Busy!

I was going to try to post yesterday, but the day had other ideas.  It started out by getting woken up at 5am by a phone call from the American trained midwife I am working with asking me for help.  In my half awake state and with the static on the other end of the phone I had no idea what was wrong, but knew that I just needed to come to L&D and quickly. 

I threw on my glasses and some clothes and was out the door, speed walking down the dirt path to the hospital in the dark with flashlight in hand.  When I had arrived to L&D it became apparent that there were two women that needed c-sections rather emergently and now we had to decide which one to take back first.  One was a Falani woman who had a previous c-section and then 6 subsequent successful VBACs (vaginal birth after cesarean).  VBACs are a little bit risky because there is a scar on the uterus from a previous c-section and the stress of pregnancy and labor on that scar can cause the scar to break open and rupture which can be life threatening to both mom and baby.  This pt had been laboring all night and had pushed her baby to a +2 station with no further descent (the baby had gotten stuck just before being able to deliver).  The baby now was starting to have some decels in the heart rate (showing signs of distress).  The second woman was someone who had been “evacuated” to our hospital.  An evacuation basically means they were at another clinic or what they call here a “dispensary” and something has gone wrong so they come to us (usually they come at the very last minute and it is a true life or death emergency).  This pt came to us because she was 8 months pregnant and had started hemorrhaging.  She hadn’t felt the baby move in the 24 hours.  We quickly threw the ultrasound on her and see that she is abrupting (the placenta is detatching from the uterus and is bleeding).  The baby still has heart tones.  Given the amount of bleeding this ptwas having and the fact that there is no electronic fetal monitoring here and all monitoring is done by intermittent dopplers we decided to take the pt with the abruption to the OR first.  Delivery of this baby went perfectly.  In the mean time the Falani patient was being prepped for the OR and as soon as we were done with the first pt we brought the Falani woman with active phase arrest back to the OR.  The pt also requested that we do a tubal ligation at the same time.  This delivery went fine as well… or so we thought. 

After bringing this last c-section to recovery I rounded on a few pts and then went back to the OR for a scheduled hysterectomy for a large fibroid uterus.  These are both fun and challenging cases because no two cases are ever the same. Todd, the long term missionary here who is a surgical PA has done many of these and it has been so great to work with him and operate under his guidance.  Just after this is finished I am asked by the visiting cardiothoracic surgeon to assist him in operating on a 4 month old boy.  This boy had a bad infection in his neck that had drained into his chest and we were going to open up his chest and clean out the space around his lungs which had filled with pus (sorry, that might be too much detail).  I had to laugh as I thought about the situation in the middle of the case.  Here is an OB resident assisting with a pediatric thoracotomy. The infant needed this surgery badly as the infection at this point had become life threatening.  The anatomy of the chest is so incredible.  Watching the lungs inflate and deflate with every breath and the heart beat to keep the child alive is amazing.  In the middle of this I get called to go the L&D immediately.  It sounded very emergent so I scrubbed out of the case and went to see what was going on.  Our second c-section of the morning was hemorrhaging.  The nurses had already given her all of the medications that we have to stop bleeding.  I went to see the ptand pulled clot after clot of blood out of her uterus.  I asked the nurse to get her vitals and the pt no longer had a blood pressure.  The pt was beginning to become unresponsive. This was bad. My heart quickened and I instructed the nurses to open the IV fluids wide open and to start transfusing blood into this pt.  I also asked them to grab one of the surgeons for help. Todd came around the corner after they pulled him out of the OR where he was prepping a pt for a colostomy take down.  It didn’t take much explaining on my part to tell him what was going on.  He immediately instructed the nurses to move the pt back to the OR.  We were going to do a hysterectomy.  The poor pt who was already on the OR table, spinal in place getting prepped for surgery for the colostomy take down was taken back to the recovery room and this hemorrhaging pt took his place.  I am not even sure that our pt had completely received the ketamine (the anesthetic drug we use for sedation) before we started opening her.  In the 30 seconds it took us to get back inside her abdomen her uterus was filled with blood. We completed the hysterectomy and her vitals started to stabilize.  Praise God.  My hands were shaking as we closed.  What a morning.  I looked at the clock as we finished and it was only now 1pm.  At this point I had missed  both breakfast and lunch, hadn’t showered, brushed my teeth, put in my contacts or even remembered to put deodorant on ( I told everyone to stay far away).  It was time to head back to the guest house to take care of some of these necessities.  I was exhausted and super thirsty.

