Character Influencing Work

Oh Africa…
I’ve had several experiences recently that have really showed me how poverty and the difficult climate shapes the African mindset.

I’m in the hospital treating a man with florid heart failure. I don’t have a probe to adequately ultrasound his heart. I can’t measure creatinine, so I don’t know when I’m pushing his kidneys too hard with Lasix. He’s been deteriorating over the past 2 days and I’ve been warning the family that things are worsening. More and more family arrive as the end draws near and every day I’m seeing new faces. I get called to the ward because he is having agonal gasps. I give medicines to keep him comfortable and I call for a man in the family. One of the newer faces shows up and says “I’m the small Pekin.” I tell him that his father is dying imminently. 20 minutes later he dies. I call the family and witness their pain. This is the second patient I’ve lost in the span of 4 hours and I sit in the ward quietly weeping while the nurses prepare the body for the morgue. The family packs up their stuff.

Less than an hour later I get called the ward to check on the patient across the way. He says, “I can see that you really care for your patients and I appreciate that.” And oh, by the way, can I have the bed that is now vacant? He can see the shock on my face as the bed is hardly cool and hasn’t been cleaned yet. He quickly clarifies, ‘That bed is under the one working fan in the room.’ It’s heart breaking to me that death is so frequent and our wards are so under furnished that patients are asking for transfers less than an hour after their neighbor dies.

Later, the accounts office comes to find me so I can do the death certificate. There’s lots of shouting going on from the family. I ignore it, as I don’t really like being around when people are talking money. But even 30 minutes after I finish the paperwork, the shouting is still going on. I go to see what is causing people to be so vexed (as they say). After asking 3 people who are all shouting, I find out that the family’s fan has been stolen. The ‘small Pekin’ wasn’t part of the family at all. He was just hanging around to steal stuff. He came to me as family, kept a sober face when I told him of his “father’s” impending death. All for one standing fan.

This story is just crazy to me: A long con, through a tragic death, to steal during a time of crisis. And while I will always feel shock, I had an opportunity to watch a man work about a week later. We hiked up a local mountain and met a man making gravel. And by ‘make gravel’ I mean that he chisels off big pieces of rock, then smashes them with a hammer into smaller pieces of rock. He told me it would take 3-4 days to finish smashing the big rock pile. It was impressive how much he's worn down the metal on his hammer. Plus, he holds the victim rock with his flip flop foot before he smashes it. I wouldn't have 10 toes if I had his job. It really take some strong character to work when your alternatives are to smash rocks for almost no pay or to steal while people are mourning…

I still live in awe of these hard working people who are scrounging a life from nothing. But I’m going to be asking more questions of the families in the future.

Christina

I want to tell you about my patient Christina. She came to the hospital over a month ago barely conscious, incoherent, in respiratory distress. Her blood sugar was 600. She had diabetic ketoacidosis: DKA.  It is cases like this when I remind myself I worked urgent care for a reason in the States! This patient would have ended up in the ER, then admitted to the ICU with a battery of labs performed, her electrolytes closely monitored and an insulin drip started. Well, now I am a hospitalist who relies heavily on UpToDate without access to electrolyte monitoring or insulin drips. We managed to get her blood sugar back to a more manageable range with only fast acting insulin injections and IV fluids. She improved. She left the hospital on the only oral medications we have for diabetes. She needed insulin, but she does not have electricity, therefore no refrigerator, so she would be unable to keep the medicine from spoiling. 

Patients here are surprisingly good at keeping their follow up appointments. When I saw her again in my wonderfully air conditioned office at 75F, her blood sugar was still too high and I discussed how I could only increase her oral medications so much and that she really needs insulin. We talked about far-fetched ideas like her coming to the hospital every morning for an insulin injection. Instead, she decided she would work on lifestyle. 

