8/28 - a day of rest

I'm sorry for the tone of my previous notes.  I know I have seen a lot, and there is a lot more to see.  If I was too direct, or too hopeless, I will attribute it to too little sleep, and the start of getting sick.

 

On Sunday I felt that ominous feeling of deep, untouchable throat pain that often indicates and upcoming illness.  My Monday, the pain persisted, and more of a head cold has also taken hold.  I had a cough that I tried to squelch as I knew it was too deep and would in an instant lead to a loss of stomach contents.  I was definitely not running on all cylinders, but was managing, and getting by.  I felt too unsettled to eat breakfast or lunch, but took all extra given opportunities to sleep, in hopes of passing the time of illness more quickly, and be strengthened by the added rest.  Throughout the day I would drink a bottle of refreshing, chilled water, and less than 5 minutes later, be impressed that it was still somewhat refreshing, and thankfully free of the harshness of stomach acid.  By evening time my total input had been an egg, and orange and an apple.  Last night I went to bed early, and due to my dis-settled stomach or too much rest, spent must of the night in the bathroom, or tossing and turning.

 

This morning, Tuesday, I awoke thankful for the sleep.  I knew I still wasn't back up to snuff, and had soaked through my T-shirt with sweat in less than an hour.  There was sweat dripping from my head, and even clinging to the rims of my glasses.  After seeing just a few patients, I called for a 10 minute break, and retreated to my house.  After relieving myself of anything I had eaten and not yet repented of, I sat down on my bed, staring into my fan.  I knew I had ample work to do, and was not too sick as to not do it.  My thoughts were interrupted by one of the doctors calling to check on me, and invited me to take it easy; and assured me my patients were being taken care of. 

 

Both he and Lisa checked on me at the 10 o'clock break, and another doctor a few hours later.  At one point I insisted that I wasn't sick, I just didn’t feel well, and at the time it made sense to me.  I didn't have an apparent diagnosis to list on a chart, I just couldn't keep any food or water down, and was suffering some weakness because of it.  I slept most of the day, sipped on Gatorade, as instructed/commanded by Dr. Lisa, and when I had the strength to hold up the book, I read more of Evidence Not Seen.  It continues to amaze me some of her struggles in a Japanese Internment Camp and prison during WW2 that I am now relating to.

 

After drinking one large cup of Gatorade, I felt bold enough to try Ramen.  With the help of the day of rest, and all the praying visitors, I feel better, and have been able to stay out of the bathroom.  With one major exception!  For the first time in two days, I was able to urinated.  My deprived kidneys rejoiced!  I am on call tomorrow, and if I continue to feel as I do now, I will be able to do well tomorrow.  My only concern is standing in surgery, and although I've only been called for one section thus far, don't trust that that pattern will hold out much longer, and may have to ask for a bye in that department.

 

Mondays are always busy.  Seeing and hearing Lisa being called for admissions on Saturday, and having several myself on Sunday, it's hard to believe many people waited until business hours to come in, but our out patient department (OPD) was full!  I took the front desk with the interpreter.  I admitted a few very sick patients, including a diabetic with a blood sugar of 500 who had pleural effusions (fluid in the lungs) filling up half of his oxygen exchange potential bilaterally.  He was responsive to Lasix, and we couldn't risk any fluids to help his very high blood sugar because of how overloaded his lungs already were.  He was one of the few I rounded on this morning, and he had responded well to the Lasix, but still had coughing fits during which he believed he would die.

 

Another memorable patient had ascites (massive fluid swelling of his belly.)  One prior paracentesis I had done yielded a diagnosis of TB.  In this case I was prepared to send off the fluid when he grabbed my hand.  No words were needed to communicate the desperation he felt.  He pointed to his bottom.  Several patients on this day had reported rectal prolapse, or the mucosa of their rectum protruding after a bowel movement.  As one can imagine, a quite painful occurrence.  Within 48 hours, I could help replace it, but after that, the risk of infection goes up, and there is great likelihood that it will occur again.  One similar complaint of rectal prolapse earlier in the day, was actually thrombosed external hemorrhoids.  Anyway, in response to this man's distress, I put on a glove, lubed it up, and tried to do a rectal exam.  I couldn't.  My finger could not enter.  There was stool and blood from the friable area on the tip of my finger, but I could go no further.  This man likely has a very advanced cancer, and likely the fluid in his belly was a late sign of the same disease.  As it was already almost an hour after we should have been finished, and the surgeon's had already vacated their exam room down the hall, I requested that he come back the next day, and that if I wasn't there, that they call me.  I wasn't called today as I rested, but I hope he came back, and that something can be done for him.  There was a haunting and memorable look in his eyes.

 

While I held the front desk with the help of an interpreter (she was also feeling the effects of a cold, and would not have walked into the back room to provide me with any way of communicating with the family or the patient, so with his local language skills and position at the back station, they fell to Dr. JK.  Nearly every other patient he saw was a patient literally carried in and then laid down, nearly or partially unconscious, on the back exam table.  It was a very challenging day in general, and the workload seemed overwhelming, even for a Monday, but he definitely got the brunt of it.  I was thankful for him to be in the back and to see all of those unable to walk or hold up their heads.  I wasn't feeling well and all the smells of incontinence of bowel and bladder, in addition to vomit, were very trying on my empty stomach yearning to release itself. 

 

I was able to return home by 7 pm, and promptly delivered the naan I had made to Lisa, and apologized for not being able to go to her dinner party later that evening.  As I heard later, I think the naan was a hit!  Instead I found my bed, and never heard any of the laughter or joyous exclamations that were sure to have transpired next door.

Sunday, August 26

For awhile this summer I didn't know the date.  I didn't need to.  I went to class in West Virginia, I spent some time in Oregon with my family, and all I needed to know was when to get on an airplane to fly to the next destination.  Now I know the date.  I write the date on the chart of each patient I round on, and the date, and the seven to follow, on the chart of every patient I admit.  I now know the date.  I know one week has passed, and although I've thought about it, I'm actively trying not to count the number remaining.

 

Lisa and I both just finished three calls in a week.  The redeeming part is that it is home call, and home is a short, flat walk - no uphill, no snow, bothways.  But it often times is dark, and/or a torrential downpour/flooding and always vicious killer mosquitoes.