The air conditioning in one of our two ORs (the one I for some reason tend to operate in the most) isn’t working.  This makes that OR super hot.  The African sun beats down on it all day and as a female I am required to wear a long skirt and on top of that a special scrub dress and then my surgical gown and of course a surgical hat and mask.  By the time I am done with any case I am completely soaked.  My gloves keep wanting to slip off because I am sweating so much and it is sometimes all I can do to keep from dripping into the surgical field.  With all of the OR cases that morning I new that I was getting dehydrated quickly and because I hadn’t expected to get called into the hospital that morning (I wasn’t technically on call that day) I hadn’t refilled my water bottle the night before.  Important lesson learned, always be prepared.  The guest house had graciously set aside a plate of food for me.  Lunch and water never tasted so good! The long term missionaries here say that after a while your body adjusts to the heat and humidity and it doesn’t bother you as much.  I wonder how long that takes?  I have started to develop a really wonderful heat rash on my arms, neck and chest. 

I was so tired and worn out yesterday and knew that I needed to just spend some time with the Lord.  I was reading Ephesians 4 which was exactly what I needed.  When I am tired or hungry or uncomfortable it is so easy for me to start focusing on myself and my needs.  I got the gentle reminder from the Lord about my attitude to walk with humility, gentleness and patience bearing with one another in love.  I so needed that.

I just realized that I never told you about the other staff that I work with here.  The long term missionaries are Todd – a US trained surgical PA who more often than not fills in as a general surgeon, Kelly – a US trained pediatrician who is here doing the Samaritan’s Purse post residency program, Rhonda – a US trained midwife, Brenda – a US trained medicine PA.  There is one other short termer here with me and his name is Ed.  He is a US trained cardiothoracic surgeon, but has surgical skills that go far beyond just the heart and lungs.  There are also a couple of Togolese nationals that work here as medicine PAs.  That is the staff for the hospital.  Such a wonderful team to work with!

I was technically on call last night, but after the morning that I had praise the Lord that I had a quiet night and didn’t even get called in once!  I was so tired, I needed a full night’s sleep.  I can’t remember the last time that happened. 

Prayer request from here – there is a 4 year old girl named Bernadette that came to the hospital 2.5 weeks ago and it was discovered that she has a benign brain tumor in the back of her head.  It is not cancerous, but it is growing quickly and she was starting to have some really bad symptoms from it.  She needs surgery, but there is no one here in the country of Togo that has the skills to help her.  Even though the tumor is benign, she will die from it because of it’s size if she doesn’t have surgery. Through a series of events we were able to tell this American organization called Healing the Children about her and they arranged for a pediatric brain surgeon in Louisville, KY to operate on her.  We were able to get a passport and visa for her in two weeks ( unheard of here in Africa) and Healing the Children arranged for her to fly to the US.  The pediatric surgeon and his family agreed to house her in their home while she recovers and then she will come back to Togo.  What a blessing.  She is scheduled to begin the journey to the USAtoday, however, the last few days have not been going very well.  Her pain has worsened and she now has a fever.  They are racing against time.  They have decided to get her on the airplane as pray that God will let her live until she reaches the US.  I suspect she is going to go right from the airport to the hospital if she makes it that far.  Please be praying for her as well as for Kelly who will be going part of the way with her.  So many times situations like this in Africa are without hope, but this little girl actually has the chance to have surgery, be cured and live a normal life.  The outcome is truly in God’s hands.  

