A Traditional Sudanese Birth?

Akul first came for help two weeks ago. She was sure it was labor; but her contractions were unconvincing.

Although obviously painful, her contractions lasted no more than 15 seconds and weren’t bringing any progress.

Since it was her fifth pregnancy I admitted her for observation; and for the next 5 hours we watched and waited. But nothing happened.

Now, I’ll be the first to admit I’m cautious when it comes to Braxton-Hicks contractions. I used to educate women on them, reminding them that it wasn’t labor until there was progress, etc. But after a year and a half of malaria cases, I don’t like to risk it anymore.

Why? Because I cannot tell the difference between Malaria-Labor and Braxton-Hicks contractions.

Yes. It might only be Braxton-Hicks contractions. But what if it’s not? What if she has chronic malaria and the pregnancy is masking the symptoms? What if the paracheck gave a false-negative? What if...?

So when I have a woman like Akul --in pain with regular but short contractions-- I treat for malaria if I haven’t seen any progress for several hours.

This was the case for Akul; so I gave her the first line treatment and sent her home. When I didn’t see her the next day, I figured the medicine worked, or she’d delivered at home.
    --Follow-up on patients here isn’t as easy as you might think.

I didn’t see her for two weeks. Then two days ago, she returned with the same symptoms. In the course of her evaluation it became clear she did not take her medicines properly.

We were right back to square one.

More pain. More spastic-y contractions. More worrisome watching.

But since her symptoms were worse this time, I started her on IV medicines and kept her for the night. By morning she hadn’t dilated even a centimeter.

I gave her a new course of treatment and sent her home, warning that her labor could start at anytime and she’d need to come back if her water broke... or the pain got stronger.

She returned 12 hours later saying her water broke.

I wanted to believe she was in labor... but all I felt was irritation. Stupid malaria. Stupid, stupid malaria.

Grumbling under my breathe about the evils of this debilitating parasite, I watched her suffer under its torment.
    --Childbirth is painful enough without adding this nasty plague!

But when I re-evaluated her, she hadn’t dilated at all. However, her water had most assuredly broken. I wasn’t sure if she was in labor... but I figured it’d come soon enough.

I told her as much, then gave her the option of staying the night again or going home. She wanted to stay.

I didn’t argue. Even if she didn’t progress, at least she’d be close.

However her labor surprised me.

Her contractions got strong rather quickly, shaking her body like a ship in a storm. They went from being every 20 minutes to every 8 minutes in under an hour. 

Another hour went by and she was pacing --pacing and moaning rhythmically.

It was close.

Her husband, a man who had faithfully sat by her side each step of the way, watched us pace together but made no comment.

His dark, lanky frame stood in shadows and watched. In the black of night, the only thing visible was the reflection of the clinic lights in his eyes.

Less than an hour later, Akul was asking to push. No... she was NOT asking; she was grunting, moaning, jerking, clenching, and whimpering.

It was time.

I asked her if she wanted to deliver on the birth bed or on the floor.
-- “The floor,” she whispered.
-- “Okay. Once this contraction is over,” I said as a strong wave of pain rushed over her, “we’ll help you get positioned on the floor.”

Nodding, she answered with another whimper. 

Once set up, I invited her husband to join us. He had been sitting silently on the bench outside.
-- “Tell him that he can come in if he wants to...” I told my translator, “He doesn’t have to come in... but if he wants to, he should come now.”

My translator called for him over the thin wall, and he noiselessly entered and sat down.

Turning my attention to Akul, I said, “Only push when you have a contraction. Okay?”

She nodded determinedly but said nothing.

Her husband sat in the corner, firmly grasping his knees to his body in an effort to stay on the stool. It was a tight squeeze for his long legs.

After a few minutes, he spoke his first words.
-- “How do women deliver on a bed?” he questioned innocently.

It was child-like in tone. And I could see his mind whirling as he considered the plastic-covered birth bed in front of him. It had a hole at one end and a movable flap at the other. Very confusing.

He wasn’t asking me, but my translator, so I didn’t butt in until the conversation was over. I had understood a bit of it and asked my translator to help me understand it all.

