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)!

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. :)

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.

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.

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

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.

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.

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.

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?

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...