated every day (from much love and attention). He is actually pretty smart, and as an outside dog, already knows to do his business in one area of the grass! Things with the other Emma (the White’s boxer dog who officially rules the Tenwek compound) are not so hot, however. Just today, dog Emma went directly to this “area” and overrode his business with her own. She’s the boss.

Total Hip Replacement at Tenwek

Last Monday, the first total hip arthroplasty with Kenyan obtained components was performed at Tenwek. Thanks again to Keith Braun who was here to offer moral support, and sweat with me as I cemented in the acetabular component (the plastic socket). The patient has done very well and now is up and about with minimal pain in her hip. We thank God for his incredible faithfulness and favor in allowing us to offer this service for patients at Tenwek.

Prosthetic Limbs at Tenwek

God continues to bring the right people at the right time. Allen Dolberry, a prosthetist (person specializing in the manufacture and fitting of artificial limbs) and his wife Kim, have been at Tenwek for the past month using their skills to serve the poor. Amputations are viewed as a death sentence in Kenya because of the lack of ability to fit prosthetic legs. During the last four weeks, Allen has custom-manufactured and expertly fitted 22 legs so that people without hope can walk again. It is amazing to see people take steps for the first time in years!!

Joint Replacement Surgery in Rural Africa?

The vast majority of orthopedic surgery at Tenwek is related to trauma: motorcycles, Masai swords, pangas (machetes) and similar instruments of pain and suffering. Often, the patients that present with these injuries are very poor and unable to pay their hospital bills. Since coming to Tenwek, Heather and I have been praying for ideas to provide a means to subsidize the care for the poor and help the hospital financially. Joint replacement surgery has been at the top of the list, although this seemed like an incredibly far off possibility in rural Kenya. As in the US, many people suffer from knee and hip arthritis here. But joint replacements, while common in the US, are performed by only a handful of surgeons in Kenya, typically only in big cities like Nairobi, and fetch a high price.

Knee and hip replacements have been done at Tenwek by visiting joint replacement surgeons in the past, with components donated from the United States, thankfully, most recently just last month. However, with the new stringent rules set forth by the US Department of Justice for implant companies and surgeons, donated implants and supplies are becoming more and more difficult of obtain. So, since coming to Kenya, I have been looking for a local supply of implants for purchase (both trauma and joint replacement), in order to reduce our dependence on donated supplies from the US. Sovereignly, while at the Kenya Orthopedic Society Meeting in Eldoret last March, I was introduced to Rose, a Kenyan lady representing DePuy (a division of Johnson and Johnson), who distributes orthopedic implants in Kenya.

In short, last Monday, we performed the first total knee replacement at Tenwek with components obtained locally in Kenya! Our first patient, “John,” is a very enthusiastic and animated former English teacher who, aside from a little pain with urinating from a Foley attempt gone bad, did very well. I was thankful to have Keith Braun (a visiting orthopod from Mesa, AZ) here to share the moment, and he, at one point, said “Ernie Steury (the first physician at Tenwek) could never have imagined this.” And, next Monday, we have our first total HIP replacement scheduled with local components! We are amazed at the speed at which God has answered our prayers for the start of an ongoing total joint replacement program here at Tenwek as a mean to help subsidize care for the poor! And selfishly, I am excited because joint replacement surgery is what turned me on to orthopedics in the first place.

Please pray that God would continue to bless the orthopedic department at Tenwek, and that the joint replacement program would assist with the overall care of the poor, and viability of the hospital. Pray that our patients would have good outcomes and that God would be glorified through this new work, and that many would hear the good news as a result. Thank you for all your support!

Psalm 113:5-8 Who is like the LORD our God, the One who sits enthroned on high, who stoops down to look on the heavens and the earth? He raises the poor from the dust and lifts the needy from the ash heap; he seats them with princes, with the princes of their people.

Psalm 140:12 I know that the LORD secures justice for the poor and upholds the cause of the needy.

Road Trip to Eldoret: One Body, Many Parts

Photo op with Dr. Lew Zirkle, founder of SIGN (second from left), and Dr. Lelei, the chairman of the Moi Orthopedic Department (right).

On the road to Eldoret...

Stephen demonstrating his surgical prowess (and lack of restraint) with Dr. Zirkle and I in the background.

I think every man enjoys a good road trip, so when I was invited to attend the demo of the new SIGN hip construct device in Eldoret, it was difficult to turn down. Stephen, Mwangi (the most current visiting orthopedic resident from Moi University), Keith Braun (a visiting surgeon from Arizona) and I piled into the van and, fueled by beef jerky, Costco trail mix (luxuries from the US) and diesel, we made the 4 hour dusty, jarring journey through the famed tea fields of the Kenyan highlands. After chai (tea) and mdazis (little fried doughnuts) at Mwangi’s apartment we checked into the “4 star” Grand Prix Hotel (from the name, you have to know it is fancy).

