Mbingo 2015

As many of you know we are back at Mbingo and have been since the beginning of August.  We are able to stay here for 6 weeks on this trip.  We wanted to give you an update on how things are going.

The flight over went really well.  The boys slept and watched some movies and there were no breakdowns.  They adapted to the time change very quickly.  This picture shows Benjamin sleeping in a relaxed pose in his seat.  Thanks for buckling your seatbelt for landing Ben!

The teaching school year starts on August 1st at Mbingo, so Mbingo was welcoming the new residents just as we arrived.  Dennis Palmer is in the US while we are here, so Chuck has been filling in as the CIMS (internal medicine residency) program director.  This involved speaking at the White Coat Ceremony for the new residents just 2 days after arriving.  PAACS (surgery residency) was also involved with the ceremony.  The picture shows Chuck speaking while the other CIMS and PAACS leadership is at the table and the new residents are off to the left.

Chuck was also able to bring two residents from Charlotte with him this time.  Chuck is on faculty at Carolinas Medical Center and has developed an international rotation for the internal medicine residents there.  This was the first trip for them to come with him to Mbingo.  The picture shows Dr. Ruchi Jain rounding on the female ward with the ward team.

Dr. Todd Gandy is the other resident that came and this picture shows him rounding on the men's ward.  He is surrounded by two CIMS residents, a house officer, and a nurse practitioner student.  Todd and Ruchi were able to round on the wards, lead daily teaching conferences, and do many procedures.  They did ultrasound-guided fine needle aspirations, thoracenteses, paracenteses, bone marrow biopsies, and even a few EGDs.  They also enjoyed many hikes into the beautiful mountains here.

This is a picture of the GeneXpert machine.  It is a PCR test for tuberculosis.  It is much more accurate than looking for AFB on smears and we finally have one at Mbingo.  Prior to this we were sending our samples to be run on a machine in Bamenda.  The machine takes about 2 hours to run a sample and can do 4 at a time.  You can see the blue topped specimen container that fits directly into the GeneXpert machine below.  The results are then displayed on the computer to the left.  This machine has made a huge difference in our ability to diagnose TB and therefore properly treat our patients.

Yes, that is a chicken in our house.  We bought a chicken, but we were not able to get it killed that day.  While we were out of the house, he got out of his bag and was wandering around the house.  Chuck tried to guide him back to the mudroom, but the chicken was having none of it.  Finally, we had to trap him, pick him up, and carry him back to a box to keep him in until the morning.  Isaac and Ben thought this whole thing was hilarious.

It has been raining like usual in August at Mbingo.  Everything is nice and green and the boys are enjoying walks, rain or shine.  This is Ben walking around with Angela.  This is one of the rare times he was standing under the umbrella.

This picture shows Isaac and Ben with Nathaniel at the Mbingo II Church.  Nathaniel is the oldest son of Jason and Meridith Axt.  Jason is one of the faculty surgeons here at Mbingo with the PAACS program and a friend from Nashville, TN.  We kept Nathaniel for them for the weekend while they celebrated their anniversary with a weekend trip.  The boys had a lot of fun together.  The Mbingo II Church has been expanding and recently put the walls and roof up on this new building.  It is fully functional now while they continue to raise some money to fill in the walls and finalize the flooring.

Helen has been able to cook for us at our house again this time.  This picture shows her making cookies while the boys watch.  Her banana bread and cookies are hard to beat!  We are thankful for her help.

Mbingo really is a paradise for our little boys.  They drive their toy trucks, dig in the mud, collect bugs, swing sticks, and get as dirty as possible.  This picture shows Isaac with his bug collecting box. He is showing some new colorful bugs to Ben who is pushing his toy truck around.

Did we mention mud, rain, shovels, and getting dirty.  Here are the boys digging in a puddle behind our house after a heavy rainstorm.  They are usually so dirty by the end of the day that they have to have baths/showers before coming inside for dinner.

Thanks to all of you for following along on this trip.  We appreciate all of your prayers and support.  It has been great to reconnect with our Cameroonian friends here and jump right back in to work at the hospital.  Thankfully, we still have another 2.5 weeks here before heading back to Charlotte.

Back at Mbingo

As many of you know, we are currently back at Mbingo.  We have been here for 3 weeks and we head back home to Charlotte in a week.  It has been a busy few weeks and a lot is going on at Mbingo.

