Walk With Me

A view of Vanga Hospital's tin rooftops on the left, the Kwilu River on the right, with fields and rainforest inbetween

It starts becoming light around 5am. Since I’m pregnant and am up frequently at night, I should know. Shortly after the light comes, there is a stirring in the community. As there are no competing sounds of cars or electricity (other than our own fans which run off our batteries), the sounds of birds singing, a baby goat protesting his mama, middle school girls bantering as they walk down to get water from the source, and the intrusive BANG of a mango falling on a tin roof fill the air. Around 5:45, only my fourth trip to the bathroom this night, I hear the first of the church bells go off that keep time in this village. I hear my daughter stirring, talking, singing her two-yr-old language. 30 more minutes until my alarm goes off. I crawl back under the mosquito net and try to find a spot in the foam mattress that hasn’t sunken flat from a night of body weight smashing it.

Mosquito netting over the bed

My phone alarm goes off. I hit the snooze. My daughter is still contentedly playing this morning. I wake a few minutes later and decide to get up. Another trip to the bathroom and I hear my sweet daughter call to me. “Mama. Awake!” I open her door and she stands up tall, all smiles, partly wrapped in the mosquito net she has pulled into her crib with her. “Mango, crash,” pointing to the window. “Baby, blankie, sleep,” putting her doll down on the bed. “Bonk! I fall, giggle” purposely running into the side of her crib and finding the result. She doesn’t seem to be in a hurry to get out of bed either. I put on my make-up as she decides. The 6:30am church bell rings.

The over 100 yr mission church, founded in 1912, still ringing its bell to tell the village the time

“Want to wake up Daddy?” I ask as I finally pick her up. “Yeah, daddy!” nodding her head. “Book! More more more, baby,” citing the name of a book. We go to the living room and retrieve the book. “Goose,”referring to another book about Petunia. We go back with the two books, and I plop her, heavy, on the bed. She jumps, slides, crawls over and says, “Daddy! Awake! More more more,” and I get my scrubs on and medical pocket reference books, fill my water bottle, and set my bag and white coat by the door. I contemplate a bowl of cereal. Nope, hypoglycemia. I decide on a glass of milk and a spoonful of peanut butter. I peek in on my family. They are both reading, separately, because that is what she asked for, I suppose—he’s reading about a silly goose, and she’s jabbering about a baby wanting more. I wave to him. Usually she opens the door for me and yells after me through the window, “Bye-o. Later. Mama,” but today I’m running late and she is happy. The 7 o’clock church bell rings as I brush my teeth. Yep, late again.

Sydney opening the door, saying "Bye-o! Later. Mama."

I walk down the sidewalk between the rows of purple tropical plant leaves, the sunflowers staked upright because their strength didn’t match their height during a recent rainstorm. Our sentinel opens our front gate with a familiar metal clang, saying, “Bon travail,” (Have a good work day, in French). I check my pocket- phone is there. My other pocket- my scrub hat is there. My bag feels light. Oh my water bottle. I trudge back up the sidewalk which seems steeper than normal today. I am always forgetting at least one thing, but I cannot survive the heat and humidity without extra water.

Our front sidewalk lined with flowering plants, a view from our gate

I pass the sentinel again as I depart and wave, a bit sheepishly. A family sits outside our fence, shaded by a large tree in the open watershed area ahead of me. A baby plays in the sandy dirt, tracing motion with a stick. A young man sits, waiting for someone to buy cell phone minutes. A mama arranges her bags of peanuts and a couple of pineapples that are for sale. A chicken picks up a peanut bag when she is not looking and scuttles off with it, making an impressive run as an 8 yr old throws available sticks and an old plastic bottle towards the chicken, who finally gives up her treasure as a stick makes a direct hit. She is almost proud as she kicks her chicken feet off and gets out of harm’s way. I’m halfway down the hill.

The nursing school just opposite our house

I pass nursing students, just in front of the male nursing student house, some are also selling cell phone minutes, to earn money for notebooks or pens, no doubt, but just a mere 20 yards from the first Vodacom rep. I cross a small landbridge that is successively being washed away in the rain—a culvert would work great right here, I think for the 20^th time. The nursing school is on my right. The red flowering tree is quite beautiful, as are the tall palms that line one side of the school. The ground slopes away, down toward the Kwilu. I can see the other side rising up with its own set of palms today, no clouds, no haze, just raw beauty. Hospital staff and nursing school staff housing is on my left. The fruit tree, of which type of fruit I am clueless, has left a minefield of slippery apricot sized balls to keep my attention on the path in front of me. A goat follows its fellow goat through an opening in the natural bamboo fence—I suppose to see if the grass is really better on the other side of the nursing school fence.

I smile at the old and young women who line the path nearest to the hospital gate, selling peanuts and pineapple and green vegetables I still don’t know the names of. Yet another small stall sells cell phone minutes. That’s 3 Vodacom representatives in a 5 minute walk, and I know there are usually at least two inside the hospital property as well. I think about their meager prospects for making a profit, and also the lack of good jobs for young men. Quickly my mind turns to the women as I pass by the maternity ward, listening for babies crying, for the rare shout of a woman in labor, and searching the doorway to see if a nurse is anxiously looking out of it for physician instruction for a critical patient. Not today. I cross the sidewalk, pass the women sitting on steps—women in waiting. They are waiting for labor to start, or waiting for a loved one to be discharged, or waiting for a follow-up appointment. But all have come from a distance; otherwise they would not be paying to stay in a rudimentary cement room, lying on straw mattresses, and cooking food over a charcoal fire under a pavilion with 20 other women and children. Some days they stare or try to get their children to wave at the mundele (white person), but today they smile and wave, no doubt remembering my daughter’s bouncy red curls and shouts of “mbote,” (hope you are doing well! In the local language) the night before as we walked back from our daily swim in the Kwilu.

Just one of the pavilions where families of patients cook food, wash clothes, bathe, and live

I walk into morning report. A row of medical students who have been on overnight duty lines the front wall, 2 per service: OB/GYN, pediatrics, internal medicine, and surgery. The staff doctors and residents are in the front row, with 5 rows of medical students behind them. Each pair of students is called to give their detailed report of just one of the patients that they took care of overnight. Questions are posed by the staff, diagnoses and treatment discussed. Occasionally there is a disagreement and lively though friendly argument that breaks out among the staff. A student is sent to chase off the goat that is yelling for its mama right outside the open windows. I speak up and ask a few questions, clarifying a few points when OB/GYN is in front. I remain mostly silent for the rest, scouring my brain for the answers to questions in medical disciplines I haven’t studied since medical school.

