Sunday, December 15, 2013

A funny, likely distorted sense of humor

Hats. People wear some funny ones, mostly passed down from a holiday. But they aren't wearing them for a holiday, they are actually wearing them for a hat. 
Thanks America for the costume!

I don't even know what caption to write. Go get em tiger.

Well, I thought this lady had on a hat, then I realized that it wasn't. 
Baby Santa. Thanks again America!
The old, distinguished man hats aren't like ours.
Santa Motorcycle Taxi. No extra charge. 

Okay, enough with the hats. Though they never cease to make me laugh. 

Next is hospital scenes.

Sometimes you just need a good soft place to rest. 

The taxi just at the hospital gate. Poor fellow in the trunk, as if it hasn't been a hard enough day. 

So, maybe you can't see this, but even though balancing a  huge mass of junk on the head and in the hand, she still has the skill to use her cell. And you thought you had talent. 

Never saw this in the sterilizing room in the US.

Wheres Waldo? I mean, where in the world is my scrub tech?

This isn't funny to me. It's a darn plague of flying insects - everywhere around the hospital.

And this is the kind of plague they like. Grasshoppers everywhere. They catch and eat. This is the storekeeper at the hospital showing me her bag of the ones she caught in the store. Including the ones that just came off of the toilet paper rolls that I bought. I told her she could have them. 

And then for road scenes.
These are a combo, the two are always found together. They know that nobody is going to pay attention to a silly "caution, sharp turn" or "low shoulder", so instead, they quantify how many people have died at this particular location. (Ici 10 morts=here 10 dead). I'll admit that this is dark humor, but I think these signs are funny cause they would never be culturally appropriate in the US. 

Sometimes you just know someone is a nice, warm person. Other times, they probably aren't. Bumper stickers state "Beware of BAD friends" and "SHUT UP, are you God?" x 2. Makes me want to beware of him.

And around the village
"Mbingo - Upper Old Peoples Club"
You are looking at the old peoples gardening spot just behind the sign, inside the "fence". I have no idea if there is actually a clubhouse.

And around town about an hour away

This gang of 4 or 5 police women are streetside high heel shoe shopping on their shift. Machine gun in tow on shoulder. I can't take authority seriously when they are buying stilletos. Really???

Monday, December 9, 2013

Health Care

Every 9 or 10 days I run out. Hand sanitizer is supposed to be provided by the hospital, so I go to get some more. For decades we have had evidence that clean hands by health providers saves lives, but most of the nurses and staff never clean their hands between patients. I must say this is probably partially due to the painful waste of time that acquisition of necessary cleaners can be. I stick my head in the pharmacy window, explaining that I need some more. “It is finished”, is the response. At first, I assume the obvious truth that such a statement means that there isn’t anymore. But during those extra few delayed moments, she adds a statement indicating that maybe there is more, but it isn’t in the pharmacy. So I ask, “where would it be?” The answer is “in the store”. The store is only 2 small cement buildings away, maybe 50 steps needed to get there. I can clearly see it from the window which I am looking in and from which she is looking out. However, in spite of the fact that multiple employees have come for a refill, no one has found it important to go see if there’s any in that building. So, I turn and head for it. There are three doors, I step in the only open one. “Is there any hand cleaner? The pharmacy says they are out.” “You’ll have to check next door”, is the response. I move toward the next door, but it is closed. I return to the other man stating that the door is closed, asking if I should go ahead in. He never looks toward me or acknowledges me, though he is aware that I am there and speaking to him. So, I leave and go back to the second door, push it open. I look over each of the shelves, seeing many items, but no hand cleaner. I return to the man, asking more loudly and in such a way to encourage a response, “do you know where it would be, I am not seeing it”. He finally looks at me and eases up from his seated position. He walks to the second door. Less than a second of glance inside the door brings a response, “I am sure, it must be finished”. I respond, “are you sure, or are you guessing?” He again says the same statement “I am sure, it must be finished”,  never looking within the room again, zero effort to try to find the item that I am seeking. I again respond, “Are you sure, or are you guessing?” Finally he realizes that I am not leaving until some effort is made to actually assess if the hand gel is there or not. He yells, in an obviously bothered tone, to a man walking on the sidewalk, “Is the hand gel finished?” The reply is that there is plenty. Within a few seconds, the new face is walking over carrying a whole box full of the gel. I take a whole large bottle, hoping to avoid this same scenario for at least a month. My tongue gently, yet untamed for the moment again speaks as I turn to the first man, “So, are you sure, or just guessing?”

It’s a foolish example intentionally. There are other examples within every area which are not so foolish and have direct patient effects. Stat labs still unresulted after 12 hours, no staff has checked on them but they are “not back”. Necessary medications were not given, arguments blame nursing staff, no pharmacy, no nursing staff again. None of it is charted, so who could know? Medical records “have not been found”, but it turns out they were never looked for. The patient was admitted, but no one looked at her all night, so they never noticed the complication or notified a doctor. No area that affects medical care is exempt. It is sort of depressing.