This is the family in our African outfits that the residency program gave us when we left in May.  We put them on to go to church.  Needless to say, the Cameroonians liked it.

Since we left, part of the road between Douala (where the airport is) and Mbingo has significantly worsened.  The government has been repaving part of it, but had to stop due to the rains.  Now there is about an hour and a half stretch that is full of deep potholes.  This picture is out of the front window showing the potholes and traffic on one of the main roads in Bamenda (the large city 45 minutes from Mbingo).  This should hopefully get repaved when dry season comes.

Before we left last year, we raised some money with the Youngs to help the hospital build a new house for volunteers.  This was a big need as we often had to tell volunteers that they could not come due to lack of housing.  There was also not a good option for a place to stay for families with kids before.  This house will help fill those needs.  It was just finished before we arrived and we have been staying here and setting it up with some of the items that we had from being here for 2 years.  The views are great too!

It is a Cameroonian tradition to have people over to eat when there is a new house.  So, we first invited all 40 of the hospital workers that were involved with the house to come to the house to eat fufu and njama-njama and fish (Cameroonian favorites).  This is the crowd enjoying the meal.  They really did a great job with the house.

We also had the chance to host the CIMS residents, the house officers (medical interns), and the nurse practitioners that we work with to a meal.  This shows most of the crowd enjoying the jellof rice, chicken, and homemade chocolate chip cookies.  The best part of this evening was that the doctors were able to relax and spend time together outside the hospital.  They talked the next week about how much fun they had.

This is Norah Njini, one of the 3rd year CIMS residents.  She has an amazing story that we wanted to share.  Norah was certainly qualified, but unable to get into the one medical school in Cameroon years ago when she applied.  Because of this she had to search elsewhere which included China.  Going to medical school in different countries in Africa is common, but China is not - mostly because of the language barrier.  Norah was able to go to China a year early and learn Mandarin Chinese and then do all of her medical training in Chinese.  She then returned to Cameroon and started working for the Cameroon Baptist Convention and later joined the CIMS residency at Mbingo.  She is a great resident doctor and we are amazed at her ability to learn medicine in Chinese and now practice medicine in English and never miss a beat.  (She speaks French and Pidgin English too!)

Before we left to come to Mbingo, people asked us a lot of questions about Ebola.  The effect that Ebola is having on Sierra Leone, Liberia, and Guinea is a tragedy on the largest scale.  Fortunately, Nigeria was able to control the outbreak in its country and now has no cases of Ebola.  Cameroon borders Nigeria, but is almost 2000 miles from Liberia (the closest current case).  When Ebola was in Nigeria, Mbingo requested and received PPE (personal protective equipment) from Samaritan's Purse to be ready in case Ebola did come to Mbingo.  This threat is low now, but as we know things can change.  The PPE has many parts to get on and is quite difficult to take off correctly.  This picture shows Chuck with all the gear on during a practice session.  If PPE has to be used, there even needs to be a person in full gear that is responsible for helping others get their gear off.  Let's all pray that Mbingo and Cameroon never see the virus and that the current outbreak will be controlled in those countries that have been hit the hardest.

In addition to having the PPE on hand and making plans for how to deal with isolating patients, we have also instituted some screening.  Chuck worked with Comfort (the head nurse for the outpatient department who is pictured) to have a basic question for all patients as soon as they arrive to Mbingo.  When they first get registered, they are asked, "Have you traveled outside of Cameroon in the last month?".  If the answer is "Yes", which is rare, then we ask which country.  If they were to answer any of the countries currently involved in the Ebola outbreak, the patient would immediately be dealt with differently in an isolated setting.  Because those countries are so far away and travel is so difficult, it is highly unlikely that we will get a patient from there, but we felt this basic screening was important.

As always we continue to see interesting medical cases daily.  This X-ray was from the men's ward where Chuck has been rounding.  It shows the globular shape of a pericardial effusion.  This patient has advanced HIV and his echo showed a thickened pericardium as well as an effusion.  This was due to TB and represented constrictive-effusive TB pericarditis which is an uncommon, but well-documented, overlapping of different stages of typical TB pericarditis.  TB drugs and steroids were started, but there is still a high risk of the constrictive pericarditis worsening to the point of needing surgical pericardiectomy in these patients. 

