The Best-laid Plans...

So this is how my (Patrick's) Wednesday morning should go. Wednesday is my one half-day of the week. I normally wake up (sometimes with gentle encouragement from my lovely wife, as well as the aid of our neighbor’s roosters and the nursing students shouting in the dorms) around 6/6:15. I read some scripture and maybe get some exercise in before Luke wakes up. Anna goes to women’s prayer at the hospital around 6:45 and I get the kids breakfast and get myself ready for work until Denise, the kids’ nanny, arrives or Anna returns home. I then go to work, arriving between 8:15 and 8:30. We round in the ICU then La Salle d’Urgence (Urgent Care) then Semi-Prive (rooms for two patients…we sometimes call it “semi-oublié”—that is, semi-forgotten—because the nurses often forget to do vital signs and surveillance of patients). Ideally, we finish before noon. Then over the next 30 minutes to an hour, I do some ultrasounds, follow up on some xrays, see some clinic patients, etc. Around 1pm I go home to spend the afternoon doing some medical reading, correspondence, and other things that I otherwise might not have time to do.

Again, that is how my Wednesday morning SHOULD go. Below, please find today’s real-life Wednesday morning. Anna woke me up at 6:10 (my phone/alarm had died overnight). Miriam was already crying when I woke up. I love to get her from her room in the morning, despite the immediate rejection I always receive due to her severe breast-milk withdrawal symptoms. I tell her to say goodbye to her animals and she often squats down and kisses them and tells them “nigh-nigh”…then restarts her calls to “nur…nur…” Today was no different—until Anna put her on the ground after nursing her. At that point I had grabbed some coffee and was reading the Gospel of Matthew. Suddenly Miriam started crying and frantically trying to get away from something. That something was—you guessed it—her shadow, that ubiquitous absence which ever since last night has been fearfully present to Miriam (she went outside last night with Anna, noticed her shadow and was terrified). Incidentally, Luke when he was two and a half called his shadow “a statue of myself.”

Anna left around 6:45 to go to women’s prayer, and Luke almost immediately woke up (with help from Miriam’s screams). His awakening is usually announced by him flinging his door open with a crashing sound. We sat on the couch together for a while given Miriam’s shadow-phobia. I then got them some food to eat—mangos and pumpkin bread. Miriam unfortunately found the Malarone (anti-

malarial prophylaxis) that I had hidden in her bread and refused the bread. While the kids were eating, Mama Georgette (who I call the “market pre-emptor” arrived with her wares—avocados, potatoes, passion fruit, squash. I bought passion fruit and potatoes from her (which Anna later informed me was completely unnecessary as we already had more than enough of both). Around 7:45, Luke came in the kitchen to tell me he had to go pee. I told him to go to the bathroom, but he told me he was afraid because it was dark (which, incidentally, is not true at 7:45 in the morning). Inexplicably, Luke has recently been afraid of “air monsters” in the bathroom. We’re unsure if this is a true fear or just a manipulative maneuver to keep from having to go to the bathroom alone. I told Luke that I would not go to the bathroom with him and that it was not dark. He whined in response. I told him that he’d just have to pee in his pants in the kitchen then and to do what he had to do. A major tactical error. Luke proceeded to urinate in his pants, which pooled at his feet, even running under the cabinets (where we can’t clean). I got Luke cleaned off in the bathroom and made him wipe

his urine up with dirty clothes, then I mopped the floor. At this point, Anna returned saying that a bridge on the road between Nyankunde and Bunia had collapsed and she had been asked to drive to pick up some folks from Samaritan’s Purse who were flying out of Nyankunde with MAF. Luke asked if he could go and then cried when Anna said no. In the end, thankfully, MAF picked the folks up themselves. During all this time, essentially whenever Miriam was on the ground and looked down she started crying in fear of her shadow.

Another bridge experience...this time with us in the car

I got to the hospital at 8:30 and my team had already rounded on our two patients in the ICU (a man with suspected neurosyphilis and a woman with AIDS). Last night, I had done a blood gas on a 7 month old with a history of colon dysfunction requiring an ileostomy and found him to be acidotic from renal failure and either infection or ischemia of his bowel. This morning, I took a little time to talk with the training doctors about acid/base disorders, with which they have very little experience due to the general absence of blood gas machines outside our hospital. It was fun to teach a bit on this (believe it or not) very interesting subject.

As I left the ICU, I ran into a man whom I had seen yesterday and who we had found to have pericarditis with a pericardial effusion (liquid filling the sack around his heart). We suspected tuberculosis and had asked him to come back for a possible pericardiocentesis (needle drainage of the pericardial sack) this morning. We did an echocardiogram, confirmed the effusion but decided it was too small to drain (without risking injuring the heart). We decided to treat him for tuberculosis (at least 6 months of therapy). As we were finishing up I remembered that I had not seen the diabetic patients yet this morning to prescribe insulin. At the point, the man’s wife told me that she was a diabetic and that her sugars were always 300 to 400 (very high). She proceeded to tell me that she had been prescribed an insulin regimen that (in my opinion) made absolutely no sense. So we talked a bit about insulin, decided to do some lab tests, then realized that she had an enlarged thyroid and did a quick ultrasound to confirm there wasn’t any evidence of cancer.