But I was riding down the road the other day and saw something interesting. The previously battered road was being repaved. Now, the typical way for road repair is to have some dusty man in torn pants, and an oversized, dirty shirt filling in the hole with dirt or gravel. As the drivers pass by the area where he has obviously been working and sweating during that day, they may give him a coin as his pay. But, this particular road repair was a world apart from that. It was the developed world apart. A French company had been hired to repair a large section of road. The employees working were all Cameroonian. The sight was not anything like a normal process in Africa though. Traffic was stopped in an orderly manner, giving me a good time to watch. Dumptruck after dumptruck of gravel came and went in an orderly fashion. As they dumped the rocks, immediately they were leveled out by the workers on the ground. No one was standing around, there were no extra people. On the other side of the road, an orderly system for grading the land was occurring. The whole process was like watching the inside of a watch – all of the parts were working together to make the clock tick. I had never seen anything so systematic and successful in my travels in West Africa. I wondered, how did they make this work so well? The existing systems did not support such effort, response, or effect. But what had been brought in as the standard within this company was working. The workers wanted work. If they didn’t want to do it within the standard put forth, there were hundreds more standing behind them who would be glad to. Hmm.

It made me wonder. Health care is certainly different. It requires more training and skill than basic manual labor. Developing a good system could not just be “dropped in”. However, how can one make a system that actually is effective within this setting. Is there a way to change the present system? Each missionary doctor comes with that expectation, that some part of the system will be improved as we pour our lives into it. But every one of us would say that the change we have made is much less than we had hoped. I am not foolish enough to believe that there is a place on earth where all frustrations cease and all problems are solved. But I must continue to believe that there is a better way, a more supportive system, for such change. I long to learn more about such a method. I want to see, is there a way to pour out a life where more is left when we finish than just our sweat which has dried invisibly into the ground we have toiled? I believe that whatever work we do should be done well, and that in doing so is a part of how God is glorified through His people. That we should implement systems that are sustainable within our communities and areas of influence. And that the people we serve with should be trained and empowered to carry on after we are gone. But all of that takes a better system than I have seen. Practically I don’t know how to do it. Yet, there is something inside me, determined and stubborn, that refuses to settle for less. I don’t want to see my patients unnecessarily at risk for generation after generation. I want to see life-change, and system-change, and method-change. Ultimately I want the health care that I provide to glorify God both in the present, and long after I’m gone. And that requires some plan for better care of patients and communities.

On the other side of the world, in the land that I would proudly call my home, there is a whole different battle for health care. One of which, as a doctor, I admit that I still do not understand well. It is also true, that I do not have some magic answer that would straighten out the whole, messy system. My world is much simpler, the baseline needs are much greater, and the resources to meet those needs are much less. Of all of the problems that the US has, the developing world has piles more. And there are fewer people committed to solving them. One isn’t more important than the other – I want my family cared for well there, just as I want someone else’s family cared for well here. We all certainly need wisdom in these times. Better systems are needed all over the world. How do we keep the patient a priority, while building an effective system to serve them? It turns out I am not the only one who doesn’t know. A whole army of healthcare thinkers can’t figure it out. There is no easy, obvious answer. May God grant us wisdom as we attempt to care for the people around us. We certainly need it.

Thursday, December 5, 2013

The small physician degraded, the Great Physician at work

I was called after liters of blood were already on the floor. Besides a dead baby being delivered and now lying in the baby warmer, now another complication with massive blood loss. I went through all the possibilities of how to treat her, and none slowed the bleeding. The only option left was to go to the operating room. It was a quick surgery without complications. Unfortunately, her uterus had to be removed in order to save her life. I thought that we were out of the woods. I was a little bit proud of myself, that now these complications don’t really get me too excited, not like when I first came out to work here. I’ve had an awful lot of “opportunities” and experiences of big cases for this one to get me flushed.

I went home for lunch. I hate to miss a meal. Just as I finished my soup the call came. Her incision was bleeding heavily. A moment later the phone rang again, now she was bleeding profusely from the vagina too. I knew it wasn’t a surgical issue, all the areas had been repaired well and were not having any bleeding issues only a short time before. I also was aware that such bleeding is much worse than something that can be stopped by surgery. See, sometimes when someone bleeds excessively, they run out of the particles in their blood that actually make the blood clot (yes, DIC for you medical folks). I knew that this was the case with her. Some blood had already been given, but she needed something more. She needed fresh blood to get her the substances that would make the bleeding stop. Really fresh blood. I asked the type, and of course mine would do.

So, off I went to the lab. I sat upright and squeezed my arm, watching the life-blood drain out of my arm. Finally the bag was filled. I knew that if I didn’t take it directly to her that delivery would be much slower. And I knew that every minute counted,  she really needed it immediately. I thought I could do it. I grabbed the blood and walked toward the ward.

