we make decisions//decisions make us

“Indecision is like a stepchild. If he does not wash his hands, he is called dirty. If he does, he is wasting water.” (African proverb) 

"Somewhere along the line of development we discover what we really are, and then we make our real decision for which we are responsible. Make that decision primarily for yourself because you can never really live anyone else's life, not even your own child's." (Eleanor Roosevelt)

                  I remember how painful and pathetic of a realization it was, one day, to finally notice how desperately afraid I was to make a mistake.  I was sitting with my friend Mary, on her neatly made bed, in her warmly and kindly decorated bedroom on an inhospitable, rather unpleasant winter’s day.  I had brought myself to her place to chat, as I felt in those times that I had become caught in a stall-formation of stagnated living; I wasn’t sure which way to go next and I was afraid to make a decision.  She and I had been discussing my own life at great lengths – what I felt like were my personal successes and failures, what I had done wrong and right in my own eyes, and specifically, ways in which I felt like I had made the wrong decisions and left other people to sift through the aftermath.  After a tiresome and really exhausting litany, then exposing a whole host of what I considered to be my emotional liabilities, she looked at me with a restful face.  She said something like, “My dear, you are a lovely young lady who simply needs to stop constantly thinking about all of the mistakes you think you have made.”

                  As a medical practitioner I am required to make decisions about my patients’ care every single day.  As the “nurse in Kenya” I have had to learn to trust my guts, listen to my intuition, draw from my experience, rely on my intellectual knowledge, and decide what to do next.  Knowing that I am on the front line and similarly at the end of the line of almost all of the medical decisions here at the children’s home sometimes feels like a weighted responsibility. Really though, most of the time I feel like it is a keen and really unique privilege that I cherish.  I do have the duty – the sometimes formidable, but actually precious, duty – to decide what should happen next with our sick kids, and frequently even my sick coworkers.  Lately decisions come easily as I’ve “learned the ropes,” as they have affectionately tied and knotted themselves around me.  It wasn’t always that way, though.  Don’t forget – I came here knowing almost nothing about tropical medicine, and having cared for fewer than five children, on the clock, ever in my life.

                  I think back to a time I was in nursing school.  I look back on what it was to appreciate the fact that I was going to be responsible for other people’s lives.  It was a frightening and overwhelming notion to realize that the responsibilities I had considered for whole life were finally becoming real. 

I knew from what my mother and father had taught me, growing up at a dinner table where medical jargon was passed around with the green beans and the pepper shaker, that medicine was about so much more than passing meds and writing prescriptions.  I had been raised with the caring mentality: that house calls were still appropriate, that you took care of the sick even when it made you sick yourself, and that you, as the practitioner, were the end-all-be-all for that ailing or even helpless patient.  I remember being in grade school, listening to my mother while she leaned against our white-tiled kitchen counter telling me stories about tough decisions she had to make in her career as a critical care nurse. I remember wondering how it all could have come so easily to her. I visited the operating rooms in which my father would cut people’s eyes open and give them their sight back and I wondered how he could be so confident to take someone’s life into his hands like that.  I witnessed my mother tirelessly caring for her own infirmed mother in our home around the clock for nearly seven years and admired her commitment to her decision not to put her back in a nursing home.  My parents demonstrated to me what it meant to joyfully embrace the responsibilities of caring for human beings and I looked up to them for it, with every word-almost-too-long-for-me-to-understand along the way. 

But then, all of a sudden, I was twenty-two years old and the charts were in my hands.  It was my signature at the end of the progress notes, my thumb on the syringe plunger, and my brain doing the calculations to determine how many mLs of a vial of medicine to draw up to equal a prescribed dose.  And those patients – it was their hearts beating in my eardrums at the end of the stethoscope, their sweaty palms I held while they pushed their babies out, and their loved ones I was comforting while they died.  I remember feeling ill-equipped for the task put upon me, for the career to which I knew I had been called.  I remember being afraid that someday I would make a mistake that would hurt someone or that I wouldn’t be able to provide my patient with what they needed, when they needed it most.  After all – it is a big responsibility, and I knew I would make mistakes and that I couldn’t possibly meet all of their needs all the time. 