Unfortunately, for today, both OB/GYN and pediatrics share the same mother-child dyad. A woman came in during labor at term, having faithfully attended her prenatal care visits (more rare than not). She has 2 living children, after which she had 6 newborns that died in the first day of life. Yesterday I had seen her when she was in early labor, trying desperately to find a cause through a good series of questions about her past history, through laboratory tests (of which we have few) and through an anatomy ultrasound to look for problems. I found nothing. And now I’m hearing in morning report that the child was born last night, full term, but didn’t breathe well. They ordered lab tests overnight which haven’t been done yet. The baby is doing poorly despite the oxygen given in pediatrics, oxygen saturation remains in 50’s (normal is 92+). I know I need to find this child right away, examine him for myself, and perhaps do an ultrasound to look for anomalies.

Morning report ends, and I walk out into the already bright sunlight. I talk briefly to the OB/GYN students, telling them I’ll see them shortly for rounds. I search out the pediatrics team, only to find out the child in question died while we were doing morning report. Not sure what is culturally acceptable, I ask another staff doctor if it would be appropriate to do an ultrasound on an already dead infant. I surely hope that some of the labs ordered had been done before the infant’s death. I search for the child, but they mention that he was no longer in the pediatrics ward. Neither had the lab work been done. Rats! I walk quickly over to the maternity, hoping to be able to at least examine the child. When I arrive, I am told that they have already come to get the child to bring him back to the village for burial. With how slow some things are, this one rapid act is extremely frustrating. I now have no more information for this mama than she already knew before—all of her babies are dying of something, even with good pediatric care available immediately.

I return home quickly to use the internet to write an email. Maybe my high risk maternal-fetal medicine professors from residency can give me something to go on, something to tell this poor sad mama. I drink more water while waiting for the wheel of death, that circle that keeps going round and round on the computer with slow internet—a fitting name for today. I prepare mentally for the rounding on maternity. I don’t have anything to say to that mama yet.

A view of the maternity, with covered sidewalk connecting the rooms

I make the 5 minute walk back down to the hospital quickly. We start in the post-cesarean section room that has 9 beds in it. Today most of them are doing well. One hasn’t bought any medications yet, antibiotics nor pain medicines, and she has a high heart rate and fever. I have lost patients to overwhelming infections treated to late because of inability/unwillingness to pay—or because they flee in the middle of the night and return with an infected wound, sutures still in place. I know I’ll pay for her antibiotics and whisper to the nurse to bring me her bill after rounds. It’s only $10 out of a $120 bill for the surgery and hospitalization. Turning back to the medical students, I ask questions about the indications for cesarean sections, their risks. We move on to the next room where there are some women who have had hysterectomies, then onto a room full of women still pregnant, hospitalized for malaria or typhoid fever or kidney infections. I prescribe a few antibiotics, change a few plans. Walking out of doors (imagine an old-school motel where doors to rooms open to the outside with a covered sidewalk between), a woman comes up to me with a paper and asking to see me. Yes, around lunchtime after the medical student activities, I assure her. Then it’s on to the postpartum room with 12 beds in it, mostly full of mamas who delivered vaginally without problems, babies in arms or nursing, but one doesn’t have a baby and I know why. I can’t talk to her today. I have nothing to say. Tomorrow, I think. I hope tomorrow I have something, though I doubt it.

The group of students, tired of standing, trudge into the meeting room where one of them has prepared a presentation on bleeding in pregnancy. A nurse pulls me aside as I’m walking into the meeting room. Her brother is in the emergency room and needs surgery. Can I help? Oh, and there is another patient who wants to see you after the presentation. Too many people need me. I feel like a mom with toddlers pulling on her ankles while she is trying to make dinner. I tell them all I need to finish up with the medical students first. I escape. The medical student is talking already. I follow most of the French, though some words I have to clarify still. Medical terminology wasn’t emphasized in language school. Critique, however, was emphasized. Immediately after the presentation, the staff doctors (me included) evaluate aloud the presentation. The other doctor states, “Well, that was poorly presented. You need to organize it better, look how many people were sleeping during it.” And instead of being dejected as I would have been in his shoes, he takes notes on what to do better next time. This is definitely a French system. I begin, “Thank you for the presentation. Next time, if you look at the audience and don’t read off the computer screen as much, it will be better. But the content was good.” Yes I’m American. I have to sandwich the bad comments between something positive.

The group of medical students and residents working in OB/GYN

It’s noon. The students scatter, as do most of the nursing staff. They take lunch break seriously here, for 2.5 hours. I’m hungry, but since I don’t have regular consultation hours, I take patients as they come to see me in the maternity. The nurse waiting for an answer on whether I’ll pay for part of her brother’s surgery looks at me. Not now. I call a nurse who is on call over the lunch hour to come in to help with translation. Surprisingly, now there are 3 patients waiting. We start with the first. Pain. Menopause. Irregular periods. I’m happy I can give them instructions on how to improve their health that don’t require surgery or expensive medications. Soy beans, palm oil, reassurance. All three are similar cases. I finish fairly quickly, as documentation here is not as necessary nor do I always have the proper French words to explain my findings. Finally, I finish, and as I head out the door, I turn to the nurse still waiting on my answer and hedge, “Come up to my house after lunch. I have to discuss this with my husband.”

I walk up the hill, which at times seems like a mountain. Halfway there, I make a detour and walk through the nursing school. I’m looking for the academic dean, because I’ve been given a few donated computers for the nursing school and need to distribute them. He has already gone home, so I continue through the field, past the new building for training nurses in a practical hands-on way. A nursing student stops and asks me to give her money for books. Ah, the requests don’t stop. Unhindered, culturally-appropriate here, the requests wear on me. I try to think of a good way to banter back, as I sometimes say to people asking for food on the road that I’m not a cook, but I’m tired. I just say no.

The path back up to our house, nursing school on the right, our house at the very end of the path, top of the "mountain"

I’m late for lunch, so Ryan and Sydney have already finished. Sydney is taking a nap. I sit at the table, grateful to sit, grateful for food already prepared for me and mostly still warm, always tasty, and grateful that I can turn a 12 volt fan on as afternoons can be stifling without wind. I overhear our house help talking in more energetic than normal tones. I look over and they come out of the kitchen. The gardener has just returned from the market with eggs for dinner. He overheard on the road that there had been an accident this afternoon. The details trickle out. My cook’s neighbor, a motorcycle chauffeur, was killed in a head-on accident with a vehicle. Not only that, MY neighbor’s 10 yr old boy was also killed, and his mother sustained significant injuries but is alive and being treated now at the hospital. Oh death, you are so frequent and near here.

I continue to eat, mulling over thoughts of how prevalent death is here—so IN YOUR FACE. What if that had been Sydney? Or Ryan? My empathy strength seems like a curse now. Soon, we hear it… the inevitable wailing and mourning coming from the direction of the hospital. It happens at least weekly, with the mourning friends and family passing by our house. This time it is during daylight. I follow our house-help to the front gate to watch. And I regret it. It is children. A lot of children, lamenting their friend. There are a few adults too, that look like mamas. A couple of men carry a stretcher. I want to look away, but I can’t. It is my neighbor boy, all of 10 yrs old, a surgical wrap seems to keep his head on his shoulders. Still. Silent. Tears come unbidden. The procession is now at our house and passing by. I turn and walk back inside. It’s just too much. This suffering. He is too young.

