Orthopaedic Residency Training at Tenwek: It’s a Full Go!

My partner, Dr. Kiprono and I just returned last week from Zimbabwe, where we traveled to take the second half of our fellowship examinations in orthopaedic surgery for the College of Surgeons of East, Central and Southern Africa (COSECSA).  The first half (the written portion), we took in Kenya this past September and both passed.  Hence, we were invited to the COSECSA annual meeting in Zimbabwe for the oral exams, which consisted of eight, 20-30 minute stations in which we examined live patients and were asked a myriad of questions to test our knowledge. 

In short, Kiprono and I both passed and are now Fellows in the College of Surgeons of East, Central and Southern Africa.  Additionally, during the COSECSA general council meeting, Tenwek was fully approved and accredited for higher fellowship training in orthopaedic surgery.  So along with approval by PAACS, the Medical Education Committee and the Board of Governors at Tenwek, and now COSECSA  (with accreditation and fellowship), what this all means is that our residency is officially a FULL GO!!  Tenwek will have the first ever PAACS affiliated-COSECSA accredited orthopaedic residency program in Africa!  Glory to God!

Now all we need are residents (trainees) to fill the first two positions!  As such, this Friday, we will be holding interviews for our first class of residents, and we are praying for God to provide a strong pair (academically, emotionally, spiritually and physically).  The program will be five years in length and so when fully-filled, we will have 10 residents in orthopaedic surgery.  Without outside funding or corporate sponsorship, we will need to raise the funds to sponsor these residents-in-training.  Because of our affiliation with PAACS, residents who are sponsored for training at Tenwek will "give back," year for year, at the end of training, working in areas of most significant orthopaedic need in Africa.  If you would like to become a part of training African Orthopaedic Surgeons for Africa, please join our team and help sponsor a resident (www.wgm.org/orthofund).  Training each resident costs about $20,000 per year. 

When I returned home last week, I told Levi and Claire that my prize for passing my fellowship exam in orthopaedics was 6 billion dollars.  Wide-eyed, Levi shouted something about being a billionaire and buying an airplane.  I then pulled out my wallet and extracted two crisp bills, one for 5 billion dollars and the other for 1 billion dollars, and gave one to each child.  Confused that these bills didn’t look like typical American cash, I explained that these were Zimbabwean dollars, and not worth much (I purchased both bills as a souvenir for 1USD).  Cruel, perhaps…but also a good lesson in the value of money, inflation, and things eternal which all the money in the world could never buy. 

Thanks for your ongoing prayers and support of our family!  We are privileged to serve with you at Tenwek Hospital in Kenya.

Tenwek Orthopaedic Symposium 2013

The symposium attendees from all over Kenya...love the i-Phone pano function!

 The Tenwek Surgery Building auditorium...perfect venue for our symposium. 

Sawbones workshop...Dr. Cabanela demonstrating how to do a total hip replacement using model bones.

Coolest part of the symposium...the live surgery demonstration where video and audio feed was piped live from the operating room to the auditorium.  Here, Dr. Joe Cass is asking Dr. Ray Kim questions while Kim performed a total knee replacement.

Sawbones workshop...Dr. Kim demonstrating a total knee replacement on model bones.

During the days leading up to the symposium, the team operated on some patients with challenging problems!

28 year old young lady with a badly dysplastic hip, now with a brand new hip replacement.

At the close of the symposium, the team was thanked in typical Kenyan fashion, including the rungu, symbol of (orthopaedic) strength and power!

Each attendee was presented with an official "Certificate of Participation" and CME credit was given to attending physicians.

Left to right: Dr. Joe Cass, myself, Dr. Ray Kim and Dr. Mike Cabanela.  Thanks team!

