Reviewing the Week

                I made a difference a time or two this week. Felt like a few things went right. Even in one difficult surgery where there was a complication, my initial response was the thought to call someone to help, to stand beside me, to make me feel more secure. But then after the uncertainty of the first few moments, I found myself overcome by the understanding and skill that are what is supposed to be the outcome of all the training I have had. I knew how to fix it, knew what I should do. In the states, you would have called someone, if only so that you could cover your own liability. But not here. You just put into practice the theory you once learned and fix what’s broken. It’s satisfying.

                But there are still a thousand things that I didn’t learn, or never really got secure in. Sometimes, as a new practitioner, I will get confused as to where to go during a case. And it makes it worse, because I am working with general surgery residents who I am supposed to be teaching. I want to give a clear, replicable method, but often I don’t yet have a certain way that I am in the habit of doing things. As well, since general surgery is a five year program, some of these guys have had more training than I have. And that training is on exactly the type of complicated, weird cases that they have here, not tame, benign cases. So, all of it adds up to make me a bit insecure in my skills sometimes, especially as I am trying to explain to someone why I am doing something a certain way. It can lead to frustration on my part. But in time, I will continue to learn both how to use my skills more effectively as well as how to teach others along the way.

                Other frustrations abound as well. I work with the nursing staff, and it draws my mind to compare them to “my” nursing staff from before. I really loved working with them. They made my days brighter, even the bad ones. If you’ve gotta be at the hospital 80 or so hours a week, you want to be with them. What other nurses in the wee hours of the morning when we were all weary, would let me lay my head in their lap and play with my hair or rub my back. Most of you who read this and work in healthcare might think, “um, that doesn’t happen on my unit”. Well, you’re right, it doesn’t. That’s because my unit was the best. Even recently, with the loss of one of my nurses, I have wished I could be there. Wished I could love them from closer. But that’s not where I am.

Anytime you start working with new staff it can be difficult. There is no trust on either side. Sometimes it feels like I am being undermined or manipulated. Sometimes I think they call me in the night to ask a silly question just for kicks. They must know I often can’t fall back to sleep and are just doing it for meanness. Of course I know that isn’t true, but in the night while I am lying there during what seems like eternity wishing I could fall asleep, it seems like it could be.

This week we had a poor outcome with a maternity case. The nurse said as soon as she presented with a possible abnormality noted at the ultrasound department that we should just go back for a cesarean section. He said that would be the only way we could feel like we were helping her. But as a doctor, I don’t usually treat our feelings. I make medical decisions based on facts. I didn’t think taking a 29 week baby out without being pretty darn sure what the indication was would be right. I mean, the likelihood that it would die from prematurity if I did an emergency cesarean section was almost 100% here. I wasn’t sure. So I said no, I needed to confirm what was going on first. Well, it’s hard to see if a baby is in trouble or not with no devices for monitoring. The monitoring strip hasn’t worked since long before I got here. Neither has the ultrasound on maternity. I am not very good with that funky fetoscope from the old days, and couldn’t get a heartbeat on the baby. Thought it may just be me. So I said to go bring an ultrasound from the ultrasound room which is waaaay on the other side of the hospital. It came, and by that time the baby was dead. So then that led me to multiple other hard decisions as to how to deliver the baby. I felt that nurse looking at me, condemning my decision to wait initially for the operation. I could almost hear him saying, “that death isn’t on my hands, it’s on hers”.  But the decisions are so complex, and the resources with which to make them so much more limited. Maybe that nurse was right, I don’t know. But ultimately we can’t save everyone. The best of my decisions will sometimes still end up with a poor outcome. And whether it’s because of my decision or not, I need grace from others, and help from them too. We all do. I want to learn to love the staff around me and work with them for the good of our patients and ultimately that God may be glorified through us as we image Him while we provide care.

So, to those who read this who pray for me based on the stories I tell, please pray for relationships with those I work alongside here will be fruitful. Not just workable and manageable for getting through the day, but really good. I need discernment to know what is worth fighting for and what should just be let go. And please pray that I will continue to grow in my skill and abilities. And to put some feet onto that one, if you know of anyone who could come teach me more advanced gynecologic surgery skills, ask them if they would be willing to come for a trip. It is a great place to make a difference by coming to help. But better and more importantly, a place where skills taught can be replicated as we use them and teach them to the surgeons in training who will go from here to provide care all around West Africa. 

