Sunday, December 30, 2012

That is disgusting!

12/27 OK- medical friends. I need your advice again. I seem to have developed a nasty ingrown toenail infection even though I never wear shoes. But maybe that is the problem- 17 hours of standing in the dirty hospital with a laboring woman in a puddle of amniotic fluid, blood, urine and all the other nasty stuff that in hospitals I've worked in before we've quickly cleaned up but here they allow to accumulate... anyway. That is actually part of 12/28's post. This one is about this infection in my foot.
The night after getting back from the hospital
20 hours later...

I know that the correct thing would be to seek out a physician but lets be honest, that's not happening. I'm taking erythromycin because it seems to have good results with cellulitis and abcess here but I'm not sure it is working. Soaking often. Trying to be off it as much as possible. Any other suggestions? I'm thinking of switching to a cephalosporin if I can get my hands on a good one. 

12/28 I'm sure you all wanted an update! So maybe its turned a corner. Slightly less painful tonight and quite a bit less swelling. Still draining pus nearly continuously but less and doesn't smell as bad. But what to do with that granulation tissue? It is so sensitive and painful.
12/30 I may be the only one that finds these sequence pictures interesting but here it is tonight's anyway.

It doesn't look it but it is much better. Not draining pus.  Bleeds continually all day and still ultra sensitive  but swelling is way down. Was also weight bearing much more today which may explain the bleeding. Still unable to run (or walk without limping) but soon I hope!