-- “He cannot imagine how the woman earlier delivered on the bed,” explained my translator.  (The previous labor delivered just an hour before and he had heard all the commotion. That labor had insisted on delivering on the bed.) My translator continued: “He wants to understand how it’s possible to deliver in such a way.”
-- “Did you tell him?” I asked, but then couldn’t wait for the answer.

She was pushing.

She delivered in the supported squat position a few minutes later. As her boy slipped out, a piercing screech filled the room --and then silence.

It was done.

Slimy and beautiful in every way, he complained as I wiped him down and placed him in her waiting arms. For several long minutes, we sat in silence enjoying the calm after the storm.

As we sat, I couldn’t help but think about his question. It was a good one. Very practical.

“How do women deliver on a bed?”

I’m willing to bet there are a large number of non-Dinka men (and women for that matter) out there wondering the very opposite question.

It could be equally asked: “How do women deliver on their knees?”

Ahh! Culture! Thou art a tenacious beast! You cling to our preconceptions like barnacles; you beat about our heads like waves; your flotsam and jetsam clutters our minds. How do we escape unscathed?

Underneath what we are really asking is, "What is the right way to give birth?"

There are just no answers, are there? There are just opinions colored by what is most familiar, comfortable, and common place.
           --Oh, the traditions we hold so dear! 

I’m happy to report that Akul had a traditional Dinka birth.

She delivered in a supported squat with her husband’s knees in her back while malarial parasites raced through her veins.

Afterward Akul glowed with satisfaction, saying “I’m so happy. Ana chi pou mieth. I’m so very happy.”

Yes, Akul. So am I.    --So very happy!

Please pray for them. Pray her chronic malaria goes away quickly. Pray for health and love and joy and peace.

I invited them to church on Sunday, please pray that they come. Thanks.

2.1 equals 1.1

Yesterday a young girl came for help. Reported to be early in her third trimester, she complained of malaria symptoms. Fever. Chills. Pain.

Margaret saw her and called Dr. Tom to help evaluate. I’m told she was severely pale so they asked our new lab technician, Caroline, to check her hemoglobin.

She had a hb reading of 2.1 g/dl.
    --Yes. You read that right. A hemoglobin of 2.1

(For those who don’t know, that reading is crazy low! Normal hb in pregnancy is 11-12 g/dl if you are moderately healthy.)

She needed a blood transfusion.

Remarkably, her baby was still alive. I was told Margaret and Tom were preparing to refer her to Wau for a transfusion while starting aggressive treatment of the cause --malaria.

Since church was starting soon, I decided to visit her after church. But once service ended, Margaret approached me saying she’d delivered.

What? I thought she wasn’t having contractions. When did she deliver?

Apparently in an effort to save her life, her body expelled the child spontaneously. He was born alive but severely preterm weighing just 1.1 kg (or 2.4 lbs).

Once I heard the news I went to check on him. He was breathing well but starting to show signs of distress. His mother looked sad and exhausted.

She explained that all her family was far away or in prison. There was no one left to help her get to Wau for the blood she needs.

Sigh.

With time Dennis was able to start an IV on this precious munchkin and we gave formula through an NG tube. He looked like he wanted to live.

After doing a Ballard’s score (a rating to help determine the gestational age of a newborn), we guess him to be around 31-32 weeks gestation. This explains his ability to breath well but not his size. I believe him to be small for gestational age (SGA) as well. Long term anemia will do that in a pregnancy.

Please pray for them. Her name is Ayen. She is family-less, severely anemic, with a tiny preterm baby. Please pray for God to keep them both healthy and alive. Thanks.

Stillbirth.

I’ve only seen Achan since mid-September for prenatals. She came the first time because malaria was burning through her body. However the first treatment was not effective... or she was exposed to enough mosquitoes to get it again just 3 weeks later.

Either way, she came in again last week, but this time the malaria was worse. She was vomiting and had been for days.

I stabilized her with IV meds then sent her home with orals, but her recovery was slow.

So when I saw her in my prenatal line, I was worried. Perhaps it was something worse than malaria, and I’d misdiagnosed her.

She said she wasn’t having contractions but felt really bad. So I asked Margaret to look into it.

Margaret checked her out and laughed at me for not doing it myself. She was definitely in labor she said, and was already 8 cm dilated.

Since my hands were full with prenatals, Margaret promised to keep an eye on her. But just as she was getting pushy, another woman came in to deliver.