I finish eating. A sentinel who works for a missionary currently out of town comes to get money for his sister’s hospitalization for malaria. I give it. He asks if I’ve heard the news of the accident. He gives unsolicited new information. It was a missionary vehicle. My heart sinks, thinking of which missionary is in the town nearby. Relief washes over as the sentinel explains that there was only a chauffeur in the vehicle at the time, and he is now at the police station for protection. At least there will be no cross-cultural interrogations. Nothing is simple here. I receive a phone call from the owner of the vehicle leant out this week. She wants to know details, and I give her what I’ve heard. When I mention that the chauffeur had gone to the police, afraid of retaliation, this seasoned missionary replied, “and with good reason!” I’m feeling the gravity of cultural differences.

On the heels of that phone conversation, the maternity nurse comes once again, asking for money for her brother’s surgery. I’ve looked it up over lunch—probably not an indicated surgery. I have had time to wrestle over this persistence. I don’t have money designated for the sick other than for patients I’m treating in the maternity. But this is like a family member asking for money. She is persistent. She is desperate. I finally decide I’ll give $30 as a gesture of friendship. I also explain that although I’m no expert, I think they could avoid surgery and act conservatively. She thanks me, then asks if I’ve heard of the accident. Yes. Too many times.

I am no sooner in the door when I receive a text to come to the maternity for an urgent patient bleeding after a vaginal delivery. I send a message that I’m on my way, telling them to give cytotec intrarectally to stop the bleeding. I quickly finish my glass of water, thankful that I don’t have to worry about cleaning off the table or washing dishes. I walk back to the maternity ward, being told about the moto accident two more times en route. No need for TV news here, I think. This is how word travels fast. At the labor room, the nurse has just finished placing the cytotec. I do an exam, and I’m thankful that the bleeding is currently much less than what the floor gives evidence to. I remove a few clots, and determine she doesn’t need anything further.

There is another patient waiting to be seen. I walk to an open room, sit down with her and another nurse, and go over her options for fertility treatment here. I tell her I’ll need to see her tomorrow in ultrasound to see what her ovaries and uterus look like. She is satisfied. Thunder rolls, and a rainstorm begins. But I need to go see a colleague who is past her due date. She is waiting for me at her house, wanting to discuss induction options. I decide the rain will not deter me. It is the rainy season after all. If I let the rain keep me from going out, I’d be stuck either in my house or at the hospital, potentially for hours. But a great protest breaks out as I’m leaving the maternity. First from the nurses, who laugh a bit at me after realizing I’m seriously going to walk out in the downpour like this. Then the patients and family members lining the covered sidewalk outside the maternity object. Some speak to me in broken French, others only the local language. Some are sitting against the wall, others filling containers, taking advantage of water flowing off the roof, others standing and just watching the deluge. I insist that I’m walking out into it and I’ll be fine. I’ll simply be walking through God’s shower, just as they fill their buckets with water to bathe their children in later.

The path down to the hospital becomes a small stream during rainstorms

Like a gentle caress, the water comes. It tries to find its way through my white coat and scrubs. My eyebrows drip. But it’s warm, and there is no lightening threatening my steps. The bricked walkway leading out of the hospital is now a stream, always carrying the sandy soil further downward and toward the Kwilu River just on the opposite end of the hospital. I turn right just after the gate instead of continuing up that mountain stream. I arrive for the home visit, my too-pregnant friend is surprised but happy to see me. We discuss options, pros and cons. We decide that Friday is the day, though both of us hope she has the baby by then.

It is still raining, though lighter still as I walk out of her house and on home, past the giant palms, the papaya tree that’s leaning too far over the already narrow path. There are still pieces of the afternoon left. I can be productive. But upon arrival, I discover via text that we’ve been asked by the hospital administrator to use our internet, computer, and printer to print out a document sent from Kinshasa for the official traffic report. I sit down at the computer, and realize quickly that it is impossible. The internet has been disconnected to protect the equipment from all-too-frequent lightening strikes. I relay the message of this problem to Ryan, who then walks from the house he is installing solar panels on to the internet room to reconnect to the satellite for this urgent need. The task eats my afternoon.

Our normal evening activity is swimming in the Kwilu just after work, just before dark

Having lost motivation, I decide to wash away the sweat of the morning with a bath. It’s SO cold. The water just drips. Our solar camp shower has given in to the harsh sun and frequent use, and now is obsolete with a few holes near a herniated pouch. Jumping in the Kwilu is much preferred over this, but with the threat of lightening and continued storms, this will have to suffice. Sydney is more than ready to hang out after I’m clean, and I take her from her best friend and nanny, Nancy (known as nounou). We read books while going, “rocky rocky” in the wonderful over 100 yr old chair in the corner of our living room. It isn’t long before Ryan comes in, followed by Tim and Kathy. Ever since we went to language school together in France and lived across the hall from one another, we’ve had the tradition of eating most dinners together. So even with the 15 minute walk now that’s between us, we’ve continued the habit. I turn on the stove to reheat the pork tomato sauce and the rice that the househelp have left for us. I’m grateful. For food, for not having to cook, and for a gas stove, although I miss a microwave.

Sydney reading to her monkey in the 100 yr old rocking chair

It gets dark during mealtime, as usual, though it’s only 6 pm. The geckos come out, and Sydney is too distracted to keep eating. “Gecko! Mommy. Daddy. Kat-y. Gecko, look! Baby, cute!” Soon after, “I done. Wash.” She climbs down off the stool and onto the chair, then putting her hands together, she runs off toward the bathroom. Ryan finishes eating sooner than he’d like to help wash her hands. Sydney takes the cushions off the couch, one by one. She then gets on the bare board, says, “One, two, three, Sautez! (French for Jump!)” She steps off the couch after rising up on her tiptoes. It’s close enough. Several times I think she’s going to fall when she reaches the unstable cushions, but she doesn’t, smiles, and does it again.

Sydney pointing out the geckos

The roar of the hospital generator alerts us that it is just after 6:30pm. The nearby Congolese houses and the nursing school study rooms light up like a Christmas tree without color. It is the start of our 3 hours of electricity in this village by generator power. Otherwise, we are dependent on solar energy or battery power, and most of the village does not have money for that. Thankfully, there are solar panels in many areas of the hospital which provide light when needed. As it is the time when we have the most access to electricity, I run to grab the laundry basket. I plug in the small European sized front-loading washer that is located in our back covered entryway. I load it full of scrubs and towels, and start it. It usually takes 2 hours, after which our sentinel will hang the clothes to dry in the entryway as well. I remember to take in the cup I’ve used to pour in the laundry powder. If not, with the humidity here, it will be partially filled with water by morning.

The back of our house, with covered entryway (the door you see) where we do laundry and hang clothes at night

The Rices head back to their house as we get Sydney to bed. It’s nearly the same every night. Sometime around 7pm, we brush teeth, change her diaper, and sing “Jesus Loves Me” as we put her under her mosquito net and into the pack n play. She rarely protests. After all, it’s been dark over an hour. I walk out to the living room and tidy up the cushions, put away yesterday’s clean laundry. Ryan has already put all the dishes in the kitchen.

