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.

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.