My recent internal medicine rotation was emotionally intense and demanding time-wise. This post is the result of my ruminations of one of my patients there.
"He was a good man, a good father," she tells me through her tears, "a hard worker." We stand beside the bed of the man in question, now demented after multiple strokes to the point of near-total disorientation. He has been increasingly agitated and begun refusing not only oral medications but also food. Even the home-cooked food his family makes lies untouched, his wife and daughters unable to make him eat despite much affectionate cajoling.
I think about this man and what his life was like. Despite his wife's endorsement, other sides of this man have come to light during his hospital stay: a history of heavy alcohol and tobacco abuse, requests to visit some shady district of his home city, requests for a as his wife patiently waits by his bedside.
I am reminded of the uncharitable way our attempts at objectivity in medicine can affect how we see people. Would I treat this man differently if I knew who he had been before he spoke of something falling on him at school today as he patted the TV remote on his chest? Before he called out incessantly for his deceased mother and his wife when she has gone home to rest? Which of us - his wife or I - sees him more clearly? To what extent should I, can I, allow care for my patients to filter the information I have about them?
After a family meeting, his family decides against a feeding tube, and I am quietly grateful for that acceptance of the inevitable. We talk about how hard it is to come to terms with his decline, and I sit with his wife as she cries. In the end, they ask if I would want to be the patient's primary care doctor through these last days and weeks. Privileged and touched, I agree.
Thursday, December 2, 2010
Monday, November 8, 2010
struggles
It was my first time seeing her, and a long conversation about what to do with her conflicting feelings over an unplanned pregnancy was not what I expected to encounter upon entering the room. She'd been pregnant half a dozen times before, but a combination of repeated first-trimester miscarriages and third-trimester losses meant she had only two living children. Just hearing her story of waking up several weeks prior to full-term in a pool of blood and then delivering a dead baby was enough to make me want to cry for her. A history of childhood abuse and adult rape only increased my admiration for the courage that made her able to continue dreaming for her future.
But this was an office visit with limited time, so I avoided tears on her behalf as I heard her stories and brought the conversation back to the issue at hand - her current pregnancy. Due to serious health problems and a history of complicated, high-risk pregnancies, she was unsure that she should carry this pregnancy if she wanted her living children to have a mother with whom to grow up. She cried to me - a near stranger - over her agony of deciding she must end the pregnancy. We spoke of options, and I affirmed our support for her medically and emotionally whichever option she chose.
The encounter reminded me of the confusing way my roles and identities intersect as I start the practice of medicine. I believe strongly that my primary interface in any interaction is that of one human being encountering another. But as she spoke of the recommendations health care workers have made to her in the past and of her feeling that the only responsible path was to end the pregnancy, I was reminded that as a doctor I may still be a human being, but I am also more alongside that.
I am a person with power in this relationship. I feel it weigh on my shoulders as patients ask me questions. It is power to influence. Power to persuade or recommend. Power to change her mind... Or power to give away to empower another.
How do I deal responsibly with that power? How do I balance my own values as a human being with the inequality of our status in this relationship and my own deep desire not to push my beliefs on someone else? How do I reckon with the fact that I as a human being am accountable for my own choice to influence - or not - in one direction or another while also seeking to let my patient be responsible for her own choices? How do we ever persuade wholeheartedly while avoiding manipulation? How do I take off this cloak of authority and seek to relate on a level as one person, one woman, to another?
All of these questions hung on my heart, grabbing my attention and shaping the way I spoke and responded as I spoke with my patient. And all of them remained as I wrote my note on our visit together through my tears. I shared this story at a medical conference seminar on reflective writing recently. One of the comments I got in response was from a fellow believer: "You very much nailed the tension of living out our faith in a power relationship but love always wins."
Love always wins. What does that look like? I'm not sure in the day-to-day whether I make the right choices. But it is a relief to be reminded that at the end of the day - whether I agree or disagree with my patients' choices, whether I have complete peace with what I said and left unsaid - if I have loved them, I have done what is pleasing to God. And all the best advice and soundest options counseling without love would be worth nothing. Now for learning the wisdom of figuring out when love looks like emotional support and when it requires hard conversations...or maybe it's both.
But this was an office visit with limited time, so I avoided tears on her behalf as I heard her stories and brought the conversation back to the issue at hand - her current pregnancy. Due to serious health problems and a history of complicated, high-risk pregnancies, she was unsure that she should carry this pregnancy if she wanted her living children to have a mother with whom to grow up. She cried to me - a near stranger - over her agony of deciding she must end the pregnancy. We spoke of options, and I affirmed our support for her medically and emotionally whichever option she chose.
