Thanksgiving

I am sitting here in the early morning hours on one of my favorite holidays just watching in awe as the sun rises welcoming in a new day.  Jet lag is the cause for this early morning treat, but I can't help but think of the last sunrise I saw and how I was awake at this hour for a much different reason.  What different worlds.  Before leaving for Togo I had a huge burden of anxiety sitting on my shoulders.  Anxiety of the unknown, anxiety that I would be presented with things I wouldn't know what to do with, anxiety of desperately wanting to help, but feeling utterly helpless.  As I spent some time praying this morning and just reflecting with the Lord about my last month I could do nothing, but praise Him for His incredible provision.  My anxious thoughts were all for nothing.  I was faced with some huge, challenging and at times heart breaking situations and decisions, but never once did I feel alone. Of course right?  I should have known better.  The Bible is full of promises to the contrary.  I have so much to be thankful for. 

I was listening to this song by Matt Redman this morning and it just seemed so appropriate.

"Never Once"

Standing on this mountaintop
Looking just how far we’ve come
Knowing that for every step
You were with us

Kneeling on this battle ground
Seeing just how much You’ve done
Knowing every victory
Was Your power in us

Scars and struggles on the way
But with joy our hearts can say
Yes, our hearts can say

Never once did we ever walk alone
Never once did You leave us on our own
You are faithful, God, You are faithful

Kneeling on this battle ground
Seeing just how much You’ve done
Knowing every victory
Was Your power in us

Scars and struggles on the way
But with joy our hearts can say
Yes, our hearts can say

Never once did we ever walk alone
Never once did You leave us on our own
You are faithful, God, You are faithful
You are faithful, God, You are faithful

Scars and struggles on the way
But with joy our hearts can say
Never once did we ever walk alone
Carried by Your constant grace
Held within Your perfect peace
Never once, no, we never walk alone

Never once did we ever walk alone
Never once did You leave us on our own
You are faithful, God, You are faithful

Every step we are breathing in Your grace
Evermore we’ll be breathing out Your praise
You are faithful, God, You are faithful
You are faithful, God, You are faithful

You are faithful, God, You are faithful
You are faithful, God, You are faithful

This Thanksgiving comes on the heels of a journey that took me to the other side of the world.  Many of those I worked with have never seen a television, felt the refreshing coolness of airconditioning or even slept on anything other than the hard packed dirt that serves as the floor to their homes.  It is not the wealth and luxaries of the United States that have captured the attention of my thankfulness though, but the unending promises, greatness and faithfulness of the God I serve. 



"...but those who hope in the Lord with renew their strength.  They will soar on wings like eagles; they will run and not grow weary, they will walk and not be faint."  Isaiah 40:31

Made It Home

I flew in safely to San Diego last night where I am going to spend Thanksgiving with my family.  Thank you for all of your prayers.  I am very tired, but feel so blessed for the experiences of the last month.  My journey home was relatively uneventful except for the marriage proposal I got from the airport guard as we were leaving Togo and missing my connection from LA to San Diego.  My flight from Paris was 2 hours late and less than one hour to get through customs and then recheck my bags and make my connecting flight is not really realistic though I gave it my best shot.  Thankfully, they had another flight to San Diego that left a couple of hours later that I was able to take.  After traveling for almost 3 days what is a few more hours?

As I was getting ready to leave Togo I started thinking about how this last month so sharply contrasts with my life back home.  In the last month I haven't:

-Talked on a cell phone
-Worn pants
-Been cold
-Sent someone home from triage
-Carried a pager
-Slept without a fan going
-Spoken to a patient in my own language
-Operated on someone weighing over 200lbs
-Understood a single word spoken at church
-Driven a car
-Blow dried my hair
-Gone a single day without sweating
-Gotten called in the middle of the night to address heartburn or hemorrhoids
-Looked at a computer for electronic fetal monitoring
-Done a single med reconcilliation
-Had a post call day
-Watched TV
-Read the news
-Used a dishwasher
-Gone one day without a mosquito bite
-Worried about insurance coverage
-Regreted a single moment

What a blessing.  The Lord has been so gracious!  I have learned and grown so much over the last month and am so thankful for my time in Togo.  It was bittersweet to leave, but I am so greatful for the week ahead to spend with family and friends before returning to work and adjusting to life as I used to know it.  Life sure is different between these two worlds that I have been straddling.  What an incredible journey.  Praise be to my God!

Back from Mango!

We have all officially made it back to the hospital from Mango!  What a great trip!  I am so glad that I got the chance to see this piece of Togo.  It was a 16 hour road trip for Rhonda and me on Wednesday, but we finally made it to the town of Mango dusty, tired and very sunburned.  It was so great to see so much of the country.  We ended up driving through almost every major town in the country.  It gets progressively more dry and grassland like as well as progressively more poor as you travel north.  When we got to Mango we stayed with a long term missionary named Anna.  What an incredible person she is!  She is about my age and has moved to this far northern city by herself.  She lives in a compound with the people and has really settled in making it home. She has learned the language and has reached out particularly to the Falani people (the tribe that I sort of described gypsies in a previous blog).  The Falani are looked down upon and discriminated against by just about everyone else.  They can’t even shop in the markets in town without getting cheated just because of the tribe that they are from. It is so sad.  Anna, however, has made friends with many of the women and has been welcomed into their lives.  She freely visits them in their homes and they often come to hers to talk and spend time together.