 

I didn't go to local church because I was on call.  (I have not yet ventured beyond the gates of the hospital.)  I can't say I'm necessarily looking forward to local church either.  It is 2.5-3 hours long, its hot, and not in English.  That is a test of will.  The folks on the hospital compound go as an act of solidarity with the local church, and sometimes things are translated into French, although it sounds like that isn't even recognizable to those who understand it.  I was able to make it to part of the compound service, in-between admitting patients to the hospital.

 

My first C-Section was today.  Dr. S was the primary, for which I was thankful.  The procedure was different.  I washed my hands with soap and water, but no scrub brush.  I turned off the faucet with my elbow.  I dried off my hands on a towel so thin it was like gauze, and then double gloved (high rates of infectious diseases - HIV/Hepatitis, etc and poor quality of the gloves combined).  My gown was fabric, and under it I wore a plastic apron.  Under that I wore as scrub top and scrub pants.  Nobody said anything differently, so I just did it.  Supposedly women are supposed to wear skirts, even in the OR.  I feel like I have been very brave with the whole skirt ordeal and if I can take a centimeter (not even a mile), then I will.  I also dawned my scrub cap from Kenya!  (Actually, I have been wearing it daily.  I wore a head scarf for almost three days, and then traded it in for the scrub cap.  Again, nobody has said anything, and I'm not asking.)  After the opportunity to say I'd never been involved in a Nigerien C-section, I was awarded a front row seat to see the action, and we talked through the process that was going to come.  A vertical skin incision on everybody - in part because most are emergencies, and the rest because women don't get C-sections for simple labor.  They get them after 3-4 days of labor, or dead babies, or seizures, etc.  After getting through all the layers down to the uterus, careful to avoid the bladder, there is a low transverse uterine incision, as we typically do in the States. 

 

The indication for this section was a breach baby, and a teenage mom in labor for several days.  There is a characteristic sign of a breach baby after being in labor for several days, and it is not a smooth rounded belly, but kind of like a belly with a belt around it, and rounded at the top and bottom.  I've never looked or noticed it before.  After releasing the heavily meconium stained amniotic fluid, the uterus is not pulled laterally, but from the top and bottom, toward head and feet.  Also different.  Dr. S put his hand in and patiently tried to orient himself to the position of the baby.  The baby's head was down.  Way far down.  IE, not breach.  (My dad was butt-first breech.  Poor Grandma!)  A technician was called in, gloved up, and went under the drapes to push the head back up out of the birth canal where it was well lodged.  The baby was trying to come out face first!  I never saw a face presentation in the States, but it is an indication for C/S!  The baby's head was so misshapen and so elongated.  From chin to back of the head must have measured 10-12 inches.  That kid is going to need a hat for quite some time!

 

The food situation is not nearly as dreadful as I had imagined.  Perhaps it is because we are willing to pay a price.  Between the co-op that has the flour, sugar, butter and canned goods which is open on Tuesday and Friday, the fresh produce/fruit/eggs that are available on Monday, and a local lady takes orders for Samosa's - a flat bread stuffed (I guess I should say filled...no...containing some meat and cabbage), some kind of a fried bread, some kind of a sauce, and fried chicken. 

 

I have made a potato salad (Gram Abu would have been proud, but would have said I used the wrong brand of mayonnaise, the vinegar was too weak and I should have put in onions!), a two bean/corn salad - you know the one with kidney beans, green beans, corn, and a vinegar/sugar sauce, and a cabbage salad - the one with a vinegar/sugar sauce and some ramen noodles in it  (one of Grandma Ma's famous recipes!)  I also ground hamburger with a manual grinder I somehow figured out how to assemble because it looks like one we use to grind fresh clams for chowder at the beach house!  (My grandfather Werner was a butcher, and he would have been proud!)  Today, I made homemade yogurt and naan - an Indian flatbread.  I had to mix yeast with warm water, and wait 10 minutes.  Nothing happened.  Being impatient, I went on and added the sugar and salt to the mix.  Just before adding flour, the phone rang and I had an admission.   The yeast had really gone to town by the time I came back!  I had to let the dough rise twice, and then roll it out.  Next time I'm settling for just plain old bread!  (Although, I may try tortillas again because that was fun to have in Kenya!)

 

At this point, my fridge is full of fun leftovers, so I'll be in good shape for the upcoming week.  But, may need to be careful because the power went out for several hours last night, so I'll have to keep an eye on that.

 

Since I'm on call again tonight, I'm going to try to sleep fast now, before I get called in again!

August 22-23

In two days, for better or worse, the newness is wearing off.

 

A day in the life includes rounds from 8-10am, and a 30 minute break from 10-10:30 (for which I am usually late as I have had a lot of patients to round on), and then clinic from 10:30 to 1 and 3 to 6.  The two hours from 1 till 3 are for lunch and resting.  I also don't often finish at 6, but go back to the hospital to check on labs and sick patients.

 

I had another patient die last night.  That is one nearly every night, and most didn't even look that sick when I admitted them.  Last night's death was a strikingly beautiful young girl, about 2 years old.  She had a special light in her eyes, plump cheeks and a wonderful smile, when she felt well enough to use it.  She came in for fever, like every other kid, but she had a swollen elbow and couldn't extend her arm.  She also had sickle cell.  And malaria.  It is crucial to remember that it is sickle cell trait that offers some protection against malaria, not sickle cell disease.  In sickle cell disease, they get malaria, and then they have hemolysis from both sources, irregular blood cells that are distorted in shape, causing problems everywhere they pass, and it is a recipe for a quick death.  Literature on the topic also recommends that patients with sickle cell disease be on malaria prophylaxis for life, but I haven't seen enough patients to know if that is being done, and the cost of that would likely be prohibitive in itself.  The patient that died was pale and I wanted her in the hospital, and also getting antibiotics for whatever was going on in her elbow, although the Xray showed no evidence of osteomyelitis (infection) or fracture.  Mom said that she had to go home, and she did.  At some point the next day she returned.  That night the baby died.  I had filled out the admission form when I saw her in clinic.  Maybe I shouldn't have done that, so that someone would have had to see her again (after another 24 hours of hemolyzing her blood and dropping her circulating volume).  I hate that death is such a normal part of life here.