I so appreciate everyone's comments, prayers and encouragement.  It is nice to know that I am still connected with those back home even though I am half a world away.

First call - done!

My first call night is over and now I am onto my second.  Thank you for your prayers! There is never a dull moment.  I had my first in the middle of the night c/s (cesarean section).  I also had a post-partum seizing HELLP syndrome patient come through the door.  HELLP is a disease of pregnancy that we see occasionally in the States, but rarely do we ever see those patients actually have seizures.  Severe forms of HELLP can be life threatening and in Africa it seems that you never see anything less than the severe form of any disease.  This patient’s overall presentation was a little bit unusual, hypotension instead of hypertension, normal urine protein instead of high urine protein, normal hematocrit instead of being hemoconcentrated.  I prayed about it asking for wisdom as I waited for the labs to come back and when they did the Lord made it obvious.  At home eclampsia or HELLP syndrome might be top on your list, but here malaria, parasite infections, electrolyte abnormalities from dehydration, epilepsy all must be considered.  The differential diagnosis is just so different.  Often with the lack of patient education and the language barrier getting a good history out of the patient is almost impossible.  I put her on IV magnesium to stop the seizures and she has done great since her arrival though and will likely be going home soon!  Praise God!

Something I have been thinking about since coming here is how little my medicine matters compared to the Lord.  We can do everything known to medicine, everything the lastest and greatest research tells us to do and still not be able to save a patient or be able to improve their lives.  That control ultimately doesn’t belong to me, or any other doctor.  It belongs solely to the Lord.  I think He has been teaching me about how little control I have and how great of control He has.  So humbling and yet also sort of a relief.  God calls us to give everything our best effort, to work with such conviction as if our every act was for the Lord directly.  He demands high quality work, but the ultimate result is never taken out of His hands no matter how seemingly perfect our efforts appear.  There is a popular worship song that has a line that goes “I want more of You and less of me.”  I sort of think it should be changed to “I want all of You and none of me.”  Take me out of the equation.  Apart from Him nothing matters.  Mother Theresa talks about her attitude when it comes to working for the Lord in this quote which I love, “I am simply a pencil in the hand of God.” That totally sums it up.  I am now coming up on my second call night – such a great thing to keep in mind.

It is mid-afternoon as I write this and the temperature is rising.  The pattern seems to be that the heat builds throughout the day until the daily afternoon storm.  The storm seems to last for less than an hour, but the amount of rain dumped in that time is probably more than California could hope for in 2 years.  It is always important to keep track of the time and the clouds so that you don’t get caught out in it!  The humidity here has made every book and piece of paper I brought with me buckle.  I guess it is living proof that things here are always wet.  This might be too much information, but I have been sweating so much that my sweat is no longer salty! So weird!

As today is Sunday I had the chance to go to one of the local churches.  The service was all in French, but it didn’t really matter.  Church services are a full body worship experience.  There is singing, dancing, cheering, clapping and just about everything in between.  It makes us Amercians look so boring!  The pastors seem to think that the louder and more animated they are the better they are at reaching their audience.  Watching a grown man jump around on stage, shouting into a microphone in a language you don’t understand is actually pretty funny.  I love their enthusiasm.  I almost wonder if that is how God intended worship to be….so overwhelming that you almost want to explode with joy! Tonight there is going to be a worship service on the compound in English.  I am really looking forward to this, but I am sure it won’t be nearly as animated!

