Amen?

Well - the experiment is complete and I think was very successful. I am so proud of my team for their flexibility, resiliency and effort. We are so thankful for all of our supporters and readers here who in many ways came along with us.

As a public searchable document, the content of this blog has been carefully worded. If you would like to know more about all that is happening at the Hospital of Hope and that area of the world, I would be happy to meet with you or chat more. To get this wonderful place to a sustainable and thriving level, many more staff and significantly more money will be needed, so I will be looking for more helpers in this work. My observation though is that God’s hand is on it, it is His work and He is blessing it.

I have known for awhile that I wanted to conclude this blog with the Lord’s Prayer. Not coming from a liturgical worship setting, I actually don’t read or recite or think about this prayer very often, but recently a portion of it in the lyrics of a song caught my attention.  Just last month I was reading to my son from the The Jesus Storybook Bible, a lesson taught by Jesus about prayer. In it Jesus was saying that we don’t need to pray like the “Extra-Super-Holy People," but that we can pray in our normal voice, like this....

Mentor

My mentor Bob has impacted and inspired me more than he knows. My admiration for many of his characteristics and skills, coupled with his unrelenting efforts to pour into my life, have resulted in a lifelong friendship

We met back in 2004, when I chose an elective medical school surgery rotation at a hospital in Southern Togo. In 1985 Bob had helped start that hospital. After raising four sons in an austere environment, family health concerns transitioned him back to residence in Michigan. However, a large part of his heart remains here in Togo.

In 2008, Bob was an integral part of the effort to raise several million dollars to start another hospital, this time at the request of a destitute area in Northern Togo. That campaign kick-off coincided with the American financial crisis and the beginning of global economic woes. Bob pressed on. 

On top of that monetary challenge, this Northern Togo location isn’t exactly an easy place to get to or a desirable place to live. During an early-phase construction site visit to this new hospital, one respected leader in global surgery said “Bob, this is a crazy idea, no one is going to come here.” Bob was not deterred. 

A visionary in every sense of the word, he seems to see things in the future as if they are already happening. He is a winsome and convincing man and probably had a dominant role in the recruitment of most of the expatriate medical staff and most of the donated dollars that have been required to get the Hospital of Hope started. Of course, you would never know this from talking to Bob. It is true of him what Ronald Reagan meant when he said “There is no limit to the amount of good you can do if you don't care who gets the credit."

Bob was here briefly for the opening of Hospital of Hope. Stuggling to control his emotions, the words he spoke to our group at the end of that first week meant more to me than all others.

Bob returned to Togo this week to cover surgery for most of May. The long land route means that we had to drive south (for upcoming departure) in the vehicle that took Bob on the return journey north. Bob will pick up where I’ve left off. I love the give and take of the mentor - mentee relationship.

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In keeping up with the then and now theme photos - here are a couple of wrap-up family photos. Back in 2004 it was fairly easy to get an all smiles photo. 

In 2015 it is impossible to get all smiles coordinated and we barely all fit in a selfie despite my long arms. 

Fear Math

I have been helping out with my sons’ math homework here. It is fun to relive my glory days in math and engineering classes. I must say that some of these new learning methods seem odd and I am tempted to just have them use my memorized, tried and true formulas (the area of the triangle is 1/2 base* height already!) instead of graphing things and counting graph paper squares.

I have also been contemplating my fears on this trip. There are many new ones that crop up in places like this. I have reviewed my attempts and methods to manage my fear in the past - some were just laughable, like the “NO FEAR” that I scribbled in big letters on the inside of my baseball glove.

Getting back to the math connection, I often counsel people about risk to benefit ratios when discussing surgical operations and I think my mind just works in this mathematical numerator / denominator sort of way. I have been mulling a new equation and the best answer to this multiple choice question:

a) Fear / Love > 1

b) Fear / Love = 1

c) Fear / Love < 1

d) Fear / Love = 0

I guess there are various examples where each choice can be true. Choice A - when your fear of rejection is greater than love, you decide not to ask the girl out or you chicken out of telling someone the truth when they need to hear it. Choice B - a state of paralysis when you just keep thinking about demonstrating love but that desire is not greater than the fear or risk, and so action is not taken. Choice C -  when love overcomes fear and you step out, you rescue the person from the burning building or you help the help the person who you fear might take advantage of you.

Just yesterday I asked my son what Psalm 57:10 means when it says “your steadfast love is great to the heavens” and he said - “it means God’s love is infinite.” Hey, maybe my math teaching is going okay.