 

Last night Lisa and I went to a campus bible study on 1 Peter 1.  Lisa was in her element; sharing her wisdom and insights!  She has shared her insights with me weekly for the past year, but last night was different; amazing.  My main insight was when the question was asked, what does it mean to love?  My gut instinct was, "to save these children; to not let them die."  Then I wondered, what if that is just the easy way.  It's easy to wave and smile and say "Sannu!" when the kids are getting healthier, and going home.  It is miserable to look desperate parents in the eyes and beg them to be patient while we hope and pray that their child will respond well to our medicine, and to see the child lay lifeless in bed, day after day, practicing somehow for death, the only connection to life being some primitive habit of letting the heart beat, the lungs move inside the body, and the pupils respond to light.  What if that is like how easy it is for everyone to love their friends, but the true test is to love your enemy.  What if the converse is also true here?  What if love is not just preventing children from dying, but loving the family at their time of devastation and disbelief?  And yet the deaths happen at night, with a family member nearby, but no nurse or doctor to know or even attempt anything heroic , in the not-so-quiet hallway, with the lights still on from the busy day that came before.

 

I made a cognizant effort today to try not to admit every kid I saw today, like I did two days before.  There were some that needed admission, and accepted.  Others needed admission and said they couldn't.  (Whereas in Kenya, patients had to pay before they were allowed to leave the hospital, in a sense, being held hostage for the cost of hospitalization and treatment since there is no billing department.  However, here, the "flight" risk is high, patients have to pay before they are admitted, and as I saw today, many don't have the money.)  Others seem to want to be in the hospital, but returning home with a medication and hope that their kid will get better is sometimes acceptable. 

 

One child whose family couldn't afford to pay lived close by, so we were able to treat with an injection today, and do injections until the patient is well enough to tolerated the oral medication, or sick enough to require hospitalization and blood transfusion.

 

The other child is from Nigeria.  Her ear is nearly falling off.  There is no necrosis per se, and it seems to have stuck to fascial lines.  The smell was foul, and there was sign of infection, but it was a relative clean wound with no massive amounts of pus or drainage.  The wound extended from the top to bottom behind the patients ear, and from about 1 cm proximally from where the ear should attach all the way to about 1 cm from the distal edge of the ear.  The ear seemed to be flayed open almost, allowing a good visual, but probably not a good prognosis.  The patient had had intermittent fevers over the month since this appeared, and it started, by report, as a simple bug bite.  Thankfully there were no other such lesions on her body, except for behind the other ear.  If anyone has contact information for an ENT (like an email address) please let me know...I have a picture that might take me the next month to upload, but I am willing to try!

8/21/12 -My first call.

Today I was able to find an interpreter from clinic to help me with rounds.  I only had a few patients that I had admitted from the outpatient clinic (age greater than 5), so rounds were not too long.  I was able to send one kid home who had recovered well, and the elderly gentleman who was carried into clinic by his family, whose oxygen saturation was 36 % (normal 98-100%, but acceptable greater than 92%) was sitting up in bed and chatting/answering questions!  He checked some labs, and his goal for the day was to eat and drink better, which he did!

I filled the rest of rounds seeing some other patients, and then it was time for clinic at 10:30.  I saw a few patients in the outpatient ward - patients who had been seen the day before, but came back with lab results today.  After that Lisa had finished an LP (lumbar puncture) and took over.  We are switching between the adult and pediatric clinics because so many kids are admitted because they are that sick.  Lisa admitted at least 12 kids between the pediatric clinic and being on call, so it was my turn to get my census up!

My greatest fear in going to the pediatric clinic was only in part how sick the kids have been, but even more so, not being able to speak French or Hausa.  A nice young man was discovered(!) working in the repair shop who speaks very good English, and Hausa (although no French!)  He was great!  We helped me all day in clinic, and helped me check on a few patients after clinic as well!  He will help me round tomorrow, as well.

So, the language piece aside, thankfully there were not as many kids as the day before, and we only rarely had to think that a kid may take his/her last breath as we listened.  Again, most were malaria, and of those, most were cerebral malaria at that.  And several required blood transfusions. There were also a few kids with the grand spectrum of malnutrition.  Some were scrawny and wasted, some were swollen in their bellies and feet from lack of protein.  One girl's black hair was a light red color from malnutrition.  Needless to say, I admitted most of the kids I saw.

One child came in for convulsions.  The kid is what we would say to ourselves, or at the dinner table where medical folk tend to share their experiences, a FLK (this is a largely inappropriate term, and definitely not diagnostic, but more of an observation - Funny Looking Kid.)  This baby was 2 months old and weighed 3.3 kg.  All of his sutures were prominent and his fontanels were sunken - a sign of dehydration.  His body and head were small, but the back of his head was still elongated, like right after delivery of a kid who has been in the birth canal for too long.  His jaw was small, his first toes bilaterally were widely spaced from the other toes, a so-called "sandal gap" deformity, on one foot he had six toes, he had poor tone and poor skin turgor.  Unfortunately, I didn't do a more thorough exam to test for reflexes, test for hip laxity, look for palmar creases, etc.  I did want to admit for rehydration and malnutrition, but the family was unable to do so.  I hope to see them in one week to follow up.  Given that there was another child born who looked like this one, but died, and a second child was stillborn, we have a high degree of suspicion for a genetic abnormality.  I know there is some association between the sandal toes and Down's, but this kid didn't have that appearance…  If you have any ideas, let me know!

I was wondering how many patients I would round on tomorrow, and then I was called in at about 9 pm.  There was admission after admission, and there were 7 or 8 admissions before we were able to go home about 11:30 or so.  Most were patients with vomiting and/or diarrhea, and most would not have required even IV fluids if routine monitoring could be done, and admission likely would not have been required if the patient had presented to the clinic during the day time.

One 30 year old woman may have cholera - profuse, watery diarrhea that can be quickly fatal due to dehydration, and another 30 year old woman was carried in by her family, and who had abdominal pain that I could not localize.  On my differential was anything from pregnancy to her gallbladder to her appendix.  Thankfully she had no vaginal bleeding.  In the States I would have gotten a CT of her abdomen, and here I would have liked to get - haha, by that I mean personally perform and interpret! - an ultrasound, but ours was locked safely in the outpatient clinic.  Her breathing was fast, but her heart rate was strong and normal.  Both myself and my supervising doctor did suspect there may be a psychiatric component, but without even an ultrasound, that was premature.  We treated her with some Tylenol, and some antibiotics until we can get a closer look, and maybe a surgeon's opinion in the morning.  I was relieved to see that she was resting well at 4am.