This past week, the Tenwek Department of Orthopaedic Surgery hosted our first-ever, 3-day teaching symposium on hip and knee replacement surgery for surgeons and medical personnel from all over Kenya.  More than 50 people attended to hear teaching, participate in workshops, and see live surgical demonstrations (via closed circuit TV from the operating room to the auditorium) on adult reconstructive orthopaedic surgery.    Two of our three guest speakers, Dr. Mike Cabanela and Dr. Joe Cass, were consultants I had the privilege of working with while I was a resident at the Mayo Clinic in Rochester, MN and the third, Dr. Ray Kim, was my chief resident when I was a junior on the orthopaedic trauma service.  Their teaching was outstanding, and many of the attendees told me personally that this was the best symposium they had ever attended!  We thank God for this special opportunity and that, overall, the symposium was a smashing success!

Emmanuel – God with us

Emmanuel, a 19 years young man, with a painful mass on the back of his leg.

X-ray showing this large osteochondroma growing off the top of his fibula, essentially filling the back 1/2 of his calf.

Removal success!!

Emmanuel was shocked (as were we) at the size of this mass which he lived with, in pain, for several years.

Other evidences of "God with us."  Dr. Dylan Nugent (left), who will join the ortho team (God-willing) in 2015 after he finishes residency, and Dr. Will Moore (right) who joined us 2 months ago, a stellar surgeon, team-member and friend.  (Dr. Kiprono - absent as he was on well-deserved leave after several months of faithful service - often alone - while I was away.)

Will showing "the love" during a femoral nailing.  He loves the big and bloody ortho procedures!

"God with us," as we continue to teach and train orthopaedic and surgical residents.

"God with us," as we continue to care for the myriad of patients who come to Tenwek for orthopaedic care - last week in Wednesday clinic, 137 patients...a new record.

"God with us," as our inventory grows.  The inaugural use of our new Biomet distal femoral locking plates. Huge...

 

Dr. Will, choosing the right plate for the job. 

 

"God with us," as we continue to share the good news of Jesus Christ with our patients.

 

Two days ago, I met (for the first time) a young man named Emmanuel who had a huge, firm mass growing in the back of his leg.  A previous biopsy had confirmed the mass was benign, a large tumor called an osteochondroma, which was growing off the top of his fibula bone.  All that needed to be done now was to “simply” remove this mass, which had grown to the size of a grapefruit (was now enveloping all the major nerves and vessels of his leg), and he would be “cured” of the years of pain associated with it.   

Assisted by Dr. Dylan Nugent, a visiting 4^th year resident from the U.S. with a particular interest in orthopedic oncology, we proceeded, first isolating and protecting the peroneal nerve, then trying to shell out the tumor from the surrounding normal tissue, which proved to be anything but “simple,” as the tumor had grown to the opposite side of the leg, directly behind the tibia, where it was pressing directly into the large vessels that feed the leg and foot.  Our fear was that, in removing the tumor, damage would be done to these delicate structures. 

After removing the tumor and releasing the tourniquet (which allows a relatively blood-less surgical field), we encountered significant bleeding, although not pulsatile (i.e. from an artery), but rather a dark, steady flow (i.e. from a vein).   A small hemostat was used to (somewhat) blindly clamp the torn, bleeding vessel.  After tying off this small vessel with suture, the bleeding stopped, but we noticed the tissue surrounding was thumping at the same cadence of his heartbeat.  The vein we had clamped and tied (a branch of the major vein of the leg) was only a few millimeters from the tibial artery, which was completely intact, without any sign of injury, our hands sovereignly guided by a God who cares deeply for our patients at Tenwek.

After showing Emmanuel the mass (he was completely awake, anesthetized by a spinal), and enjoying his wide-eyed shock at the size of his tumor, I asked him, “Emmanuel, do you know what your name means?”  He responded with an eager smile which belied a deep inner faith.   “Yes,” he said, “it means ‘God with us.’”   Sensing God’s presence throughout the entire procedure, and amazed and humbled by the fact that we serve a God who shows up in times of our desperate need, I said “God was with us today, Emmanuel…He was with us today.”

