Monday 30 December 2013

Adventures

Well, I started this blog post two weeks ago, but needless to say, a lot has happened in the interim. I was initially going to write about my adventures in Kenya, a country that I visited for the first time mid November during my break. It was an amazing experience - having the privilege and opportunity to see first hand wildlife in its natural environment; zebras and elephants galore, prides of lions lounging about the savannah or fresh from a kill, all manner of fauna and flora so that the senses are bewildered at the enormous variety of God's creation on display! In fact, here are two of my favourite pictures from the safari (Swahili for 'journey'). On the left is a herd of zebras staring as we drive off and on the right is an elephant in the marshlands against the awesome backdrop of Mt Kilimanjaro, both taken in the Amboseli National Park, my favourite destination of the trip by far.

His House of Hope Hospital is on Google maps!
His House of Hope Hospital
is on Google maps!
But, circumstances have certainly changed. What with the attempted coup in Juba a couple of weeks back (only two weeks? It feels like a lifetime ago!) and the escalating tensions that spread like wildfire to Bor (Jonglei), Bentiu (Unity) and Malakal (Upper Nile) - all in the north or northeast and all significant for different reasons (Bor was the birthplace of the Second Sudanese Civil War and the SPLA/SPLM, Bentiu is one of the major towns involved in oil production and Malakal has the only international airport in the country outside of the capital) - our little hospital was closed and all the missionary staff evacuated to the neighbouring country of Uganda.

Although it may seem to appear (and feel) as if we were abandoning the South Sudanese, the timing was, as much as could be said to be the case in such a time, fortuitous. You see, the other Aussie doctor, his family and our missionary nurses were all scheduled to leave this week to attend a missions conference in Ethiopia. I was intended to hold the fort along with a visiting obstetric nurse from Canada for the next two weeks, a prospect that left me in immense dread, as you can imagine.

By the by, that is no longer the expectation; a silver lining in a very dark cloud. Pray for South Sudan. It is such a wretched situation; it tears me inside that this longsuffering people who have already endured half a century of conflict is on the brink of being thrown back into the calamity of civil war. With these politicians busy grabbing for power, it is the common people, caught in the middle, who pay the price. Not just the poor souls who have already been killed as a direct result of the unrest, but also all who grieve their loss and those who have fled into the bush for fear of their lives. The country with the highest maternal mortality rate and one of the highest under-five mortality rates in the world can ill afford such a setback; the little progress made in development initiatives by NGOs and international corporations would be lost and probably even regress.

In this season when we celebrate the incarnation of our Saviour Jesus Christ, may we remember the promise that heralded His coming:
Isaiah 9:1-7 
1Nevertheless the gloom will not be upon her who is distressed, as when at first He lightly esteemed the land of Zebulun and the land of Naphtali, and afterward more heavily oppressed her, by the way of the sea, beyond the Jordan, in Galilee of the Gentiles.
2The people who walked in darkness have seen a great light; those who dwelt in the land of the shadow of death, upon them a light has shined.
3You have multiplied the nation and increased its joy; they rejoice before You according to the joy of harvest, as men rejoice when they divide the spoil.
4For you have broken the yoke of his burden and the staff of his shoulder, the rod of his oppressor, as in the day of Midian.
5For every warrior's sandal from the noisy battle, and garments rolled in blood, will be used for burning and fuel of fire.
6For unto us a Child is born, unto us a Son is given; and the government will be upon His shoulder. And His name will be called Wonderful, Counsellor, Mighty God, Everlasting Father, Prince of Peace.
7Of the increase of His government and peace there will be no end, upon the throne of David and over His kindgdom, to order it and establish it with judgement and justice from that time forward, even forever. The zeal of the Lord of hosts will perform this.

Revelation 22:20 He who testifies to these things says, "Surely I am coming quickly." Amen. Even so, come, Lord Jesus!

Saturday 16 November 2013

Interlude

The pic is of one of my all-time favourite patients, precious little Anna :) She's one and a half years old and was admitted for just over three weeks. She came to us severely malnourished (weight under 5.5kg!) and near death with severe malaria complicated by severe anaemia (Hb under 4.0g/dL!). After much intensive therapy involving IV artesunate, whole blood transfusion, therapeutic feeds, and lots of hugs and kisses (she was everyone’s darling), she was sent home on Friday.

Dear Lord, please watch over her; we may not understand her social situation and why she got so sick in the first place but You do. You know how her parents are separated, how she lives with her abuba (grandmother), and how she may not have enough to eat at home. I know You love her so much that You gave up Your own life for her; I trust that You know best how to take care of us, even though we may not comprehend the whys and whereofs.

Isaiah 55:8-9 “For My thoughts are not your thoughts, nor are your ways My ways,“ says the Lord. “For as the heavens are higher than the earth, so are My ways higher than your ways, and My thoughts than your thoughts.”

Job 42:2-3 “I know that You can do everything, and that no purpose of Yours can be withheld from You. You asked, ‘Who is this who hides counsel without knowledge?’ Therefore I have uttered what I did not understand, things too wonderful for me, which I did not know.”

Romans 11:33-36 Oh, the depth of the riches both of the wisdom and knowledge of God! How unsearchable are His judgements and His ways past finding out! “For who has known the mind of the Lord? Or who has become His counsellor? Or who has first given to Him and it shall be repaid to Him?” For of Him and through Him and to Him are all things, to whom be glory forever. Amen.

When tragedies occur, it’s natural – even expected – to ask where was God in all this and why He would allow it to happen in the first place, given that He is indeed sovereign and a good God.  I don’t have any glib answers to this thorny question; I don’t believe anyone on earth does. There have been many theologians and philosophers over the centuries that have attempted to unravel this mystery of mysteries. All I know is that one day, we will find out; if not here, then in the hereafter when we shall see Him face to face. In the meantime, all we can do is trust that yes, He is omniscient (all-knowing), yes, He is omnipotent (all-powerful), but at the same time, He has been, is, and always will be goodness itself.

Isaiah 29:16 Shall the potter be esteemed as the clay; for shall the thing made say of him who made it, “He did not make me”? Or shall the thing formed say of him who formed it, “He has no understanding”?

After all, can we truly say that our lives are in total submission to His will? Are we so sure that the blame for whatever malady that befalls us can be laid at the feet of His whims and fancies rather than that of our own desires or the consequences of a fallen world badly in need of an overhaul?


P.S. The title refers to my upcoming break where I will probably not be blogging for a few weeks; see you all back in December!

Sunday 10 November 2013

Strength in weakness

This photo was taken by one of my favourite kids around the compound, a 10-year-old boy who's discovered how to use the camera (or rather, the Photo Booth app) on my iPad mini in more ways than I previously realised even existed.

Not much to update this time but I do have to confess how immensely grateful I am to our heavenly Father and to our excellent missionary nurses here for bringing me through the past two weeks safe and sound of mind. Words cannot express the dread and trepidation with which I was anticipating being the sole doctor at our hospital when my colleague went on his (much-deserved) leave. Our God knows our far our capabilities can be stretched and never allows us to be tested past them; or else, He gives us the strength to go that extra mile.

1 Corinthians 10:13 No temptation has overtaken you except such as is common to man, but God is faithful, who will not allow you to be tempted beyond what you are able, but with the temptation will also make the way of escape, that you may be able to bear it.

2 Corinthians 12:9-10 And He said to me, "My grace is sufficient for you, for My strength is made perfect in weakness." Therefore most gladly I will rather boast in my infirmities, that the power of Christ may rest upon me. Therefore I take pleasure in infirmities, in reproaches, in needs, in persecutions, in distresses, for Christ's sake. For when I am weak, then I am strong.

John 16:33 "These things I have spoken to you, that in Me you may have peace. In the world you will have tribulation; but be of good cheer, I have overcome the world."

In the aforementioned two weeks of working solo (so to speak), I have had more nights of unbroken sleep than while the other doctors were around. The women in labour were considerate enough to present during daytime hours more often than not and I could call another missionary doctor for advice over the phone. Contrast this with the week that has just past: three sets of twins were delivered just yesterday (including one set via C-section and one set at 22 weeks' gestation, i.e. not viable in our context) as well as two babies with severe birth asphyxia (one from likely chorioamnionitis in the setting of preterm premature rupture of membranes and the other from cord prolapse). I am so, so ready for my own break - coming up in just over a week's time, hallelujah!

The following song is dedicated to my longsuffering family who has had to put up with my obstinacy and stubbornness, from my decision to come here (although to be fair, it wasn't my decision per se but rather an attempt to follow what I have perceived as God's calling) to other petty issues I'll reserve for another time. I miss and love you all dearly.

