Healing to Thy Bones.

Foul pus leaked from the open wounds on her legs, attracting a steady stream of flies and gnats. The stench permeated her clothes as the once white fabric lay stiff with dirt and pus. The acrid taste of death clung to her skin, filling the room with rot.

Osteomyelitis.

The decaying fetor of infection had been her cloak for 14 years, rotting her from the inside out.

Her knees, knobby and swollen, sat awkwardly atop her skin-coated shins; they mesmerized me. I tried to follow the emaciated thighs to their source, but they ended abruptly in the billows of her grey, stained skirt.

No doubt self-conscious of her legs’ effect on those in the room, she hesitantly tucked them beneath her fragile frame and expertly withdrew behind the folds of her cloak.

As she did so, her lanky limps secreted to their hiding place and she morphed into a child. Though easily in her late 20s, she looked no more than pubescent girl.

But her eyes gave her away.

Dulled by pain and constant rejection they reflected nothing. Absolutely nothing. Hope and joy were long gone. Peace and love were strangers.

She described the pain of walking with the insipid monotony of familiarity. She could only go a few yards before the ache forced her to the ground for rest.

How she found the will to breathe baffles me.
... but life is not easily quitted. One cannot will their lungs to cease or their heart to stop.

Yet life takes on dimensions altogether unexplored when pain sets in. These dimensions seemed banal to her --common and vulgar.

She didn’t plead or beg. In fact, she asked for nothing.

Instead she presented a letter from the government hospital requesting we transport her to Wau as they could do nothing more for her.

She just sat on Dr. Tom’s bed and waited for him to read the letter. The letter just spurred more questions.
-- What hope did she have of getting medicine in Wau if she couldn’t get it in the Tonj hospital?
-- Why were they sending her there when she had no money and no family to help?
-- How could they unload her on us... again!?

Yes, again.

A few months back she spent two weeks curled in a ball on our back porch or shuffled from bed to bed in our observation room while we treated her with every drug we had. Eventually, we realized we could not keep her for the months of IV meds that she needed and arranged for her to get the help in the government hospital.

And now... to have her returned to us with a note pinned to her shirt like an orphaned child. Rejected once again from yet another hospital....

“Is there really nothing we can do?” I asked Tom.
“She needs months of IV antibiotics or possibly both legs amputated,” he vented, “How can we do that here?”
I just nodded and listened, my stomach reeling from the stench of her situation.
“But the letter is asking for her to be taken to Wau, not for us to treat her,” he reminded me. “But what is Wau going to do for her. If we take her there... who will care for her?” he asked.

Nothing. No one. I thought to myself.

I didn’t have to say the words out loud for them to be any truer.
        -- Lord?

Although I understand his words and recognize our limitations, I’m heartbroken that we must send her away. I’m distraught that we can do nothing to relieve her pain or social ostracism.

But as I prayed, God reminded me of Proverbs 3:5-8

“Trust in the LORD with all thine heart; and lean not unto thine own understanding. In all thy ways acknowledge him, and he shall direct thy paths. Be not wise in thine own eyes: fear the LORD, and depart from evil. It shall be health to thy navel, and marrow to thy bones.”

Lord, may her trust be in You. By Your grace and love, heal her bones! Amen.

Please pray with me. Fourteen years is long enough! 

A Puzzle.

Athong on her first prenatal.

This week brought many new and strange cases to my door. Cases ranging from possible placental abruptio, to ectopic pregnancy, to placenta previa. None of which, could I properly diagnose (no ultrasound machine), so I quickly referred them to Wau.

Why my brain goes to all these worst-case scenarios eludes me. I must be tired. Perhaps, they were just having normal bleeding.... but when is bleeding and sharp pain ever normal in pregnancy? My point.

Plus, I had to tell, not one but three women, that their babies had died in utero. Definitely low points this week. 

But of all the women, who lay on my prenatal bed, one stands out. Her name is Athong.

(For the midwifery minded out there, she is a G6 P3 L0 A2. Not good.)