 

Anna, Kristen, Rhonda

We stayed with Anna while in Mango and had a wonderful time.  What a great hostess.  When we got there she had dinner waiting and then gave us a tour of the place. As soon as I stepped inside the house I could feel the temperature difference.  The outside air temperature had begun to cool down, but her home was still very warm.  I took my shoes off and walked inside and noticed that the cement floors felt like they were heated.  Back in the States people pay a lot of money for heated floors….here it come for free!  She showed us our room that Rhonda and I would be staying which had two mattresses on the floor each with a pillow and covered with a fitted sheet.  There were no other sheets or blankets to put over us at night, but honestly I was thankful because it was pushing 100 degrees in her house.  She showed us the bathroom which had a modern sink, toilet and shower.  I just had to laugh because along with giving us the tour she informed us that she was having a little bit of a frog problem particularly in the bathroom.  These little orange frogs like to sit on her toilet.  We were instructed to just push them into the bowl and flush them down.   Haha, wow.  Yep, I am definitely in Africa!  We were also told not to touch them with our hands because they have some sort of toxin in their skin that stings.  Looking at the frog currently sitting on the toilet seat I wondered if that toxin gets left behind on anything they have touched.  I decided at that point not to test it out and I would just avoid sitting on the seat.  I was so thankful for a shower that night to wash away all of the grit from the day.  I don’t think I have ever had such a bad farmer’s tan.  When I stepped into the shower I just had to laugh.  There was only one knob to turn, which in Africa means that the water only comes in one temperature.  Great!  Who would want to take a warm shower in this weather anyway?  It was perfect.  We finally went to bed after visiting with Anna for a while and when I laid down I could feel the heat from the floor coming up through the mattress.  How in the world was I ever going to sleep?  Heat was coming at me from all sides.  I was trying to lay as perfectly still as possible without letting any limbs touch or any joints bend to avoid trapping any unnecessary heat.  I just prayed that the Lord would allow me to sleep.  I was so tired that I drifted in and out for about an hour or so before I fell into the best, deepest night’s sleep I have had in over a week.  Praise God!  The temperatures outside continued to cool and eventually permeated the inside of the house.  So wonderful.

 

We were woken up around 4am the next morning by the Muslim call to prayer.  In many towns this is conducted over a loud speaker system that can be heard throughout the whole place.  However, in Mango this was replaced by a man that got up every morning between 330 and 430 and ran up and down the streets yelling in a raspy voice to wake everyone up.  I just had to smile.  What a job this man had! 

 

We got up hours later, had breakfast and started to make our way towards the compound where the new hospital is being built.  It takes a long time to get anywhere in Mango with Anna because when she is walking down the streets all of the women come up and greet here.  It was so wonderful to meet all of her friends.  We made it to the compound and took a tour of the construction site.  I was so impressed!  This is going to be an extremely well done hospital. 

There are a few homes and other structures already completed on the compound which include a guest house, homes for some of the missionaries, a work shop and a pool.  The quality for all of these buildings would rival anything we have back in the US.  After visiting with some of the missionaries and seeing the construction site we wandered back into town to go to market.  Like most African markets it was an open air event with different stalls set up selling various things.  What made this market different though was that it was nestled under a canopy of trees.  This is so key to help keep the temperature down.  We bought little snacks along the way and made this lunch.  We also stopped by the home of Anna’s friends who is a Falani lady and she had the most wonderful fried chicken prepared for us when we arrived.  What a treat!  After visiting for a while we then stepped out to walk around and see more of the town.  We visited with more people and then walked down towards the old section of Mango.  It was at this time that I started to really notice the heat and felt like I should probably start thinking about doing something to get to a place that was somewhere cooler.  Some of the missionaries from the hospital drove by and offered to pick us up and take us back to the hospital for a meeting.  I gladly took them up on it.  When we got back to the hospital we were told it had reached 122 degrees!  No wonder the heat was starting to bother me.  I don’t think I have ever been in weather that hot.  Thankfully, there was no humidity which did make it much better.  After taking a rest inside and out of the direct sunlight Anna, Rhonda and I wandered over to the water tower on the hospital compound.  What a view you can get from the top! 

Enjoying the view from the water tower

 

Very few things can beat the beauty of the sun setting over the African grasslands.

 

The African grasslands of northern Togo are totally the description everyone thinks about when they think of Africa.  Simply beautiful.  The waves of golden grass extended for miles in every direction and just reminded me of how incredibly great and vast my God is.  We watched the sunset over the horizon and then headed back to the guest house for dinner.  This would be the last dinner for the construction team of short term missionaries currently working on the hospital before they head back to the US.  After dinner we all decided to go for a night swim in the pool.  What a perfect evening!  The water was so refreshing and the African stars so incredibly bright.  I absolutely cannot believe that I have had the honor and privilege to spend the last month here.  We got a ride back to Anna’s house in town and no sooner had we stepped foot inside her home than there was visitor after visitor of African women coming to say hello.  People were just wanting to talk, play games and many brought meals.  What an incredible example of how to fully integrate into another culture and love people who are so different than you as truly part of your family.  It was such a good, tangible example for me to see.  I learned so much by just spending that little bit of time with this incredible and dedicated missionary.  It was getting late so we finally just had to close the door to keep more people from coming.  Bedtime followed the same routine as the night before and again we were woken up at 4am by a raspy voice shouting down the street.  The van with the short term construction team that we were going to be getting a ride back to the hospital down south would be here soon.  The time in Mango just flew by.  I am so glad we were able to see it.  The ride back was uneventful and comfortable!  The van actually had air conditioning.  I don’t think I will ever take such a luxury for granted again.  We made it back here to the hospital just as the sun was setting.  My last night in Togo.  Wow.  It is bittersweet.  After checking in at the hospital Rhonda and I spent some time dipping our feet in the pool and just watching the African sky. One shooting star after another danced in front of us.  So peaceful.  I will definitely miss this place. I know there is much reflection and processing of the events of this last month yet to happen, but I cannot describe the contentment and joy that I have had in the opportunity to serve here.  I have had the privilege of working with some incredible people and the honor of loving the people of this little known country.   I just praise God for His incredible grace in allowing me the chance to do this.  Where I will serve in the future long term is still being heavily prayed over. I know His guidance will come at just the right moment and not a second sooner.  I just thank the Lord for the work He is doing now and for whatever may lay ahead.  Tomorrow I leave to fly back to the US.  I am so thankful that I will get the chance to spend Thanksgiving with my family this year.  Oh how He has so sweetly provided.  Thank you for your continued prayers and encouragement.  I cannot tell you enough how much it means to me.  Blessings to you all, goodnight.