Since returning to Kenya almost a month ago, life at the Galat house, and in the hospital, has been absolutely crazy.  Between unpacking, settling, changing diapers, organizing the orthopedic storeroom, entertaining guests, preaching, operating, homeschooling, cooking, etc. our lives could probably be described as chaotic, at best, out of control, at worst.   Our days are such a paradoxical mixture of highs and lows, struggle and victory, and good and bad feelings at all the difficulties and challenges we face (“normal” for missionary families, according to Mission Training International).  Yet God’s grace and faithfulness continues to overwhelm us on multiple levels, and more than ever, we are comforted by the fact that we serve a Savior whose name is Emmanuel – God with us.

Thanks for all your love and support of our family!

Karibu Tena Tenwek!

During my whirlwind two week trip to Kenya (having just returned to the U.S. a few days ago), I must have heard the words “Karibu tena Dakari” (meaning “welcome back Doctor!” in Kiswahili) more than 100 times.  It really felt good to be greeted by so many people who (at least) appeared to have significantly missed me while I was away these past six months of furlough, and to experience again the sights and smells of the place that our family has now come to call “home.”   

Two days after arrival, I dropped Jeremiah off for his junior year (!) at the Rift Valley Academy, said goodbye (yet again) and then headed to Tenwek with Dr. Will Moore, newly graduated orthopedic resident (who traveled with us to Kenya) and our new partner at Tenwek for at least the next two years (joining Dr. Kiprono and I, who, I am convinced, had a tear in his eye when he saw the two of us on early morning rounds the following day).

Jeremiah in his new dorm room, with his Vitamix...for making protein shakes, and perhaps a few smoothies for the ladies...

 

Dr. Will Moore with one of his first patients at Tenwek.  I can't tell you how glad I am to have him with us!  Karibu sana Will!!

 

Not operating much over the past months, it also felt good to “be back in the saddle.”   After a long day of surgery, I was greeted with another hearty “Karibu sana” after which I was told about a young man in Casualty who was walking along the side of the road, just a few kilometers from Tenwek, when we was struck by a lori (semi-truck).  I ran into emergency room, and saw a large group of clinicians around this poor man, who was truly a horrific mess.  The impact had caused an “open book” pelvic fracture, accompanied by a large open wound in his groin, a left anterior hip dislocation, a mangled right leg, an open right knee dislocation, a humerus fracture, and a large avulsion of the entire right side of his face.  After several hours of surgery well into the evening (including an emergency amputation and external fixator to hold his pelvis closed), unfortunately, the man succumbed to his injuries.  I couldn’t help but think this man was someone’s son, brother, father, husband.  I certainly don’t miss the senseless myriad of road trauma at Tenwek. 

Pelvic x-ray showing "open book" pelvic fracture, with left anterior hip dislocation.

The following day, Dr. Kiprono and I traveled to Nairobi (with a team of PAACS general surgery residents) to take our written exams for Fellowship in the College of Surgeons of East, Central and South Africa (COSECSA), in preparation for the start of our new COSECSA-accredited, PAACS-affiliated (pan-African Academy of Christians Surgeons) orthopedic residency program.   The morning of this exam, ironically, I received, via email, my results from the American Board of Orthopedic Surgery exam (passed…again!), which gave me a boost to take this African exam (in some ways more difficult with a large essay section, and interestingly worded multiple choice questions).  On the way back to Tenwek, Kiprono and I stopped to view the wreckage of a bus crash which made international headlines just a few days before our arrival in Kenya.  The bus, sorely overloaded with people and cargo, traveling after midnight to avoid the law, lost control on a steep curve, careened over a “guardrail” and rolled several times, ripping off the entire top half of the bus.  42 people lost their lives. Again, hard to process the senselessness…

 

The other Tenwek-PAACS General Surgery residents who traveled with us to take their separate COSECSA exams.  Fun times all stuffed into the Landrover!

Dr. Kiprono and I just after our COSECSA fellowship exam in orthopedics. Glad it's done!

 

42 souls lost their lives...only 26 survivors. 

