Strange Encounters

Things that would be strange in the US are totally normal here. I notice it daily, but thought I would jot down a few instances.

I'm walking through the hospital and a nurse pulls me over, "I need you to meet someone." I think it's a patient's family or one of her friends. Instead, she leads me to a white person (a rarity). She says, "Hello I'm Paula. I'm a cardiologist from Italy." She asks if I mind if she gives some recommendations about one of our admitted patients: a 50 year old woman who came in with blood pressure of 240/120 who had been on IV antihypertensives combined with triple oral antihypertensive therapy for 3 days without any effect. What a perfect consult for a roaming cardiologist!
"I hear a mitral valve regurgitation murmur, have you considered lasix?" Firstly, I have no idea how she heard that with the nurse's stethoscope. Secondly, in this country I'm always happy to have a second opinion from any non-witchdoctor. Because I frequently want to have a cardiologist around, I ask "How long are you in Waterloo for?" She casually replies, "Oh, probably another 4 hours." I wonder if she could see the disappointment on my face. Unfortunately I didn't have another consult for her within 4 hours, but I certainly did within 12. Either way, both me and the patient were blessed by the roaming cardiologist.



A few weeks ago, right as the coronavirus fears were really picking up, we had a Chinese man walk into our hospital. He asked how many masks he would be allowed to buy. Now normally we don't sell medical supplies. But we have thousands of masks that it'll take us years to use and since we struggle to make payroll, for the right price you can have almost anything. After he made the purchase and left, Dr. Kabba noted, "I hope he doesn't know a coronavirus patient."
The next day he came back, wanting several hundred more masks. Then rumors started flying around the hospital. Is he hiding a coronavirus patient from the government? Is he trying to protect himself and his compound without telling anyone? Well, we're desperate for money so we sold him the masks. But when he arrived back on the 3rd day in a row, enough was enough.

Dr. Kabba notified the Ministry of Health, who called Immigration, who requested backup from local police. Soon the hospital was swarming with uniforms. Any man in a uniform is instantly interested by an Apoto (white person), and it's not always for good reasons. So Dr. Kabba recommended that Rachel and I make ourselves scarce. In the end, they discovered that he was just a shrewd businessman making a pretty profit in China. There was no risk of exposure. But with all the police around, they needed something to do. So they accused the hospital of selling government supplies. Dr. Kabba, Mr. Fobbie the business manager, Augustine the clinical supervisor, and Danquah the chaplain all got hauled to the police station. For several hours they were held and asked multiple times about exactly which staff member did the selling and where the masks came from. Once they learned it wasn't government cheese being sold, they still wanted to arrest a staff member. Dr. Kabba said, "If you want to arrest someone for alerting the Ministry of Health for the good of the country, you can arrest me. I was the one who gave the ok to sell the masks. I'm sure the news will find this story interesting." Needless to say, nobody was arrested. But I saw a lot fewer patients visiting the hospital that afternoon. I'm starting to believe the local version of "No good deed goes unpunished" is actually translated: "No one who calls the police in Africa goes un-harassed."

Hello!

Every day as we walk to the hospital, there is a 4 y/o boy who lives across the street. He loves to yell “Hello!” to see our reactions. Usually I wave; if he persists I use two hands; if he perseverates I even try to wave with my feet and hands simultaneously. It doesn’t matter the circumstances: rain, sun, big trucks, weekends, he always greets us.

Last week the mother called me over and told me that he was sick. I walked across the street and they pulled up a chair for me. I sat in their front ‘yard’ (really more dirt) while they tried to find him. I looked him over and he wasn’t dying. So I didn’t commit to free consultations or medications like they wanted, but they also didn’t ask outright. I noticed a deep dimple on his tongue at the same place I’d expect his frenulum to attach from underneath. I asked about it and it’s been there since birth. I asked if he talks ok and the mother gave him a firm nudge (that in the US would be ‘hitting’) and commanded him: “Talk!” Under those circumstances, nobody would have anything to say. So I squatted down, shushed his mother, and said “What’s your name?” He responded, “Ishmael.” Sounded good to me, so time to have a little fun. “What’s my name?” I asked with a smirk. I honestly didn’t expect any response at all. He smiled back at me, waved his hand, and said “Hello!”

The small crowd that had been gathering laughed, as it was obvious I’d been out played by a 4 year old.

Spiritual Battles

The longer we stay in Sierra Leone, the easier it is to see the spiritual warfare.

Every time that someone moves into a new office in our hospital, the staff gather for a prayer of dedication. It didn’t seem unusual to me, until the office prayer was delayed for several days due to busy schedules. The staff member refused to move into the new office until the prayer. I asked around and learned that it is often dangerous to be promoted. Jobs are so rare, everything is seen as a zero-sum game. So, if someone is promoted they become a target: threats, poison, curses, etc.  Spiritual attacks are so common the phrase, “I’m going to Waterloo for you” means that you’re headed to Waterloo to find one of the many witchdoctors to order a curse on someone. One of the reasons people are so happy to work at a Christian institution is they feel some safety from these attacks. Prayer is protection.

I had another case where a young Muslim man (maybe in his 20s) came in unconscious. Nobody from his family could provide any conclusive history. On physical exam, it was clear that he wasn’t completely unconscious. I would lift his leg and after letting go, it would slowly return to the bed. I told the CHOs, “I don’t know what this is, but you need to be thinking beyond just physical. In the States, this would be a psychiatric issue.” I ordered a bunch of labs, all normal. I ran some IV fluids and just waited.

Oh, I did have to tell the family I didn’t want them rubbing raw garlic all over his body. Who knows what else they did at home.

After several hours the nurse came to me and told me that the family wanted discharge. “What‽ Do they want to take him home unconscious?” The nurse responded like I should somehow know without being told, “No, he woke up and feels fine.” I pulled the patient into Mr. Abu’s office, because I didn’t trust my Krio enough to dive into psychosocial issues alone. Without the family present, I delved into all the sensitive issues: Sex, HIV, Drugs, Anxiety, Abuse, Depression. All negative. As I dug into psychosis, I got an unexpected answer: “Does your mind ever play tricks on you? Do you see and hear things other people don’t see or hear?” “Well, no. But 7 nights ago a Devil came to me in my bedroom.”

He told me that more than a week ago, he went to the ocean. He was swimming while wearing a hat, and he lost his hat into the waves. With fear in his eyes, he described how he was unable to retrieve the cap. (Demons and beliefs relating to water are very common here). Then after a few nights he was asleep and a Devil woke him up and presented him with two identical caps. “One of these caps is yours, one is mine. Pick the correct one or you will be sorry.” The man grabbed the one on the left. “Wrong!” the Demon shouted, as he started to cackle and dance around the room. Then he vanished.

For several nights, the Demon visited to ‘torment’ the man: ‘You’re going to die’ ‘I still have your cap’. Then the next few nights he slept well. Later he was in town, walking down the road and the Demon appeared. “Give me my cap right now! I need it!!” The man pleaded, “I don’t have it! I’ll go home and get it right now.” “Too late” screamed the Demon and the man went unconscious.

It was at this point that I realized my mouth was hanging open a bit. I asked him, ‘Have you told your family about this?’ He hadn’t. I asked him if he would benefit from a Christian prayer and he declined. Mr. Abu and I encouraged him to tell his family so they could provide ‘Muslim Prayers.’ He left and I never saw him again.

In the States, Demons and spiritual battles are the last thing anyone thinks about. Here, even rashes can be attributed to spiritual curses. I’m learning more and more that the truth lies somewhere in the middle. I need to keep an eye on the Great Controversy, while also leaving room for a contact dermatitis of unknown origin.

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.