Going to Mango

The internet here has been a little touch and go over the last few days making it hard for me to post.  Sorry for the delay.  The weekend call went fairly well.  I ended up being awake most of Sunday night with a pt that came in term with bad malaria.  That was a little beyond what I am used to taking care of back in the States.  She had a high fever and baby wasn’t liking that too much.  I asked several people the next day how to proceed with caring for this pt and every time I asked someone new I got a new answer.   Haha, well sometimes things just are not very cut and dry.  Thankfully, both mom and baby are doing well and mom is well on her way to recovery. 

The hospital here is currently constructing a sister hospital up in the northern part of Togo in a city called Mango (pronounced Mongo).  This is a city that has no medical care at all.  The closest hospital to them is over 2 hours away.  If ever there is a medical emergency there is very little the people can do.  If a mother needs a c-section it often ends in death for both mom and baby.  There is not a single surgeon in the area and there is tremendous need.  An opportunity over the last couple of days has come up for me to go there and see the building of the new hospital and compound as well as the surrounding city.  I am very excited to get to do this!  We will be traveling by car which means I will get to see most of the country of Togo while I am at it.  It is going to be a quick trip, leaving early tomorrow and then getting back on Friday.  I am scheduled to fly out of Lome on Saturday.  I cannot believe it is coming up so quickly! I would love prayer for the trip up there and back that the roads would be ok and that the vehicles will not have any problems.  Rhonda will be going too which will be wonderful to get the chance to spend some time together outside of the hospital context.  I don’t believe that I will have internet access up there, but hopefully I will be able to post again when I get back here Friday night.  Thank you to everyone for your prayers, support and encouragement for my time here.  It has meant everything.  I am on call for one last night here in Togo and praying for God’s sustaining hand.  I cannot believe that my duties here at the hospital are coming to an end.  I have learned so much and been stretched in so many ways.  There have been a lot of moments filled with laughter and joy as well as those that threatened to rip my heart out, but I cannot say enough how much I have enjoyed my time here.  I am thankful for the opportunity to be here and serve alongside some incredible individuals to a people who truly are in need.  One of my medical school mentors had a saying that I think has been very true of my time here in Togo, “God loves you just the way you are, but He also loves you too much to leave you there.”  That is how I feel about much of the growth that has occurred over the last several weeks.  Many of the experiences, challenges and lessons learned will not be forgotten for a very long time.  Praise God for allowing this time to happen. 

Simply Beautiful

Today is the one week mark.  I only have one more week here in Togo.  Where did the time go?!? I have gotten to learn and see so much that the time has passed by very quickly.  I haven’t had the chance to blog about half of it.  Last night I was on call, but got a full 8.5 hours of sleep!  I think that is the most sleep I have gotten since coming to Togo….and for those that know me well know that I really like to sleep J  I think the fact that it was much cooler last night after the rain we got helped a lot. 

I woke up this morning and rounded on the pts and then did a c-section for twins!  Multiples are so fun! One boy and one girl.  Everything went really well.  Mom and both babies are doing great.  This pt brought extra family with her to help with both little ones.  The babies here are so cute.  They are all born with the most adorable fro.  It would be the envy of many back home who put a lot of effort into getting their hair to look this way. 

So refreshing!

 

Having fun, clothes and all!

 

 

This afternoon a bunch of us got to take a hike out through the local mountains to a waterfall.  What a great way to see Togo!  Hiking along this dirt path we got to see many people out harvesting things from the surrounding jungle, small villages and family compounds, people doing laundry in the local river and  hauling their goods back to their homes hoisted upon their heads. A lot of the hospital staff lives back in the jungle behind the hospital where we were walking.  It just gave me a much better sense of where the nurses and pts live and how they do life.

When we finally reached the top we got to this really beautiful waterfall and swimming hole.  Yes, I jumped in clothes and all!  So refreshing. I don’t think I have been that cool since arriving in Togo.  God sure has created some incredible stuff.  Africa is so beautiful. 

View from the trail

The views from the mountains we were hiking up just spoke of His greatness and vastness.  I am sure that the pictures I took do not even capture half of the wonder of it all.  Everything is green.  The tall jungle trees grow all sorts of nuts and fruit that can be eaten. The wild flowers come in some of the brightest colors of reds, yellows and lavenders.  The dirt we walk on is a rust color that contrasts with the green jungle surroundings.  There were also a fair number of chickens, goats and pigs we saw roaming around eating whatever they could find.  I am sure that they all belong to someone, but I have no idea how anyone keeps track of them all.  The children seem to be working just as hard as the adults carrying fire wood, flour or water on their heads back to their compounds.  As we were walking back it was getting closer to dinner time and many of the families were cooking in the open air in the middle of their compounds with big pots set on top of open fires.  Families and extended families all seem to live together in the same compound and so they share meals together as well as communal chores.  Their homes range from mud huts with thatched roofs to small square cement buildings with tin roofs.

One of the compounds where they were drying food

 All of them appear to have dirt floors.  A compound usually consists of several such homes arranged in a square or circle with all of their doors facing inward to a central open area where most of the day’s activities take place.  Each compound also has a communal meeting area which consists of an open air shelter with a thatched roof and a few wooden benches underneath.  The dry season is coming when there will no longer be fresh fruits and vegetables.  As we were walking through the different compounds I saw many people laying out their goods to dry in the sun so that they could store them for the coming months without any rain.  I am so thankful to have had the opportunity to step away from the hospital for a bit and see a little bit more of this country.  I can’t believe that I have been so blessed to spend the last month in such a place as this. 