Eloquent by Sanctus Real
I'm as eloquent as an elephant
About as headstrong as the mighty King Kong
On a rampage throwing airplanes
I can't believe you haven't gone away

I'm difficult, argumentative
About as thick skulled as the dinosaur bones
On a display in a glass case
I can't believe you haven't run away

[Chorus]
It must be different through your eyes
Because you look at me like it's the first time
That you've ever seen my face

I'm preoccupied with a crowded mind
I get off track like a train rolling back to the future
Never too sure who'll be here when I come back around
But I'm finding out

I see you the way that you see me
I don't understand the way you see me
- From the album The Face of Love - (see: http://www.youtube.com/watch?v=F1qXj4XOt8w)

As a footnote (although this news deserves more than that), please find out more about how you can help those recently affected by the catastrophic Typhoon Haiyan, which has already laid waste to areas of the Philippines and is currently heading towards Vietnam and Laos. Apparently there are 10,000 estimated dead in one city alone! You can start here:
World Vision - http://worldvision.com.au/Issues/Emergencies/Current_Emergencies/Typhoon-Haiyan-Philippines.aspx
Compassionhttp://www.compassion.com.au/content/typhoon-haiyan/gkkegp
Samaritan's Purse - https://www.samaritanspurse.com.au/typhoon-in-philippines/
OM http://www.om.org.au/give/find-a-project/philippines-appeal
Barnabas Fundhttps://barnabasfund.org/Poor-Christian-communities-hit-by-Typhoon-Haiyan-in-Philippines.html

Saturday 26 October 2013

Deliverance is nigh

Deliver Me

Deliver me out of the sadness
Deliver me from all of the madness
Deliver me courage to guide me
Deliver me your strength inside me

All of my life I've been in hiding
Wishing there was someone just like you
Now that you're here, now that I've found you
I know that you're the one to pull me through

Deliver me loving and caring
Deliver me giving and sharing
Deliver me this cross that I'm bearing

- By the Beloved from the album X -
(Covered by the David Crowder Band here http://www.youtube.com/watch?v=lnXYxevk-ak)

"In You, O Lord, I put my trust; let me never be ashamed; deliver me in Your righteousness. Bow down Your ear to me, deliver me speedily; be my rock of refuge, a fortress of defense to save me. For You are my rock and my fortress; therefore, for Your name's sake, lead me and guide me." (Psalm 31:1- 3). In the midst of turmoil, I will learn to trust that God has my best interests at heart. On the other hand, I've to admit that it's a rather self-centred conceit.

Sometimes I wonder how it's like to be God, to have to balance the good of the majority vs that of the individual (or as Spock would put it, 'the needs of the many outweigh the needs of the few' - utilitarianism neatly encapsulated). What type of philosophy would He subscribe to? Is it possible to chart a path through life that would result in the best outcome for every single created being, from the lowliest amoeba to the current leaders of the so-called free world (no comparison intended)? Theoretically, I guess the answer is 'yes'. All I know is I wouldn't like such a job, just thinking of the scope of the responsibility involved is enough to do my head in! It'll be worse than trying to spin plates, juggle balls, turn somersaults and eat fire (pardon the circus similes) all at the same time.

In the grand scheme of things, do my decisions make a difference? Does what I do in the here and now make a dent in how the future plays out? Does it ultimately matter if the answer was 'no'? Ah, the hubris of it all! The need to be known for something, anything, has been the downfall of many a person. The desire to leave a legacy, to make a mark that shows that yes, 'so-and-so was here'. Truly, "all flesh is as grass, and all the glory of man as the flower of the grass. The grass withers, and its flower falls away" (1 Peter 1:24).

"For no other foundation can anyone lay than that which is laid, which is Jesus Christ. Now if anyone builds on this foundation with gold, silver, precious stones, wood, hay, straw, each one's work will become manifest; for the Day will declare it, because it will be revealed by fire; and the fire will test each one's work, of what sort it is. If anyone's work which he has built on it endures, he will receive a reward. If anyone's work is burned, he will suffer loss; but he himself will be saved, yet so as through fire." (1 Corinthians 3:11-15) Even if it is my destiny to be forgotten, may my work be found to bring Him praise and glory forever, world without end.

Monday 21 October 2013

Haste does not make waste

Before I expound on the title of my current post, here's a pic for those wondering why I've not shown any photos of myself. As you can tell, I'm quite well fed here (although I don't think I've put on weight, as trivial a concern as that is). The kids up at the orphanage are way too familiar with my iPad now and have been taking random photos of (almost) everything, including yours truly. It's one of the five dresses I had tailor-made in Kampala and I must say I'm quite pleased with the result.

Yesterday was rather depressing as my day at the hospital ended with another child's death. This time, of a two-year-old boy who likely had severe malaria and multiorgan failure. He came to us febrile, tachycardic (>200bpm!!), tachypnoeic (70-90/min), hypoxic and markedly jaundiced. Over the course of the afternoon, he became more and more obtunded and was anuric for the entire duration of his stay. It was such a frustrating day as there were a multitude of events that did not happen as (I thought) they should have. What with delays in getting the first dose of artesunate in, the NGT for rehydration (since no one could obtain IV access), the dextrose as he became severely hypoglycaemic (the glucometer reading dropped from 1.6mmol/L to "Lo" half an hour later) and finally, the decision to proceed to insert an intraosseous line. Was there a single person to blame? Would it have changed the outcome? No, but I feel that things could certainly have happened half an hour to an hour earlier at the least. Then, I can truly rest easy (or easier) that we had done everything that was possible within our limitations. As it is, it tears me inside that this sick, sick kid wasn't initially taken seriously enough and treated with the respect and urgency that the severity of his case demanded.

In contrast, another two-year-old boy today almost crashed as well but I'm hoping we caught it in time. This kiddo is one of the worst cases of malnutrition I've seen yet. He's two years and three months old but weighs just under six kilograms; yes, he's lighter than most infants! Poor boy's from a nearby camp for Congolese refugees (it still astonishes me that there are people who would seek refuge in South Sudan). He had a NGT inserted today as he was losing weight despite being on a therapeutic feeding regime; a few minutes into his second feed, he became acutely unwell with marked respiratory distress. I suspect he aspirated; as it is, we got him on oxygen and antibiotics pronto. At the moment, he still looks pretty terrible but thankfully, not as moribund as before.

Before I started serving here, I don't think I truly understood or grasped the concept of the so-called "golden hour", the hour in which one can potentially change the clinical outcome of a critically unwell patient (although I think the concept came out of trauma medicine). There are so many factors that affect how a resuscitation plays out, e.g. if the patient deteriorated around handover time, the proximity of the patient to vital equipment, the seniority of the staff on duty, if it was a normal working day or a weekend and in daylight hours as opposed to in the dark of night etc. I recall one of the codes I attended while on cover shift back home: a middle-aged man scheduled for elective cardiac bypass grafting had arrested on the ward the day before his operation and I was sent to get his ABG results. I was flabbergasted when first the ICU nurse then the ED nurse refused to let me process it in their respective wards. Seriously, this guy doesn't have a heartbeat and you're saying that I can't use your machine because the correct procedure is to bring it to the lab?!

This rather reminds me of Jesus' warning to His followers to discern the hour of His second coming.
"Now learn this parable from the fig tree: When its branch has already become tender and puts forth leaves, you know that summer is near. So you also, when you see all these things, know that it is near, at the very doors...But of that day and hour no one knows, no, not even the angels of heaven, but My Father only. But as the days of Noah were, so also will the coming of the Son of Man be...Watch therefore, for you do not know what hour your Lord is coming. But know this, that if the master of the house had known what hour the thief would come, he would have watched and not allowed his house to be broken into. Therefore you also be ready, for the Son of Man is coming at an hour when you do not expect Him." (Matthew 24:32-33,36-37,42-44)

Sometimes, we need to know when to hurry. It may well be that we still have time to eat, drink and be merry. But it might also be that this very night, our souls will be required of us (Luke 12:13-21). Before Whitney Houston, Michael Jackson, Heath Ledger and Cory Monteith closed their eyes for the last time, I doubt any of them imagined that they would end up six feet under shortly thereafter. Whether self-inflicted or not, death comes for us all. May we be found ready!

Addition: Sadly, the second boy passed away today afternoon (22 Oct); I was called to his bedside after he arrested but this time there were no warning signs or any preceding deterioration. It's a bit of a mystery but my money's on some electrolyte imbalance or overwhelming sepsis.

Sunday 13 October 2013

Eye of the storm

The picture depicts a recent thunderstorm here. A more violent version of the drizzles we get in Melbourne and similar to the ones we have in Malaysia that causes roads (and homes) to flood and closes schools and offices for the day.