The encounter reminded me of the confusing way my roles and identities intersect as I start the practice of medicine. I believe strongly that my primary interface in any interaction is that of one human being encountering another. But as she spoke of the recommendations health care workers have made to her in the past and of her feeling that the only responsible path was to end the pregnancy, I was reminded that as a doctor I may still be a human being, but I am also more alongside that.
I am a person with power in this relationship. I feel it weigh on my shoulders as patients ask me questions. It is power to influence. Power to persuade or recommend. Power to change her mind... Or power to give away to empower another.
How do I deal responsibly with that power? How do I balance my own values as a human being with the inequality of our status in this relationship and my own deep desire not to push my beliefs on someone else? How do I reckon with the fact that I as a human being am accountable for my own choice to influence - or not - in one direction or another while also seeking to let my patient be responsible for her own choices? How do we ever persuade wholeheartedly while avoiding manipulation? How do I take off this cloak of authority and seek to relate on a level as one person, one woman, to another?
All of these questions hung on my heart, grabbing my attention and shaping the way I spoke and responded as I spoke with my patient. And all of them remained as I wrote my note on our visit together through my tears. I shared this story at a medical conference seminar on reflective writing recently. One of the comments I got in response was from a fellow believer: "You very much nailed the tension of living out our faith in a power relationship but love always wins."
Love always wins. What does that look like? I'm not sure in the day-to-day whether I make the right choices. But it is a relief to be reminded that at the end of the day - whether I agree or disagree with my patients' choices, whether I have complete peace with what I said and left unsaid - if I have loved them, I have done what is pleasing to God. And all the best advice and soundest options counseling without love would be worth nothing. Now for learning the wisdom of figuring out when love looks like emotional support and when it requires hard conversations...or maybe it's both.
Friday, October 8, 2010
breathing
started to be written in early September 2010:
I just finished my surgery rotation. As part of the rotation, we spend a few mornings with anesthesiologists doing intubations, practicing breathing for people with the bag-mask, etc. It is common practice after someone is asleep/unconscious to breathe (ventilate) for them using the bag and mask for a little while so that their lungs fill up with oxygen for the body to use while they are not breathing temporarily during the actual process of putting the breathing tube in place (intubation). It struck me watching the bag-mask ventilation how intimate a process this is. It's not mouth-to-mouth resuscitation, but the motion of my right hand pressing the bag to push air into the mask and my other hand holding up the chin to open up the airway for the air to pass through is strikingly crucial for the patient who is asleep.
I am reminded in thinking about breath and the life to which it connects us of how often that image comes up in the Bible. It is there in the very beginning as God breathes his breath of life into the human being, "and the man became a living being" (Gen. 2:7). It is the promise of God to his people as they wait in exile, feeling dead and disassembled like a pile of dry bones without the breath of life to hold them together and give them purpose: "I will put breath in you, and you will come to life" (Eze 37:4-6). It is there when Jesus speaks to the startled, uncertain disciples after his resurrection, breathing on them and giving them the Holy Spirit (Breath) along with his peace and his commission (Jn. 20:21-23).
That final image always reminds me of the way C.S. Lewis picks up the image of God breathing on us in the Chronicles of Narnia. He pictures the great Lion Aslan breathing new life and courage and vision into his children. Aslan breathes onto Lucy to help her meet the challenge of doing right alone. He breathes onto the cold stone statues of the Witch's courtyards, bringing them to radiant life.
The word in both Hebrew (ruah) and Greek (pneuma) for spirit and breath/wind are the same. Thus, the promise of God's Spirit to live in his people is a promise for his breath, his life, to live in us, enabling us to live the life we were made to live. It is God's promise that he will pour out his Spirit on all people, Jews and Greeks (Acts 2:17). It is his Breath in us that is our deposit of salvation, a guarantee of our inheritance (Eph. 1:13-14).
So as I have the precious and uncommon opportunity to breathe temporarily for others, I think about the breath I myself breathe. I think about the life I live and the possibility that I have to live out God's life, his Spirit-empowered life, in my own hours and days. I think about the possibility of breathing out the fragrance of the knowledge of Christ, the smell of life, the rich, sweet, poignant aroma of the Living One (2 Cor. 2:14-16) in the midst of lifeless bones, despairing hearts, suffering people. As Paul says, "And who is equal to such a task?" May it be so.
