Liver Failure Week

I am back in a normal hospital ward for a change, and it feels so relaxed in comparison to the weeks I have spent in the ICU and in the COVID wards. It turns out this is the week of ascites and liver failure. I do not recall ever having so many patients with liver failure at the same time in Kijabe. Alcoholism, Hepatitis A, and still to be diagnosed causes for liver failure fill the wards. I have been opening my computer and looking up possibilities for liver failure and ascites to try and solidify diagnosis. In addition heart failure, intestinal bleeding, and bone infections round out the service.

I am glad to be on the wards, because we have more clinical officer interns and medical officer interns present to know and to train. Frequently I find myself pushed to improve through their questions. This week I am working with one specific intern who begins many of his questions with the phrase “with all due respect”. When I hear that at the beginning of a question, I know that I have possibly missed something and that my intern is feeling pretty secure in questioning a treatment plan. This intern has me on my toes, and it is good. He makes me look into why I am doing some treatments in the manner I am doing them. Have I gotten a little relaxed in a resource limited setting? Am I still pushing for excellence in the care of our patients? He knows what the book says, and he wants to know why what we do does not always match the guidelines. Often there are reasons that are sound because of the financial and logistical constraints of the hospital, but other times I am left with the thought that I should be pushing harder for increased levels of care. In this way it is a good push, despite the discomfort of being questioned. Even as I sit typing the post, I am wondering if all of the internal medicine consultants should get together to see if we should go over our guidelines again to see if we can become less constrained by our resources and push for less limitations in our ambitions.

This is ascites due to liver failure. It is a picture of a patient in Peru that I used to care for periodically when he came to the hospital.

Information for Hospital Volunteers

This is from the Samaratin’s Purse website.

Mission Organization: Africa Inland Mission (AIM)/Africa Inland Church (AIC)

Profile: Kijabe Mission Station was first established by missionaries from AIM as an outpost in 1903. The first hospital at Kijabe, Theodora Hospital, was established in 1915. This served the medical needs of the area until the present complex was begun. The first building of the present complex was opened in 1961.

Today, Kijabe Hospital is a non-profit, 363-bed hospital owned and operated by AIC of Kenya as part of a network of four hospitals and 45 dispensaries. It employs over 900 staff and strives to balance Kenyan and missionary consultants. The hospital offers a broad range of inpatient and outpatient curative services to people from the surrounding farming communities. The hospital includes five inpatient wards (general surgery, medicine for adults and children, obstetrics and gynecology, neonatal care, and rehabilitation), nine operating rooms, an outpatient clinic and 24-hour casualty department, an eye clinic, and a full-service dental facility. Support services include a clinical laboratory, a fully equipped pathology department, X-ray, ultrasound, electrocardiogram, pharmacy, physiotherapy, and central medical supply. Kijabe’s laboratory offers immunohematology, hematology, biochemistry, parasitology, urinalysis, bacteriology, and blood banking services.

The pathology department provides tissue diagnostic services to 37 mission hospitals in East Africa. The OPD provides services for general acute illness as well as specialty clinics in diabetes, orthopedics, rehabilitation, ophthalmology, TB, gynecology, high risk pediatrics, and AIDS. Malaria, pneumonia, TB, tropical diseases, and AIDS are common diagnoses. A Maternal-Child Health Centre (MCH) within the hospital provides antenatal care, family planning, and childhood immunizations. Kijabe also sends mobile health teams to 12 villages each month to provide these same services.

Kijabe is a general hospital and performs more than 200 operations each month. In past years, the most commonly performed operations have included: C-section, tubal ligation, exploratory laparotomy (non-trauma), skin graft, supra-pubic protatectomy, D&C, hysterectomy, ORIF femur fracture, salpingectomy (ectopic PG), sequestrectomy (osteomyelitis), and removal of various cancerous tumors. A dental department was begun in 1978 as a satellite clinic of the main AIM dental clinic in Nairobi. The hospital also trains nurses and medical students and has Community Health Evangelism (CHE) and chaplaincy programs. Because people know they can receive quality care at Kijabe, many are willing to wait weeks or months for their procedures. Bed occupancy averages 80 percent.