A fitting simile to the one plaguing my heart and mind, in other words. I'm officially unemployed for 2014 and I'm in a quandary regarding the right way forwards. It's definitely not the end of the road; there are many options available but I just don't know which is the correct one to pursue. I haven't had time or energy to properly seek God's will in this matter; poor excuses, I realise.

On one hand, sure, it's a blow to the ego, but I'll live. On the other hand, I don't want to take the path of least resistance for the sake of convenience. It's disrespectful to the other party and just plain lazy on my part. I could apply for a job elsewhere (which would most likely be overseas since most of the job openings in Australia have closed). I could undertake some postgrad courses, an option that has always been on my radar (specifically a Masters in Public Health or Diploma in Tropical Medicine which would involve travelling to either the USA or UK for a time). I could bum around (an option that would probably give my parents a heart attack!). And I could always stay here if Pioneers and Harvesters would have me, I suppose. Again, I just don't want to make any decision out of desperation and merely because I don't have any alternative choice.

I have strived to operate under the belief that God has placed a calling on my life; to medical missions long term but also to first complete my specialty training (whatever and wherever that may be). Have I been mistaken? I don't think so but there's always the danger that my desires have clouded my hearing from His Spirit regarding what He wants, as opposed to what I want. They may not be dissimilar but I doubt they're identical.

Acts 20:24 "But none of these things move me; nor do I count my life dear to myself, so that I may finish my race with joy, and the ministry which I received from the Lord Jesus, to testify to the gospel of the grace of God."

1 Corinthians 9:24-27 "Do you not know that those who run in a race all run, but one receives the prize? Run in such a way that you may obtain it. And everyone who competes for the prize is temperate in all things. Now they do it to obtain a perishable crown, but we for an imperishable crown. Therefore I run thus: not with uncertainty. Thus I fight: not as one who beats the air. But I discipline my body and bring it into subjection, lest, when I have preached to others, I myself should become disqualified."

Philippians 3:8-14 "But indeed I also count all things loss for the excellence of the knowledge of Christ Jesus my Lord, for whom I have suffered the loss of all things, and count them as rubbish, that I may gain Christ and be found in Him, not having my own righteousness, which is from the law, but that which is through faith in Christ, the righteousness which is from God by faith; that I may know Him and the power of His resurrection, and the fellowship of His sufferings, being conformed to His death, if, by any means, I may attain to the resurrection from the dead. Not that I have already attained, or am already perfected; but I press on, that I may lay hold of that for which Christ Jesus has also laid hold of me. Brethren, I do not count myself to have apprehended; but one thing I do, forgetting those things which are behind and reaching forward to those things which are ahead, I press toward the goal for the prize of the upward call of God in Christ Jesus."

All three passages echo the sentiment that our journey through this earth is an ongoing process that would only find completion in the next life. But how to see clearly where the road leads? And what should we do when it branches? I don't do well with uncertainty but that's just too bad, I guess, since that's part of living in a fallen world. God help me, I just want to serve You. As Mary said to the angel Gabriel in reply to the Annunciation, "Behold the maidservant of the Lord! Let it be to me according to your word." (Luke 1:38). May my life ever reflect Your glory and Your goodness. May it be that at the end of days, when we finally meet face to face, I would have the passing joy of hearing You say, "Well done, good and faithful servant" (Matthew 25:21,23)!

Wednesday 9 October 2013

Life and Death

It has been a turbulent week to say the least. How to chronicle the emotional rollercoaster of resuscitating a baby born with severe birth asphyxia for an hour before withdrawing treatment then see her practically come back to life an hour later? Of having to inform a family that their three-year-old son probably has only hours left to live? Waking up to the wailing of a mother who has just lost her child?

How to address one of your patients for whom you've been caring from the time she was admitted with preterm contractions, held at bay for a week or so before elective Caesarean section delivered her a pair of beautiful twin girls, only to be robbed of one of them a couple of days later? Do you avoid her gaze when passing her in the corridor? Try to pretend nothing's happened? What do you say after the paltry and customary 'maleesh' (sorry)?

What words are there to comfort the primigravida (first time mum) whose premature daughter has had multiple episodes of apnoea and bradycardia requiring CPR each week during her one month stay? It breaks my heart every time I see the look of fear in her eyes, wondering if her child will survive to the next day. And this in the context of her having already seen at least three or four others in the adjacent beds not making it. In the photo, her daughter's the one to the extreme left; these three precious bubs were all born at 31 weeks' gestation.

At least, let me tell you the story of Gloria, our miracle baby (not shown in the pic). It's one of the most amazing sequence of events that I've had the privilege of witnessing. She was born twenty minutes past midnight after a difficult second stage via vacuum assisted delivery. There was meconium present and a history of prolonged rupture of membranes but her mum did receive one dose of prophylactic ampicillin. She had poor Apgar scores from the start - floppy, bradycardic and only occasional spontaneous respiratory efforts. We bagged her for an hour but her cardiac output seemed entirely dependent on artificial ventilation, which unfortunately isn't sustainable in our context. After some tearful discussion with family, we decided to stop and allow the baby to pass on in peace. This was followed by a sorrowful outburst from the mother, who cried out to God asking over and over for forgiveness and for Him to spare the baby.

Well, at this point in time, the baby was still breathing but only at a dismal rate of one per minute (contrast this with the normal range of 40-60/min), the kind of pre-terminal gasping that heralds imminent death. We fully expected her to die over the course of the next few hours. The team subsequently debriefed in a separate room; after an hour of wrecking our brains trying to figure out what went wrong and what could have been done differently, I returned and was promptly informed by the baby's smiling aunt that the baby was ok! And indeed, the baby was breathing spontaneously at a regular rate with a strong pulse and much improved tone.

What did all this mean? Was it transient respiratory depression secondary to...what? No drugs were implicated, there was no evidence of a neurological cause, the baby was not floridly septic and yes, the baby was born at term. Was it a divine answer to a desperate cry from the heart? We later found out that the mother had been pleading for forgiveness due to a messy history of the baby being conceived to a different man to the one she was intending to marry - her original plan was to basically abandon the baby to the biological father. Not ideal but it could have been worse (I recall another mother who almost bled to death from a self-induced abortion). Whatever the rational explanation accounting for this remarkable turn of events may be, I firmly believe God was behind it. Nature may elucidate the how but never the why.

I am reminded of the following passage...
1 Samuel 1:15-16 And Hannah answered and said, "No, my lord, I am a woman of sorrowful spirit. I have drunk neither wine nor intoxicating drink, but have poured out my soul before the Lord. Do not consider your maidservant a wicked woman, for out of the abundance of my complaint and grief I have spoken until now." Then Eli answered and said, "Go in peace, and the God of Israel grant your petition which you have asked of Him."
And He did! Hannah had a son, the great prophet Samuel. Only God knows what Gloria will grow up to become but we've a hunch it'd be anything but ordinary. :)

Wednesday 18 September 2013

A prayer to the God of my life...

The backyard of a local church compound
Psalm 23:1-6
The Lord is my shepherd; I shall not want. He makes me to lie down in green pastures; He leads me beside the still waters. He restores my soul; He leads me in the paths of righteousness for His name's sake. Yea, though I walk through the valley of the shadow of death, I will fear no evil; for You are with me; Your rod and Your staff, they comfort me. You prepare a table before me in the presence of my enemies; You anoint my head with oil; my cup runs over. Surely goodness and mercy shall follow me all the days of my life; and I will dwell in the house of the Lord forever.

Psalm 42
1-2 As the deer pants for the water brooks, so pants my soul for You, O God. My soul thirsts for God, for the living God. When shall I come and appear before God?
5-8 Why are you cast down, O my soul? And why are you disquieted within me? Hope in God, for I shall yet praise Him for the help of His countenance. O my God, my soul is cast down within me; therefore I will remember You from the land of the Jordan, and from the heights of Hermon, from the Hill Mizar. Deep calls unto deep at the noise of Your waterfalls; all Your waves and billows have gone over me. The Lord will command His lovingkindness in the daytime, and in the night His song shall be with me - a prayer to the God of my life.

Psalm 27
1 The Lord is my light and my salvation; whom shall I fear? The Lord is the strength of my life; of whom shall I be afraid?
4 One thing I have desired of the Lord, that will I seek: that I may dwell in the house of the Lord all the days of my life, to behold the beauty of the Lord, and to inquire in His temple.

Monday 16 September 2013

Serenity

I captured this photo on an idyllic afternoon last week. It's hard to discern the features unless you zoom in but if you do, you may see in the centre a little boy pushing a huge tyre (as big as himself!) with a stick. It's one of the favourite games the kids here play.

