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.