Playing with Daddy at the end of the day

It’s now time to use the internet for the remaining 2 hours that it is available to us. With satellite internet, an electrical system prone to damage from lightening, and with living in the lightening capital of the world, the internet is disconnected from all electricity around 9pm. So I hurriedly try to catch up on emails, send out requests for medical advice, chat with friends on Facebook, learn about world news, and I write this blog. It’s been a good day. I thank the Lord for all He’s given us and provided for. And I pray for all the patients in the hospital that are suffering, the mama who’s lying in the hospital bed, mourning the loss of her son and hurting from injuries herself. I pray for the large group of friends and family gathered at the nearby church to mourn the loss of the motorcycle chauffeur and the little boy. They will be there all night, sitting, singing, just being together in solidarity. This is life and death. This is Congo.

A malnourished child, just outside the pediatrics ward

The Kwilu River at morning light

Ovaries, Victories, and African Efficiencies

Ovaries

It was diagnosed by ultrasound- an enormous mass filling her pelvis. Also on the report was the statement that the uterus could not be visualized. Patients here frequently have surgical scars for which they have no knowledge of the type of operation, so it was unclear whether she had already had a hysterectomy. We scheduled her for surgical removal of ovarian mass. At the operation, we noticed that both fallopian tubes were attached to the mass, and its origin (right or left) was a mystery. We carefully extracted it without spilling its contents as ovarian cancer can be spread during surgery. I was assisting one of the other staff doctors, and he informed me that there, indeed, was no uterus present. I found this a bit hard to believe, with both fallopian tubes connected to the mass. Just below the mass, I located a slightly more firm part and told the other surgeon that I suspected that it was the cervix.

After removing the mass completely and closing the abdomen, I took the mass over to further investigate. On close inspection, it was clear that the uterus, small as it was, was connected to the mass. I was able to show the curious medical students the origins of the fallopian tubes and the parts of the uterus. Then I opened the mass. It was almost all liquid, but to my great joy it also contained hair and some calcium deposits (that we like to call teeth) - it was a benign growth and the woman had a great prognosis. These discoveries are a joyous occasion and just an example of some of the bright moments working here in Vanga.

Just before opening the mass to find out what it was... usually a pathologist would do this.

Victories

It was the morning before my first scheduled lecture at the nursing school for the 1st year midwife students. I was sitting in morning report by the students when I saw one of the interns who is working on OB/GYN leave suddenly. He returned a short time later and talked with another staff doctor working on OB as well. The staff doctor looked at me and made a slashing motion with his hand, indicating that someone had come in that needed a C section. I walked out of morning report to talk more with the intern. The patient had come in after laboring for 2 days at the health center close to her house. She was completely dilated, but had been pushing since the evening before, had a small pelvis, and the baby wouldn't come out vaginally. She definitely needed a C section, he said, and told me he had the nurses getting her ready. I told the intern that I would not be able to do the C section as I was scheduled to teach, but I'd go evaluate her myself and return to morning report after seeing and verifying the necessity.

I walked into the labor room, and the patient had an IV and urinary catheter already placed. Indeed, she was tiny and appeared at high risk for obstructed labor due to a small pelvis. But as I walked toward her, I noticed that I could see the baby’s head. Unless all of that was edema (basically fluid under the skin), that baby’s bony head had already passed the point it should have gotten stuck with a small pelvis. I asked the nurses standing there, “So have you asked her to push?” They replied negatively, because obviously she hadn’t been successful for over 13 hours of pushing… I put on my gloves. Indeed her pelvis was tiny, and the baby’s head was clearly pushing the limits, but I felt like the bony parts of the head were past the bony parts of the pelvis. I told the somewhat incredulous nurses that we needed her to try pushing. Maybe the long journey had adjusted the position, maybe they didn’t have her in a good position before, and maybe she could do it. Less than 5 minutes later, she delivered her baby’s head. At this point, my mind started racing because I just knew the shoulders would get stuck and we’d have a different emergency called shoulder dystocia. However, the shoulders came, and she didn’t even need stitches!

I walked back into the morning report about 20 minutes later, and I made a motion with both of my hands to the other staff doctors signaling that she had just delivered vaginally. He got a surprised grin on his face, and morning report concluded without further interruptions. It was a great teaching moment for the nurses and the intern. It is important to always examine the patients yourself, and always give the mama a chance to deliver vaginally as long as the baby is doing okay. I was also able to show them a couple of simple maneuvers that came in handy in this case.

I finished the morning with a very enthusiastic group of new midwife students. Despite some limitations with my French, they seemed to understand and enjoy the teaching quite a bit, especially as I am currently in my third trimester and they were able to see first-hand some of the things I was teaching about signs of pregnancy. Some days here are like that, with happy endings, teachable moments, and the feeling that I made a difference in the healthcare system for the women in this country.

Efficiencies

Truly, you read that right. I am talking about how very efficient I can work sometimes here in this context. One Saturday after rounds were done around 11 pm, I had 2 patients waiting to see me for a consultation. I decided that they both needed ultrasounds, and since the ultrasound room was open until noon (after that it simply requires that I open it with a key and don't have help), I walked with them over to the pediatrics building where the ultrasound room is located. "Oh Dr. Janeen, we are so glad you are here! We have a patient for you." This is more often than not the phrase I hear when I enter the room with one of my patients. 

So I proceeded to do not two, but three ultrasound examinations. One of my original patients I gave a prescription to and sent home, the second I decided I needed to do an exam in the operating room to remove her IUD (intrauterine device for contraception) because though the strings were not visible, I could see it in place on ultrasound. The added-on ultrasound was a pediatrics patient with cyclic pain for 11 months but no period yet. The opening to her vagina was blocked by a septum. This is a rare condition, but I have seen it twice in 2 months here. Also, it's easy to treat and has a good prognosis. But with significant pain and an easy fix in the OR, I felt like it would be a waste of resources to give her pain medicine when I could just make an opening to relieve the pressure in a short time.

I walked with the two patients needing surgery to the operating room. It was not yet noon, so I knew the staff would still be there, though not for long as they take their lunch breaks from noon to 2 pm unless there is a surgery planned. I discussed with the chief nurse in charge of the OR that I needed to do two quick procedures in the operating room. At first, he said, "Can't it wait until Monday?" (a scheduled surgery day). Knowing he is a softie, I said, "Go look at her face and tell her we'll wait 2 days." He smiled, and walked to meet the patient. Sure enough, after seeing her pained expression, he put his arms around her shoulders, looked at me, and said, "Ok, let's go." 

I changed scrubs while they prepared the tables, which were in the same room together. I quickly located the IUD and removed it without difficulty. Secondly, I walked the 15 feet to the second table and made an incision in her septum which immediately relieved the pressure built up for 11 months in her tiny body. I left a little after 1 pm to eat lunch. I could NEVER do that in a US hospital for a clinic patient. I had seen 2 patients, done 3 ultrasounds, and performed 2 unscheduled minor procedures in the OR in a couple of hours. Some things here can be very efficient!