At any rate, last weekend almost broke me, mentally speaking. I was so tired that I slept from 9pm last night till noon today - 15 hours of bliss. Let me give you a taste of what confronted me over the past week:

Paediatric ward:
In bed 1, we've an 11-day-old female who presented with 48 hours of seizures. She had a home birth and the mother had not received any antenatal care prior to delivery. Diagnostic dilemma: febrile convulsion vs cerebral malaria vs meningitis vs neonatal tetanus. Malaria smear was negative but we had otherwise no way of proving any of the other possibilities so we ended up covering with ampicillin, gentamicin, aciclovir and metronidazole as well as phenobarbital and diazepam (no neuromuscular blockers, paraldehyde or chlorpromazine). At any rate, over the course of her admission, neonatal tetanus became more and more likely as her seizures were tetany-like and were provoked by touch. Pray for us as we'll be deciding in the next few days if treatment should be withdrawn depending on what we think her neurological outcomes could be (which is going to be a challenge since no one can besides God can foretell that with certainty).

In bed 2, we've a two-year-old boy with gross generalised oedema (swelling) and 16 hours of anuria (no urine output). The anuria was later found to be secondary to urinary retention as he had one of the worst cases of penile and scrotal oedema that we've seen and he required a suprapubic tap to relieve the post-renal obstruction. We've finally got the ability to test electrolytes (hallelujah!) but the machine was playing up; our first specimen gave a potassium of 14.2mmol/L (!!!) and the second was so high it could not be recorded. The troubling thing about this was that both samples were arterial in source since none of us could get venous access due to the oedema. However, it's doubtful he would have lasted this long with such severe hyperkalaemia.

In bed 3, we've a one-year-old boy with the same presentation but less severe.

In bed 5, we've a fourteen-year-old boy with worsening dyspnoea and chest pain as well as abdominal pain and distension. Found to be febrile and on examination to have massive hepatosplenomegaly as well as cervical and inguinal lymphadenopathy and CBC showed severe anaemia (Hb 4.9) and thrombocytopenia (Plt 21). Treated for presumptive malaria and transfused one unit but the Hb post transfusion actually dropped to 4.8g/dL and there was bilirubin and urobilinogen +++ in his urinalysis, indicating an ongoing haemolytic process. CXR did not show any obvious cardiomegaly, effusions or consolidation, his WCC was normal, LFTs were only mildly off and both ESR and triglycerides were elevated. At this point, our differentials were leukemia/lymphoma, autoimmune haemolytic anaemia, autoimmune lymphoproliferative syndrome +/- Evans syndrome, haemophagocytic lymphohistiocytosis and macrophage activation syndrome. We started prednisolone on Saturday night but unfortunately, he developed worsening respiratory distress overnight and passed away this morning.

We had a total of five premature infants last week, four born at 31 weeks! Sadly, two died.
- The first died on the night of admission: I wasn't on call that night but the little two-day-old boy (~35 weeks' gestation born at home a/w possible meconium-stained liquor) had been tachypnoeic since birth and apparently had frank haemoptysis/haematemesis before passing on. We still can't figure it out but one hypothesis is the nasal cannulae causing epistaxis which bubs normally swallow and then cough out and another possibility is meconium aspiration syndrome but his respiratory distress seemed more severe than expected if that was the case.
- The second died on Sunday morning; the one-week-old boy had been noted on Friday and Saturday nights to have reflux associated with apnoeas and bradycardia. This was a particularly vexing case for me since the sequence of events was that at 5am, the mother notified the night nurse on duty that he seemed to be in a bit of strife; by the time the nurse arrived, there wasn't any cardiac output but I was only called about it 18 minutes later! By which time, it was way too late. Argh...so frustrating, especially since his twin later developed the same problem that afternoon but we got there within a couple of minutes and basically brought him back, thank God. The poor mum, a 15-year-old primip, was crying into my lap for an hour and a half.

Obstetrics ward
In bed 1, we have a HIV-positive mother who is two weeks post elective C-section (four previous scars) with acute right hemiparesis and facial droop as well as mild dysarthria and confusion. She had only one documented fever, was normotensive without any signs of pre-eclampsia, and had a normal ECG but was surprisingly neutropenic (0.8). Was it a stroke? Cerebral toxoplasmosis/TB? Some autoimmune disease? CNS lymphoma? She was asymptomatic and well besides these neurological deficits so it's a bit of a mystery. We covered with cotrimoxazole and sent her back to the local antiretroviral treatment centre to hopefully be recommenced on HAART.

In bed 2, we had a 20-year-old primip who delivered twin girls; one a stillbirth (foetal death in utero at time of presentation) and the other one of the prettiest babies I've ever set eyes upon. Both mum and baby had malaria and received adequate treatment but the mother was persistently anaemic (with Hb levels < 5.0g/dL!) despite four units, which is a lot in our context (most patients get only one unit even with Hb levels as low as 1.9g/dL). She was later found to also be Hep C positive and had massive splenomegaly; no retained tissue on ultrasound examination. DDx: FDIU-related coagulopathy, hyperreactive malarial splenomegaly (aka tropical splenomegaly syndrome), Hep C-related cirrhosis and some form of autoimmune haemolytic anaemia. None of it was ever proved or disproved but my money's on the first two.

On Friday evening, a two-year-old boy arrived in status epilepticus, later found to be secondary to cerebral malaria. On Saturday morning, we had another primip who proceeded to C-section for foetal distress followed by a VBAC with unproven pelvis (first child was delivered via C-section for breech presentation) that eventually required a vacuum. That evening, a lady arrived near-collapse a day post septic miscarriage at 10 weeks' gestation. And in the early hours of Sunday morning was the death of the second premmie.

Amidst all this madness, we were also taking care of one of our nurses who had the misfortune to be in a hit-and-run pedestrian vs motorcycle accident the week before. He almost certainly had a base of skull fracture (bleeding from both ears and nose as well as left sided LMN facial nerve palsy) but thankfully has gradually recovered with conservative management (the only option available to us considering there isn't a CT scanner or neurosurgical service in this country) and is now fully oriented to TPP with mild persisting dizziness and no further headaches.

God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And wisdom to know the difference.
- Reinhold Niebuhr, 1943

Amen and amen, brother.

Sunday 8 September 2013

Faithfulness

Hymn by Brooke Fraser
If to distant lands I scatter
If I sail to farthest seas
Will You find and firm and gather
Till I only dwell in Thee

If I flee from greenest pastures
Would You leave to look for me
Forfeit glory to come after
Till I only dwell in Thee

If my heart has one ambition
If my soul one goal to seek
This my solitary vision
Till I only dwell in Thee
That I only dwell in Thee
Till I only dwell in Thee

- From the album Albertine -
http://www.youtube.com/watch?v=jRW8WV5cFaU

No matter where, no matter how, He will neither leave us nor forsake us. May this be our prayer for the world in which we find ourselves today. May we remember our brothers and sisters suffering in Syria, Egypt and countless other countries (Making sense of the Middle East). May we know His love is stronger than death and may this truth be lived out in our every word and action.

This is a faithful saying: For if we died with Him, we shall also live with Him. If we endure, we shall also reign with Him. If we deny Him, He also will deny us. If we are faithless, He remains faithful; He cannot deny Himself. 2 Timothy 2:11-13

Wednesday 4 September 2013

Home is where the heart is

The three resident cats
Psalm 137:1, 4-6 By the rivers of Babylon, there we sat down, yea, we wept when we remembered Zion...How shall we sing the Lord's song in a foreign land? If I forget you, O Jerusalem, let my right hand forget her skill! If I do not remember you, let my tongue cling to the roof of my mouth - if I do not exalt Jerusalem above my chief joy.

Being in South Sudan now for two months (three if I included the brief time I was here in March/April), I'm naturally homesick. Frankly, I get homesick quite easily (like the time in internship when I was attached to a rural clinic about two hours out of Melbourne, I would drive home every weekend I wasn't on call). This takes it to an entirely new level.

No family. No friends. No car. No Chinese food. Just to get basic amenities like soap or groceries means a trip into town, which involves catching a boda (motorcycle) and negotiating the dirt roads that turn into slippery mud in the rainy season. No international ATM machines so you better hope you brought enough cash prior to arrival. No 000/911/999 number to call in case of any emergencies; e.g. if in need of an appendicectomy, your options would be to either submit yourself to the local health service or going down the very complex (not to mention expensive if uninsured) route of organising a medical evacuation. No postal service so what you packed in your luggage is what you'll live with for the next few months or, at any rate, until your next flight out to neighbouring Kampala, Nairobi or back home.

Truth be told, it isn't all bad. I gained a new family in the other missionaries here in the compound (some of whom have been here for over a decade and have lived through the war together with the longsuffering Sudanese). I've the chance to make new friends in the people I meet everyday, be it as a doctor, kawaja (foreigner) or otherwise. I'm young and healthy - I can walk where required. I've three prepared meals a day (we have communal meals here in the compound) and I can cook (although procuring ingredients can be tricky; I'm currently lamenting my lack of foresight in bringing essentials such as oyster sauce!).