At 4 am I was called in for another admission.  It was another kid who looked relatively well, but we will keep an eye on for the remainder of the night.  These admissions here are impressive in their brevity.  If I were to ask about medical history, I would get a blank stare, or perhaps be pointed in the direction of the patient's outpatient record that they carry with them.  More often than not, there is none, or none available.  When I ask about medications, I am told how many pills are taken, but without any recollection of the name.  That makes the history much shorter, and limited to why are you here, and for how long have you had those symptoms.  After a quick exam, deciphering the spelling of the patient's name from their intake sheet as well as their village, writing a week of dates on both sides of the admission card - one side for vitals, the other for medications, and filling out the treatment, I am finished! 

In the States, most of our patients end up with 10 problems on admission, and by the time they go home, at least 20 problems we have acknowledged and treated!  That makes the admission and the discharge time consuming, and an average patient with all the paperwork, dictations and orders takes 45 minutes to over an hour to admit (ICU of course, often taking longer).  Here - if the history is right, and the exam confirms, an admission can be done in about 5-10 minutes, including the required use of an interpreter!

I'd hope to impress my family medicine attendings and the KIS attendings (the hospitalist group we worked with in Wichita) with the sheer number of admissions and how proficient and efficient I've become on only my second day, but I can't.  The reality is that a lot of these patients would be in the ICU in the States, and some may die before I round tomorrow.  I am grateful for the long termers advice, suggestions and help in managing these very sick patients.

I haven't gotten any more calls yet, so will try to sleep for another hour before rounds!

8/20/12 - First day. Crazy stuff.

First real day.  Phew.

We started rounding at nearly 9 am.  And, had essentially seen everyone by 10 am, when we take our first break - most people eat some breakfast or a snack or tea then.  I was able to buy some vegetables: potatoes, cabbage, cucumbers,  and eggs and apples.  Although they provide a list of what things should cost, everything was more, and without speaking Hausa, it would have been very challenging without a friendly face that helped!

There were a few patients to follow up on in the afternoon, after the morning rounds.  One was a woman, about 50, admitted with diarrhea, who was looking much better than the day before (when she had looked very sickly.)  We were considering turning off her IV fluids if she continued to do well, and maybe let her go home.  I searched all over for her chart and couldn't find it.  Finally we learned that she had died.  Her daughter had also been admitted, in the bed close by.  She had looked much worse today than in the past, and I hope she has a better day tomorrow.  I can't imagine watching a family member die.

On a happier note, there was a little girl, maybe 3 (ages are hard here as nobody knows their birthday, and age is a guess, and kids are very small in size compared to our US standards and obesity epidemic) who had pneumonia and had been requiring oxygen.  She was able to come off oxygen this morning as we rounded, and when I came back about 6:30p, I decided to check again.  I'm clearly a stranger, can't say a word of reassurance to her, and everybody has been poking and prodding her, but when I showed her the O2 sat handheld machine, she stuck out one finger for me!!!  It was the cutest thing, and her mom had the proudest smile!

Outpatient clinic had more, not only malaria than I can count, but also cerebral malaria!  These kids come it with hematocrits often less than 15 (ie, a hemoglobin of 5), and often comatose or seizing.  The lowest hct I've seen has been 6.  I don't know what the survival rate it when kids are that sick, but this has been a very bad year for malaria, and we are seeing several deaths daily.  Out of the hundreds of malaria tests being done daily, I've only seen 2 that have been negative!

I can honestly say that I can palpate a spleen and liver now!  I saw an older gentleman, about 50 yo, whose spleen was AT LEAST 15 cm below the costal angle (whereas it should be covered by the rib cage).  It was so odd to see the kidney in the left lower quadrant!  (But, on the other hand I did see a 56 lb ovary that had grown from the left lower quadrant up to the rib cage while I was in Wichita!)

A 25 year male complained of abdominal pain, and his bladder was the size of a 24 week uterus.  We sent him to have a foley placed, and they couldn't do it, so he was sent on to surgery.  I'm not sure what happened from that point on.

We saw some very wasted elderly people - for whom we've offered hydration, but who could really use a social work consult for hospice, a new diagnosis of HIV, and two kids with likely severe range nephrotic syndrome!

I had too many patients to recall who were carried in, laid on the exam table seizing or in a coma.  Most of our admissions were in urgent need of a blood transfusion.  I don’t think I will be prepared to learn how many died over night.  There is very little we can do after treating patients.  There is little resuscitation that can be done, and even if it can, there are no ventilators or defibrillators! 

One very sick, 70 year old man was carried in obtunded and badly dehydrated and malnourished.  His oxygen saturation was 36%.  And I confirmed this on a second pulse ox, as well.

The labs were also bizarre.  Not that we are trusting or repeating these, but a sodium came back over 200, and a potassium was read as 9.

I have been told that I would see more death here than I would in years in the states.  I believe it will be true; and that I will have seen more deaths in the first week or two, than I did in all of residency.  It still doesn't feel real yet.  It was a shock to plan to check on a patient, only to find that she had died.  I think this will become more and more challenging as I get to know more and more patients, admit and follow patients.  Perhaps not speaking Hausa or French has been a shelter somehow?  I'm very thankful to have Lisa right next door.

Lisa was on call today, and was working in the pediatric clinic.  I heard estimates that there were over 100 patients to be seen in just a few hours today.  And they were all very sick.  As I flipped through charts looking for those I was going to follow up on, I saw her name atop countless ones.  She had many more malaria patients, presumptive cholera, and even DKA.

We had house helpers today!  They cleaned the floors (which get very dusty when it is dry, and muddy after all the rains!  The bottoms of my feet right now are sooo dirty!!  It also means we have clean laundry!

We had a wonderful dinner, our last arranged get to know the neighbors meal tonight!  We also had our intro to Hausa greetings lesson.

For the first time since leaving, I was able to get ahold of my family by phone today!  I spoke with my brother at 6am (he is on vacation! :) but was already awake) and my parents tonight.  I only got disconnected about 10 times for 20 minutes of conversation.  I should probably not call when everyone on the compound is on the internet!  The GoogleTalk experience is much better than the Skype experience of medical school 5 years ago; although I'm sure that is more technology and time than switching providers.  It is just wonderful that GoogleTalk is free to call the US!!

I am on call tomorrow, so will try to head to bed now!