Travel: Fly by commercial airline to Nairobi; drive approximately one hour to Kijabe (6 km down a steep, winding, narrow but paved road off the main Nairobi/Nakuru highway). Time Difference +7 hours Daylight Savings Time (EST), U.S.A.; +8 hours Eastern Standard Time, U.S.A.

Location: Kijabe Hospital is located about 60 km north of Nairobi. The altitude is 7,200 feet up on the edge of an escarpment overlooking the Great Rift Valley which extends from the Sea of Galilee to Zimbabwe. People The largest group of people served by Kijabe Hospital are the Kikuyus, although the number of Masai patients has recently increased.

Language: Swahili and English are the official languages of Kenya although local tribal dialects are also spoken. All medical staff speak English fluently, and nurses provide translation to Swahili or Kikuyu. Medical records are written in English.

Religion: The population is primarily Christian (Protestant and Catholic), although some of the more remote tribes practice animism and spirit worship. Muslims and Hindus comprise a smaller portion of the religious community.

Climate: Kijabe is a Masai word meaning “Place of the Winds.” Although strong winds are common, there are periods of calm on most days. The high altitude makes for generally pleasant days (about 80°F) and cool, windy nights (about 55°F). There are two rainy seasons in March–June and October–December. June–August can be quite cool and December–March is typically dry and hot. There can be a lot of mud in the rainy seasons. June––August can be quite cool. December–March is the driest and hottest season.

Housing: Housing is in modern, comfortable homes, duplexes, or apartments which have kitchen equipment, hot water, and electricity. The housing is simply furnished, secure, and near the hospital. Daily housing costs cover electricity, water, security, appliances, and furniture. The Pathology Department has its own apartment for visiting and/or resident pathologists.

Food: Meals are not provided at the hospital so be prepared to buy your own food and prepare your own meals. Most basic items (including fresh foods) that are available in U.S. grocery stores can be found in Nairobi. For More Information Contact Mackenzie Welde by email or by phone at: (828) 278-1371.

The Third Wave Appears to be Fading

We appear to be finishing our third wave of COVID infections in Kenya. I am rounding on the COVID ward this week, and while we started the week with every bed full, as the week has progressed we have decreased our census. The way the COVID ward works is that any patient who comes to the hospital with low oxygen levels, cough, shortness of breath . . . basically any sign of respiratory disease . . . will be sent to the COVID ward clinic, or if they are sick enough they go to the COVID emergency room. When I am working in the COVID ward I cover the COVID ER, the COVID wards, and the COVID ICU. I take care of patients who have COVID pneumonia (not that many currently), but I also have the task to figure out who actually has another disease such as heart failure or some other issue that can look like a COVID but is not. We assess them, and if we determine they do not likely have a coronavirus infection we send them to other parts of the hospital to receive more appropriate care. This week has been a good week. In the past everyone looked like COVID. Now most look like something else and I have been able to move them out of the COVID ward. It is a real relief.

Unfortunately, our fourth wave is predicted for July. We are all praying that despite not having many vaccines in Kenya, that maybe we will avoid the fourth wave.

COVID WARD

I am working in the COVID / Respiratory Ward this week. It is a great place to be, but it can be hard. In the past 24 hours we have lost two patients . . . one from COVID, the other from renal failure. On the other hand, the chance to be in the midst of suffering as a source of compassion is a great privilege. I would likely feel different if I was the one going through the suffering. Being amidst suffering is definitely different than suffering itself.

I really enjoy my work. I like teaching, and I like serving the sick patients in the hospital. I like my Kenyan colleagues from whom I learn so much. Every day is a challenge, but (almost) every day is good.

Thanks for supporting us in our work. I believe that God is doing good things in Kijabe!