It's taught me that 'home' is a fluid concept. I guess I first learned this when I migrated from Malaysia to Australia as a teenager back in 2003. It took me almost eight years to get over my homesickness then, and I still consider Malaysia my first home. Home is such an integral component of one's identity, so much so I firmly believe that it could cause a crisis when there's an inability to shift or to reconcile a dissonance between what was and what is. Will there ever be a time when I can say that such a place is no longer home? I don't think so. It will always be a part of my heart and soul, but I believe that these can expand to include other people and other places. It has to as a matter of necessity, even if only to survive the emotional trauma.

Psalm 122:1, 6-9 I was glad when they said to me, "Let us go into the house of the Lord."...Pray for the peace of Jersualem: "May they prosper who love you. Peace be within your walls, prosperity within your palaces." For the sake of my brethren and companions, I will now say, "Peace be within you." Because of the house of the Lord our God I will seek your good.

For the sake of my family and friends both in Malaysia and Australia, I will always seek the good of these countries and uphold them in my prayers. Who knows whether this place would eventually take on a similar role one day? All I know is our final home will never change, and I choose to find comfort in that irrevocable reality.

Sunday 25 August 2013

Pressure

This week has been one of the busiest weeks of my life! At the end of Wednesday, the other doctor (a recently-employed Ugandan-trained South Sudanese PGY2 - who has done 200 Caesarean sections during her internship!!) and I looked at each other and mumbled that if the rest of the year was like that day, we would totally break down in exhaustion. Well, ironically enough, Thursday was worse than Wednesday and Friday was even more terrible! I heard yesterday was très horrible too, hopefully things have settled down by today.

We had another bub who died on Friday. She was born via vaccum-assisted vaginal delivery two days prior. Her mother had a previous C-section but did report one successful VBAC (vaginal birth after C-section). In retrospect, I thought it would have been reasonable to take her to theatre for repeat C-section; she had prolonged rupture of membranes (over 24 hours) and there were multiple decelerations on monitoring as well as a persistent anterior cervical lip on examination. Anyway, that didn't eventuate and it mightn't have changed the outcome either (hard to predict since we had no way of telling how long the foetal distress had been present). We try to avoid C-sections if at all possible since contraception's unheard of here and it'd be disastrous for a woman with two or more scars to deliver at home.

Anyway, on delivery, there were large amounts of meconium in the liquor as well as in the baby's airway, she had low Apgar scores and took quite a bit of resuscitation. She seemed to do well over the next few hours and was even weaned off oxygen. Right around midnight, I was called back to the ward since she started developing respiratory distress and became febrile despite already being treated with IV ampicillin and gentamicin. The next 36 hours was chaotic as we battled with temps over 41 degrees, seizures presumably due to the high fever, and ongoing laboured breathing even with oxygen and CPAP support. Poor baby, it was all too much for her and she just gave up after around midday. The first hint I got of it (since I was on clinic duty) was when I saw the large group of people congregated around her bed, all of them standing stock still and solemnly listening to someone inside the room speaking. It was quite touching as they then sang a song (a requiem, if you like) before leaving with the body, the women weeping as they did so.

Could we have done anything differently? I honestly don't know. Meconium aspiration syndrome +/- peripartum foetal asphyxia +/- ?occult subgaleal/intracranial bleed (no way of excluding it but no pupillary or limb movement asymmetry) = ultimately futile efforts. Of course, it's no reason to stop trying; in the end, God is the decider of our fates. Because, really, we all die one day. The question is when, where and how. Will we be ready when the time comes? Am I prepared to meet my Maker? At times, I can confidently say 'yes, Jesus, take me home'! However, I've to confess that my heart has also sought greener pastures that inevitably turn out to be gateways into the wilderness instead.

Jeremiah 2:13 "For My people have committed two evils: they have forsaken Me, the fountain of living waters, and hewn themselves cisterns - broken cisterns that can hold no water."

P.S. Regarding the pic, we had an unexpected appendicectomy a few weeks ago. A German missionary from another NGO developed appendicitis (in first trimester pregnancy, no less!) and we had the opportunity to host a visiting general surgeon for the procedure.

Monday 19 August 2013

Complexity

The pic is a preop X-ray of a little boy's left foot (yes, left - I had unwittingly flipped the film over when I took the photo). He presented two weeks after accidentally kicking a fence while playing football (such a dangerous sport!), a week after his mother had found and removed a wooden splinter sticking out of his great toe just adjacent to the toenail, and a few days after he developed three sinus tracts over the dorsum of his foot that subsequently discharged frank pus. As you can (hopefully) clearly see, there is a transverse fracture running through the epiphysis of his proximal phalanx. What was worse was that when we took him to theatre for washout and debridement, it was an open fracture; the proximal edge of the toenail had lifted off, revealing the bony structures underneath. The little box at the corner of the pic shows the epiphysis of the proximal phalanx on the left and the entire distal phalanx on the right (looks rather similar to a tooth, right?); these bone fragments were found to be completely detached from the neighbouring soft tissue once the nail was removed. At any rate, he's probably headed for a partial amputation, poor kid.

Two days ago, we had two deaths, both boys under the age of five years. The first was dead on arrival; he had been admitted at our facility for over two weeks back in June with developmental delay, stunted growth, pectus carinatum (pigeon chest), and an incidental finding of malaria, which was treated but never really made a complete recovery. At any rate, he represented with respiratory distress, was seen at another clinic that morning and got referred to us. However, due to it being Saturday, he was left sitting outside the clinic (which is closed on weekends) for around half an hour before I was notified of his presence and by the time he was brought to the ward, had already passed on, presumably from a primary respiratory arrest.

And neither's even the complex case I wanted to discuss. The second boy, aged 2 years and 8 months, has got to be one of the most complicated cases I've encountered in my brief career and, in my humble opinion, would have warranted ICU admission posthaste as well as a postmortem back home (but unfortunately, such resources are unavailable here). He presented in a pre-terminal state - obtunded with minimal response to external stimuli, bradypnoeic (RR 8/min) with a Kussmaul's respiratory pattern, as well as generalised oedema. In fact, he was so puffy that none of us could obtain intravenous access and we had to rapidly make the decision to insert an intraosseous line. On the (correct) hunch that hypoglycaemia could have contributed to his moribund state, we gave a bolus of 50% dextrose with immediate improvement in his respiratory effort.

Over the course of the afternoon, more history was elicited; the oedema was first noticed a MONTH prior to presentation, which in turn was preceded by (non-bloody) diarrhoea, some oral as well as buttock sores and possibly a sore throat. On the other hand, his respiratory distress was an acute event, having only started that morning after breakfast. A CXR and quick ultrasound scan did not reveal any drastic effusions (pericardial, pleural or otherwise), consolidation, cardiomegaly, cardiac valvular pathology, hepatic/splenic lesions or ascites. We don't have biochemistry so we were unable to exclude renal or hepatic impairment but his urine output was borderline adequate and there was no obvious hepatosplenomegaly, jaundice or coagulopathy; urinalysis did reveal a mild degree of haematuria and proteinuria with white cell casts seen on microscopy. No paediatric sized blood pressure cuff either so his BP remains unknown.

At this stage, my top differentials were glomerulonephritis of some form (likely post-streptococcal) +/- malaria (smear proven two weeks ago with likely suboptimal treatment elsewhere). As you could probably tell, that wasn't the end of the story. As a matter of fact, it only got curioser and curioser (as Alice would put it). He then developed seemingly refractory hypoglycaemia; it was persistently low despite numerous boluses of dextrose. Was it due to leakage of the dextrose solution from the intraosseous line? A false reading since the samples were capillary in source and there was gross oedema giving a dilutional effect? Or something occult like central adrenal insufficiency? Not having any hydrocortisone, we trialled a stat dose of dexamethasone. Either way, despite our throwing everything we have at him, it was a case of too little, too late. Spontaneous respirations ceased eight hours later; throughout the whole admission, he had been (almost malignantly) tachycardic with laboured breathing and a decreased conscious state.

If it had in fact been GN, why was his respiratory distress so acute one month after the precipitating cause? If it was malaria causing severe hypoglycaemia, why was the smear at our lab negative when it should have shown at least some degree of parasitaemia? If it was APO secondary to some other cause (cardiac, hepatic or otherwise), why was it not shown on CXR? Why did the hypoglycaemia not respond to treatment? Could it have been HUS secondary to enterohaemorrhagic E.coli; if so, why was bloody diarrhoea absent? There were just so many points that didn't add up and it's left us confounded. Worse still, it's left his family with one less member. His mother wasn't even present to say goodbye as she was at home with a newborn. At least, he died surrounded by his father, grandmother and a cohort of aunts and uncles.

