Left Turn

 

According to the urban dictionary, Left Turn can mean "an unexpected change in events." That would describe my day. It felt like a whirlwind.

Normally, Monday’s are operating room days. There are 6-10 major surgeries and many minor procedures scheduled. I went into our morning report with the medical students as usual, after which I headed down to maternity. It was more chaotic than usual, with 2 patients bleeding with placenta previa (placenta blocking the cervix), one woman with a miscarriage that was bleeding, and a grand multip (lots of kids already) with a normal labor but with the breech (bottom) coming first. I quickly made plans… let’s do a C section ASAP for the one at term, give medication to stop the labor for the second, and reevaluate the lady with the miscarriage. The grand multip could continue her labor without interference or medicine. When things were in a semblance of order, I headed over to the OR, both to inform them of the incoming C section and also to start our long list of procedures.

BUT----When I got near the door, I was met by a staff doctor, informing me that all the doctors in the hospital were called to go to a “nearby” village to vote in person for something. So surgeries were canceled that day… all of them, and now I was supposed to go on a 2 hour drive over bumpy rutted roads to cast a vote. I rushed back to the maternity where we performed our first C section in the new maternity OR!! The novelty of it and the celebration it really deserves were dampened a little by the stress of the change of the day, and the need to get done quickly so as to get ready for a trip. I'll celebrate it a bit with several pictures of opening day before continuing the story.

Chief of the operating room standing by the new maternity OR bed and lighting. 

Preparing the first case in the maternity OR-- a C section for placenta previa

Praying together before we make the incision to start the surgery

Sure enough, I was just scrubbing out as the assistant was closing the skin when I was told to finish quickly because the vehicle had been prepared and other doctors were waiting on me.

I started panicking just a bit. I hadn’t pumped or fed Zack since 6:15am and it was already after 11am. I had to go back to the house. I was going to miss lunch. I had no idea when I’d get back- afternoon or evening. I finally decided the prudent thing to do would be to simply take Zack with me, endure the 2 hour roads there and back, but at least not be out of control with his needs. I ran back, Ryan helped me gather water, diapers, changes of clothes for Zack, and I stuck in a jar of peanut butter. That’ll do in a pinch. My phone rang but I missed the call. I was out of units to call back. I was certain they were calling to say they were about to leave. And I started off down towards the waiting vehicle. A woman called after me on the path, waving her medical chart paper. I felt completely overwhelmed by everything going on, by the still-bleeding patients in the maternity, by the need to take care of my son, by the heat of the midday sun beating on us, by the total and utter randomness of the change, and by my incomprehension as to what we were doing this for.

BUT----When I arrived at the vehicle, it was neither ready, nor filled with waiting doctors. It really was quite confusing. Zack was stirring in the baby carrier, wanting to be fed. It was hot. Two of the doctors, seeing me with Zack and a little harried from rushing around all morning, suggested that it wasn’t so important that I go. I had a hard time understanding what was so important that all the doctors of the hospital were told they should go and thus the operating room schedule had been canceled so abruptly, if indeed it weren’t so important that I go. But in the end, I started back up to the house, a little sheepishly as I was still uncertain of the decision. I called a couple other doctors to try to understand this situation more culturally, but in the end I decided to stay.

I readjusted my expectations to be the bleeding ladies who needed treatment in the maternity. Sure enough, I got a phone call that the second patient with placenta previa needed a c section because her hemoglobin had dropped from 8.7 to 4.5. Even though the baby would not make it, and just by a few weeks, we needed to save the life of the mother*. I hurried to feed Zack, and ran down to do the C section.

BUT----She was still in the maternity, lying just as she had when I had left her. Though the C section didn’t seem quite as urgent as I thought initially based on the phone call, I did agree with its necessity. She wasn’t gushing blood, but with a very low hemoglobin, starting a C section before finding a blood donor didn’t outweigh the risk. It’s the family/assistant of the patient that has to find someone to donate blood or pays $10 for the lab to find a donor in the community to keep the blood in the bank. This can take time, sometimes hours. So I trudged back up the hill to catch the end of lunch with the family. By now, it was almost comical to see Ryan’s face when I walked in the door not having done what I had expected to do moments before.

