Tuberculosis...

This last week, I peeked in on Dennis to ask him about something. What I saw was very unusual. A young boy lay twisted on the bed, crunched a little with a protruding bump on the center of his spine. When he sat up, Dennis showed me two very enlarged lymph nodes. He was struggling for breath because of the pressure they placed on his airway. He was small for his age and looked very unhappy. He knew he was sick...

I had never seen anything like it. Dennis explained that he had tuberculosis of the spine. He added this was the first case he’s seen in the year and a half he’s been here and that it was well advanced. We had no choice but to refer him to Wau. The mother seemed to appreciate the gravity of the disease. I can only pray she went.

Of Jews and Gentiles

Beverly and Greg Wootten are Bible scholars and teachers from Kenya, here to cover the Pastor training while Sabet’s away. They have been walking with the Lord for over 30 years.

I learned their story over dinner one night and I wanted to share it with you. Greg is a Jew who immigrated to Israel with his young wife (raise Catholic), Beverly, to live in a Kibbutz.

After 6 months of picking olives in utter misery on this kibbutz, Greg picked up a New Testament and started reading. He opened to the Book of Acts and was so captivated that he called in at work. He read it from morning ‘til night. That night he prayed to God, “If this is true, I want this.”

The next morning he woke up a new man. Everything changed. The job he hated soon became a dream job as it allowed him to read passages out of the Bible between picking olives and meditate on them.

Bev got saved shortly after and says that instantly the whole kibbutz was a stir. “Did you hear that Bev and Greg are Born-Again-ers?” Apparently, there are no secrets on kibbutz. But then again... Greg wasn’t keeping it a secret. Not at all.

However, finding fellowship was challenging. On one of their rare days off, they hopped on a bus and went north because they’d heard of a Dutch colony that had a church. But when they got there, Bev and Greg were just too hippy-ish for them. They were asked not to return. Keep in mind this was 1976. Think bell-bottoms, long hair, platform shoes. Can you hardly blame ‘em?

Their next day off, they found their way to a Christian bookstore in Jerusalem. But it was closed. So they sat on the doorstep all day, hoping. Eventually the owner came and they asked to buy a Bible.  Instead, she gave it to them for free and offered them a place to stay. It was getting dark and they had no place to go... so they accepted.

She called an American pastor, who picked them up, took them to a furnished house and got them settled. There was just one condition.  He wanted to show them  Jesus throughout the whole Bible -- Old and New Testaments.

Greg says, that by the end of that man’s Bible study, it was a done deal. He has never been the same. Beverly is right there with him. They lived a total of 20 years in Israel, only coming to Africa two years ago as missionaries. They teach at Bible schools all over Kenya and Sudan and are very good at it too.

It cracks me up that God brought this couple to Israel to get saved. I love how He does stuff like that! I love that God continues to call His people, Israel, to Himself by simply reading the Gospels. I love that a Jew, knowing nothing of Jesus could read the Book of Acts and radically be transformed.

No one preached at him. He didn’t hear some powerful alter call. No one even told him to read the Bible. But he did. He read the conversion of Paul on the road to Damascus and said, “Wow... wait up! What was that again?” A Jew, like me, was persecuting Christians, rushing off to have them incarcerated and stoned... and then everything changed in an instant. Yes... God spoke.

The olive branch will be grafted back again... : - )  (see Romans 11:11-24)

Charcoal and Goat Hair

A woman walked up to the clinic holding a lethargic boy in her arms. She didn’t hurry. She didn’t scream. In fact, she barely even asked to be seen. Saturdays are reserved for emergencies, so I went to assess her. The translators standing by explained that the child had been sick and in town for the last three days.

One of them asked her as to why she was just now coming. I saw no hope in her eyes. That worried me.

He was feverish, lethargic and severely pale. I called for Dennis as I have no experience getting IV lines in 8 month olds, and started on a paracheck (test for malaria). I was pretty certain it was malaria. It was.

When the translator asked her how long he had been sick, she explained that she had come from a far village. She had been in Tonj three days but... was being treated by the witch doctor.

The witch doctor diagnosed him with heart problems and even withdrew ‘charcoal and goat hair’ from it. But it didn’t help.

So, as a last resort and even as a bit of an after thought, she brought him to us. When we got him the quinine he needed, he immediately started getting better. We kept him overnight... but he was able to go home the following day.

Doctors one! Witch doctor zero!

Natali.

My favorite employee got fired today. I’m bummed.

I’ve been training a guy named Natali in the antenatal room for 2 almost 3 months. He was good. He translated well. He understood the details of midwifery... what’s more, he wanted to know it. He was eager to learn.

During births he was compassionate and encouraging. One time he crawled up on the delivery bed and helped a woman into a supported squat. He didn’t think it strange, nor did she. But I know none of our other staff would have done it... not even on threat of termination. He was different. He was a very understanding Dinka man. I never saw him get angry with any of the patients. I had high hopes for him.

But I’m told he didn’t play well with others. He almost got in a fist fight with one of the other employee (who is an instigator) and then this week, he seems to have been acting out a lot – refusing to do his work, arguing, ... I’m not sure what else.

So today, they terminated his contract. I’m bummed because he is my friend, a good “midman” and he needed this job. He’s expecting a baby any day. I’m sad because the yahoos that still work with us pale in comparison to his eagerness to work well (at least for me). I also bummed because... now I have to start all over again.

Please pray we find honest, hard working and eager to learn national staff. I especially ask for a woman to train. One that can work with me almost exclusively in the antenatal room – even two would be even better.

Natali learning to use a feteoscope.

Why do you love our women so much?

Today a young mom-to-be came in terribly sick with malaria. She thought she was in labor but wasn’t. (Malaria if not treated quickly can cause contractions and prematurity.) Instead she was just very sick.

I tested her immediately and got her the drugs she needed. Then I called her husband in so I could explain to them both how to take the meds and assure them that she was not in labor quite yet.

He was a soldier dressed in fatigues with a strong, pleasant disposition. And he was tall. I didn’t even reach his shoulders. I’d guess he’s 6 foot 7 or so. I felt like a midget.

I did all my explaining to the woman (almost ignoring her husband). He was there only as back up in case she was too sick to understand. They both listened carefully, happy to get answers and help.

After praying for her and asking her to come back in a month, the husband asked with a laugh of incredulity, “Why do you love our women so much?”