Unreasonable Hope

She lay there on the operating table, and as I watched her breathing, her hair discolored from malnutrition, her thin frame like a child's beneath the surgical drapes, I knew that despite our best efforts we had not been successful. She was no better off than before we started. And yet, I had an overwhelming, confusing sense of peace. I felt an unreasonable hope for her. 

Always be prepared to give an answer to everyone who asks you to give

 the reason for the hope that you have. -1 Peter 3:15

The OB/GYN ward in the waning hours of the day, around 5pm

 She was a "typical" fistula patient... very very poor, abandoned by her husband. Her only child had died during labor many years ago, and she has been leaking urine constantly since then. We had removed a 4cm stone from her bladder about a month ago. It is important to wait to repair the hole in the bladder because of the high rate of infection associated with stones and thus a high failure rate in closing a fistula. After the initial operation, we waited until she was fever-free for 2 weeks, adding on a week because of one thing or another (couldn't find her in the hospital grounds to get her registered for surgery multiple times). Because she had already experienced a delay of more than a week for no reason, I insisted on adding her to the schedule as there were only 8 other major cases listed (sometimes there are 10 or 11!). I was trying to be her advocate.

Hindsight is 20/20. The downside to adding her to the schedule was that she went last in the day. We were all tired, and 5:30 pm is not a good time to start any non-urgent case, much less a very difficult case. We started to operate, and immediately I realized there was a ton of scar tissue and very little good tissue left. Secondly, there was not just one but two holes in the bladder (one was clearly visible and fairly "easy" to close). As the surgical team only takes breaks in-between surgeries to eat peanuts, tea, and bread, at this hour, I was quickly becoming hypoglycemic with my pregnancy as well. I switched back and forth being the main operator and assistant with another experienced general surgeon. Long story, a bit shorter, we stopped the operation vaginally after we realized that most of our sutures were just pulling through very fragile tissue, and we then made an incision in her abdomen from above. Upon entry, her bladder literally tore open. And my heart broke with it.

At this point, it was 7pm. I was feeling very poorly, and had to step out of the surgery. Open abdominal operations on the bladder aren't really my specialty, but I felt guilty nonetheless. I went out to take off the hot surgical gown and get some water, but realized I had already finished my bottle of water. This was not good as there was no tea left, and I can't drink the unfiltered water here without potentially getting sick. I sent an urgent message for someone to bring me a banana and water if possible. After the banana and water, I indeed felt much better. The operating room staff instructed me to leave and go home, but I knew I couldn't. She was my patient. I had insisted on her being on the schedule. To top it off, I knew the surgical assistant, herself, was sick with malaria and yet she was still there. No. In good conscience, I couldn't leave.

Back in the operating room, the surgeon told me he had found not 2, but 3 holes in the bladder. He had repaired 2 of them from above, but was now again trying the repair of the 3rd vaginally. As I didn't want to "waste resources" by scrubbing in again and using 2 more pairs of gloves and another gown, I stayed out but offered advice. I think one or two comments made a difference in his management. But he otherwise closed the holes as best he could. (I'd say he is king of doing surgery in the dark- not always precise, sometimes potentially causing harm, but probably more people are helped because he isn't afraid to try.) I certainly would have done things differently, but I had no choice but to abdicate my responsibilities and my position as the operator in this case because of my health.

It was as they were closing the bladder and abdominal incision from above that I experienced that unreasonable hope for her. I've heard people say things about their ailing grandparents like, "I know they will go to a better place..." but I've never really FELT that hope and that gratitude for good endings for someone, let alone someone so young. And that phrase- that cliche- didn't capture the peace that came over me. I have no doubt that God will redeem her, that God will completely restore her health when she is in heaven, and that it will truly be a wonderful ending. I may have "failed" to see God's kingdom come here on earth as it is in heaven through a physical healing now, but I have the HOPE, the CERTAINTY, that His Kingdom will come and she will have a new body. And in the meantime, perhaps she experienced a bit of emotional/spiritual healing by the love shown to her by those of us here at the hospital.

Pic taken from the OB/GYN ward towards the lab, surgery, and post-op.

Some of our colleagues work in a remote area of Cameroon, and they recently blogged about how we can best love the poor around us. I'll include the link, and I hope you'll read this story in full, but it describes a bit of what I was feeling.

"There are so many problems here: illiteracy, disease, very limited access to medical care and clean water, violence and so on. Honestly, I want to try to fix them all. Although we can attempt to solve these problems, we want so much more for these people then just clean water. Jesus said himself that everyone who drinks physical water will be thirsty again but whoever drinks of the water that he gives “will never be thirsty forever” (John 4:13-14). If this is what Jesus supplies, then is this not a long-term solution to Simon’s water problem? In the same way, even as we are ready to help Simon pay for a surgery, what we really want for him is to get a whole new body that will never pain him again. Every day he walks very far away on a dirt path to his field, and although it would be nice to have a smooth paved road, what we really desire for him is to parade through the clean, gold-laden streets of Heaven forever."

Always be prepared to give an answer to everyone who asks you to give

 the reason for the hope that you have. -1 Peter 3:15

I'll end with a second quote from their blog:

"So when you pray for [our fistula patient], pray big. Pray that [she] will be able to have every needed surgery, but do not forget to pray that [she] will get a whole new body. Pray that the Lord will provide [her] daily water, but remember to pray that [she] will follow Christ and never be thirsty again. Do not just pray that [she] will have a nicer house but pray that [she] will live in a mansion made for [her] by Jesus. Pray [she] will not spend [her] days worrying about what [she] is going to eat, but pray that [she] will seek God and ask God to “worry about” providing for [her]. Let us not just give our neighbors an America here in Africa, let us aim to give them the very Kingdom of God."
http://haretranslation.blogspot.fr/2015/09/how-can-we-best-love-poor.html#links

"Puff! Puff! Puff!"

It’s not what you think. Trust me. Has nothing to do with drugs, or make up, or girls, or a magic dragon, or even CPR. It is a phrase that has uplifted me in the midst of a difficult week. 

There are times when I am struck with an unreasonable feeling of discouragement or loneliness. It happened this week again. We were able to reconnect with some friends and family over the weekend, and should have been refreshed when the week started. Instead, I watched as Ryan struggled to find his purpose and place, feeling frustration over our lost shipment and over the fact that he hurt his knee playing soccer (minor this time) and is unable to connect on the one place he is most comfortable- the soccer field. Instead, I felt lonely for our friends we have left. Instead, I felt as I worked on Monday that I was working in the dark without cultures or pap smears or the ability to biopsy. This feeling of working in the dark, along with the numerous patients with cervical cancer too advanced to operate, gave me pause as I advised a resident doctor not to do a hysterectomy; nevertheless, the cervix looked ok (to the naked eye).