8/19/12, 3p, 10p

I slept ok, but not very restfully.  I was up a few times to the loo, and the temperature was quite warm, despite the fan, as the mosquito nets are not very air permeable.  There was also a terrific rain storm that invited me to open the windows and curtains to let some of the fresh coolness in, but even that didn't get through the mosquito net very well.

I had a lazy morning.  I woke up for church, but didn't feel comfortable enough yet to walk 15 minutes into town, and sit at a church service for 3 hours, in Hausa, a language I haven't yet begun to understand.  Instead, I stayed close to the loo, kept myself hydrated and will wait for the GI adjustment to the local cuisine to pass.

We had lunch with Dr. EP, a German OB/GYN who we will have the opportunity to work with if adult and pediatric medicine departments slow down after the rainy/malaria season, and likely when we are on call.  It was a wonderful German meal - a dish that looked like a german pancake on the outside, but had a biscuit/lasagna noodle type filled with chicken and a cheesy sauce with mushrooms.  It was quite rich and delicious.  We also had a cucumber-dill type slaw and some local baguette, that Lisa and I were both excited to hear exists, since we had stocked up on a few loaves in the capitol for concern that there wouldn't be any.  Dessert was a very rich vanilla pudding with a delicate chocolate shaped as a butterfly or an angel.

We said our good-byes and thanks, and left as the thunder was starting to pick up, and the misting was starting to thicken.  We made it home dry, but since that time it has been pouring constantly and heavily.  Lisa went into shadow the doctor on call for a few hours, or else I'm sure we would be sharing the Rains in Africa song again!

There was a service for the compound at 5:30 this evening.  And, they really meant 5:30, with no inclination of African time!  We arrived 3 minutes late after dancing around thick mud from the rains, and they were finishing the first song!

Some of the prayers included the arrivals of the newcomers (us), departures of some short termers, and the floods in the capitol.  The pouring rain we've gotten here has made the roads muddy, but in the capitol, 205 miles away, sandbags are needed and damage is being done.  Also, the number of deaths yesterday was seven.  This is a busy hospital, but that is a lot of death for one day.

Afterwards, we were invited to dinner by the STAs, or short termers.  It was another wonderful meal with great company.  Oregon is quite popular in this remote African village - and one of the teachers at the school went to college at George Fox University, in my home town of Newberg, Oregon!!!  And, she used to  drive up my road to Bald Peak State Park as a reprieve from school!!  Another girl who was born in San Diego, but grew up in Peru, was recently in Bend!  And then there was the nurse/doctor family who worked at the VA/trained at OHSU!  I love the talking about home, away from home!

The internet has been out, so I am just now going to post some updates to the internet!

Work starts tomorrow.  I probably won't be able to write as often.

8/19/12 930a - copilot and hospital welcome

We got back to our place late after watching the movie, and were supposed to be ready early the next morning for our flight to the hospital.  After a shower and a bit of organizing my belongings, it was time to rest quickly.  Although we were taking the bigger plane, we were still allowed a total of only 200 lbs of luggage.  Since Josh's luggage still hadn't arrived from Paris, we figured all of our carry-ons would be about 100, and then Lisa and I each brought one of our 2 - 50 lb checked suitcases.

At the airport we didn't have to show a passport or go into the airport at all!  Our pilot made a few stops, and then we were off to the hangar for systems checks.  The luggage was stowed in various nooks and crannies of the plane.   After going through the whole checklist, the plane was pushed and pulled into place, and we boarded. 

I was awarded the honor of shotgun!!!  Not just shotgun, but co-pilot!  I watched as the pilot tinkered with the throttle, how to communicate with flight control and where he dialed in various coordinates.  In short order we were racing down the runway and then gliding through the air. 

Flying above the capitol we could look down and see the river full of mud-stained rain water, the clusters of huts or homes and green.  As we flew on, the green disappeared from view, and there was only brown.  Whereas the river could be seen in the capitol, no longer could whole rivers be seen, but only water in some parts, apparently disconnected to the water appearing in the same riverbed some distance away.  It’s a good thing we had already seen our giraffes, because we didn't see any more on the flight.  As we arrived closer and closer to the hospital, things became green again!  I had a wonderful view on the slightly overcast, 205 mile flight.

Our landing was perfectly done; better than many full size planes!  I had heard horror stories of small planes, but this four seater was a wonderful ride!  (Definitely thought of my uncle Jerry who is a professional pilot and may have been the pilot for some of those rougher stories!!)

Upon arrival, we were greeted by several warm faces, smiles and handshakes.  Faces and names, and details to be learned over the next few months.  We carried our small stuff up to our new homes, and a four wheeler delivered our trunks/suitcases.  Lisa and I have our own places, but they are right next door to each other.  These houses are amazing.  I have a living room with a couch, a love seat and a chair, a kitchen with stove, microwave and fast running water filter, a dining room with kitchen table, chairs, and a welcome message with my schedule for the day.  Some filtered water, bread and eggs were already in the refrigerator!  I also have a full size bath tub/shower, a regular toilet (not squatty potty), and sink.  My room has a small desk and twin size bed, with screened windows on two sides, and a fan overhead.  There is no A/C, but a swamp cooler that is half in the living room and half in the closet of my bedroom.  Instructions for use included turning it on to soak the sponges for about 5 minutes, and then turning it on.  Soaking the sponges prevents the fan from stirring up tremendous amounts of dust, and allows the air to flow over the wet sponges, somehow allowing cooling to take place by humidifying the air.

We had a packed first day!  We first went on a tour of the compound, and then had lunch - the best tuna salad I've ever had, at the house of the CMO/an FP from Portland, OR!!  and his wife who had worked as and ICU nurse at the VA, before coming out here.  We had seen Dr. KL (not Katy) riding a bike over to the hospital as we were on our tour, so we reviewed some more orientation materials.  Upon returning, he said that a child had died, before they even had time to admit the child (which is a very quick process here compared to the states.)  The child had sickle cell and malaria.  Sickle cell is usually somewhat protective from malaria because of the deformed shape of the cells, but this little one had a severe burden of malaria, and must have had sequestration from malaria and sickling crisis concurrently.

We were able to go to the co-op, but I will likely continue to call it the coop because there is no hyphenation utilized on the phone list.  This is a little store open to those who live on the compound and is stocked with all sorts of goodies.  There is sugar, milk powder, ramen, canned beans, corn, peaches, pears, peas, dish soap, laundry soap, toilet paper, just to name a few! 

