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Guatemala 2020 We recently returned from another annual trip to Guatemala with Knoxville Medical Mission. I have had the privilege to make this trip many times and it is always a personally rewarding experience. I missed last year as the dates conflicted with my trip to Kenya, so I looked forward to getting back this year. Our team was comprised of doctors, surgical techs, nurses, an anesthesiologist and nurse anesthetists. Some were returning and for some it was their first time. We arrived late Saturday and screened patients in preop clinic on Sunday. We operated all day from Monday until Friday. We had a busy week and were able to provide surgical care for 69 patients. The patients, their families, and the hospital staff there were very appreciative of our efforts. Comparing the Guatemala experience with my KENYA trip I note several differences. Obviously the travel distance, time change and length of stay were significantly different. Another big difference in my particular case is that my work in Kenya was almost exclusively obstetrics whereas in Guatemala we are limited to gynecological surgery. Swahili is the official language in Kenya, but most Kenyans speak English whereas most Guatemalans we encounter speak only Spanish. I assume this difference stems from the fact that one country was originally a British colony and the other Spanish. It was also interesting to note that pelvic organ prolapse is quite common in Guatemala while relatively uncommon in Kenya. This may be due to basic differences in the anatomical characteristics of these 2 groups. Finally, on our Kenya trip, my wife Dana and I traveled alone to connect with a team already in place, whereas on our Guatemala trip we bring our team and work together with folks we already know and work with back home, which is a great opportunity to build on those friendships. Either way, these have been great opportunities to go and share our gifts and resources with others. Many thanks to our team, leaders, and the people of Guatemala once again for allowing me to have this opportunity.

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Okelleys in Tenwek 2019

Since returning from Africa, my wife Dana and I have found it difficult to respond when asked how our trip was. “Good” or “great” is the usual one-word response but many more adjectives come to mind, as it was a trip filled with a mixture of different encounters, experiences, and emotions. And somehow just one or two words do not suffice. It would definitely be accurate to say that it was eye-opening.

We came to this particular place because of the Many family. Most folks know of our long-term friendship with them, so I won’t elaborate here, but it was wonderful to visit them and experience what life is like for them at Tenwek. I believe they are where the Lord wants them to be, but like life anywhere, Tenwek has its share of happiness and hardships. We had learned what we could ahead of time about Kenya and Tenwek from materials provided by Samaritan’s Purse who took care of all the logistics of our trip, as well as from conversations with the Many’s and also from our daughter Claire, who had visited with them for several months in 2015. But nothing really could prepare us for a place that is so different from our everyday experience back home.

Our drive to Tenwek hospital took us 4-5-hours from the airport in Nairobi on a rough road that had become paved only 5 years prior. Tenwek is located in the rural highlands of southwestern Kenya which has no large or modern cities nearby, yet the population in the general area is quite large. In addition, patients are referred from long distances for treatment at Tenwek which is one of Africa’s largest mission hospitals. As you might expect in a developing country, the people there do not have most of the things we take for granted. Clean water, reliable electricity, passable roads, and adequate sanitation are still hard to come by there, and there would be no access to adequate healthcare without Tenwek Hospital. It is a 300-bed teaching facility with a long evangelical-centered mission to provide the best healthcare possible. 72 of those beds are designated to the maternity service, where I spent my time working as a member of the “OB service”.

Most women in this area give birth at home. There are smaller clinics in the area which provide very basic care but lack the ability to handle most emergencies. So, women who come to Tenwek either arrive from their village, or are referred by these smaller clinics with little or no prenatal care and are either high-risk or suffering some sort of complication related to pregnancy or childbirth. The maternity service delivers about 3-400 babies per month, and also receives a large number of patients who have delivered elsewhere and are experiencing complications. The single delivery room holds 3 delivery beds or “couches” and is used for deliveries, triage, and labor exams. There is a 5-bed “labor” ward for laboring patients, inductions (of which there were usually 4-5 daily), and any high-risk antepartum patients. Of course, this ward stays full and often spills over to the other rooms on the unit, which normally accommodate lower risk antepartum, postpartum and post-operative patients. Healthy newborns stay with their mothers. Mothers whose babies are in the neonatal intensive care unit (NICU) stay until their babies are discharged. The NICU has a capacity of about 45. So, the halls are normally crowded with patients, visitors, and staff, and it is not unusual to have 2 mothers assigned to the same bed or 2 babies assigned to the same isollete due to overflow. There is one O.R. in maternity for cesarean sections, or other minor procedures, but it is only available from 9 AM to 4 PM. Outside these hours an emergency cesarean section must be done in the main O.R. or “theatre”, which is in another building.

To say that the conditions in the hospital are different than what I normally have available at home would be an understatement for sure. That being said, Tenwek provides excellent care for maternity patients considering their limited resources. Nurses manage all labor patients and perform all uncomplicated vaginal deliveries. They have medications such as Pitocin and magnesium sulfate for inductions and treatment of preeclampsia but do not have infusion pumps. They also have available the usual medications to treat postpartum hemorrhage. There is no continuous fetal monitoring available including for patients on Pitocin or with other high-risk indications. There is no epidural service available. Intermittent fetal monitoring and a vaginal exam (VE) usually are performed by the nurses every 4-6 hours on all labor patients. Inductions are performed with misoprostol, Pitocin or Foley balloon. Patients are not screened for group B strep but antibiotics are available to treat infections and are given preoperatively. Patients with one previous cesarean are allowed to “TOLAC” (trial of labor after cesarean). Everything is in short supply, and items we normally consider disposable in the U.S. are “repurposed” until they are no longer usable, such as Bovie pens and laparoscopic trocars. O. R. packs included cotton drapes and towels, which are sterilized and reused.

