We also wanted to invite you again to adopt an orphan to pray for, or add one if you are already praying.  If you are already praying, we say THANK YOU!  The difference in some of the kids from past years is obvious, and you should see their faces light up when we tell them they each have someone in the USA praying for them! I think it is very powerful to them that someone across the oceans knows their name and what they look like. We have about 30 kids that we still need to connect with people for prayer. 

There was a recent article in Christianity Today about how effective child sponsorship is.  Kids that are sponsored do better in life.  We certainly aren't a well oiled machine here at the Kettler house as far as communication and organization over this goes, but we would love to send you a picture of a child or two (OR a sibling group), along with whatever info we have on them, and have you pray.  If monetary sponsorship helps kids, IMAGINE what prayer sponsorship does!!  

And... of course.... If you would like to support Kitoben Vision Children's Home financially, that would be great!  Financial support can be sent to Nations to Nations, 5101 Lake Jackson, Waco, TX  76710.  Put a note with your check that designates it for Kitoben.  Every penny you send goes directly to pay for education, food, and clothing for the children, none is used for administration.  Some of you generously gave last year, and we have enough to get everyone through 2013.  Hallelujah!  Love to all,  Tom and Anne

We have been back for over a week now. I am at work full time and the business of life has returned. Unfortunately I have been sick for the past week and a half, When your illness originates in Africa it causes you to pause and reflect, but I think it was just a bad cold. I continue to have coughing fits, usually at night but they are decreasing. Anne also came down with a similar virus so we have been slowed but not stopped. I wanted to try and fill in a few of the gaps during our time in Kenya. I have enjoyed the blog because it allows everyone to see many of the places and people we have written about through the years. It has also been nice to direct some of my long time patients and friends to the site. During the first leg of our journey home I went through my journal and a lot of my old notes concerning our times in Africa. It is always good to reflect on the past, the good and the bad. Now that years have gone by, it is more like the perceived good and the perceived bad. Not quite so black and white. I have come to appreciate that sticking with things and enduring together brings about a deeper understanding and satisfaction. It also promotes a deep rooted thankfulness for God and our utter dependence on His "big picture and larger story" way of doing things. Our first trip to Kenya was 1998 and we stayed for three months, followed by two month stints in 1999 and 2000. We then had a hiatus, but worked in Rwanda in 2005. From that time on we have always returned to Kenya; in 2006, 2008, twice in 2010, 2012 and 2013. We have combined our medical work with our work at Kitoben Children's Home. Much has changed in the past 15 years, but amazingly most of the people have stayed the same. One thing that has not changed is that the ride back to Nairobi is always an adventure and the line of cars and trucks that have to be negotiated at the end will cause your prayer life to instantly blossom.

Morning Report occurs almost every day at Tenwek. It begins at 8 am in a large conference room. There are sometimes over 50 people with the majority being doctors and doctors in training. If you show up at 8:00 you might be alone but by 10 after everyone is there. No early bird sayings here. Some speak very softly and you may never be able to pick up what they are saying. Asking someone to speak up does not, under any circumstance work, so I usually smile and watch the new people struggle with thinking they are missing something. I can now confidently say I can understand the majority of morning report. 51% is a majority. One day a week, on Tuesday we have M and M rounds. That is mortality and morbidity rounds. Usually it is morbidity that leads to mortality and the presentations and discussions can be quite lively. That is usually thanks to the surgeons who drill down on what happened fairly quickly, exposing what went wrong and how the care could have been improved. There is no thin skin allowed. It is all about learning and growing and is sometimes painful. I have been on the receiving side of M and M., but not this time. It was most entertaining this year, as instead of the patients dying, they lived, and were even discharged and went home. I was on the edge of my seat as I kept thinking any minute they were going to give us the bad news.

