How was Africa?

What do we say when we're asked, "How was Africa?" After over two years overseas, we have about 6,000 pictures and about that many stories.  I have no idea how to answer. Its like we have been to another world. How does one explain what the least developed country in the world is like to people who live in one of the most developed? Its still hard for me to comprehend that Niger and America exist on the same planet.  So, we show a few pictures and tell a few stories all the while still struggling to process the experience ourselves.

Inevitably, we then come to the next question- "What are you going to do now?" We are still working on the answer to that, too. Mostly we are praying a lot, seeking guidance, and trying to relax a bit and enjoy our time back despite all of the uncertainty.  One thing we do know...we are looking forward to meeting our baby girl in less than three months!

 

goodbye

Leaving. I knew it would be a sad day. I had no idea it would be this sad. The last two years were the most challenging, difficult, and intense years of my life. To leave the ones who were there through all the hard, exciting, and heart-breaking experiences...words cannot describe the loss we feel.

Our month of goodbyes in pictures. We said goodbye to those who we became good friends during our first few months of language learning.  We give these folks credit for keeping us alive when we first arrived.

We said goodbye to the operating room and surgical nursing staff at a lovely farewell dinner.

We said goodbye to M, who is a lovely friend and helped keep us fed by cooking beans and rice, tortillas, and bread for us.

We enjoyed an early Thanksgiving dinner with the entire compound.

we said goodbye in church (Luke spoke in Hausa...which was kindly translated into "better" Hausa that everyone could understand). :)

we (thankfully) said goodbye to Luke's beard :)

The schoolkids had a farewell party for us and gave us lovely custom tie-dyed pillowcases

we will miss you Buddy :(

Finally, a bunch of people (including most of the operating room staff) came to the airstrip to say final goodbyes. Many tears were shed.

As you can see, there were so many goodbyes to so many people we have come to know and love.
And, this isn't everyone. There were many more good byes with many more people, but you get the idea.  It has been one of the saddest months of our lives. But we are also excited to get home and see our families and see our friends that have been praying for us and supporting us these two long years and to tell them of the great adventures that we have had. Mixed emotions, Argh!!!!

we'll miss you, too, Martin

To all the peeps!

We are approaching the quarter pole of our African journey. Our break in Europe for a couple weeks gave us the chance to step back and think about all that we have accomplished over the past year and a half. Tab did so many surgical procedures she practically completed a second residency. I learned so much about computer networks and bio-medical equipment that I feel like I could actually be of value to a medical center somewhere.

We also started to realize that our time here is winding down. I decided to make a list of goals that I want to complete before I leave. I know this sounds like a procrastinator panicking but, this was something that I couldn't do before.  It took over a year to begin to understand where we are and where we would like to see this place go. With a lot of work and little luck we might get an electronic medical records system up and running here before I leave. It will be huge task but also a huge step forward for this hospital. Tab is just hoping to make it through the next several months of every other night call. We'll see how it goes and keep you informed.

And finally, I would like to give a HUGE shout out to all the people that have sent us care packages over the past year and a half. The little tastes and sights of America have been an incredible encouragement and fun respite from the realities of being so far from home. But now, since our time in Africa is coming to an end (for now) we must ask that you cease and desist. Or, if you are going to send them, send them now! :) Well, you don't have to, we just might not be here to enjoy it. But there will probably be people here that would enjoy it for us...

This picture pretty much says it all. I couldn't eat all of these. But wait...I almost have!  I still have some. Fourth of July peeps woot woot.

by the numbers

This week marks one year (!) since I started operating as an attending surgeon in Africa. Wow. And what a wild ride it has been. In the spirit of the annual report I sat down and tallied my cases for the past year.  Here are some numbers I found particularly interesting:

• I've done over 750 major cases. Compared  to an average of 200 major primary cases a year during my five years of residency that is a 375% increase in case load.
• 169 of those cases were C-sections...which I didn't do at all in training.  
• 106 were inguinal hernias...without mesh. I only fixed three without mesh during training.  
• 82 laparotomies to repair intestinal perforation from typhoid  (you guessed it...never operated for typhoid in training)
• 17 Graham patches for perforated stomach ulcers.

