Ebb and Flow 27 Oct 2014

(Late blog post out of order...)

32 weeks is long enough, right? A baby boy was born prematurely and his first 24 hours were rocky. 

I was called to the OR immediately after the morning worship service finished outside at the hospital. 

  The baby was in my OR because it's our "ICU" when there is trouble. He was a 32 week preemie born at 4am and now he wasn't breathing well and his pulse was too slow. Actually he was also cold and wet and apparently his cord wasn't clamped when they found him at 7am. Sometimes the night shift in Chad can be dangerous. 

He improved after receiving oxygen, CPR, and lots of warming. Score +1 pt for the good guys. 

  Unfortunately by noon he was back in the OR.  We were just finished with a surgery when the baby was rushed in.  This time he wasnt breathing and was pulseless. I wonder what our adult patient was thinking when we ignored him on the OR table and worked on this baby boy right next to him. 

-1pt for bad follow up care, but nothing is easy here. 

Despite the odds we resuscitated a 32week preemie again! After 10 minutes of CPR and manual ventilation he was alive! 

I even managed to get an IV started in a preemie neonate's femoral vein (no ultrasound available--just good old fashioned landmark technique). We warmed him up, gave him antibiotics, glucose and tiny fluid boluses. The mother was brought into the OR to witness the entire resuscitation and she was so grateful. That was really rewarding. She even attempted to breast feed the newly resuscitated baby before returning to maternity with him.  Strange timing but A for effort. Wow! +1 for the good guys. 

I was walking tall and feeling pretty proud of myself--- I even hurt my arm patting myself on the back.  I AM GOOD!

  That unnamed baby boy died later that night. No one saw what happened. No one called for help. No one woke anyone up. Gone. 

I don't usually keep score. We win many more than we lose but it always stings me a bit more when a baby dies. 

 So I named the baby Merci. I don't know if that's a reasonable first name in Chad but its a reminder to say "thank you" during the good times and the bad. 

Merci tout le monde. 

-Mason

 

Abundance 11/4/2014

Abundance is not a term used to describe Chad unless in the manner of poverty. There is an abundance of poverty. Yet, right now, we are experiencing an overwhelming abundance. 

Just two weeks ago the shipping container, carrying hospital supplies AND our household goods, arrived.  This coincided with the completion of plumbing and electricity in the home planned for us prior to our arrival. We were now able to move into a larger home with all new furnishings.

Last November (2013), we received notice of a container destined for Chad from California. We traveled across the country to shop for furniture and household goods to add onto the container; all the while thanking the Lord for his provision. 

I was disheartened to learn, just prior to our departure from the U.S. in May, that not only was the container significantly delayed, the home planned for us wasn't completed either. We were temporarily housed in a one bedroom apartment with the few meager possessions we carried with us in our cases and (thankfully) quite a few more borrowed or loaned from other team members. 

I have been very eager to have more space and to have a bit more privacy as visitors could look into our old bedroom from the front porch. And visitors, I had a plenty, many days it was a continuous wave.  From those selling items, needing items, needing money, needing my time, the locals'  "clapping" could be heard coming from the porch alerting me to their presence should I not be sitting or standing a mere foot away in the dining room, bedroom, living room or office.

So happily, we traveled to Moundou, 3.5 hours away during rainy season to unload the container filled with our belongings plus a bevy of medical supplies and equipment for 3 hospitals and a few other families in Chad. It was Christmas in October for everyone!! But most especially us!!

Yet, as we began to unpack all of our new possessions, we had so eagerly awaited the arrival, the feeling of overwhelming abundance weighed upon us. In a culture of the truly impoverished, who have so few possessions, little access to clean water, no electricity and poor education, it was difficult to celebrate our good fortune. We unloaded a 40ft shipping container in front of some of the poorest people in Africa. Our 1000 sqft corrugated, metal warehouse with cement floors seems too large, too grand, too much. We are embarrassed by the abundance our new home and possessions.

Still, as we adjust to our larger space, I am thankful, in hindsight of course, for His timing and providence. We will not take our possessions for granted or as our own. "The earth is the Lord's and everything in it." I am abundantly grateful for the home and comforts He has provided us. I hope we remain steadfastly faithful in sharing with others what has been given to us. 

Living refreshingly grateful and abundant in Chad, "Do not give me poverty nor riches, but give me only my daily bread lest I be full and forget or deny You."

-Kim

Ikea showroom headquarters--Central Africa? Oct 24,2014

I'm sharing an email response I just sent some missionary friends in Ghana. It's a decent recap/update on our life here in Chad, Africa. 

-M

-------------

Hello to you both!

We are excited to read you email. I really appreciate you reaching out and offering encouragement. 

Bere, Tchad is probably a lot like you remembered it. Rich with hope but materially impoverished, mostly HOT, and terrible roads (nearly impassible in rainy season). We really do love many things here and we've been touched by the people and their generosity and kindness. Obviously it is a challenging environment and the transition has been difficult at times for the entire family. 

I believe we live in the little one bedroom "apartment" attached to the house you lived in. We stuck a bed in the living room for Kim & I but the girls share the real bedroom. It's small but we have water and electricity so that is a blessing. 