I felt prepared for heat, for mosquitoes, for limited options for medicine. I felt prepared for the inability to perform minimally invasive procedures like hysteroscopy (looking with a camera at the inside of the uterus) and laparoscopy (doing surgery through tiny holes with a camera). I felt prepared for difficulty with follow up with patients, for tropical diseases and conditions I’d never seen, and for bigger complications like uterine rupture. But I didn’t feel prepared for the battle within my mind of just how inadequate I might feel when asked for advice by residents and students, or for the loneliness that I might face, or for the darkness of discouragement. But God is good, and He reminds me time and time again to rely on Him for strength and provision of grace. It is so good to know that He is the one ultimately in control.

Four things encouraged me this week, one of them being “puff, puff, puff!” First, I was able to talk with a colleague who is working in Kenya with Samaritan’s Purse as well. Her experience is much the same, and that certainly helps me not to feel alone. I know there are many many people lifting us in prayer daily. Secondly,  I also have been able to keep in contact especially with two very close friends from language school- we are all living in different places here in Congo, and that has been a great source of laughter and sharing of tears. The third and fourth things happened while teaching in the maternity ward.

Sydney also got to practice helping the baby breathe

We started teaching a course, internationally known, called Helping Babies Breathe, for the maternity nurses.  Dr. Rice and his wife Kathy, nurse educator, and one of the Congolese doctors and I directed the course. It is so much different than the rote memorization I think they are used to. We had life-like baby mannequins and real ambu-bags and practiced every step of the way. At first, it was like pulling teeth to get them to come up from their chairs and practice with the babies. Kathy and I acted like crazy pregnant women coming during active labor, and soon they were laughing and playing along. And even though what we were practicing was very simple (we only did the first part which is when the baby is breathing and everything goes smoothly), we could immediately correct the small errors that they were making.

I watched as one of the older nurses went literally from sitting in the corner with a disinterested look on her face to actively participating, feeling for pulsations in the umbilical cord before cutting it, and telling the younger nurse, in French of course, “Well we haven’t been doing it like that, but we are going to start doing it like this from now on!!” I also watched as she connected what she had seen me doing in a delivery with her earlier this week, which at the time had seemed quite strange to her, with what we were teaching them now. She was all smiles with her new knowledge of the importance of drying off the baby, skin-to-skin contact with the mom, and waiting to cut the umbilical cord.

Practicing Helping Babies Breathe

And lastly, I spent one afternoon in the maternity ward, while waiting for patients or any questions from nurses, with the medical students and a resident. They had their heads buried in their books at first, but I told them I thought it was important during their clinical year that they be taught practical and hands-on things, as these are hard to learn from just reading. I brought in my suture training kit, and I told them we were going to practice tying surgical knots. Here in Congo, they almost solely use instrument ties as this conserves the suture the most and is the most simple. But time and time again, I watch as they make one crucial mistake in this knot which makes it more like a slipknot and susceptible to come untied. I first reinforced with the students the concept of square knots, and changing directions. Then, we moved on to one-handed and two-handed knots. They eagerly tried it out, teaching each other after they had figured it out. And then they would groan as I told them they had to switch hands (dominant hand switching to non-dominant hand) because from my experience, if they can switch hands, they truly understand the theory and technique of that knot. The resident explained that they had only been taught one part of the one-handed knot in their school. So when I explained that that would make more of a slipknot than a square knot, and had to be paired with its opposite, they were eager to call the first part the Congo knot, and second the Shannon knot.

One of the students, in particular, looked to me as he tried out the two-handed knot. Each time I affirmed that he had the technique or movement right, he nearly shouted with excitement, “Puff!” So as he got more proficient, I just saw his smiling face as he went through the motions, “Puff! Puff! Puff! Puff! Puff!” The joy of teaching is summed up in that face, in that smile, and in that shout of “Puff!”

I joked with him that I would go to bed that night, hearing him in my head saying over and over, “Puff! Puff! Puff!”

Serenity in the Delivery Room

I find the familiar Serenity Prayer very applicable at this time.

God, grant me

the serenity to accept the things that cannot change,

the courage to change the things that can,

and the wisdom to know the difference.

I often find myself wondering where my expertise should outweigh their experience here. What would be good to change? What is best left as it is because through trial and error, it has proven to be the most effective? When should I insist on my knowledge and when should I rely on the years of experience of the nurses? I find this to be an extremely difficult balancing act. Again, here is an example…

Last week we had slew of bad outcomes—three uterine ruptures and 1 baby who died shortly after C-section at term for unknown reason. Indeed, I learned many lessons last week about the system, discussed areas of delay or poor communication with various departments, and in general was overwhelmed with sadness at the loss of these babies. While waiting for a patient to arrive from the maternity for what was supposed to be an urgent C-section, the scrub nurse had asked almost incredulously why I was so worried. “If the baby dies, you didn’t kill it. God decides who lives and who dies.” And while that is very true, the delay of a C-section can in fact cause the loss of a baby who might have been saved a half an hour earlier. On rounds in the C-section postpartum room, only 2 of the 6 mamas there had babies in their arms. At least there were still 6 mamas there.

My surgery shoes, for some reason went unwashed this week, but were reminders to me of the bleeding from the uterine rupture as well as blue from the blue dye test where we found a vesico-vaginal fistula after prolonged labor elsewhere.

After such unfortunate results, the knee-jerk reaction in the maternity ward was to prepare and ask for a C-section as soon as anything abnormal was detected. A pregnant mom came in with the fetal heart rate very high. I was told by the students and residents that there was fetal distress and therefore a need for C-section right away. Everything from my training was telling me that tachycardia (high heart rate) in the presence of contractions is not usually a sign of distress but commonly from maternal fever. Everything from the past week was screaming at me to just go along with their thought process and get that baby out before it died.

I decided to go with my training this time, a bit reluctantly. She did, in fact, have a fever. But the fever had been present for several days. Perhaps the baby was septic (infected) and suffering. But no, when I scratched the baby’s head, it moved a lot and the heart rate increased. That was reassuring. But what might malaria do to a baby? But no, there were no drops in heart rate during or after contractions to indicate distress. We gave Tylenol and started antibiotics, and waited… and the heart rate was still high. “We need to perform a C-section, I think,” the resident said again. And one of the nurses agreed. My gut just didn’t agree. “Wait. Please just wait. I think the heart rate should normalize with a bit more time,” I replied, not knowing if that time would be detrimental to the baby.

I called another experienced staff doctor over to see if he had any further insight. At first, he advised to go ahead with the C-section to avoid having another dead baby. Just at that moment, the nurse listened to the fetal heart rate and it had finally dropped to the upper limit of normal. Upon hearing this, the staff doctor agreed with me that we could continue to wait. Just before I left the maternity ward for the night, the lab result came back positive for a high level of malaria parasite in the blood. We started treatment for malaria right away, and then made both the lower level resident as well as the supervising staff doctor aware of the situation. They both seemed a bit skeptical but agreed to just continue to wait for labor and watch the fetal heart rate closely.

