Quarterly Report---I'm STAYING!

Dear Friends and Family,

                I’ll start with saying that I’m staying for at least two more years.  In order to stay I need friends, family, and siblings in Christ to contribute towards my month support.  Please prayerfully consider being part of my financial support team.  If you feel that God is placing this on your heart, send me an email at ari.cale@gmail.com for more details.

Spiritual Growth

                I think one of the areas that God has been helping me grow the most recently is the Christian responsibility of justice (or lack there of).  I think my culture and my impatience with the Peruvian culture has affected my lack of understanding of God’s desire in this issue.

                Some examples: in Febuary it’s “Carnivales” in Peru and the guys go around getting the girls wet, even if they don’t want to play.  Even the adult men are involved.  I get angry because to me it’s a male dominated culture making it acceptable that they can maltreat not only their wives but any women they want (because the women are never strong enough to win, plus the men just get angrier if they get wet).  The American within me says, it’s my responsibility as an American to ensure justice for all the poor oppressed women here.  And my mind goes to the extent of saying, it’s my responsibility as a Christian to give justice to all of the poor and oppressed in the world.  And in my anger I start praying down curses on the men.  A group of men were working on the house next door one Saturday, and I couldn’t come and go as I pleased for fear of them getting me and all of my groceries wet.  I managed to escape twice—once running and the other time on my bike.  I prayed every single curse down upon them:  I hope they get sick and don’t earn any money until they repent and change their ways.  I prayed curses on the house, that they couldn’t continue building, etc.  Maybe God answered my prayers; I never saw that group of men working on the house ever again.  For a time no one was working on it.  Later only one or two people were working on it.

                Another example:  We’ve started renting an artificial grass field for our Ultimate Frisbee night (I’ll explain more about this change later).  We’ve been renting it from 7pm until 8:30pm and we pay in advance.  (Which is a plus for the owner because the majority pays afterwards).  We are always there at 7Pm sharp.  There were various different groups that played the hour before us.  A new group who was playing soccer arrived late and so ran into our time.  It’s a problem because a lot of David’s (one of my friends who is a math teacher at the Diospi school) students are coming so the Frisbee runs late.  Initially it was 10 or 15 minutes over.  Then one night they were 20 minutes over.  We talked with them, and they said 10 more minutes.  But in 10 minutes they had no interest in stopping.  When we put pressure they said 15 more minutes.  The owner was playing with them, but is a coward and wants everyone happy so that they keep renting his field, so he didn’t say anything.  And the men think they can do whatever they want because we were mostly teens and kids.  I was so angry that I had to walk away and leave it to David to sort out.  I was thinking, just wait until you come to the hospital dying and you can wait 20 minutes, and we’ll see if it makes a difference (the truth is, time is life with emergencies).

                Obviously this isn’t from God:

                “God blesses those who hunger and thirst for justice, for they will be satisfied.”  Matt 5:6

                “What sorrow awaits you teachers of religious law and you Pharisees…you ignore the more important aspects of the law---justice, mercy, and faith.”  Matt 23:23

                “For God has set a day for judging the world with justice by the man he has appointed, and he proved to everyone who this is by raising him from the dead.”  Acts 17:31

                “In his justice God will pay back those who persecute you.” 2 Thess. 2:6

                “I have singled out Abraham so that he will direct his sons and their families to keep the way of the LORD by doing what is right and just.” Gen 18:19

                “This is what the LORD says: Be fair-minded and just.” Jeremiah 22:3

                “Never pay back evil with more evil.  Do things in such a way that everyone can see you are honorable.  Do all that you can to live in peace with everyone.  Dear friends, never take revenge.  Leave that to the righteous anger of God.  For the Scriptures say: ‘I will take revenge; I will pay them back,’ says the LORD. Instead, ‘If your enemies are hungry, feed them.  If they are thirsty, give them something to drink.  In doing this, you will heap burning coals of shame on their heads.’  Don’t let evil conquer you, but conquer evil by doing good.” Romans 12: 17-21.