I smiled and looked at him a little confused. My translator was laughing with him too. At first, I thought it was meant as a compliment. And it possibly was. But the sound in his voice was one of confusion and disbelief... and wonder.

Then he asked again, “Why DO you love OUR women so much?”

It made me stop and think. What had I done to impress this man? I had not acted any different with his wife than I had with the 15 women before her. Was it because I looked at her, spoke to her kindly, touched her and prayed?

Man cannot live by milk alone... but woman can

I had a patient complain of constant bloating after eating. So I encouraged her to eat small meals all throughout the day and get lots of good, green veggies daily. She smiled. But then she said she drinks milk.

I said great. Milk is good for you. But make sure you get a nice varied diet – like pumkin leaves and kale. She smiled and repeated, “But I drink milk.” Okay, so you drink milk. Try to drink as much water as possible each day as it prevents UTIs and ... yada yada yada.

Again, smiling wide as her cheeks would permit, she repeated, “But I drink milk”.

It’s at this point that my translater finally tells me that she only drinks milk and milk is her only food.

Huh?

I asked her to explain. She said that she lives on the cattle camp. Their only food and water is milk – morning, noon and night.

Really? I had heard of this but she was my first patient that subsisted on milk. So I took the opportunity to ask all my silly questions.

Me: How much milk do you drink a day?
Her: Oh a small bucket (roughly a gallon or two)
Me: Do you like eating only milk?
Her: (giggles) Oh yes!
Me: Do you add sugar or salt or seasoning of any kind to the milk?
Her: No. Just the milk. (Big grin that the Kowaja would want to season milk! Ha!)
Me: How long have you had just milk?
Her: Oh... since April.
Me: April!? That’s... wait, let me count... one, two, three... four .... FIVE months! You’ve had nothing but milk to eat for five months?
Her: (laughing pretty hard by now) Yep.

This is not something that my midwiferying training prepared me for. I might have to look into my nutrition books to find out what supplements to give her. She looked healthy enough... but is she getting the trace minerals she needs?

I don’t know. Any nutritionists out there that want to chime in? :- ) I’m totally open to suggestions.

Disappearing Delivery

Rebecca is a young patient of mine who’s been coming in for several months. The last time I saw her, she was dealing with a very small fundal height and possible IUGR infant. She is 15 going on 12 and acts it too. She speaks with a small voice that rings of constant fear and stands little taller than my shoulders.

Her main problem prenatally has been getting enough to eat. She lives with her grandmother and has a husband (who raped her, got her pregnant, then “married” her) but he left to work in another town and gave her no money.

Because of her size, I’d expect a small baby... but it’s always been a little too small for my taste. So when she came in to the clinic in labor, I was happy to see her. She was alone (not even her grandmother was able to come) and obviously scared... but I was glad she was coming to where we could help her.

All her vitals were normal and she was already 3 cms dilated, 90% effaced, so I encouraged her to rest and promised to check on her often. But just before dark she decided she HAD to go. She told the health worker on shift she was leaving and as he was coming to get me, she took off. By the time I got there, she was long gone.

So right now, she could be anywhere. She could be home or on her way there. She could be leaning against a tree in the middle of the field.

I wish she hadn’t left.

Lord, when did I become such a worrier? And why do I keep scaring my patients away? Pray she has a safe birth. I have lots of reservations about this one....

Retained Placenta.

Today one of my patients came in with her newborn boy. She delivered at home 6 days ago and “things weren’t quite right”.

When I uncovered her boy, he was tiny. My heart sank. Another preterm baby? Really LORD? Really??? But it was clear. He weighed exactly one kilo. But he was alive. I figure he was probably 7-8 months along but IUGR (Intrauterine Growth Retardation). He was breathing fine. His vitals were normal... except he was a bit on the cold side and lethargic.

But here’s the thing. This was her first baby. She had no husband and one kind (but exhausted) friend helping her. She didn’t know much about babies and as a result thought breastfeeding only 3 times a day was perfectly reasonable. (FYI: It’s not. Newborns need to breastfeed every 1-3 hrs minimum depending on their size and suck potential. :- ) I stressed the need for better feeding and she said no problem. Then we moved on to her.

She then explained that her placenta didn’t come out for 24 hours after her baby. When it did finally come, only half of it was there. The other half fell out all black and smelly just yesterday (5 days postpartum).

I was horrified.

When I did a speculum exam to find out more, it was not good. I’ll spare you the details. Suffice it to say, she needed a D & C quickly.

Part of me was hopeful to use our new Manual vacuum extraction machine. Dennis is going to teach me how to use it. But when I asked him if this would be a time to use it, he told me no. That once infection has set in, the risk of uterine perforation is too high. She needed a D & C.

My heart sank with the news. How is this little girl going to get the money to get to Wau? How is she going to afford a D & C? How?

When I explained the news to her and her friend... she just listened with her eyes averted. When I mentioned going to Wau... she just cuddled her baby closer and looked down. Her friend listened with tears rimming her eyes. They were scared.

They put on a brave face. One standing strong. The other in denial. But I didn’t detect much hope.

Here’s the thing. Had she come the day of her birth I could have gotten her placenta out any number of ways. Had she come on day one, two or three postpartum, perhaps it would have been possible to use the vacuum aspiration. But by waiting until sepsis set in, my hands were tied. My window of opportunity had passed. I had no choice but to refer her.

Perhaps I’m in a pessimistic mood, but I don’t think she’ll go. I think she’ll stay at home and die, along with her precious son.

Forgive me Lord. I don’t know what else to think. Save her. Make her whole again. By your strength and love, touch them. Heal them. Amen. Please pray with me.

What's Bread?

Today a very pregnant and very sick woman came in with malaria.  She had been vomiting for some time. It was bad. We started her on meds immediately… but went the tablet route so that she’d have time to make it home. If she had gotten an IV she might have to be admitted over night. The problem was… her vomiting.

So we gave her an anti-emetic as well. But by the time we got her all her meds she had to swallow… and keep down 7 tablets. Yikes.

Knowing she needed to take them with food, I snuck into the kitchen and grabbed a piece of bread. But when I handed it to her, she looked suspicious. I told her it was bread. She should eat it to keep down the medicine.

Again… she looked confused. “What’s bread?”

She had never eaten bread before and wasn’t sure she’d like it. I assured her it tasted fine and laughed. I can’t tell if I just misunderstood or she has never really had bread before.