No Such Thing As Bad Hospital Food

Back home one of the common complaints across hospitals is that the food is terrible.  Having experienced patient life first hand I can attest to the fact that the rumors are indeed true.  When you have a hard time deciding if what is in the mug is supposed to be coffee or vegetable soup you know you should look elsewhere for your next meal.  The hospitals here in Togo have it figured out pretty well….they just don’t serve food at all.  They have then completely avoided all of the usual complaints.  J Actually, being in the hospital is an entire family affair.  No one can be admitted to the hospital by themselves because they need to bring family members to come and help care for them.  It is the members of the pt’s family that do the cooking and provide all of their meals.  They also do the laundry, bathe the pt and supply them with blankets and clothing.  Such a different way of doing things than back home.  Consequently it is important for the hospital to have some extensive grounds so that members of the family can cook and do wash (all of which is done outside).  At night, the family members sleep on the tile floor next to the pt’s bed.  Each ward consists of one big room with beds lined up next to each other on either side.  Privacy isn’t something many seem really all that concerned about.  Between the pts and their families you can pack a lot of sleeping people into one ward.  It is always interesting as the practitioner when I get called to see a pt in the middle of the night and have to step over a bunch of sleeping bodies to even reach the pt’s bedside. 

Sometimes back home we joke about the hospital being more like a hotel.  The laundry is done every day, the pts get room service with their meals set right next to their bed and they even have a menu to choose from.  It is not completely unheard of for a pt to request to stay much longer than medically necessary because they feel well cared for and are lacking nothing.  I guess that speaks highly of our medical care, but it can be frustrating on the practitioner side of things to have pts in the hospital who don’t really need to be there.  Funny, this is never an issue in Togo.  With the family being burdened to care for the pt’s needs and thus having to be away from home as well as with the lack of health insurance and the personal responsibility of having to pay for the hospital bill, pts are more than willing to leave when the time is right.  We did have one father offer to bribe us to release his premature son from the hospital early due to the mounting inconvenience of the things I have just mentioned.  No, we did not accept the bribe or discharge the baby, but it is such a different attitude than what we sometimes struggle with back home.

It has been raining all afternoon!  The thunder rolled over the mountains behind us just after lunch and it has been steadily coming down ever since.  I never thought I would be so excited for rain, but what a refreshing break from the heat.  I am on call tonight and might be sloshing my way to the hospital on the muddy dirt path between the guest house and L&D, but I am not sure that I even care!  Oh so nice to be excited about the simple things in life!

Broader Shoulders Than I

Yesterday afternoon was relatively quiet.  There is no clinic on Wednesdays which means there aren’t the normal lines of pts to see.  No elective surgeries are scheduled on Wednesdays giving the hospital and its employees time to catch up and focus on just the emergencies and the pts already admitted to the hospital.  The need here is seemingly endless and having a day in the middle of the week that is designed to be slower so as not to spread people too thin was a wonderful idea.  During the lull of the afternoon I was back in my room reading a passage in Phillipians 4.  I knew that the words were hitting home with me, filled with meaning, but I had no idea that they were really preparing me for the night to come.  This passage talks about letting go of your anxiety, letting the Lord of all creation take that anxiety for you.  He promises to cover you with peace when you fully hand over all of your fears.  What an incredible promise!  It is a truth that I have to constantly remind myself of and am not very good at practicing.  When am I ever going to learn?

I knew my break from the hospital had come to an end when the phone rang in my room and I heard that all too familiar voice on the other end, “Please! Come to maternity.” (Maternity is what they call L&D here)  I was on my way.  A pt had arrived in labor that needed a repeat c- section.  Gladly.  I was so thankful this happened late in the afternoon instead of the early morning hours.  The c-section went very well.  The proud mother gave me a huge smile and grabbed my hand in the recovery room after the surgery was over.  I just praise God for another wonderful life born.  I made my way back to the guest house for dinner and was just finishing up when I got called to the hospital again.  Another laboring pt had gotten sent to us from an outside facility.  It was back in the OR for another c-section for us.  Beautiful delivery number two!  Before we had left the OR we received word that there was another pt that needed our attention immediately.  Ed and I quickly went to see what we could do to help.  A young lady had come in with complaints of abdominal pain, bleeding and a positive pregnancy test.  The flags went up in my head.  Something wasn’t right.  Back home these pts come to the ER and often have an ultrasound completed before I even receive a phone call, but here the ultrasound was going to have to be done by me.  There were two things I was looking for, a miscarriage or an ectopic pregnancy ( a pregnancy outside of the uterus which is not compatible with life for the baby and can be life threatening to the mother).  I have never done the ultrasound myself to diagnose an ectopic, but as with many things on this trip, there is a first time for everything.  I placed the ultrasound and didn’t see anything remarkable inside the uterus.  I was praying that if there was something that I needed to see somewhere else in the pelvis that God would show it to me.  I knew this was critical and if I missed something it could catastrophic for this pt.  As I scanned to the left the diagnosis jumped out at me.  There was an ectopic pregnancy in the fallopian tube.  There was evidence of fluid in her abdomen and I knew at this point we needed to move and move quickly.  This pregnancy was already starting to hemorrhage and as we waited to place the IV I watched as this pt’s blood pressure started to drop.  Ed and I brought her back to the OR and opened her abdomen quickly clearing the blood out as we went.  Sure enough, the dilated tube stared back at us as we placed our clamps and removed the left side.  I am so thankful this pt came in when she did and that we were already at the hospital when she arrived so that no time was wasted.  It is amazing how fast these pts can go from stable to unstable.  Praise God that she survived and was doing well this morning!