Winner Man

Today is a national holiday in Togo.  Tobasky day.  It is actually a Muslim holiday, but it is celebrating when God provided for Abraham so that he did not have to sacrifice Issac on the altar.  Such an interesting thing to think about on my first day on call.  First, that God provides and is faithful.  Second, He demands faithfulness from us.  Third, how Muslims and Christians actually do have some similar roots though in this modern time it is easy to forget that.  Even though this is a Muslim holiday, because it is celebrated nationally the hospital observed it too.  We still had clinic, but put more of the elective stuff on hold until next week.  I learned today that one clinic visit costs a Togolese person $3 (in US) though this does include a follow up visit.  Since today was a holiday, however, the price increased to $4 a visit.  Sort of puts an interesting spin on the $25 dollar copay that I normally have to pay when visiting the doctor.

Here is a question for my L&D folks out there.  10ml of pit mixed in 1L of NS. How many drops a minute would I need to start dosing/titrating pit correctly? And then how fast can I increase it by (keeping in mind the fluid volume I am giving the pts)?  I have been thinking about this and am not quite sure I am figuring it correctly.  If anyone has any input let me know.

It has been interesting to twist my brain into thinking in Kg, Celsius, and hematocrit instead of hemoglobin.

The Wilm’s tumor baby did well today.  The surgery went better than expected.  Such a blessing.  I had a couple of women come into “maternitiy” (which is what they call L&D here) with sickle cell disease in a sickle cell crisis.  Sickle cell disease is much more common here than in the States.  I have only seen this one other time during my residency.  Sickle cell disease makes pregnancy high risk and can be life threatening to the baby.  Unfortunately, one of these women had lost her baby before she even got to us today.  My heart breaks for her.  Not only is she in severe pain, but she found out that her baby has not survived.  I hope to stabilize her tonight and then we will start the long, hard induction tomorrow.  These are the times when I wish I spoke the language the most. 

French is the most universal language here, however, the tribal language in this particular area is a tongue called Ewe (pronounced ey-vay).  Most of the men and those with education speak French, however, not all women here have been educated and sometimes Ewe is all they know.  There is another group of people here called the Falanies.  These are people probably best described as gypsies.  They look and dress very differently and seem to be a people without a country.  They are found in Gana, here in Togo and also in Benin.  They speak a different language altogether.  There are only a small handful of hospital staff that speak the Falanie language at all.  

Today I had the privilege of being invited to one of the anesthesiologist’s homes for a lunch party.  He is a native to Togo and we were celebrating the end of an internship for some of the OR assistants.  Let me tell you, the Togo people know how to eat! It is rude to not finish everything on your plate that you have been served, but I thought I might literally explode from the inside out by the time the lunch was over.  I don’t know how a single person could consume so much food in one sitting… us Americans that attended were the only ones who couldn’t seem to muster it. The lunch consisted of a 4 course meal.  It started with a type of cole slaw (yes, I am praying hard that I don’t get sick), then a huge heaping pile of rice with a homemade hot sauce on top.  Next was….well, I am not sure how to describe it. The name of the dish is Pot (haha, yes I had to laugh a little at this one too), it is a starch that probably best compares to really bland mashed potatoes that they cover in a sort of spicy gravy and then they put roasted chicken on the side.  The Togolese people eat the chicken bones and all.  In the interest of saving my teeth I only ate the meat.  The fourth course was a sweet bread cake that you ate with your fingers and again dipped in hot sauce.  All of the portions were an entire meal in and of themselves.  I don’t think I am going to eat for another week!  The whole experience was really interesting.  I am so glad that I got to try some of the native food and see a little of life outside of the hospital compound.  These are the moments when you really get to experience what the country is like.  At the end of the lunch we all stood in a circle and sang a song that involved lots of clapping.  The Togo people were really serious about the song and it took a lot to keep an appropriate expression on my face as we sang.  The lyrics were simple and just repeated over and over again.  Imagine the following in a sort of French/Jamaican accent.  “Jesus is a winner man.  Jesus is a winner man.  Winner man, winner man, winner man.  Jesus is a winner man.”  If that doesn’t make you smile, I don’t know what will.

Bonjour!