Some of the sutures we have available to use during surgery

I walked into the maternity ward in the morning, certain I’d find her in the post C-section room, hopefully with a baby, but maybe not. The nurses came out to greet me with a good morning, and I asked about the lady. To my surprise, they pointed in the opposite direction, to where ladies go after a normal vaginal delivery. I may just have let out a little whoop of joy. The nurses seemed a bit surprised but definitely joined in the celebration outside the maternity building. I think they are used to doctors who like to operate, so finding my joy so abundant at a normal vaginal delivery perhaps was weird. It was just the encouragement I needed. I’ve made plenty of judgment calls, some good and some less than stellar. Hindsight is always 20/20, and this is especially true in OB. Sometimes we all just need a good vaginal delivery to make it through the day…. Said no one but me probably. :) 

Later in the week, I saw evidence for change in the vitesse (quickness) of urgently-needed cesarean sections. Because of a few conversations I’d had last week with the OR staff and maternity, we sped up the process by eliminating a few of the steps (like going to the lab and finding a blood donor and paying up front and finding an IV bag and finding a catheter and shaving the patient, etc…), and significantly reduced the time between decision to incision. We were able to perform two cesarean sections back-to-back and both babies who had previously had heart rates in the 90s (normal is 120-160) were born alive! The OR staff was pumped that the surgeries were done so quickly, and one of the medical students exclaimed, "Wow, that was great! That was so fast! You saved those babies!" I immediately thought of the conversation with the scrub tech earlier in the week and pointed out, "If I take credit for saving these babies, I need to take responsibility for the death of the others. God is the one who decides, God is the one who heals. I'm just working to do my best."

I may not understand all the time, but I trust that God is good. 

The problem: 

Your wisdom and knowledge, they have deluded you; For you have said in your heart, 'I am, and there is no one besides me' - Isaiah 47:10b

A  good reminder:

"Where were you when I laid the foundation of the earth? Tell Me, if you have understanding."- God to Job in Job 38:4

The solution:

If you seek [wisdom] as silver and search for her as for hidden treasures; then you will discern the fear of the Lord and discover the knowledge of God. For the Lord gives wisdom; from His mouth come knowledge and understanding. - Proverbs 2:4-6

For it is God who works in you to will and to will and to act in order to fulfill his good purpose. - Philippians 2:13

To end, I'll end with an adaptation of St. Augustine's quote. It is one of my favorites. 

Work as though everything depends on you.

Pray as though everything depends on God

Because it does!

A Goat and a Bag of Peanuts

“I only have a goat and a bag of peanuts. Can you save my wife?” When I say that almost everything is different here as it regards to medical care, I mean, really almost everything: the language, the terminology and classifications used, the medications and treatments available, the depth of poverty, the lack of a safety net for the poor, etc. As someone who was supposed to come in as an “expert,” I am so thankful that I am being given the opportunity these first weeks/month(s) to do more observation and learning of the system, rather than being primarily responsible or acting alone. Stories are better than abstract principles, so read on…

One of the differences- this is a main road leading to the hospital. Some patients are carried as in this photo (a woman in labor who is sitting on a wooden chair which is tied up to a pole that is carried by two men on their shoulders), others come by motorcycle or pedal bike, and most walk.

I met her in the ultrasound clinic room. She had been sent from the local health zone prenatal clinic, which is run by nurses, to get an ultrasound because her uterus was not growing in size as expected and she reported no fetal movement for 3 days. During the ultrasound, I confirmed the dreaded news—that her baby had died in her womb at almost 7 months. But something else was not quite right. Despite the abnormalities that can be seen on ultrasound with a fetus which has not had a heartbeat for an unknown amount of time, something about this was just unclear. Something was blocking the cervical canal. The quality of ultrasound is a bit different than in the US, but I could see that the placenta was in the front and low in the pelvis. The placenta was potentially blocking the cervix, which is bad news for someone who has had more than one previous C-section. The risk that the placenta has invaded the muscle of the uterus within the previous incision site is >60%, which can mean a hysterectomy would be necessary.

I normally avoid doing a cesarean section in cases where the fetus has died in the womb, but I found there was no choice in this case. I mentally prepared myself for a cesarean section with hysterectomy, just in case. Upon hearing the news, the patient was understandably distraught, but even more so after I told her she needed an operation. Both she and her husband were in tears. Both looked chronically malnourished, with very short stature and thin frames. The husband looked at me, and understanding the seriousness of the situation, said very sincerely, “I have only a goat and a bag of peanuts. Can you save my wife?”

Because this was an urgent (and not by choice) operation, we were able to proceed despite their inability to pay in full prior to the operation ($80-120 is a typical surgical fee). As with most surgeries, though, the family is required to find someone to donate blood, hopefully with a matching blood type. Sometimes the medical students and residents volunteer to donate money or blood to their patients. It is not uncommon to have a post-operative patient make the decision between an antibiotic and pain medication! Just as heart-wrenching as it is to see this, it is equally hard to see starving mamas selling—not eating—the little food that they have grown during this dry season so that they can pay for things like school fees.

After praying briefly for the operation and the health of this mama, we opened her abdomen. It was a mess. As with the ultrasound, nothing was clear, except thankfully, that the bladder was not involved (as can sometimes be the case when the placenta comes through a prior incision). The incision into the “uterus” was our first clue as to what the situation actually was. The “uterus” broke open just like one might expect the bag of waters to break… because it was the bag of waters (amniotic sac)!  The placenta in the front had masked the fact that there was no uterine muscle surrounding the amniotic sac. In actuality, what was “blocking the cervix” was in fact the uterus itself, empty. It is a very rare form of ectopic (outside the uterus) pregnancy called an abdominal pregnancy. Usually it is caused by a fertilized egg that implants in the tubes, which after it grows big enough, breaks open the tube and then re-implants somewhere if it finds a good blood supply. In this case, the placenta had attached to the intestines, the fat in the stomach, and the tubes and outside of the uterus itself. The baby had died simply because its need for blood outmatched the ability of the intestines to provide that blood to the placenta. Because of its numerous attachments, we were forced to leave much of the placenta in place to resorb on its own.

A few days after the surgery, the husband found me walking outside the maternity building and asked where our house was—he wanted to bring us some bananas from his village in gratitude. Indeed, this could have been deadly for his wife, but thanks to the team effort of the nurses at the health zone level, the small level of outside donations provided to the hospital for these situations, and the willingness of doctors here in Congo to work in a rural setting, she was able to get timely healthcare. And, I’m happy to report that here the 10 year contraceptive implant that will continue to protect her life (while the placenta is still in place, it would be very dangerous to get pregnant again) is only $5 instead of over $200 like in the US, and I think that a bag of peanuts sells for more than $5. Hopefully their family can keep the goat.  

