Interesting cases part one

For those of you a bit queasy, this post is not for you. This is for those either a)medical or b)interested in medical stories.

This is a photo depicting the leg of a young girl, I believe she is 11 years old. The probe is in her femoral vein, if I remember correctly. She presented with a swollen, painful right calf. Two weeks prior she had cut her foot on a piece of a tin can. The cut on her foot had healed, and did not look infected. We did an ultrasound to look for DVT, but unfortunately did not look high enough in her leg (only looked from about the calf down, since that is where the swelling was). The next day she was admitted to the ICU with tachycardia, hypoxia, and right heart strain. She also developed high fevers. We did a more thorough ultrasound and found a large thrombus in her femoral vein. With all her signs and symptoms, we suspected a septic thrombus. We put her on heparin, but without thrombolytics, there wasn't much else we could do except amputate the leg above the thrombus. We did an amputation of her right leg, and this photo shows the amputated portion. When we cut into the vein, there was pus that came out. She improved dramatically in the days following the amputation. Clearly the surgery saved her life. She did fairly well emotionally too. Her father has some form of deformity in his legs (I can't recall what), so the idea of a person walking with crutches for their whole life wasn't foreign to her or her family. I think this helped her to cope, and had it not been the case, I'm not sure her parents would have agreed to the surgery. Dr Lindsey is looking to see if it will be possible to obtain a prosthesis for her.

This next photo is the leg of a sweet little girl who fell at least a year prior, and sustained an open tibial fracture. Obviously it wasn't well reduced (often a result of traditional treatment), and resulted in part of the tibia sticking out of the leg. We gave her anesthesia and pulled out the dead bone you see here, then put her in a cast to stabilize the leg as the remaining healthy bone heals in. I suspect her fibula will tibialize to support her weight. 

This little boy presented with abdominal pain, fever, and a distended abdomen. While the first concern from the history was for peritonitis, further physical exam and ultrasound confirmed a large abscess between his abdominal muscles and skin, which extended down into his scrotum. It required a very large incision to drain. This photo is after several dressing changes, when it was starting to heal. Soon after, we were able to close the skin secondarily, and he was able to go home.

This young lady, in her mid 20's, sustained this ankle fracture in a motorcycle accident.  (Which is where most of our Ortho cases come from.) She presented several months after the accident. This was beyond our ability to treat, as ankle/foot fracture of this nature are a challenge even to orthopods and podiatrists. When we told her we wouldn't operate, she fell to the ground, crying and pleading that we would do something for her. Then we called in her mother to console her, and when we informed her the same news we told her daughter, she also fell to the floor and did the same. They weren't without hope, as there is a doctor in a nearby town who was willing to operate, but they were hoping they would have something done at Nyankunde.

I came in one morning to see two of the Congolese doctors attempting a D&C for a retained placenta. They were using ultrasound guidance, and found the placenta seemed to be oddly placed...very superior in the fundus, and no plane of separation. This is because she had placenta increta, where the placenta has grown into not just the endometrium, but the myometrium (uterine wall) as well. Thankfully it wasn't through the serosa (which would make it placenta percreta), as that is more difficult to treat. Kimiko and I are doing a hysterectomy in this photo.

This young 40 something year old presented with early satiety and an abdominal mass. She was also anemic and appeared mildly malnourished. The mass you see in her abdomen is her spleen. The following photo is her spleen after we removed it. I believe it weighed at least 5 lbs! It was heavy, at any rate! It's not often we do a splenectomy for splenomegaly, but in her case, it was definitely warranted.

This x-ray is from a young man who presented with shortness of breath. Diagnosis? 

He felt much better after we placed a chest tube. 

This 30-something year old man came in with a leg mass that he had for at least 2 years. It has progressively increased in size. We offered to do surgery to remove the mass (it appeared well-circumscribed, no boney involvement) but he never returned for surgery. I'm not sure if he was still looking for money to have the surgery done or he decided to go elsehwere.