I made it safely to the hospital.  It is so nice to be settling in.  The 2.5 hour drive from Lome to the hospital where I am working was uneventful, however, I am beginning to think that abiding by traffic laws is entirely optional.  The only rule that seems to apply is whoever avoids the pothole first wins. 

When I arrived I was shown my new room which will be home for the next month.  It is probably one of the nicest places I have stayed in Africa.  This just might be my first trip to this continent that will be bed bug free!  I am pretty excited about that.  I am, however, sharing my room with a resident gecko who greeted me on the wall above my bed when I first walked in.  Some things just have to make you smile.  I have my own bathroom and shower along with a king sized bed that has way more room than I know what to do with. I tried to attach some pictures, but for some reason it won't let me do that.  I will keep working on it to figure out a way to post pictures on this blog with this computer system.

After getting settled in all of us staying at the guest house had dinner together in the dining room.  Someone along the way trained some Togolese women to make American food.  Dinner last night consisted of ham and cheese sandwiches as well as mac-n-cheese.  I guess you could say we were going for comfort food J

Yesterday was my first full day at the hospital.  This morning I helped with two hysterectomies and then spent the rest of my time getting to know my way around and figuring out how things work at the hospital.  I have never seen an ultrasound machine that was so…..um, antique? It is going to take a little getting used to in order to figure out all the buttons, especially when half of them have their labels worn off.  I just can’t help but laugh a little. 

So far I have been very impressed with the organization and capabilities that this facility has.  They are able to do some pretty big OR cases for their limited amount of resources.  Today they are going to operate on a 3 month old girl with Wilm’s tumor.  This is a tumor that grows often in children out of one of their kidneys.  This tumor has gotten so big that this poor little girl is having trouble breathing.  I am praying that they will be successful in getting the tumor out without much bleeding.

Tonight and tomorrow will be my first call shifts.  I have been a little nervous about this.  I could definitely use some prayer.  The way obstetrics is done here is very different than how I have been trained.  I know I will learn a lot.  I am just praying for wisdom and insight whenever a new patient crosses my path.  I hope to write more soon.  The internet here is what one would expect for third world country dial up J

First Morning in Togo

I slept super well last night.  Probably making up for my lack of sleep over the last 4 days.  It was wonderful.  They also had air conditioning in the room for free which was a huge blessing.  The moment I stepped off the plane last night I started dripping from the heat.  That is something I am going to have to get used to.  I just learned that the ORs in the hospital have airconditioning.  What a huge blessing!  Being in the city however, I did get woken up by the 4am Muslim call to prayer.  Always an interesting reminder of what dedication to prayer can look like.  Gives me something to think about. Alright, off and running!

Made it!

I am officially in Lome!  I landed in the capital city of Togo about 2 hours ago.  What a blessing.  I was able to sleep on both flights and navigate the Paris airport with a little help :-)  I ended up having two seats to myself on the flight from the States to Paris.  At 5'2" that was just enough room to curl up and take a nap.  I woke up singing 10,000 Reasons....."Bless the Lord oh my soul, oh my soul, worship His holy name."  Perfect.  When I made it to Lome I stepped off the plane and everyone around me was speaking French and all I could do was laugh at myself.  Here I am, traveling by myself, in a foreign country without an ounce of understanding of what is being spoken around me.  What was I thinking!?!  Thankfully, very little thinking was required. I am so thankful that World Medical Mission had me apply for my visa in advance which greatly sped up the process of going through customs, both of my bags made it all the way from the States without issue AND they sent a female American nurse to meet me at the airport with my driver!  Praise the Lord.  I don't know why I worry sometimes.  God has the details all under control.  What more could I ask for? 

Tomorrow we will be waking up early to run some errands around the city before making the 2.5 hour drive out to the hospital.  Right now it sounds like there is one surgical PA and one general surgeon taking all of the surgery call including cesarean sections.  They are switching off and taking call every other night without a post-call day.  I really hope that I can help with some of that burden and take some of the c-sections off their hands.  I am so excited to get started!  Tomorrow is going to be a big day. 