Nothing else was pressing so I went back to try to get a few hours of sleep.  That was not going to be my last phone call of the night.  My phone rang again in the early morning hours.  A pt of ours had arrived, in labor, with a history of 2 prior c-sections and the nurse was now not able to find the baby’s heart beat.  My heart sunk as I pulled out my flashlight and hurried toward the hospital.  What was I going to find when I got there?  I immediately turned on the ultrasound and took a look.  The pt’s belly was so tender and hard.  What I saw on the ultrasound left a pit in my stomach.  This was something I had never seen before, but only read about – uterine rupture.  From the grainy quality of the ultrasound it looked as if the scar from this pt’s previous c-sections had burst open and the head of the baby was now in the pt’s abdomen. Scanning some more I confirmed that indeed there was no heart beat. It was too late to save the child, but we still had a chance at saving the mother if we could get her to the OR quickly enough.  I made the necessary phone calls and prepared for surgery.  One swipe with the scalpel through the pt’s skin was all that was needed to see the infant’s curly hair poking out at me.  I groaned out loud as we opened further and I realized that the entire body of the baby and the placenta was outside the uterus floating in the abdomen.  I don’t think I will ever forget the overwhelming sadness of scooping that lifeless body up and handing it to the waiting nurse.  If only this pt had come in sooner, if only she hadn’t waited at home while she was contracting, if only, if only, if only…..but it is not my place to play the if only game.  I am not the one that holds the power to correct the past and change the future nor do I want to be.  I am not the one to question the events that were, I simply must be ready to help in the events that are.  Only God has the answers to the whys and the what ifs and He is certainly not obligated to give me an explanation.  I am so humbled.  We stopped the bleeding and repaired the damage.  In all of the suffering and pain that I have seen here thus far I have never once seen a Togolese woman cry until last night.  This would be her last pregnancy.  Her physical and emotional pain is more than I can fathom as I watched her silent tears drip down her face.  Lord, I know there is redemption in even this though I don’t see it in the moment.  He loves this Togolese woman more than I do and feels her pain even more acutely than what is piercing my heart.  I am so thankful that two lives were not lost last night and that the Lord was able to guide us through the necessary surgery to save this mother.  Why one woman made it to the hospital in time and one did not I will never have the answer, but I do know that the outcome does not change the Sovereignty of our God.  Nothing surprises Him and nothing is too big for Him to handle.  God has broad shoulders, much broader than mine and I have to rest in that. 

Ups and Downs

I was able to send home the mother with the breech twins this morning!  Both babies weigh about 4.5 lbs and are probably some of the cutest things I have ever seen.  Everyone is doing well.  Praise God!  When I was talking to this mom yesterday she said that she had no idea she was having twins until she delivered.  What a surprise!  I have asked them to come back in a couple of weeks to monitor how these two little ones are growing.  I so hope I get to see them again before I leave. 

Today was a slower day at the hospital for me which was nice as it has provided some much needed rest.  There have been a couple of hard cases over the last few days which have been sort of draining.  Abortions are fairly common in Togo and I seem to see a lot of people coming to the hospital a week or so after having an abortion performed by some medicine man infected and in need of treatment.  Two nights ago I got called to the hospital to help with just such a case.  I am not sure that we ever really get the complete story, but this pt had an abortion about a week prior and was now complaining of pain and fevers.  Ultrasound showed that tissue was still remaining inside her uterus and needed to come out.  Whoever had performed the original procedure had left some of the tissue inside and then to add injury to insult poked a hole in the uterus so that infection from their dirty instruments seeped into her abdomen.  Very few things make my blood boil like this.  I have seen many pts come to clinic with a history similar to this one who years later are married and desire to get pregnant, but are no longer able to.  It is both frustrating and sad.  They often beg me to do this test or that surgery in hopes that they will be able to conceive, but in reality there is very little I can do to help them.  Both of our hearts end up broken. 

Yesterday, we had several successful deliveries which are always wonderful.  There is no sound quite like that first cry of a newborn child.  It makes me smile every time.  Rhonda and I got to work together with several of the mothers. It is always so much more fun to do things as a team.  We did have one difficult case though of a mother who came in at term, in labor, with a stillbirth.  No matter how many times I have done this my stomach still drops when I place the ultrasound on the mother and see that lifeless body staring back at me.  The delivery was hard and it took almost 20 minutes to deliver the body of this baby.  I cannot imagine the torment of that poor mother.  There are no epidurals here in Togo, there is nothing we can do to dull the pain.  Like many of these cases there was no obvious reason for the death of this little one which just serves to make the situation harder by leaving a lot of unanswered questions.  Rhonda and I both prayed for this mother, there was nothing more we could do.

I have been so blessed to have Rhonda here.  When I was coming to Togo no one told me that I would be working with an American trained midwife.  I was under the impression that I would be working on L&D alone.  I realized this morning that I was praying for Rhonda even before I left the States.  I prayed that the Lord would send someone to help me, someone that I could talk with, discuss cases with and share my joys and sorrows with.  I prayed that this person would also be female and here by herself.  I really was just praying for a friend.  I love the work that I am doing, but I knew that if I was here and felt truly isolated the work here would become much more difficult.  I love that He provided long before I even asked.  Rhonda has been here for months!  We have made such a great team, both learning from each other, wanting to explore the country and understand the Togolese people as well as having a deep desire to serve the Lord.  God is so faithful.  He has provided for my every need even before I knew I had one.

Quick Update

I am on call tonight and just have a few minutes to write.  I wanted to give an update on Bernadette, the 4 year old girl I asked for prayer for.  She made it as far as Ethiopia where it was decided that she was too sick to travel all the way to the United States.  She ended up having surgery in Ethiopia and to the glory of God it went well!  She spent 36 hours in the ICU and is now on the regular floor recovering with what appears to be full function.  She has a shunt in place to help drain the fluid from around her brain.  We are praying that they will be able to remove it because living with a shunt like this in Togo is not really compatible with life because of the infection risk and the care it requires.  If all goes as planned she may be able to come back to us as soon as next week.  This is such an incredible outcome for this little girl.  Thank you to everyone who has been praying.  I so love the comments and emails I have been receiving from people back home.  It is so wonderful to still feel connected even though I am half a world away.  Alight time to try to get some shut eye before being called back to the hospital.  From Togo - good night!

His Mercies Are New Every Morning

All was quiet when I went to bed last night, but that only lasted a few hours.  A call at 3am broke the respite we have had over the last couple of days on L&D.  The nurse on the other end of the static filled line asked me to come quickly.  A pt came in from a different facility seizing.  That was all the information I needed to tell her to start an IV as I rolled out of bed and started down the dirt road to the hospital.  That short walk is always an interesting one as my mind races with the possibilities of what I am going to find once I arrive at the hospital.  The pt was post-ictal (the very sleepy state that people go into after having a seizure) when I got there.  Her blood pressure was high and I started magnesium to prevent any further seizures.  The facility she had come from had taken her blood pressure, watched her seize and then sent her to me without any intervention.  I ordered some labs to be drawn and then went to work trying to figure out how far along this pregnancy might be.  The pt was in labor and progressing.  I breathed a sigh of relief when I confirmed that she was indeed far enough along that this baby should be able to survive without a problem.  I was in the middle of addressing her blood pressure issues when another pt got brought to L&D in a wheel chair. 