It reminded me of how finite our knowledge is, how limited our skills and talents are, how powerless we are in the face of death. The good news, thankfully, is that through the love of God incarnated in the body of Christ, we can transcend this mortality and know that this is not the end.

1 Corinthians 1:20-25 Where is the wise? Where is the scribe? Where is the disputer of this age? Has not God made foolish the wisdom of this world? For since, in the wisdom of God, the world through wisdom did not know God, it pleased God through the foolishness of the message preached to save those who believe. For Jews request a sign, and Greeks seek after wisdom; but we preach Christ crucified, to the Jews a stumbling block and to the Greeks foolishness, but to those who are called, both Jews and Greeks, Christ the power of God and the wisdom of God. Because the foolishness of God is wiser than men, and the weakness of God is stronger than men.

Sunday 11 August 2013

Let the little children come

This picture is of a precious little girl who can be seen most days running around the hospital compound as her mother is one of our cleaners. She is such a cutie! And very bright too. She now associates me with my iPad mini, which I carry everywhere with me (since it contains most of my medical references such as UpToDate) and always asks to see the photos on it and has already learned to swipe to get to the next pic! Mind you, this is on the background of most people here having never seen a computer or a camera.

Kids can be found in abundance here. In fact, I recently met a patient who was surprisingly distraught over the revelation that she was 17 weeks pregnant. She kept repeating, 'No, I'm not pregnant. I cannot be pregnant!' in spite of my showing her on ultrasound that there was clearly a baby in her womb and his or her heart was beating along at a happy pace. With further probing, it appeared that she was so upset because she was currently breastfeeding her second child (a nine-month-old girl who, incidentally, I later found out was an inpatient in our ward suffering from malaria) who was also conceived while she was breastfeeding her first one! So much for lactation as a form (really, the only version here) of contraception.

But Jesus said, "Let the little children come to Me, and do not forbid them; for of such is the kingdom of heaven." (Matthew 19:14). Expanding in Mark 10:15 that "whoever does not receive the kingdom of God as a little child will by no means enter it" and in Luke 9:48 that "whoever receives this little child in My name receives Me, and whoever receives Me receives Him who sent Me. For he who is least among you all will be great."

It has often puzzled me what He meant by "receiving the kingdom of God as a little child". Did He mean in innocent wonder? Open acceptance? Trusting credulity? All of these and more? I haven't been a child for a while now (although my parents still treat me as one!) and I don't have one of my own so feel free to leave any thoughts or comments on this point. For now, I guess I will have to study these little ones and attempt to discern the difference between childlike and childish faith :)

P.S. To my amazement, I discovered that the little girl's hair was NOT held up with any hair tie or band; apparently, the hair fibres of the Africans here are stiff enough that when braided, will hold together of their own volition! Pretty crazy, hey?

Monday 5 August 2013

The socioeconomics of health (or the lack of it)

View from the front of the hospital
My nose is running (leaking?) like a tap. Probably an after-effect of almost 25 hours of work yesterday; got woken up at 4.30am to attend to an increasingly tachycardic pre-eclamptic primigravida lady post vacuum-assisted vaginal delivery. She turned out to have postpartum haemorrhage (with an acute drop in haemoglobin level from 113 to 53 in less than 12 hours) requiring manual evacuation of clots under sedation. And didn't get to bed until 5.30am the NEXT morning. "You have got to be kidding me" was my apt reply when informed by the nurse on duty at 10.30pm that the heavily pregnant mother of one of our long-stay patients (a malnourished pre-school boy) had gone into labour. I've been awake for much longer before but haven't needed to be "switched on" (seeing patients and having to navigate the intricacies of their management) nearly that entire time.

Anyway, that brings me to another of our long-stay patients, also incidentally a malnourished boy who's just under 3 years old. He's been with us for 2.5 weeks (which is very very long by the standards of a mid-level rural African hospital where the average turnaround time is just a couple of days). Poor kid's severely wasted and we've been trying to get his weight up to little avail despite successfully treating his malaria and diarrhoea (secondary to ascariasis, which I previously didn't know existed). We think it's most likely attributable to his HIV-positive status. We've been trying for over two weeks now to get him to the local public hospital's antiretroviral treatment centre (the only clinic in town with UN-funded HIV meds), which has to be one of the most trying endeavours I've ever embarked on.

First time, his mum 'forgot' the referral letter we had given her. Second time, she said that the centre had told her that there were no meds available. Third time, we sent our own VCT counsellor (voluntary counselling and testing for HIV prevention) to go along WITH her to firstly, act as an advocate on the patient's behalf and secondly, because we were suspicious that the mother had never actually reached the centre. You see, due to the stigma associated with the disease, most patients are (understandably) very reluctant to be seen anywhere near that centre. It doesn't help that it's located prominently right smack in the centre of the hospital compound with the sign "ART Centre" (antiretroviral treatment) written in large letters; not very subtle, indeed. Anyway, they were sent back to us the third time without any mention of further management for the kid's HIV, whether his CD4 count or viral load were tested and when and how ART should be commenced, etc etc. Just some desultory notes (which were basically copied from our own notes) about his intercurrent infections and starting cotrimoxazole (which we've already done). Gah! Felt like screaming at them.

And against all this was the backdrop of the mum's insistence on being discharged home in spite of the kid weighing less than on admission (hovering betwen 6.4kg and 6.8kg from 7.3kg for a 2 years and 7 month old boy on a maximal therapeutic feeding regime)! So so frustrating. Upon further questioning, the socioeconomic factors behind that bizarre request were elucidated. Firstly, she was concerned over how to pay for the boy's admission as she, being his full-time carer, was obviously out of work (just as a fyi, we never force our patients to pay and there have been many a patient who has defaulted). Secondly, she was worried about her husband and what he was up to; he had been MIA the whole time, which is pretty unusual as I've seen most African dads showing up every now and then to check on their family. Thirdly (and this I found most strange) she wanted to go buy soap and her boy's favourite food items since he didn't like what we offered (and I don't blame him - it consists mainly of beans and rice BUT it's probably more than what he would have gotten at home; when I suggested that she could leave the boy on the ward during the daytime to get the food, she actually confessed that she didn't have the money for the purchases so I thought this a moot point and just another excuse to leave).

Anyway, tomorrow's our fourth attempt at trying to procure these ridiculously elusive drugs. God willing, we will be able to start him on the meds he needs and that would prove to be the solution (since we've already exhausted all other options). The harrowing likelihood (and what's most depressing) is that the boy is going to return to his baseline state and possibly die in the next few weeks or months as soon as he goes home unless his social situation dramatically improves.

Why fight so hard for what seems to be doomed for defeat?
James 2:14-18 What does it profit, my brethren, if someone says he has faith but does not have works? Can faith save him? If a brother or sister is naked and destitute of daily food, and one of you says to them, "Depart in peace, be warmed and filled," but you do not give them the things which are needed for the body, what does it profit? Thus also faith by itself, if it does not have works, is dead. But someone will say, "You have faith, and I have works." Show me your faith without your works, and I will show you my faith by my works.

As the Apostle James so poignantly puts it. This passage has been one of my life's driving forces over the past few years. A Christian who does not lift a finger to help his or her brethren is no Christian. When would the church wake up and realise that there is so much need outside her doors? That God put us on this earth not just to eat, drink and be merry, but to use what we have been given for the greater good and for the glory of His name?

11-Aug-2013 Update:
Bah! The public hospital straight out refused to give him the meds without his attending a supposedly obligatory three-session education course which takes place only once a week, i.e. we've to wait a further three weeks to start him on ARV meds! This is despite our giving the hospital's medical director a call, who promised to give us what aid he could but then backtracked and gave in to the clinical officer (not even a doctor for crying out loud!), who persists in being obstinate over a stupid protocol! Dear God, give us patience...

Tuesday 30 July 2013

Did you know?