2-3 nurses cover active labor patients and inductions in 12-hour shifts, and 2-3 to cover postpartum, gyn post-op, etc. There are another 2-3 in the nursery caring for the newborns who are sick or premature. As I mentioned, the nurses perform the labor checks, non-stress-tests (NST’s), and routine deliveries and call the intern or physician for complications. The only patients directly under the supervision of the OB team are antepartum admissions, post-surgical patients, and patients with complications. During my time there were 2 medical officers (completed one year of post-medical school training), and 1-2 Ob- gyn’s, depending on who is available on a given day. The Ob-gyn doctors are currently Americans including Dr. Cheryl Cowles and Dr. Angela Many, but there is a new Kenyan Ob/Gyn starting soon who had just completed residency training in Uganda. There were also 2 clinical interns and 3 medical interns. Clinical interns have similar training and background to physician assistants in the U.S., whereas medical interns have completed medical school and will be medical officers at the end of their internship. Night and weekend call are divided among the Ob gyn doctors, medical officers, and family practice residents; however, the Ob doctors are always on the hook if needed to help with complicated cases. The interns take call also, and work pretty much like interns in our training programs back home, which is to say “hard”. On the OB service during my visit there was also a 1st year family practice resident and a 2nd year surgery resident. The daily rounding list included post-op, antepartum, ICU, and any other patients with complications and usually had 40 or so names on it. There were usually 10 or more new admissions every day. Many patients presented with “LAPS” (lower abdominal pains) and were full-term or post-dates based upon their last menstrual period but had no prenatal care and no ultrasound to confirm their due-date. There is one portable ultrasound machine on the maternity ward used by OB physicians and medical officers for performing scans. Typically, these patients would receive an ultrasound, NST, and a VE and were either induced, kept in the hospital for observation, or discharged undelivered and given a follow up appointment in the clinic in 1 week with the prayer that they would keep that appointment or return in labor and deliver a healthy baby.

So, between daily rounds, clinic, scheduled surgeries (non-emergent surgeries are booked on Tuesdays and Thursdays in the main theatre), new admissions, and emergencies, the OB service kept very busy. In fact, the number of patients and seriously ill patients was more than I had ever encountered in one place. The diagnoses on our rounding list resembled the contents section of an obstetrical text book. Tenwek mothers are also chronically anemic and that is a bad thing in obstetrics, where the potential for rapid blood loss is high. We ordered more blood transfusions during my 2 weeks than I have in over 10 years and possibly my entire career. Family members were required to donate, and nursing students, medical staff and missionaries were also called upon often to give blood in order to address the critical need. OB patients occupied 3 out of the 6 ICU beds in the hospital the first week I was there. Unfortunately, 2 of the 3 did not survive their illnesses. We also had several babies born premature and several stillbirths and most of these outcomes could have been prevented if they had gotten to the hospital earlier in their illness. I often thought of how back in Knoxville I would transfer such seriously ill or preterm patients somewhere else for their care, but at Tenwek there is no such thing as “somewhere else”. I took call 4 nights in 2 weeks including an entire weekend. I lied awake at night waiting for the beeper to go off and it usually did. I was able to take call from “home” (our small apartment at the guesthouse which is a 5-minute walk away), but they were not particularly restful nights.

Tenwek is a teaching hospital. So, we would begin “teaching” rounds every morning between 7 and 8 am, just like back in medical school and residency. This took some getting used to since I had not done this in 30 years, but I did enjoy the interaction with clinicians in training. Of course, acting as first assistant and helping an intern learn to perform a cesarean section requires patience, but this is critically important at Tenwek as the goal is to train more Kenyan nationals to provide for the healthcare needs of their country. There were daily conferences such as grand rounds, and “M&M” (morbidity and mortality), just like in any traditional academic setting. But there is also a clear spiritual emphasis here that cannot be missed; one that is related to the spiritual well-being of the interns, residents and ultimately the patients. The motto at Tenwek is, “we treat, Jesus heals”. Prayers are said for the patients before rounds and before every surgery. These prayers became a great source of comfort and strength to me personally as we cared for many seriously ill patients. In addition, a morning team devotion preceded rounds each day, and there is a devotional meeting for the entire medical staff every Wednesday morning in the hospital auditorium. In the evenings there are small group meetings for Bible study and fellowship in the homes of the missionaries for medical staff, interns, and students.

As you might gather from my description, the daily conditions, work load, and severity of illnesses which I encountered during my time at Tenwek was almost overwhelming. And yet I was humbled and amazed by the ability of the medical staff and missionaries to carry on tirelessly with great compassion and concern for their patients. Before the trip, I read a book entitled “Miracle at Tenwek”, which describes how the mission of Tenwek began and has since remained focused on seeking God’s leadership in sharing the gospel through medical missions. I believe that the success of Tenwek is due to the fact that the focus is still the same today. “They still do it right”, was an assessment I heard from a returning missionary in describing Tenwek in it’s mission to train individuals to provide compassionate care for the physical as well as the spiritual need of their patients.

So, to find one word to describe our trip to Kenya is difficult. It was a trip filled with joy, kindness, and beauty as well as suffering, sorrow, and poverty. But if I had to choose one word, I would use the word that another visiting physician kept saying: “amazing”. It’s a good word to describe Africa, Kenya, the Kenyan people, and the missionaries who work at Tenwek. But it is also a great word to describe God, whose hand we saw in every aspect of our trip.