Denis Nkenji came to see Angela in clinic the first week we were here.  He is the boy that we were able to help with the cost of his heart surgery (see previous blog posts).  The surgery went well and he has now recovered and is feeling better than he has ever felt.  The VSD was closed and the aortic regurgitation has improved.  He will need to continue to be followed, but he now has a chance at a normal life.  We were so happy to be able to see him again and see how well he was doing.  His mom even brought us bananas and beans as a gift.

Ben is enjoying rainy season here at Mbingo.  As any boy loves to do, he wants to play in the mud and the puddles.  This was one of the days that we just let him loose.

Isaac likes to walk Mom and Dad part of the way to the hospital in the mornings.  This shows Angela and Isaac passing the house that is being renovated to be a daycare.  He always gives us a big hug and kiss before running back to the house.

You can't come to Mbingo without hiking.  It's just too beautiful.  This is the family during a hike to "The Knob", a little elevated area along a ridge at Mbingo.  It was a 3 mile hike and Isaac walked the whole way!  Chuck is enjoying carrying Ben, especially since he weighs a few less pounds than Isaac.

Betty, Angela's mom, came with us for the month.  She has been an incredible help and the boys are loving spending the days with Nana.  Having her here has allowed us to get much more done at the hospital and know that the boys are in good hands.  We are very thankful Betty.

This is our last week here, but it will be busy.  Chuck is traveling with Dennis Palmer to Yaounde (capital of Cameroon) on Tuesday and Wednesday to meet with the US Ambassador and some members of the Prime Minister of Cameroon's staff as well as visit the teaching hospital in Yaounde.  The reason for the trip is to continue to pursue full recognition by the government of the CIMS residency program at Mbingo.  These things move slowly in Africa, but meetings like this help.  Chuck is also currently serving as the Chair of the Advisory Board for CIMS, so he will speak on behalf of that board during the meetings.

It has been good to be back at Mbingo and it is hard to believe a month has almost already passed.  We look forward to getting back to Charlotte, but we will miss our friends and Cameroonian family here.  Please continue to pray for the hospital, the staff, and the missionaries here at Mbingo.

Denis Nkenji Update

We wanted to give all of you an update on Denis Nkenji.  As you will remember, Denis is the young boy with a serious cardiac lesion.  Without repair, he would not live many more years.  With the help of many of you giving generously, we were able to help pay for him to have his needed heart surgery.  The surgery was done at Shisong Catholic Hospital in Cameroon.  It was done in May when a European pediatric cardiac surgeon was at the hospital.

The surgery went great!  We immediately heard that it was successful.  He then spent a few days in their ICU and then some more time in the hospital, but always on the path of recovery.  He then went home and we just recently got more good news.  He returned to the hospital for his follow up appointment and he continues to do well.  We look forward to seeing him and his mom when we are back in Cameroon in October.  Below are some pictures that the cardiologist at Shisong Hospital shared with us.

This is Denis with his mom after getting out of the ICU and into a regular bed at the hospital.

This is Denis when he came back to the hospital for his regular surgical follow up appointment.  Nice suit Denis!

 Thanks again from Denis, his mom, and us to each of you for all the prayers and financial support.  Denis Nkenji's life has been changed.

Goodbye

It is hard to believe that we have been at Mbingo for over 2 years and we are getting ready to move back to the United States.  As we mentioned before, we are moving to Charlotte, NC.  Mbingo has become our home over these 2 years and it will be tough to leave.  However, Cameroonians do know how to do a proper goodbye with multiple parties and multiple outfits.

The hospital gave us these "country clothes" as a way to say thank you for the time we have worked here.  They are traditional outfits for the NW region of Cameroon.  They are quite intricate with hand stitched embroidery and very colorful.  They even made one for Isaac and a small one for Ben!

It seems there is a cloth for every organization here.  This is the official cloth of the Cameroon Baptist Convention Health Board.  It shows a patient being cared for and part of the mission statement of the health board - "Assisting in the provision of health care to all as an expression of Christian love".  This picture was from the tablecloth at one of our going away parties.  We have seen official cloths of churches, regions, women's/men's groups, weddings, and many other events and the men and women usually have an outfit made from the cloth that they wear proudly.