Friday, December 28, 2012

Another delivery

Monday, Christmas eve, was a clinic day and I have to be honest, I had really thought it would be a quiet one. I had actually even asked myself if there would be any patients at all. If only. Early in the day two women came within 20 minutes of each other both in active labor. The first was dilated to possibly 6 and having contractions rather close together but was adamant that she did not want to go to the hospital. The only reason that she came is that she heard that I gave away baby sweaters. The second lady was a primip and not dilated very  far. But she told me she had been having hard pains since Sunday morning. We took tea together and she was indeed having long contractions about 3 minutes apart but seemed to be tolerating well. She wasn't sure she wanted to go to the hospital (very few village ladies do) and I didn't want to force her so when she suggested she go back home I didn't disagree but gave her husband my number.  Oh, meanwhile a lady came in covering her eyes saying she had been attacked by a spitting cobra and the snake had gotten some in her eye. The right eye was seriously swollen and tearing constantly. If I understood correctly it took them more than 30 minutes to walk from the garden to the clinic because she couldn't see anything. I gave pain meds and flushed the eye as well as I could with saline while the other nurse arranged transport. She told me that because the sight was already gone there was no reason to rush and they could take public transport.  No one complained and they quickly headed off on the back of a passing truck.
But back to my laboring patient. I just had a feeling about her. She seemed strong and I've found very few ladies that complain here about labor pains. And 24 hours already seemed long. But FHTs were good, BP was good, I had no reason to be concerned and chalked it up to first pregnancy worries. But it didn't surprise me at all when they called me at 10:00 pm asking if I could please come and help them. I arrived in the village and had a terrible time assessing her as it was really dark and my flashlight quit. They lit a candle for me but when I suggested we just go to the hospital everyone was quick to agree. They got all of their stuff together and we set off. We arrived just before 11 and discovered the ward was overflowing (20 beds full and people sleeping on the floor), there were 5 ladies pushing, three babies in the lone incubator and one stressed nurse (and a partridge in a pear tree) . It was obvious my patient didn't take precedence.  The nurse did a quick exam while I monitored her other patients (HA!) and declared her dilated to 3 and fine. She was to go walk around outside and she would be checked again in 4 hours. As there were no open beds anyway it didn't seem to matter that it was 11:30 at night.  I checked that Winny (the laboring mom) and Johnathan (the soon to be father) and Dina (their very young attendant who was 16 and brought along to fetch water, cook, and do the wash) didn't need anything. They discovered they didn't bring any mats to sit outside on and didn't have anything to eat. So I ran home and grabbed some things for them and brought it all back. At this point I decided there was little I could do for them so headed back home to bed. At 7 the next morning (Christmas) I stopped back in the hospital hopping for a baby. But no luck. Johnathan didn't have a phone so couldn't call me but they had never been checked again. They had been waiting outside all night. I got a bit assertive and asked the nurse to pay attention to my patient. She did an exam and told us she was to 4 cm. She also broke her water at that time which I thought was a terrible idea but did it before I knew what she was doing. I checked FHTs and they were still good but it was very obvious Winny was exhausted. Contractions were few and far between and externally felt much weaker than 24 hours before. We were sent back outside and I tried to get her to lay down and sleep for a bit.
Winny in a "labor room" at the hospital.
She said she felt too painful lying and wanted to sit. While talking, her husband mentioned that she had been feeling like this since Friday. Like what? Not laying because of contractions. Only sitting or walking. I asked Winny to clarify, knowing she told me Sunday. She said the contractions had gotten stronger Sunday but she had been  feeling them very regularly since Friday. I felt so out of my element. I knew something wasn’t right but clinically didn’t really have any indication except the long labor. Around mid-morning we decided to leave the hospital (as they were doing NOTHING for us anyway) and went to my house. I coaxed Winny into a hot shower (she had never had a shower before, let alone one with hot water) and then she laid down on my couch an seemed to doze off when her contraptions seemed to really pick up again. Several minutes long and quite painful. Everything seemed good, FHTs good, she lost a lot of amniotic fluid on my couch, had some juice, and labored for a few hours. It seemed time to head back to the hospital. They didn’t even notice she had been gone.  The nurse checked again and told her 4 cm. Seriously?! I asked for her to be examined by a doctor. She was crying during contractions and not moving at all between them. Once again they were very ineffective and slowing down. Finally, after asking for hours (literally, it was late afternoon by now) a doctor came. He started pitocin which she immediately lost control during contractions, thrashing, yelling then practically catatonic between. She was making me really worried. I didn’t have my stethoscope and the nurses were not checking FHTs but at least only an hour went by before the doctor came back. Actually he was checking on another patient but as Winny was in one of 5 labor beds all in the same room he had to pay attention to her too. He finally seemed to listen to me and examined her again and said maybe she had Cephalopelvic Disproportion as she was still not progressing at all. Her hips were wide and it didn't seem right but I was in no position to argue with him. I pointed out she had not progressed since arriving almost 24 hours before and had possibly been in labor for 5 days. He was doing a vacuum extraction on another laboring patient that was going very poorly so as the decision to head to surgery with that one was made he told me that if Winny was still unchanged he would take her to surgery next. Having no idea another solution I agreed (and immediately reached over and turned the pit off). I know this story is already too long but I have to put this in too. While one nurse and doctor were 20 minutes away (the surgical theater is nowhere near the delivery room) another patient began crowning with contractions  She was alone (most woman are- the staff hate it that I stay with the ones I come with!) and calling out in ateso. I stuck my head down the hall and told the other nurse she was crowning to which I got an eye roll and "I'm coming." I pulled gloves on from my pocket and tried to encourage the patient to pant. Yeah right. I yelled again for the nurse but within seconds the head came with an obvious nuchal cord so I slipped it off and the rest of the baby and placenta immediately followed. The mother had been laboring in nothing but a towel so I laid that on her chest with the baby. Still no nurse.  The patients have to bring their own ties and razor blade so they were right there. I tied the cord and cut- still no nurse.  I was looking around for something, anything to wrap the baby up with and put the placenta in.  Finally the nurse arrived and immediately started screaming at me. She was already mad that I was demanding so much attention for my patient and now more pissed about me messing with another one.  Whatever lady!
But back to Winny, She looked terrible. I went and got a gurney and loaded her up myself and headed over to surgery. It took him an hour and a half to finish the first patient (sections are NOT quick here!) and it was 10:00pm that he finally took her back.

30 minutes later we had a 5.8 pound baby. He was  clearly full term and healthy but tongue tied (ankyloglossia) and small! No indication of why the terribly prolonged labor. By 11:00 she was back on the ward and in bed. It was a really, really long day leaving me wishing for some midwifery training in the not so distant future.
Anyone want to weight in with things I could have done better, ways to help the patient, any ideas for next time? I'd love to learn from this...

Saturday, December 22, 2012

Christmas Carols

We sang some Christmas carols tonight at team worship and I love how these songs really hit me differently here. Partially because this is the first time this year I'm hearing them. I haven't heard them on the radio, in the mall, on TV or anywhere else. And also because life here is a bit more like Jesus would have experienced it. So, I've been hearing some of the words afresh. I want to challenge you too to hear them afresh too.
How about this one:

Truly He taught us to love one another,
His law is love and His gospel is peace.
Chains he shall break, for the slave is our brother.
And in his name all oppression shall cease.