The surgery ward lies uphill from the other walkways. In order to get up to it, there’s a sidewalk with a grade. Usually it’s no big deal. But there are times, like when you are emergently pushing a patient, that you realize it definitely has an incline. When you’re pushing that stretcher, you can feel the back of the thighs and butt really having to work to get up the hill. Well, that day, there was no stretcher, and no pushing. But by the time I reached the top I knew that something bad was about to happen. That incline got me. I hadn’t had anything to drink all day. And my body screamed at me that it wasn’t going to take dehydration, followed by the blood loss in the lab, followed by a brisk walk. It was over. Things started spinning and flashing. I saw one of the anesthesia students who is a friend walking by. I reached out a hand with the blood and said “take it to the ward”. Then I sat down, put my head between my knees, and tried to recover. At this point my autonomic nervous system decided to continue the craziness – was it passing out that was coming? No, vomiting…wait, diarrhea… one wave of possibilities followed the next. Even in my current status of degradation and confusion, I could imagine things getting worse and more de-humanizing. I hoped it would just be vomiting. One of the staff saw me and came by to see if I was okay. I could only say, “Get Doctor Keith”. He is the anesthesiologist, and a friend of mine, who I knew was there because he was also watching my bleeding patient. I never lifted my head, just said, “take me home”. He came and shuffled me into a wheelchair. I looked like I was dead. Normally I am one of the palest ones at the hospital (ha ha, like my joke?), but today was especially pale. As well, I was doubled over with my head between my knees, slumped in the wheelchair. Anytime I lifted my head things would start spinning again.

Being a doctor-patient with all the hospital watching was embarrassing. On and on we went, over speed bumps and gravel. I could hear people talking, but couldn’t see anyone with my head tucked down. Even without vision, I could feel them all watching me. Keith kept saying “She’s fine, I’ve just gotta get her home”. Finally I saw the grass passing beneath the wheelchair, and I knew that we were almost there. I heard Anna’s voice from inside the house. (She is one of my best friends here and works at my house one day a week, helping to prepare stuff to cook cause everything is really from scratch – like grind your own corn kind of scratch). I could tell she was a bit scared. I told her I was okay as I wobbled to the bedroom. Within four minutes, I could hear voices in my house. My initial thought was, “Why are their voices in my house? Intruders, and I am not even able to fend them off!” Then heads peaked around my bedroom door frame, and I saw that it was the clinic and maternity staff. They had let themselves in so they could catch any action. When they realized it was just me laying in the bed, unable to get up, they lost interest, said they hoped I felt better, and went back to the hospital. Forty-five minutes later after a good bit of water and a coke, I was pretty much back to normal. I headed to the hospital to check on the patient.

She stopped bleeding when my blood got into her. I’d like to say it was cause my blood was exceptional, however, it was really just God’s grace. She was even starting to make a little urine, which is a great sign that someone is having enough blood in their vascular system. I was cautiously delighted, at least she didn’t look like she was walking straight for death’s door anymore. She had turned the first corner.

I got the call at dinner that her condition was again deteriorating. The hope from earlier quickly began to dissipate. Now she was vomiting blood, and her belly was distending out. When I saw her, I knew that her condition was not just deterioration, she was standing at death’s door again. And this time there wasn’t really anything more I could do. All over the world, her condition would have a high mortality rate. Anywhere in the world, the doctors would have done the same thing and would be hoping that somehow she would turn around. But hope was dwindling. I talked with the family, letting them know that there was nothing that I could do to intervene. I told them that we would watch her, but that likely she would not make it. They understood. I left her there to die.

I thought of her each time I awakened in the night. Finally in the five o’clock hour I woke and reached for the phone. I wanted to see what time she had died. I asked about her, and they said that she had not died - she was still alive! I hung up the phone, praised the Lord, and jumped out of bed to do a little dance. It was no attractive, choreographed dance, but a soul thrilled, wild expression of delight. I was like a little kid jumping around. It was so exciting to hear, so beyond medical expectation, I couldn’t help it. The doctor turned into a four year old jumping and spinning around, giggling laughter and praise. Death was grabbing hold of her by big handfuls, in such a way that no medical intervention could help, and yet now ALIVE!!! I got it under control a bit, dressed and went to see her. From a beyond-treatment, miracle-hoping condition, to talking to me and asking if she could eat. I was so thrilled but cautious – I laughed and like an overbearing mother, then cautioned her - “no eating, no drinking, no moving, no nothing, just lie there and breathe”.

And she did. She kept breathing, and kept doing better and better and better. Day after day she improved. I did eventually even allow her to move and perform all other bodily functions. And then this afternoon I wrote on her chart, “D/C home”. I stepped over to the bed to tell her goodbye. Tapping her leg, I gently woke her up. I gave her the general instructions to call if there was fever or pus or worsening pain. And then I gave her a little glimpse from within my eyes. I told her that she had gotten so sick that I knew that there was nothing that I could do. Walking away from her was the first time that I just left a person in their bed to die. She had been beyond our medical capabilities. We gave her all we had, yet it was not enough. But God had been gracious, and had amazingly restored her health and life. She was the closest thing I’ve seen here to a medical miracle. Like God was just showing off His Great Physician skills. They were indeed great, beyond my capabilities and my mental grasp of possibilities. I am so thankful to watch Him move. I revel to know that He is indeed the one who controls all things, and that sometimes, beyond reason or expectation, He just chooses to save. Bless His name.