Did you know that:
  • South Sudan has the highest maternal mortality rate in the world?
    The UN quotes a 1 in 7 chance of a South Sudanese woman dying during her lifetime from pregnancy-related causes (2,054 per 100,000 live births).
  • It also has one of the highest under-five mortality rates in the world?
    According to the World Bank & WHO, 1 in 8 South Sudanese children do not live to reach their fifth birthday (121 per 1,000 live births).
  • The average life expectancy in South Sudan is only 62 years?
  • Nearly 1 in 3 South Sudanese kiddos are malnourished?
  • Merely 25% of the South Sudanese have access to any form of health care?
  • The poverty rate in South Sudan is over 50%?
  • Less than a third of South Sudanese are literate?
  • South Sudan was the epicentre of Africa's longest running civil war (over the greater part of the 50 years between 1955 and 2005)? Cost: 1.5 million deaths (population: 9 million).
  • South Sudan is the youngest nation on this planet as of 9 July 2011? It celebrated its second independence day just three weeks ago!
Sources:
United Nations Development Programme: Millennium Development Goal 5
United Nations Development Programme: About South Sudan
World Health Organization: Under Five Mortality
The World Bank: Under-Five Mortality Rate
Save the Children: South Sudan
BBC - Sudan Country Profile

Why did I ask? Because all these stats, these numbers that seem so overwhelming initially, means that the work we do at my hospital here is not for naught. The photo is of the foundation that is being laid for our new special care nursery as well as an expanded labour/delivery suite. Improving the health of South Sudanese women and children is our daily bread (and butter - not that we get that here!). So I'd urge you to prayerfully consider giving towards this service; all the missionary staff here (including yours truly) work free of charge so rest assured that the money isn't going to fund our imaginary Lamborghini sports cars or Hermès Birkin handbags :)

Operating Funds Goal: $238,217 ($19,850/month) - $33,249 raised so far
Capital Funds Goal: $105,844 - $37,225 raised so far

Find out more here: Bet Eman - His House of Hope Hospital for Women & Children
Donate here: Harvesters Reaching The Nations

Monday 29 July 2013

Waiting in the dark of the night

Well, it's 11.18pm and I'm sitting on my bed safely under the cover of my mosquitto netting (double layer for the win! The one provided with the room was full of holes). Waiting for a primigravida to progress to the second stage of labour and hopefully deliver her baby uneventfully in the next few hours (wishful thinking?).

At any rate, this is my second or third night on call solo and it's been pelting rain the entire evening, which means slippery mud, clothes that won't dry and fewer patients than usual (which makes perfect sense when one considers that there are no tarmac roads and the primary form of transportation here is either by foot or by boda [motorcycle]. Only 'kawaja's' [the Juba Arabic term for white men] and the wealthy South Sudanese own cars - or more appropriately for this environment, four-wheel drives). Hats off to the long-term missionary docs here; I can't imagine doing this - being constantly on call without a break - for years! Just a few months will soon wear me out without the help of God's Spirit.

It calls to mind this particular verse from the Bible:
Jeremiah 12:5 "If you have run with the footmen, and they have wearied you, then how can you contend with horses? And if in the land of peace, in which you trusted, they wearied you, then how will you do in the flooding of the Jordan?"

I've often pondered on this passage and wondered what it means in my life and how it can be so pertinent in situations like these. Ever since I started medical school, and now even more that I've graduated and have entered the work force, my default modus operandi seems to be one borned out of tiredness (it's became a joke in my family that whenever they ask how I am, I reply, 'Tired!'). No, I'm not anaemic (had my haemoglobin level recently checked when I donated blood and besides, I always feel rested so long as I get my beauty sleep). It's quite easily explained due to a combination of bad sleeping habits (sleeping past midnight even when I used to start work before 7am back home) and a multitude of activities always running in the background (severely trying my multitasking skills). Sometimes, I think it's a good thing I'm single because I think the degree of my fatigue would be at least doubled if I had a family of my own.

It also underscores the importance of keeping a consistent quiet time and of being disciplined in seeking rest in God and God alone. As Jesus once said,
Matthew 11:28-30 "Come to Me, all you who labour and are heavy laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and lowly in heart, and you will find rest for your souls. For My yoke is easy and My burden is light."

Of all the promises He's made, it definitely ranks as one of my favourites. And it's one that I have to remind myself over and over to practise, rather than trying to find escapism in trivialities such as the latest TV series, a good storybook or even the higher pursuit of time spent with loved ones. It is in Christ that our souls will find repose. As St Augustine aptly puts it all the way back in the 4th century AD, "Thou hast made us for thyself, O Lord, and our hearts are restless until they find their rest in thee." (Confessions).

Tuesday 23 July 2013

Babies and more babies

Well, it's official! The English royal family has a new prince. In other news...

1. Primigravida with ruptured ectopic pregnancy
A 23-year-old primip presented to our hospital mid last week with severe lower abdominal pain on a background of 6 weeks of amenorrhoea. My colleagues did a quick ultrasound scan of her belly before admitting her and saw a possible right adnexal mass; however, it also looked like there was an intrauterine gestational sac (?heterotopic pregnancy) without any signs of peritonism or guarding. I saw her on the ward in the evening and she was haemodynamically stable, smiling and appeared comfortable. The next morning was a whole different scenario; she was on her knees in obvious pain and a repeat scan showed a definite fetal pole in her right fallopian tube with an empty uterus.

Rushed to theatre, we were waiting for induction when my colleague took a peek around the drape, saw her suddenly turn pale and made the (correct) call that the ectopic had ruptured. Proceeding to laparotomy, we found massive haemoperitoneum. It was rather scary as she continued to bleed profusely even after the ectopic was removed; there was a question of whether the blood was tracking down from other parts of the intraperitoneal cavity following the initial rupture or whether it was from another source (she also had smear-proven malaria and the possibility of splenic rupture was considered). Ultimately, we decided to close the abdomen, estimating blood loss of at least 1.5 litres. Thankfully, she recovered very nicely. Her postoperative Hb did drop to 6.6 from an admission Hb of 12+ despite intraoperative transfusion (with just one unit of whole blood - this is South Sudan, after all) but she remained clinically stable and was discharged home after three days with a discharge Hb of 7.8.

2. Yet another case of postpartum haemorrhage
Another of our patients, this one pregnant with twins at 36 weeks gestation, represented one day after discharge in active labour. The first one delivered fine but CTG showed fetal distress with the second bub (known to be breech and smaller in size - 500g difference from memory). Thank God, he delivered soon after; Apgar score at 1 minute was 4/9 and he was initially bradycardic and floppy but a couple of minutes with positive pressure ventilation quickly fixed that.

Everything seemed hunky dory in the next few hours until I did a quick evening ward round and the mother told me that she was concerned that there was more lochia (vaginal bleeding and discharge after birth) than expected. Alarm bells went off in my head since she had a multiple pregnancy and a second-degree perineal tear that was left unrepaired, both risk factors for PPH. Say what you will, I think it was the Holy Spirit that prompted me to take her back to the labour ward to properly examine her, and I am so grateful to God that I did. There was quite a bit of ooze from the perineal laceration, which we repaired without further ado. What was more concerning was how we subsequently uncovered large amounts of clots coming from further up (i.e. the womb). In fact, we had to then sedate her with ketamine to manually evacuate the uterus.

This time, the haemorrhage was managed in a more or less controlled fashion, and better still, we had a satisfactory outcome for both the mother and her twin babies. In other words, the stark opposite of the case of PPH we had just a short two weeks ago!

Psalm 127:3-5 Behold, children are a heritage from the Lord, the fruit of the womb is His reward. Like arrows in the hand of a warrior, so are the children of one's youth. Happy is the man who has his quiver full of them...

Sunday 21 July 2013

Breath of life

This little girl has been with us for almost two weeks on oxygen - such a cutie, right? :) Poor little bub had a bad case of bronchiolitis and it was an epic struggle to get her off the oxygen. Anyway, most of you would know that I aspire to be an anaesthetist (or anesthesiologist for the Yankees among us). It's not an accident that in cardiopulmonary resuscitation, A (for airway) comes before B (breathing), which in turn precedes C (circulation). An obstructed airway kills within seconds (at most, minutes), and hypoxia (poor oxygenation) is more lethal than hypotension (low blood pressure). Of course, in reality, these three factors are often interlinked and rarely occur in isolation. In my current hospital, the greatest amount of oxygen that we can deliver is 5 litres via an oxygen concentrator (compared with 15L on a normal ward back home). And things in the capital aren't much better, as I recently found out; apparently the concentrators in the main public hospital in Juba goes up to 8 litres (only!).

It reminded me of the story in Ezekiel 37 where God breathes life into a valley full of bones. In the passage, God commands Ezekiel to prophesy to the bones, saying, "Surely I will cause breath to enter into you, and you shall live. I will put sinews on you and bring flesh upon you, cover you with skin and put breath in you; and you shall live. Then you shall know that I am the Lord...these bones are the whole house of Israel. They indeed say, 'Our bones are dry, our hope is lost, and we ourselves are cut off!'...Behold, O My people, I will open your graves and cause you to come up from your graves, and bring you into the land of Israel...I will put My Spirit in you, and you shall live, and I will place you in your own land." (vs 5-6,11-12,14).