Or this one.....

No more let sins and sorrows grow,
Nor thorns infest the ground;
He comes to make His blessings flow
Far as the curse is found,

He rules the world with truth and grace,
And makes the nations prove
The glories of His righteousness,
And wonders of His love!

May the awe of what our Savior has done be prominent in your mind this week!! 
Merry Christmas! 

*pictures from Nakayote in June, their "hungry" season..

Wednesday, December 19, 2012

A new branch of the culinary arts

I do a lot of driving back and forth from Karamoja right now and cooking is challenging to say the least up there. But I love cooking (and more than that, I love eating well) so I've embarked on a new branch of the culinary arts- manifold cooking. Anyone know any good recipes? I've successfully done chicken and rice and eggplant. But I'm open to other suggestions.

Tuesday, December 18, 2012

It's a girl!

So this is what I spent my birthday doing.... 
This is Ashley Jennifer. Born 12/18/2012 
My Team mate Tanya, labor coach and friend of the mother. 
Mother after a LONG labor but she did great!

Tuesday, December 11, 2012

Your mission, should you choose to accept it...

Ok family, I have a mission for you. I’m putting it here on my blog so that other people will maybe encourage you in it. Or even help you do it, that would be even better!  I’m willing to bet real money that you all have not taken any pictures since I was home last (12 months ago!) that I could put on my fridge. Pictures of Izaac or Ellie, with other family members in the background don’t count! So, with Christmas coming, I know you will be together. Please take some pictures! Then send them to me. Electronically is fine. I’ll figure out a way to print them. I know, it is a tough mission but I’m sure you are up for the challenge. This message will self-destruct in 5 seconds.
This is mostly unrelated to the post but a few days back I purchased  "Mission Improbable" 1 through 4. But Tom Cruise is in them and I only paid $0.50 for all 4 of them. Nice huh? 

Monday, December 10, 2012

Transformed lives lead to transformed communities

In my newsletter I mentioned the day that I headed out with the ladies from church in Karamoja to visit and help an elderly widow. (Mostly I have more pictures than could fit in the newsletter so I have to write some more about it.)  I should know by now that these ladies work hard! And that I was going to be tired and sore by the end of the day!! We arrived at the home of a blind widow (blind I suspect from incorrectly home brewed alcohol) who told us right off that she wanted to die. She asked for alcohol because she was hungry and didn't have any money. A few of the ladies I came with sat down and started talking to her and the rest started ripping down her fence. You need to know that I get about 2% of what is going on around me when out in the remote villages so I wasn't really sure what was up. But I could tell the fence was already falling down and it soon became clear we were gathering material  for a new one. Within two hours these 14 woman had build what I estimate to be 200 meters of new fence. 

Resting, admiring some of our fence, sitting together in the shade, praying over the home and sharing a meager lunch.
A few bowls of un-shelled sunflower seeds as all these women had for lunch and still they willingly shared.
And I don't want you to think this was easy work! It was hot, heavy, tough work to gather branches, dig a foot or so down into the hard ground then weave and tie this stuff together.  But I was there to provide comic relief. "Look at this foreigner! It looks like she has never build a fence before!" "But she is a woman isn't she?!"  "Yea, but her hands are so soft! And she has no idea how to weave!" "Strange! How has she survived this long in life?" "I know right?!" "Just watch her!" This is not a direct translation but you get the idea. :-) 

Nothing like a 60+ year old woman with a machete to remind you how tough these ladies are. 
As the sun was setting we wrapped up and began the trek home. 
The blind old widow and young grand daughter to care for her. 

Saturday, December 1, 2012

Back to Soroti

So we headed back to Soroti yesterday as we are still waiting on blood work for a definitive diagnosis  but are really thinking it is Glucose 6 Phosphate Dehydrogenase (G6PD) deficiency. There is still a chance it is an autoimmune issue but less likely. It is good know know what Abraham has but is discouraging as there is no cure. The only treatment is to avoid the causes that trigger a hemolytic episode and to transfuse if he does get into trouble. We will taper him off the steroids that he never should have been on in the first place, see if we can get him on some malaria prophylaxis and educate his parents on his triggers. This picture is Deborah and Emma, Abraham's parents and Abraham in orange. Also his baby brother. Missing from this family picture are his older brother and two sisters. 
Thanks everyone for your prayers!!  