We are just about to move into a new building on the compound.  It will be amazing to have a little breathing room but its actually making me feel embarrassed. In a country where nearly everyone struggles in poverty, we are getting a brand new home that is filled with furnishings that just arrived on a container this week from the United States.  Equipment for Bere, Moundou, and Abeche was shipped here and they gave us some room for beds and tables, etc so we bought some stuff and had it sent over. It feels too extravagant and now I'm self conscious. The girls and Kim deserve it but it doesn't diminish some feeling of guilt for all the new abundance. In the U.S., the home would be considered a small metal warehouse or garage but here it's a 2 bedroom palace with Ikea furniture. 

The hospital compound would be unrecognizable to you. 

Maybe you have seen the One Day churches that are made of corrugated metal? Bere hospital received a large donation of these structures and this place has grown HUGE. AHI has really worked hard to improve Bere. There are mostly empty metal buildings everywhere but they are connected by actual concrete sidewalks.  Eventually we will have new hospital buildings from the same materials. New maternity ward, 2 new operating rooms, post op wards, etc. perhaps in the next 2-3years. It depends on money and manpower-- just like most things in this world. God has provided everything we need so we just have to remember to be patient. 

Kim has been busy keeping a malnutrition program open until the new director arrived. It was a labor of love and cost a lot emotionally and financially but it was time well spent. She also works with the local school-- she spends time nearly everyday with finances and student registration and she is also struggling to get teachers and administrators to work from a realistic budget. That's nearly impossible and pretty frustrating but its worth it to help the local kids get access to a better education.  This school is considered one of the best around, partly because they limit class size to ~60 students per classroom! That would be at least twice the normal size back in the U.S. 

I came here to give anesthesia and teach others to be anesthetists (as much as that is possible for them). I ended up doing that PLUS overseeing pediatrics.  That has been particularly challenging to round on pediatrics in the morning and get to the OR for a reasonable starting time for surgery. Add to that-- I'm not a pediatrician but fortunately God put enough people around me to get me back up to speed. I haven't focused solely on pediatrics since 1994-96 and I never studied much detail of tropical disease management. The re-learning curve was steep but I began to feel more confident after a month or two. Dealing with poverty (& parents inability to buy medicines) and the too "frequent" death of children from preventable/avoidable diseases has been difficult and I spent more than a few nights crying. Like most things, it gets easier as you adapt to stress but its sad to deal with the things that just don't exist in modernized countries. I may not be able to continue with Peds once we get really busy in Dec-Mar when we try to do 8 surgeries/day in one OR. Time will tell.

Our daughters were always homeschooled but after much discussion, we decided to enroll them in the local school. We realized that the academics would be lacking but we felt it was important for the girls to make friends and learn the many languages. It's been rocky and difficult for them but they are persisting. I would love it if you could remember Grace and Emmie in your prayers. And pray for our family to rely on God and stay close together. I know you remember the stress of raising a family here. We are managing fine but its much different compared to the United States. 

You can already guess our menu: rice with sauces; pasta with sauces; we've had goat a few times; I just received a chicken for a "thank you" gift so we ate it yesterday. I eat mostly vegetarian but not exclusively so we graciously ate the food that likely was a big sacrifice for a local family to give away. 

Kim and I are speaking French much better now and that is a relief, though I still miss out on a fair amount since they often speak quietly or too quickly :-)

Now I just need to learn Nangjere, Arabic, Malba, and Gumbay and I will be in great shape to chat with almost everyone. Communication is so important and so difficult here!

So overall we are doing well and learning from our successes and failures. 

If we are ever in Ghana we will drop in for tea or coffee :-)

Not sure what Internet is like for you but we have a blog you can read if you would like to:

whyweshouldgo.blogspot.com

Thanks again Peter & Esther. Your email was like a breath of fresh air. 

Blessings to you, your family, and your work in Ghana. 

With love,

Mason, Kim, Grace and Emmie

Our mailing address:

McDowell's

 L'hopital Adventiste de Bere

52 Boîte Postale

Kelo, Tchad, Afrique

I-Message & email info: mcdowellcrna@gmail.com

Sand in my mouth 10/9/2014

  In Chad we have had to get used to an extra crunch at meal time because we occasionally get sand in our food.  This afternoon I stood in the Operating Room and continually felt the crunch of sand in my mouth but I hadn't eaten a meal. 

  After administering a spinal anesthetic, I heard someone urgently shouting my name from Preop along with some rapidly spoken African French . I had to come quickly...My wife...Child...Emergency...Accident at school.  I told the surgeon they could start without me and had a nurse watch the patient.  

  I sprinted out into the African heat of midday and through the front gate of the hospital. The school isn't more than 1/2 mile down the dirt road.  I had no idea where exactly I was running and hoped it would be obvious. 

  I quickly found a crowd at the edge of the field by the school. Kim was there, hovering over a small child and she was grief stricken...the kid was motionless and wet. 

  I took a quick look and started CPR. This sweet 3yr old boy has fallen into a well.  No one could tell me how long he was under. Chest compressions, mouth to mouth resuscitation, pulse checks again and again.  Life support classes tell you what to do for pulseless & lifeless children but they don't describe what cold little lips feel like as you desperately try to breath life back into them.  His pupils told the story. Fixed & dilated. 