One of the long term doctors has had it with all of the abbreviations used in the meetings. I have talked about this before, but it is worth repeating. SL = sick looking. BM = body malaise, or bowel movement, or bone marrow, or bacterial meningitis, just depends. GBM = general body malaise. HOB = hotness of body. CAP = community acquired pneumonia. NTB = not too bad. MAEW = moves all extremities well. PTB = pulmonary tuberculosis. P*, J*, C*, and O*, with those asterisks signs being the power symbol 0. That means patient with no pallor, no jaundice, no cyanosis and no oedema (british). Then there is also P+ and P++. He went on about how no one understands all of these abbreviations, but I was sure the majority did. The very next day he said that a DPL should have been done on a patient, that is a diagnostic peritoneal lavage. I just smiled.

Follow the ladders...

Some of my favorite signs in Africa are: The Toe Jam Inn, The Lazarus Funeral Home, The Anointed Candy Shoppe, The God Almighty School Bus, Flush Thrice with Vigor, Beware of Low Height Mind Your Head, and one of my all time favorites from the great state of Arkansas, that being a waste removal business, with a sign saying something like, "Our business stinks, but it's pickin up."

We have begun our journey home. We left Tenwek a few hours ago and just passed the "Annointed Candy Shop." I am wondering why in the world we didn't stop there, but now it is too late. What could be better than Annointed Candy!? There are always mixed feelings leaving. This time we made some closer relationships with the other Americans in the guest house because we ate there everyday and played games together at night:)) Hannah is an intern with Tenwek this year, and as I mentioned before, just graduated from Wheaton. She's just Katy's age and I would like to adopt her as my fourth child.  Trouble is she has a family already. Anyway, she was so much fun. I will miss her. Also, Jerry, the guy who helped build the first dam at Tenwek. He was from North Carolina and his deep southern accent and personality stole our hearts. So it was a little hard to leave them, and of course the Kitoben crew.

We visited Kitoben for the last time on Monday. Alot of the older kids have left for school, but those in grade 3 and lower are there and are attending the newly opened "Ketcasa School" right there on the property. I have tried to make an effort to hug each child each time we visited this time around. They were sometimes a little reluctant, but Monday they had warmed up and all gathered around. They approached shyly with chin a little low, one arm outstretched to touch my shoulder and waited for me to hug them. I guess you can imagine that I was trying not to boo hoo loudly. We know the older kids pretty well by now, but there are so many new young ones that I can't keep them straight. I will try to study their pictures when I get home. I need some more people to pray for kids if you are interested. No other obligation and no shame, no guilt, just a picture and a breath prayer when you see it or think of them. One or two prayers a year would be better than none. Alice gave me a complete list of sibling groups this time, so that's been kind of helpful. For some reason, I really want to "see and know" each child, and I want someone else to "see and know" them too. Kind of like with Hagar, God is the God who sees, so I think He wants us to see people too. Some of you are praying for older kids that have grown up, so if you want to add a younger one, let me know.

If you remember, we were thinking about starting a college fund for the kids to take out loans and pay half of back. We pondered it, and decided to just go ahead and open it at Kitoben's bank and let Alice and Samwel administrate it. I went to the bank with Alice this time. Tommy usually does stuff like that because he is better at it, but after some intense discussions with several bankers I think we walked out with an understanding of the difference between dollar accounts, which we opened, and KSh accounts. We wanted her to get the best possible exchange rate. They will write some bylaws for the account, and have the people who borrow sign a document which they will keep at the bank. Someone gave us a gift before we left thru Nations to Nations to do whatever with, so that's what we chose to do. It's kind of exciting really, and Mercy, the clinical officer student, will be one of the first beneficiaries. Right now she owes a lot of money and they won't grade her tests from her first year until she pays.

Tommy hasn't had much of a chance to write, but is planning to do some when he gets home.  Thanks so much for reading along.

Tommy found our first chameleon yesterday.  He is taking a nap on our curtain rods.

Tom led a D group in the endoscopy suite this morning and I got to attend. Afterward, he told them all how much he appreciated their compassion, kindness, humility and team work. They also expressed their appreciation to him, for his help, his wisdom and perspective, his willingness to come and just his presence. It was very cool.