But when I think about it... if someone served me millet porrige, I’d likely turn my nose in questioning suspicion too. Can ya blame her?

Stroke?

Yesterday, I spent all day in bed recovering from malaria. I rested well and had a sweet time with Jesus. It was a good day. But when I went to dinner (I had to eat something with my malaria meds), I learned that Margaret and Dennis had spent a lot of time with an eight month pregnant woman who was very sick.

She came in with significant paralysis on one side of her body. She was sweating profusely and I'm told had an 'impending sense of doom'. This is not good.

What she needed was an immediate cesarean. She needed basic life support and we told her family that this was very serious. She needed to get to a hospital quickly. They listened and then took her home.

Yes. They took her home. I'm not sure if they had the money to get her there. But most people say they don't but they are really saying the won't.

They won't sell a cow. It's too valuable to them.

They chose to take this woman home to die than sell a cow.

Sigh.

This morning they sent someone to tells us that she died early this morning. Had they gotten in a car... gotten to Wau... gotten the emergency care she needed, her life could have been spared.

But instead both she and her baby died.

Why are cows more important than people here? Why?

August Newsletter 2010~ Midwifery Times

Here is my August Newsletter 2010. I hope you like it.

Malaria.

So yesterday I started feel funny. I wanted to vomit, had numbness in my limbs. It was strange.

Then last night, I was up every hour with a new complaint. Fever. Chills. Joint pain. Headaches. I kept going through the symptoms in my head. These were all symptoms of malaria but.... I didn't have malaria! I couldn't! God wouldn't do that to me... and well, malaria is some feared disease that makes you feel really bad. I didn't feel REALLY bad. Just strange.

Today, I've had no appetite. But for the most part, all my symptoms have gone. I've had a few chills and a slight fever but not much else. By mid afternoon, I was convinced it was some intestinal thing that my body had just gotten rid of. But Margaret wanted to test me just in case.

I knew it would be negative as I don't feel THAT bad. But I figured, why argue. Just do the test and be done with it. Then we could figure out what is causing this problem.

When she told me I had malaria, I laughed. I couldn't believe it. I even made her show me the results. Yeah, so I don't feel super great but COME ON! This is all it is? Malaria. Really?

Margaret shook her head in confusion and laughed with me. Silly American.

Lest you think me some sick masochist, let me explain.
All my life I've worried about getting malaria and having the disease lay dormant in my body, wreaking havoc on my system. And more recently, I've been watching little children come into the clinic and die of malaria because it wasn't treated quickly enough. The word 'Malaria' has had this aura of fear and mystery. But mostly fear.

I had been praying that somehow miraculously I would never get it. But God chose to do something else. I now have it. But instead of fear, I'm annoyed. How could I have feared this for so long? It's really not as bad as I thought.

I know... I know... I'm an idiot for saying it. Don't I realize that there are different kinds of malaria? Don't I understand that it kills more people each year than I can count? How dare I say that it's nothing? But that is what I'm doing.

It's like being afraid of this scary monster in my closet and then learning it's just an umbrella.
I feel oddly disappointed -- in a relieved sort of way. ha ha

But seriously, I do ask that you'd be praying for a quick recovery all the same. Thanks.

He bends down to listen.

"I love the LORD because He hears my voice and my prayer for mercy. Because He bends down to listen, I will pray as long as I have breath!" Psalm 116:1-2

Imagine that! Our God, our Abba Father bends down to listen when we speak. When I read these words I see an image of a crying child too hurt to say anything but a whisper, running to his father. I see a loving father softly bending down and leaning in to hear what is wrong. It's an image of tenderness and love.

What father wouldn't want to hear what his precious child has to say? In the same way, our Father in Heaven delights to hear from us. Do we delight to speak to Him?

What keeps us from prayer?

Some people chose not to talk to God because they worry what others will think. They worry they'll say the wrong thing and look silly to their friends. Others don't pray because they let life's distractions crowd their day until they are too tired to do much more than nap. And I'm sure there are those that refuse to pray because they have it all figured out. "Why ask God what He thinks when I'm going to do it my way anyway?" Selfishness. Stupidity. Sin.

But I think it's more than that. I think we don't pray because we don't understand who God is and what a privilege it is to speak to Him. 

We have the RIGHT to talk to God! He delights to hear us speak! He bends down to listen!

Think about it! If we really had a clue as to how radical a statement that is, how outrageous an honor, we wouldn't stop praying!

So I exhort you. Pray without ceasing because He's listening.

King George.

George. George. George of the Jungle is our new lab technician. He’s Kenyan and loves Jesus. He talks a mile a minute and has some of the funniest facial expressions. I think if I understood half of what he said, I’d be in stitches. But .... he’s hard to get.

Today he was telling me a joke. The poor man had to tell it twice and explain some of the words before I got it. I think my foreign accent application is on the fritz. I can’t get a lot of what is spoken among the ‘English speaking’ Kenyans. ha ha. Oh Lord open my ears, that I might hear intelligible things here in Sudan. :- ) he he.

We call him King George because so far he’s the man to beat in scrabble. I found him reading the dictionary on Sunday in preparation for a match with Margaret. He’s pretty cocky about winning. I have not had a turn yet. But I’m ready for a smack down. Meaning, I intend to clobber him... the problem is.... I’m not sure I can. Stay tuned for scrabble updates.

Anyway... I write only to introduce the newest member of our team. He’ll be helping us with laboratory tests once the lab gets set up completely. We are all very excited for this new possibility at the clinic.

Imagine a clinic able to properly diagnose and treat infections! Woohoo!

Can I get an AMEN?!

One Depressed Dog.

When Suzy and the kids left on Friday, Ouchi, the happy-go-lucky-wag-my-tail-till-it-hurts dog started sulking. At first she just moped and wondered the compound aimlessly. But then it escalated. Each day something new was destroyed. She chewed the stuffing out of couch pillows one day and gnawed through her leash the next. 

What can I say? She has lost her spark for life.

Today wasn’t so bad. She played football with the boys and ran about cheerfully. She has even decided to eat her food again. Stacy says she’s moping as much for Jane (our cook that returned to Nairobi after 6 months) as she is for the kids. I think she might be right. Ouchi’s life is either in the kitchen or chasing kids.

Hopefully she’ll snap out of it soon. But who knows, it might take them all coming back for her to bounce back. We’ll see.