The Togolese people have a much higher threshold for pain so when a pt comes in with distress you know something is wrong.  One look at this woman’s face told me something was definitely up.  As we moved the sheet covering her lap to move her to the bed my eyeballs almost popped out of my head as I saw a baby that had been breech (feet first) and almost completely delivered, hanging by it’s head with arms and legs waving back at me.  Thank God that the nurse with me had her wits about her and she reached down and quickly delivered the baby.  I went to the phone and called one of the other docs to come help resuscitate the baby.  As I was making the phone call the nurse calls me, “there is another.”  I looked at the pt to see what she was talking about and sure enough, there were twins!  What a morning.  I pull the ultrasound over and yes, this too was a breech baby.  Vaginal breech deliveries are not something we do very often in the States.  Most often these women have c-sections before they even go into labor as delivering breech has some definite risks.  This was the dilemma, I have never delivered a breech baby vaginally and it was likely that this baby was going to be delivered before I could mobilize everyone to do a c-section.  Also this pt had delivered 4 other babies successfully not including the breech baby that had essentially just delivered itself.  Ok, I guess there is a first time for everything.  I called the surgeon to be on standby just in case.  The second baby ended up delivering footling breech shortly after without a problem.  Praise God!  I breathed a sigh of relief when everything was done and all three of them were safe.  We are trained so much in all of the things that can go wrong with breech deliveries that I just kept replaying all of those possibilities over in my head.  I am so thankful everything went that smoothly. 

I then turned my attention back to the pt with eclampsia (seizures).  Our one Doppler (hand held machine that allows us to listen to the baby’s heart tones) was out of batteries so I was left with our one ultrasound machine in L&D to evaluate heart tones.  Baby still sounded good.  I was so relieved because all of my attention and the ultrasound had been turned toward evaluating the twin delivery for the last 40 minutes.  I asked the nurse to give the pt more blood pressure medication and then walked down the post partum ward and stepped out the back door of the hospital to stand on the porch.  The African sun was just starting to rise.  What a beautiful gift in the midst of a busy morning.  I was reminded of the verse that says, “His mercies are new every morning.”  What peace comes with that.  The Togolese women were already busy doing wash on the grass at the back of the hospital.  I wanted to linger a little longer, but knew that I needed to get back to my sick pt.  No sooner had I walked the 100 feet back to where she was laying than another pt came in emergently.  She came from another facility for non-reassuring fetal heart tones.  Because I only had one ultrasound to evaluate both pts with and this ultrasound had to remained plugged into the wall I had them put this new pt in the bed right next door.   The curtain was removed from between the two beds so that I could go back and forth with the ultrasound quickly if I needed to – so much for privacy.  The heart tones on the newest pt were ok for the time being.  I decided to allow her to progress in labor, though I had my doubts because one look at her belly made me have to reassure myself with the ultrasound that she wasn’t having twins.  This was going to be a really big kid.  After laboring for 30 more minutes the heart tones began to drop.  Everything was in place for a c-section if we needed one. I called all the necessary people and we headed to the OR.  As soon as the head was delivered I knew we had made the right decision.  The baby weighed 9lbs 6oz….that is toddler size for a Togolese woman.  We quickly handed the baby to the midwife and began sewing the pt back together.  Something felt something wet by my feet and looked down to see that blood was dripping off the table forming a puddle on the floor and now effectively splattering my unprotected ankles underneath my scrub skirt.  Bummer.  At least my socks are black so no one will see the stains!  As we were closing this pt I received word that the heart tones for our eclamptic pt were starting to go down.  C-section number two of the morning.  We traded out pts in the OR and were able to get the next baby out without a problem.  Everyone is now safely delivered.  I had every intention of going to church this morning, but the pts had other ideas.  By the time we were done operating it was 10 ‘oclock.  Rhonda was coming on and it was time for me to head back to my room to take care of my blood stained clothing.  For some reason showers here feel so much more refreshing than back home J Hopefully, that is all the excitement for today.  You never know what is going to walk through the door.  I just praise God that every single pt was taken care of and all ended well by the time I left the hospital.  His mercies are new every morning….

What is normal? Who sets the standards?

After rounding in the hospital this morning a bunch of us girls took a day trip into one of the larger cities in Togo called Kpalime (pronounced Poly-may).  It was really nice to leave the hospital for a bit and see some more of Togo.  We had one of the guys that works at the hospital drive us in one of the hospital vans to the city.  Our first stop was at the Blind Center which is a place established by one of the first missionaries to Togo.  It is this really nice compound that is sort of a boarding school for blind children.  You can imagine how having such a handicap as blindness would be completely devastating in a third world country.  This is a place where children with blindness come from all over Togo and really all over West Africa to learn and be taught a trade so that they can have some sort of standing in society.  It is really a neat place. I was very impressed.  On the compound they also have a boutique of sorts where they sell all sorts of African goods.  Some are made by the children at the blind center and some are purchased from reputable people and of course the proceeds go towards the children.  It was really neat to see how well taken care of this place was.  Next we stopped at one of Susana’s favorite shops (Susana is the one that organized this trip, she is a long term nursing missionary here) where there were more wood carvings and paintings and things to look at.  We then went into the heart of the city to “market.”  Saturday is market day in Kpalime and it is quite the event!  Market consists of open air stalls set up for miles in no real rhyme or reason with people selling just about everything from produce, to fish, to meat, to fabric, to pots and pans, to soaps, to some of the biggest mouse traps I have ever seen.  I don’t know how the mice grow here in Togo, but by the size of the traps it looks like they are more the size of a small cat.  Gross, I am glad I haven’t seen one yet.  The market would not be exactly what I would call sanitary as there is no such thing as refrigerators for all of the meat which sits out all day in the African heat with flies landing freely.  There are tons of people milling around and children that are partially clothed sitting on the ground playing in the dirt. As I was walking through the maze of vendors I just kept thinking to myself, “this is how the vast majority of the world does life.  This is NORMAL and what I am used to with Kroger, Albertons and Target is strange.” I am the odd one out and just have to continually remind myself of that when faced with these cultural differences that at times seem so shocking. 