Next time I saw her she had bought a long sleeve shirt on the way to the clinic because the AC in my office was too cold. Since her last visit she felt like a virus was coming on and she blamed by AC. The cold causing illness myths are everywhere! About diabetes, she had lost some weight, had been exercising daily, and eating healthy foods. Her fasting blood sugars were within normal range! I was ecstatic. This is a lofty feat for an American who has ample access to places to exercise safely and a wide variety of foods. Here in Africa, the roads are dangerous to walk on due to traffic and the vegetables in the market are limited and expensive for locals. This is a HUGE achievement. She is going to school to be a seamstress so she can have a business, save up money, and hopefully get a visa to visit her two sisters that immigrated to the US. 

She let me take a picture with her. She’s the first patient I’ve connected with in this way and it was truly encouraging. Sometimes I feel like I’ve moved all the way out here just to spend all my time figuring out how to eat and survive, read UpToDate, struggle with hospital finances and politics when supposedly we came to do ministry. I’m not sure when we will start to feel like we are actually doing ministry, but this patient certainly ministered to me.  She didn’t pray with me or preach to me but my heart felt lighter after my visit with her. I think God can use interactions that don’t fit the cookie-cutter “ministry” to glorify Himself and to bless those around us. I’m looking forward to seeing Christina again, and I’ll be sure to turn my AC off when she comes. 

Power

It's routinely amazing to me how much power my 'white' skin and my profession bring. Most of the time I shy away from it, but last week I had an experience where I was happy to exert my influence.

I was at home eating dinner with Rachel when my phone rang. Since there's no doctor or CHO on duty from 4:30 pm until 8 pm, I always fear phone calls during those hours. It was a nurse telling me there was an 'emergency.' Then she hung up. Phone calls are charged by the second. So if there's an emergency you'd better walk fast. As I'm rushing through the hospital at dusk, Pastor Kamara calls me over and starts telling me a story. Standing next to him is a woman who is weeping. I listen to his story for as short of a time as is polite because I don't know what the emergency is.

Turns out, it wasn't an emergency. But after finishing the admission I go meet Pastor Kamara again. He tells me that this woman was attacked and beaten by 3 men. She went to the police station and was given a letter to go to Freetown to be examined by a 'Police Doctor.' Pastor Kamara explained to me that she had no money to get to town, no way to contact her family, and there wouldn't be any doctor on duty anyways. She was too upset and shaken to give much information. In fact it is common in Sierra Leone for severe emotional distress to cause unconsciousness. So, what to do?

I got to make a unilateral and unquestioned decision. I said that we would admit her to the female ward for free. There's security, light, a bed, and she doesn't have to be alone to sleep overnight. My exam didn't show any fractures or serious injuries and she denied being raped. She was lucky because rape is super common here. So I wrote myself (I didn't know her name yet) a prescription for Tramadol, paracetamol, and ibuprofen. She took some meds and Kamara brought her some dinner. She slept overnight and her husband showed up in the morning.

The accounts didn't question me, the nurses were happy to help, Kamara thought it was a great idea, and the pharmacy didn't care that I wrote a Tramadol prescription for myself. Every single person in this hospital is always happy to help. To provide someone services like that in the US would have taken multiple hours, but takes the Waterloo Adventist Hospital only 30 minutes. I am truly honored to work in a place where the church and the healing ministry can be so closely integrated.

Snippets of Life

1) Snapping

Every day I am thinking about the financial status of the hospital. We have excellent support from AHI and other very generous donors, but the day to day operating expenses are still difficult. This difficulty comes from 70% of our patients not being able to pay their full bill and the fact that the hospital receives no government support. So I've been working on a section of our website designed to help with operational expenses. This means that I've almost always got my SLR camera on me. It's not uncommon for me to hear people shouting at me "Snap me! Snap me!"

Just the other day, a man on a moto drove up to me and asked for me to 'Snap' him. I obliged. Then he pressed me, "Make sure to send this picture to America!" 