I pressed my ear against his wet shirt straining to hear anything. No pulses heard or felt.  As I shook my head, the wailing escalated. I confirmed what the crowd already knew. I pulled a cloth over his body, scooped him into my arms and stood to carry him home. Some friends of the family accepted his lifeless body and took him home. 

  I stood silently for a few moments trying to make sense of what just occurred and then walked back to the hospital to rejoin the surgery already underway. My scrubs were drenched and stuck to my body-- partly due to running in the heat, the adrenaline from the emergency, and the baby boy's wet clothes pressed against my body as I carried him. 

  The surgery that I had to rejoin went well. Unfortunately I spent much of the time thinking about the sand crunching in my teeth. 

I'm ok with a little sand in my teeth from poorly washed food. That's life in Chad. I'll never be ok with sand in my teeth after doing mouth to mouth on a drowned baby lying in a dusty field. But, that's life in Chad. 

Matthew 11:28

 Come to me, all who are weary and burdened. 

Prayers for Grace... 10/8/2014

  We had a sick baby arrive for consultation today. The mom walked up to the benches set out in the pediatric courtyard under the mango trees with her child in obvious distress. The nurses insisted that she go donate a unit of blood for the obviously distressed and anemic baby-- typically a result of severe malaria. 

  While the mother was donating blood, her sweet little baby died under those mango trees with the nurses.  She waited too late to seek treatment and the malaria was too severe. 

  My own daughter, Grace, has had a fever for 24 hours. We knew what to look for, what to worry about. We started malaria treatment last night when her fever spiked again only slightly-- no vomiting or rigor, just sleepy with fever that day. We tested her first thing this morning-- positive for malaria, just as we suspected. 

  I am truly thankful to have been born in a country where education, and money, and good health are accessible. 

  Thanks in advance for your kind thoughts and prayers for Grace for an uncomplicated recovery. Please also remember the many, many people who aren't in the same position. 

  -Mason, Kim, Grace & Emmie

10/6/2014 Worth the risk

I've had a sad 3yr old patient with abdominal pain for several days. He had already been to two other hospitals with no improvement. 

He cried all the time and he never responded to our medical therapy. But he was eating food, no diarrhea, not vomiting, afebrile.  Abdominal physical exam wasn't conclusive. 

There is no CT scan or X-ray here... I finally took a chance this morning during my Pediatric rounds...

He was no better but no worse--  he just screamed off and on all night.  I told the parents not to let him eat or drink anything and I put him on the surgery schedule. It had to be a surgical problem, right?

I didn't feel good telling his parents "we need to operate-- but I don't exactly know why."

  I whispered a quick prayer as I induced anesthesia and we did a laparotomy. It turns out he had a big intussusception that we reduced before his bowel got ischemic. 

His anesthesia & surgery went great. (Thanks Dr. Rollin Bland for the flawless surgery). Praying for this little boy'a recovery. 

Chalk one up for the good guys 

:-)

-Mason

(Anesthesia nerds: IV ketamine 0.5mg/kg then Halothane inhalation induction,  Halothane maintenance, spontaneous respiration  +/- manual ventilation  assistance using Diamedica DPA02 draw over vaporizer).  No neuromuscular blockade. Monitors: Precordial stethoscope and earpiece I bought in 1998, cheap $30 Pulse oximeter I bought off Amazon & a mostly malfunctioning automatic BP cuff. No EKG, no expired CO2 or gas analysis--Yep, it's possible)

10/1/2014 first day of school

Remember that "first day of school feeling" you had when your kids first started kindergarten?  You were excited and worried for them? Kim and I experienced that for the first time today. Always homeschooled, our 11yr and 9yr old daughters dressed in uniforms and walked to a "real school" for the first time this morning. The school is 100% immersion in French language. Send up a prayer for our girlies.

Friday night lights 9/20/2014

Friday night lights 9/20/2014

  This is my first Autumn in 20 years that I won't experience the crisp air, steamy breath, crunchy leaves under my hiking boots, or the pumpkin pie that accompanies Fall. And even though I don't follow football like I did when I was young, I still associate the game with this season. 

  It's Friday night in late September and for many people that includes the "Friday night lights" of football season.  But things are different here in Chad. It's after midnight right now & I just returned from a walk. I couldn't sleep so I decided to look at my own Friday night lights.  Here in the bush in Africa it is pitch black dark and the sky is intensely illuminated by stars in a way that many people have never experienced because of city lighting. Honestly it's beyond extraordinary. 

  As I walked to the open field behind the hospital, I paused in front of the old church that is now the pediatric building. 

I stood quietly and listened for trouble that comes in the night. 

All the windows in this old building are open so its easy to hear any commotion if someone is doing badly...and too frequently someone is.  Peds is my responsibility and it is the most agonizingly rewarding place I have worked in many years.  I know we are making a difference for many of these kids.  I worry at night though. Last night a baby boy and a baby girl died in Peds from malaria. They were new arrivals in the middle of the night and didn't survive until morning. 

  I make rounds first thing each day before starting the surgery schedule. Today rounds began with that sad news: 2 admits in the night but both died within hours of arrival.  I don't know that there was a lesson learned from their deaths. Nothing was completely preventable. Kids are malnourished, they get very sick and arrive in desperate shape. Sometimes we can save them & sometimes we cannot. 