Visit to the USA

We will be visiting home this summer. David will start at Abilene Christian University in the fall as a freshman student. We are sad to see him go, but at the same time we are happy to drop him off in Texas to start the next independent phase of his life. To say he is ready to go is an understatement. We feel like we just left the US, which is true. After being in the US for 7 months during COVID, we are barely settled back in to life in Kijabe, and now we go back to Texas again. However, this visit will be much shorter. We arrive in mid July, and we go back to Kenya toward the end of August. During this time we believe we can see more people than we did last time home despite the brevity since laxer COVID restrictions should be more visit friendly. We hope to have at least 2 gatherings to share about the work in Kenya. We are eager to meet in person in smaller groups and even one on one. If you have a church or friend group that would be interested in helping to support us, would you please let us know. We are trying to increase our monthly support by around 1500 each month. That is not an insignificant amount, but with David now a university student our expenses have gone up. And because of the pandemic, the cost of living has gone up in Kenya. Finances are tight. We also have to renew everyone’s passports before we can fly back to Kijabe. We are hoping there is no delay in that process, as we have heard it can take longer than usual. It has been impossible to schedule an appointment in the US embassy in Nairobi due to the pandemic, and so we are hoping to fast track the renewals in the US. We also plan to take one last family vacation together before David leaves, and so it will be a busy time. Please keep us in your prayers as we also keep many of you in our own. These are challenging times for many, and our thoughts are with you.

Medical Education – How Does it Work

What does medical education look like? Let me describe today.

I was up early for some reason, eyes open at 4:30 AM. I have been getting up early this week . . . but 4:30 is about an hour earlier than usual. So after showering and some reflective time and Bible reading, I started reviewing my notes for today’s lecture on shock and sepsis. This review was an ongoing process while waking up the kids multiple times until they are out of bed, and then seeing them off to school. I went into the hospital around 8:30 AM, quickly walked through the ER and the two step down ICU units, finally ending my walk in the ICU. I wanted to see who had been admitted overnight. Around 9:00 AM as I was reviewing my patient’s labs and x-rays while also updating our audit sheets, I was called by the ER doctor that he had just intubated a young woman in the ER and was sending her to the COVID ward. He wondered if I was covering COVID. I told him I was in ICU, but that I could help in the COVID ICU if needed. One of our medical officers is covering the COVID ward this week, and I am her back up for complicated patients. I decide to run down to the COVID ward to meet the patient on arrival. Unfortunately, the patient was not there yet, but I spent the opportunity to review antibiotics, ventilator settings, and plan of care with the care team in the ward. This was an unplanned teaching moment, but it was a typical educational opportunity at Kijabe. We teach at the moment of giving care or preparing to give care. Not all the interns or medical officers are comfortable with the ventilator, and reviewing the machine is a good chance to teach about how the lungs work, how the body balances acid and base levels, how circulation functions in different pressure scenarios, and how to think logically about the process.

While there, I got a call from the gynecological team for help with a patient. I was just across the courtyard, and so I ran over and gave a mini-lesson how to manage inpatient blood sugar levels and how to start insulin on a new diabetic patient. That was my second unplanned teaching moment of this still early day. Since the patient had still not arrived to the COVID ward, I ran upstairs to round with the ICU team. My trainees are muslim and Christian, and it is a good chance to try and model Christian medical ethics to all of them. This was my first scheduled teaching time. We had several new patients admitted overnight to meet and several previously admitted patients to review. With each patient there is a new topic to cover. Diabetic Ketoacidosis, tuberculosis, meningitis and renal failure in one bed. An epidural hematoma in the next. A hemothorax and multiple trauma injuries suffered by our next patient. The fourth bed is an HIV patient with a cheek tumor. Then we went on to the two HDU’s to discuss hyponatremia, seizure disorder, stomach hemorrhage, and stroke among many other things. After rounds, I ran down again to the COVID ward to discuss the new admission. We reviewed her chest x-ray, the possibilities diagnosis that she might have and how we were going to sort them out. Again I did a quick review of ventilators. This is another great chance to try and teach. I went back up to the ICU, and as I was reviewing some other patients I get a call that the woman in COVID ward is needing resuscitation. So we spent 40 minutes trying to save this patient, and through it all we are reviewing the rules of Advanced Cardiac Life Support and Basic Life Support. We got some labs back that show she is in complete renal failure, and so we spoke a bit about that. We teach while treating patients. Then I was tasked with informing her husband about her passing, and I did that with one of our interns. This is different, but it another form of education. It is a chance to model Christian compassion while breaking bad news.