So Margaret took over her care, and I turned my attention to the gap-toothed mama on my bed.
She was very active, and before I had a chance to do a vaginal exam, she was pushing.

Not 15 minutes later her girl was born!

She hemorrhaged which took several medicines and maneuvers to control, but eventually things calmed down and I transferred her to the recovery room, cleaned up, and went to see if Margaret needed my help with Achan.

I found Achan trying to push as a friend supported her back. Margaret kept insisting she needed to push harder and longer. I wasn’t sure how long they’d been at it.

Picking up the doppler, I found the heart tones with ease. They were steady at 120 bpm but dipped when she pushed to 90s. I suspected head compression since the head was passing under the pubic bone, and wasn’t initially concerned.

However, as she pushed the heart tones continued to drop. Margaret kept trying to get her to push harder; I suggested new positions.

Achan’s eyes flashed wildly in fear, so I comforted her with gentle words. The tension in the room thickened the air; emotions were high. So I prayed.

As I listened to the heart tones again, I whispered to Margaret that they were dropping still. They were in the 60’s and 70’s. The baby needed to get out quickly if we hoped to have any chance at resuscitating him.

Although Achan pushed her best, the baby was slow to come. Five minutes before he was born, I could no longer find the heart tones. They had dropped to the 50s; then were gone.

My hope was that he was just too far down in the birth canal to be found, but my gut told me otherwise.

He was born pale and limp.

Margaret cut his cord immediately, and I took him to resuscitate. Though his color was pale pink, his heart was completely stopped.

Tom came to give rescue breaths, while I pumped his tiny chest. This went on for several long minutes, as the room silently watched.
    --Would the Kowajas get the baby to live?

After 10 minutes with no heartbeat, we pronounced him dead, wrapped him in a blanket, and handed his blue-tinged frame to his grandmother.

The grief in her eyes was too great to look at directly, and I furtively studied my shoes.

“Malesh mama. Malesh. (I’m sorry mama. Sorry.)” I said softly.

She nodded that she’d heard, reached for him, and sat down slowly on the edge of the bed.

I had to leave the room to breathe again --my chest, tight with grief, needed the sun, the air, the song birds. It gasped for it in panic, and I sobbed.

Fortunately, Nancy (a wonderful Christian woman here to help with the pastors) was near by and she let me blubber while she prayed.

Later the pastors and staff surrounded Achan and her family in mourning. We prayed and loved on them as best we could, and then they returned home.

This death was particularly hard for both Margaret and myself. Although I could see he was declining, there was no way we could get the baby out any faster. And once he was born, there was no clear reason as to why he died.

Please pray for Achan and her family as they grieve, and particularly Margaret. This death has rattled her severely. Thanks.

Two Liters Too Few.

Her precious children.

Angueth came in barely conscious. But by the time I was called, my translator had little time to do much more than learn her name and get her to lie down on the bed. It was a busy night.

So I busied myself with fundal heights and heart tones while he asked her more questions.

“Ask her how long she’s been sick like this,” I instructed my translator.
She responded but I couldn’t understand her words. She was slurring them.
“Is she drunk?” I asked again, confused and not a little worried, “Or has she had a stroke?”

The man who brought her in, didn’t know so he asked her daughter. There was a brief discussion,  during which it became clear that this man wasn’t her husband. He may have been a neighbor or a random stranger. But he wasn’t family.

“The girl says she doesn’t drink,” I was informed.

Angueth was barely hanging on at this point. Every few minutes she’d slip from consciousness and I’d try to pull her back.

Limp and cold, her extremities were swollen and her mucosa was white. She was severely anemic. I screened her for malaria symptoms.

She’d had all the major symptoms for some time, but she’d not been able to talk right for three days.

“This is outside of my scope of practice,” I explained to my translator, “Please get Dennis. I need his help.”

He grabbed the flashlight and left in a hurry, leaving me with Angueth, the Good Samaritan and a handful of kids.

Three to be precise.

Her eldest looked to be about 10 years old; the other two were both under 5. And all three sat quietly on the bench in the hall.

I continued checking her vitals while I waited.

Search as I might, I found no heart tones and eventually gave up. She looked to be about 7-8 months pregnant.