 

Hair-pin turn on steep slope where bus lost control and rolled several times.

 

Another few busy days at Tenwek were met with multiple meetings with various persons and staff.  Plans for a new Galat guest apartment/ministry area were drawn after midnight, and entered into the approval pipeline for hopeful soon commencement.  Most significantly, the day before I left to return to the states, the Tenwek Medical Education Committee met and officially approved the start of our new orthopedic residency, the culmination of years of vision and planning.

“Karibu sana” became “kwa heri” (goodbye) as my two week trip came to a close, and I traveled back to the U.S., greatly excited to see my family again, especially baby Josie (who, by the way, put on a significant amount of “chub” while I was away).  The greetings will return again, however, as exactly two weeks from today, we all return home, as a family, for our third term at Tenwek Hospital. 

"Chuma" our dog, well cared for by the Roberts family, eagerly awaits the arrival of our full family in a few weeks!!

Baby Josie at one month.

Overall, I am amazed at the sheer volume of incredible things God has accomplished over the past several years since heading to Tenwek in 2008, and these things stand as a testimony of His goodness and grace in the lives people who are so far from deserving.  And per God’s design of “partnership,” all this has been possible only through the prayers, financial support, and encouragement of many people who have joined us in this work to serve the underserved in Kenya.  Thank you! 

If you would like information on how to partner with us in this next term, as there are many areas of opportunity (i.e. sponsorship of new Tenwek PAACS/COSECSA orthopedic residents, the Orthopedic Compassionate Care Fund for financially needy patients, a new housing complex for Kenyan interns and medical students, and/or support of our family) shoot me an email at dgalat@gmail.com! Thanks for all your love and support! 

 

Joy through Suffering

After personally witnessing what Heather describes as “the most difficult labor of the five,” I have been reflecting on a subject that has honestly perplexed me over the years: pain and suffering.   In the weeks leading up to the birth of our new baby girl, Josie Grace, our two main prayers were for (1) a healthy baby and (2) a quick and relatively easy labor and delivery.   With the myriad of potential problems that could possibly occur during pregnancy and delivery, we were so thankful for the answer to prayer #1.  But prayer #2 was a different story, as in the end, the labor was certainly not quick, nor easy.  Heather pre-decided that this birth would be completely “natural” (or un-medicated as it is described in 2013), not because Heather has some amazing pain tolerance (her words) but because of a previous complication from an epidural when Emma was born.  In her mind, the pain experienced during child birth was nothing compared to a week-long spinal headache from a botched epidural.  Levi was also born “naturally” but his labor and delivery were within a few hours of arrival at the hospital.  So we were figuring little Josie Grace would come in the same way.

Heather was admitted to the hospital the afternoon of the 13^th with fairly regular, but light contractions.  After several hours, we decided with the midwife that it would be best to “break her water” to hasten the process.  Shortly thereafter, hard labor began, and Heather spent almost the entire night laboring in the shower, with contractions coming fast and hard.  At 6am, exhausted, the midwife suggested that Heather get in bed so that she might check her progress, and we were distraught to discover that after all that work, she was only 3cm dilated.  “I can’t do this any longer,” Heather whispered, clearly discouraged at the slow progress.  “God help her,” I thought as I had her roll onto her side to continue this trial of labor.  What happened next was quite amazing.  Hooked to the monitor, I was able to see the baby’s heart rate and the onset, strength and duration of each contraction.  Lying on her side, the contractions became widely spaced (approx. 8-10 minutes apart) which allowed Heather to sleep soundly during each interim.  When each contraction came, however, Heather would abruptly awaken and work, with difficulty, through each extremely long and hard episode while I rubbed her back and helped her breathe.  This continued for the next 5 long hours, and what I thought was a slowing of the process with widely spaced contractions, was actually God allowing Heather to rest and prepare for the last “final push.”