So here you go, Mr. Man on a Moto that I have no idea what your name is. Here's your picture being sent to Americans:

2) Treasure

I walked into the isolation room. The woman lying on the bed is cachectic, easily less than 80 lbs, I can just look and see almost every bone in her body. Her body is just being consumed by HIV and TB. As I enter, she looks up and smiles. I sit on the bed and glance down and notice a Bible opened to Isaiah 34; ‘Interesting choice,’ I think to myself. I ask her what she’s reading. She grins and responds, “The Bible.” To which I respond, ‘Oh, what are you learning about?’ For the first time, she is not smiling. She looks down sheepishly. Her family member pipes up from the corner, ‘She can’t read. She’s just looking at the pages.’

I’m caught totally off guard. It hadn’t even crossed my mind that someone could treasure God’s word so much to just look at pages of text you can’t read. Now I’m the one looking embarrassed. I mutter some acknowledgement to the family and rush into the medical stuff where I feel safe. Even still, I take my many blessings for granted. 

3) Spatula

CHO: “Did you leave a spatula on the floor?”

Me: “Spatula?”

CHO: “Yeah, you know a vaginal spatula?”

Me: “What‽‽‽”

CHO: “Did you do an exam on a woman recently?”

Me: Trying to hold back on laughing in his face. “Oh, you mean a speculum...”

Heh… I may be calling that tool a vaginal spatula from now on.

How to be Close Minded on Two Continents Simultaneously

     Last week it seemed that God was trying to remind me that I may not be as open minded as I would like to think I am. It all stemmed from a surprising outcome in the hospital and a book about Trump.

            The patient was a 40 year old female. History of headache for 1 week with chronic hypertension. That morning she had been found unconscious, non-responsive, with posturing on the left side and excessive drooling. I had trouble getting reflexes and pupillary reaction and we did not have a cuff large enough to get an accurate blood pressure (didn’t think I’d have that problem in Africa). Because we so frequently see strokes even in young people, I had made up my mind that this was a massive stroke. I thought this patient would likely die or be handicapped the rest of her life. I ordered some medicines and was called away to another patient before I could order labs. But then again, why order labs when you have already made your diagnosis? Fortunately the nurse was more on top of things that morning than me and brought me the lab order sheet right away. Oh yeah, I guess this could be hypoglycemia, HIV, severe anemia, or DKA. When the patient’s blood sugar came back at 30 I both felt relieved and horrified. Thankfully this was a treatable condition and the patient could end up completely normal. But I was horrified that I had almost missed this crucial diagnosis that could have killed her. We gave the patient some IV glucose and she immediately sat up and started shouting and praising God at the top of her lungs, her family singing songs of praise right alongside her. It is how I imagine people reacted when witnessing miracles in the Bible.

            Then comes Trump. I like to think of myself as open minded and eager to see things from other’s point of view. I’m certainly not so cemented in my ways of thinking that I cannot be swayed with a rational and compelling argument. So, when my dad recommended The United States of Trump by Bill O’Reilly I thought it was a great opportunity to prove this to myself. The test comes when reading a book about a man who I have few positive things to say about written by a man I’m not fond of. Look at me – so open minded! Well, turns out I have completely made up my mind about what kind of person I think Trump is. I could interpret everything Bill was saying to support my current views and beliefs. I even took notes, and it was difficult for me to think of anything positive and I didn't feel that any of my views had been changed or refined. 

While I obviously still have room for some personal growth it did help me take a step back and more easily withhold judgment of others who hold their views so tightly. This is especially difficult on subjects I think see as black and white. It’s hard to change a belief you’ve held for years, even more so when it stems from your worldview. In some way you may feel it defines you or shows weakness if you change. You may have social pressure from friends or family to continue with your current thinking and behaviors. We see this frequently with people going to the witch doctor before pursuing Western medicine, even if it means a family member dies due to this decision. This feels similar to the belief that vaccines are a government hoax. It’s also frustrating to me when in obviously complex issues, beliefs are held so tightly that there is no room for grey: homosexuality, abortion, transgender medicine. These strong held beliefs can simultaneously make me angry and shake my head in disbelief. But after this book, understanding the foundation and rationale for those beliefs is helpful. I can now say understand how or why someone would support Trump. I can also say I keep my differential diagnoses far more inclusive!