The Workweek in Stories

The worst moment...
I found myself kneeling on the floor sobbing. The patient didn't start off as mine, though I had met her as well as her sweet mother the day before. The mother grabbed my hands that day and kept saying stuff like, "she is in your hands doctor", and "we trust you doctor". I didn't know them, and they weren't in my hands. I didn't even do her surgery. I wasn't really invested in her. Until I came by just to do a quick check and realized that she had a major post-operative complication. I was so frustrated by the fact that it could have probably been prevented, should have been caught at a much earlier time. If the ultrasound department would have been open, they could have helped me make the diagnosis, or if the ultrasound on labor and delivery would have turned on at least I could have confirmed it. But none of those things happened. So I made the clinical decision to take her back to surgery. Reopening her confirmed my suspicion, except it was worse than I had ever seen. Someone asked, "what should we do?" I pretended that I wasn't scared and just said that I didn't know. I felt so helpless. If I weren't scrubbed in I would have gotten a book and started reading, or found a computer and hit google, up to date, something, anything to find an answer as to what to do. Finally, we closed the wounded exterior of her abdomen back together and decided to just wait. I wondered all day if she was still bleeding in there, hidden inside that maternal frame. I thought of how young she was. Thought about her mother holding the new grandchild in her arms while she wondered what would happen to her own daughter. So finally I made it home in the evening and found myself weeping before the Lord, begging Him to heal her. She needed a better Physician than me. I found myself in a place where we never like to go, to a place where we are helpless. But for those who serve the Father, it is not a place of true despair, but where desperation and hope meet. It is there where God often shows Himself  and makes Himself known. The place at the end of ourselves, where we lay down the burden that was too heavy for us. Where we realize that we can bring our worries and needs and cares to place them in the hands of our Father.

The most humiliating moment...
Frustrating moment after frustrating moment. Having to leave my patients waiting while I walked all over the hospital grounds looking for someone to answer my questions time after time. I had held my tongue so well and hidden my frustrations all day long. And then here came another. I had already had to send a couple people back to ultrasound that day. And then another mistake. Could they not understand that I needed clarity with this patient. I am deciding whether to deliver her based on their ultrasound measurements.  If I use one of the numbers versus the other, it leaves me over a month off. That means the difference as to whether the baby can breathe or not. So up the walkway I came again. I wasn't yelling, but making it very clear that this was important and that I needed an answer. Their numbers weren't working out. I explained it over and over again. Brought out my little round wheel that calculates a baby's age. Over and over showed the man how he wasn't making any sense. And then he brought it to my attention that I was looking at a month advanced of the actual date. That would account for being just over 4 weeks off of the date they were calculating for me. I wish there would have been some way for me to keep my pride, you know, brush it off as if I knew that all along. But there wasn't. The best thing to do was just to stop. So I looked him in the eye and touched his shoulder. "You are a very smart man. And I am a very dumb doctor. You are totally right. And I am acting like an idiot." They were all gonna say it once I left anyways, so I thought it best just to get it out in the open.

The moments that are starting to feel more normal...
I just killed another massive termite as I was about to write this sentence. Not like our termites. Flying huge winged insects. Killed it with my bare hand. Before I was using a shoe. But then last night things got out of control. I don't know what specific natural oddity occurred, but they were everywhere. All I can compare it to is the plagues in Egypt. I became a bug killing machine. Its like I was trained as a marine or something. They were assaulting my house, and I defended it well. I still have them all scattered around on the floor from where I won that battle. I found something here that I am really good at.
Another thing that I thought I was getting good at was my breathing regimen. See, to get to my clinic room you have to walk the path beside the toilets. I can be a bit slow at times, so it took me a couple days to notice where in the world that smell was coming from. But then I started practicing. Big deep breath about 20 feet away as approaching...hold it...hold it...hold it...walk faster...don't pass out...ahhh, big breath again. I thought I had it. But then today I got it wrong every single time. Turns out breathing appropriately is really hard to learn.
The rain comes every day. I thought the sun didn't come, but turns out I am just working when it is out. By evening when I am off, it's raining again. But it isn't tricking me anymore. I've got my umbrella in my pocket. Got my purple rain boots at the door. Rain jacket and waterproof headlamp standing ready. And instead of finding it dreary, I find great pleasure in walking through puddles in my boots. Children know well the inexpressible delight, but somewhere along the way we adults lost the joy of it. But I have gotten that joy back. I smile a goofy grin as I plod through the deepest parts.