When I graduated from nursing school I started in the ICU right away and I felt like I had bitten off way more than I could ever chew.  Over time I felt more comfortable being around the critically ill as I learned more about what they needed from me, what I needed from the physicians, and what I needed from myself to get the job done.  I went through plenty of struggles coming to accept that I was being asked to, and was also able to, make decisions that would dramatically my patients’ outcomes.  I asked a lot – a LOT – of questions.  To me, it was worth it to swallow my pride and approach my senior nurses for their experience instead of acting like I knew how to handle every problem my shift could throw at me. I had doctors demand that I be the one to make the decision, even if I didn’t eventually (like that time right before I heard the phone slam down on the other end, ending a two-a.m. call I made to ask for orders when my once-alert patient become unresponsive, when I heard the doc hiss, “do whatever you want.”) After not too long it all got a lot easier and I realized that together, as a team of nurses, we could handle anything together.  We had had good nights and bad nights, and some of those good nights were when all we could do was our best to handle horrible outcomes.  By the time I left the ICU, I felt like I had been well-equipped to handle what was thrown at me because I had been given, and forced to employ, the tools of critical thinking and clinical decision making: understand what you yourself know, ask questions when you don’t know, get the answers and put them to work for you, do what you can to help your coworkers, and never be afraid to ask your teammates to pitch in when the water is too rough to tread it on your own.  I saw many shifts come and go living in that work philosophy, with many people still dying and even more surviving despite the most dire circumstances.  I had accepted the responsibility of making decisions in that setting and it worked out.

Then I came to Africa.  Here I was (here I am), the sole medical professional at an orphanage of more than a hundred and twenty kids (now more than a hundred and fifty), most of whom were under the age of five (six, now), and I had pretty much no idea how this was going to come off.  I was given a set of keys, a computer with all of the kids names and their recent medical histories that also could organize meds to be administered on a daily basis, and a room full of goodies (meds, supplies, and instruments).  I would take the kids to the local doctor, and then follow his orders.  When emergencies happened in the middle of the night I would call him and he would tell me what to do.  Sometimes early-on we had no cell service in our village and I had to figure out what to do on my own.  Over the past almost year-and-a-half I can say that it has been quite the journey figuring this thing out, being on the frontier of this children’s home, and equivalently, of myself.

In Kenya, it’s not like it is in the United States.  Most practitioners are offended if anyone – especially a “lower” medical practitioner – questions them.  It is not appropriate for me to ask physicians their rationale for writing a certain prescription or ordering a certain treatment.  I would sometimes have an untoward look or unfriendly tone thrown back at me, but my least favorite response to my still-persistent questioning was an answer that I knew couldn’t suffice for me.  I knew even ten or so months ago that my practice was shifting, and that eventually I would be the one making most of the medical decisions, and I knew that I had to equip myself and allow others to equip me for this role.  It was a role cut out for me to fill, as many nurses in Kenya prescribe and act as practitioners, “doing everything except surgery,” as my local nurse practitioner reminded me.  At the same time, it is not proper for me to work outside my scope of practice, or my scope of experience.  So, I had to expand my practice and accumulate experience.  I knew I wasn’t going to be able to always rely on the books, the monographs, the package inserts, or even other practitioners for what to do and when.  I had to be able to make decisions, and they had to be the right ones.

I have had experiences in Kenya where I knew that I was not willing to trust what practitioners – with more letters, presumably more experience, even if they did have fewer years of schooling than I did – were telling me to do.  I’m so thankful that these times have been few-and-far-between, and that I trust all of the providers with whom I regularly collaborate.  But in those few-and-far-between times, recognizing my role as the nurse to be the patient’s advocate above all else, I have occasionally, within my scope of practice, had to explore other therapies or treatments for these kids here.  They were decisions my directors and my own guts required me to make, and when I learned to be comfortable doing so, things got a lot easier.  It was five years ago that I was that twenty-two-year-old nursing student, in a nauseating and poor-fitting teal scrub top, with equally heinous white pants, wondering how she would ever feel comfortable enough with the burden she knew the universe was asking her to lovingly welcome.  I guess I’ve grown up as a nurse, if even just a little bit.