“My lower abdomen hurts,” she mumbled softly while rubbing the spot.
“Is it a contraction?” I asked in Dinka.
“Yes, it hurts. It hurts.”

Although I could not see or feel any contractions, I suspected her body might be delivering in an effort to save her life. So I did a vaginal exam.

Sure enough she was dilating. She was already 5-6 cm along.

Dennis arrived and I filled him in. He assured me that she hadn’t had a stroke but was in the late stage of severe anemia. Surprisingly her blood pressure was stable. So we started her on antimalarials and admitted her for labor.

Late as it was, there was no hope of getting her to Wau for a transfusion. Plus the Good Samaritan had quietly slipped away, and we had no way of contacting her family.

When I told her that she was very sick and was delivering early, she wasn’t surprised. But when I told her that her baby was no longer alive it took her a while to come to terms.

“So my baby is coming?” she asked, bubbles forming at her mouth.
“Yes,” I said looking at her full in the face. Her eyes searched mine in an effort to understand.
“When he comes. Will he be alive or dead?” she continued on.
“Your baby will be dead.”
Whimpering softly in response, she closed her eyes.

I think she wanted to say more, but the effort to speak was too great. Staying conscious was a hard enough.

Margaret took over her care in the night. She told me that Angueth’s labor progressed naturally, and a few hours later she delivered a girl. She was dead but hadn't been for long. Fortunately, Angueth lost only the slightest amount of blood, and her blood pressure remained stable throughout.

The following morning when I went to check on her, I was surprised to find her fast asleep. But when I tried to rouse her, she was completely unresponsive.

Although she’d been assessed shortly before by our night staff, it was clear the vitals were off. So I took them again. And sure enough, I was right.

She was unconscious and in shock.

With cold extremities, high pulse, and blood pressure bottoming out, I called for re-enforcements. First I called Tom, who listened to her chest for the sound of heart failure in the form of fluid build up. But eventually announced that it was out of our hands, saying she needed a blood transfusion.

Yes. That was clear.

Then I called Dennis, who helped me elevate her legs and suggested I give her Hemosele (a blood replacement IV fluid) to see if her blood pressure might at least stabilize. It was 68/42.

Blissfully unaware of the seriousness of the situation, two of her three children napped on our porch while the eldest went to get porridge.

When she returned I asked her to find an uncle or an aunt. Anyone. I told her that I needed to speak to them urgently. Could she do that for me?

Eager to help, she smiled sweetly and left right away. And I returned to her mother. I continued to monitor her vitals, but the fluids didn’t help.

Her blood pressure continued to plummet, and her breathing became more rapid and hoarse. A choking rattle filled the room as I watched... and counted. She was up to 60 respirations a minute.

A few minutes later, she passed away, shedding two tears without waking. They streamed down her cheeks and onto the bed.

Then the rattled ceased.

At the sight of her tear-stained face, I couldn’t hold back my own. And I mourned for this stranger as if she were my sister, grateful no one was there to watch.

A few hours later, Albino was able to track down her brother and uncle. They hadn’t even heard she was ill. Apparently her husband left some time ago. She lived alone.

Her family gathered around and I told them the story of her death. They were sad but thankful to have a few answers. Then one of our guards walked her children home while the rest of us placed her in the ambulance.

Rigor mortis had already set in.

As I helped lift her body into the vehicle, I had to step over two shovels and a pick.
    --How long will it take them to dig her grave?

Lord, please teach us how to do blood transfusions and send us the equipment. I’m tired of watching these women die for the lack of two liters of blood. Better still... Lord, send them to us for prenatals.

And if by some miracle any reader out there knows how to do transfusions and can teach us what kind of equipment we need, I want to chat! Write me in the comment section.

I’m praying that God will send us the equipment and the expertise to do transfusions. Will you pray with me?

Hemoglobin.

 

A month ago she gave birth at home to her second child --a girl.

Because of untreated malaria she was already anemic when she started to bleed postpartum. She bled a lot.

She bled and bled; but she lived.         --Barely.

A month ago she gave birth to a healthy child but she has been too weak to hold her. She nurses lying down between episodes of vomiting.

She is severely anemic; and the malaria that destroyed her blood cells still runs in her veins --a month later.