Her first baby died during delivery after a 3 hour shoulder dystocia. (Yes. Read that again. 3 hours.) Her second baby was born prematurely (at 6 months), and died a few hours after the birth. Her third baby also died within hours of his premature birth (also at 6 months). The fourth baby miscarried at 3 months. The fifth miscarried at 2 months.

She was now on my bed telling me she was 5 months pregnant... or maybe less. There was no baby bump and no fetal heart tones, so I ordered a pregnancy test. Honestly, I was leaning toward her NOT even being pregnant.

When it came back positive, I got hopeful.

What her history screamed to me was an incompetent cervix due to her traumatic first delivery. But that would only explain the two premature births, not the two miscarriages. Sigh.

Differential diagnosis made me think syphilis or some other kind of STD; but perhaps she had a Rh-negative blood type and became sensitized somehow. Wouldn’t that explain her history better?

She was a puzzle-- a sad puzzle where each piece brought tears and dashed hopes.

Fortunately, our lab can test for blood typing and syphilis, so I sent her for an evaluation. Her blood was Rh-positive and she didn’t have syphilis. (Both results pointed toward incompetent cervix.)

I asked if I could do a speculum exam to see if her cervix had any noticeable tearing or scarring. She agreed happily, saying, “Whatever you need! I will live here at the clinic if you tell me to, so long as this baby lives!” We laughed jovially. There was hope in her voice.

During the exam, I didn’t see any tears, but I did see extensive signs of STDs, which explained the last two miscarriages.

What that means is, if she is really 3 months pregnant now, then there’s time to do a cervical cerclage to help her maintain this pregnancy. Whoohooo!

(For those who don’t know, cerclage is when you sow the cervix closed to reinforce the pregnancy, until it’s term. The sutures are removed in the third trimester, so labor can progress naturally.)

I don’t know how to do this procedure, but I’m told Dr. Tom does. All we have to do is treat her STDs, make sure the pregnancy is viable, stitch her closed, then watch her like a hawk.

When I explained this possibility to her, she jokingly promised: “If you help me have this baby, and it’s a girl, I will name her Akuac! And if it’s a boy, I’ll still name him Akuac!”

We laughed heartily at the idea of a boy walking around named after a female cow, but I’m pretty sure she’s serious. Ha!

I warned her that I was not guaranteeing her anything. I was only promising to do everything possible to help, and pray like mad!

Will you join me? 

May this baby be the one that lives!

Tuberculosis of the Spine.

Last summer, I went to ask Dennis a question while he was treating a young girl. At first sight of her, I forgot my question momentarily and just stared. It was rude, I’m sure, but I’d never seen anything like her.

She was very sick, and she knew it.

Enlarged lymph nodes on her neck restricted her breathing, and large nob protruded from her back at a right angle, causing her to bend unnaturally forward. Plus, she was emaciated; a shell of skin with no substance.

Thin, weak and hunched over, she looked more like a wheezing hermit crab than a little girl.

Equally curious and horrified, I asked what was wrong with her. Dennis showed me her back and neck while explaining she had tuberculosis of the spine.

Fortunately, a Catholic charity in town runs a clinic that tests for HIV and tuberculosis. Dennis referred her to them for treatment.

Over these last few months, I’ve thought and prayed for her often. She was too small to be so sick. The image of her face and hump wouldn’t leave me alone. So, when she came in this week for some minor aches and pains, I was overjoyed!

I didn’t recognize her at first; her mother had to point out the nob on her back and I had to review her book before I connected the waif of last year as the girl before me.

She was vibrant and healthy, even dancing to music while waiting in line. I couldn’t believe how drastically she had changed!

Sure, the hunch is still there (I’m told her back will never grow normally again), but the vacant stare of death is gone. She smiled so sweetly during her examination, moving her neck with ease as I examined her lymph nodes (which are still enlarged but improved). I loved it.

Just thought you would all like to know her story. Pray for her as the Lord leads. Thanks.

Updates on a few stories.