I've also removed 11 bladder stones, 11 uteri, 9 [huge] thyroids, 13 hydroceles, 3 esophageal foreign bodies, one worm...and only 6 gallbladders. No laparoscopic surgery. Lots of pediatric surgery. 

One thing is certain...there is no lack of work to do and no lack of variety!  I am so grateful for all of you that follow this blog, leave encouraging comments, and otherwise support the work that is happening here. We couldn't be here without you. 

resolved...

At the risk of making ourselves even more homesick, we did New Year's Resolutions a little differently this year. Instead of a listing what we want to do better or accomplish, we made a lighthearted list of things we've missed in the last year and are looking forward to "accomplishing" by this time next year when we are in the USA.  Many of you (in America) could complete this list in one week...I dare you. :D


Tab:

Eat real blue cheese (the stuff here isn't the same at all...its gooey not crumbly and tastes odd).
Drive a vehicle
Have Red Robin Blue Ribbon Burger with bottomless fries and ranch dressing
Play pinochle [with my family]
Shop at Trader Joe's and Target
Peruse the magazines at Barnes and Noble while drinking a holiday flavored coffee drink

Luke adds...

Watch a football game in the daytime
Go to a Mexican restaurant at eat queso, guacamole, enchiladas, and tacos
Buy a dozen Krispy Kreme donuts...and see how many I can eat
Go to a grocery store and just look at the food
Go to an English-only church service (or even an English-at-all one)

Together now...

Meet our new niece and nephew
Eat a sandwich made with lunch meat
Have strawberries and raspberries (if not fresh, frozen will do)
Enjoy a Cowboy Breakfast at the ranch (bacon, eggs, coffee, and pancakes cooked over a fire)
Eat Tillamook ice-cream


(Don't worry.I have a list of 'serious' resolutions too. They're just not as fun). :)

why now?

It may not always be an appropriate question. But sometimes I just can't help myself. I am curious. I don't understand. ..and sometimes the answer is important.

What causes someone to finally come to the doctor after waiting months or even years? Every day in clinic I see more advanced pathology then I ever did in training. Its "the worst" of this and "the biggest" of that.

Why do patients wait until their condition is so bad it often can't be fixed? What finally pushes them to decide to come? How many people never come? Likely it is a combination of lack of education, lack of money, and a fatalistic worldview...but I'm still asking questions... looking for clues. So I'll ask. "Why now? Why today?" Then, I try to figure out if we can help.

some people may find the following medical images disturbing

Here are some examples from the past few weeks.

An all-too-common story. Little boy whose dad brought him in 2 weeks after an elbow dislocation/fracture. His arm below the fracture was so tightly wrapped in the traditional manner that all the skin was dead and had to be removed.

Young boy complaining of trouble walking after a motorcycle accident two years ago. He came in because he has been having more and more knee pain. Check out his x-ray:

Yep, its broken!! It healed..just not straight and he's putting stress on the knee joint causing permanent damage.

Several years after an elbow dislocation...chronic nerve injury. Not much we can do.

there's  been something wrong with my foot for the past year...now we have to amputate

Advanced male breast cancer (there for a year). Breast cancer is more rare in men, but we have about 1-2 women a week come in with an advanced breast cancer similar to  this.

A woman my age...huge mass involving the lower abdomen and hip. I had to tell her that there is nothing we can do.

Two years with an infected, exposed tibia bone.  He sat on the floor in front of me because he can't walk (he can't straighten his knee). I asked him why he waited so long (Imagine two years as a kid...not being able to walk without help from his mom). He showed me his elbow fracture that had healed on its own (with a small residual deformity) and said he had hoped his leg would heal too. Now the only thing we can do is amputate...but at least then he'll be able to walk with crutches.

I bumped my elbow...

A year...probably longer than that for a tumor this size. Now she needs an amputation.

"Doc, I've had it 50 years...can you please take it off?" At least it looks benign. :)

Seeing all these people reminds me of how broken, physically and spiritually, we are. Sometimes its not as obvious...but we all need healing.