15 going on... pregnant.

Just as the day was winding to an end, I was called in by Margaret to counsel a young girl who was crying inconsolably. She was crying so hard, I couldn’t tell what was wrong. So I looked at her file. She was pregnant.

I brought her to a quiet place and asked her a bit more about it. Poor Natali (my translator) acted like he didn’t know what to do. Apparently, a crying woman is just as perplexing to Dinka men as they are to men back in the States.

It took a while but eventually she started opening up. She was 15 years old. Her father was dead. Her mother lived far away and her brother took care of her. She was beside herself with fear thinking what he would do to her when he found out. The father of the child would probably marry her. But what upset her most was, she would have to drop out of school.

As I watched her shoulders heave and sigh with each new sob, I tried to imagine myself in her shoes. If I had gotten pregnant out of wedlock at 15, I would have thought my world had ended too. Perhaps it has. No doubt her world as she knows it is over. But a new world can begin.

I encouraged her to be truthful with her brother soon because she wouldn’t be able to hide the belly for long. I also told her to return for prenatal care next month so we can help her have the best pregnancy possible. Then I prayed for her.

I prayed for the fear and dread she felt at the possible beating she might receive. I prayed for the father of the child to be honorable and marry her. I prayed that no harm would come to her or her baby and reminded her that God has a purpose for each and every life-- even unexpected ones.

Please join me in prayer. Her name is Veronica.

Preterm Sadness.

Another preterm baby came in today. His mom was in a lot of pain but didn’t look anywhere near as bad as her baby did. We did a Ballard’s score (to tell how preterm the baby is) which placed her at about 27 weeks gestation. She only weighed 1.8 kg.

It seems prematurity is epidemic around here.

The baby had a number of problems. Her breathing wasn’t good-- nasal flaring, chest retractions, apnea. Plus, she wouldn’t suck. She looked like she was barely hanging on. My heart went out to her. But I had hope.

Then something changed. As Denis was doing the physical exam, he couldn’t find an anus. He called me over for a second opinion. Nada. The baby had an imperferate
anus (in short: the anus is missing). In the states, this requires surgery and pretty quick.

But here?

Denis referred them to Wau but they didn’t look even remotely interested in going. Lord, may this tiny treasure find her way to Your precious arms soon. May her suffering cease.

Strange Cases.

It's hard to see but this is the infected breast.

Yesterday a one week old little girl came in with what could only be MASTITIS of the right breast. Her mother reported that she was able to get a lot of milk out of it the day before. When I checked, lots of milky pus was expelled. It was very strange.

I should explain that baby girls sometimes have side effects from their mother’s hormones of pregnancy. These hormones can cause her to have a ‘period’ not long after birth. Some girls have ‘witches milk’ -- or start lactating. It’s normally nothing. The period is only once and the milk goes away after awhile as the hormones make their way out of the baby’s system. But mastitis (aka: infected milk duct)? That’s a new one for me.

My differential diagnosis is a plugged milk ducts, an abscess, breast cancer. But I’m open to ideas and suggestions. My money’s on mastitis though. She’s on meds now. I’ll let you know how it goes.

Reasonable Tradition?

I don't know how to begin my story, so I’ll start in the middle. Earlier I wrote how a woman was in “labor” with a stillbirth after severe bleeding for a day and a half. (read her story below: VASA PREVIA.)

You prayed. I prayed. Here’s what happened next.

Well, She had been at our clinic all morning, stable and ready to go to Wau once the family got the money. They found the money but then needed to get bus tickets or a car. They went to look for it and some more money. I waited patiently for the family to return with the good news...  and take her to Wau. They didn't come. Then I waited a little less patiently. I even got loud.

What's going on? Don’t you know she's sick? Why aren't you doing anything?
They just looked around confused. She looked fine to them... what's the big deal? So what if she’s barely able to sit up and urinating blood so dark it’s purple? She doesn't look that bad! I wanted to beat something... someone. They had given up.

But part of me doesn't blame them. They tried to raise funds and got enough to get her surgery but when they went to buy a bus ticket to Wau, the driver extorted them for more.

A ticket that should cost 30 pounds would cost THEM 150 a person because she was desperate. Yes. You read that right. They'd have to pay five times as much... double even... because a care taker must go as well. Pay 300 pounds and we'll take ya! I understand why they gave up. Three hundred pounds is more than most people make in a month.

But I don't understand why the bus driver would do that. Here a woman's life is in the balance. They saw only dollar signs! AAAAhhhhhhhgGGGG! I was so angry I could have spit!

Fine so the bus option was out. But the good news was they had enough money for the hospital stay. We were driving to Wau the following morning and would take them with us. All she had to do was stay alive through the night. I was prepared to do everything possible to make that happen.

It’s at this point that I decided to induce her. Perhaps if we could just deliver the baby, the bleeding could be controlled. Perhaps, by God’s grace, she wouldn’t have any further bleeding. It was a risk but one I was willing to take.

Just as her contractions picked up, they started talking about taking her home. What? But if she goes home, she might hemorrhage even more and a blood clotting disorder can happen. (This is called DIC -- disseminated intravascular coagulation). If it happens, she'll not be able to clot her own blood and bleed out quickly. It's dangerous. It’s better she deliver at the clinic where we have life saving measures available. But the family kept insisting. They wanted to take her home.

I begged them to stay until Sabet came back from his trip. He had been away all day with the car. (That's why we couldn't take them to Wau ourselves). He was due home at 5pm. They agreed to stay... but were anxious.

However, as God would have it, Sabet got delayed. And with each passing hour, they insisted louder. I told them they were free to go whenever they wanted. I couldn’t make them stay. But I kept praying they’d stay. I felt like a prison guard keeping her hostage. She wanted to go. Why? I wondered. To die? Eventually after waiting 3 additional hours, I unhooked her IVs (she had two) and let them carry her away.

As she was unable to walk, we drove them home. And as they loaded in the car, her brothers assured me they'd be back tomorrow morning to go into Wau with our truck. Just then Sabet arrived. But it was too late to convince them to stay.

They drove off and my stomach sank. Ten hours I kept her stable and alive. The induction was working and she was already 4-5 cm dilated. *When I did the last vaginal exam, I felt only placenta. My best guess is placenta previa but one that was completely detached. (I say this because she had absolutely no pain.)