Friday, November 30, 2012

Learning stuff in Kampala

So were pretty sure we’ve learned Abraham’s diagnosis (G6PD deficiency Pub Med article here if you want more info) but more about that on tomorrow’s blog. Today, I want to talk about the other things we learned while in Kampala. Abraham learned about watching movies. He saw his first one last week- I chose Lion King. He was so into it even though he doesn’t speak a word of English. He was dancing around to all of the songs. His father learned about television and maybe more fascinating, the remote. In the guest house there was a TV with 3 channels and we rotated between those three over and over and over and over again.  Rhoda learned about skinny jeans and wanted to know how they can be comfortable. I told her they are not comfortable but that isn’t the point. She also learned about Ramón noodles and wasn’t overly impressed (as someone who spends HOURS a day cooking I couldn’t believe she didn’t like a 3 minute meal!) but Emma loved “that thing that is somehow like rice”.  Abraham learned about mannequins and finds them quite fascinating though is unable to tell the difference between a white person and a mannequin. However, in his defense all of the mannequins are white and all white people look the same. Abraham also had to learn about indoor plumbing and how he couldn’t just go outside and pee whenever he needed. I had to apologize to the others at the guest house several times. At least he is super cute so they didn’t mind much. One concept that I’m sure we have not yet mastered is hot water from a tap. I spent quite a bit of time explaining how to use the hot water heaters in our rooms (you have to turn them on and wait for them to get hot before getting in the shower here) but I guess I missed some key bits of information. One evening, after we had been there several days, Abraham climbed up on to my lap and he was freezing. His dad had just given him a bath and judging by his fingers and toes it was a really cold one. I asked his dad if their hot water had stopped working and he told me no- it was working too well. The water was too hot to bathe Abraham in and he had to use the cold instead.
I’m glad to tell you that my village friends were not the only ones learning things in the big city. There is a huge market, (huge is not a big enough word for this market that stretched for literally miles!) here that Emma and Rhoda had heard about and really wanted to visit but I had never been to. It is called a second hand clothing market but has everything from suitcases and belts to baskets and CDs. I had to wait near the truck for them as I was pretty sure the young men loitering around were just waiting to hone their B&E skills but Abraham and I found a building near where we could look over the market still see the truck. He could practice his stair climbing skills (as he has never climbed stairs before- no buildings in Obule have them) which he did over and over while I tried to capture the vastness of this market with my camera. I didn’t do it justice but I tried.

Each one of those roofs and tarps is a different market stall. 

Another picture taken from our vantage point 

The direction we needed to head after they were done in the market. I needed Valium. 

Abraham chilling in the back of my loaded truck while we waited for his dad and Rhoda. 

Wednesday, November 28, 2012

A taste of real Italian ice cream

So nothing to actually report today from Kampala except that I'm so mad at myself for not having my camera when Abraham had his first taste of ice cream.  We put a small bowl of it in front of him and he tasted it and screwed his face up. Then had another spoonful and tears came to his eyes. By the third spoon he was crying and still trying to eat. We we all laughing! Kids here are so programmed to eat what it given to them that he was trying even though he thought it was so cold it was physically painful.  I took his bowl away and he was just looking at me like he wasn't sure if he was happy or not. Then I handed him an orange instead and got a huge grin. Don't worry Abraham, I got the message: ice cream is not your thing.

Tuesday, November 27, 2012

A little glimpse of the system that is IHK (International Hospital Kampala)