Transitions

Endure hardship as discipline; God is treating you as his children. For what children are not disciplined by their father? If you are not disciplined--and everyone undergoes discipline--then you are not legitimate, not true sons and daughters at all. Moreover, we have all had human fathers who disciplined us and we respected them for it. How much more should we submit to the Father of spirits and live! They disciplined us for a little while as they thought best; but God disciplines us for our good, in order that we may share in his holiness. No discipline seems pleasant at the time, but painful. Later on, however, it produces a harvest of righteousness and peace for those who have been trained by it. Therefore, strengthen your feeble arms and weak knees. "Make level paths for your feet," so that the lame may not be disabled, but rather healed.
Hebrews 12:7-13

     This 33rd year of my life has been a challenging one. It has been a year full of transitions, and there are more transitions yet to come. I've transitioned from living and working in a hot, humid environment in Impfondo, Congo to living in cooler, less humid Indiana. I've transitioned from working in a culture not my own, speaking daily in a second or third language, and struggling with finding the right words, to working in the US, in my own language, but in a job less fulfilling. I've transitioned back to another culture, similar to the one in Impfondo, but yet different, in Nyankunde. I could at least speak French and some Lingala, but now limited by lack of speaking Swahili, and struggling with another language barrier.
     During all these transitions, my faith has been challenged. I've been forced to re-evaluate many things.  I feel as though God has been breaking down certain barriers I have built up over the years so He could either create new doors, or rebuild the wall in a structurally sound manner, rather than my feeble human-erred attempts.  He's calling me to draw closer to him, to put aside any distractions I've had in the past, and step out in faith.
    The question remains-step out where? I am not yet sure. I have some ideas, but I am not yet ready to share them with the world, and they require much more prayer before things are clear. I was hoping that during my three months in Nyankunde, I would have a clear direction as to the next steps in my life. However, the only thing that is clear is that I must trust God and depend fully on him. Jennie Allen, author of the book Restless, writes "He likes his kids completely hanging on to him for dear life more than he cares about the perfect plan being executed. He is after us, and uncertainty is usually what keeps us glued to his side. He is in the trenches with us. In the fear. In the uncertainty. He is in the unknown-knowing and leading and working. What we don't know yet is meant to lead us to dependence."
     Every time I read that last sentence, my mind wants to read "What we don't know yet is meant to lead us to independence. Which is exactly the opposite of what she is saying. Learning to be dependent is very difficult for this independent woman (ask my mom, I've wanted to do things myself since I was a baby. I wouldn't even take solid food until I could feed it to myself). But through these last three years, God has been asking me and teaching me to be dependent on Him and others, rather than trying to do it all myself. I've found through many mistakes and cultural faux pas that being independent often hurts ourselves and others-it deprives us of community and the ability to truly bear one another's burdens, and it causes undue fatigue and stress on ourselves.
  There are no words to thoroughly express the thankfulness and joy I have for my friends and family who have been by my side during this time. There has been some laughter, and many, many tears in the last year. I'm so thankful to have them nearby to wrap their arms around me (literally or virtually) and love me without condition. It's been exactly what I've needed.    
  So I ask you to gather round, pray for me as I pray for you, that we may bear one another's burdens. Pray for guidance for my future, and that I rest comfortably in the Savior's love for me. I will be praying the same for you.

Therefore, since we are surrounded by such a great cloud of witnesses, let us throw off everything that hinders and the sin that so easily entangles. And let us run with perseverance the race marked out for us, fixing our eyes on Jesus, the pioneer and perfecter of faith. For the joy set before him he endured the cross, scorning its shame, and sat down at the right hand of the throne of God. Consider him who endured such opposition from sinners, so that you will not grow weary and lose heart. 
Hebrews 12:1-3

It's about Redemption

 When they had finished eating, Jesus said to Simon Peter, “Simon son of John, do you love me more than these?”

“Yes, Lord,” he said, “you know that I love you.”

Jesus said, “Feed my lambs.”

Again Jesus said, “Simon son of John, do you love me?”

He answered, “Yes, Lord, you know that I love you.”

Jesus said, “Take care of my sheep.”

The third time he said to him, “Simon son of John, do you love me?”

Peter was hurt because Jesus asked him the third time, “Do you love me?” He said, “Lord, you know all things; you know that I love you.”

Jesus said, “Feed my sheep. 

John 21:15-17

Godly sorrow brings repentance that leads to salvation and leaves no regret, but worldly sorrow brings death.

2 Corinthians 7:10

When I first felt called to come to Nyankunde over a year ago, I knew that God had something special in mind for me while here. I knew that I would have direction for the next steps to take in my life. Little did I know what else He had in store for me. 

When I first arrived here, I found it strange at first to hear a mixture of Swahili and French, rather than Swahili and English that I've heard when in Kenya. Hearing the Swahili brought back memories of the two months I spent in Eldoret, Kenya while in medical school. Memories that were good, yet also painful. 