Second week... and how to (and how not to) party in Vanga

We had the privilege of having a great cultural and language interpreter this week- Katherine Niles. She is the daughter of late Dr. Dan Fountain who is credited with decentralizing healthcare for this area, starting a nursing school to staff the outside clinics, and has written several book about it. Katherine grew up in Vanga and speaks the local language. For her, it is like a vacation to come from the city of Kinshasa and be able to swim in the river every afternoon and stay in the house she grew up in.

I, Shannon, started work at the hospital this week, malimbe-malimbe, or slowly slowly as they say in Kituba. Katherine said it is better to start slow and observe a lot because hospital work is endless and can swallow a person before he or she knows what to prioritize or the global picture. More on that later.

Household progress

Working at the house (she had just woken from a nap, that's why she has quite the expression :)

Our other large task was organizing our household. We moved into our house over the weekend, but without electricity save the 3 hours given by hospital generator from 6-9pm, and also without any appliances like stove or fridge. We spent time organizing and orienting househelp, although at times it really felt like the other way around. J We have chosen, for now, to ask several people to work for us that have worked for years and years for other missionary families, including families who lived in our house. So many times, I just asked them how it worked, what they would like to do, or what foods I needed to buy in Kinshasa vs at the local market. I think it might take me a long time to learn what they know so well. But that is the best thing about hiring well-known and trustworthy people.

Ryan spent a considerable amount of time coordinating temporary workers. We had carpenters come and replace a ceiling tile that was rotted, painters come to paint a very dark pantry a welcoming bright white (as well as the replaced ceiling tile), a tailor come to recover a chair that is over 100 years old, etc. Ryan also removed old electrical lighting fixtures and put up new ones, installed some child safety locks, and went with the maintenance man to see his workshop and discuss needs at the hospital and at home.

Yesterday, Saturday, was a huge day because Katherine’s husband and son came overland with our oven, washing machine, solar panels, batteries, and cables in their truck. They got 4 large panels installed on our roof by lunchtime. It really was cool to see! And we have had electricity for longer than 3 hours in our house today (Sunday) for the first time!

Solar panels going up!

Medical Work

Monday morning, Dr. Rice and I were introduced to the nursing staff at their morning circle. Then, we were given an extensive hospital tour (which Ryan joined us for part of) for more introductions and also a better knowledge of patient flow, where to go for X-ray, ultrasound, labs, etc, and where the pseudo-isolation rooms are located, etc. Ryan commented that he was surprised by the immensity of the hospital. It really is quite remarkable to have a 500 bed hospital in a village like this. I met with nurses in the maternity, a couple of doctors who are on the OB/GYN rotation this month, and also with Dr. Rice to sort out a temporary schedule. On Thursday, I attended “grand rounds”with the residents and staff doctors, observed the prenatal clinic at the local health zone offices in the morning, performed and taught ultrasound in the afternoon while consulting on some of the difficult OB cases.

A little more should be said about the prenatal clinic. They are held every Thursday all over the health zone at each center. Some are held under trees, but here there is a nice large open room with plastic chairs for each patient to sit in. Two exam rooms are at one end. The room was packed this week just as it had been in 2012 during my visit. The ladies were split into new patients and old patients. The new patients gathered around for a basic talk on prenatal nutrition, and it was great to see the interaction between the wise and experienced nurse and the patients asking questions. “What do we call someone who doesn’t have squash seeds or greens or peanuts to eat?”They responded, “Lazy!” (because they grow in the soil here) And the nurse then said, “But if you don’t have fish or meat, it’s not your fault.”And they all nodded in agreement.

After the general education, each patient is registered and pays a one-time fee. They are given an HIV test, iron tablets, and three times a pregnancy a medication for the prevention of malaria. Their blood pressure, height and weight, fundal height, fetal heartbeat, and expected due date are all recorded on a sheet of paper which the patient is charged with keeping throughout the pregnancy. In my opinion, it is a system that works very well here, even though there are a couple of things I think could be improved with very little effort.

I haven’t started doing surgeries yet, but I will plan to start the observation process this week. A new group of medical students and other temporary doctors start their work this week, so it should be a good transition point for us all.

And now, how to party (and not to party) in Vanga

Sydney is sleeping wonderfully since we received a pack n play which we will borrow until a more permanent solution can be found. We are so thankful for this. We were excited to move up to our house this past weekend, despite the paucity of electricity. The village seems quiet, and after the hospital generator turns off at 9pm, the lights are out as well except for those with battery and solar power back-up. It is a great environment to sleep in… we thought, until Tuesday. The first warning was the eerie sound of a microphone feeding back. Then there was a sound of some piano synthesizer that was turned up way too loud for the system, causing the sound to be very muffled/unclear. A few notes were played, repetitiously, and I thought, “do they realize that it is 10:15pm?? I hope Sydney doesn’t wake up because it sounds like it is right outside her window!” In France, we were used to quiet hours starting at 10pm, and it really was quiet. Here in Vanga, our annoyances had been just the rooster, and occasional loud conversations or a goat stuck in a fence bleating. Surely this synthesizer will stop.

But at 10:30pm, the horrible sound had not gotten quieter nor any different. It really was just the same few notes played over and over and over and over and over and over and over... and we asked a night guard what was going on. He had no idea, but said there were quite a few people and he didn’t feel comfortable asking them to stop. Ryan decided to just stay up rather than be frustrated by trying to go to sleep with that racket. But alas, when I awoke at 5:15am, it was STILL just as loud and still going on. I wouldn’t even call it music, just noise! Ryan had given up around midnight. The sound didn’t stop until just before 6am in the morning! Not a cool thing in a “quiet”village!

Thursday night, there was a bit of a racket again, but this time it was quieter and much more musical in nature. We didn’t really mind it so much. And anyway, we knew that there was a big graduation for the nursing school Friday morning, and that nursing school along with its student dorms are just across the path from our front gate. Friday morning before the graduation ceremony, we heard the sound of drums—not African drums, but big band bass drums along with flutes. The sound came from the soccer field close to our house. As it got closer, I went outside to see a parade of children surrounding 5 flute players and 3 drummers as they played walking down the road. They paraded onto the grounds of the nursing school, where I lost sight of them.

I continued to hear the flutes and drums just until the time of the graduation ceremony, so I’m thinking that they picked up the students along the route and paraded them to the church where the ceremony took place. I was outside the packed church (and I mean packed, with kids sitting in the windows and crowds outside the doors and windows!) when the ceremony ended. People were dancing (especially moms of grads), the drums and flutes started again, and then the flouring began. This we had already seen a bit in Kinshasa. When someone receives a diploma or a passing score on a big exam, the student as well as his or her family gets showered with a white powder, which usually flour. It shows up brightly in their dark hair. The application of the flour reminds me of coaches who get iced after a big win. There is a chase, but really the person is quite happy to have deserved the shower.

Friday afternoon, there were receptions throughout the village with dancing and food for friends and family of the graduates. It looked like a grand time! And Friday night, not a peep of loud sounds was heard throughout the village. They had probably eaten so well and danced so hard that they were plumb worn out the night of their graduation. Now that’s a way to party!