I quickly ran home for some lunch, then, as there was a small break in the rain, I ran back to the hospital. Now it was a formal teaching time, and I reviewed for one hour sepsis and shock with the interns assigned to the ICU. Afterward, I received two calls from my medical officers, reviewing patients with them. More informal teaching. The afternoon exit rounds were spent reviewing a man who had been in a car accident in whom we found a diaphragmatic rupture on CT that we ordered in the morning. I spent another 30 minutes going over all of his x–rays and CTs trying to see if there was a way it could have been found earlier. That was a learning time for me, trying to get better. And I hope it models a certain humility and need to always try and get better to our interns.

That is how teaching works in a teaching hospital, and specifically at Kijabe Mission Hospital. Formal times mixed in with many random opportunities. I learn each day, and I try and pass on how I learn and what I learn to those interns who entrust their education to us.

Thoughts on Faith

I had a discussion with a more experienced physician of whom I was asking for advice. I call Steve with medical questions because he can help me sort out the balance of taking good care of patients in a resource limited situation and how to weigh futility against aggressive hope. But our conversation this time was more about interpersonal relationships in a pandemic when opinions can be so varied. We drifted into discussions of the role of missions in Kenya versus other parts of the world, how do we deal with people dying who would never die in a developed nation. We acknowledged that we deny the trauma of watching people die compartmentalizing it into some sort of work related box disconnected from our emotions. Finally we ended up in theology. Later, I was emailing with another friend Matt, and shared some thoughts that came out of that conversation which I have posted below copied from our email. This thought has been stuck in my brain since talking with Steve, and I am trying hard to sort whether it is true.

I have been thinking a lot about how as Christians we are called to die, not called to live. Also wondering about affluent Christianity, and how it affects my own thinking. Kenya Christians and Peruvian Christians think about God as suffering with them, not taking care of them. A subtle difference, but I know I pray for God’s provision probably as much as his presence (or I am thinking more of his care of me instead of just being with me). I am afraid that is cultural baggage and not the true message of Christ. Our truly poor brothers probably have it more correct.

Steve mentioned that he had been studying the story of Jesus in the boat with his disciples. Jesus slept, the storm came and threatened to sink their boat. The disciples woke Jesus and he calmed the storm saving the boat and his followers. We often read this story as Jesus protection and power over even the storm. And I agree with that. But Steve pointed out that God does not always save the boat. We see Jesus followers die all the time. Within the last week I have watched two mothers die leaving widowed husbands and motherless children. Jesus own disciples (except John) were all killed for the gospel’s sake. But Jesus is always in the boat with us, whether it stays afloat or goes down. So he may not rescue us in our times of struggle, but for sure he is with us, and that is good news too.

COVID in Kijabe

We have had plenty of COVID patients in the hospital. It is a weird disease. If you are low risk, you are definitely in good statistical shape in regards to your quite low probability of dying. If you are older, obese, or diabetic your risks are higher. And it is an infection that when it gets going, and if you are susceptible, there is no good way to stop it. Dealing with it in a resource poor hospital is even more challenging. And so we continue to do our best within the situation we find ourselves in. I am one of those who has respect for COVID, but not fear. And I strongly feel like the Christian response to a pandemic should never be fear. Caution is normal, but as followers of Jesus we should run toward the infected and not away from them. If someone needs a final hug before dying we should give it. We are the ones who lay down our lives for the sake of others. I know that vector transmission and societal good complicate how a person views Christian compassion, but I strongly believe that compassion to the person in front of you even when you are at risk is a character trait of highest value.