The rest of the day was pretty straightforward without further huge left turns. I nearly cried with the baby who we delivered just a few too many weeks early to survive here. It would likely have done well in the US. It did cry, and was sent to pediatrics for as much support as we can give here, but if it survives the night, I’ll be surprised.** I then headed over to see about doing a dilation and curettage for our bleeding miscarriage. However, she met me on the sidewalk and said she felt like she had passed something since the ultrasound that morning (which had showed retained products of conception) but lamented the fact that the placenta always stayed in. Unfortunately, she had already had 4 miscarriages. I decided she needed further evaluation again before taking her to the operating room.

It was amazing! As in, I’ve never seen it except in cool professional photography. The gestational sac with the 10 week old fetus had come out intact with the medication we had given. We were able to see the fetus floating in the amniotic fluid, with its formed arms and legs, spinal cord, and head. Its heart had stopped beating long ago, but it was amazing to see this tiny being just a bit bigger than a gummy bear. So cool!! 

8-10 wk fetus inside its intact amniotic sac

The emotional sting of the miscarriage had dulled over the two days since its diagnosis, and the mother was truly fascinated by the tiny being that had been growing inside her. She and her husband both wanted to see it, which is very rare in this culture. Afterwards, I used an ultrasound (from our new mobile ultrasound available in the maternity!!) to check to see if she had anything left in the uterus requiring further management. Fortunately for her, she did not need it. I asked her for permission and then proceeded to teach about 15 medical students, nursing students, and nurses the basics of ultrasound as we looked at her uterus, her bladder, her liver, her abdominal aorta, her kidneys, and her heart. It’s a joy to be able to see the wonder of learning something for the first time.

The new ultrasound is mobile, so we can easily move it into the delivery room if we have an urgent need for further evaluation.

Teaching ultrasound in the new maternity ultrasound and consultation room

As I headed home in the evening, I was greeted on the path by my kids with Nancy, their beloved nounou (nanny in French), who will be leaving at the end of the week. She graduated from high school and won’t be living here any longer except for limited periods. This season of life is coming to an end for Sydney- Nancy has been with her sporadically since the very evening of her birth and daily since she was 9 months old. We are all happy for Nancy, but very sad to see her go. At any rate, I joined them as they walked down to the Rices’ house. We had pineapple ice cubes for a snack, went and jumped and played in the river with Tim and Ryan also joining us. We ate dinner at the Rices’ and afterward came up to our house, put the kids to bed, and watched the second half of a movie we’d started. Overall, despite the crazy changes in expectation, it was a great day!

*From the Dublin Declaration 2012, an international consensus regarding abortion to save the life of a mother. “As experienced practitioners and researchers in obstetrics and gynaecology, we affirm that direct abortion – the purposeful destruction of the unborn child – is not medically necessary to save the life of a woman. We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child. We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.”

**The baby has, in fact, defied all odds and is still alive. As a colleague of mine said as we encouraged the nurses to make the normal efforts in neonatal resuscitation at the C section, "We think the baby is too premature to live, but God can still do a miracle."

Short stories- Maggots, Goats, and Rats

With two kids now, I find my days very full with work at the hospital, running back and forth to keep up a milk supply, with free time spent kissing scrapped knees, redirecting, playing with, scolding, and laughing with an increasingly active and talkative two yr old, and when the kids are finally asleep in the evening, I just want to do something mindless or I fall asleep quickly from exhaustion. So I've written several short stories throughout the last months, and just now am getting it posted. 