The Skirts

The fact that I have to wear a skirt at all times while in Togo has been an object of fascination for lots of people at work.  This skirt wearing includes when I am in the hospital and operating in the OR.  In the States this would be unheard of.  Our hospital uniforms of scrub shirts and pants are the expected attire and I don't think I have ever heard of anyone wearing anything else while operating. 



This is my typical look when working at the hospital in the States. Yes- I look like a smurf.

 

Because scrub skirts/dresses are not so commonly worn in the US it took a little searching to find someone who makes them.  I finally found some and ordered three to bring with me.  I wasn't sure how they would fit so I ordered three different ones hoping that at least a couple of them would work.  Well, given my short legs I learned years ago that ordering clothes online without trying them on first can be a risky deal.  Sure enough one of my skirts came and I promptly realize that it was going to be much more efficient as a floor mop than a functional piece of clothing.  This was definitely not going to work.  I talked with one of our wonderful L&D nurses and she graciously agreed to help me with this problem.

 

One of our wonderful L&D nurses volunteered to hem this skirt.

 

This is how I ended up modeling my scrub skirt in front of everyone in our L&D report room.  I am not sure that I am ever going to live that one down.  

Psalm 91

I am sitting here in the hospital in the lull of the early morning hours watching as the clock ticks away the minutes for my last night shift before I leave for Togo.  It is coming up so quickly.  I have been preparing for months and can hardly believe that I will be actually getting on a plane to fly over there in less than three days!

Over the last week several of the staff that I work with here in the hospital have come up to me independent of each other and given me verses out of Psalm 91. Such an encouragement, and such a wonder that the same verses are being given to me over and over again. 

Psalm 91

1."He who dwells in the shelter of the Most High will abide in the shadow of the Almighty. 2 I will say to the Lord, "My refuge and my fortress, my God, in whom I trust."...

4 He will cover you with his feathers, and under his wings you will find refuge; his faithfulness is a shield and buckler...

11 For he will command his angels concerning you to guard you in all your ways."


I have been marinating in this Scripture all week. As I was taking time this last weekend to think over this next month my heart started to just swell with joy. I am so excited to do this. It is really easy to get bogged down in the details of a big international trip and I have to constantly remind myself to take a step back and remember the 'why' behind all of those details.  Someone asked me this last summer "If you could do anything with your life what would it be?" I honestly could not come up with an answer different from what I am doing right now.  There are moments when a wave of nervousness and fear sweeps over me.  I am so very aware of my own limits, but am thankful that I serve a God that has none. 

Togo Culture

Different cultures and customs has always been very interesting to me.  What offends one person may be completely commonplace and acceptable to another by happenstance of geography and the setting in which one was raised.  As I have been preparing to leave for Togo in less than three weeks I have been reading up on some of the cultural norms that I should be aware of before I arrive.  Here are a few that I thought were most interesting.

Clothing: Women must wear skirts that cover their knees.  This is starting to change, however, for a long time only prostitutes wore pants and there still is an underlying association.

Handedness: The left hand is considered unclean and should not be used to give or take anything unless there is no other option.  I wonder how that works in the OR when I am standing on the left side of the table and having the scrub tech pass instruments to me?

Posture: Women crossing their legs is a sign of arrogance.  She is essentially saying she thinks she is important.  This shows authority and independence equal to that of a man. Standing with your hands in your pockets or on your hips is a sign of disrespect when talking to another individual.  This one is going to be a challenge for me.

In public: Sneezing and coughing, especially loudly is not polite.

Entertaining: When a Togolese person invites you over to their house they will offer for you to sit in the best seat in their home.  This invitation should be accepted.  When it is time for you to go, you must ask permission to leave before standing up. 

Just some interesting thoughts to keep in mind as I am preparing myself to go.