Out here I sometimes miss the team I worked with back in New York.  I miss being able to ask my other nurses, “does this QT-interval look long to you?” or “can you help me out in room 8? Either I’m not feeling these twitches or my Nimbex dose must be off,” or “I’ve never had many Wound-Vacs to troubleshoot, would you help me figure out why the darn thing won’t stop alarming?”  Of course, I don’t have any of those problems here, but I have different ones, and sometimes I have issues outside the scope of what the third-world is used to accommodating.  Sometimes I want to be able to ask, “Hey, can you make any recommendations that will dissuade this pregnant chick I’m consulting on to stop eating mud?” (as is the Kenyan way, it is very normal for them), or, “Can you help me get a line in this four-year-old? I really don’t want to have to give this ceftriaxone IM,” or, “What do you think this looks more like, a spider bite or a bee sting?”  Sure, I have docs I work with here, and sure, I have a brain on my shoulders, but it was nice to have that safety net.  I guess all of this African medicine has made me think harder and faster about certain things, while having to let go of some of the indeed hard-and-fast rules I learned back on the unit.  It’s all about decisions, decisions: nursing, medicine, and life alike.

Sometimes, even with all the information we can possibly have, it is still difficult to make a clinical decision.  There have been many times I have found myself in the desert of the mind, unable to see the stars, with a broken compass in hand, unsure of which way to go.  I usually ask all the questions I can ask, try to find as many answers as I can, get other people’s recommendations, and then go from there.  So far I haven’t hit any land mines out in the sand, and a source of water is never too far off.  I guess that’s what happens when you know how to ask for directions, even if you aren’t sure how to fold the map back up afterward.

I’m happy to say that I do have support from the States even though I’m thousands of miles away.  In upstate New York there is a growing body of generous physicians committed to patient care who have employed a program called iClickCare (visit them at http://www.clickcare.com) so that providers can collaborate with one another through a secure server.  Providers can exchange pictures and patient information quickly and confidentially in order to receive expert consultation upon request.  I have used this service many times and have been absolutely thrilled with my ability to connect with the first world from far away.  It has been a huge relief to be able to be able to pick these doctors’ brains about what they would do if they were in my shoes (or sandals, as the case is usually) in a variety of situations.  I can definitely attest to the fact that if I have any kind of first-world medical team it is only through iClickCare.  I am deeply grateful to the Drs. Kerr and the whole iClickCare team as they have assisted in several difficult case presentations – they have really made a difference in the lives of our kids over here.  If you are a medical practitioner, in the first-world or beyond, I strongly recommend that you consider participating in this service. 

Nurses, Nurse Practitioners, Physicians Assistants, Osteopaths and Medical Doctors are all practicing medicine - we can never have all of the answers in and of ourselves.  My experience has been that if we think we do have all of the answers, we are headed for trouble.  We best serve our patients by continuing to keep an open mind by learning and considering others’ clinical experience, without abandoning our guns that we have seen fire reliably.  Their lives depend on us making decisions, that those decisions be sound, and then that they also be executed properly.  Making clinical decisions isn’t a cold and detached process either – it might be as important in the long run that we chose the correct dose of the correct drug as it is that we took an extra two minutes to sit on the edge of their bed, take their hand in ours, and just listen to what they need to say. 

Maybe one reason why it has become simpler to make clinical decisions is that making my own personal decisions has become equally as simple.  As I mentioned at the beginning of this essay, there was once a time that I felt paralyzed in my own skin by a fear that I would make the wrong decision and mess up my life or someone else’s.  Indecision, I learned, is as lethal personally as it is clinically.  How long did I spend my days worrying about what I should or shouldn’t be doing, instead of doing or not doing without fear, willing to accept the consequences of my actions without regret?

Honestly, when I came to Africa the very first time I remember feeling like life cornered me against a wall and seized me with its fingers around my neck.  It looked me in the eyes and talked to me so close I could feel flecks of its spit on my face.  It seemed like it wanted to yell, but kept its voice low and hushed, as it explained to me that I couldn’t be afraid of making the wrong decision anymore – that I was not practicing my lines in a dress-rehearsal, but that I had been on the stage of life all along.  It reminded me of something I had once knew, but had forgotten since I was a kid: that it was my job to live my life the way I best saw fit.  It urged me to confront myself: the desires I tried my best to ignore and dismiss, my brilliantly painted dreams I had left to dry out and flake off onto the floor into a pile of dusty chips that I dreaded sweeping up.  It forced me to see, accept, and enjoy that I was who I was.  Life got me alone here, long enough in the Rift Valley some two and a half years ago, to make me realize that I had been avoiding it for too long, that it missed me, and that it wanted me again.  So I let life have me.  I made my decisions and lived them out.  I’m still living them out.