Eldoret, north and slightly west of Tenwek, is home to Moi University, which has a large teaching hospital, medical school and brand new orthopedic residency program. Tenwek began hosting Moi orthopedic residents in April, which has been mutually beneficial: we provide qualitative (and of course quantitative) training in orthopedic trauma, and the residents provide a much needed helping hand. By God’s grace, this relationship with Moi is growing and strong. Dr. Lew Zirkle, the founder of the SIGN company, which designs and manufactures implants for use in developing countries, was at Moi demonstrating a new implant he developed for hip fracture patients, hence our invitation to attend. Much like the intramedullary nails developed for femur and tibia fractures, the SIGN hip construct is designed to be placed without the use of fluoroscopy, but it has a steep learning curve. Dr. Zirkle would like Tenwek be one of a few institutions to trial the new implant. It was an honor to meet a man dedicated to serving the world’s medically underserved in the unique way for which he was designed by God.

Because RTAs (road traffic accidents) are in no short supply around Tenwek, mainly due to dirt cheap motorcycles from India, no licensure requirements, and improving roads that allow excessively high speeds (it is difficult to go fast when the road is full of pot holes), our trip to Eldoret was cut short to two days…otherwise the cases would just continue to pile up. Thus, after returning late Friday afternoon, the whole of Saturday (12+ hours – only a “half day” as my dad used to say) was spent in the operating room catching up, and treating new admissions. The work load continues to increase, and even with help from visiting residents and surgeons from the US, we are overworked and, at times, overwhelmed.

In what way have you been uniquely designed for God’s purposes, for the service and glory of His Kingdom? If we want to finish well, and live a life of true meaning with eternity in mind, I think this is an important question to ask. It may seem small, the part we are called to play, but like a thread, it is woven into the tapestry of divine history. Find that calling, and by God’s grace, excel in it for Christ’s glory.

The body is a unit, though it is made up of many parts; and though all its parts are many, they form one body. So it is with Christ...But in fact God has arranged the parts in the body, every one of them, just as he wanted them to be...Now you are the body of Christ, and each one of you is a part of it. (1 Cor. 12:12, 18, 27)

Please continue to keep our family in your prayers. We need prayer for strength to persevere, wisdom for the complex cases that present, emotional health to minister to the people that God brings into our lives, and for unity as a family, for Heather as she continues homeschooling, and as we move into new temporary housing next month. Also pray that God would continue to bring short (and longer) term orthopedic visitors to Tenwek to participate in the work, educationally and spiritually, that God is doing here. Thanks so much!

Holistic Ministry: Long term at Tenwek

Gently used lead aprons recently donated to the orthopedic department.

Chronically dislocated ankle...a challenge to reduce.

Dr. Kisorio and Josh Carter, performing a tibial SIGN nail.

Jeremiah's favorite Jackson's Chameleon appropriately named Feisty.


Prior to medical school, Heather and I spent two years in the Chicago suburb of Deerfield, where I attended Trinity Evangelical Divinity School. While I started with the idea that I would pursue a degree which would prepare me to be a pastor, the end result was far from expected. Through a series of sovereign events, including Heather landing a sweet job in the Missions Department, God resurrected a past dream I thought was long dead (medicine) and combined it with a present calling (missions) to provide a new hybrid vision: Medical Missions. As a culmination of the education at Trinity, I was required to write a final integration paper which I entitled “Holistic Ministry and Medical Missions.” The main premise was that ministry which was most effective was not only “incarnational” but also “holistic” in nature, that is, meeting the needs of the whole person: physical, emotional, cultural, and especially spiritual. Medicine provides a unique opportunity to minister to the physical needs of people, especially the poor, as Jesus has great compassion on, and healed, the sick and needy. But his message never stopped there, the healing serving as a segue to the true need of all people: spiritual healing.

The patients who come to Tenwek for orthopedic care are varied: male, female, young, old…some with acute injuries, others with chronic…some with injuries secondary to foolish decisions, others injured by no fault of their own. The common denominator however, regardless of the etiology, is a need for physical help, which Tenwek is thankfully equipped orthopedically to provide. Thus, our days are spent fixing what is physically broken, using plates, screws, rods, pins, saws, cement, etc. I would not say, however, that this is our primary reason for existence at Tenwek. Although the fixing of broken bodies is of inherent value, if the spiritual needs of the patients are not being addressed, then all we do is merely humanitarian in nature. Rather, we have the opportunity, and responsibility, and privilege to ask patients if they know Jesus, if we can pray for them, or meet their spiritual needs in some other way.