I’m at what I consider the best hospital in Kampala (this trip has not yet changed this opinion) and a few things still knock my socks off. AS we were looking for a place to park, a portion of the lot was unusable because apparently the hospital’s septic system was having some problems. As we passed they were prying the lids off and you cannot imagine the number of cockroaches that ran out. Sick!
We walked up to reception, registered and paid a registration fee. They then determined what kind of service we needed. For example, this time I wanted a pediatrician but was willing to settle for a GP. They said the pediatrician wasn’t too busy so we could do that. Then we went over to the peds office and filled out more paperwork and did an ultra brief triage with the nurse. She then sent me over to the cashier’s office (back down on the first floor) so I waited in line to pay and get a receipt. Then back upstairs because now we could wait in line to see the doctor. Eventually we got in to see her and got orders for labs and radiology. We took the lab requisition slips over to the lab (which is both inpatient and outpatient) where we waited while they filled out the bill which I then took to the cashiers to get that receipt. (I tried to pay the bill for radiology at that time also but, silly me, was told I had to go to radiology first).  While waiting in line there I realized that I wanted to add several labs to what the doctor ordered because I don’t want to be doing all of this again in a couple of days. So, back to the lab to ask them to add CBC and CMP.  They didn’t even hesitate. The doctor had already ordered a Hb electrophoresis, blood smear, and a few other very specific things but I wanted a broader general picture. Back to the cashier with an updated bill, then finally got in line again to have the blood drawn. We were given a card with a # and a date to know when to come back to collect the results to bring to the doctor. Then over to radiology to get in line for another bill with that requisition slip. Then back over to the line at the cashier’s office (seeing a pattern here?!) to get a receipt and back into the radiology line to finally get the scan.
The astounding part of all of this is that if you don’t bring someone with you to do all of this (like I’m doing for Abraham and Emma) then you have to do the back and forth and up and down yourself (it isn’t a huge hospital but it is still a lot of moving around!) like the poor guy who was bleeding from his head behind me in one of the many lines I was in. I’m not a doctor but I still think he shouldn’t have spent hours standing in lines today while losing blood like that.  One other mildly entertaining thing was how often at the cashier’s they couldn’t make change for me. Both of the times that they didn’t have my balance I knew I was coming back so I was OK with it when they just scribbled a note on the top of my receipt that they owed me 20,000/= or whatever.  But it seems a little strange that they really only have one job…
But enough of all that. Back to Abraham. He got his ultrasound this morning (I didn’t stand in all of those lines yesterday. I saved some for today.) We learned that his spleen is normal, or at least as normal as any child who has had malaria a bunch of times. Yay!! But his liver is way too big for a kid his age. This finding really does a number on his differential diagnosis and the hepatomegaly makes me REALLY wish I had added a liver panel to the labs. But now we kick back and wait until we see another doctor on Thursday afternoon.

Abraham enjoying some R and R with is new favorite toy (thank you Elliot for sharing!) at the guesthouse this afternoon.

Monday, November 26, 2012

Abraham in Kampala

It has been a very long day but sitting here at the end of it I’m really content so thanks for all your prayers everyone. For those who don’t know the current adventure I’m in is attempting to get Abraham a legit diagnosis. For a little background (tune out for this next paragraph if you follow my blog regularly), Abraham is a sweet 4 year old boy who has some mysterious issue causing hemolytic anemia that the medical system in Soroti is completely unable to address. 12 times in the past 3 years he has gone to the hospital (many resulting in admission).  Usually there is a diagnosis of malaria but several times I had tested him and already knew that it was not malaria. They always put him on some enormous doses of antibiotics that rarely seem appropriate, effective or age/weight adjusted. They put him on a moderate dose of steroids which makes practically no sense and he has been on it for more than 6 months now. Every time he gets sick he gets a high fever and urinates blood. He complains of abd pain, gets very jaundiced and occasionally bleeds from his nose. This last time he was vomiting blood and needed to be transfused he was so anemic (but the blood bank didn’t have any blood to give him).  They also didn’t give IV fluids causing me much irritation and they upped his steroid dose which made no sense.
So, 6:15 this morning found me packing to go to Kampala. We arranged for Roda, a young lady in the church with fluent English, to come along as translator and Abraham’s father Emma, as his mother has 4 other children to stay home with. Abraham is well at the moment causing us to discuss if we should wait but every time he gets sicker than the last and one of these times he isn’t going to turn around. So we embarked on the arduous 6 hour trek anyway. We arrived at the hospital around 3pm and managed to get into see the pediatrician with only a 1 hour wait. At least she admitted right away that he was a pretty unique case. She ordered labs and an abdominal ultrasound. The labs will take 3 days to get the results but we at least got them drawn today. The ultrasound we’ll get in line and wait for tomorrow.
Emma was last in Kampala as a 15 year old kid and Roda has never been very far out of Soroti. She admitted that she has never used a shower “like this” (with the water coming out above her head instead of in a basin at her feet) until today.  They were all very impressed with the sheer volume of the Nile and ordering off a menu at dinner was surprisingly complicated for the adults. Abraham seems to be oblivious to it all except traffic noise which he mimicked for the entire two hours we were stuck in Kampala traffic today. (There are a surprisingly large variety of horn sounds when you pay attention!) So that was our day. Please keep praying!