When love (the denominator) approaches infinity, Choice D is true. 

This was actually my original thought of a fear / love equation. I have made it through my time in this less than “safe” part of the world with this one verse in my heart from a great passage, 1 John 4:

“there is no fear in love, but perfect love casts out fear…” 

I keep telling myself the powerful truth in Choice D.  Fear / God's Love = 0.

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Say, in less abstract math - this sign sits right outside of our duplex. Marked by a prior Indiana team, as the crow flies, Indianapolis is 8980 km away. While our route is not exactly a straight line, that is a  [8980 / 1.61 (km/mile) = 5580 miles] journey that we’ll embark on later this week!

And, for more applied math, please check out this link, published on the BBC News website this morning. I'll look forward to sharing my up close look and perspective on this reality with anyone who is interested.

Five billion people 'have no access to safe surgery'

http://www.bbc.com/news/health-32452249

Broken

Well I have had enough orthopedics for awhile...

My time here has reaffirmed that I have found my true calling in general surgery and I am happy and at home operating in the abdomen. Partly this is because of the plasticity of the organs involved - infected or injured portions can be removed, healthy segments can be reattached and back to normal use in days. For example, a 12-year-old malnourished girl can arrive with a distended abdomen and four days of vomiting and a big scar down the middle of her abdomen. She or her mother will not know (will not have been told) what operation was done in the past. But, if you remove the chronic and now obstructing stricture of her small intestine (stripped of it’s blood supply in a prior bowel resection operation) and reattach dilated but healthy small bowel back together with her colon, she can be eating well within three days and asking to go home.  

However, if someone broke their leg last year and they were casted in a non-functional way or, worse, instrumented with hardware that is now infected or that didn’t result in healing - the correction isn't so straightforward or complete and certainly takes a whole lot longer. 

If they have osteomyelitis in every extremity like the boy in this picture (an all too common bone infection in the setting of malnutrition, poor hygiene and limited health care) - now you have mess on your hands. 

In many scenarios - for example when their joint hasn’t moved for years -  there is nothing you can do to fix it, even if you work at the Hospital of Hope. Giving this disappointing news is hard and is taken hard.

There are many examples of ingenuity and tenacity that you see in orthopedics though and it does appeal to that inner construction Mr. Fix-It part of you (though I left most of that part of me behind on roofing jobs during my Huber Construction days). 

There is also an amazing company call SIGN that has developed a system to place intramedullary (through the hollow marrow portion of the bone) nails in fractures in resource settings like ours. In response to reporting of data and outcomes by hundreds of such hospitals, this company generously provides the nails free of charge (http://signfracturecare.org). We have already placed several of these nails in my brief time here.

Thankfully we haven’t had any falls from mango trees in awhile - hopefully they are all picked for the season. Here is the boy and his dad who I mentioned in a prior post - at a clinic follow up visit. There is definitely a bright and rewarding side to the care of orthopedic injuries. 

A Day in the Life

A few of my family members, mainly my mom, have been asking for weeks what a “normal day” looks like for me and the kids.  So, here goes:

6:00am – I wake, hopefully before the kids, but the sun comes up around 6 too, so we’re usually all up soon.  I think the kids aren’t sleeping in much because it is usually pretty hot in their room, and once they wake, they are up for good.  Nate works out at the pool with a few guys some mornings, and on the other mornings, I try to go for a quick run (in an athletic skirt!! because we are in view of the hospital and women don't normally wear pants in this part of Togo) before the sun is too intense.

7:30 – Nate heads to the hospital for morning rounds followed by scheduled surgeries.  The boys walk to the sheep pasture to feed their beloved sheep.

8:00 – Kids start on schoolwork and I do a quick Bible time with them.  A few mornings a week, Denise, a Togolese young woman, comes to our house to help with some cooking and cleaning.  She is wonderful!  Her English is limited, and my French is even more limited, so it can be a challenge to let her know what I would like her to help with each day.  Typically, she sweeps the floor (the dust is unbelievable and builds up like crazy when the windows are open), washes dishes, washes and bleaches vegetables and makes a Togolese tomato and peanut sauce for us.

9:00 – I take Truman and Fiona out to swing or play for a break.

10:00 – The older boys need some help with school, so I distract Fiona with a tub of water on the back porch and she plays while I help Avery and Finley with their questions and work with Truman on his sight words and reading.