Psalm 103

 Bless the Lord, O my soul,
    and all that is within me,
    bless his holy name!
² Bless the Lord, O my soul,
    and forget not all his benefits,
³ who forgives all your iniquity,
    who heals all your diseases,
⁴ who redeems your life from the pit,
    who crowns you with steadfast love and mercy,
⁵ who satisfies you with good
    so that your youth is renewed like the eagle's.

One year and a day.

It has been a whole year since we were left Seattle and arrived here. It seems so long ago but it also doesn't. We have done so much and experienced so many things in this year. Overall we are thankful. Thankful; for all that we have blessed with since coming here. Thankful; for our wonderful supporters that faithfully pray for us and send notes of encouragement. Thankful; for the opportunity we have had to learn so much in the past year and that God has protected us and provided for us in every way. Here's to one more year!

We finished our tree today. I think it looks pretty awesome for being made out of cardboard. A special thanks to our friend S. She gave us her paint when she left. Now she can know it was put to good use.  Also, my multi talented wife did an awesome job making card board ornaments. Merry Christmas!

the ocean

"For the needy shall not always be forgotten,

and the hope of the poor shall not perish forever." 

Psalm 9:18

Perspective.

Yesterday morning I did teaching rounds with the residents. We saw every surgical patient in the hospital. There were 46. It took almost three hours to see them all. Seven patients with typhoid perforations. Two with peritonitis scheduled for exploratory laparotomy after rounds. Seven patients with neglected infections that will lose or have lost an arm or leg.The little boy who lost his arm because he came to the hospital several weeks too late. The girl with epilepsy who burned both of her hands and needs multiple finger amputations, but refuses as her fingers become more black and shriveled every day.

Healthy, straightforward patients seem few and far between- there is the man who can pee now because we took out his prostate, the child with the hernia repair, the thyroid removal. Despite all of the suffering, almost every patient responds with a huge smile when I greet them. Even the kids smile with just a little coaxing and a piece of candy. They are amazing, resilient people. I'm not so strong. By the end of rounds I just want to go home and forget about the suffering somehow.

I find myself thinking...Why does being a doctor here seem so hard? Why does it feel like there is a never-ending ocean of patients needing help?  

Because there is . 

It feels hard because it is hard. 

Turns out, its a big adjustment to move from practicing medicine in a country ranked number three on the UN Human Development Index to the country on the bottom of the list.  Last week, I read an article that was recently published in the Lancet, Malaria and Malnutrition: Niger's Twin Crises. Somehow, it helps me mentally to have a bigger perspective of the health care situation here.

"According to the UN Human Development Index, there is no country worse off than Niger. The landlocked West African nation, which is mostly desert, lingers at the bottom of the index: 186th of 186. Its government, heavily dependent on foreign donations, spends a paltry US$10 per person on health care every year. Vast swathes of the country are effectively wild: without schools, roads, or security. There are fewer than two health-care workers per 10 000 population (23 is considered the minimum number for provision of essential care) and more than 2 million people live in chronic food insecurity, of a population of 16 million." 

Life is hard. But there is hope. So I didn't go home after rounds and hide in my house. I did what little I could. I stayed and repaired a typhoid perforation and a stomach ulcer. Yes, its only a drop in the ocean, but I think I'm ok with that. I'm not here to save the world.

Friday night sunset

The Uncool

A few years ago I worked for UPS. There were thousands of people that worked in the facility. I could walk from one end of the building to the other and only exchange nods with people. I was just one of the crowd. I was a regular person. People knew I was a supervisor but no one except my employees knew my name. That was AMERICA. This is AFRICA.

Some days working here makes you seem like a rock star. Everywhere you go, people know your name, they greet you, they want to talk to you. They know your name even though you've never even spoken to them before. They know you were in town yesterday. They heard you bought mangoes. They wonder if you still want to buy a bicycle, their cousin sells bicycles. They might even know what you had for dinner last night. They invite you to have lunch with them or to stay in their house etc... It is kind of nice to be in such a friendly place. But after a while it can be ego inflating too.