It was such a great day!  I am so thankful for the opportunity to not be a doctor and just be Kristen for a few hours.  It was so wonderful to see life here in Togo and see another realm of life that my pts experience on a daily basis and yet I am so far removed.  It was a welcomed reprieve after a hard night.

I wasn’t on call last night, but ended up being at the hospital until the early hours of the morning.  A bunch of us were having dinner together last night when Rhonda walked in and told me about a pt that had come to the hospital who was about 26 weeks pregnant and was bleeding.  Uff…my heart sank.  The very earliest this hospital has ever had a child deliver and survive is 28 weeks.  There are no ventilators and our ability to do feeds and abx is pretty limited.  After getting the history it sounded like an abruption (bleeding from behind the placenta as the placenta starts to separate from the uterus).  I was hoping that we could just hold on and ride this out – that the bleeding would slow and stop while mom and baby remained stable.  If the abruptions are small enough things often stabilize and you can prolong the pregnancy, unfortunately last night this was not the case.  The baby’s heart tones started to drop, mom started contracting and we were losing ground.  The baby got one dose of steroids and a mag bolus as we wheeled back to the OR.  This was an 18 year old first time mom.  These situations are always so hard.  Having children here is one of the only ways a woman can have any standing in society.  Her worth is wrapped up in the number of children she has.  Men often have multiple wives and the one that is favored is the one that can bear the most kids.  A cesarean section often limits the number of children a woman can have because of the stress pregnancy and labor puts on the scar that is now on that uterus.  It also is dangerous here because people don’t always come to the hospital and often labor at home which is very dangerous when you have had a prior cesarean.  By doing a cesarean section on this first time mom I was putting a huge mark on her future.  Was that the right thing to do for a baby that most likely wasn’t going to make it?  Is it any more humane to allow that baby to die and then induce labor naturally?  The cusp of viability back home is 23-24 weeks.  Working with that knowledge pushes you to do everything you can to save the life of the child even though you know the odds you are facing.  I leaned over the OR table and prayed hard as I watched the spinal being placed.  I pray that God keeps me from making huge mistakes in situations like this when all I want to do is the right thing.  The baby was resuscitated at deliveryand to my delight was still alive and seemingly doing well this morning when I came in to round at the hospital.  Praise the Lord!  The next week or so will be very telling. 

(Disclaimer – don’t read the following if you just eaten or have a weak stomach) While Todd and I were doing the c-section another pt came in that needed our attention urgently.  She was an elderly woman with a nine day history of what turned out to be a strangulated, perforated inguinal hernia.  They tried to treat this at home in some remote village with their medicine man who had given her some herbs, but by the time she made it to us her blood pressure was dropping and she was threatening to leave this world on the OR table before the first incision was even made.  I have been hoping to learn some bowel surgery while here so I volunteered to stay and help Todd with the case.  As he opened her abdomen a stench that I cannot put into words filled the operating room.  I turned my head and gagged several times afraid that I was going to throw up inside the mask I was wearing.  Necrotic tissue and stool was everywhere.  My heart cried out for this woman.  This was going to kill her.  We resected the bowel and did our best to sew her tissues back together, but so much had already died inside of her it was hard to find healthy tissue to reapproximate to each other.  We were trying so hard to do everything to save this woman, to give her the best chance at survival sifting through stool and decaying tissue to clean out as much of her insides as possible knowing that the odds were well against us.  That seemed to be the theme of the night – operating against the odds.  We finally were able to close most of her tissues leaving several drains in place and wheel her out of the OR.  She died early this morning.  At home she would have been placed on a ventilator, been sent to the ICU, received some of the best antibiotics known to man and had a decent chance of walking away from this alive, but this is not home.   

Lord, only You have the power and the right to decide who lives and dies.  I am simply here to be Your instrument and You can override my best efforts at any moment.  My medicine is nothing apart from You.

This little piece of Togo

I realized today that I haven’t ever sat down and really described what this part of Togo is like.  Let’s start with the hospital.  The whole hospital compound is surrounded by a huge cement wall that encompasses both the hospital and beyond where many of the missionaries are living.  There is the guest house for short term people like me and for longer term people there are actual houses that have been built for them to live in with bedrooms, living areas and kitchens.  The concrete wall surrounds all of this which is actually quite a bit of property.   The compound it self is landscaped with grass and trees that are well taken care of.  There is plenty of space for a good game of soccer.  I have been impressed with the set up for the compound and hospital.  Whoever started this place knew what they were doing.  The picked out plenty of space and even put in a basketball court and a swimming pool.  They knew enough to dig a well to provide fresh water to everyone living within the concrete wall including the hospital which is key.  Almost half of third world illnesses can be attributed to unclean water.  They also set up a generator system so that every time the power goes out (almost daily) the generator kicks on in 3 seconds.  Mango, lemon and grapefruit trees were planted all over the compound property.  The hospital itself is made up of a bunch of different buildings that are all connected to each other one way or another.  Very well done.