Afterwards we met Dr. KL for a tour of the hospital.  Every few stops, however, he was met with more admissions, and there was one more death.  The mother of the child who had died earlier in the day, was also in the ER for palpitations and pain.  Her diagnosis was response to grief, and GERD, and she was treated with antacid for a few days, that would in no way touch the ache in her heart.  Another discussion over dinner  revealed that the burials usually occur quickly, and that by dinner time she was likely either buried, or would be before sunrise.  I hope there is no unreasonable level of guilt.  Ramadan ended today, and hopefully there was no hesitation in bringing her in for those reasons.

Most of the beds were full, the patients looked quite ill, and there were mats laid out between the beds where family members would be found sleeping.  Some were even sleeping on the bare concrete.  Flies are everywhere!  Some of the smells were profound - and not necessarily of cleaning products.

We walked through the wards, the ER, the surgery recovery area, the post partum, the medical wards, and toured the not yet open future post surgery area.  We also went through the OR's, of which there are 3, and one is divided in two. 

We were welcomed by another family for dinner, and enjoyed chili, cornbread and rice, with mango on pudding and cornbread for dessert.  It is fascinating to learn what has brought people to where they are, and the impact it has had on their families, mostly for the good.

After dinner and a long day of meeting, greeting and heat, I was excited to be home, check some emails, and go to bed!

8/18/12 - late entry

Last night we did have Indian Food, and it was terrific.  I had butter chicken and garlic naan.  (The butter chicken wasn't as good as Jaymica's in Grenada, but was great none-the less.)  I even have leftovers to enjoy it all over again.  We ate with Lisa's friend whom we had met the afternoon before, and her roommates.  It was a conversation full of laughs.

One of the "interns" at the organization Lisa's friend (B) worked for was heading back to the states that night, so we went back to the same internet café, and met a few other co-workers there.  Since we had just eaten, a few of us got a scoop of ice-cream, after informing the workers where the flies had landed on the ice-cream and helping them clear the field.  I tried kiwi!  Not sure that I would do it again, but as a one time experiment, it was good!

We then went back to B's house.  You wouldn't believe how hard it was to pick a movie between 3 girls and a guy.  We each picked two, and then eliminated each others until we had one.  We ended up watching Toy Story 3, in part because none of us had seen it.  (In case you've seen it, I had really hoped that the old purple bear would have a change of heart!  I thought when he was reminded of how much he had been loved, and how it was a huge accident that led to him being so badly hurt, and having new toys accept him and be willing to risk their lives to save him despite the ways in which he had been mean and brutal to them, but alas...he was hardened and even though the chance to help them was easily available, he walked right past.)

8/17/12 430p - Giraffe Hunting!

This morning we woke up earlier than we have before, with an expedition on the horizon!  Our amazing short-term welcomer had arranged to borrow an automatic vehicle from a friend, and drive us out the main road, to pick up a guide, in search of Giraffe.  We had our eyes peeled as we drove out hoping to just see the giraffe near the main road, but alas, we did not. 

Multiple times little kids, women, men, whomever would come up to the vehicle, but we knew we weren't yet to where we needed to be.  At one point, the kids came up, all jabbering away, and when we asked them about the giraffe, they pointed in the opposite direction of where we knew we needed to go.  We thanked them, but continued on down the direction we were going.  After locating the guides and paying our fees, the guide, indeed, directed us back the direction the children had volunteered freely to us!  We went back to an area where you could see tire tracks leaving the main road onto the hard clay, and within 5 minutes or so, we caught a glimpse of our first baby giraffe!  We drove a little further, and saw 3-5 eating away at the top of acacia trees, in small groups dotting the horizon.  Interestingly, there was a lot of other vegetation around, including corn, that looked a lot more lush than the acacia, but they passed up everything else in favor of the trees!  I don't know exactly how many we saw in all, but at least a few dozen.

They are cute, but funny looking.  They have long faces with some harsh features.  The little nubbins atop their heads look either comical or misplaced, sitting right next to their ears, but look somehow important.  Their backs are so slanted anyone not tied on for a ride would slip right off, I guess, unless holding on to those nubbins!  As they walked with their long strides, their front left foot would still be planted at the time the back right foot would come right beside it.  The footprints seemed to be two by two by two right next to each other, as opposed to alternating like our prints.  There were huge prints - bigger than our feet and way wider, and baby ones - about half the size of the palm of our hands.  After we were watching the giraffes for a while, some local farmers came to watch us (it seemed), and they brought along their herds - cows and goats; which would explain some of the smaller prints, probably, more accurately.  When all was said and done, the adventure cost about $10,000 each - 6,000 for the guide, fees and admission for the car load, and 4,000 for the gas used during our safari!  It was lower than previous estimates we had heard!  Of course, that figure is in cfa, and therefore 500 fold less in USD.

After being in Kenya, and the Wichita zoo, I was 0/2 of zebras, giraffes and elephants, but not anymore!!!  Thank you Niger!

We came back in time for lunch - fresh baguette and some pseudo-laughing cow cheese with eggs.  It was a wonderful lunch, and this evening, we will venture out for Indian food!

8/17/12 - Our last day in the capitol

Our last day in the Capitol!

Yesterday we began the day with orientation at the main office.  Most of the discussed materials were to be expected.  Some of the emphasized items included the importance of taking time to greet all of your coworkers; being loving in all interactions as the community is so small, everyone takes note of all of your behaviors and outbursts; the importance of setting healthy boundaries, especially as single people; the importance of how one is corrected in the shame culture that we are in - and how questioning someone's authority should be done with the utmost respect, and these interactions should not be done publicly; a reminder to have grace despite poor sleep and abundant heat; to be aware of the extreme poverty that surrounds us; and to take time to be healthy, in all senses of the word including spiritually - to take time to rest, read and pray. 

There were also culturally related reminders or lessons - such as prolonged maintaining of eye contact between a female and a male may be an unknown "invitation", wearing jeans is often indicative of being a prostitute, and a young, single male and female should never be alone together, and if they are, the rumor mill will turn!