Young kids. So fun and cute. So exhausting too. :)

Maggots

She came in walking a bit hunched over, but there was more to it than that. It was almost a waddle. When we examined this elderly woman, her problem was obvious. Her feminine parts were completely outside her body. There was large ulcerated part of this mass that was the size of a grapefruit hanging inbetween her legs. As we cleaned it off to distinguish what was cervix, what was the ulcer, what was the situation, I noticed something moving. This poor woman had been dealing with this complete prolapse so long that maggots had taken up house in her ulcerated inside-out vaginal tissue, eating dead tissue and keeping it relatively “clean.”

Sorry for those who get grossed out. For those who are curious, the skin of the vagina is shown, the cervix is the very bottom of the photo that is a bit purple, and the circular area is the skin worn away and the bladder hanging out. Maggots are the whitish yellow around the bladder. Ewwww.

I indicated a vaginal hysterectomy, reduction of the prolapsed, and closure of the vagina. Basically, I was going to take out what was not useful, push everything back, and hopefully cut out the ulcerated, maggot-filled tissue so that this poor woman could walk down the street as proudly as every other woman who achieves the feat of old age in this culture and this hard life.

At surgery, let me summarize it by saying  I experienced a number of firsts: first time operating with maggots present, first time I couldn’t find the rest of the uterus even though the cervix was clearly in my hands, first time I couldn’t find the abdominal cavity, first time mistaking the bladder for the uterus. It was very difficult surgery, with distorted anatomy. In my experiences in the US, I usually felt like we had a good deal of control. If bleeding was found, we could cauterize, suction, readjust lights and find the source. If structures were unclear, we could use fancy imaging to figure it out. We could call in back up general surgeons, urologists, etc. But here, sometimes we tangibly feel the powerful hand of God, we pray for Him to give us supernatural wisdom, to give us skills we didn’t know we had, and to heal patients that probably shouldn’t have a good result. It feels quite out of control sometimes, but God getting the glory is exactly the sort of thing He prefers.

Back to this difficult surgery… we repaired the giant hole we had made in the bladder. We removed the cervix and what we could find of the uterus. We systematically replaced the mass back intra-abdominally, cut away excess skin, and closed the vagina. It took 4 hours. During that time, there was a middle-aged woman with a relatively simple operation on the other OR table in the same room. For some reason, she coded- as in, her heart stopped. They did CPR, tried the defibrillator, and eventually withdrew resuscitation efforts. It was traumatic to witness the death while trying to finish my complex case in the same room.

In the days that followed, I kept expecting to have urine leaking or some problems, but the only complaint that this woman had was that the catheter was uncomfortable. We removed it the second week, and she fled the hospital that night with her family. (This is not an uncommon occurrence with a good chunk of patients unable to afford their care, however modest the costs compared to US standards.) I am praising God for giving this woman the ability to walk out of the hospital upright and without a strange gait, even if it was in the middle of the night. Perhaps we’ll see her again one day, though I hope she simply goes home and lives out the rest of her life maggot-free, with the Lord as her guide.

Why did the Lord decide to heal this old poor woman with a significant medical problem, and yet allow the young woman on the other side of the room to die when the latter was receiving a relatively simple operation? Matthew 5:45- … for He causes His sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. This was a reminder to me that we only have the false perception that we are in control- it is the Lord who directs the outcome.

Sydney grabbed a boy's hand while we walked through the hospital. It was adorable, so I am including it.

Who cares?

I was grabbing my towel after a swim in the Kwilu when a goat just a few hours old, flies clinging to its still (barely) wet hair, timidly sidled up to me with wobbly new legs and plopped down, right at my feet. Instinctively, I reached down to give it a pat. Who can resist one of the cutest baby animals in the world? I scanned the dirt path to the left along the river which disappeared around a bend of bamboo. No mama goat staring back at me. I glanced up the steep dirt incline towards the houses, and there was no sign of its mama. As I started to walk up the path, I hesitated. The tiny heap that was just at my feet was starting to make noise. Where was the mama? What kind of goat mama leaves its newborn like that? Just abandons it? I started to get angry. Then worried. What if the mama got chased by some boy running through the trees? What if the mama was herded back to a fenced-in enclosure and the owners didn’t notice she had already given birth? I started walking a little faster up the hill. I could hear a goat or sheep bleating somewhere. I needed to find its mama for that helpless goat.