So to answer all your questions, I don't know if she lived. All I know is she left our clinic alive. We called numerous times the following day but no one answered. That morning on the way into Wau, we drove by their house but it was empty. The locals I asked all think she was taken to the witch doctor. I don't know if she lived. I wish I knew. It eats me alive to think they chose to take her home than spend the night at the clinic. But that is the case.

I asked Sabet why they'd insist on taking her home when we could keep her stable and transport her to the hospital the following day. He explained that the Bongo tribe (of which she is a part) do a number of rituals on a dying person. It's VERY important for them to make sure all the rituals are observed. They would not have had the chance to do them at the clinic.

So in the end, tradition won out over reason. And in this case, it may have cost a life.

*(midwife disclaimer): I know I'm not suppose to do a vaginal exam when there is bleeding. It was a judgment call. Once I knew there wasn't a chance I was going to get her to the hospital, I needed to know what I was dealing with. Please understand. And if necessary, forgive.

Moon-alender.

For the last few weeks I've been seeing a lot more girls from the villages around Tonj. Sometimes they walk 5 hours to see me. These girls can't read and don't know how to count very well... either that or they don't know the months of the year.

Often I'll ask them when their last period was, and they'll say two months ago. Then I'll ask them what month they got pregnant and they'll say December of last year. Huh? But two months ago was June.

I just laugh and shake my head. Then I ask them how many months pregnant they are and they'll tell me they are 7 months pregnant. What? You had your period two months ago but you're 7 months pregnant? I'm often VERY confused.

Then I remember, they cannot read or write. They've never had any formal education. They do things differently here. So I do what I can and guess by fundal heights and such.

But... here's the thing. Each time I ask them how many months pregnant they are, they are able to tell me with accuracy. They have no calenders but they know very well when they are due. How? 

I finally asked one girl how she knew she was 7 months along. She smiled and explained she just counts the phases of the moon. She knows she got pregnant during a certain phase. When she sees that phase again, a month has passed. And it's been 7 moons since she got pregnant. I love it.

So this week after writing in a woman's book when I wanted her to come back for her next visit, she looked sheepishly confused. But how will she know when it's September 10? She asked me.

It made me pause. What do you mean? I asked. Doesn't anyone in your town know how to read? Is there a calender in town?, I asked. She said there were some children who went to school. She could ask them to read it for her.

It occurred to me then, that what I write in their medical books must look as foreign to them as Arabic looks to me right now... absolutely indecipherable.

So I remembered this moon thing. I told her to look at the moon tonight and come back when it is like that next time. Then it will most likely be a month. She smiled really big. Because, one, she could do that. And two... because a Kowaja knew about the moon-alenders of the village.

I smiled too. It made me pause because I keep telling these women to come back on such and such a day and am confused when they come two months later or sometimes the following week. Now I know why. They don't know how to read. They don't have shoes, why would they have a calender? 

Lord please change me and the way I look at the world. Teach me to be more culturally sensitive. Amen.

Common Knowledge.

Some days teaching is a blast. Some days... not so much.

I've been teaching our health workers to count fetal heart tones and take pulses. Simple stuff, Right? I thought so. But it isn't getting through. Today I asked one of them to count a woman's respiratory rate for 15 seconds. But after waiting a good minute he still wasn't done. I figured he was just losing count and restarting. Then I thought... maybe he thinks he needs to count 50 seconds not 15.

I asked, "You know you only need to count 15 seconds right?" Yes. He says. He understands... only 15 seconds. So he does it and comes up with 75. What?

I tell him that's impossible. She'd be hyperventilating. So I ask him... you do know what 15 seconds means, Right? He just cocks his head to the right and looks at me.

Then I grab the clock and point out 5... 10... and 15 seconds on it. Then the lights turn on! OOOOHHHHHHH!!!!!! So that's 15 seconds!

Huh?

Then he proceeded to count for 10 seconds. I showed him again. 5... 10... 15.... Let's try again. By the third time he got it.

I'm not saying he isn't smart. He's one of our best health workers. I'm saying, I have to remember that what I think is common knowledge isn't here. I keep forgetting that.

Most of the women I treat don't know how to read let alone what month it is. Many of the health workers we are training have only gone up to the 5th grade in school. They are very smart men... just not educated in the same what as I was. Sigh.

Lord may I have patience to train them properly and always remember that common knowledge isn't always so common in Sudan.

Vasa Previa?

A mom is at our clinic right now in very serious condition. She had painless vaginal bleeding after ROM (rupture of membranes) a day and a half ago. By the time she got to us, her pulse was through the roof and her blood pressure non-existent. She was in shock.

We got her stabilized and after several liters of IV fluids, found her blood pressure. But it's pretty low still. But her baby is dead. There are no fetal movements and I can't find a heart beat. What's worse... I can't even find a placental sound.

My best guess right now is vasa previa or placenta previa.

The problem is... she is not responding to induction methods. My hope was to get the baby out quickly so we could control the bleeding. But we are hesitant to insist on induction since her risk of DIC (disseminated intravascular coagulation -- a blood clotting disorder that can happen after hemorrhage of this type) is very possible.

Her family is doing a mad scramble for funds so they can get her to Wau (nearest hospital). But it's taking forever. I'm frustrated because we asked them to start looking for money hours ago but they just sat there. I don't think they believe me when I say she can go downhill very quickly.

They've found some money... but need more. But they also need transportation there. Lord, please provide us with an ambulance. We desperately need one. Sigh.

Pray she lives even though her baby hasn't. Pray. Pray! PRAY!!!

Update on a few stories...

The young man who had a motor bike accident is doing well. (Read his story below: FACE OFF) He has been coming in regularly for wound care. No permanent damage. I wonder if he'll ever get back on a bike again.

Then the story about the woman covered in burns (See her story: BURN UNIT) is also doing fabulous. She has been coming to the clinic by herself these last few days. She comes crawling on the ground... scooting forward as the pain allows. The first time I saw it I was amazed and mortified... But she is strong. Thank you so much for praying for her. Most of her wounds are 80% better.

And sadly... I have to say, my badger is gone. The man who 'gave' him to us wanted money. I refused to pay so he took him back. The sad thing is, he probably won't even keep little Corriander alive. I miss his sqwaaaakkkk. :- (

Shift Change.

Tonight is the last night of some of our short term volunteers. Jessica and Daniel (who’ve been here two months) are heading home. The have blessed us so much with their faithful service. I’ll miss them.