The residency program had their own goodbye party for us as well.  This is a picture of us in the outfits that they gave us along with just some of the people at the party.  We ate well and enjoyed the fellowship, but it would not be a Cameroonian party without speeches.  A few of the residents and faculty each took a minute to say some nice things to us and we were able to thank and encourage each of them during this time of transition.  They really are an incredible group to work with.

Angela also received a Cameroonian outfit from the women's group she attends and another outfit from the maternity ward.  She will have to give a Cameroonian fashion show when we get back to the US.

As we leave, there will be some gaps in internal medicine and pediatrics.  Over the past 2 years, Angela and JR and Lindsay Young have worked hard to produce two protocol books - one for pediatrics and one for neonatal care.  These books were recently finished and printed and we have been handing them out to everyone that cares for children here at Mbingo.  We are now in the midst of distributing copies to all of the hospitals and health clinics run by the CBC throughout Cameroon.  Having these books in the hands of the doctors and nurses will greatly improve the quality of pediatric care in Cameroon.

This is Angela with Zidane.  Angela and JR and Lindsay have been caring for Zidane for the past year.  He was extremely ill from an autoimmune vasculitis and has improved with immunosuppression. He has had many bumps along the way, but always has a great attitude.  He is also one of the more knowledgeable patients about his condition.  Although he is only 14, he usually has to arrange his own ride to get to the hospital (he lives hours away) and keeps track of his own medications.  Angela has been able to work with one of the residents (Stephanie) over the past few months to arrange for her to care for him in our absence.  Stephanie will do a great job with Zidane, but she knows we are all just an email or phone call away whether it be for Zidane or any other patient.

This is Unity (on the right) with her mother and child.  Unity has renal failure, but did not know until she presented in respiratory failure from volume overload after she stopped making urine.  Her child was 5 months old.  We did not think she would make it.  She is only 22 years old.  Chuck started peritoneal dialysis on her to stabilize her while we talked to her about longer term dialysis (hemodialysis).  The government helps provide for hemodialysis in Bamenda, but the cost is still out of reach for almost all of our patients.  Unity did not have the money to start dialysis.  In fact, she could not even pay her bill here at Mbingo.  We used some money that had been donated by many of you to help pay her hospital bill here and get her started with dialysis in Bamenda.  The family said they could afford the ongoing costs of dialysis if they could get her started.  We don't know how long she will be able to afford hemodialysis, but we are thankful that we could help her for now.  She and her mother both wanted their picture taken after her bill was paid.  They were so happy and just clapped out of joy for a few minutes.

We are also happy to tell you that Denis Nkenji is scheduled for his heart surgery on May 12th.  We have told his story over the past few blogs and continue to be thankful for your generous giving to make this possible.  Please keep him and his mother in your prayers especially around the time of the surgery.

Dr. Kamdem will be graduating this year from the CIMS residency program.  He spent time at Tenwek Hospital in Kenya doing an ICU rotation last year and has progressed significantly in endoscopy over the past few months at Mbingo.  Chuck has taught him diagnostic EGD, some therapeutic EGD, and colonoscopy.  After he graduates, he is going to stay at Mbingo for a little while during this time of transition and his skills in endoscopy in addition to internal medicine will be a great asset to the workload at Mbingo and the residency program.  He has even started to teach the residents below him some diagnostic EGD and is doing a great job.  Chuck is proud of what Dr. Kamdem and all of the other residents have accomplished during the past two years.

It is also amazing to see how much Isaac has grown at Mbingo.  He was a toddler when we came out and now he is a little boy.  This picture replicates one of the first photos we took at Mbingo and put on the blog.  Take a look to see how much Isaac has grown over the past two years - Feb 7, 2012 Blog.

Ben is growing too and he is loving the swing in our backyard.  He is getting teeth and smiles all the time and we love him very much.  At the goodbye parties, the Cameroonians like to refer to Ben and Isaac as "Mbingo Boys" since they have spent most of their lives here.

This is a picture of the missionaries and short-term volunteers that celebrated Easter with us at Mbingo. You may notice that Mike and Betty Kimbrell are in the picture too (Angela's parents).  They have been here for a couple weeks and will be traveling back to the United States with us this week.  It has been great to have them here to help as we pack and will be great to have them with us as we try to take a 30 hour trip home with two kiddos!