I remember having a good walk with the Lord when I arrived in Kenya. I remember that I read my Bible daily, and was comfortable in prayer. It was while there that I felt called to long term missions. Yet at the same time, it is also when I feel I started to drift away a little...I wanted control in one area of my life...one area in that I wanted to direct and do as I pleased. I could tell this was not pleasing to God, but it's easy to start talking yourself into things once you've started.  I have struggled to turn this area back over to God in the nine years that have followed. I have come to realize in the last few months (perhaps a year, but the realization and acceptance has been growing) that the real problem has been a lack of true repentance. 

And so, it was in hearing the Swahili again that these memories came to mind. Painful reminders of my sinful thoughts and behavior which cried out for repentance. God wants me, and ALL of me, all parts of my life, and I needed to give that back over to Him. I felt shameful of my actions, of trying to keep this part of my life from Him. I felt shame in seeing and remembering the hurt relationships as a result of my actions, perhaps causing others to stumble in their walk with God. 

Then one day in February, while laying on the floor, crying my heart out to God, I heard God respond: (not in an audible voice, but in my thoughts)

"Laura, do you love me?"

"God, you know I love you."

"Feed my lambs."

"Laura, do you love me?"

"Lord, yes, I love you."

"Take care of my sheep."

"Laura, do you love me?"

"Yes Lord, I do love you!"

"Feed my sheep."

Just as Jesus restored Peter after he had denied Him three times, he was restoring me. He was letting me know that I'm forgiven, I'm redeemed, and set free. Those things I've done in the past that weren't healthy for my walk with Him? Forgiven. Totally, unequivocally, and irrevocably forgiven. 

Dont' get me wrong, I've asked for forgiveness before, and I know I've received it. But one thing I had lacked was the one thing He desired-true, utter repentance. That is the difference. That is what finally occurred in both my mind and heart, bringing me to my knees before God. And that I where I received Grace. It is where Jesus redeemed me from my past, so I can go on living a different future. I know it won't be perfect. I'll have to keep giving this area of my life back to God over and over again. But I no longer live with guilt. 

So this Easter I'm especially thankful for the events that happened so long ago in Jerusalem. I'm thankful for his sacrifice on the cross, and rising from the dead. I'm thankful that we are no longer dead in sin, but alive in Christ. I'm redeemed, I'm redeemed, praise the Lord!

A long week

Some of you may know the maxim "All bleeding stops eventually". The phrase came to mind this week as we dealt with multiple difficult cases. (This may be too graphic of descriptions for some, so I'm giving you fair warning to stop reading now if this is the case. I'm also going to use medical terms and not explain everything. Suffice it to say, we had a difficult week with one emergency after another. Not many survived.)

Monday was a busy day. There are often cases that have been admitted during the weekend that aren't urgent enough to require us to come in during the weekend, but do need to be handled that day. We had several procedures already scheduled, plus the usual outpatients. Around 1pm we heard some vague rumors about a patient with hemoptysis and severe melena. But it wasn't clear where this patient was, and what exactly was happening with him. Then about 2:30 pm or so, we found there were several endoscopies which the medicine team wanted us to do. These patients had presented during the weekend with hemoptysis, but had been otherwise stable and could wait until monday for endoscopy (we look for esophageal varices, which are common here due to high incidence of infection of schistosomia, which causes peri-portal fibrosis, portal hypertension, etc). We did the endoscopies (I got to do two of them-and made it through the pylorus both times!), and even banded a few varices (which I did not do). Then we heard more about the patient with hemoptysis and melena, around 4pm. Turn out he was hypotensive and while blood transfusions had been ordered, donors had not yet been found. We got a line in him (he had had a 22G in the wrist), and about that time a friend of his and a passing nursing student were able to give blood. We did an endoscopy and found a large duodenal ulcer. We thought we could cauterize it, but when we did, then it started bleeding heavily. We rushed him back to the OR, and had him open and pressure on the site of bleeding in no time. Fortunately we had a case earlier in the day that we had cancelled, but the drapes, instruments, and gowns were all still in the room, which allowed us to start the case that much faster. He had lost so much blood that his organs were white, and nothing was bleeding. We managed to stop the bleeding, do a vagotomy, and close. He got two units of blood intra-operatively, and another post-operatively.
He remained stable overnight, but the next morning he developed tachycardia and hypotension and was transfused another two units. He was awake and talking to us, but you could tell he had this sense of doom about him. We tried to encourage him, to get him to fight, but I think he had lost hope. By thursday he had passed away.