I just finished my surgery rotation. As part of the rotation, we spend a few mornings with anesthesiologists doing intubations, practicing breathing for people with the bag-mask, etc. It is common practice after someone is asleep/unconscious to breathe (ventilate) for them using the bag and mask for a little while so that their lungs fill up with oxygen for the body to use while they are not breathing temporarily during the actual process of putting the breathing tube in place (intubation). It struck me watching the bag-mask ventilation how intimate a process this is. It's not mouth-to-mouth resuscitation, but the motion of my right hand pressing the bag to push air into the mask and my other hand holding up the chin to open up the airway for the air to pass through is strikingly crucial for the patient who is asleep.
I am reminded in thinking about breath and the life to which it connects us of how often that image comes up in the Bible. It is there in the very beginning as God breathes his breath of life into the human being, "and the man became a living being" (Gen. 2:7). It is the promise of God to his people as they wait in exile, feeling dead and disassembled like a pile of dry bones without the breath of life to hold them together and give them purpose: "I will put breath in you, and you will come to life" (Eze 37:4-6). It is there when Jesus speaks to the startled, uncertain disciples after his resurrection, breathing on them and giving them the Holy Spirit (Breath) along with his peace and his commission (Jn. 20:21-23).
That final image always reminds me of the way C.S. Lewis picks up the image of God breathing on us in the Chronicles of Narnia. He pictures the great Lion Aslan breathing new life and courage and vision into his children. Aslan breathes onto Lucy to help her meet the challenge of doing right alone. He breathes onto the cold stone statues of the Witch's courtyards, bringing them to radiant life.
The word in both Hebrew (ruah) and Greek (pneuma) for spirit and breath/wind are the same. Thus, the promise of God's Spirit to live in his people is a promise for his breath, his life, to live in us, enabling us to live the life we were made to live. It is God's promise that he will pour out his Spirit on all people, Jews and Greeks (Acts 2:17). It is his Breath in us that is our deposit of salvation, a guarantee of our inheritance (Eph. 1:13-14).
So as I have the precious and uncommon opportunity to breathe temporarily for others, I think about the breath I myself breathe. I think about the life I live and the possibility that I have to live out God's life, his Spirit-empowered life, in my own hours and days. I think about the possibility of breathing out the fragrance of the knowledge of Christ, the smell of life, the rich, sweet, poignant aroma of the Living One (2 Cor. 2:14-16) in the midst of lifeless bones, despairing hearts, suffering people. As Paul says, "And who is equal to such a task?" May it be so.
Saturday, August 21, 2010
labor, birth, and rebirth
I recently completed four weeks on obstetrics, logging 12 normal deliveries and two c-sections. I enjoyed it, observing the normal labor course and learning to recognize what falls off the normal curve. I also gained experience in coaching and encouraging women in labor and in pushing and caught a good number of what a friend of mine calls "slippery little buggers." Really, though, I most enjoyed the almost magical moment that usually happens after the birth when the new mom and the baby are enveloped in a happiness that far outweighs what she went through to get there. It so overshadows the previous pain that she usually temporarily forgets that she still has to deliver the placenta. :)
In the course of OB, though, I was reminded that labor and birth are frequent images in Scripture, vivid reminders of how much closer everyone in a community used to be to the pain and blood and delight involved in bringing a new life into the world. This ranges from comparing the prophet or people's pain to the "pangs" of a woman in labor (e.g. Isa. 21:3) writhing "in agony" (Micah 4:10) to descriptions of the Father himself crying out in suffering, gasping and panting, "like a woman in childbirth" in his heartbroken response to the people of Israel's unfaithfulness (Isa. 42:14). This vivid familiarity with the birthing process was even such that the prophets could differentiate between the more intense and longer-lasting pains of a woman's first birth (e.g. Jer. 4:31) vs. subsequent ones. God also recognizes the vulnerability of a woman in labor, promising explicitly to call women in labor back (along with the pregnant, blind, and lame) to the security of Jerusalem and home after the pain of exile among strangers (Jer. 31:8).
The image of birth is used for various "children." In Deuteronomy, Moses calls the people of God to account for deserting and forgetting the God who "fathered you," "who gave you birth," calling to mind the great suffering God has endured in loving and calling and pursuing and wooing such a forgetful, faithless people to give us a new identity in the world as his children (32:18). In Isaiah 26, the people confess that they have "writhed in pain" as in labor but have given birth to wind - to something insubstantial and effervescent - instead of to "salvation," to "people of the world" (vv. 17-19). Most often, however, it is Israel who is pictured as God's child, as far from being forgotten or forsaken as the baby at a mother's breast whom she has borne (Isa. 49:14-16).