Greater love has no one than this, that he lay down his life for his friends.

John 15:13

I hope that as a Christian brotherhood and sisterhood we spend some time thinking through the theology of Christian love in an era of pandemic. What does it mean to be a follower of Jesus, the one who came into our world of sin and died because of it for the sake of all of us? I want to be different than a normal person. I want to be a Christ-affected person who shows compassion even at risk of personal safety and security. It intimidates me to write it, because it is such a high standard, but the highest standards are worth striving toward.

Sunday Night in Kijabe

Some random thoughts this morning. Most often we attend a small group Bible study on Sunday nights. This week we hosted at our place. It is a nice time to relax and enjoy other’s company. It is a good time to pray corporately. Almost always it is part of making new friendships in the transient world of a missionary community. We miss friends back home . . . did you know we have been living outside the US for almost 9 years! It has felt short and long. Our kids were small when we left, and now we send our oldest off to college next year at Abilene Christian University. Time really does fly as they say. It is sad to see him go, especially after such a bummer year with the COVID restrictions. On the other hand I am really happy for him. ACU is a blast, or at least it was. I hope it continues to be so. In the picture below are several of our Kijabe friends. One couple runs an organization committed to environmental protection while encouraging productive farming. Another teaches at the local seminary. Another is helping to establish small clinics in the poorest communities of Kenya. Another is an anesthesiologist at the hospital. There is a lot of good work being done!

Help Our Friend Isaac

This is a long story, and so let me cut to the chase. We are trying to raise 6000 USD for our friend Isaac. He is a man who is trying to break a cycle of poverty and family abuse while providing for his wife and three children. If you can help us raise this support we will likely influence generations as he will be able to support himself well enough to send his kids to better schools and possibly even university education. This is straight charity with no tax breaks and no hope of payback, but he is our Christian brother in need. Maybe and hopefully this will have one of the greatest impacts of any of the work we have done in Africa and Peru. Or it could all fail, but not every Christian act of kindness produces fruit we can see. But it all is used by God for his purpose. Read Isaac’s story below.


To give, please contact me directly at wcaire@gmail.com or WhatsApp me at +254 700 895 116. We are in great need help for Isaac by the middle of April. Support for this will not be going through our mission agency as it does not technically fit our mission’s goals.


This is a very brief summary. I am happy to give more details in private. Around 18 months ago Isaac’s house that he had built on his family’s property washed away in a flood. At that time a friend of mine who does community development came to Isaac to discuss a project for farming in the valley. It seemed a like a good new start for him, and Isaac was naturally excited. Unfortunately the COVID epidemic messed up those plans, and the man who was the driving force behind this community development has returned to the US. Meanwhile due to bad family dynamics including physical abuse of his wife by his family, Isaac had to leave his family and find a new place to live. He has moved from place to place over the past year trying to find a place his wife can be safe from his parents and sisters. Finally in his eagerness to try and provide for his family he has overextended himself financially, and he needs to be rescued from losing land that he has purchased to try and better his life, support his family, and provide education and way out of for his children. This is a rescue plan for Isaac, and I need your help. I have been employing Isaac since the day I arrived in Kenya. He was almost the first Kenyan I met, and he has worked for me 3 days a week since that time. He is industrious – in fact in the 6 weeks he has had his land he has planted crops, built a house, planted a hedgerow, dug a 35 foot pit latrine, and installed a water tank. I do not believe our generosity will be wasted. However he needs our help. 6000 USD is not much for a bunch of Americans working together. For Isaac that is 6 years salary. Please help me help him if you can. Please email me for more details of why he is in this situation and how to send money to help. Thank you.