We all make decisions every day, mostly without even realizing or consciously thinking about them.  The substance of our lives is a conglomeration of the effects of every decision ever made for us or by us.  There are times when we need teams of people to help us make decisions, while other times it just takes the actions of one person, even across the world, to change the course of life forever. It has taken me some years to realize that, in a world where many decisions are made for us, it’s critical that we make the decisions that are ours to make ourselves.  There are times to ask questions and get opinions and there are others times when this is not necessary or even appropriate.  I have come to embrace life’s inevitability of errors, and my own determination to pursue their resolution.  Today, the decisions I make in my own life have taken on a new dimension of their own; they are accommodating and generous, warmly lit and inviting.  They are mine to make, to enjoy, and to love. 

And, oh, how I love them.

 

Edith

Gilbert

Churchill

"Sweety" Michael

Theresa

Laura - after an attempt to feed herself

Rehema and Sandra learning math at In Step Academy

Shalom Danae

Sweet Milli 

Alice

Ayub

Japther

Chris

Austin

Brighton

Brian

heart conditions

"Look to this day! For it is life, the very life of life." 

- Kālidāsa

There was a time in my life when I was so tortured by everything that was unsettled in my heart, it was like a cage from which I struggled to escape. Once I did, I realized I lost the key to the lock with which I had secured it.  And so an animal roared captive inside my chest, unfed and angry. When I finally found the Key back into my own heart, it was so fragile and weak inside that it kept getting broken over and over again. The sharp and jagged pieces barely held themselves together. I did all I could to take care of that heart of mine, and over time the pieces grew together, but it was in a completely different shape compared to how it looked and felt since before it broke apart. To me it looked ugly, not like everybody else’s, and I wondered where I had gone so wrong and what was the matter with me. After a while I realized that all the breaks allowed pieces of my heart to move outward from the center and that when it all healed there was more space inside than there had ever been. It was no longer a prison to be escaped, an animal to be tamed, or a safe to be broken into. After all the years of growing up I discovered that God had helped me create a home in my own heart that could never be disturbed. All of the brokenness healed to accommodate a vast and warm place out of which I could live and love, deep and far.

            It has been a busy and enjoyable time. Life in Africa seems to move to its own tempo and it very much resonates with the beat of my own heart.  Not that it was what I was necessarily after, but I seem to have tripped over quite a bit of happiness lately.  I went a few weeks without being too sick, exercised and ate and slept well, and have enjoyed being in contact with family and friends. I feel very much at peace enjoying the present.

            A few weeks ago, one of our visitors had organized all of the medical contents of the clinic and found a Fetal Heart Rate Doppler: an electronic device that detects fine “sounds” and vibrations and amplifies them so they can be clearly heard.   As soon as he showed me what he had found I was excited to be able to try it out on Grace, our “oldest kid” who is now married and expecting her first child.  I knew it would be a special treat for her, especially considering that most Kenyan women never get to hear their unborn babies’ heartbeats so clearly and with such a “fancy” machine – usually a simple stethoscope or even a “cone” device is used by health practitioners to appreciate the fetal heart rate. 

            I invited her to Sickbay, letting her know I had a surprise for her and that I wanted to examine her, with something having to do with the baby.  She came to the room first by herself and after she got herself comfortable on the examining bed I explained that I was going to put a device on her belly that wouldn’t hurt her or the baby, and that would just help make sure everything was alright.  I apologized in advance just before I put the cold ultrasound gel on her tummy, but she still let out an adorable twenty-one-year-old giggle.  I placed the transducer on her abdomen and adjusted the volume.  I made my best guess as to where the fetal heart rate would be transducible and luckily found it right away.  Once we heard the rapid trot of the baby’s heart, nearly twice the rate of its mother, I stilled the hand-piece to minimize interference.  I listened and looked up at Grace’s face.  Her mouth was slightly open, her eyes bright and wide, and she was holding her breath.  She looked up at me and said nothing.  I asked her if she knew what she was hearing and she didn’t answer; she just glanced at me, half-stunned and half-confused.  I told her that she was hearing the heartbeat of the baby inside her and I watched as the corners of her mouth pulled up and back while her eyes squinted with joy.  I think she quietly said something like, “aye,” a common Kenyan exclamation.