Only after her family realized she was at death’s door did they carry her in. Too weak to walk by herself, she stumbled in with two strong men holding her on either side.

Tom saw her and immediately recognized the signs. He started her on malaria medicines, blood replacement fluids, and tested her hemoglobin.

Not having a lab technician we were not sure of the results but they were better than nothing.

She was said to have a hemoglobin of 2.8 mg/dl!

A normal level for an adult female should be 12-16 mg/dl. Again... I suspect the reading could have been off a little (or a lot), as the person who did it is not professionally trained.

Regardless, she needs a blood transfusion.

Her family rallied and got money to pay for the fuel to Wau, and we took her by ambulance this morning. Please pray for her to get the blood she needs and to make a full recovery.

You may be asking yourselves why she didn’t come earlier for help...
I asked the same thing. As it turns out, she lives 5 hours away by foot. Such distances are not realistic for a woman in her condition. It took a month of family discussions and pressure for them to bring her. I’m so glad they did.

Please pray for her to live. Her name is Adut. Thanks.

Monica's Story

A picture I took of her shortly before her death... when I still hoped.

It was a busy clinic day with lots of preggos coming and going and two labors in various stages of dilation. So when a car pulled up I didn’t even notice.

But soon afterward there was a small tap at my door. One of the newest translators timidly informed me I had a labor. Sighing in mock frustration, I quickly went to meet my new labor at the clinic entrance.

Honestly, I was not ready for what I saw.

A small girl --looking no more than 12 years old-- lay pathetically against the entrance door. Beside her a woman with pleading eyes locked gazes with me; she was doing her best to hold the child upright.

“Is she pregnant?” I asked not believing someone so young could be ‘in the family way’.
“Yes, but she is sick,” one of the translators informed me.
“Bring her inside,” I said and quickly turned on my heels. I needed to inform Margaret of this new development.

Once we got her inside, I could see the small belly-bump low in her abdomen. Yes, she was definitely pregnant.

“How old is she?” I asked, trying to hide the disapproval in my voice.
“Fifteen,” I was informed by one of the many family members in the room. It’s as if half the village had entered my 10 foot by 12 foot cubicle.

“What are her symptoms?” I quarried while systematically checking her vitals from head to toe.

She was lethargic and barely able to stay conscious. There were no fevers and no reports of convulsions but I instantly thought of malaria.         --It’s always malaria.

Desperately fighting to breathe she gasped for air at the rate of 90 breaths per minute. That’s a breath and a half a second!

By this time Margaret had joined me and quickly looked at her eyelids to see is she was anemic.

“She’s a plus-plus for pallor,” she informed me then showed me her paper-white lids. I’ve never seen anyone so pale.

“She’s severely anemic,” I informed the family, “How long has she been like this?”

As we continued taking her vitals, the family informed us of the little they knew of her case. She was living with her uncle in Wau. Yesterday, she came home to be with her family. They brought her in to see us once they realized she was having trouble breathing.

“That’s it? That’s all they know?” I asked more than a bit confused. This girl has been sick a very long time. Why were they only now seeking help? I wondered. But that didn’t matter. Caring for her was what mattered now.

She measured to be about 7 months pregnant, but she could have been more. None of her family members seemed to know, and she was too exhausted to speak.

As I searched for heart tones with my doppler, I wasn’t expecting much. If this child was still alive, it’d be a miracle.
        --But I found none and eventually gave up.

How does a 15-year-old living in a big city get this sick? How?

After wavering back and forth on whether to give her IV fluids and consulting with the rest of the staff, we decided to test her for malaria. There had to be an underlining condition for it all.

She was positive. Malaria --that parasitic curse-- had struck again.

We gathered her family together and explained that she was desperately sick. She needed a blood transfusion immediately or she would die.

They listened.

“If she gets new blood she can recover,” I assured them, “But we are a small clinic. We have no blood here. You must get her a ride to Wau right now, so she can live.”

Four pairs of eyes searched my face as I explained. They could see she was dying. The only question was whether or not she could live.

“Get her a blood transfusion right away and she will live,” I went on. The steel in my voice was unmistakable but I realized I no longer felt the need to beg. They would either go or not.

Once I finished speaking the grandfather left without a word.

The girl’s mother and two aunts helped us to get her to the observation room and we started her on malarial medicines.                                  --I had hope.