The imagery of birth is picked up most fantastically in the New Testament with the incredible story of the birth of God himself as the helpless newborn Jesus to Mary, recounted in Matthew 1 and Luke 2. It is also recorded in its cosmic significance in the revelation of John as the birth of a male child "who will rule all the nations" (Rev. 12:1-2,5). It is clear from the New Testament account that Jesus represents the true Israel, the one in whom all that Israel was meant to be is encapsulated (e.g. OT images for Israel being applied to Jesus with him fulfilling their purposes) and in whom the prophecies and promises are and will be fulfilled. He is the one Man who is truly God's Son, who reflects the Father's image, his heart, his holiness, his love, his compassion, and his justice.
And yet, the apostle John's poetic account of the coming of Jesus begins to hint that there is still even more to the story. Not only, he says, did "the Word become flesh" and make "his dwelling among us." Not only have we "seen his glory," the glory of the one "who came from the Father." But we also have the opportunity - nay, more! - "the right to become children of God." This is not something physical, he clarifies. We are not children born "of natural descent" but "born of God" (Jn. 1:12-14). That picture of Israel being God's child can still apply to us (us!) even though Jesus has come and shown us just how far we as the people of God have gotten off track, how little we bear the image of our Father. We can still be the children of God.
John uses this imagery most in the New Testament, both in his gospel and in his epistles, describing what it means to be a child of God - not continuing in sin (1 Jn. 3:9) because we are of God's seed, loving one another because love comes from God (1 Jn. 4:7), being "born of water and the Spirit" in Jesus' words explaining what it means to be "born again" (Jn. 3:3-5). Peter, too, picks up the language, explaining that we have been born again "not of perishable seed, but of imperishable, through the living and enduring word of God" (1 Pe. 1:23).
The use of birth imagery doesn't even stop there, however. It is used of us as believers, too. We now also have the opportunity to participate in this imagery as something beyond the child of God that is born. We are also part of the birth process. This appears in Romans 8 where creation and we ourselves groan "in the pains of childbirth" as we "patiently" await redemption and adoption with "eager expectation" and with hope (vv. 19-25). Paul describes himself enduring "the pains of childbirth" so that Christ may be formed in the his spiritual children, the Galatian church (Gal. 4:19-20). We have the opportunity to participate in that formation so that we as God's children may more closely resemble our elder Brother, God's Son. The apostle John also picks up the imagery as he quotes Jesus comparing the pain of the disciples' temporary separation from Himself to the pain of a woman giving birth to a child. Just as a woman giving birth quickly "forgets the anguish because of her joy that a child is born into the world," however, he promises that the disciples' joy will far outshine their present pain (Jn. 16:19-22).
These pictures mean more to me as I think about the women in labor I have seen. The pain of separation from God is more vividly pictured, as is his pain over us when we turn away from Him. The process of birth and the precious fragility of a newborn is all the more poignant for the fact that the Maker of mankind was once so very breakable. The immediate and consuming joy on a mother's face as she is handed her little one, able to hold him for the first time and automatically comforting and cuddling the wailing infant, helps me to remember God's tender care for each of us and his delight over new children's births as his children. The satisfaction in participating in the labor process and seeing it through to the birth encourages me to keep holding up my end of participating with the Holy Spirit's work of forming Christ in me. The way in which the weariness, pain, bleeding, and risk are all ever so worth the baby at the end enable me to await with more hope and eager expectation my and our own redemption and adoption.
"Praise be to the God and Father of our Lord Jesus Christ! In his great mercy he has given us new birth into a living hope through the resurrection of Jesus Christ from the dead, and into an inheritance that can never perish, spoil or fade—kept in heaven for you, who through faith are shielded by God's power until the coming of the salvation that is ready to be revealed in the last time" (1 Pe. 1:3-5).