Tuesday, November 20, 2012

Writing curriculum

Prayer requests: I’m in the process of writing new curriculum targeting mothers and medical problems their kids have. There are tons of misconceptions and abuse of medications and bad treatments. I want, most of all, for it to honor God and share truth. It needs to address relevant issues but in a way that is easily understood. Sometimes they don’t like what I have to teach because it is different than that they’ve been taught before (like there isn’t a medicine for EVERY problem) but it is really needed teaching. Most of the mothers I’ll be talking to are illiterate so it needs to be visual and simple but also not be superficial and a waste of their time.

Life in Kangole

Several times I’ve done a day in pictures of what my days are like in Soroti but never while I’m in Karamoja so last week I took some pictures to try to give you a glimpse.  
The day starts early and if you want a hot caffeinated beverage you need to start a fire.
Getting water for the day takes a while so leave yourself some time.
The hut seems to collect dust and bugs like it is grass thatched (which it is) and I have to do laundry at least twice a week (which means an additional trip to the borehole) so often the cooler morning hours are spent working. 
Laundry with my home behind

Got to store up a few solar hours for light later.

Fill the water filter to have clean water for the day. 

Generally later in the morning I have all my other things done, and I head the half mile to my language tutor’s house.  She is always working when I arrive and I sit while she works and learn vocab, verbs, and various other things you have to try to comprehend while learning a new language. Occasionally I attempt to help her with the work to get a break from thinking. 
When I tried this they all laughed at me and I hurt for 3 days so enough of that.
This week's work was gathering sticks to build a shade for their yard.
This is their current shade structure until the new one is constructed. 
Most days, after my language lesson, I spend a few hours working in the CLIDE office on things, or try to do computer work, but to be honest, some days I just take a nap. Then in the later afternoon I head into the town center or market or visit a few of the church ladies to practice the things I learned. 
Girls in market

Trying to sell the pumpkins they grew. (I know the word for pumpkin now!) 

Lots of activity in the Kangole market.
Could get a new "eburangkit"
Talked with these girls for a bit but only after I bought something!
Then a few hours to make dinner and when the sun sets I read or study a bit. That is it, pretty simple life for now. As my language learning gets more advanced I’ll have more ministry activities to do but I’m going slowly for now with lots of learning. 

Monday, November 19, 2012

Hospital- a picture is worth a thousand words

Several weeks ago I talked about hospital pictures. Finally managed to get a few. Sorry about the poor quality as I was trying to be really subtle and not look like I was taking pictures for the most part.

This is outside the woman’s surgical ward. Make sure you bring someone with you who will watch your baby and fetch water for you.  Some of these patients have been waiting literally days to be seen by a physician.
There are no beds left so this young patient sleeps on the floor. You can’t see in the picture because he is hep locked but his IV abx treatment is just tied to the side of the neighboring bed.
This is Abraham (the child I was visiting) and his bed mate, who his family didn’t know before yesterday! Their charts are there above their heads and if you look closely at the bed behind Abraham’s you can see there are three patients sleeping in it and two moms sitting as there are no chairs in the whole ward.
Abraham finally stopped vomiting blood on Friday and was discharged Saturday but after being in the hospital for seven days never received a diagnosis (and was only seen by a physician 3 times and had labs done once).  Next week Monday the plan is that Abraham, his father Emma, a member of their church (for translation purposes) and I will head to Kampala to attempt to get some real treatment for Abraham's condition.  I'm learning that many children, boys especially, between the ages of 3 and 7 are dying in rather high numbers due to this unknown condition. It seems that 7 did last week while Abraham was in the hospital. The doctor told me that they really started seeing it in 2008 and have not yet determined a course of action. He has been on prednislone for nearly 4 months now but it isn't changing anything. So feel free to pray for us as we go that I won't lose my salvation over frustration in a ridiculous medical system. (Remember this and this?)