  I keep wondering about the

things some of these mothers may have been thinking or seeing. Imagine that its night and the baby has been getting sicker for a few days. They have no money. Can she wait until morning? The baby is burning with fever. Now she's breathing badly and finally convulsing. The mad scramble ensues as the mother walks 5, 10,or 20  kilometers in the dark through muddy paths and rutted dirt roads. Only to have the child die on arrival... Or maybe the baby survives because their are people here who care. 

  Despite all of the headaches, hassles, and heartaches, I believe in what we are doing.  Nearly every day a mother will come to our door or sit under the tree outside of our home asking for Kim and I to help a child.  Nearly everyday I provide anesthesia services for people who may have suffered without me. And nearly everyday we offer financial or physical or spiritual assistance to people in need. 

  So here I sit tonight under my Friday night starry lights asking myself questions. Why am I here? Am I making a difference? What's my purpose?  

I don't have all the answers but God knows I'm trying. 

  

  

  

Giving and receiving 9/9/2014

  There is a village far from here that I have never visited. Apparently I cared for a very sick baby who lived there. He died from malaria. One of the younger men who works at the hospital approached me today and called me aside in private. His parents, wife and children live in that remote village but he rents room here in Bere so he can work at the hospital.   I have helped him with food and some other things in the past... He told me his mother was so grateful that I helped him and I cared for that baby. She sent her son to me with a sack containing 9 eggs--40km in rainy season over horrible flooded muddy roads. It was pouring rain (3" in a few hours).  He humbly presented this gift of thanks. 

I'm telling you, Im not sure I've ever received a better gift in my life. 

 I know perhaps not everyone reading this reads the bible but I was reminded of the story of the woman who gave a puny offering 

but it represented all she had. 

Today a woman I never met gave me all that she had. And I'm the one who is supposed to do the helping and giving.  

  I hope I will give as much when it's my turn to prove it.  Some days this place breaks me and other days it lifts me sky high. 

-Mason

The Widow’s Offering

Mark 12:42-44

42 But a poor widow came and put in two very small copper coins, worth only a few cents.

43 Calling his disciples to him, Jesus said, “Truly I tell you, this poor widow has put more into the treasury than all the others. 44 They all gave out of their wealth; but she, out of her poverty, put in everything—all she had to live on.”

Bad 9/6/2014

 I've been a bad dad and husband. I have been really focused on my work, just as I was before we moved here,  and  haven't given Kim or the girls enough attention. And, I've been too judgmental as well. Kim is feeling really hurt and isolated right now which she only just verbalized today. 

I have embraced "less is more" in a way that has obviously outpaced Kim's comfort level.  When she has expressed frustration, I have been less than sympathetic.  We don't  necessarily have the same expectation/observations of our life here.  A problem is likely I'm a bad listener and we plan differently. 

  Essentially, Kim is overwhelmed by needs presented at our door. Constant requests for physical and financial assistance which we cannot meet are draining. Our network here doesn't share the same sense of organization or prioritization that would help resolve our issues in the short term. 

  I think she is correct about most of the things which are stressful to her. I apologized today and committed to being a better communicator and partner. I'm surely focused on the mission but need to exercise better sensitivity when it comes to responding to my family's concerns.  

  I'm writing in the hopes you will pray for us. Pray for peaceful conversations, reduced worry over  finances, and for grace. 

  This isn't meant to be an alarming message. We are fine. I just feel like I've missed opportunities as the head of this house and I'm asking for your prayers that I would do a better job all around. Transitions are never easy and we still have a lot to learn about serving on the mission field. 

  I appreciate your wisdom, guidance and prayers. Feel free to reach out to Kim if you feel inclined. You can send me a message too and remind me to stop behaving like a moron. 

-Mason

Our mailing address:

McDowell's

 L'hopital Adventiste de Bere

52 Boîte Postale

Kelo, Tchad, Afrique

I-Message & email info: mcdowellcrna@gmail.com

Grace and Love 8/6/2014

Sorry this is out of order but we forgot to post this update:

Grace and Love 8/6/2014

Though most of you know Madison as "Maddie", she has chosen and prefers her middle name Grace. She tried to switch last summer but upon returning to school, the old name "Maddie" was predominantly used by her friends, her sister and me too. Change is hard!

Leaving the States made her name transformation into Grace quite easy. Everyone and everything was new so she has had a fresh start. "Maddie" is seldom heard here in Beré except from slips by Emmie and myself; Mason adapted much quicker than us. 

Our current home sits very close to the edge of the compound next to a low clay-brick wall with see through fencing on top. During daylight hours, village children gather at the fence to peer through at the new "Nasaras", the local name for any foreigner no matter your skin color but whose meaning is white man. 