11:30 – The kids are pretty much finished with their schoolwork, so they read or play ipad games while I figure out lunch.  Even heating up leftovers for lunch can be an ordeal with multiple pots and pans on the stove.  I miss my microwave!

12:30 – Nate comes home for lunch and usually has an hour or so before he heads back to the hospital for afternoon clinic.  We are staying a couple hundred yards from the hospital, so it easy for him to go back and forth.

2:00 – While Fiona is napping, I try to prep dinner so we can be outside late afternoon when the temperatures cool a little.  I catch up on email if the internet is working and sometimes read a book aloud to the older kids.  Avery and Finn let the sheep out to graze and keep an eye on them so they don’t end up inside the hospital.  The boys have also done way more reading here than they would at home.  There is a small “library” at one of the nearby houses, books donated from all kinds of places, and the kids have read some really great books.

4:00 – We head to the pool.  It is tough to be outside during the middle of the day, so we try to maximize our time outside from 4-6pm.  The other missionary families who live in town or on the hospital compound are usually there as well, so the kids have friends to swim with.  There are twin 12-year-old girls, Abby and Ali, who love Fiona and are pretty amazing babysitters to her.  She usually prefers them over me when they are around.

Abby handmade this kitty shirt for Fiona...she is so sweet!!

5:30 – Nate is hopefully home to play baseball with the boys.  They love this time with him.

6:00 – Dinner, then maybe a game or movie or ping pong at the guesthouse.  Nate is on call every other day, so he is sometimes at the hospital if patients aren’t doing well or a new surgical patient comes in.  He operates after normal work hours only a few times a week, but the surgical volume is quickly picking up as the word gets out about the quality healthcare offered here.

8:30 – Boys head to bed and I spend at least an hour grading their work from the day and assigning work for the following day.  This has been more time-consuming than I expected.  Not having true homeschool curriculum or teacher’s manuals means I am reading the textbook to make sure Avery has all the facts straight about the French & Indian War.  At least I have learned a few things myself, including how to do that crazy lattice multiplication method that is so head-scratching to all parents of 3^rd graders!

So that's my life the past couple months.  The routine isn't exciting, but we have had some pretty memorable times as a family that will definitely be laughed about for years to come.  Because we are so isolated and recreation options are severely limited, we have spent a lot of time just...together, talking about patients at the hospital and what God is doing in this area of the world.  I feel like I know each of the boys better than I did a few months ago and going through their schoolwork with them each day has given me insight to their strengths and gifts.  These benefits help me keep perspective when I am dripping in sweat. :)

List

Ten signs that your family is in Sub-Saharan Africa....

10. It's hot. You can get sunburned in 30 minutes. It can be 96 degrees F at 8 pm (inside
      your house).

9. You only have brown eggs for Easter egg coloring. 

8. You have to move over for cows on your hike.

7. Your co-workers have names like Petro, Moussa, and Cherry.

6. Every Tuesday is “Terrible Tasting Tablet Tuesday” and every Friday is "Fanta Friday."

5. Fred, the pet chameleon, crawls across your dinner table and he is welcome there.

4. Baseball practice (usually in flip flops) is never cancelled by rain.

3. Your sons herd sheep on their bikes and enjoy mending fences. 

2. The tooth fairy pays in francs.

1. You see things that are best explained as miraculous. 

Tiny

This boy was born prematurely in another village at 31 weeks gestational age. We think that attempts to deliver his cord dislodged his twin’s placenta. Despite an urgent C-section, his brother died shortly after birth here. Now, at one week of age, Tiny’s abdomen became very distended and an X-ray this morning confirmed an intestinal perforation.

This 1 Kg baby is one of the smallest humans I have seen, let alone operated on. We found a perforated cecum - the first part of the colon and lots of contamination (spilled stool) in his abdomen. I think he has an obstruction of his colon that caused the upstream bowel to become massively dilated and eventual just die and fall apart. He now has a tiny ostomy in the right lower quadrant of his abdomen. No long term ventilation here - he breathed on his own throughout the operation (which he barely survived) and is clinging to life. There is something about having your hands inside someones abdomen that make you very attached to them.

If you feel moved, you can join us in prayer for him. Tiny and his mom will appreciate it!

Languages

“Why can’t everyone just speak the same language?” was my son’s blunt observation / question soon after we arrived in Togo.