So, goodbye for now Mbingo.  We will miss you.  Although we are leaving, we know God has great plans for the hospital, the training programs here, the hospital workers, and the patients that come for their care here.  As we have mentioned before, we are going to be able to return 2 months a year to work at Mbingo, so knowing this has made the goodbyes not quite so hard.  Still it is hard to leave our Mbingo family, but we are excited about the next stage in our lives and look forward to being back to Mbingo soon.

Partnerships

We have recently had the chance to work together with people from different hospitals in Cameroon, Kenya, and the USA.  We wanted to share some of those experiences.

This photo shows Angela giving a lecture at the Njinikom Catholic Hospital.  Njinikom is only 40 minutes from Mbingo by car and we recently met some family medicine missionaries that moved there a few months ago.  We have served as consultants to them from meeting in our living room and going over cases to answering phone calls and emails about how we would handle patients.  A few weeks ago, they invited us to give a lecture and tour their hospital.  Angela spoke about 4 pediatric topics where small changes can make a big difference - neonatal jaundice, pediatric malignancies, neonatal hepatits B, and sickle cell anemia.  Chuck spent time answering questions on management of difficult medical cases in a resource-limited setting in Africa.  It is great to be able to partner with the Catholic hospital in Njinikom to try to improve the quality of care for all people in this region.

This photo is from the front of Njinikom Catholic Hospital.  Another catholic hospital in Cameroon is Shisong Cardiac Center.  This is where Denis Nkenji (7 year old boy that we have been raising money to help) will get his heart surgery.  The money for the surgery has now been paid and he is scheduled for this open-heart surgery on May 9th.  Please keep him and the surgeons in your prayers.  Thanks again to each of you who donated money towards this surgery.  What an amazing blessing you have already been to Denis and his mother.

This picture shows John and Lovely Mbah.  We took this picture one evening after we all had dinner together.  John is one of the main nurse anesthetists in the surgery department and Lovely is the charge nurse on the pediatrics ward.  They are two of the best and most dedicated staff at Mbingo.  Their partnership and dedication to the hospital started at a young age - they were both born at Mbingo!  They have sacrificed through the years in giving their time and energy to caring for patients and Mbingo is certainly a better place because of it. 

This past week we were happy to have Brent and Morgan McDonald visit us.  They are great friends from Nashville, TN and work at Vanderbilt.  Morgan is a internal medicine/pediatrics attending and the assistant program director for the med/peds residency program.  She rounded on the pediatrics and medicine wards and helped with many of our teaching conferences.  This picture shows Angela and Morgan just after rounding in the neonatal ICU.

Brent works in hospital administration at Vanderbilt and met with our hospital administrators to see how he could help both now and in the future.  It was great to have them visit us and show them what life is like at Mbingo.  This picture is from a hike that Brent took with Chuck.  While hiking up one of the mountains, a local farmer asked us to stop while he went to get his son. He told us his son (pictured) had never seen a white man before.  Brent offered to shake his hand and the boy slowly made his way to the fence line that keeps the cows out of the man's farm.  They shook hands and the boy just stared at Brent and Chuck for a minute or two.  It is amazing that someone that lives just a few miles from our house has never seen a white man before.

This is our new BiPAP machine.  It was brought to us by a respiratory therapist named Annette who has been working at Tenwek Hospital in Kenya.  She came to work at Mbingo for a few weeks.  While here, she helped Chuck take care of a few young adults in severe respiratory distress.  The BiPAP machine delivers positive pressure with each breath and can function somewhat like a ventilator, but with only a mask instead of a tube in the trachea.  Using this machine, we were able to keep the patients alive and breathing long enough to diurese or dialyze them to improve their respiratory status.  In addition, the machine will be able to help many post-operative patients who are still having trouble breathing after surgery.

We also recently started a partnership with Bamenda Regional Hospital here in Cameroon.  They have a GeneXpert machine that does rapid PCR testing for TB (very sensitive test to find TB in sputum, tissue, or body fluids).  We had a meeting with the doctors who run the machine and worked out a way for Mbingo to be able to use the machine as well.  We now collect samples and send them by courier to the Bamenda Regional Hospital (45 minutes away) each day.  After the test is run, the results are texted from a cell phone in Bamenda to our SMS printer in the lab (only requires cell phones to be working).  We then act on the results, whether positive or negative.  The machine is far superior to looking for AFB (TB) under a microscope and even gives information on drug resistance if the sample is positive (rifampin resistance which is a marker for MDR-TB).  Chuck and Angela created the algorithm pictured above to guide our doctors and other staff at Mbingo on the correct way to manage possible TB patients while utilizing the GeneXpert machine.