The final event of our orientation was somewhat of a right of passage.  Each of us had to copy, in our own handwriting, and in French, without mistake, correction or misspelling (I know some of that is redundant, but emphasis was on perfection!) a will.  There was a model of which we filled in the blanks, including 5 locations where an extra "e" had to be added to denote that the writer was a female.  I messed up the first time just writing the title.  Without knowing what the will said, I had no idea which letters to capitalize, and ended up starting over after only a few strokes of my pen.  The next attempt went well, and two-thirds of a page of writing and completing about 2/3 of the statement, I wrote the letter "a" instead of the letter "o."  I knew immediately that the little tail sticking out would immediately be noted and I gave up, knowing that I would have to start again. 

On my final attempt I was doing well, and after finishing the first page, I made a loud sigh as I reached for a new piece of paper.  To my pleasure, my friends responded with, "Oh, Sad!" and seemed to understand my frustration at being so close to the end.  I wrote the last few sentences on the new piece of paper, signed my name, and turned my sheet in for evaluation!  To everyone's surprise I was reaching for the final sheet to finish, instead of having to start all over again as they had assumed.  I was proud of the success of my intentional misconception!  Lisa, our French expert finished on the first try, and Josh on his second attempt.  I, despite my five attempts, still finished second.  As Ms. Rogers, my first grade teacher used to say, "I need to pay more attention to details."

Our reward for this almost excruciating French exercise was the chance to go downtown to an internet café, and write emails, post our blogs, etc.  From the time I posted the address to my blog, and before we left, I was thrilled that I had 53 views, and even more thrilled that not all of those could have been done by me or my parents!  Thanks so much for reading!!!

Josh and I went to the grocery store - my return and his inaugural endeavor.  I was looking for ramen noodles - knowing we have the bigger plane, and sometimes how nice it is to have something easy, and able to replace lots of lost salt quickly was exciting, but alas, none could be found.  I was also looking for a cream of mushroom package sauce mix, but there was only cream of asparagus.  At checkout I had bought a package of noodles, ketchup, a few more nectarines as they are so amazing and our stay in the capitol was delayed! I also had a container of tahini.  I've never made hummus, but it sounds like it is the thing to do.  I refused to bring any from the states as the containers were heavy - at least 1 lb each, and I wasn't willing to give it that fraction of my allotted luggage weight.  Now, Lisa and I will try! 

Josh will be mostly in the operating room, and didn't seem to be sure about cooking 100% of his meals!  He bought some  cookies, granola bars, spaghetti and sauce and pseudo-nutella.  He really wanted some peanut butter but without our French expert, the only thing the cashier could come up with as what we wanted was real butter!

The French fries, "frites"  in Niger, are as amazing in Kenya, only actually available!  I can't put my finger on the difference, but they are unlike anything America has to offer - fast food or otherwise!

After our shopping and internet excursions, we returned home and soon after met a friend from Lisa's past.  We all chatted until it was time for dinner, and the three of us walked across the street to a Lebanese restaurant.  We were joined by many other ex-pats working short or long term in the country, most of whom were teachers; our group was 1- in total and we were seated under a thatched roof with fans overhead, and ultimately multiple mosquito coils under the tables and a few blitzes of repellent to the legs and arms.  After two hours of conversation, our meal was served!  Lisa and I shared the two best meats surrounded by a light pastry (as recommended by the waiter) and a plate of salty and garlic-y hummus with baguette bread.  It was a nice meal.

And, in contrast to the past several nights, we both slept well!

8/15/12 9 pm

This morning we again woke up late, but it was ok because we didn't have plans until 3 pm.  We were both awake for hours overnight, and sleeping in seemed to cover the missed opportunity earlier in the early morning.  After eating breakfast we read and lounged until 3 pm when we went back to the bakery for fresh baguette to take with us when we were to leave tomorrow.

At 330 pm, we dodged a rain shower, but nothing like last night.  We went to Musee - which has several huts, most of which were closed, but the ones that were opened had some historical artifacts.  Around the buildings was a zoo - we saw some chimps, a hippo submerged in water, a crocodile, some small deer like creatures, and a statue of a giraffe.  On my trips to Africa and the Wichita, Kansas zoo, I am 0 for 3 on giraffes, zebras and elephants.  Wichita's excuse was that it was 33 degrees Fahrenheit and the animals were inside,  but that didn't stop Jody Elson, Dr. Amy Seery and I!

Upon arriving back at the guest house we met the newest member of our team going to the hospital, a between third and fourth year medical student who will be at our hospital for 4.5 month, and then in another location for 4.5 months.

We had a wonderful dinner of French Baguette, Peanut Sauce, Spaghetti and cucumbers and tomatoes!  And dessert was amazing cookies.

We walked home in a slight mist, and filled out some paperwork before deciding it was time for stories to pass the time until an appropriate post flight bedtime for Josh.

We also found out today that instead of flying out to the hospital tomorrow, we will be flying out on Saturday, two days later than expected.  There were problems with the airplane, and taking the bus wouldn't be a good option based on the amount of rain that has been falling.  So, we'll see what the next two days holds, but we will remain in the capitol!

8/14/12 6p

We had a busy day today.  Well, relatively speaking.

I don't know if it was the awkward sleeping on the plane in bursts, or the pure release of exhaustion from packing and dreading and excitement, but sleep was easy to come by last night.  I'm sure we were in bed and asleep by 9 pm, and I slept more soundly than I have in a long, long time.  I awoke at 1 am, feeling as if I'd slept more than enough, but thought it was best to sleep more.  After thinking and praying for 3 hours, my desire was granted, and I fell back to sleep.  A few hours later, I was up, showered and ready to face the day. 

About 10 minutes before we were supposed to meet a welcoming face to face the town, I figured I should wake up Lisa.  She had enough time to shower and get presentable.  Then I was sent back to the changing room as I was told my shorts wouldn't cut it.  We walked to the main office, and then to lunch, then part of the way until we decided the 3 of us would split up as we couldn't find a taxi that would fit all of us together.  All the while walking, my legs cried.  There was a beautiful breeze of which they couldn't take part.  They were sweltering and sweating, and I mourned with them.  Respect vs comfort.  Modesty vs comfort.  Custom vs comfort.  Whatever the reason, I did what I had to do.  Day 1.  I'll skip ahead for a moment only to say, first thing after walking into our house, I put away my groceries, the drank and filled up my water bottle.  That is all to say that, only after that, did I rush to our room and change into shorts.  In one day, I have grown.