Then tuesday we a fairly average day...two prostatectomies, removal of an ovarian cyst, etc. But Wednesday was another matter. We had a 2 year old present with hemoptysis. It is very unusual for such a young child to present with hemoptysis, even in an area with schistosomiasis. He was transfused and an endoscopy performed. It was found he had some form of vascular malformation in his duodenum, but no longer actively bleeding. It was decided to give fluids, blood, and observe him. He was doing fairly well the next morning when around 10am, he vomited again, copious amounts of blood. We rushed to the OR and found the site of bleeding and were able to stop it. However, his extremities remained cool and clammy throughout the procedure, and we weren't able to get a good oxygen saturation the whole time. After returning back to the ICU, we were called because he was noted to have dyspnea. He had an IV in his external jugular vein which infiltrated, and was causing respiratory compromise. It's unknown how long this had gone on before it was noticed. His breathing was rather Kussmaul-ish. We checked his pupils-fixed and dilated. My suspicion is he was hypoxic for a significant amount of time, whether during the OR case or after the IV infiltrated. He died not long after.

Thursday we had another man present with bleeding-this time a large amount of melena, but no hemoptysis. His hemoglobin was stable at 13, and no further melena, and his vitals were stable. In light of the long day of events on thursday and him being stable, we decided to wait until friday to do his endoscopy. But around midnight, he became agitated and was given tramadol and diclofenac by one of the other docs. Then at 7:30 am, he had acute onset of abdominal pain, tachycardia, hypoxia and hypotension. He was found to have free fluid in his abdomen. He did not follow the axiom that "Bleeders don't perforate and perforators don't bleed." We needed to resuscitate him with fluids before we could take him to the OR, so a central line was placed, we tanked him up with fluids, and blood was ordered. However, he remained too unstable to operate, and he passed away.

Not to mention the other cases we did this week: three cesarian sections added on to the schedule on either wednesday or thursday, I can't recall. Two with good indications, a third that was thought to be term by her last menstrual period with a hand presentation but was actually 28 weeks with twins (no ultrasound had been done, and apparently no one had figured it out by Leopold's maneuvers). The twins did not make it.  We also found out that another patient we had operated on a few weeks ago (menigocele repair) had died.  It seemed that death was all around us, despite our best intentions or best efforts. Perhaps we should have intervened sooner in some cases. Perhaps there are things we could have done differently, and the outcome would have been different. There are many what if's, but we have to live with what was. 

Then friday, I noticed one of the doctors had posted this to Facebook:
Dans un bon nombre de situation difficile,Dieu nous demande simplement d'avoir confiance en son plan et de continuer a avancer jour apres jour,sans baisser les bras.Alors quel que soit votre vie a un moment donne,prenez courage Dieu reste Dieu,il est assurement avec vous et il vous aidera quel que soit le defis devant vous. Philipien 4:6

Which means: "In many difficult situations, God asks us simply to have confidence in his plan and continue forward day after day, without giving up. When this comes to your life, take courage that God is always God, and he is surely with you and will help you no matter what the challenges before you. Philippians 4:6"

Philippians 4:6 says "Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God."

It gave me courage to read his post, and to remember that as he said, God is always God, no matter the circumstances. 

That's not what you want

Recently I've had some experiences of where the person I was interacting with had a different idea of what I wanted or needed than what I thought I wanted or needed. Examples:

A month or so ago I was at the market and asked for 150 francs worth of lentils. She told me no, I wanted 300 francs worth. I accepted, mostly because I probably could do something with them, and I understood she wanted to sell the last of what she had (which was 300 F worth).

Last week I had a little bit of hot water in with some coffee grounds in the French press to make a second cup of coffee. I hadn't filled it all the way because I wanted to add more hot water before I left the house, so it would be hot at work. Esperance, the Congolese woman who helps at my house, saw it as a dirty dish and washed it. Guess I really only needed one cup that day. 

Last weekend we went to the market and I wanted just 200 F worth of dried kidney beans. The lady gave me a look as if to say "are you crazy? That's not enough to for a meal."  I still only bought the 150 F. And by the way, it's plenty.