            So we just sat and listened in silence otherwise.  That little heart skipped along unknowingly – unaware of its young mother’s adoration, of the excitement of her friends and family, and of the tumultuous and uncertain world into which it will soon be born.  This was the heart grown out of her own heart and that of her beloved; it was a rhythm of anticipation, of creation, and of the truest life.  Grace listened to that tiny drum beat on and on as if it played a song she never knew she longed to hear. 

            I held my hand still and every once in a while the little one would move around and I’d have to chase it to hear the beat again, but it wasn’t hard to find.  I stopped for a moment and asked her if she wanted me to go get her husband and sister, and she agreed.  They came in and we played the same game, to have them wonder what I was doing and what they were hearing.  Grace’s sister, being a very intelligent young lady with a knack for science, had the excitement of the moment painted across her gorgeous brown face.  And as for the dad... I watched his eyes soften as his own heart likely skipped a beat.  There was less wonder in his eyes, but more affection, for mother and child alike.

Grace and Alfred

I didn’t expect that performing this routine assessment would have such an effect on me personally.  I, myself, was humbled by the experience. I felt so blessed that I could help facilitate such a beautiful moment between an unborn child and its family, across a physical gulf easily traversable by innovations of modern science.  I thought about how many prayers have probably been lifted up to God begging for the biggest and yet tiniest miracle of a baby.  Maybe I was so affected by this because I remember the stories my own mother told me about how she desperately wanted to have a baby but had been told, a few years after my older brother was born, that she would never have another child.  She herself told me about the excruciating and very persistent longing she experienced.  I am fortunate that my mother is such a faithful woman who did indeed pray without ceasing.  It took more than eight years, but obviously, as evidenced by the fact that you have something to read here, it’s clear that her prayers were eventually affirmed. And so, as we are born of our mother’s hearts (and technically, all of our physical bodies are derived exclusively from the egg, from our mothers) I am grateful for her heart in mine.

            Although we are in the business of caring for children who are disregarded and abandoned, not all of them were so left.  We care for children here who have been orphaned by mothers who died during childbirth or shortly after, who, I suspect, would have loved to raise their children well.  Some of our children come from families of mentally or physically ill parents who were simply unable to provide proper care.  Circumstances aside, each child we have the privilege of caring for is as precious as the next. Often my heart breaks not only for the children here but also for the broken families dogged by tragedies who were unable to be a part of their lives. With so many suffering children in the world, it warmed my heart to be able to participate in the joy of a family expectantly awaiting the arrival of their firstborn.

***

Although some of our children may not have experienced what Grace’s child will experience – its own delivery into a family enraptured and captivated by its mere existence – the value and strength of our kids is far from lost on me.  I admire the spirits of these children of God here at In Step, whose own heartbeats continue to march out along various challenging paths of life with courage and persistence.  While many of them are still too young to have an awareness of their own personal narrative history, some of them remember traumatic events or have otherwise come to know about their stories. We pray for our children, collectively and individually, that they will be able to put their own upbringings into perspective and have peace in their hearts and spirits about the natures of their childhoods.  I believe that God has placed fierce and gentle hearts in each of them, but hearts still bound by the constitutions of their own flesh, as all of ours are to an extent.  As the spirit flows through us, we are all refreshed, and we can “take heart” that all circumstances and happenings of this world have been overcome.  For us personally, the beat of our own hearts is the rhythm of hope, as it strikes away moment after moment, remarking to us that our work, our experience, and our blessed privilege of experiencing this beautiful life has not yet expired.  The sound of our own hearts tells us that no matter what has happened in our lives, we have the opportunity to move forward, to grow, and to love... again.

My account of our hearts beating in unendingly in an unremitting and proper manner is, of course, anecdotal and not clinically accurate.  As sentimental and whimsical as my descriptions of our physical heart’s involvement in our emotional life may be, they are purely imaginative, and it goes without saying that they have little medical significance.  In fact, here at In Step we recently took steps to prepare ourselves for the unlikely but formidable possibility of a life-threatening emergency.  As a richly experienced and well-trained Paramedic was literally delivered to our doorstep on the third team coming from parts near Rochester, New York, we seized the opportunity to have a certified CPR instruction visiting our home.   