For those of you who've been following along in these adventures for some time, I have a number of updates to share with you.

Yar: The young girl with the bone sticking out of her arm, in need of surgery (read her story here), has had a 'break through' of sorts. We have been dressing her arm for weeks, trying to keep infection from setting in while we look into flights and raise funds for her surgery. Last week, a piece of gauze got stuck on the bone. While trying to remove it, the bone came out as well! Now all she has is a wound that is healing nicely. She can move her arm without much pain. There are still limitations, and we still need to get an x-ray, but it's looking up. Woohoo!

Achok: The woman with the outrageously engorged breast (read her story here) came in for another prenatal today. She is open to having surgery on it if we are able to help her. I'm told there is a surgeon coming in a few months for a short-term trip and/or she might be taken to Kenya. All this is a bit speculative but I remain hopeful. Pray for her. Twelve years is a long time to wait for relief.

Veronica: The young girl I prayed for last year after finding out she was pregnant out of wedlock at 15 years old (read her story here), returned for a prenatal today. We were just finishing up, when it occurred to me that she was the brokenhearted little thing, weeping her eyes out just a few months back, but I wasn't sure. So, I asked her and she smiled sheepishly, apparently happy to be remembered. Relieved to see her again, I asked her for an update: Was her brother understanding? Did she have to drop out of school? Was the father of the child honorable? She explained that she was able to stay in school (at least this year), her brother didn't beat her and the father of the child is helping support her. She looks great. Praise God!

Broken and beautiful.

Last week during one of the basketball outreaches, a young girl came out to play. She is beautiful and has a smile that takes you by storm. My best guess would be she’s about 8 years old. She’s more fair skinned than some of the other girls in town and I was told her mother was of Arabic descent.

When they realized that Sabet (from Sabet’s Clinic -as the IDAT clinic is referred to by the locals) was there, they brought this girl to him. She lifted up her sleeve to show a bone sticking out of her shoulder -- pus filled and exposed.

They explained that two years ago she fell from a tree. The bone broke and came through. They couldn’t afford to fix it, so they did nothing. She lived and it started to heal a bit. And slowly, she regained some use of her arm.

He told her to come to the clinic the next day for a dressing. She came. And every other day, she returns. We cannot reset it without x-rays and are looking into taking her to Kenya to be treated. In the meantime, we see her regularly.

Yesterday, I saw her napkin keeping her place on the bench. It was so dainty and fun, I had to take a picture. She is all girl... needlework and nail polish!

12 years... ?

A woman came in today for a prenatal. She is 4 months into her 7th pregnancy and is almost (if not well into) her forties. The Sudanese sun hasn’t been kind.

She has a disarmingly sweet smile but it’s not the first thing you notice about her. 

When I was checking her in, I noticed a large growth on her side. It was well hidden by her wrap, so I couldn’t tell what it was exactly. But one thing I knew for sure, it was big.

Due to her age, I thought she’d be menopausal with some kind of abdominal growth. I was wrong -- twice.

Her growth was actually her right breast. It was roughly the size of a small cantaloupe melon with a 40 cm diameter. When I asked her how long she’d had it, she explained that it’d been that way for 12 years.

Apparently, after one of her babies her breast got very engorged. It increased to the size it is today within a few days. And at the time it was very painful. Ever since, she has been unable to breastfeed from it and after each pregnancy, it leaks “pus”.

When she walks it dangles mid-thigh and only hurts her chest due to its weight. She explained that she sometimes wraps it up over her left shoulder but it just gets too hot. She prefers to let it dangle to her side.

It’s symmetrical and non-fluctuant, even a bit fibrous. I’ve never seen anything like it outside of obscure medical books.

I asked her if she has ever seen a doctor about it. She explained that three years ago she went to Wau for a check-up but they said they (too) had never seen anything like it and couldn’t do anything for her.

I encouraged her to go back and get another opinion. I know of doctors (in the Philippines) doing full mastectomies in the jungle, why couldn’t they do something about her right breast in Sudan?

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.