When you step outside the concrete wall (which is normal for all hospitals here to have walls and guards around them) you walk out onto a sort of paved road which is littered with potholes.  The dirt on the side of the road and in the potholes has a red tinge to it.  This is the only road around and runs north south connecting small little villages with each other along the way.  If you head south from the hospital you are heading towards some of the bigger villages and if you go north you immediately start climbing up a steep mountain.  Because it rains so much here it is more like a jungle than a dessert.  There are lots of tall green trees and grasses as well as vines and other jungle like plants.  Just outside of the hospital along the road a few people have settled and set up little shops, but I wouldn’t really call this a village.  It is just that a few people found a way to make a living just outside the hospital gates as they sell their things to those that come and go.  Their houses are made of mud and cement walls with either tin roofs or roofs made out of tree branches that have been tied together.  Most houses are one room with a dirt floor. No bathroom.  This one room is where they sleep, eat, cook and do laundry.  There are lines strung up between houses and trees where the wash is hung to dry.  All of the paths between the houses are dirt with children running around playing amongst the goats and chickens that are free roaming.  Half of the time the children have clothes on and half of the time they do not.  The women carry huge baskets of laundry, goods to sell or oranges or lemons they just picked from one of the local trees on their heads.  I can only dream of ever having such balance.  Sometimes they have huge loads (one of the missionaries weighed one of their baskets once and it weighed 65lbs!) on their head and have a baby strapped to their back.  They basically just take a long piece of cloth and wrap it around their baby and then tie it around their waist.  The babies sort of sit in it like a sling.  The women sit around cooking or doing laundry talking loudly to each other either in French or their native language.  They laugh very easily.  You don’t see the men around in the day very much.   I haven’t been off the compound at night (not super recommended for safety reasons), but I am sure these mud/concrete huts don’t have electricity so I am not sure what they do once the sun goes down.  Most people in Togo seem to get up early (4 or 5 am) and work until the hottest part of the day and then they rest and resume work until 8 or so at night.  I for some reason have found myself waking up around 4 am every morning on my own too.  It is nice to have the morning to get some things done.  Anyway, I hope this gives you a better idea of what life is like here.  With how slowly the computers and internet work here I haven’t found a very feasible way to post pictures.  I will definitely add some pics to my blog when I get back to the States.

All Saints Day

Today is All Saints Day which means the hospital has another holiday.  Clinics and elective surgeries from today got moved until tomorrow so we are primarily just taking care of emergencies and the current inpts.  It is an incredibly beautiful day and the breeze is blowing slightly which makes it even nicer!  What a great day for a holiday.

Last night three more short term missionary physicians and their families came to the hospital.  Many of them will be staying here for over a month.  It is always so wonderful to have extra help especially with Kelly the pediatrician gone until this weekend.  Last night was Halloween which is not a holiday celebrated here in Togo, nor really encouraged by the missionaries here.  Instead, we had a bonfire and made smores.  It was fun and the kids enjoyed the special treat.  As I looked around at now more than 30 white people sitting under the African stars around a campfire in the sweltering heat roasting marshmallows I could only laugh.  So comical in so many ways.

Roommate update: I am now sharing my room with a gecko and a lizard.  The lizard scurried in the door when I was coming home one day before I could stop him.  There are so many lizards of every size and color here.  Growing up in San Diego I am used to lizards, but there are far more here than even from back home.  The gecko decided to surprise me yesterday as I was opening the curtains in my room I apparently knocked him off from under one of the folds where he was sleeping.  He landed on me.  I screamed.  That was about the end of it.

Yesterday, Rhonda took me to eat with her off the street from some of the vendors just outside of the hospital grounds.  She says that she has done this for months and hasn’t gotten sick so I decided it was probably a low risk deal.  We had so much fun!  I finally got to experience some real Togolese food which was wonderful.  The guest house where I am staying only serves American style food which is fine, but I definitely felt like something was missing.  The crazy thing was that for both Rhonda and I to eat lunch plus buy a few snack items for later it cost a grand total of 60cents in US money!  Fast food has never been so cheap.  Even the dollar menu at McDonalds can’t beat that.  I think we are going to try to do this for lunch more often.

(Warning – this next part is not for the squimish) This morning we had a normal delivery that went very smoothly, but as we were standing around waiting for the placenta to deliver a very interesting conversation was started.  I have noticed that we send all of thepts home with their placentas.  Occasionally people back home ask to take their placentas home with them.  Sometimes they use them as fertilizer and plant a tree, but sometimes people take them home and eat them.  They are a rich source of iron and can be dried and ground up and put into pills or made into soup, etc (I am not necessarily advocating this practice, just telling it like it is).  I sort of assumed that when everyone was taking home their placentas that they were taking them home to eat them.  I could never have been so wrong!  When the nurses heard that people back home sometimes eat them it was all I could do to keep from falling on the floor from laughing at the looks on their faces.  This is clearly not a Togolese custom.  Apparently it depends on what village you come from as to what you do with the placenta when you bring it home.  Many just simply bring it home and burry it.  Others, however, have the custom of sending it to the maternal in-laws as a type of birth announcement.  That made me smile.  Could you imagine that happening in the States.  Up walks the FedEx guy with a package that you sign for only to bring it inside and open it on your kitchen table to find a bloody, gooey mess!  Oh so interesting.

Update on the 4 year old Bernadette that I posted about last time:  She made it to Ethiopia where she was supposed to have a connecting flight to get her to the US.  Her condition was deteriorating though and they had an ambulance that was supposed to meet them on the landing strip at the airport when they arrived.  The flight was two hours delayed so when they got there the ambulance had already left.  Kelly somehow managed to get Bernadette to the hospital.  After talking to the surgeon in the states and the surgeon in Ethiopia it was decided that Bernadette needs to stay in Ethiopia and have the surgery done there.  We are asking for a lot of prayer because none of us are really very sure or confident in the skills of the neurosurgeon in Ethiopia in regards to this surgery, but at this point it doesn’t look like there are very many other options.  Kelly and Bernadette are staying in the ER there with all of their luggage until surgery which is scheduled for tomorrow.  I talked with Bernadette’s father today (Healing the Children does not allow the parents of the pts to accompany them to other countries for treatment) when he came by the hospital.  My heart is breaking for him.  You can see the weight of it all sitting on his shoulders as he is not sure if he will ever see his 4 year old daughter alive again.  He did say though that he was talking with his wife this morning and he told her “you and I did not make Bernadette, God did and she is His. He is the one who will decide what will happen to her and it is because that I know He is alive that I can go on and face another day.”  Such incredible faith.  It took almost everything to keep the tears from welling up.  Tomorrow will be a big day.