The endoscopy team

 For the bible story, we read and discussed the story of Jesus calming the sea in Mark 4:35-41. I love the differences in how we all look at things, and I learn so much from the Kenyan people every time we come here. Today I was struck by a couple of things. First, when you ask what they are thankful for, no matter the age, a good percentage (1/4th to 1/3rd) will say, "The gift of life." Every time I hear someone say that, there is something about it that really captures me. I have to confess, sometimes I think it would be easier just to go on to heaven. But, I do simply want to be thankful for the gift of life.

Also, as we discussed the story, I asked whether they thought the disciples should have awakened Jesus when they were afraid. They all immediately said "Yes! Absolutely! They had too! Their unified response kind of took me back. I had actually been considering whether they just should have kept a stiff upper lip, tried to have faith, and waited for Jesus to wake up. He knows everything, can do anything, and even though the boat was filling up with water He would have gotten them to the other side, right? Maybe, but I think they grasp something about needing Jesus and the interaction between God and man that I forget. In the story, Jesus points out their fear and lack of faith. I was trying to think what the disciples could have done to demonstrate that they did have faith. But after reading this many times, I think the lack of faith was shown in their question, "Don't you care about us?" and not by their need of His help.  Another thought is that maybe He wanted THEM to believe and rebuke the wind? Anyway, Jesus's stories are so multifaceted; so deep and wide in their application and stimulation of thought. I'm sure that's why He used them. I want to try to think about them more.

I'm on call today. (Tom) It began with a patient dying in casualty before we really got started. He was a young man that I really never figured out. Probably a mixture of trauma, alcohol, and being in the wrong place at the wrong time. So far today was a busy day of hard cases. Five admissions, one consult on an OB patient with oligouric acute renal failure, hyperkalemia, hyponatremia, severe anemia with pancytopenia, probable sepsis, and she delivered a baby that died 2 days ago. I had to read about that one with many trips to the unit. We had no blood to give her as the hospital was out, and she was O positive. It didn't take me long to remember my own blood type is O pos. She needs dialysis as well, and her potassium was 6.3 on last check. I had an unfortunate poisoning patient who tried to take her life by ingesting Triatix. She was really sick and we had to intubate her and put her on a ventilator. But prior to getting the ventilator, I had to take another patient off a ventilator. Hopefully they will do ok. We only have so many. It's nine in the evening now and I think there are only 4 more left in casualty that are coming in, hopefully none too bad. I have another day of call tomorrow and then I am finished with call. Anyway, I'm getting my money's worth. It takes me back to when I was young. Way back. Things continue to go well here and I am looking forward to this next week. We leave for home Wednesday afternoon, so plenty of time for more adventures. We went to tour the hydro plant and the beginning construction of the new hydro-electric project this morning. We are here with Jerry who is working on this new project.  He was one of the original team that built the dam back in 1986. What a story.

Tom giving blood for his patient

Anne and Jerry walking up the construction site on the side of the dam.
As Jerry said, 'It is sturdier than it looks"

I do have to say, this has been the most encouraging visit we have ever had concerning Kitoben Vision Children's Home. Lots of times, I mean LOTS, we have questioned and wrestled with this thing. We have known that God tells us to take care of orphans, and that our involvement with Kitoben was His idea and not ours, (the thought of an orphanage in our future had not EVER entered our mind before the first time we came here in 1998), but the question of how to go about it has been ever looming and even agonizing at times. We are clueless. How and when does helping REALLY help? I know many of you have asked the exact same questions, and I have no answers. I do know that God asks us to be dependent on Him, humble and repentant, and to persevere through struggles. This may be over dramatic, but I feel that we have been flat on our faces begging for His help and wisdom, and He has been pulling us along by outstretched arms. God HAS been so very faithful to Alice, Samwel and the kids. So many of you have been used irreplaceably in council, prayer, and financial support along the way. It is really like a refreshing cup of cool water this time to see things seemingly going along so well!