In the course of OB, though, I was reminded that labor and birth are frequent images in Scripture, vivid reminders of how much closer everyone in a community used to be to the pain and blood and delight involved in bringing a new life into the world. This ranges from comparing the prophet or people's pain to the "pangs" of a woman in labor (e.g. Isa. 21:3) writhing "in agony" (Micah 4:10) to descriptions of the Father himself crying out in suffering, gasping and panting, "like a woman in childbirth" in his heartbroken response to the people of Israel's unfaithfulness (Isa. 42:14). This vivid familiarity with the birthing process was even such that the prophets could differentiate between the more intense and longer-lasting pains of a woman's first birth (e.g. Jer. 4:31) vs. subsequent ones. God also recognizes the vulnerability of a woman in labor, promising explicitly to call women in labor back (along with the pregnant, blind, and lame) to the security of Jerusalem and home after the pain of exile among strangers (Jer. 31:8).
The image of birth is used for various "children." In Deuteronomy, Moses calls the people of God to account for deserting and forgetting the God who "fathered you," "who gave you birth," calling to mind the great suffering God has endured in loving and calling and pursuing and wooing such a forgetful, faithless people to give us a new identity in the world as his children (32:18). In Isaiah 26, the people confess that they have "writhed in pain" as in labor but have given birth to wind - to something insubstantial and effervescent - instead of to "salvation," to "people of the world" (vv. 17-19). Most often, however, it is Israel who is pictured as God's child, as far from being forgotten or forsaken as the baby at a mother's breast whom she has borne (Isa. 49:14-16).
The imagery of birth is picked up most fantastically in the New Testament with the incredible story of the birth of God himself as the helpless newborn Jesus to Mary, recounted in Matthew 1 and Luke 2. It is also recorded in its cosmic significance in the revelation of John as the birth of a male child "who will rule all the nations" (Rev. 12:1-2,5). It is clear from the New Testament account that Jesus represents the true Israel, the one in whom all that Israel was meant to be is encapsulated (e.g. OT images for Israel being applied to Jesus with him fulfilling their purposes) and in whom the prophecies and promises are and will be fulfilled. He is the one Man who is truly God's Son, who reflects the Father's image, his heart, his holiness, his love, his compassion, and his justice.
And yet, the apostle John's poetic account of the coming of Jesus begins to hint that there is still even more to the story. Not only, he says, did "the Word become flesh" and make "his dwelling among us." Not only have we "seen his glory," the glory of the one "who came from the Father." But we also have the opportunity - nay, more! - "the right to become children of God." This is not something physical, he clarifies. We are not children born "of natural descent" but "born of God" (Jn. 1:12-14). That picture of Israel being God's child can still apply to us (us!) even though Jesus has come and shown us just how far we as the people of God have gotten off track, how little we bear the image of our Father. We can still be the children of God.
John uses this imagery most in the New Testament, both in his gospel and in his epistles, describing what it means to be a child of God - not continuing in sin (1 Jn. 3:9) because we are of God's seed, loving one another because love comes from God (1 Jn. 4:7), being "born of water and the Spirit" in Jesus' words explaining what it means to be "born again" (Jn. 3:3-5). Peter, too, picks up the language, explaining that we have been born again "not of perishable seed, but of imperishable, through the living and enduring word of God" (1 Pe. 1:23).
The use of birth imagery doesn't even stop there, however. It is used of us as believers, too. We now also have the opportunity to participate in this imagery as something beyond the child of God that is born. We are also part of the birth process. This appears in Romans 8 where creation and we ourselves groan "in the pains of childbirth" as we "patiently" await redemption and adoption with "eager expectation" and with hope (vv. 19-25). Paul describes himself enduring "the pains of childbirth" so that Christ may be formed in the his spiritual children, the Galatian church (Gal. 4:19-20). We have the opportunity to participate in that formation so that we as God's children may more closely resemble our elder Brother, God's Son. The apostle John also picks up the imagery as he quotes Jesus comparing the pain of the disciples' temporary separation from Himself to the pain of a woman giving birth to a child. Just as a woman giving birth quickly "forgets the anguish because of her joy that a child is born into the world," however, he promises that the disciples' joy will far outshine their present pain (Jn. 16:19-22).
These pictures mean more to me as I think about the women in labor I have seen. The pain of separation from God is more vividly pictured, as is his pain over us when we turn away from Him. The process of birth and the precious fragility of a newborn is all the more poignant for the fact that the Maker of mankind was once so very breakable. The immediate and consuming joy on a mother's face as she is handed her little one, able to hold him for the first time and automatically comforting and cuddling the wailing infant, helps me to remember God's tender care for each of us and his delight over new children's births as his children. The satisfaction in participating in the labor process and seeing it through to the birth encourages me to keep holding up my end of participating with the Holy Spirit's work of forming Christ in me. The way in which the weariness, pain, bleeding, and risk are all ever so worth the baby at the end enable me to await with more hope and eager expectation my and our own redemption and adoption.