The Things We See As We Walk Through

Began in the morning with a chapel service. The nurses from the labor ward were leading the worship time, so I made sure I was there to participate. Maybe it was because I knew the people up there singing, or maybe it was that I heard them practicing the day before, but it was easier to enjoy corporate worship than it has been anytime thus far here. I loved to watch them dance, and part of me wanted to stand and move so my whole body could worship too. However, the guy beside me was sitting very close to me on part of my white coat and didn't look like he wanted to be there and certainly didn't want to move a bit. So, I just worshiped from my seat. But I swung my arms a little extra hoping to knock that guy beside me into worship mode too. 

Rounds went fine afterward, getting to see the patients who I had begun to enjoy getting to know  over the past days. Then I walked around to take some pictures. People always want to know what it's like. So, for my L&D and high risk nurses at home I took a few.. . 

 The delivery room

The baby warmer

The postpartum ward

Then I saw walked by some offices and snapped a couple photos for the nurse managers and administrators, I thought maybe they'd be able to use the idea and make some up for the hospital there in Greenville...

Then away from the hospital I went, up into the hills. Not all that far, but far enough to be different and somewhat exciting. We chose the road less traveled on the way up. And when I say road, I don't mean it. Wasn't even really a path. Eight foot high elephant grass all over and just pushing our way through. Until we met up with the dirt road, the road more traveled, but no less beautiful. And to the river that cuts its way over the green slopes to crash over the edge, creating a massive waterfall. It wasn't an extremely long hike, didn't take us too far away really. But it gave time for the mind and soul to find refreshment. 

I've grossed my sister out for years when I mention the names of basic organs within my field of practice. It has always seemed funny to talk about a "hoo-hoo" or "wee-wee" when I am a doctor. During residency I have used "boo-boo" slang many times when my more ghetto-saavy patients didn't know what I meant by bowel movement. That stopped when I found "poop" to be a universally understood term in the english language. It seemed more honorable than the other. I thought I had heard them all...

But that was before I came to Mbingo. Here, as the gynecologist, I am constantly asking questions about "de woman-skin". And I giggle a little inside each time I use a crude term for urinating (the p--s word) or defecating (the s one), but I'm just using the words they understand. It's not distasteful at all to them, in fact, they don't understand it said any other way. And it gives me a funny laugh in my heart as I ask about the different things they are passing. Now, blogging as a missionary doctor I can't bear to put them on the paper in full, it feels like some sort of turn against pure speech. But not when I'm talking to my patients, then it is their norm.

The odd changes are more than mere words. Today two men came to my clinic. The first sat down and I immediately said, "I think there is a problem. I am a gynecologist, and you are a man." He wanted some STD testing. I looked at the swab I should use. Then I looked back at him. It's not that I don't know where it should go, I mean the options are sort of limited. Yet, I haven't had anything to do with "de man-skin" since required to in medical school. Maybe I've gotten immature as I've gotten older, but I thought I might bust out laughing during the practicalities of getting that testing completed. I mean, I don't remember how far the q-tip has to go up there. And then, he gave me a way out. He described some additional pain in the upper abdomen. I told him that the internal medicine doctor down the way was very good at taking care of the upper abdomen, and all that I knew was the low pelvis. And then I wrote on his medical book "see internal medicine doctor for probable gastritis. and please do a chlamydia and gonorrhea swab to evaluate for STDs." Done. One down. I don't remember what the other one wanted, but it was probably gastritis too. :) I'm not sure how they got triaged to me in the first place.