                Justice is the Lord’s.  My responsibility is to BE just and to LOVE my enemy.  When I’m worrying about fighting all the injustice in this world, I feel hatred and not love for my enemies.  The funny thing is that in writing and in retrospect it sounds obvious.  But with the influence of culture and bad habits it’s taken years for me to grasp this simple concept of what God wants from me in these circumstances.  Pray for my continued growth in this area.  It’s a lot easier said than done (or felt in my heart).

Actinomicosis

                Actinomicosis.  A rare, chronic, pyogenic (pus forming) granulomatous infection caused by actinomycetes, a group of anaerobic gram-positive bacteria.  The most frequent features are ulcer and granuloma formation, and the presence of multiple abscesses and sinus tracts that may discharge sulfure granules.  The most common clinical form is cervicofacial, but thoracic, pelvic and abdominal actinomycoses also occur frequently.

                I had never seen a case before.  The only thing about Actinomicosis I remember from medical school and board questions is that if the question describes a diabetic with severe infection eating away at the face into the brain the diagnosis is “Actinomicosis.”

                I arrived at the hospital at 12:30pm after flying from Lima to Cusco and then taking a car from Cusco to Curahuasi.  I’d requested 8 new patients because I was the only general doctor in the afternoon (other than a Peruvian Family Medicine resident).  When I arrived I reviewed the clinical histories in my box.  One history had a note started by Josias, a Peruvian medical student who had been working in the hospital in the morning.  Dr. Martina had been overseeing the medical students in the morning, but there was about a 2 hour gap between when she had to leave and when I arrived.  Laura, one of the German medical students explained what their diagnosis and plan they had decided for the patient…but I remembered the patient…

                Luis was a 31 year man from a rural village that had presented to the hospital a month prior  with right lower quadrant abdominal pain (the area suspicious for appendicitis).  He had been seen by Loures,the Peruvian Emergency Medicine third year resident that was working with us for a month.  The ultrasound of his abdomen showed only hydronephrosis of his right kidney (dilation of the kidney because something is blocking the urine from passing down to his bladder).  His CRP (a blood marker of acute inflammation) was 270 and his white blood cell count (another sign of inflammation) was elevated.  The resident didn’t realize that we can give discounts if patients can’t afford tests or treatments that they need.  So without consulting anyone, the resident sent the patient home to come back the next day with enough money for the CT scan of his abdomen.  He didn’t come back.

                The resident presented his case the next morning in the morning report and of course everyone was upset and concerned that Luis had been sent away.  But we felt a little better knowing that he’d had the pain for 2 months and he didn’t look that sick.  Even when he finally came back a month later he still didn’t look that sick.  But he had peritoneal signs on his physical exam (when the abdominal muscles tensen involuntarily suggesting that there is severe inflammation and infection within the abdominal cavity).  I remembered his case the second I saw his history.  Because to the students he didn’t look that sick and his pain had been going on for 3 months, they wanted to send him back home to bring back the CT that he said he’d had done in Cusco and he’d forgotten to bring with him (turns out it was an IVP, a contrast study looking at the flow of urine from the kidney to evaluate an obstruction).

                I admitted him.  His ultrasound still only showed hydronefrosis  (Dr. David, our new urologist, placed a stent—a tube to allow the urine to pass through the ureter where there was the obstruction) and no appendicitis.  CRP was 280.  WBC 80% with 80% neutraphils.  Dr. Annette, the surgeon, thought that clinically it looked like a blastron.  Here the people delay in operating their appendicitis, so the body walls off the abscess to prevent the infection from spreading through the body, and it is called a blastron.  This would explain how he didn’t look so sick with CRP 280.  Here is his CT that we performed:

                So Dr. Annette took him to the OR.  Only to her surprise to find not a blastron but that all of the intestines were matted together in a ball of pus and inflammation (and this mass of infection was compressing the right ureter so that the urine couldn’t pass, causing the hydronephrosis on the right).  There was no way to operate without taking out all of the intestines and Luis couldn’t live without intestines.  So Annette took several biopsies and shut him up.  Annette’s and Martina’s thoughts were that it could be intestinal tuberculosis (which is common here) or typhoid perforation (which isn’t very common here in comparison to Niger where I’d done a one month surgical rotation).  One test for TB (an ADA) was done in our lab with one biopsy and was negative.  The test for typhoid was negative in the blood.  So continuing Ceftriaxone and Metronidazole, we waited for the pathology to come back from Lima.  Two weeks later it came back with the diagnosis of Actinomicosis peritoneal.