Cardiopulmonary resuscitation or CPR, in my own words, is the process of forcing oxygenated blood throughout the body, when these functions spontaneously or progressively cease, in an attempt to maintain organ function and sustain life.  CPR is required when someone’s heart stops, for whatever reason, if they have decided in advance that they want lifesaving or “heroic” measures to be performed.  Such an event, leading to or causing cardiac arrest, almost always requires really aggressive and invasive interventions if someone is going to be kept alive.  Usually people who are very sick or have chronic health conditions are most at risk for problems like these but sometimes... things just happen.  We wanted to be prepared in case of an emergency.

            For an entire week, our visiting CPR Instructor, Vince Brennan, gave classes in Basic Life Support (BLS) techniques for adults, children, and infants.  In order to accommodate literally every staff member present including all of the missionaries and even some of the oldest kids age fourteen to eighteen, this dedicated man gave ten classes, each for a couple of hours a piece.  He was even on treatment for malaria during this whole time of instruction.  All of our Kenyan staff members and missionaries who work directly with the children were required to attend, learn, and demonstrate CPR and techniques to rescue someone choking. I was very impressed with Vince’s instruction and I thank God for sending him to us. Vince, thank you again.

            Having just expanded so much on the precious nature of a beating heart, it’s probably ironic that I’d explain how we just had CPR training in the event that this wouldn’t be the case.  The fact is that, while in one way I believe that we “can’t avoid our time” or “delay the inevitable” if we are to die, I’ve seen horrible and really tragic circumstances lead to what seem like absolutely avoidable injuries and illnesses, which do eventually cause cardiopulmonary failure.  In a sense, I suppose it’s more coincidental and less ironic that I’d discuss this, as all we would be trying to do would give the victim a fighting chance to continue on living as I described earlier.  We may not be able to avoid the inevitable, and we certainly aren’t trying to play God, but if there’s something that we as people can do to prolong someone’s life in a dignified, comfortable, holistically healthful manner, then I think it’s something we ought to try.  If something happened to someone here at the home I’d want to do everything possible, in accordance with their personal decisions regarding resuscitation, to keep them alive. I hope and pray to Almighty God that we never have to do that here but I do choose to be prepared in case we do.

            When I was working in the ICU in New York I can’t even remember how many times one of us nurses was called to a code, or attended to one of our own on the unit, to resuscitate someone.  Sometimes we anticipated it and sometimes it was a surprise.  Sometimes people’s hearts just “gave out” from metabolic stress, sometimes trauma and hemorrhaging led to the a direct loss of blood flow and oxygen to the heart, and other times the heart itself was so sick that it just couldn’t do its job.  I remember looking into people’s eyes one minute and an hour later I was in the same room, now surrounded by twenty people all making their best and concerted effort to save a life.  We would pump fluids into them, push medications into their bloodstream, deliver pure oxygen into their lungs, hook them up to electrodes and try to stimulate the heart electrically, and compress, compress, compress the heart.  I remember the feeling that there was something like gasoline running through my own veins as I was seized by urgency, realizing that someone’s life was slipping out of our reach. I watched people’s mothers or fathers or siblings or spouses or children die. I’ve thought about their lives as I leaned over them and pushed down on their chest as hard as I could, over and over and over.  I’ve watched flat lines stay flat, numbers drop to zero, and times of death called.  I’ve watched tears fall like drenching African rains while parents’ bodies crumpled over those of their dead children, lost “before their time.”  All of these experiences have never left me and they humble me, teaching me about the sacred nature of life.  Thinking about those people I watched die, many whose names I still remember, puts my own life into perspective.  It makes me delicately consider how I want to spend my time and live my life; it makes me realize the opportunity I have by simply being alive, let alone to be healthy and happy.  It makes days like the one on which I got to see Grace’s face react to hearing her baby’s heartbeat all the more perfect, precious, and priceless. 

            Having turned my own heart inside out, pressing buttons on this keyboard so I can simply understand my own life more deeply and share my experiences with you, I’m confronted with what I feel like is a very fundamental characteristic of human life: the nature of love itself.  All this heart talk and emotional fervor, however well-passioned or circumstantially descriptive, leads me to write on about a topic that is somehow as mystifying as it is simple.  I’ve had bluebirds circling around my head about this whole love bit, as I’ve alluded to in past entries, and it’s been on my mind more than usual in the past couple of months.  I suppose that, when looking at life, death, and the gratitude that overwhelms me on a daily basis, I must address or at least approach questions within myself that I have been attempting to answer for the past ten years or so.