We sent off some brief emails from the main office to our parents to say "I'm alive."  My parents have requested that I do that every so often, to prevent them from having to send one asking just that.  In a new city and a new country, I felt obliged; even without prompting.

We then went to a restaurant called Mango; although we say no mango anywhere on the menu!  I ordered "capitan," although the word I had learned for fish was poisson.  Alas.  It was one of the best fish I've ever had!  It was thick, meaty, tasty and the texture was perfect! 

After a relaxing meal, mostly, I presume, because of how long it took to prepare our meal, we set off for the Missionary School to exchange money, and then to the market.  Taxis were taken, walking was done, and multiple requests for money and who knows what else were received.  The store was well stocked, but not quite as colorful as I remember it being in El Doret, Kenya.  What helped in Kenya was a list from the missionaries there of what we should buy in town, and what was available back at the hospital.  We had a large list from some past friends, but the local recommendations were to buy cheese and chocolate.  Not knowing what is available in the town we are going to, or the mission store, I pretty much bought just cheeses, but also some fruit and juice for our time here in the guest house.  In Kenya, we were travelling in the "ambulance" and there was ample space for our large box of treasures.  Here, we were travelling by taxi and it seemed more reasonable to limit my purchases to one grocery bag.

I bought a SIM card for my Grenada phone, but alas, the phone was too high tech, and not "unlocked."  Instead I had to buy my fourth phone in order to use my previously bought SIM card.  I now have phones for use in Grenada, St. Vincent's, America, and here; purchased in that order!  To think my first ever cell phone was not from the US!  Such a world traveler I am!

We had an uneventful taxi ride back to home base, and then rested and read for a bit.  I am reading Evidence Not Seen, by Darlene Diebler Rose.  It is a book DD gave me, and came highly recommended by everyone in my River small group!  The author was a missionary in the jungles of New Guinea who survived a Japanese prison camp.  A quote from the preface.  A particularly interesting quote from the preface states, "Now, suspended between captivity and a new life, I felt a fear I'd never known.  Would I know how to live outside of the confined, yet familiar regimen of suffering."

I don't see the next five months as being captivity, but definitely a new life; and I have ample fears of the unknown.  I pray that the suffering does not become so familiar as to necessitate its overlooking.  There is a fine line between what is needed for survival when kids are dying daily and how to sincerely recognize how each death will impact their parents, children, or relatives.  I hope that no life is in vain, and that something good could come of each of these trying interactions.

It is raining now.  Lisa just played a song for me by Toto, called Africa.  "I'm thankful for the rains down in Africa…"  Maybe you have to hear it to recognize it, but it is a popular song.  And I have a new respect for the rains down in Africa.  I feel as if the temperature had dropped at least 10 degrees.  Any honking of horns on the street and the jeering and requesting money on the streets has been hushed out by the sound of rain on the sand and the tin roof.  It is a massive rain.  Large drops, high velocity and getting the job done.

I am sitting on the front porch - facing out toward the entrance of the guest house.  The compound is gated and guards are present to maintain security and offer a word of goodbye, or hello.

 There is a tree in front of me.  He had about a six inch deep area about 8 feet in diameter around him.  I watched as the rain coming off the roof started to travel a path toward the tree.  It first reached the tree, then crept around, trying to find the right place to settle.  It seemed as if some was evaporating just from the left over heat from the day.  The rest continued it's quest.  After reaching midway toward the trunk, the water branched out trying to reach around the trunk, then that mission was complete and then, with time and patience, the whole basin around the tree was filled.  As the rains continue to cool and refresh, the whole front yard is nearly covered, and only a few roots around the front are seen in the soil.  I can't think of a good reason that was important for me to see or to not, but it was and I have. 

Perhaps hope that every rain drop is not just an ignored drop in the bucket, but to some refreshing, to some life providing, to some destructive.  Maybe to remind me of Oregon, or Grenada.  This has been a long trip, regardless of which origin, and I hope the upcoming is what I'd dreamed it would be.

We arrived in the Capitol!

Tuesday, August 14, 9:30 am in the Capitol.

We are at the guest house.

We left Wichita at 12:30 pm, went through Atlanta, Paris and then to the capitol.  Our seats on all legs were accidentally(? )upgraded to business class!  That was unexpected but quite pleasant.

Upon arrival we found the longest line to check our VISAs, but got our passports stamped without problem.  After waiting at the baggage claim until all the remaining pieces had gone around several times, I was short one trunk.  One huge, heavy trunk.  As Lisa went to fill out lost paperwork, I spotted it at the far end of the baggage claim area, apparently having fallen off the conveyer belt.  It was nice to welcome it back!  (Unlike Kenya when our bags were left or lost and made it to us a few days after arrival at our destination!)

We made it through customs with no problems - I would comment more on the simplicity of the system, but probably shouldn't discuss  anything regarding security, politics, etc.

We met our taxi driver, and crossed from the capitol to our guest house.  It was a Monday and commerce was going on beside the streets, cars and motorcycles that would never pass the DEQ were putting off ample emissions, and the heat was ok with the windows open providing a breeze.

We arrived at the guest house safely, and it is very comfortable.  There is a full kitchen, ample opportunity to get cold and clean water, a nice sitting area, our bedroom has three beds (and there are 3 other rooms), and fans in every room to help move the air.  On arrival the guest house was 90 degrees, and by the time we went to bed it had cooled off!  To 86 degrees.  There is an AC in our room, charged by the hour, and I was able to sleep comfortably.

We went on an excursion to visit a nearby bakery for baguette and stopped by a road side stand for eggs and oranges.  There is a drought and famine here, and I wonder if that changes the rules about bargaining.  As we learned later, some food is available, but most is unaffordable to the locals.  There has been rain nearly every day for a while now, and everything on arrival and driving through town was green, but the lack of food now stems from last years drought, and this growing season won't be available until October.  There is some great fear that locust will destroy the crops, when the grow, and spraying can't be done over neighboring countries as the planes may be shot at.

We were invited to dinner by some missionaries a few blocks away, and it was nice to have somewhere to go, good food, good conversation and good company.

It had been a long journey, but thankfully uneventful.  We went to bed early, and I slept well.  Although between hours here and there on the plane, there were several hours overnight I could not sleep, but none-the-less woke up rested.  I enjoyed a cold shower, and since have been sitting under a fan, writing this; to be posted when internet is available.

Thank you for your prayers for safety in travel.