When the time for pushing began, we discovered that the reason the labor had been so long (aside from the fact that she was the biggest baby Heather had delivered), was because Josie’s head was turned 180 degrees.  As such, pushing was no easy task either, and after what seemed like an eternity, Josie finally arrived, almost 24 hours after admission, with a massive cone-shaped head from being squeezed through a disproportionately small space.  As the midwife placed Josie on Heather’s chest, her face radiated sheer relief and joy.  “You did it!” I exclaimed, personally trying to hold back my own tears of joy and relief. 

As I reflect on this incredible and almost surreal experience, what impresses me is the fact that God did not answer prayer #2 in the way I thought He should have.  He did NOT deliver Heather from suffering, but delivered her through it.  He did not lessen the pain, make it go away, or even shorten it.  It was all there in its full, visceral, unbelievable “glory.”  But God did provide the help she needed, when she needed it, so that she might persevere until the task was complete.  And the relief and joy that resulted was indescribable.  The analogy to our spiritual lives is striking.  God never promised to shelter us from trials, suffering or pain (contrary to the teaching of many well-meaning, but incorrect Christians).  In fact, Jesus communicated clearly and with absolute certainty that pain would come, and that when it did, it would not be easy.  So where then is our hope in the center of our pain?  Only one place...Jesus.  After all, he had his body scourged, his beard plucked, a crown of sharp thorns crushed on his head, and his hand and feet nailed through to a cross, not to mention being betrayed, ridiculed and abandoned.  And somehow, I don’t think that He was shielded from any bit of that unimaginable pain.  But He persevered through it, overcame, and arose to utter and complete joy.  Jesus, God in the flesh, overcame, and as we put our hope and trust in Him, so will we, and thus, experience that same intense joy that can only come through suffering.  We may not understand it, but we can have the faith to believe God at his Word, that He will cause us to persevere, that (somehow) there is purpose in the pain, and that the end result will be joy unspeakable.

 

Welcome Josie Grace!

 

Heather and the girls, a few weeks before Josie's birth.  With such beauty, why not add another?

 

Long labor (almost 12 hours) and a natural childbirth completely wore out mom and baby (and me, but to a lesser degree).  What an intense, almost surreal, experience!

 

Letting Josie know she is loved by God and by her parents.

 

Heather's sister-in-law (also Heather), took some incredible pictures right after Josie's birth!  Thank you Heather (and Birdie Girl Photography).

 

 

Well hello, rosebud!

 

 

 

 

 

The Galat kids first meeting of Josie.

 

 

Jeremiah with grandpas x 2.

 

 

Emma and Josie.

 

 

Claire and Josie.

Levi and Josie.

 Grandmas x 2

 

 

Going home outfit, replete with clip-on bow.

 

 

 Josie's first passport photo (taken at 2 days old!).  We are leaving for Kenya in just 6 short weeks as a family, to continue the work God has called us to at Tenwek.

 

Thank you for all the love, prayers and support you have given our family!  

 

“Is it worth it?”

After several weeks of intense preparation and (literally) thousands of practice questions, I finally took the written exam for the American Board of Orthopedic Surgery last Thursday (for the second time).   Having already passed this exam directly after finishing residency in 2008, I remained “board-eligible” for the past five years while we continued our work as orthopedic medical missionaries at Tenwek hospital in Kenya.  However, since I have not been able to work in the U.S. for the required two full years in order to sit for the second half of this exam (to become “board-certified”), my eligibility expired; hence, the reason for the distinct pleasure of taking this brutal exam for a second time.  Round three will come in another five years if we continue our work in Kenya, and the Board maintains its policy regarding the requirements for “step two.” 

Post-test celebrations where cut painfully short, as I had to begin collecting all the documentation required for my next certifying exam, which I am scheduled to take in six weeks.  In September, Dr. Kiprono (my Kenyan partner) and I will sit for the written fellowship exam for the College of Surgeons of East, Central and South Africa (COSECSA), in preparations for the new orthopedic residency program set to start at Tenwek early next year.  As part of the “collection process” for this exam, I was required to catalogue all the cases I have done at Tenwek into a master “log book."  As I reviewed each of these procedures individually (1700 in total), I was struck with the severity of the injuries of so many of these poor patients (multiple open fractures, etc.), and sighed at the thought of the workload that awaits me when I return.   Contemplating the recently-re-completed ABOS exam, the upcoming exam in Kenya, and the prospect of returning to significant difficult work, the thought went through my mind, “Dan, is all this worth it?”  