There are some funny things that are new and different. But there are also a thousand things that aren't funny. They are frustrating and stressful. A new environment is always a bit trying. But then feeling like I don't know my place and responsibilities and function between the OR, the obstetric ward, the gynecology clinic. Big masses that I don't know what to do with, infertility that you will keep coming to me for even though I have nothing more to offer, questions about chemotherapy regimens for weird cancer scenarios. And the never ending line of patients. I mean never ending. In the morning, they are there waiting when I finish my obstetric rounds. And their eyes look at me as I walk by to go by the house to grab something to eat, wondering why they are waiting and I still find the need for food. And then some of those same stares again in the evening as I walk past, having had to shut the door and turn people away. They've waited all day just for me to walk by. But I have to walk away sometime. I can't have a 24 hour ob/gyn clinic with just me. None the less, it feels like I am letting them down and turning away from their need. I am trying to imagine ideas to improve the system, but I don't even know where to start. I've gotta make appropriate boundaries, but knowing what that looks like practically isn't in some manual they give you before you step on the plane.

But in the midst of all of that stress that can leave me burdened, sometimes I see the funny things around me and laugh. Sometimes in the midst of rainy season, the sun comes out from behind the clouds and makes me lift my eyes to the beautiful green, rolling hills surrounding me. Sometimes in the middle of what feels like floundering in ignorance I will have a grand thought that will actually change someones life for the better. There are really a thousand "sometimes" to be thankful for. But all the times, the best and worst, happy and sad, broken or triumphant, I can rest in the One who holds it all together.

Colossians 1:17

 Home Sweet Home :)

 Cloudy mountain view 

View from hospital

This morning, after I had greeted God and gotten ready for the day, I found myself waiting for the guys that would be giving me the 7 hour car ride up to the hospital. I kept waiting. And consoled my timely self that African timing (without regard to the actual hour) was a normal variant. So, I read a bit of Piper to take my mind off of focusing on how here and now was supposed to be somewhere else and now. I really enjoyed a prayer he wrote at the end of one of his chapters, so I will share it with you. It is from the book Seeing and Savoring Jesus Christ.

O Lord, the suffering in the world is so widespread and the pain is so great! Have mercy, and waken the souls of suffering millions to the hope of some relief now and unsurpassed joy in the age to come. Send your church, O God, with relief and with the word of the Gospel that there is forgiveness of sins through faith in Christ and that no suffering here is worth comparing to the glory that will be revealed to the children of God. Protect your church, Father, from callous thoughts about calamities that leave millions destitute, and protect her also from cowing to critics, like Job's wife, who cannot trust the wisdom and power and goodness of Christ in the midst of inexplicable misery. Oh, help our unbelief. Incline our hearts to your Word and to its assurances that you "work all things according to the counsel of your will" and that "no purpose of yours can be thwarted" and that you are doing good and acting wisely in ways that we cannot now even dream. Keep us in peace, O Lord, and forbid that we murmur and complain. Grant us humble and submissive hearts under your mighty hand. Teach us to wait and watch for your final and holy purposes in all things. Grant that we would "rejoice in hope" even when present circumstances bring us to tears. Open the eyes of our hearts to see the greatness of our inheritance in Christ, and send us with tender hands to touch with mercy the miseries of the world. In Jesus' name we pray, amen.

Packing and repacking. Overweight. Aaarrrgh! Too much or too little. Shift the weight around. Should I just take another bag. Two hundred dollars, what??? No way, no more bags. Shift the weight again. Combined with change of address and power of attorney, plus a hundred other seemingly insignificant errands to check off. Quality time with you, and you, and you, which I love. But, oh darn, I missed somebody. Then the frustrations lead to irritability.

And then for a little while I just stop.
Stop running as hard as I am able.
Stop trying to get too much in.
Stop feeling the stress welling up inside me.

To remember that this is a blessing. The opportunity to go and serve is what I have poured years of my life into. Preparations long before today have been made seeking to glorify God with a life lived. And so, in the midst of hustle and bustle, God can bring refreshment. I remember what He has walked me through time after time in the past. How many times He has overwhelmed me with joy. And how many times He has comforted me in my tears. I look forward to what He will take me through during the journey yet to come. And  I look forward to walking every road with Him.

Thanks for praying for me. The paths of life have been much more pleasant due to getting to work, live, and play with many of those of you who will read this.