No matter how long we have been dead in our hearts (as indicated by how dry the bones were), God is (as some preachers are wont to say) in the business of resurrection. One of my favourite verses in the Bible is Ephesians 5:14, where the Apostle Paul writes, "Therefore He says: 'Awake, you who sleep, arise from the dead, and Christ will give you light.'" Note the sequence: just like the Creation account in the first few chapters of Genesis, rhema (the revealed Word of God) anticipates life. It was His breath that made it possible for us to live; once at our birth into this world and again when we are born of the Spirit (John 3:6). Don't you think it makes a rather nice parallel - how breath is vital to life both in the earthly and spiritual sense?

Sunday 14 July 2013

When it rains, it pours...

Remember my previous post about the little boy dying? Well, the days that followed made that a week of horrors, really. What's about to follow is a series of clinical vignettes so feel free to skip ahead if you're non-medical (or even if you're medical and don't want to hear any more about our work that seems all too pervasive at times!).

1. Postpartum haemorrhage
A multigravida lady presents just before dawn having delivered a stillborn infant at home and is now in the throes of delivering its previously-undiagnosed twin. Sadly, the second bub is also stillborn. Just after our morning staff devotions are completed at around 9am, my senior colleague receives an urgent phone call from the nurse who was at her bedside as the patient is now unresponsive. Apparently she had been slowly bleeding out the entire time and her uterus remained boggy despite an oxytocin infusion and methylergometrine. On examination, she was found to have a ruptured (!!!) uterus.

Rushed to theatre, the anterior tear (which I never got to see since I was on the other side of the drape doing "anaesthetics") was successfully repaired but it was rocky to say the least. She kept having periods of apnoea when we had to bag her and periods of bradycardia requiring boluses of adrenaline (without concurrent ECG monitoring due to our not having metaraminol, ephedrine or even just plain atropine). Maintaining blood pressure was a nightmare since the only intravenous fluid we have is normal saline and 5% dextrose (no Hartmann's, let alone gelofusine, voluven or albumin - 4%, 20% or otherwise). She did have two 16G IV cannulae, thank God, so we had blood running through one drip and normal saline through the other. Even obtaining the blood was a complex process since we didn't have any of her blood type left in our fridge and we had to find a suitable donor, bleed him/her and then get it to the patient (which takes at least 15, usually 30, minutes).

There was also a frustrating difference in opinion as I was all for pouring the fluids in asap since she was obviously in hypovolaemic shock but my colleagues were reluctant to push her into fluid overload. I had to argue that she was more likely to die at this point from an inadequate circulation rather than pulmonary oedema that we could offload later on (which we often do in ICU with frusemide infusions) before we came to some form of consensus. And the pulse oximeter wasn't working - partly because she was so shut down peripherally and partly because the actual machine wasn't functioning properly (I tested it on myself). My requests that we find one that work were repeatedly ignored since "there would be no change in management"; fair enough, but having a pulse oximeter means not having to manually measure her falling heart rate (causing us to be one nurse short who had to auscultate her chest every few minutes to get this number) and having a beat-to-beat report on at least two of her vital signs. The donated monitors that we received from an American charity also died on us due to some problem with its power inverter. Argh!

Anyway, I left to get to clinic after she was (seemingly) stabilised. However, an hour or so later I could see a crowd of people gathered around the operating theatre and hear wailing from inside. Apparently she had become apnoeic again, was intubated but then went into cardiac arrest. So in the space of four hours, the poor patient's husband had lost both his twin newborns and also his wife. In retrospect, would an emergency hysterectomy have saved her life? It's hard to tell. Apparently her uterus was still uncontracted at the end of the repair and we don't have prostaglandins or the ability to perform embolisation. Another possibility was arterial ligation. In either case, none of the staff members have ever done any of these procedures so the outcome may have been exactly the same.

2. Severe dehydration
I can't emphasise enough the importance of knowing a patient's electrolytes. We do have a biochemistry machine but we lack the trained staff to use it. A very young boy presented to us that same day in severe dehydration (the first time I've seen markedly reduced skin turgor!) secondary to vomiting and reduced oral intake (combination of severe malaria and malnutrition). As expected, none of us could get IV access. This round, having learned from the previous case where we couldn't get access as well prior to the little one's untimely death, we didn't waste any more time and took him to theatre to put in an intraosseous line. Well, things seemed to be on the mend and he survived the next two nights appearing euvolaemic. Unfortunately, on the third night, we could hear wailing coming from the hospital's direction and a quick phone call proved that he too had passed away.

Was it hypokalaemia? Hypernatraemia? Acute renal failure? Something else altogether? I guess we'll never know now.

3. Why I would never choose obstetrics as a long-term career
It's all a bit muddled in my mind now but I believe we had either an emergency Caesarean section or a complicated labouring woman (pre-eclampsia, breech presentation, floppy neonate requiring chest compressions etc) every night that week. I don't particularly find the prospect of facing yet another placenta attractive in the least, no offence to all my O&G friends.

Anyway, at the end of the week during our Pioneers (the American-Australian missions organisation that sends us) get-together, one of my nursing colleagues shared this passage with the rest of us, which was truly a timely word of encouragement from God Himself:

Isaiah 65:17-25 "For behold, I create new heavens and a new earth; and the former shall not be remembered or come to mind. But be glad and rejoice forever in what I create; for behold, I create Jerusalem as a rejoicing, and her people a joy. I will rejoice in Jerusalem, and joy in My people; the voice of weeping shall no longer be heard in her, nor the voice of crying. No more shall an infant from there live but a few days, nor an old man who has not fulfilled his days; for the child shall die one hundred years old, but the sinner being one hundred years old shall be accursed. They shall build houses and inhabit them; they shall plant vineyards and eat their fruit. They shall not build and another inhabit; they shall not plant and another eat; for as the days of a tree, so shall be the days of My people, and My elect shall long enjoy the work of their hands. They shall not labour in vain, nor bring forth children for trouble; for they shall be the descendants of the blessed of the Lord, and their offspring with them. It shall come to pass that before they call, I will answer; and while they are still speaking, I will hear. The wolf and the lamb shall feed together, the lion shall eat straw like the ox, and dust shall be the serpent's food. They shall not hurt nor destroy in all My holy mountain," says the Lord.

Amen and amen. Lord, come quickly!

Living water

This is the water tower that supplies our house. Due to some miscalculation during its construction, its height is apparently insufficient to generate a constant pressure - but this applies only to the shower heads and only for the hot water, something my engineering friends can explain, perhaps? Anyway, shower times have become a rather laborious process due to this quirk. Call me a princess or precious but I like being (and feeling) clean, especially in the heat and dust that characterises this country.

It's become an adventure to stand under the shower head, turn the faucet and hoping madly and wondering if some hot water would trickle out. Failing that, the next best option would be that hot water is available from the mixer tap (from which I could bend and still get a bath of sorts - a good thing I don't have a bad back!). Otherwise, it'll mean a very quick shower since I hate cold showers (hot water was my norm even when growing up in tropical Malaysia). Another part of life in South Sudan, I guess. At least we have running water that's safe and hot for part of the day (the water only gets heated between 7pm and 9pm). Most of the locals don't even have that!

In Lopez Lomong's autobiography (Running For My Life - Lopez was a 'lost boy' from the Sudanese civil war who became an American Olympian; an amazing story by the by, do read it if you can), he spoke of the need for easily accessible clean water in his homeland. Most of us would know the dangers of drinking contaminated water, be it rainwater or water collected from a river or well. What I didn't realise was that that wasn't the only danger. For instance, Lopez's sister was ambushed and raped on her way to the river. And I recall being told that gathering water was usually a job for the younger children, especially girls, and having to walk a few miles there and back every day meant missing out on school. It's shocking how something so seemingly trivial can compromise not only one's health, but also one's education, dignity and most likely, one's future.

It also brings to mind the story in John 4 of the Samaritan woman at the well and of her encounter with Jesus. She who had been married five (!) times and was currently cohabiting with a man who wasn't her husband was told by the Saviour of the world that, "whoever drinks of the water that I shall give him will never thirst. But the water that I shall give him will become in him a fountain of water springing up into everlasting life." (verses 13-14). We are told in Revelation 22 that in the new Jerusalem (i.e. heaven), there will be "a pure river of water of life, clear as crystal, proceeding from the throne of God and of the Lamb".

Without water, there cannot be life. He invites us all to partake freely of Him. When will we give up our foolish indulgences and futile desires and instead choose to live and live abundantly?
Isaiah 55:1-2 "Ho! Everyone who thirsts, come to the waters; and you who have no money, come, buy and eat. Yes, come, buy wine and milk without money and without price. Why do you spend money for what is not bread, and your wages for what does not satisfy? Listen diligently to Me, and eat what is good, and let your soul delight itself in abundance."