Daily, we hear the call of "Nasara" from the fence but it is peppered with our girls' names, Grace and Emmie, as the children become acquainted with their names. Grace is a cognate with an accented "a" pronounced as in "auto." (Grawce). Emmie has been slightly altered in pronunciation to the word in French for love, "Aimer." (Aye-may)

Though Mason and I are still "Nasaras", it is pleasant and unlifting to hear "grace and love" sail over the fence.  In effect, we have brought "grace and love" to Tchad with us ;-)

Many days are challenging for a variety of reasons but we are holding dear the local names for our children. A reminder for us to respond to those around us in grace and love but also an uplifting reminder of all our friends from afar covering us in prayer. As we hear "Grace and Aime" being called from the fence, church or soccer field, it is felt as a blanket of whispered prayer, encouraging and most humbly appreciated. 

Thank you all for your continued support and encouraging comments and messages. These have all truly buoyed our resolve, purpose and faith. 

 -Kim

Sunset moto ride 8/26/2014

  I took a ride on the motorcycle after I finished my day at the hospital. The roads were slightly drier since we didn't have rain today so I was able to relax and take in the scenery. Most of my rides happen around sunset and it is just beautiful here. We live in rural Africa and there are vast expanses of land with just a few small mud brick structures dotting the landscape. As usual, my ride was peppered with gleeful shouts & waves from the local kids who ran alongside me while shouting out variations of "Nasara bye bye". 

 Before returning home I pulled off into a field and turned off the engine. The sun was slipping away and I sat in near silence and took in a deep breath. Rainy season is such a nice break from scorching temperatures. We traded in sweat soaked sheets for mildew on our bath towels. Kim prefers the former but I'll take this weather any day. Tonight the air was thick and humid though not hot and I could smell the rich soil and manure. 

 This setting is somewhat similar to the smells & sounds of any farmland in the United States but this is Chad so there is no machinery, no tractors, no man made noise.  I sat quietly while listening to birds, and frogs, and cows & distant laughter. As the clouds gathered  in the distance I was reminded of the effects of rain here in Chad. 

  Rain waters the crops & provides drinking water for people & animals.  Unfortunately it also floods the dirt roads and paths, limiting access to supplies for us. Worse still, it means travel to the hospital will be difficult for families. Typically a torrential downpour is a killing rain: it multiplies malarial mosquitos and restricts the victims to their home village. It takes a day or two after a hard storm to see the aftermath--as flooding recedes, families will trickle into the hospital with a lethargic baby burning up with fever.  Sometimes its just too late to turn things around.  

  As I finish writing this update, it is pouring rain. Thunder and lightning fill the sky and we are strategically setting out our buckets to catch the rain that leaks through our ceiling. And I am thankful. 

  I am thankful we have this house with running water, & electricity, & a roof that keeps us mostly dry.  I'm thankful we have full-stomachs tonight after 3 good meals today. I'm thankful for the screens with only a few holes which cover our windows & keep out most of the mosquitos. I'm thankful that my family is healthy, safe from war & Ebola, & the other problems plaguing many other countries.  And I'm thankful for your thoughts & prayers (and occasional Oreos & coffee beans-- gotta do something while it rains!)

-Mason

  

Did somebody call for an anesthetist? 8/8/2014

Did somebody call for an anesthetist?  8/8/2014

  After 2+ months in Chad, it has become apparent that we are being served at least as much as we are serving others. We also find ourselves taking on roles we didn't anticipate. Almost everything here is foreign and we rely on a lot of help. Hospital employees, friends, new neighbors, and short term missionaries, all contribute something to making our lives better or easier or more efficient. 

  Even my patients offer encouragement or joke with me when I butcher their local languages. My French is improving quickly but so many people only speak other languages. Normally I speak to the nurses in French and they will translate that into a handful of other languages. Occasionally someone from another family steps over to help translate if we encounter a language we can't speak (no HIPAA issues here).  I have managed to pick up a few "other language phrases" but rarely say them correctly. The other day I thought I  asked a mom if her child had diarrhea  but I actually asked her for a kiss. I wish all my intended jokes got as much laughter! Needless to say, I am pretty popular at the hospital. 

  With 2 physicians gone on annual leave for 2months, I now serve as the Pediatrician AND Anesthetist. I felt a bit like a fish out of water at first since I haven't focused on pediatrics since the late 90s. It turns out its a lot like riding a bike except this time the bike has malaria.  My work day begins with morning rounds on Pediatrics: 90%of my ~28 kids have malaria and the average age is probably 18 months old; There likely will be closer to 40 inpatient kids/day in the next month as rainy season is in full swing and malaria overwhelms the villages.  Everyone gets malaria. Some kids will be brought for treatment but many will die at home.   It's a sad reality. 

  I also treat typhoid, and meningitis and pneumonia, and Giardia, and everyone seems to have worms. Unfortunately we are seeing more snake bites now that everyone is working in the fields. Burn injuries are also common since children live with little or no supervision and everyone cooks over open fire. Scalds from boiling water are typical. Still, malaria gets most of my focus. 

  Many children come in with a hemoglobin of 3, or 2, or even  1.1--my all time new record low!!)  high fever, lethargy & occasionally having convulsions. Scary sick kids are becoming routine and malnutrition is ever present. Now I refer children to Kim for nutrition consults and she refers them to me for medical care. We see each others names in so many medical records now. What a team! 