Jessica’s a nurse and has taught me a lot at the clinic. What’s more is she has shown me an example of joyful service that I’ll not soon forget. I keep praying and asking her to come back. Everyone has. Plus I’m pretty sure at least 4 men here would marry her on the spot. I can’t blame them. She’s a keeper. That’s what makes saying goodbye so hard.

Daniel (my adoptive younger bro) fits into that same category for me. He has encouraged me so consistently and powerfully over these last two months, I’m not sure I’m ABLE to let him go. I see so many gifts in him... so many amazing gifts... that my heart is to keep him here. To let him go means to lose a powerful prayer warrior and talented teacher. I know God has other plans for him... but it’s hard not being selfish.

A couple from California, Paul and Elaine, also will be leaving. They are so fun at dinner time and they live to tell people about Jesus. I love that. They were a joy to have these last few weeks. Elaine helped from teaching the kids to counting meds in the pharmacy and Paul taught the pastors along with Sabet and Daniel.

With them go a few others on staff... but only for a month’s respite. Suzy and the kids, Caleb and Jane (who’s going for 6 months). They will all be missed.

As they leave, two guys from CA have come to dig a bore hole -- Chris and Eric. Soon, we’ll have a water hole in Malone. What a blessing! Also, our lab technician arrived. His name is George and he’s Kenyan. I can’t wait to be able to run tests. Yeah!

Welcome all! Goodbye dear friends.

Namesake.

Regina holding her little girl.

This week’s theme seems to be prematurity. Twice already we’ve had two mom’s deliver  preterm at home and then come in because of complications. Each time the baby died. Both moms were referred for different things-- One for a blood transfusion due to massive hemorrhage postpartum, the other because she was in a coma for some unknown reason and wasn’t improving. So when a young girl come into the clinic today in premature labor, I wasn’t sure what to think.

She was acting pretty melodramatic. I admit I thought she was exaggerating a bit... or I did until I saw the contractions. There was no doubt something was going on, but could it be labor? Maybe it was just Braxton-hicks contractions? She was 7 months pregnant by LMP and only measured 27 cm. Not good. Her belly was way too small.

The last time this happened, we tried to refer the mom to Wau, but she never made it. She just ended up having the baby at home. Fortunately, all went well. But we weren’t there for them in their need. I didn’t like that. So, this time, I decided to keep her at the clinic.

I thought keeping her here would be a no brainer but her family wanted to take her home. I cautioned them that if the baby was really  7 months gestation, it was better to have our help. To my relief, they agreed.

Baby Stephanie Akac, weighing in at 1.5 kg.

So when Regina started pushing, we were ready. We had resuscitation equipment set up and mentally, I was ready for another anything -- even another death. I know that’s pessimistic of me, but I had to steel myself for the possibility at least. Not one baby born that early has survived here in my (short) experience.

I prayed over her and left it up to God. The Creator of all life certainly knows how to preserve it. I prayed for His will to be done. Besides, He knows what I can handle. I’ve mourned these children all week. If I am meant to mourn another... He’ll walk me through it.

The birth went smoothly. Regina only pushed a couple of minutes -- surprising for a first time mom. And as the head passed the perineum, I was surprised to see a tiny face looking up at me. :- ) (She was born completely posterior!)

Although she was minuscule in stature, you wouldn’t have guessed it from her lungs. She screamed and wailed and made such a ruckus that Margaret and I couldn’t help but laugh... and sigh in relief. No resuscitation necessary.

But would you believe she is only 1.5 kgs and (by Ballard’s score) only 28 wks gestation. That is how old the baby boy brought into our clinic on Monday was as well. But he weighed half of that (only 600g). Dennis and I were so confused we did the test twice but the results were the same. This little one is only 7 months old.

The good news is that... by God’s abundant mercy and grace.... this little girl is doing great. She is vigorous and very interested in breastfeeding. Pray that continues.

Her father was so happy with the good news, he asked if he could name her after me. So I have my first namesake. Rejoice with me as I’ve discharged little Stephanie Akac this afternoon. Both mom and baby are doing great. But they need prayer... lots of it. The risk of complications and infections are higher with prematurity. Thanks.

600 grams Miracle

Please be in prayer for a very sick mom and her very premature baby. They were brought in this evening. The mom was unconscious but not from hemorrhage this time. She has been ill for the last four days, and today delivered prematurely in a matter of minutes. She went unconscious. It’s then that they decided to come in for help.

We treated her for a number of possible infections but she’s still unconscious. In reality we don’t know what is causing this. When she stirs, it’s groans and mumbles. It doesn’t look good. Her baby however, a little boy, is doing fine. This is the miracle of it all.

He only weighs 600 grams and according to gestational aging methods (the Ballard score) is only 28 weeks gestation. He’s tiny but able to eat. We’ve fed him by syringe, and the mother’s sister (who is currently breastfeeding her own child), is giving him expressed breast milk.

Please pray for them. I really want him to make it. We made him hot water bottles out of plastic soda bottles and have him under a lamp as a warmer. His main concern in staying warm enough.

The mom however, isn’t out of the woods. We don’t know what is wrong with her. Pray for wisdom for the staff and God’s grace and mercy for her family. Pray this little boy would one day be coddled at his own mothers breast. Amen.

Update (Aug 12)
The day after I wrote this (even though I’m only able to post it now due to internet issues), the little boy died.

We kept resuscitating him and getting his heart rate up, but he was no longer able to breathe on his own. Once we would stop resuscitation efforts, his heart would slow to a stop. After doing this repeatedly, we finally decided to let him pass.

His mom was referred to the hospital in Wau because she never came out of her coma. We are still unsure what put her in it in the first place. Pray she recovers.

Hot as death?

Warning: this story might not be for everyone.

Last night, after closing down the clinic for the night, I was ready to head home when three figures walked up with a baby.

I thought about letting the on-call health worker take care of it but God refused to let me go. My feet felt glued to the ground. The figures seem so solemn, so resolved. I decided to assess them and then call the doctor. When I asked them what was wrong, they just showed me the small baby in their arms. He lay calm and still. Too still. He looked like he wasn't breathing.

I figured it was the poor light in front of the clinic so I had them hurry in. I touched the baby and he seemed warm -- hot even. I started thinking malaria. But as I assessed the baby more, it became very clear he wasn't breathing.