A still small voice crept into my mind, chiding me. Who cares, really? Who am I? Do I think I care about that goat more than God does? Even if it dies? Yes, even if it dies, it’s not a surprise to God. 

Who cares when a poor woman dies because she couldn’t afford antibiotics? Who cares when yet another mom comes in too late to save her baby, her uterus ruptured, all because there is an inexperienced nurse at the remote health center who didn’t recognize danger signs?

A face off between Sydney and a sheep

We’ve gone through a rough patch here in Vanga. A wall was constructed and we ran into it, figuratively. Now we are trying to figure out whether we are supposed to climb the wall, go around, turn around, or just knock the wall flat. 

But the sign given to me with the goat (who was shortly after spotted with its mama) was that God is in control, and God cares about Vanga more than I do. So whether we stay and are a part of God renewing this place, or whether we leave, God has got this. He is not surprised. And He cares so much more than I do. This is a great source of comfort to me amidst uncertainty about the future. 

Rats... so many rats

They were eating our fruit. Every morning, we’d find evidence that rats or mice were invading our house, with our fresh fruit looking more like the moon than bananas and passion fruit. Our neighbors have cats, and even a cat ladder to help them get between the roof and the house to eat rodents, but we don’t. 

The awesome cat ladder. Look for cat eyes at the top. :)

Without a local hardware store to run to for a mousetrap, we asked our househelp for suggestions. They assured us that it was easy to poison them. They got a medication from the local pharmacy, put it in some fish, and laid the fish in hard-to-reach places so that Sydney couldn’t get to them. Wait. Now we had a fish smell. And then? Apparently the stench of the fish is overpowered by the stench of a dead mouse/rat. Awesome.

The stench of the fish went away. The pieces were gone. But still no stench of a dead mouse. Around the 3^rd day, I remarked that Zack’s diapers sure were potent- significantly more than normal. Our househelp said the same thing, and asked to take his diapers outside before we got them washed. I came home later that day to hear that the smell we had been blaming on poor Zack was, in fact, a dead mouse behind the dresser. Yay. We got em.

Not so fast... I was changing sheets on the beds when I noticed that the top layer was covered in ?rodent? poo and pee. Surely not. I went to get a second opinion on what the stains were. Just as we were lifting the top sheet out of the drawer, a huge rat jumped and scurried further into the deep drawer. I ran away. I ran to get reinforcements in our other househelp. They came together to combat the rat in the drawer. They closed all the doors, but since the drawers were at the end of a T shaped hallway, Sydney and I stood guard at the end of the T with a broom in hand to scare it back. They took the linens out one by one, and eventually were left with only the rat. Sydney got the honors of taking the dead rat to the cats up at our neighbor’s house.

Taking the rat to the cats

The black cat was a bit afraid of such a big rat, but the runt of the bunch (calico) seized the moment, jumped off her flower pot and snatched that rat up and ate it while hiding under a flowering plant

That night, we opened our kitchen cabinets and saw something scurry behind the cups. Again I called in reinforcements, this time Ryan and our night sentinel. I fled the room, but I know that a mouse was killed and taken up to the cats.

Fast forward a week. I opened the cupboard to get a glass for water, and was startled by a mouse running on the second shelf. I ran to get our sentinel. He came in, gingerly took out the glasses in front of said mouse, and... whoop, the mouse jumped out of the cupboard and into his free hand. He clutched it against his chest, and took it out to the cat. This operation took all of a minute.

Fast forward two weeks. We came home from a weekend in Kinshasa, and our househelp showed me my prized imported mint M&Ms had been eaten by a rat. 

Sad days. I love mint M&Ms and I'd been saving them. There is a hole in the bag and bites out of all of these M&Ms.

Yep, bag bitten through, tiny rat sized bites taken out of the candy shells. You better believe we have more poison fish strategically placed.