  As I make my inpatient rounds, I greet each patient and family with a handshake. Sometimes the kids will cry as I approach simply because I am white and that is an extremely rare sight. I also have a puffy beard now and am affectionately named "the lion of Chad."   Sometimes I make a silly introduction or joke as I lay my hands on the child's forehead, chest and stomach. I whisper a quick prayer  over those children as I'm checking for fever, respiratory difficulty, and hepato/spleenomegaly. I also gently pry open their eyes to see if their inner eyelids are too pale indicating severe anemia. After a quick glance to make sure the IV isn't infiltrated, I quickly order labs or explain test results and treatment plans, request blood transfusions, add or change medications, discharge, etc. Ideally I spend 3-5 minutes at each bedside in a large, dimly lit, noisy open ward that apparently is an old abandoned church on the hospital compound. It is crammed with beds, family members, and a small entourage of nurses & sometimes students. "Has she eaten today?", "Is he vomiting or having diarrhea?"

 With +\- 30kids, Pediatric rounds normally take at least 2hours. It takes even longer when I have to ask why a nurse didn't give medicine, or why parents didn't buy medicine, or is someone coming today from their village with money? When the child is very sick and there just is no money, what do I do? Discharge her and say "good luck with that?"

  Lets just say being the Pediatrician has become an expensive profession. There is no social safety net here. The reality is, I buy a lot of medicine for my patients or they will die. It's a common model that the missionary docs follow here. In a land filled with overwhelming need, who could ever say no?  [One day I want to write about Olen & Danae. They do so much for so many people and are absolutely humble heroes.]

  Finally after finishing rounds we try to begin the surgery schedule. Luckily we are pretty slow in the OR right now. Everyone is in his field working during the rainy season so elective surgery just isn't happening for most people. They also have no money because they haven't harvested crops to sell yet. Weeks ago we were doing surgery 5-6 days/week, typically not stopping for lunch and pausing around 4pm until we return later for urgent surgical add-ons or an Obstetric emergency.  For now, I'm thankful for more time in Peds, more time to eat a midday meal, & more time to build relationships. It's so gratifying and exhausting at the same time.

I wrap my day up by eating a final meal around 7 or 8pm to keep up my calorie count, guzzling lots of water, and studying some French and reading a lot. Mostly I read about pediatric care in Africa. 

  Children die in my hospital.  It still guts me every time. Typically they come here too late after a disease has ravaged their frail little bodies. It's a heavy burden and I have become a bit obsessed with studying tropical diseases, malnutrition, and pediatrics. I spend each night reviewing research, treatment protocols, and guidelines published by the World Health Organization, other NGOs or other African hospitals with similar situations & limited resources. I finished my doctoral studies when I was 41 yrs old but it seems I will never be finished learning. And that's just how I like it. 

  P.S.  

The power went out at the hospital the other night. Guess who is in charge of checking fuses, resetting the inverters and maintaining the generator? Thankfully Rollin can lend an experienced hand & Olen is (usually) just a text message away. I knew I would be stretched when I came to Chad, but I didn't imagine how much.  

Um, did somebody call for an anesthetist? 

-Mason

Goodbye sweet baby girl

  Please keep Kim in your thoughts and prayers. This is an extremely difficult day for her. 

  Chantal Tcha Kouma was Kim's first baby girl in the nutrition program and she was tiny. She was also perpetually sick. Kim manages the malnutrition nutrition program here & I am serving as the pediatrician for the next two months so our patients often overlap. 

  Today Kim called me out of the Operating Room to see Chantal and her mother, Anina.  Chantal was in real trouble. She had been getting nutritional & medical treatment for many months but never improved. I took one look at the baby and swallowed hard as I scooped Chantal up into my lap & rested my cheek on her head. We knew this day was coming. My eyes burned as I spoke to the mother in French: we have no other medication to help. Chantal is going to die..today. 

  With a lot of sobbing & tears, Kim and Anina held each other and stayed with Chantal.  I blocked off our preop & delayed patients so two loving mothers could sit in silence with that beautiful baby girl.  

 In a few short minutes, sweet little Chantal took her last gasping breath and was gone.  Friends, this is what real pain feels like. Please God, give us strength.  

 -Mason

Goodbye Beautiful Boy 7/28/2014

From 7/28/2014

  Guedna died last night. In our minds, we knew it would happen. In our hearts, we kept believing he would recover. He didn't. 

  A woman from the village walked to our home to deliver the news. Kim was sobbing. This was her baby. The one who needed the most attention.  Guedna, 2 years old,  was so sick. His mother, Julienne, wanted the best for him and she did everything right: medicines, nutrition program, follow up consults. A recent widow, she was willing to do anything to raise money to support her four children. 

 Upon notice, we immediately packed our bag with some tea leaves, sugar, and beans. Taking a gift is customary when attending a grieving family as it  helps feed the masses who are gathering. 

  We drove the motorcycle to their home while Papa, a local resident teenager who we often call upon for Nangjere translation, readily volunteered to accompany us. He was relegated to Grace's bike without complaint. 

  Just off a dirt path, we arrived to find a sea of people. The men were sitting on rickety, wooden benches at the front edge of the yard.  The women, sitting hip to hip, were huddled together on mats spread around the area near the fire and home.  Others were preparing food, tending the fire or serving guests. There wasn't much chatter, just the heart wrenching sounds of mothers grieving together. Kim sat, cried and prayed with Guedna's mom. Someone brought Papa and me a bench to sit upon  in the same manner as the other men.