I called for my translator and asked them how long he'd been this way. They seemed confused. What do you mean? Isn't he breathing?

As my translator went for the doctors, I started resuscitation efforts. The family was sure that he had just now stopped breathing. "Just as we entered the clinic gate," they assured me. But it didn't look that way. His little hands were curled in tight fists. His body semi-rigid.

I gave oxygen and started chest compressions but was unable to restart his heart. Once Caleb got there we worked on him together. While Caleb did compression, I stopped to take his temperature. He was burning up with a temperature of 38.8 degrees (102 degrees).

Caleb pronounced him dead after assessing the rigidity setting in. Shaking his head to my hopeful looks. When I handed him to his mother, she too shook her head in disbelief. No, he's still warm. He must be alive. She put her ear to his mouth and said there was a rattle. She could hear it. But there wasn't.

It took her several minutes to believe us. She just kept looking hopefully to each of our faces. I told her that her baby was hot not because he was alive but because of the fever that killed him. I told her that we could no longer hear his heart beating. I told her that he wasn't breathing. He wasn't moving. I won't soon forget her face as that news finally settled in.  

I broke down and cried as I prayed for her. She seemed so hopeful. She had come from so far. He was still so warm. And yet all I could offer her was a quiet shake of my head and my prayers. I wanted to give her so much more.

He was only nine days old. He had spend 5 of them on fire. I used to think that death was cold but I don't anymore. I've learned that here, death can be hot as well.

Strike.

Today all of our staff went on strike. Not a one showed up for work.

They are disputing their pay and were hoping to make the clinic close down. They thought they were indispensable. But they aren't.

They all showed up late in the morning and were furious when we wouldn't stop caring for the patients and hear their complaints. They were angry that we were able to function without them.

But in fact, today went smoother than anyone expected. We were able to find translators to cover us and were even done by lunch! Imagine that 125 patients by lunch! ha.

Tomorrow is conflict resolution time so please be praying. Some of them will be losing their jobs due to their actions. And all the rest will be on suspension for three days.

Pray for the clinic all next week as we will be pulling extra hours and scrounging for translators. And pray that they understand they are only hurting their community by their actions -- not us.

Impossible.

“I will turn all my mountains into roads...” - Is. 49:11

God is speaking to the nation of Israel in this passage of Isaiah. He is promising them restoration in the land. This prophecy to the nation is one of hope and compassion. God reminds them that His covenant with them will be honored. They will never be forgotten. The thing they have given up on -- even despaired of-- will come to pass. Why? Because God said it.

He tells them that what looks like a mountain to them is really a smooth road to Him. For God nothing is impossible.

This comforts me as I’m easily overwhelmed by the mountains in my life. This person or that work is just too challenging. I want to give up. I want to run away.

But God reminds me not to despair. That mountain is put there to grow me in grace. This  person is here to teach me patience. That obstacle will work God’s perfect will in my life-- all for His glory.

He know all things. He is the source of all strength. For Him mountains are smooth paths. He is the God of the impossible.

If there is a problem in your life, trust Him with it. He will make your path smooth. Just you wait and see!

Is Nausea Contagious?

Today was a woozie. I can’t tell if it was the heat, the endless line of prenatals or the soup I had for lunch but I was sure I was going to hurl on my patients at one point. I couldn’t focus enough to get my words straight. I wanted to pass out. Pray for me. I hope it nothing more than a bit of dehydration. I’ve only had 3 liters of fluids today! That must not have been enough.

I guess there are other reasons for nausea but some don’t quite fit. I know I’m not pregnant (he he he) and I’m hoping beyond hope that I’ve not picked up some kind of bug.

Even now, I’m still ready to give up my lunch. Anyone want to send me some saltine crackers? (ha!)

Premature.

After lunch, I was quickly called back to the clinic because a woman had delivered prematurely and her placenta was ‘stuck’ inside. My translator looked worried and so I rushed. I told the rest of the staff (who had started lunch a bit later due to other emergencies) about it and they agreed to come soon.

However, Jessica (volunteer/Nurse) hurried after me, eager to learn as much as she could. I wasn’t told anything more than that the baby was preterm and the mom had a ‘stuck’ placenta.

The last time this happened the placenta was sitting in the vaginal vault and needed the slightest tug to come out. Today was a much different case.

When I walked into the room, the mom was covered in blood and motionless on the bed. A family member was holding her baby, wrapped in a blanket and gasping for air. The baby girl only breathed every 15 seconds or so and her heart rate was a cool 60 bpm. (It should have been in the 130 range). She was dying.

I started to resuscitate and Jessica was quick to help with chest compressions. The Ambu-bag we had was much to large (due to her prematurity). She had lots of secretions and was pale.

Caleb and Maggie came in shortly afterward. Caleb took over my job in resuscitation and Maggie helped me assess the mom.

All the while, I kept calling out for more information. When was the baby born? How long has she been bleeding? How much blood has she lost? How long was her labor? How many babies has she had? Which ones of them are alive? Has this happened before?

The story unfolded for me question by question as I continued to assess the young girl. This was her forth pregnancy. Each of her babies were born premature. Each of them died.

I remember looking over to the table where Caleb and Jessica worked tirelessly on the baby girl. She wasn’t breathing spontaneously. Her heart rate would jump from 30 to 100 depending on resuscitation efforts. It didn’t look good.

Meanwhile, Maggie was getting an IV started as we could see the young mom was in hypovolemic shock. Her blood pressure was bottoming out. Her pulse was through the roof. She had been bleeding non-stop since birth (which was 3 1/2 hrs earlier).

I could see her heart beating in her chest. I didn’t need to take a pulse to count it.

When I evaluated her placenta, it was partially detached (the reason for all the bleeding). What’s more, is it was very determined to stay that way. I had to do a number of maneuvers to knock it loose. But when it came out, all the membranes were still inside.

My only option then was to do a manual exploration for the membranes. This is not comfortable but it was the only way I could be sure the membranes wouldn’t continue to cause bleeding. Fortunately it worked. Her bleeding stopped.

A second IV line was started, as we flooded her with fluids. She got 5 liters before her blood pressure even remotely stabilized. She was pale as a sheet, desperately needing the one thing we couldn’t give her; blood. 

The baby died but she didn’t. I think the baby could have survived if she was born in the clinic. But even then, I’m not sure. Maggie tells me that babies born that early here rarely survive.