This picture shows some of the local kids in their school uniforms on their way home after school.  They all decided to give us a thumbs-up, except the girl in the middle who gave us a pose.

This is Ginger (Chuck's mom) with Ben.  Ginger stayed with us for almost 6 weeks and was a huge help taking care of Isaac and Ben while we both worked.  We already miss her and the boys miss their GiGi.

Connected

It is easy to feel disconnected living so far away from family and friends.  We are thankful for the friends we have here, but we are also thankful for the way the internet allows us to stay connected to our family and friends in the US.  That being said, we often have problems with our internet here at Mbingo, but we have recently had some help to improve things.

This picture shows Chris Jackson high in the air on a tower to install an internet radio at Mbingo.  Chris Jackson is a missionary with Wycliffe (Bible translators) and generously donates his time to help us at Mbingo when our internet is giving us problems.  Over the past 6 months, he has started converting us from an overgrown often-failing home type network to a much more stable and consistent business style network.  Currently, our internet comes through the air from a town 45 minutes away bouncing off multiple towers as the signal makes its way to Mbingo.  After the tower receives the internet signal, it spreads through the hospital and also broadcasts the signal back out to our houses to allow us to have internet at home.  We are thankful for all of the efforts he has made.  Despite significant improvements, we still continued to have many connection problems...

Josh Shinar has also been helping us tremendously with our network.  This picture shows him with Lori, his wife, and Charlie, their daughter.  They were missionaries in the Central Africa Republic before being evacuated last year in the midst of violence.  Now they are missionaries in a small town in Cameroon (Banyo), but have been living next door to us for the past month here at Mbingo.  Josh owned his own IT company before becoming a missionary and has been teaching a 2 week IT course for Cameroonians while here at Mbingo.  He also has helped us take the next steps in having a much more reliable and dependable internet connection.  Now that he has most of the kinks worked out of this increasingly complicated network, we need to find some money to buy more bandwidth!  Lori was an oncology nurse before moving to Africa and she has been helping with our chemotherapy and palliative care departments this month.  Charlie has enjoyed playing with Isaac and we will miss all of them when they go back to Banyo next week.

In addition to staying connected to the US, the internet is an incredible medical resource and an increasingly effective way of teaching.  Over the past 2 months, we have been taking part in an online HIV course for the medical residents and nurse practitioner students.  The course is run out of the University of Washington in Seattle.  We show a 2 hour lecture each Friday and hold discussion groups during the week in addition to the online homework and quizzes.  This picture shows Dr. Kamdem and Dr. Tumi (2 medical residents) following the powerpoint on the computer while watching the lecture in class.

Chuck recently went with 5 other guys from Mbingo (a mix of full-time and visiting doctors) to climb Mount Cameroon.  It is the tallest mountain in West Africa and remains an active volcano.  The picture was from the top after 10,000 feet of climbing!  It was an incredible trip.

Mount Cameroon's last major eruptions were in 1999 and 2000.  This picture shows the group approaching two of the volcanic craters from these eruptions.  It was incredible for Chuck and the other doctors to explore this volcanic region, walk across lava fields, and finally end the 3 day hike while descending through a rainforest.

Chuck's parents have been at Mbingo for 2 weeks now and have been a big help.  Isaac and Ben have loved spending time with GiGi and DoDad.

Chuck's father, Charlie, is a gastroenterologist.  He has been working with Chuck doing endoscopies when he is not spending time with Isaac and Ben.  One of the new endoscopic procedures that Chuck has been doing is placing esophageal stents for advanced esophageal cancer.  Chuck and Charlie had a chance to do three of these together this past week and this picture shows Charlie placing the third one.

Some of you will remember a picture from the early days of this blog with Isaac looking at Chocolate, his favorite horse here at Mbingo.  Now Chocolate has a little sister who is only two months old.  Isaac loves to go each day to walk around Mbingo to try to find Chocolate's mom and the new horse.  When we look back at that picture and compare it to this one, we can really see how much Isaac has grown up since we moved here.

Speaking of horsing around...These are the three Barrier boys in the backyard.  It seems Ben is getting bigger each day!