There's a great scene in the movie Almost Famous about The Uncool. William has just spent the last month touring with a rock and roll band and having a mostly great time. The scene involves the teenage William making a late night phone call to his mentor. The story he is set to publish is going to make one group of people upset with him either his employer for wasting their time and money on him or his new friends in the band.  He is faced with a reality that he didn't want to return to. The truth comes from his mentor in an honest and brutal statement. It goes like this:

Lester Bangs: Aw, man. You made friends with them. See, friendship is the booze they feed you. They want you to get drunk on feeling like you belong.

William Miller: Well, it was fun.

Lester Bangs: They make you feel cool. And hey. I met you. You are not cool.

William Miller: I know. Even when I thought I was, I knew I wasn't.

Lester Bangs: That's because we're uncool. 

I think it is interesting that after several months of being a mini-celebrity you change. You can go places expecting people to be nice and to know who you are. But then, there is the other side of fame and fortune. When you are just going for a walk to get away from people and think, often you encounter someone that knows who you are, and wants to know if you need someone to wash your bicycle, or buy you mayonnaise, or wants to ask you a million questions. It is hard to have a good attitude either way. I find I struggle to have a good attitude in both situations.

It will be interesting to be back in America where I am just an ordinary person again. Will I miss the days of being a VIP? Will I have a good attitude about it?

This is one of the "I've never seen anything like it" cases today.  A teenage girl comes in with an umbilical wound present for 4 days, vomited once, normal bowel movements. On further questioning, her family tells me she delivered a baby 2 weeks ago.

On exam:

Malnourished girl with very distended abdomen, mild tenderness, something eroding from the umbilicus with surrounding cellulitis.

Her ultrasound looked kind of like this...her abdomen was filled with a multicystic mass with thin walls, uterus looked normal.

 What is it? I don't know. Ovarian tumor? Mucinous cystadenoma? Omentum eroding from an umbilical hernia...or a Sister Mary Joseph node.

Mystery. I'm not sure if I love it or hate it. I suppose its a little of both. I wish I were the type of person that just loved an endless supply of the mysterious and unknown. But I'm not. Unless there is a way to find the answer. Than its fun. Otherwise, it can be stressful and hard. Especially when another person's health/life is involved.
 
Here was the rest of my day...notice that less than half of the patients have problems that a general surgeon would take care of in the states. Its helpful to remind myself of that- there are good reasons to feel a bit frustrated and exhausted after clinic here!

1. Man 3 months post orchiectomy with a non-healing scrotal wound.
2. follow up after tibial sequestrectomy
3. follow up after Graham patch for perforated ulcer
4. Chronic draining sinus of left thigh
5. Chronic left leg wounds
6. Left thigh abscess
7. Nonspecific abdominal and leg pain
8. Child with 12cm incisional hernia several months after laparotomy
9. Resolved abdominal pain
10. Left hip abscess
11. Urethral stricture
12. Vesicocutaneous fistula, ultrasound for possible foreign body
13. Gangrenous toes in a diabetic
14. Peritonitis
15. Follow up chest contusion
16. Palatal mass and malaria
17. Finger infection
18. Large breast mass in young woman
19. Follow up shoulder dislocation
20. Follow up 20% body burn
21. Impacted bladder stone
22. Follow up toe mass removal in a child
23. Follow up chest burn
24. Peritonitis
25. Severe leg cellulitis
26. Urinary concerns in a man- stricture versus prostate
27. Left knee pain
28. Huge abdominal mass in young woman
29. Stage III breast cancer
30. 3 week old foot fracture
31, 32, 33. Young men in a motorcycle crash with various arm/leg fractures and lacerations
34. Young man pelvic fracture
35. De-gloving injury to fingers four days ago

36. Mastitis
37. Young man with testicular/epididymal mass 
38. Boy with ankle abscess after an iron fell on it four days ago

and a few I forgot...there were still more people to see, but we stopped letting patients in at 6pm. There is an ocean of need here and I can only do so much. It just never seems like enough.  Perhaps I just need to change my attitude...relax a bit more and try to enjoy the mysterious and stop trying to solve every mystery and treat every disease.  Perhaps then I won't wear myself out. *sigh*  I'm ready for the weekend.