            What makes me grateful that I am fortunate enough to be alive? Other than what is physically obvious, what is flowing out of this heart of mine? What do I believe is most important? How do I want to live my life? Am I dancing well to the rhythm of life that God plays for me?  What am I doing with this intangible, yet very real heart of mine?  What do I want to do with the handful of heartbeats that have been allotted to me today? If I died tomorrow, could I know that today I lived my last day with my whole heart?

            Last year I wrote to you in an entry titled “mrembo” about my friend Rachele.  She had visited us here in Kenya and we had bonded quickly and tightly.  Later that year I went back to the United States while an immigration matter was being sorted out and I ended up spending a great deal of time with this woman. I confided in her about the difficult and confusing times I was then experiencing and she generously and lovingly cared for me as a dear friend. My gratitude for her careful ear and sweet words never left me. Just before I returned to Kenya at the turn of the New Year, she and I had a serious misunderstanding and afterward we did not speak for several months. It was a painful and challenging time for us both but God led us in ways bright and lovely, and we did reconcile a few months ago.  She returned to Kenya in September and is still visiting with us now. This time she was accompanied by her kindhearted husband Mark, and the two of them celebrated their twentieth wedding anniversary with us on the compound with a renewal of their vows.  It was an honor and a privilege to be a part of their special day.

            I can’t even imagine what it would be like to be married for twenty years.  Don’t think I don’t intend that for myself, as I most certainly do, especially now.  I guess I just can’t imagine the kind of wholehearted, full-spirited bond that exists, which grows and evolves, in such a union.  I think of the axiom, “all it takes is all you’ve got,” and wonder if even such a comment would be an understatement. Being fully united with another human being as imperfect as yourself, being faithfully devoted to them exclusively, and sharing all aspects of your life and self with a true partner... all of these ideas used to absolutely terrify me. Over the past couple of years they grew in my heart to attract me magnetically, electrically, and actually quite naturally.  I am under no supposition that it would be easy, I am aware that the classically idealized “fairy tale” is a joke, and I know that challenges will have to be endured in kind with joys shared. I think about the people I know who have been married for a long time and wonder what their experiences have been. Recently, a friend of mine who has been married for a long time told me, “you can’t live on love,” explaining that the sustenance of a marriage requires so much more than that which usually initiates it. Looking at Rachele and Mark, and having a vague understanding that their lives have been as typically imperfect as could be expected, I admire their commitment and their devotedness.  I suppose that, considering love, there is so much more than that which our society commonly projects and portrays.

            Sure, romance is lovely, and almost magical in its own right.  I thought I had experienced it before but I’m experiencing it now in a markedly different light. Yes, personally, in the only ways it can truly be experienced. Romantic love is dazzling and blinding; a stunning experience of the shifting of perspectives as a mutual fascination between two people deepens the appreciation of the present and ignites an anticipation of the future.  It amazes me how, not just an emotion but also an experience, can be so mystifying and yet so peaceful.  Sure, I’m in love with a man alright, and at the same time I acknowledge its nature: elevated levels of highly reinforcing neurotransmitters hard-wired into mental pathways designed to eventually (way, way, eventually) lead to perpetuation of the species coinciding with a deep, broad, very substantial admiration for him, in alignment with practically everything that draws my spirit to life.  Maybe it’s vulgar and distasteful to describe one of the most powerful forces on Earth in such a biological and frivolous manner, but please do forgive my minimization of this very splendid experience I do so cherish.  I wish I was a better writer: I can only write what I know and experience, and while I feel like I am knowing it and experiencing it in the newest way, as unbelievable as that sounds, I don’t yet have the words for this kind of stuff. In any event, if we can’t just live on love, what do we live on? How do I reconcile the tendencies of my wild heart with the immediacy of my mind and the eternity in my spirit?