Three hours later, her grandfather had (miraculously) returned with a car. I had even more hope. I even took a picture of her so I could ask you to pray.

Five minutes later she died.

She died with a few final gasps with her head on her mother's shoulder while her aunts prayed. One aunt left the rooms in deep wails. Another sat quietly knowing --too grief-stricken to speak.

They knew long before I would even admit it.

She was dead.

Dennis and Tom came to pronounce her because I was unwilling to admit it. I kept fighting for more hope. But in the end her heart just gave out.

Later on as the pastors came to minister to her family we learned more of her story.

The pastors praying for her family after her death.

Her name was Monica. She was 15 years old. She lived with her uncle in Wau. When she got pregnant out of wedlock he was furious and kicked her out of the home. She begged for months from friends and strangers. No one knows how she survived. When she got sick she had no money to seek treatment and no money to get home. Finally a stranger took pity on her seeing that she was very sick and let her hitch-hike back to Tonj. She died in our clinic the next afternoon.

She died of heart failure due to severe anemia caused by untreated malaria.

All of it could have been prevented had she known about us and come. Had she been able...

Pray that such senseless loss would end. Pray that we can find a way to get these women the prenatal care they need and deserve. Pray that no more 15-year-olds would be lost.

But just pray...

Third Trimester Malaria

On Sunday, Aguak arrived in a lot of pain. Even though she complained of everything BUT malaria, I knew she had it.

She was burning up. She was writhing in pain. She was pregnant.

I admitted her and started her on IV medications because she couldn’t keep anything down. At one point she said she had only been sick a day at most, but her symptoms seemed too severe.

Malaria will cause contractions, and she kept insisting she was in labor. I assured her that once her fever came down and the medicines took effect, her ‘labor’ would stop.

While the quinine slowly dripped into her system, I assessed her baby. This was her first pregnancy, and she was well into her third trimester. Perhaps she WAS in labor.

As I measured her belly and listened for the heartbeat, I was disturbed by the silence. Even though she insisted in a half-dazed malarial rant that the baby was alive since it was moving, I didn’t believe her.

I could feel no movements. I could hear no beating heart.

That was two days ago.

Last night as her medicines had finally worked their magic, she was well enough to understand her child was dead. She took it bravely but it was hard news nonetheless.

Normally, I’d be willing to induce her. But she is still so weak. I’m worried she won’t be able to handle the induction.

After informing the family of the death of the child and potential dangers it poses --the baby decomposing and causing her to get septic or her developing disseminated intravascular coagulation-- I asked them to take her to Wau.

At first I was hopeful. They have the money and even took her home this morning. But then they came back again this evening.

Apparently, despite all their searching they were not able to find a ride to Wau. They seem to be unwilling to go on the bus (I can’t figure out why) and private transportation is too expensive.

Perhaps they will go tomorrow. Please pray that they do.

Pray for Aguak and her child. May mercy, grace, love and peace surround them all during this difficult time. Thanks.

April Showers bring... Malaria.

One of my patients with her new mosquito net.

The rains are late this year... or so I’m told.

Normally, the glowering grey nimbostratus clouds start in April, but this year they just now arrived. Smotheringly low, these mantles of would-be water threaten showers but rarely satisfy. Occasionally they breathe small gusts of chilly delight, causing this blistered land to shiver in momentary hope; and then it’s gone.

More heat. Sweat. Heavy air.

The only ones truly happy about it are.... the mosquitoes.     

Yes, we’ve traded the dry, merciless days of summer for mosquitoes. We’ve escaped the 120 degree weather only to run into the arms of bloodsucking beasts.

Malaria season has begun!

Honestly, the annoying high-pitched hum of my would-be assailant sets me on edge.

But slapping my leg at the slightest movement, covering my limbs in greasy DEET, and meticulously tucking my mosquito net in at night, seem useless. By the end of the day, I still end up bit to pieces. Am I just wasting my time?

Last year, I got malaria twice.

Fair enough, I wasn’t as anal as I could have been about protecting myself. I didn’t take the antimalarials prophylactically, and I only slathered myself in DEET when it tickled my fancy. But still...

Don’t get me wrong, malaria sucks! But... it’s such a hassle. (Insert pathetic whining voice here.)