The young mom, turned her head from me in sorrow when I told her but she didn’t cry. So I cried for her. I cannot begin to fathom her pain. Four time pregnant. Four time heartbroken.

The only reason I can think of her premature labor is an incompetent cervix. I told her how to fix this problem next time she gets pregnant. But I’m not sure she believed me. I think she’s lost hope of every having a baby live.

Pray for her. She’s in desperate need of blood but her family doesn’t have the resources to get her to the hospital for treatment. I think she will recover. It might take months without the blood but it’s still possible.

Laughing him out!

Yesterday morning, just as I was getting ready to start a full day of prenatals, in walked a labor. She was having contractions every 3 minutes and they were super strong. When I found out this was her first child, I was surprised she wasn’t making more noise.

When I checked her dilation, she was already fully with the head at a +2 station (for you midwives out there). But when I looked at her, she just smiled back at me calmly and fell asleep between contractions. I would never have guessed her to be so close to delivering.

Not long afterward, she started pushing spontaneously but there was little progress. She was just getting the feel of things. After an hour or so, she worried that the baby was never going to come out.

I explained to her that she had yet to push effectively and showed her how to do it again. She got serious (with a little help from me) and found her groove. A beautiful baby boy was born just 30 minutes later!

When he came out, I was astonished. He was so long. It felt like he would never end! He was more legs and arms than anything else but also had the typical oblong shaped head of a first-time mom.

She laughed when she saw his funky shaped head and tried to rub it back down. She giggled at how funny he looked and then... we all joined her. It was such a fun birth. She was so thrilled to have his little boy.

She was so excited to push and was so strong! Would you believe she never once screamed out in pain. Even during the crowning stage she didn’t make a peep. The only noise coming from our room was that of laughter and a baby crying!

The Truck has arrived.

On Friday, our dearly desired and much needed supplies arrived! Thank you Jesus! It only took 8 days for the truck to drive here... but it took 6 months for it to arrive. Yes, 6 months!

It has lots of food and tons of medical equipment and medicines. We were using our emergency reserves. It was getting desperate. But God brought it to us this week to our wonderful delight.

But after unloading it and counting all the inventory.... it got stuck on the way out. (see the pic above) It got bogged down in the mud. It was quite the ordeal to get it out. We ended up having to get someone to tow it out.

Thank you Jesus for supplying all of our needs, according to Your glorious riches.

Lessons Learned.

(Guest Writer: Jessica Leong (volunteer/Nurse)

I got frustrated today.  Angry even.

It all started because of the slow day.  It’s rainy and since everybody walks everywhere, we always expect rainy days to bring fewer patients.  It was mid-afternoon and I was all caught up on wound care and immunizations and was looking to help wherever needed.  I walked into Dennis’ room where he and Margaret were trying to get an IV in a small girl who lied lethargically in her mother’s arms.  She could not even hold up her own head.  I asked what was going on and they said something about possible alcohol poisoning and aspiration. She obviously needed an IV, but they had tried several times without any luck. 

Something that I’ve realized here is that they always start IV’s in veins that are visual whereas I’m used to using my index finger to feel for and find veins.  I figured I’d give it a try.  We were desperate and after one failed attempt, additional family members came in.  They seemed upset and we found out through our translator that they wanted to take her.  They obviously didn’t trust us because of the multiple times we had already tried for an IV.  They then said they were going to take her to a “magician.”  Translation: witchdoctor.  Dut, our security guard, was supportive of them for some reason.  I didn’t understand.  How could this guy who works for a Christian organization be telling these guys to leave to go to the witchdoctor?  Not okay.  Ever.

I hadn’t given up on the search for a vein, but Dennis told me to stop.  They needed to leave.  He quickly prescribed her some medication that he thought might help and let them leave.  I was heartbroken.  These people just walked out of a Bible-believing compound to go to a demonic, worldly witchdoctor. 

I sat outside, thinking about what had just happened.  I let somebody go.  She could die.  I should have done something more about it.  I was so angry with Dut for letting them leave and even supporting their decision.  I went to my room and cried harder than I’ve cried in a long time. 

Once I could think rationally again, I realized that I needed to get the facts straight.  I couldn’t assume that I understood everything that went on.  I went back to the clinic and spoke with Dennis in private and he explained what had happened that I had not picked up on.

When Dennis saw that the situation could easily get out of control, he called Dut to speak with the family members.  It was then that Dut noticed that this man was carrying a sword.  Most of the family was drunk (as was the child) and one thing about the Dinka is that they always get violent when drunk.  Dut didn’t want to put any of us in harm’s way.  That’s when he promptly came into the room with all of us trying for the IV and the crowd of people followed him.  The father in his anger told Dut that if the child died in the room he would retaliate, meaning kill one of us.  Dennis picked up on the facial expressions that Dut was making and told us all to stop trying for an IV and let the family leave. 

Boy, was I glad I got clarification on the situation!  Dut was protecting us by sending the people away and Dennis was keeping the girl from the witchdoctor by giving them some simple meds that might or might not help.  Maybe they would stay home to see if the medications would work, allowing the girl to sleep off some of the intoxication. 

Today’s lessons: 

Don’t fight the decisions of the people who have been here longer.  They know what they are doing.

Don’t freak out when things don’t go my way.  God can still protect that girl from the harm that her family may bring on her.

Face Off.

Today I helped sow a man’s face back on. I’m not taking any credit. I’m saying I had the privilege of watching and dabbing away the blood from time to time. He was brought in unconscious after being thrown from a motor bike. It’s still unclear to me if he was driving or just the passenger.

His forehead peeled back like a trap door revealing the hard skull beneath. His left lower eyelid gaped at me, bloody and mashed. It looked like someone had taken a bite out of it, exposing the bloodshot conjunctiva beneath. I honestly wondered if he’d loose it all together.

His upper lip was ripped away from his nose, leaving it swollen to two times its size. And his chin had a gash a 1/2 inch deep that looked as if someone had drilled it with a screwdriver. Then there was the road rash all over his arms and chest.

Mercifully he didn’t gain consciousness until we were almost finished. I wonder what he must have been thinking when he woke. He seemed less inclined to lie there though -- confused and hurting. We had to restrain him to finish the job but it wasn’t hard. He did have much fight in him.

He will have a long road of recover ahead of him. Please pray that no permanent damage was done.