Yesterday was a full day. Hannah, Tommy and I went to Kitoben in the morning and did the last part of the key chain. I reviewed the previous three concepts and then Tommy talked about the last verse, Matt 28:18, "Go into all the earth..." He talked about revival and how it could start with them right there at Kitoben. They were listening intently. We also talked about the many people that have never heard about Jesus in Africa. They actually broke into applause when we told them that we pray that some of them will be the ones to go into those areas and share about Him someday. It was quite exciting! I was glad there wasn't a theologian present over the last week as we tried to get these ideas across with word pictures and examples in the face of language challenges.  At one point, as we were tying to discuss putting all our hope in our divine inheritance, heaven moved from being the "City of Gold" to the "City of Cake." Cake is universally their favorite food. Oh well, maybe there will be something like cake there?

We left Kitoben late morning with Mercy (a different Mercy), Jackline and Alice so that the two of them could be seen at the hospital. We got to see what the hospital is like coming in from the other side. As visitors, the challenge was trying to balance not being too demanding of the consultant physicians with getting good care and some questions answered. They were both difficult cases. Everyone was very gracious, and we came away with a fairly clear diagnosis for each of them, and a plan to move forward. We were very pleased, but it took all day and was pretty exhausting.  Once again, we got a small glimpse into Alice's life with 80 kids, and are so thankful and appreciative of all she does. We capped off our day with a slightly cool Coke Zero from the local duka.



The kids waving their key chains and chanting "Everyday! Everyday!" after we
had talked about reading the verses everyday.

The hospital visit, Alice, Mercy and Jackline.

Enoch (center) is Alice and Samwel's oldest son and is
in pharmacy school.  Check out the keychain on the belt.

This is a (sorry) picture of a swarm of bees that came to "rest" in one of the nearby
trees.  Apparently they come to the same tree about this time every year.
The guards tried to burn them out last night, but they moved and made this swarm on the lawn,
and then by the end of the day had moved on.  I tried to take this picture from a distance:)

I have been on call a few times now at Tenwek.. My first patient to see late last night was a man who had been in a motor cycle accident 6 days before. He had some chest pain and an open fracture of his ankle. He was in the O.R. but the ortho folks wanted him to be seen due to his chest x-ray and low PO2. He initially had an O2 in the 50s but had come up to the 70s. He looked pretty good in person, but his chest x-ray did not, and the dilemma of how to manage him began. I remember little sayings in medicine, and one is, always treat the patient, not the x-ray, or whatever else might be confusing you, such as a monitor or such. I treated him with an non rebreather and increased his oxygen, held off on the ARDS dx, and intubation, and we both made it through the night. This morning I did talk to an American radiologist, Shane from Birmingham, and he said the chest x-ray looked like non cardiac pulmonary edema. Anyway he made it through the night.

What's your diagnosis?

One of the many things we do in endoscopy is put in esophageal stents. Here is how a lot of them go: Joyce is a 73yo here for an EGD to rule out esophageal cancer and have a possible stent placement. She has come from far away and has severe dysphagia. We pray prior to her EGD and someone signs a consent. We pass the scope under no anesthesia, and she does have a tumor at 25 cm. A wire is placed beyond the tumor because the scope cannot be advanced, and the esophagus is serially dilated to 36 French. She is re-scoped and her tumor is measured from 25-30 cm. Biopsies are taken, The remainder of her stomach and duodenum are normal. Her EG junction is at 37 cm. Her UES is at 15 cm. A 12 cm Chinese nickel-titanium alloy stent is marked at 20 cm, in order to deploy 5 cm proximal to the lesion, and is placed without difficulty or complication. The scope is re-inserted to check the placement of the stent, the wire is removed, and she is given the ceremonial cup of water to drink. No perforation is noted and she is discharged home with a hospice consult and a chaplain consult. This is all done with a total cost of 30,000 shillings. The shilling is 85 to one dollar, so it's around 350.00. The stent helps with swallowing and the average life expectancy of a patient after stent placement is I believe nine months. I have seen one patient that had a stent placed 17 months ago and we re-stented her last week. Tenwek is now well known for their work and are conducting research studies searching for the reason why this is a world wide hot spot for esophageal ca.




An esophageal stent