Being at Tenwek provides the opportunity for wide variety of ministry opportunities, and allows us as a family to fulfill the calling of holistic, incarnational ministry. While our work is primarily medical, we are also able to communicate the gospel, teach, preach, lead worship, disciple, and minister to the needs of the poor. I had mentioned a few blogs back that we were praying about God’s plan for our family long term at Tenwek. While the last six months have been full of many challenges, both Heather and I feel that we are to remain and continue at Tenwek beyond the two-year commitment with Samaritan’s Purse. Committing to stay long term presents us with many other new challenges (transitioning to a new mission agency, building a house, etc.) for which we would greatly appreciate your prayers. But, we feel that God has sovereignly and very clearly opened the door for us to be here at this point and time, and we have the responsibility to stay until it is just as clear that we are to be elsewhere. At Trinity, we made the commitment to pursue medical missions full-time as long as God directs, and as he continues, so we will remain. Thank you for all your encouragement and support over the last several months. We appreciate you so much!!

Six months at Tenwek: Highs and Lows

The sole cause of chronic neck pain in Africa.

Heather, Anna and Bryan.

Dr. Kisorio and Stephen with studious patient who daily reads the newspaper.

"Positive Kisii sign."

A daily reminder that without God there is no way....

Humor is often a healthy means of dealing with daily stress and this is certainly the case for me here at Tenwek. Sometimes you just have to laugh, and as a missionary, this is most often at yourself. One thing I find amusing are the various signs I see erected around Tenwek hospital. Our newest sign, which is posted just beyond the back entrance to the hospital, greets me every morning. It simply reads “No way.” I understand the intended meaning which is “please do not walk on the grass…stay on the sidewalk.” But instead it taunts me daily, simple writing on a wooden placard, reminding me that there is no way I can continue to serve the relentless onslaught of orthopedic patients at the hospital…no way except by the certain grace of God, who continues to provide strength, wisdom, and refreshment at just the right time. I can do everything through him who gives me strength. Phil. 4:13. Another sign was recently posted adjacent to a broken floor drain directly outside my operating room, in order to protect people from stepping into the small opening. It read “Warning. A hole ahead.” I chuckled to myself, wondering if they where referring to me, or to the actual drain hole.

We have now been here six months at Tenwek, and what has amazed me is variability of emotion which has been experienced, by both Heather and me. The spectrum is wide, with the highs high and the lows low. Certainly the biggest joy has been the fulfillment of the calling that God gave us over 17 years ago. Although there were rough patches along the way that threatened to derail the plan, God, by his sovereignty, remained faithful, and brought us here, despite ourselves. This calling encourages us to persevere and continue, even when we feel completely depleted. The orthopedic department is such that when you think the workload is managed, another four highly complex patients from Kisii District Hospital are admitted. Our most recent patient from Kisii was a 19 year old boy with a “floating knee” (both femur and tibia fractures on the same leg). Normally this is not difficult to treat, one incision in the knee with rods in both the femur and tibia. However, the “positive Kisii sign” (as Josh Carter, a medical student/soon to be orthopedic resident visiting from the states coined) was the fact that the tibia fracture was open, two months old, with a 10 cm segment of exposed, dead, infected, putrid bone. Another man recently admitted at Tenwek suffered bilateral femur fractures over a month ago. After lying in skin traction at Kisii hospital for more than a month, he discharged himself, and headed straight for Tenwek. The irony is that the medical officer made him sign a form that he was being discharged “AMA” which stands for “against medical advice.”

God provides continually. In April, Dr. Kisorio, our first visiting Kenyan orthopedic resident from Moi University arrived, and he has been a great partner and helpful colleague with skills well beyond his years of training. Additionally, Stephen Leimgruber, Heather’s cousin and recently graduated RN, arrived at Tenwek for a minimum one year stint with plans for two, and will be working directly in orthopedics. Stephen and Dr. Kisorio (and future visiting residents from Moi) are sharing a two bedroom apartment furnished by funds donated into our project account. As Paul McCartney and Stevie Wonder sang in the 80s: “Ebony and ivory, living together in perfect harmony.”

Heather would testify that homeschooling and the continual, unremitting needs of the community around us provide her greatest source of highs and lows. Although Heather often questions her ability and effectiveness as a teacher, the kids are learning amazingly. Our curriculum focuses on literature, reading, logic and writing…even Claire, in second grade, writes papers full of rich language. The needs around us are massive, and we have often thought that we could give all we have and still not make any effect. I wrote earlier about Anna, whose house we purchased with funds from our project account. When my brother John was at Tenwek, we visited Anna, who although thankful for the gift from you in the states, still feels the daily pressure to feed her children, and provide for their future as a single mother. We are currently “cow shopping” for Anna, who, with this asset, will have both a source of nourishment and income for her family. Thank you for donating into our Samaritan’s Purse account for needs such as these. There are countless other stories of people who have been blessed, in this way, by your generosity.

What we are reminded of daily is simply this: we need Jesus. In truth, we all do, whether or not we know it consciously, or choose to acknowledge it. We just have the luxury of living in a place where we feel it acutely every day. At times, we feel so inadequate, broken, unworthy, unequipped, and ineffective. But I have the sense this is exactly where we are supposed to be. In this way, paradoxically, the power of God is shown through the cracks, so that God, and not us, is glorified.

But we have this treasure in jars of clay to show that this all-surpassing power is from God and not from us. II Cor. 4:7