Good ole Lewi's

So, I came to Africa with three pairs of Jeans and one pair of dress pants. I thought that they would last. I was wrong. Between the sand and the hand washing, two of those three pairs of jeans have bit the dust. So, I had to go shopping, not something I enjoy doing, even in America. Surprisingly, there are no shopping malls here. However, there is a weekly market that sells many things like food, hardware, housewares, clothes, and many other random things. But selection varies widely from week to week.

the market

The clothes for sale are usually from some thrift store either in America or they are irregulars or seconds from Europe. The condition can range from almost new to worn out. To add to the difficulty of finding suitable pants is that most of the pants are for women. Since women here don't wear or buy pants the same women's pants show up week after week unsold. If you do find men's pants they are usually small or huge or some style that would make me stick out in a crowd. So, one day on my way home from the market I found these lovelies. A  pair of Lewi Strauss Jeans. They were NEW and the right size. In addition to them being a cool knock off brand they are actually kinda nice looking. 

Lewis

After this  purchase, my wearable pants total went back up to two pairs! The next week I continued to look for more pants. I found some mediocre pairs that I think will work until I make it to a big city again.

One other interesting thing I found in the market this week was a medicine man selling medicine. And by medicine I mean random animal body parts put together into a potion. He had water buffalo, crocodile, fox, and wild dog heads stacked in the front of his stall. There were strange animal pelts on the ground and walls. When I walked by he beckoned me to come closer and to buy some of his medicine. Presumably you could buy some of those animals and make medicine from them that would cure you of whatever ailments you have. I thanked him and told him I wasn't in need of medicine today. I so wish I could have gotten a picture of all the unusual stuff he had. Perhaps next week I will go back and try to get a picture.

A similar thing happened a few weeks ago, a man tried to sell me a necklace that would protect me from evil spirits. It even had a name, it was named after the deceased wife of the man that made it. He promised me that if I wore it no spirits could harm me thanks to the dead lady. Over the past several weeks this prompted a few questions in my mind. Are humans supposed to be afraid of spirits? If so, why wasn't he wearing it to protect himself from the spirits? Why did he let it just sit there on his table? If this necklace could truly protect me from spirits, why was it merely two dollars? Shouldn't it cost more than that? Actually, now that I think about it, the necklace reminds me of one of the sports necklaces that they sell in America. You know, the ones that supposedly increase your blood flow and or balance or the bracelets that improve your golf swing. You know what I'm talking about? Necklaces apparently, can do some pretty amazing things. 

Images of the week

Can you see the fracture?

A bladder stone bigger than a chicken egg!  (don't forget to drink lots of water)

Barrel chest

Another reason to be very careful when riding a motorcycle. I'd show you a picture of the foot, but it is a probably a bit too gruesome for the blog. We spent a couple of hours amputating part of his foot while trying to save as much as we could. Unfortunately, it is very difficult (almost impossible) for patients to get prosthetic limbs here after amputation.

Just in case you didn't see it. I am glad we have a dentist here that can wire jaws. I don't enjoy putting wire through people's gums- it seems so painful.

There and back again.

So there are some statistics that were left out of that last blog. This journey lasted over four months, 11,000 miles, 21 states, and that doesn't include the thousands of miles we were in other people's cars. Here's a pretty rough map of where we drove, circles means we spent the night or stayed for a while. Some places we stayed more than once.

The main concentration of our driving was in the last three weeks.Initially we didn't plan on doing this much driving, but that is how it all worked out, and it was actually well worth it. It is pretty incredible the number of people we saw and all the places we went. We had an incredible time visiting those we rarely see, and getting to know so many new friends. 

With that journey complete all I can think of now is the next epic journey we will undertake. Our journey to Africa. God was blessing us mightily during this past journey. He was with us in all of our comings and goings. He taught us lessons and kept us safe. We are looking forward to what he will teach us and lead us through on our journey to Africa. That journey, is two years, and about a billion more miles, no big deal. 

some thoughts

The elation of passing oral boards has started to wear off and my routine of worries, fears, and concerns has resurfaced to diminish the feeling of happiness. I learned a few things about myself over the summer. I worry too much about what other people think and about how I can make things work. I don't care enough about what God thinks and how He is working on me. I like being in control and having other's approval. Now, having some control isn't evil in and of itself.  I mean, it's ok to have to-do lists and plans. But, when I'd rather check tasks off my list than spend time meditating or enjoying my husband...that's a problem. So, I am trying to take a step back, enjoy the moments, replace worry with the knowledge that God is in control. I am not down here on earth alone, trying to do things for Him, but I am meant to work with Him. And, He is good to work with.