The following day, I received an email from Dr. Shawn O’Driscoll (a good friend and colleague from the Mayo Clinic who had visited Tenwek last November), which reset my perspective.  He had just received a phone call from a patient in Kenya whom we cared for during his visit.  This patient, named Helen, called to let him know that she had fulfilled the promise that she made to him last year after her injury: She would dance at her daughter’s wedding in July 2013.   Helen called just after the wedding, and told Dr. Shawn that she was dancing with all her might, praising the name of the LORD right from the middle of the dance floor!

Helen was one of several women who arrived at Tenwek simultaneously, all from the same matatu (bus) crash.  She and two other women sitting in the second row behind the driver were pleading with him to “slow down,” because his driving was so reckless and they feared for their lives.  The driver rebuked them harshly.  Literally a few seconds later, while trying to pass a semi, the matatu was forced off the road by on oncoming SUV, and crashed into a ditch.  The second row seat (where the three women sat) was not appropriately attached to the floor and was driven by decelerated momentum into the back of their legs, creating six tibia (shin bone) fractures, five of which were severely open (compound), with bone protruding out the front of their legs.  The driver escaped somehow unscathed, and the women pleaded with him again, this time for his help, as they were pinning to the floor by the faulty seat.  But the driver ignored their cries (and all the others who were injured), grabbed his coat, and walked away from the scene of the accident. 

Several hours later, Helen and the other victims arrived at Tenwek (including a patient with a broken and dislocated cervical spine which required surgery).  After several operations, including using local muscle flaps and skin grafts to cover exposed bone, Helen was on the mend, and always upbeat on morning rounds.  Dr. Shawn and Helen formed a strong spiritual bond, and we prayed with her (by her request) daily while she was in the hospital.  It was during this time that she made her promise…she would dance at her daughter’s wedding in July. 

I was blown away (yet again) at God’s patience with me, even in my unbelief at asking myself the “worth it” question.  He provided what I needed (Helen’s story), at the right time (in a valley of doubt), to keep me focused on who matters most (Jesus), reminding me to “run with perseverance the race marked out for me” (Hebrews 12:1-2).   But even so, this is a valid question to ask ourselves, as Jesus himself encourages us all (who would call ourselves His disciples) to consider the cost of following Him (Luke 14:25ff).  And following Jesus can be hard, uncomfortable, lonely, exhausting, alienating, sacrificing, requiring constant faith, and perseverance. But the joy comes in realizing that what we “give up” (i.e. stuff) can’t even be compared to what we receive (i.e. Jesus, freedom, eternal life).  As Jim Elliot (missionary-martyr to South America) was quoted, “He is no fool who gives what he cannot keep, to gain what he cannot lose.”  So, is following Jesus worth it?   Easy?...not always.  Worth it?...absolutely!

All I have it Christ by Jordin Kauflin

(Click to view on You Tube)

I once was lost in darkest night

Yet thought I knew the way

The sin that promised joy and life

Had led me to the grave

I had no hope that you would own

A rebel to Your will

And if You had not loved me first

I would refuse you still

 

But as I ran my hell-bound race

Indifferent to the cost

You looked upon my helpless state

And led me to the cross

And I beheld God’s love displayed:

You suffered in my place

You bore the wrath reserved for me

Now all I know is grace

CHORUS Hallelujah! All I have is Christ

Hallelujah! Jesus is my life

Now, Lord, I would be Yours alone

And live so all might see

The strength to follow Your commands

Could never come from me

O Father, use my ransomed life

In any way You choose

And let my song forever be

“My only boast is You”