I hate having to remember to take antimalarials. I don’t want to wear DEET (it’s so nasty). Plus... sleeping under a mosquito net can be stifling.

Sigh.

Okay, rant over.

Please pray that this year, the malaria won’t be so bad. Pray for all the women and children in this community that have to face malaria without prophylactic medications, mosquito nets or even that nasty DEET!

Fortunately, we have free mosquito nets to give all our preggos again. Thank you GOSS (Government of Southern Sudan). Pray that the women will actually use them... even though they can be stifling.

Also pray that the rain clouds would actually start depositing their oceans of blessings on this land. I’m ready for things to grow again.

Comatose.

Last Friday, a young man in his twenties was carried into the clinic by family and friends. He was in a coma and had been that way for 4 days before coming. They diagnosed him with cerebral malaria and started him on medication. No one knew for sure if he’d make it through the night, but he did. 

He stayed on a constant flow of IV fluids and quinine while his family watched him around the clock. Two days went by, but he didn’t wake up. Three days went by and still nothing.

He is the one being held up by friends.

But today he finally woke up! 

Eight days in a coma is quite the miracle for me, especially in these parts. What a tremendous blessing to watch him regain strength. Watching the family’s relief and excitement at his improvement was fun, and this evening they took him home -- weak but greatly improved.

Determined to help her live~

Two days ago, a young girl (perhaps 6 years old) was admitted with a history of seizures, aspiration and fevers due to a case of severe malaria. Dr. Tom, tired of watching these little ones die, treated her with all the meds at his disposal, but nothing seemed to stop her seizures. She continued to have them hourly despite regular doses of diazepam and Phenobarbital. It didn’t look good. You could see the worry etched across his face.

Each time a child dies in his care, it tears him to pieces. This time he was ready to give up sleep and comfort to make sure it didn’t happen again. He stayed up with her and her father all night, dosing her with medications and clearing the secretions from her mouth each time she seized. Apparently, that meant sleeping on her bed and waking every 45 minutes or so.

By 3 am, he started to see results; her seizures calmed a bit and her breathing improved. The next morning, he and her father were knackered but she was alive. Hallelujah! She continued to improve the following day but it was only this morning that she looked somewhat normal. She’s able to keep food down now and her malarial symptoms are greatly improved. Most importantly, her seizures are gone. Tom tells me she’ll be discharged this afternoon.

There is no doubt in my mind that this little girl is alive today because of his sleeplessness and concern. Thank God with me for this precious life saved. Thank God with me that me have people working here that care so much!

Witch doctor charlatanism!

The other day, a woman was carried into the clinic acting very strange and fighting her care takers. She foamed (literally) at the mouth and walked in stilted, jerky motions. It took her family a number of minutes to even get her in the door.

Such behavior is common for severe malarial patients and she was no exception. The doctors worked to get her the medicine she needed and monitored her all afternoon. As she recovered on our back porch -- Achem. I mean our in-patient room-- her family explained they first sought help from the local witch doctor.

Under his care, she didn’t improve even though he “removed” a shard of coal, a sliver of black wood and a dead beetle from her body. They even had proof. Untying her “sickness” from a plastic bag, her brother didn’t seem the least bit flustered as he showed us what they took out of her. Did he really believe that was what caused her malaria? I couldn’t tell.

The beetle, coal and wood.

When they told us how much it cost to get these things “removed” from her, I was simultaneously shocked and horrified. It cost them a weeks salary-- or 60 Sudanese pounds ($25). Charlatans!

My horror makes sense only when I explain that we charge our patients 2 pounds. The money they pay is just a one-time fee for a patient book.  All medicine and consultations are free. Knowing this, why go to the witch doctor first? I just can’t understand. I just can’t.

By that evening, she started acting normal again. And by the next morning, she was sitting up and brushing her teeth as I passed. Sane. She even smiled shyly in my direction. Not long after, we sent her home to the relief of her family. Healed.

I overheard Dennis (our clinical officer) encouraging them ‘to save their money next time and just come here.’ Her husband and brothers nodded in agreement, evidently pleased. I don’t want to speak ill of any of the witch doctors here. I don’t know any to speak ill of them. I just can’t help but wonder what they do when they get malaria....

Hopefully they take their own medicine and die!