Each time a new mother arrived to pay respects, they would approach the mat and remove their sandals  before greeting Julienne. Most would wail with her in loud guttural cries. This cycle continued with each new visitor until you are eventually shifted off the mat onto another or make your exit with handshakes for everyone as you did when you arrived.  

It was tragic and sweet at the same time. I watched one of the prettiest sunsets tonight as I sat outside, under a tree next to a mud brick shack  while listening to women crying together in grief.

  These people have very few personal possessions. Their clothes are often threadbare. Every meal,  usually lacking in sufficient quantity and quality, takes hours of preparation and work.  It's a hard life here. Yet in that moment, as I sat with them in the setting sun, I could feel the richness in their lives.  They have a loving community of neighbors, friends & family. 

  Another baby died in Chad today but deaths are not just statistics. Guedna was a son, a grandson and a brother. He was loved. And now he is surely missed. 

-Mason

Thankful 7/20/2014

Sometimes we complain about things we don't have or "miss having." Honestly, we do without a lot of things now. But today,  we had another very humbling reality check & reminder of how much we do have. 

I used my phone to take this photo from our front porch when I noticed village kids reaching through the fence. They had extended a long stick into the compost pile for the compound and were trying to drag out decaying food scraps to eat. It felt like someone punched me in the gut. My trash is someone's treasure.  I pray that I will be a better neighbor to those more in need than I can even imagine. 

Just breathe momma 7/18/2014

  77% is not what I wanted to see when I placed the pulse oximeter on her hand. We were in the OR to do an urgent C-Section. 

  This a.m. one of our OB patients was looking a bit puny when we did rounds. She was pre eclamptic & her body was swollen everywhere with edema but they were delaying the baby's delivery until it was old enough to survive. Her breathing took some effort but it wasnt terrible. Still, she was looking worse so we decided she needs to deliver today- this mom is hypertensive & fluid is accumulating in her lungs.  To be safer, her surgery was scheduled for 2pm since she ate breakfast. 

 When I arrived to preop later that day, the patient was already in the OR. I could hear her wet cough through the walls. She was struggling to find a comfortable position to breathe: on her side, on her hands & knees. She kept rolling & twisting despite 2 nurses trying to pin her down so she wouldn't fall off of the OR bed. She looked bad.  What a downward turn in just a few hours. I had them sit her up with legs straddling each side of the bed. Now she can breathe a bit easier as we finalize the plan. 

  77% oxygen saturation. For you it would probably be 97-100%.  Her cells are starving without enough oxygen and she is virtually drowning in her own fluid. In the US, I would probably intubate her so I could manage her safer. Without a ventilator, things would only worsen here in Chad...& I may never get her extubated. I chose a spinal anesthetic after quickly debating the pros & cons. I do a quick mental check: IV/monitors/turn on oxygen concentrator/ equipment ready for "plan B".  Lets go. 

  This momma is so swollen that I couldn't feel any landmarks on her back. As I pressed the skin on her back to feel her spinous process, my fingers sunk in and left a 1/2" crater. I buried the spinal needle all the way and had to push even deeper to find her spinal fluid.  Mom started twisting & moving again just as I was about to inject the medication so I shouted to her & the nurses: S'il vous plaît! Ne bougez pas! 

I was already sweating & the thought of failing on this spinal was not helpful.   Thankfully it went in easily & we laid her down to do the C-section. 

  The surgery was textbook. No problems, limited bleeding, mom looked a bit better while breathing oxygen. Unfortunately the baby was pretty floppy at delivery. Stimulate. Suction. Stimulate. He needs to be ventilated by hand. We have all the right face masks & Ambu bags for adults, children, & newborns... But only one oxygen concentrator. So who gets our only source of oxygen? The mom drowning in her own fluids or dusky newborn needing help to jump start his life? The baby wins this one-- we ventilated him for just a few minutes and then eventually returned the oxygen to the mom. I simultaneously gave mom oxytocin to contract her uterus, checked on baby, gave repeated doses of lasix to help mom eliminate excess fluid & breathe easier, irrigated the wound for the surgeons, back to check baby again. Oh, and there was a film crew here recording everything for a project back in the U.S. 

No pressure!

 Thankfully there was a beautiful ending to this chapter of the story. I whispered into moms ear: C'est un garçon et il est fort. She gave a weak smile and closed her eyes again.     

  Mom isn't necessarily "safe" after surgery but her oxygen levels were 90% before returning to the maternity ward. We can ALL breathe a little easier now. 

 

-Mason

Africa Meds 7/15/2014

Our medicine cabinet hosts the typical array of cold medicines, band aids, ointments and pain relievers but we also have a bag I have labeled "Africa meds." This bag contains a variety of of foreign treatments for malaria, worms, typhoid and other parasites; even as medical providers, these were all new to us. Though all common here, they are used quite frequently and written as standing orders for children admitted to the hospital. Today, Mason and I administered my first familiar medication Cytotoxan, though it has been over 14 years for me and 16 for Mason since either of us had used a chemotherapy drug. 