I made bread this morning and asked Esperance to put the bread into loaf pans. I got home and have two dozen rolls. I really wanted loafs. I wanted to have slices of bread. I can't really explain why, but it was important to me.

It got me thinking, I wonder how often we do something like that to God. He says "I want you to do this..." and we say "no, you really want me to do this." Sometimes we're like Jonah, who flees God's direction, or try to 'one up' what God wants. Sometimes he just wants us to be satisfied with Him. To take time to be in His presence. We try to 'one up' things, to do something 'better', but it really distracts us from what He really wants-our heart. And it distracts us from seeing and hearing Him.

Teach me your ways, O LORD, 
that I may live according to your truth!
Grant me purity of heart, so that I may honor you.
Psalms 86:11

First week at Nyankunde

     I'm sure many of you are wondering how things are going here. Well, on the whole, pretty good. I arrived Monday after a short flight from Entebbe to Bunia, then a 1.5 hr drive the last 20 km from Bunia to Nyankunde. I remember most of it, but there are things coming back to me that I realized I was a little too dazed and jet lagged to remember well at the time.
    At the airport in Entebbe I met up with Kimiko Sugimoto, a surgeon from the US who lived at Nyankunde for a few years as a child (her dad is a missionary surgeon). Kimiko is about the same age as me, and we are sharing a house here in Nyankunde. It's been fun getting to know her and share the work load at the hospital, and learn from her as we work. She's also been sharing with us what various buildings here once were, as we walk around some of the empty shells of houses that are here.
     CME Nyankunde used to be a very large, thriving mission hospital. However, in September 2002, the surrounding tribal warfare came to the hospital grounds of Nyankunde itself. (read more here) Many were killed, and hospital was ransacked and destroyed. About 10 years ago, a few returned to the hospital and found the place buried in thick grass and brush. Slowly, they cleared things out and the hospital was re-opened in 2005. Work has continued ever since to slowly re-establish what was lost. Samaritan's Purse has helped tremendously with rebuilding the hospital, including the construction of a new surgical suite and ICU. The hospital is staffed mainly by Congolese doctors and nurses. Drs Warren and Lindsey Cooper are the only ex-patriot (foreign) doctors here long term.
     Tuesday we jumped right in to work. I've been able to assist on a few contracture releases/skin grafts (all were people who developed these after suffering from burns), a post-hysterectomy following complications of a c-section done elsewhere (she needs prayers!), and a few other cases. I've also been brushing up on my ultrasound knowledge.
      The weather here has been nice and warm-in the 70's most days, but cool in the evening and early am. Much better than the -15 degrees we've been having in the US! While the snow is fun for sledding, I much prefer to be able to get out and walk around in short sleeves! The hospital is situated on side of a 'mountain' (not sure if it is technically a mountain, or just a large hill), so I've been getting some exercise going to and from work, as well as exploring the hospital compound. The guest house here is quite nice. There are three bedrooms and a nice living area and kitchen. I can even get a hot shower!! What a blessing!!
     A few things I could use some prayer on:

• Going to bed at a decent time so I get enough sleep. I tend to be a night owl, which doesn't work well when one has to get up early. 
• Humility to state what I do and don't know.
• To be able to deal properly with feelings of insufficiency. There is so much to learn, and so many times I don't and won't be able to know the answers. It's easy to feel one isn't enough, doesn't know enough, can't do enough. 

Here are a few pictures from my first week here:

View of Lake Victoria as we left Entebbe

Lake Albert (on the border between Uganda and DR Congo)

Where I'm staying. See all the flowers? I'm so happy!

One of the houses that is being renovated. The house I'm in used to be like this.

The swimming pool. Anyone want to jump in?

The soccer field and some of the housing for staff. Notice the fields on the hill in the background.
How would you like to farm that? 

Warren, Lindsey and Kimiko.

At the market

Some of the legumes one can purchase at the market.

Kimiko buying green coffee beans for us to roast.

Fabric I bought at the market.

Another piece of fabric I purchased.

The nursing school.

Little foxes

This is something I wrote a few years ago, but never got around to publishing on my blog. 

Catch for us the foxes
the little foxes 
that ruin the vineyards, 
our vineyards that are in bloom.