            I don’t think there’s a legible answer to that question. Maybe there is no real answer at all, and the journey of life is woven out of the fabric of our life in such a question.  If there is an answer to the question of how love makes sense, I’m not even remotely eloquent enough to scribble it out in anything more than a scraping and shallow fashion.  I guess it takes commitment, faithfulness, devotion, honesty, trust, integrity, communication, hope, and faith. While these are questions I feel honored to ask, the answers to them, which I struggle to give, are probably exclusively experiential. All I know is what I’ve lived through, what I believe in, and who I am.  This brilliant life has revealed to me facets of myself, dark and shimmering alike, that have colored my path into what I personally look upon as a kind of obscure artwork – a piece I definitely did not have the hand in painting. Today I trust that, although I cannot even see but a few steps in front of me, to follow the path of my life that has called me forward minute by minute, more will be revealed.  I know solidly in my heart that the mind-blowingly remarkable man to whom I affectionately, (though vaguely) refer, who has been led to pursue my heart across time and distance, is eager to walk with me on this path, however clouded it may be today by the fog of the Rift Valley.  These matters of the heart, which are absolutely mistranslated since they are really matters of the spirit, apparently have a way of blossoming themselves, although they do require affectionate and delicate care.  The horizon of life today scatters rays of light in breathtakingly majestic and almost blinding displays of the love of God Himself. I don’t even want to blink lest I miss a second of this incredible story He has written on my own heart.

            Maybe it doesn’t seem to you like these things don’t have anything to do with one another: a mother and her unborn child, the work required to save a life, the public restatement of a sacred covenant, and the nearly unintelligible scrawlings of a woman in love.  To me, it’s all connected in its every dimension; the appreciation of these happenings requires the energy that flows up from of the deep roots that have taken me twenty-seven years to grow. The explanation of these events in their fundamentally interwoven nature is the animation of the images I cling to deeply. It is the description of an exquisitely intricate and astoundingly simple force.  To me, it’s love. That’s it. I could have given up writing an hour ago and just written those two words. It’s love.

            There is something so wonderful and so incredible about this life as I’ve been fortunate enough to live it that I can’t restrain myself from pouring out my whole heart to you as I explain my appreciation for it.  Love is it.  It is what drives me, what keeps air in my lungs, and what keeps my own heart beating.  It is what would make me want to kneel next to a clinically dead person and help their heart start again. It is what I experienced holding that fetal Doppler on a woman’s gravid abdomen while she listened to the melody of her dreams coming true. It is what moves me to do the clinical work here in Kenya. Even if I don’t feel it, I know it is in the medicine cups, the bandages, and the malaria injections because the art of nursing paints a portrait of love. “It is the very life of life,” and it is more of me than anything I’ve ever been or wanted to be otherwise.  I’m telling you, the brilliance of this life need not be elusive, but it does need to find a way into us, the same way it needs to get out of us.  As much of a risk as it is to love with all we have, I’m comforted by the fact that when we give real love, there is nothing we can lose. At least, that’s been my experience.

            Loved people die everyday, not thinking it was time yet. Babies are born to mothers wed and unwed, prepared and unprepared, to those dying of anticipation and others overwhelmed with dread and shame.  Children are adored, and others are set aside. People fall in love, and maybe if its possible some “fall out of love” too. Some people get married and even some of those get divorced while others don’t. Strangers work to save lives of men and women they have never known before and are moved by tragedies and miracles in kind.  What could be more valuable than the various works of love we experience as human beings? What more could we have been created for? What else really, really matters than the love we show? Money? Things? Our careers? How many credentialed letters we have after our last names? What people think of us? Even what we think of us? If you ask me, there’s nothing I have ever known that is more powerful, more motivating, and more meaningful than demonstrating the love we have been given to share. It is what makes life worth living.

“For it is life, the very life of life.”

Sammy and Nick

Abby: a face in the crowd

Rael

Adam thinks he's on a Times Square billboard.

Lavender Karin is definitely Mama Carla's girl!

We told Baby Ray that there would be food after the ceremony, but he couldn't wait. 

Baby Gaven

Ekurudi was a little cranky about the wedding.

Joy Julia

Vio prays

Baby Laura with a very stunning Danae

Rael: look at those eyelashes!

Noel

Baby Ezra

Samaki is growing fast.

Grace's very beautiful and intelligent sister, Sharlyn

Me and Rachele - it was a long time coming.

Carla, Me, Beth Ann, Rachele, Alna, Lyn, and Danae

Jeff, Erich, Mark

Carla, Jeff, Esther

James