Ode to CIT

Expectations are everywhere. I expected to post to this blog more than once a month. I expect someone to read it. If our expectations are too high, we get disappointed. If they are too low we may avoid doing something worthwhile. Managing our expectations is important. The last month or so we went through a cross cultural training program. When we first arrived, we were not sure what awaited us. Initially I felt there was a good chance we would not get along with many of the people there. I had been to places like this before. An obscure organization like this in the middle of no where, not far from the filming location of The Hunger Games. The chances of finding people that like us could be hard. That first night we settled in and resigned ourselves to only having to be there for four weeks, then we could continue on with our road trip. That first day everyone seemed to have already made friends. Well, it took a while but we finally broke in. We were pleasantly surprised to discover that most everyone there was awesome and just like us. They were moving away from everything and everyone they had ever known to live in place that they don't know or understand. They wanted to understand it, they wanted to know it. And that is why they were all there.
This is the moment where my expectations were exceeded. Over the next six weeks (we extended our stay by two weeks) our friendships deepened. The classes were great, thanks to great facilitators and our classmates' enthusiasm for the topics. Most nights were spent sharing meals together, playing games, and just getting to know each other. As they say, all things must pass. And so did this. The last day saying good bye was sad. So in the end, we loved it. What did you expect? Thankfully, there's Facebook!

These are those peeps. Some are not pictured, such as A.J., Chessy, Erica, the Espositos, Carneys and some others. But, yeah, this is most of them. 

It can be hard to comprehend the needs of others. I look at the map above and see that there is 1 doctor for every 390 people in the USA and 1 doctor for every 33, 500 in Niger. It's just a statistic. But when I start reading stories of doctors in the midst of the suffering, it becomes so real and sobering. During residency I had only a few patients die...in Niger patients die daily. Its a different world- one I will be joining soon.

The blog posts below describe the current experiences of two doctors in hospitals in Africa...check them out. The most recent posts will give you a glimpse into the life of a physician and patients at these hospitals.

Life in Niger (from the viewpoint of a doctor spending at month at Galmi Hospital...and the blog where I found the map above)

From the Amazon to Angola (intense/heart-wrenching perspective of a doctor working at a government hospital in Angola- read the 9/20 post)

We have been memorizing 1 Cor. 4 at CIT and the first verse is one I will likely quote over and over to myself in Niger when I am weary: "Rather, since through God's mercy we have this ministry, we do not lose heart."

Back where it all started.

Have you ever lived in a place and returned years later and had old nearly forgotten memories flood your recollection?  That is what has been happening to me the last couple weeks. It has been many years since I have been to the south and many more since I have been to the place where T and I met. We met in College in Carolina, ten years ago, this week. In some ways it doesn't seem that long ago, in other ways, it seems like many lifetimes ago. Our future together began with one awkward date with a mixture of silence and over disclosure. It worked out though, and we are together forever.

We have been in the south for about a month now. I have forgotten many things, like the red dirt, cicadas, and of course, humidity. We have seen many friends that we have not seen in years. It is good to catch up on all the latest news. The marriages, babies, and careers. I wish I had been able to visit the south more often over the past decade to keep better track of our good friends. We will continue to miss them over the coming years. One day we will connect with them again as if nothing has changed. Thanks to technology, all of them can follow us on our journeys. And thanks to facebook, we can follow theirs.

Overseas

This is just a quick thought I had. Tab has been to Asia, Australia, and Africa before. I have never left North America, unless you count Hawaii. So, I think she has a much better clue what we are about to get ourselves into. Last night we slept in the bed of our truck and took clean wipe showers in the morning. I thought I would handle it no problem. By this afternoon I was ready to have a nice hotel room.
 I thought I would post some pictures of us when we were overseas.

Me, in Hawaii

Tab in South Africa 2004