We currently live in an Anufo speaking region. There are about 70,000 speakers of this tonal language in the entire world and only recently did this language begin to be written. Thus, there is much variability in meaning of words between families and towns. Most words consist of a consonant and a vowel which are strung together in phrases that might be the length of one of our typical English words. The translator I work with the most in clinic handles the English to Anufo dialogue very well. He is highly valuable to me. He can even revert to other widely spoken languages like Hausa if needed. It gets interesting though if a Moba or Mossi speaking patient from the north or a Gangam speaker from the east or nomadic Fulani shows up. That requires tracking down a hospital employee who knows that specific language. There is a printed list of which employees speak what language and I have found that these other go-betweens can be tracked down quickly.

History taking can can become quite a game of telephone though. When “how long has your abdomen been hurting?” turns into a long conversation between translators and the patient and comes back with the answer “she also says her eyes are stinging,” you just move on to the physical exam. I am always so pleasantly surprised when a patient (about 1 in 50) answers in Ghanian English and we can talk directly. 

Some of the translated answers can really surprise you too. My question - “Where is she from? Can she stay close to the hospital so we can do a post-op follow up next week?” ….. Translator answer - “Yes, she is from Niger but their herd of cows is only half an hour from the hospital right now so it is not a problem for her to come back next week.”

French is the official language of course and preferred by the hospital staff. Many patients don’t speak it though and also don’t read - a fact I just can’t seem to remember. Like when I tell the patient to go to “Echographie” - right behind the sign that says “Radiographie” and my translator pauses and says “Please, I want to show her,” and perhaps picking up on my incredulity, blurts out with a smile “She can’t read!”

Often I think that that non-verbal cues, smiles and conscientious care can transcend language barriers. The mother of our first surviving C-Section boy could understand my broken French enough today to say that she is eating and has minimal abdominal pain. She was happy to have me snap a picture of her little man. I am convinced she knows I love them both.

And the Fulani dad of the shepherd boy who fell from a high mango tree branch with the punctured lung, broken shoulder blade and broken humerus seemed to get my explanation of his sons injuries on a digital X-ray. He is so appreciative of the close watch I keep on his boy. He said that his son “has to make it” and as a dad of boys, we both get that. 

The staff here put up with my English and understand it better than they let on I think. My favorite nurse anesthetist told me “I want to teach you French but I don’t want to learn English from you because your accent is too difficult for me!” I am pretty sure he just means my pace is too difficult and I am trying to talk more slowly.

Yesterday though, I was taken aback a bit by Sanbo, one of the nurse assistants. He is a small framed man, about my age, with a characteristic Fulani face. Every morning that I see him around the nurses’ station I call out with a smile Saaan-Booooh like a sports announcer and every time he replies with soft and raspy “Oui, Dr. Na-tan.” On rounds together, we had just finished a long conversation with a female patient including discharge instructions. I asked “Can I pray with you in English?” and through the translating nurse she said “Yes, God can understand.” As we walked away from her bed Sanbo looked at me squarely and said, “Dr. Na-tan, it is important that you speak French.”

I know Sanbo, I know.

(photo credit Judy Bowen)

Snakes

I have never liked snakes. I dislike them more every day here.

Earlier this week I was walking past the nurses station and noticed a teenage boy in the ICU. The blood on the wall by his bed and on the gauze in and around his hands held up to his mouth caught my eye. “Did I miss a trauma patient?” I thought as I moved closer. I quickly asked what his problem was and was matter-of-factly told “snakebite.”  My role was to evaluate for compartment syndrome, excessive swelling in the arm or leg (as in this case) that can block blood flow to the foot or hand. This swelling can sometimes require fasciotomies (long incisions through skin, fat and muscle covering fascia) to relieve the pressure and restore blood flow. His foot and leg were swollen and painful but he had a good pulse in his foot. I was told he had received 5 vials of antivenom and hadn’t required transfusion. He seemed stable so I quickly moved on.

Yesterday, a similar scenario played out an older man bitten on the right hand. At first swelling was limited to his hand but as it ascended to the elbow over my lunch break and his tetanus shot injection site in the right shoulder started dripping blood - administration of our limited supply of antivenom became indicated.

First, I needed to verify that the snake he was bitten by was covered by our antivenom so I found a chapter on snakebite in the Principles of Medicine in Africa book in our library. I took it to his ER bed and began showing him snake pictures. He became quickly animated, pointing his extremely swollen hand to the picture of the saw-scaled viper. 