Brother holding "sickness", sister behind him.

Birth #25

Nyankiir has been back and forth to the clinic for 5 days now. She first came on thursday with labor pains... that somehow stopped once she arrived. I checked her out but sent her home. Later that night she returned in a lot of pain. But she still wasn’t in labor. She had malaria.

When a pregnant woman gets malaria, often the fevers it causes induce contractions. This is dangerous in early pregnancy as it can cause prematurity and miscarriage. 

I treated her for malaria and kept her over night for observation -- mainly because the fetal heart tones were too high. (180's with a baseline at 168) I treated her with IV fluids and paracetamol and discharged her the next morning.

She returned this morning in official labor. Fortunately all her malaria symptoms were better but she still looked weak. She wasn’t here long before delivering a healthy baby boy! Praise God!

Please pray for her. She is doing well but is tired.

Bound by Superstition.

The woman, notice the cords she was bound with...

A woman was carried in to our clinic today -- fighting and struggling everyone she encountered. Her wrists were bound by her family, with a very strong cord. It wasn’t helping much.

It took four strong men to hold her down so we could inject her with a powerful sedative. But it was quick to take effect. Whouf! What was that about?

We tested her for malaria as she was having all the symptoms... the worst of which is severe abnormal behavior and violence. It was positive and we started her on the appropriate treatment.

But the family was angry. I went to find out why.

They watched us treat her through the window and were horrified that we injected her with something. (Let me stop to explain. In this culture, there is a large fear of being stabbed. I still don’t fully understand the fear but it’s very real to them. Some won’t let you give them immunizations or injections because of this fear.) So when the family saw that we did this heinous thing. They were enraged.

They complained that they didn’t want to bring her here. They were trying to take her to the Witch Doctor and got lost. They wanted to take her away.

Dennis went to talk with them. He explained that she was very sick and needed the medicine we had to offer. They could take her but she would not get better at the Witch Doctor. Would they be willing to stay? They said they would stay.

But as we gave her the IV drip with Quinine, they continued to cause a stir. One man kept screaming at us through the window. He happened to have a rifle -- as he was a military officer.

Dennis asked them to leave as guns are not permitted on the premises but they refused. Our guards stood there like confused little boys doing nothing. It’s at this point that Dennis told them that if they insisted on taking her, they could. But they had to leave --and leave now. They came and took her away.

She will most likely die without proper treatment. Her malaria is so severe and a Witch Doctor will do nothing for her. I shudder to think of the rituals he’ll do on her.

The superstitions bind her in sickness and death as much as her cords on her wrists.  Lord free them of this burden and curse. Show them the truth. Save Lord. Save now. Please... Save her.

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!

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?

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?

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.

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.

Yom’s story…

(Jessica Leong- short term missionary/Nurse)

Monday morning – bracing myself for a busy day. Many people wait until Monday to bring their sick family members even though they would qualify as an emergency case on Sunday. That was the case for 3-year-old Yom.

She lay limp and unresponsive in her mother’s arms as we rushed them to a consultation room. She felt hot and we immediately started with the usual treatment for malaria. IV fluids, anti-malaria meds, and Tylenol to bring down the fever. It was only after initiating this first round of treatment that I put my hand on her chest to feel her labored breathing. Something wasn’t right.

I could feel fluid in her lungs just by placing my hand on her side. Not a good sign. After then listening to her lungs, we started her on IV antibiotics to treat for pneumonia.

I must say, in the States we would have treated this girl very differently if she’d have come into an emergency room. She would have been intibated immediately and deep suction would have been performed (translation: tube placed in her trachea to help her breath and mucus suctioned from her airways) then moved to an intensive care unit.

But we are not in the States. We are in South Sudan. Nearest hospital – 3.5 hours away. The family wanted to drive her there, but we all knew she would not live.

In the meantime, it’s getting harder and harder for Yom to breath. Mucus and saliva are filling her mouth with each breath. How badly I wished at that moment that I could properly suction her. The best thing I could think of was a bulb syringe (the kind used to suction the mouth and nose of newborns). We tried it over and over, but the job wasn’t getting done.

Despite our best efforts, Yom went to be with Jesus just minutes after we laid hands on her and prayed for her. We had done all we could and even tried to resuscitate her.