                We changed the antibiotics to Ampicilin (which is more specific for Actinomicosis) until he was completely clinically better.  Finally his pain went away and his intestines were functioning well.  We sent him home with 4 weeks of Amoxicillin and an appointment in 4 weeks.  This picture was taking the day before he went home.

Sunday School

                Because David is a primary school teacher, he obviously has a heart for kids.  In the IEP church I’m serving in we were dividing up the ministries and David volunteered to take of the Sunday School program, that had not previously been much of a priority.  Since this time I’ve been helping him teach and assign teachers.  The church still lacks a lot of leaders with a good biblical foundation.  So we’re teaching every two or three weeks right now.  Please pray for teachers. 

                Also the church is one room, so we were borrowing the patio of a different building Sundays for class.  But the space has now been rented and we’re looking for another space to use.  Please pray for that.  A couple of weeks ago we finally bought tables for the kids.  

Running

                I’ve run almost every day since I was 16.  When I started running I ran with my dad.   And I ran with him until I went away to college.  Since that time I never had a consistent running partner until now.  Initially David was just accompanying me on the weekends, but for the last couple of months  David has been running with me every morning.  We run about 20 minutes out of town to a peaceful field on the mountain side where we pray together.  It’s so interesting here.  We are on the mountain side in the Andes, overlooking the valley where the Apurimac River flows.  Even though we live in the elevation, often times a flock of wild green parrots fly by.  The other day when we looked up from praying, there was a bull looking at us, wondering what we were doing there. :)

Rosmerry and Dennis

                Rossmery and Dennis are now some of my dearest friends.  I continue to study with them most Sunday evenings.  David often comes with  me now (thanks God that he finally found a good bike that he can make the 30 minute uphill trek with), and either spends time with their boys Nando and Jose or with Rossmery’s significant other, Rafael.  For couples to be unmarried here is very common because of many reasons.  One of which is that the wedding is expensive and complicated here.  They’ve been together more than eight years, but the relationship is still very unstable.  Rafael professes to be a Christian but is a very immature Christian.  Often times I’m not sure if he knows what he wants from life yet.  But most recently David been getting to know Rafael better and they’re playing soccer together Friday nights.  I think God’s placed David specifically in the life of Rafael for a reason, because the majority of Rafael’s friends drink, gamble and party.  Please pray for our growing friendship together (us four).  Pray for my friendship with Rossmery and Dennis.

                Pray for Nando and Jose.  They will enter first grade in March (the school year ends in December here).  They’ve both applied for scholarships to enter the Diospi School the next year.  There are several cost and transportation issues.  Please pray that God resolves these issues.  David and I have already offered to pay their scholarships if they qualify.  (The Diospi School is funded by donations and by the tuition of students whose parents can pay.  The foreigners work for free, but the Peruvians workers earn minimal wage.  The scholarships are paid by individuals in other countries that want to sponsor a kid so that they can study.  It’s about $40 a month).

Ultimate Frisbee

                We MOVED!  Because the “shoe rule” in the Diospi school gym (only white or rubber colored soles on shoes only used inside, and never outside) we found that few people wanted to invest in shoes to play a game that they didn’t know.  And the majority of those we were targeting didn’t have money to buy anything extra (students and recent grads).  There’s a strong culture here for young people to send the extra money they earn home to help support their parents and siblings who still live at home or are studying.

                So we now rent a Turf soccer field to play.  Before moving our numbers were between 10 and 25 (with at least half foreigners).  Since moving our numbers are between 35 and 50 (with only between 2 and 8 foreigners).  The last three weeks we’ve pause for a moment for David or Miqui to share a devotional thought.  This last week Miqui invited the kids, adolescents and young adults to the young adult service Saturday night.  The majority of those playing Frisbee either don’t attend a church or are “Catholic.”  Please pray for Saturday nights.  If all 35+ come, only by the power of God can we connect with each one and help them feel part of the family of God here.