Song of Solomon 2:15

     Irritations. They can run rampant, especially on the mission field. Living in close quarters means living, eating, working together all the time make opportunities for little irritations to grow into big problems. This is especially true when we don't always feel comfortable enough with each other to address these problems face to face. This may be because we have a fear of confronting others, or worried about either how the person will react or how we will be perceived. As Christians, I think we get caught up in the idea that we need to be nice to everyone all the time, never saying a bad word and never offending anyone. 
     But is that what Christ really wants? A bunch of people being outwardly nice to each other while seething with irritations and anger inside? Being too afraid to confront someone when they are obviously doing wrong? If a person is doing wrong or actions are hurtful and doesn't realize it, how are they to change unless someone points it out to them? 
     Matthew 18:15 says "If your brother sings against you, go and show him his fault, just between the two of you. If he listens, you have won your brother over. But if he doesn't listen, take 1 or 2 others along, so that every matter may be established by the test of 2-3 witnesses." 
     And again in Mathew 5:23-24 "If you are offering your gift at the altar and there remember your brother has done something against you, leave your gift there in front of the altar. First go and be reconciled to your brother; then come and offer your gift." (emphasis mine). He wants us to have right relationships with others before offering our gifts to him.
     But it's not just when others have wronged us that we should confront others, but also when we have wronged others. One should not be so foolish or arrogant to think one does not do wrong or harm others. Jesus says in Matthew 5:3-5 "Why do you look at the speck of sawdust in your brother's eye and pay no attention to the plank in your own eye? How can you say to your brother "Let me take the speck out of your eye", when all the time there is a plank in your own eye? You hypocrite, first take the plank out of your own eye, and then you will see clearly to remove the speck from your brother's eye." So when we confront others, it should be done with a humble and contrite heart. One should examine one's own motives first-is the problem with me or with them, have I contributed to the problem? What can I do differently to improve the situation? 
    I recognize most people have a fear of confrontation. Christians in particular seem timid to confront others because:
-they don't want to seem 'unloving' or 'non Christ-like'
-they fear people's perception of them if they do
-a false perception that we have to be 'nice' all the time and can't disagree

     But I ask: Is it really Christ-like NOT to address problems within the family of Christ? Is it loving for a parent to never rebuke his or her children? No! It is a loving parent who confronts the child with what they've done wrong, discusses what they should have done differently, and helps them to change their behavior. 
     In addition, Christ wasn't always 'nicey-nice' to everyone. Sometimes he was really harsh if the situation needed it. Look at what he says to the Pharisees: Matthew 12:34 You brood of vipers! How can you who are evil say anything good? For out of the overflow of the heart the mouth speaks. Matthew 23:13-34-The seven woes. Here he calls the Pharisees hypocrites, blind guides, blind fools, blind men, full of hypocrisy and wickedness, snakes and vipers. He also tells them "How will you escape being condemned to hell? Upon you will come all the righteous blood that has been shed on earth." Pretty harsh stuff, huh? Not very 'nice'. But certainly said with love-with the intention of correcting them, of giving them the chance to see their wrongs and repent. I'm not saying we should go around calling each other slithery snakes, but pointing out that there are times for confronting others. Sometimes with love and grace (as He did to the woman caught in adultery in Mark 16), but sometimes with blunt and direct words of rebuke. I believe it is wrong for us to let someone continue in wrong, harmful, or sinful behavior because we are afraid to address the problem and might be considered 'not nice'. 
     How many of us have been around a child who is banging some sticks together to make music, or play a toy drum, but find the noise just too much for the moment. Is it wrong for him to make music? No. Is it sinful? No. (unless he was told to stop and didn't). Do you let him continue to play despite your irritation? Maybe yes, maybe no. But unless you address the problem either with yourself "he's just being a boy and it's not wrong for him to play. I choose to tolerate it", or with him "your drum playing is a good thing, but now is not the best time, you can play later", then it is only your fault if you should lose your temper and yell at him. It is the same way for us with adults. 
     So, let us not be hypocrites, let us not simply be 'nice' people, but loving. We should rebuke one other appropriately, addressing the problems between us quickly and frankly. In so doing we become much less 'nice-like'and much more 'Christ-like'. 
     I feel that on the mission field, this is even more important, as the biggest cause of missionaries leaving the field is not difficulty with nationals, or with culture, but difficulty in getting along with other missionaries. How are we to display the unity of Christ (as Jesus speaks of in John 17) if we are so consistently divided? If we let little irritations become big problems because we don't address them when the problems are small? Therefore, catch the foxes, the little foxes that ruin the vineyards, the vineyards that are in bloom.