At this point, with my schedule already completely derailed I went down to the medicine wards to see patients. I started with the diabetic patients. Treating diabetes in the DRC might be the death of me. Insulin is very expensive for patients and they don’t have glucometers to check their blood sugars. Kids eat what they can find during the day (whether mangos, sugarcane, or nothing). Doctors and nurses often don’t understand how to treat this condition. And, as happened today, the lab frequently runs out of strips to check patient’s blood sugar. I probably spent close to an hour trying to educate one patient about her new diabetes, troubleshoot another’s patient’s wildly erratic blood sugars, and comfort another diabetic patient that has been waiting for days for an operation. I went up to talk to the surgeon—he said today is too busy, that he’ll do the operation tomorrow. I broke the bad news to the patient.

Humorous interlude #1

Humorous interlude #2

Humorous interlude #3

Thankfully, my colleagues had seen most of the other patient’s by this time, but I saw the last two. The first is a man with AIDS and (I suspect) disseminated tuberculosis. We had not yet informed him of his diagnosis and planned to do it in the afternoon. However, he said that he vomited whenever he took pills and asked to be discharged to “go to prayer.” I asked him if he had to choose between death and taking pills (which is not an exaggeration of his situation), what would he choose? He didn’t answer. At this point, I felt I needed to explain his condition. For the next 15 minutes, I informed him (with Swahili translation) that he has AIDS, that his wife and children should be tested, that thankfully we have good (albeit non-curative) treatment, that if he takes his medication faithfully he will likely be able to live a fairly normal life…but that if he doesn’t, he’ll almost certainly die. He seemed to understand….but then asked again to be discharged to “go to prayer” (a very common request). I asked him where he thought someone could find God. This led into a conversation about how he goes to church but doesn’t really understand, how he’s heard that Jesus is God’s son but doesn’t know what that means. We spent 15-20 minutes sharing the good news of how God loves us and pursues us despite all the ways that we reject him and seek life in things like success/money/sex/etc. We shared with him that through the death and resurrection of Jesus, God offers us forgiveness and life in relationship with him, that God is accessible to us anywhere (not just “at prayer”) and that all we need to do is accept his gift and follow Him. At this point I had to leave to see another patient. One of the training docs asked if I had prayed with him to become a Christian…I told him that I thought it would be good for the man to think a bit about what we said. We’ll talk again with him tomorrow.

At this point I walked up to the surgery/ICU building. I saw a child with congenital hypothyroidism with Lindsey then saw a new patient that had been transferred to our service from pediatrics. This was a 13 year old with 2 weeks of cough and swelling of his abdomen and then his legs. We suspected tuberculosis. We did an abdominal ultrasound and found his abdomen full of liquid (ascites). His liver looked abnormal, almost cirrhotic (at 13 years old??). I made sure he didn’t have a deep venous thrombosis causing the leg swelling. We then took him to a different room and supervised Tim (our training doc) in doing a paracentesis. Using an IV catheter, Tim drained a liter of yellow ascites from the patient’s abdomen, which we sent for analysis at the lab. We also made sure blood had been drawn to test for hepatitis B and C viruses [turns out he has hepatitis B), and I talked to the nurses and encouraged them to watch his vital signs closely and to encourage the family to find a donor for a transfusion (his hemoglobin is 6).

Another child with ascites...from hepatitis C and a cardiac anomaly, as well as probable abdominal tuberculosis. 

By this time it was 2pm. It wasn’t until an hour later—after reading several xrays and performing ultrasounds on three patients—that I left the hospital. So much for my afternoon of reading and correspondence. I had time to write this (admittedly way too long) blog…and to try to comfort Miriam as she continues to be terrified by her shadow.

Some more pictures for your viewing pleasure:

Miriam and her friend Emmanuel (Cooper)

The sad departure of Pastor Timothy with his grandkids (Luke's best friends) to pastor a church 3 hours from here.

Luke with Lucas Folmer and pastor Timothy's grandkids

Luke, Warren and Emmanuel on the tractor

This man said his colleagues put poison in his beer and that he has not been able to eat anything other than liquids for the last month. We usually don't believe people's stories about being poisoned, but we were inclined to believe after seeing his esophagus. The first picture is of one of several esophageal stenoses (narrowing). The second is of his esophagus after we opened the stenoses with endoscopic balloon dilation. 

                  

His esophagus looks horrible...but he can eat and drink again (at least for the time being). We suspect he'll need his esophagus removed and replaced with part of the colon at some point in the future. 

Patrick