I had never even heard of such a snake before. Sure enough, it was covered by our antivenom and in fact, I read, that it is the species involved in most bites and deaths from envenoming in the semi-desert regions of Africa north of the equator. Bites from these snakes may case severe local swelling, blistering etc. but the “clinical picture is dominated by spontaneous systemic bleeding.” Early sites of of bleeding listed include the gums, nose and sites of trauma. More ominous outcomes were laid out in detail.

The maps in this section of the text were striking when you consider were Togo is on each of them.

I was called at midnight last night because a pulse oximeter reading could no longer be found on the fingers of the man’s right hand. While it was tempting to try to do something to relieve pressure in the swollen hand, I reasoned from my bed that his risk of unstoppable bleeding precluded this and I ordered another two vials of antivenom. At 5 AM I awoke. Nervous about the outcome, I walked to the hospital. Thankfully there was still some blood flow to the fingers and no other evidence of diffuse bleeding was seen. 

The final verdict on these two saw-scaled viper victims is still out, but they are hanging in there. We only have 4 more vials of antivenom left.

Access to Healthcare

Been thinking about this topic a lot.
This a my four-photo essay.

Visiting Richard

A few years ago, when we initially signed up to sponsor a child through Compassion International, I picked a child from Togo knowing there was a good chance we would visit the country again and possibly be able to meet our sponsored child.  When the details worked out to visit Richard in his village, this was one of the events I was most looking forward to during our few months in Togo.

Richard lives several kilometers outside the capital city of Lome, so we traveled about 3 hours via a taxi van that morning.  Upon seeing the dilapidated van with no seatbelt options, I took a deep breath, said a prayer and hoped we weren’t making a really unwise decision.   Our driver spoke no English.  Fiona was thrilled to climb from seat to seat and hang her hands out the open window. 

We met our translator, the Compassion project pastor and social worker at the project itself to see where Richard attends every Saturday for tutoring, medical care, worship and Bible training.  We were shown around the small property that cares for 230 children and the workers seemed proud to show us their immaculate office and organized file of each child containing details of his family, medical history, grades and records of gifts given by the sponsor and how they were used.  We were super-impressed with the integrity of Compassion.

Our next stop was Richard’s school, currently empty because the school teachers are all on strike.  Sigh.

In Richard's classroom.  Richard was #3 in his class of 90 during the last grading period.  We did the math and figured 3 or 4 students sit at each desk.

Then onto my favorite part of the day, meeting Richard and his family at his home.  We walked along the dirt path to some traditional mud-brick homes and saw a group of people gathered, waiting for us.  It didn’t take long to spot Richard’s face, the one we have looked at many times through the photo sent to us.  It was overwhelming to see him in person, this boy we pray for almost every day, the one I have pictured in my mind so many times and wondered what life is really like for him.  He was dressed in his best traditional clothing and looked so sweetly scared as he stared at us.  I, of course, couldn’t hold back the tears.  Because I couldn’t communicate with him, I think I felt like the only way I could show him love was to hold his hand or squeeze his arm or hug him.  Who knows what he thought of this, but I hope and pray he knows he is loved and cared for and that his life matters.

Richard went inside his home and brought out our family photo and every letter we have ever sent him.  It's hard to imagine they are such prized possessions, but they are.

His family was extremely kind and expressed so much thanks for Compassion.  His mother seemed to have a speech prepared, telling us through the translator that we are now family and that I am another mother to Richard.  They gave us a huge, heavy bunch of plantains and a rooster, tied by the legs with a shoot of grass.  Finley was over-the-moon about the rooster, as you can guess.

With Richard and his mother.  His youngest sibling is in the wrap.  Because of the great limited number of spots in Compassion's project, Richard will likely be the only child from his family that is able to participate.  This also means his other siblings probably won't finish school, if they are able to attend at all.  Richard's mother is quite proud of him, for good reason.  I wish my internet connection was able to load a video of his makeshift battery powered light he wired himself.  He gave us a demonstration and we were all in awe.

We took Richard to a playground and out for lunch and he reluctantly ate what was probably his first slice of pizza ever.  Our time together was cut short due to a major storm that down-poured in Lome, causing the streets to flood in no time.  We really didn’t want to get stuck in the city so we sent Richard home with the Compassion workers via a separate taxi and started our long drive back to the hospital.  The day definitely lived up to my hopes.  If any of you get the chance to do a similar visit, it is absolutely worth the effort.