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.