Our morning was filled with ethical and moral discussions for the use of this drug on our specific patient. He is  very malnourished 2 year old who has been treated for every typical infection and illness and almost every drug our pharmacy shelves. Despite months of treatments, examinations and receiving nutritional supplementation, he remains a very sick and malnourished child. Upon yet another consult and blood test, our mission physicians have narrowed the suspects down to lymphoma or TB; neither which has a good prognosis for this child. With limited diagnostic equipment and tests, treatment here in many cases is a diagnostic tool. After much discussion, it was decided Cytotoxan was the best course of treatment.

Yet Mason and I walked away conflicted with ethical dilemmas: lack of protocol, lack of medications to treat side effects, lack of educated provider, and immunosuppressing a child in a remote disease and dirt laden hospital. This treatment will surely kill this weak, weak child. Our only impetus; if we do nothing, he will also surely die. 

So yesterday afternoon, after an early morning call to one of my besties on the stateside who I knew wouldn't mind, pleading for help locating a protocol as we were unable to download anything ourselves, we began IV administration without a pump of a chemotherapy drug to our patient laying a on shared mat in the Chadian worm filled and bacteria infested dirt. Modern medicine doesn't look the same in third world country. In a few short weeks, Mason has functioned as a pediatrician, oncologist and oh yeah an anesthetist.

P.S Thank you Kleins for your expedient and informative emails

 

Momma's perfect baby boy 7/14/2014

I was going to include a photo in my post because I couldn't stop thinking about this baby. I didn't include it because he died today. Its the kind of thing that creeps into my thoughts long after seeing it.  The photo is what you look like at 14 weeks. Alive & moving. Perfect little boy.  Of course a 14week old fetus cant survive. So this  baby boy died while we saved mom. 

We were in the OR caring for a young mom hemorrhaging with an ectopic pregnancy. She didn't "look" too bad but her hemoglobin was only 3.  Mom survived the surgery (thanks to Danae Netteburg our awesome OB doc). Unfortunately another child died in Chad today. This time it was unavoidable but the sadness is the same.  We saved a man with a ruptured intestine from typhoid, a man with an eroded gastric ulcer, and another OB mom in the night bleeding to death. We win some and we lose some. It is a bit like the US, but our losses come more often. I played competitive baseball most of my youth. We won most of the time except for the year my team went 1 and 17. We won one game and lost 17 games. That was a character building year. Im going to bed tonight praying that tomorrow we win another game. I'm not wanting anymore character right now. 

-Mason

Skin and Bones 7/9/2014

Skin and Bones

Many times during my life I've been described as "nothing but skin and bones." And, I know at times it was meant as a compliment but also most saying I was too skinny.  In fact, our whole family is on the lean side; anyone familiar with Mason knows he is barely able to maintain weight. Yet even at my thinnest, I have never been close to the literal vision of "skin and bones." Since working with malnourished children, I am now quite familiar with the true description of those words.

Three weeks ago, I received a quick turn-over of the Nutrition Program, which was started and has been managed for many years by a Mission Momma & nurse, who has now relocated to Indonesia. I have taken over management of the program during the summer before a new and scheduled director (and I am sure somewhat more prepared than I) takes over in September. Currently, I see the mothers and their malnourished children, once per week on an outpatient basis. Essentially, running a clinic for the day. I assess their weight and general appearance and take a brief history of intake/output and general health from the mother, any illness or fever.

Yesterday, with the help of several members of the Public Health team and my girls, we saw 17 children from the age of 2 months to 2 years. And yes, most of them aptly fit the description "skin and bones." A new child for the program weighed in at 4.5kg at 10 months old. As I placed him on the scale, I could feel every curve and angle of the bottom of his pelvic bones; the weight upon my hands was light but the burden upon my heart quite heavy. Any child accepted into the Nutrition program to receive supplemental formula must fall within 3 standard deviations below the median for height/weight according to a WHO table. It was obvious upon first glance that he would indeed fall well below the 3rd. Thankfully, the mother breastfeeds and combined with education classes, nutritional supplements and a round of meds to treat malaria and worms, he has a good chance of recovery.  Additionally, he received vitamin A and a B12 shot. I sent him to the pediatric ward to receive his injection because after 12 years of motherhood and away from nursing, I wasn't about to jump back in with an IM injection for a child without muscle tissue.

The morning wasn't entirely discouraging, there are 3 children who are very close to goal weight and will very soon graduate from the program. Even more encouraging, 4 mother's walked over 20km to attend classes and receive formula.  In a culture where the life of infants and young children is not highly valued but seen as more transient, finding mothers committed to their child's health is uplifting. The care for these kiddos is definitely a roller coaster of emotions. The gravity of malnutrition is a tough sight yet I still spent much of the morning laughing and the mom's too. Mostly at my attempts in learning the language, they love me trying to roll these foreign sounds over my tongue. A good laugh is also had when I mix up moms and kids, they are all still new to me. And of course, it is always comical trying to express wit across cultural and language barriers.

Our time here has been short but our experiences thus far have been extraordinary. We have quickly learned willing hands can do much more work than you may expect, even smaller ones like my girl's who have been side by side with me as we learn to serve the women and children here. Overall, despite the difficult circumstances we see, it is very rewarding.