Thanks again for all your prayers.  May the Lord continue to richly bless you.

In Him,

Ari

Pulmonologist

                As I mentioned before, Dr. Malte is a pulmonologist working with us now.  He’s helping with all the patients a little but also our lung cases.  In the USA most of the chronic lung problems I cared for were complications of smoking: COPD, asthma, and lung cancer.  Here we have lots of lung cases but none are from smoking.  Smoking is very rare here.  I’ve had a couple patients who admit to occasional cigars, but never cigarettes.  Here the people cook with wood and work in silver, copper, and gold minds.  Also this time of the year at the end of the dry season everyone burns their fields. I still see a lot of COPD (destruction of the lung walls and hairs that move mucus and over production of mucus because of smoke and pollution) and asthma.  I also see a lot of tuberculosis (TB) and scarring from old tuberculosis infections.  Here if you have a patient with plural effusion (liquid levels at the base of the lungs) its TB until proven otherwise.  There’s also a lot of patients with pulmonary fibrosis (scar tissue of the lung as a result of chronic inflammation).  I have patients with pneumoconiosis and silicosis (chronic inflammation caused by toxins/metals they have breathed in while working.  I gave a bunch of my chronic lung patients’ appointments with the pulmonologist.  I’m thought he’d like the challenge.  I think he’s still trying to figure out how to treatment patients in our setting---where people who don’t have a lot of money have to pay for their CT, where the bronchoscopy is broken (pray for a new one), and where the medicines we have available are very limited. 

                This last week he saw one of my ladies who I’m treating for an Aspirgiloma (a ball of fungus in the lung).  She doesn’t want surgery (because she’d have to go to Cusco, and they don’t trust their own Peruvian doctors very much), so I’ve been treating her with Itraconazol 400mg every day for 4 months now.  The aspirgiloma is getting small little by little.  Average treatment length is between 2 and 13 months.

Neighbors

                Inessa and I live on the third floor of a 3 story building.  The owners live on the second floor.  The first floor is a party room.  On the roof live the guinea pigs and rabbits, and also there is a stone oven.  On the third floor are two apartments.  We’re in one and the other has been open for a while…but now it will be occupied.  Two young women (sisters) from Lima just signed contracts with Diospi: Daniza and Damaris.  Daniza studied theology and will be teaching at the Diospi school.  Damaris is a psychologist and will be working at both the school and hospital.  They came to the women’s group while they were interviewing here and I had a chance to hear them talk about their deep personal relationship with the lord.  They’re both probably in their early twenties.  I’m super excited to have them a Diospi but also as next door neighbors.

Ultimate Frisbee

                Thanks for your prayers. I was talking with the leadership of the local church I’m attending.  Our purpose in having ultimate Frisbee every week is so that teens and young adults who don’t currently attend evangelical churches can get to know the church, and then if we invite them to classes and services they are more comfortable and interested in coming.  We had been renting the gym at the Diospi school, but the rules were getting stricter every week: first non marking schools only, then only schools with rubber or white soles that had never been worn outside, and then they because concerned that even the white soles were leaving marks.  After praying over the issue, we decided to rent a turf field because the people we were targeting didn’t have money to buy a pair of shoes to only use once a week to play. 

                We’ve played Frisbee two weeks now in the synthetic grass field and God has really blessed it.  Both weeks we had nearly 40 kids, teens, young adults, and adults come out to play.  And mostly Peruvians.  The first night only 4 of us were foreigners, and the second only 10.  Prayers on wisdom and guidance on inviting those we reach to church.  The church is still very small.  There’s only about 5-10 of us available to take on the various leadership roles.  Miqui is in charge of the young adults. David just took on the Sunday school.  Jemerson, the pastor, is in charge of every time.  Juvenal is in charge of the music ministry.  I’m in charge of the weekly women’s group. Miqui and David are helping me with Frisbee.  There’s no one in charge of the teens yet.  They’re kind of added on to the young adult group or children’s Sunday school depending on their age and maturity.  Many of those coming to Frisbee fall in this teen group.  Please pray that God sends someone to fill this role in the church.