"Praise be to the God and Father of our Lord Jesus Christ! In his great mercy he has given us new birth into a living hope through the resurrection of Jesus Christ from the dead, and into an inheritance that can never perish, spoil or fade—kept in heaven for you, who through faith are shielded by God's power until the coming of the salvation that is ready to be revealed in the last time" (1 Pe. 1:3-5).
Thursday, June 24, 2010
gardening
I've spent a fair amount of time gardening recently, particularly since the lack of rain over the past week or two has required my early rising to water for about 45 minutes prior to our 7 am orientation day starts. Despite growing up eating fresh vegetables from our large garden all summer, I never realized how much regular work a garden was (thanks, Mom!).
In particular, though, as I learn to garden, I've been thinking about weeding. In many ways, weeding is simple - as long as you know what is supposed to grow there, everything else is pretty much weeds. It is satisfying that even if I don't recognize the weed, I have learned to recognize my small sprouting plants and so can confidently uproot the weeds and allow my plants to flourish. My mom says we enjoy weeding because it is like medicine - taking out the bad stuff and leaving room for the good to grow. I just never thought it would be so much work to keep the bad stuff under control. It grows so easily and quickly while the good stuff seems to grow relatively slowly and require a lot of careful watering and tending.
After spending three hours on it yesterday, I was thinking about the parallels in the rest of life. How much effort do I put into weeding out bad things in my life - disciplining myself not to make bad choices, to use my time wisely, to stay connected to people when it takes effort, to study when I'd rather read or relax watching clips on YouTube? How quickly weeds spring up in my life! How much easier they are to pull out when they're small and when I stay on top of the weeding than when they're better rooted! Do I know and love the good things I want to grow so well that I can easily uproot the bad things that would choke them out?
Conversely, how much effort do I put into planting and tending good things - good habits, healthy relationships, my understanding of and love for God, friendships that challenge me to grow, self-discipline - in my life? Do I carefully pick out seeds that will lead to fruit I will enjoy and do the things (i.e. plant them at an appropriate depth and keep them well watered) that will give them the chance to sprout and then deepen their roots? Do I delight in the small, fragile green growth of my seeds long before they grow fruit or even flowers (a one-inch stem and two leaves for my zucchini were so exciting that it took me far longer than it should have to prune them back to the two plants/hill they should be)? Do I mourn the seeds that didn't sprout and vigilantly fight the enemies (weeds, slugs, insect borers, etc.) that would destroy my plants? Do I prop up the ones with weak stems like I do my tomatoes, making support for their weakness because they will then be able to grow and bear fruit?
Far too often, the answers to most of these questions are "no." I have learned that it takes oft-surprising effort and discipline to get the literal fruits of one's labors in a garden. Since I think God delights no less in good fruit in my life (and mourns the bad), may I learn to be a good gardener of my own life and choices as I likewise seek to raise a healthy garden with lots of vegetables for later in the summer. May I remember always that God works alongside me, breathing life into both me and my plants, delighting in every small growth and working towards fruit we can both enjoy.
In particular, though, as I learn to garden, I've been thinking about weeding. In many ways, weeding is simple - as long as you know what is supposed to grow there, everything else is pretty much weeds. It is satisfying that even if I don't recognize the weed, I have learned to recognize my small sprouting plants and so can confidently uproot the weeds and allow my plants to flourish. My mom says we enjoy weeding because it is like medicine - taking out the bad stuff and leaving room for the good to grow. I just never thought it would be so much work to keep the bad stuff under control. It grows so easily and quickly while the good stuff seems to grow relatively slowly and require a lot of careful watering and tending.
After spending three hours on it yesterday, I was thinking about the parallels in the rest of life. How much effort do I put into weeding out bad things in my life - disciplining myself not to make bad choices, to use my time wisely, to stay connected to people when it takes effort, to study when I'd rather read or relax watching clips on YouTube? How quickly weeds spring up in my life! How much easier they are to pull out when they're small and when I stay on top of the weeding than when they're better rooted! Do I know and love the good things I want to grow so well that I can easily uproot the bad things that would choke them out?
Conversely, how much effort do I put into planting and tending good things - good habits, healthy relationships, my understanding of and love for God, friendships that challenge me to grow, self-discipline - in my life? Do I carefully pick out seeds that will lead to fruit I will enjoy and do the things (i.e. plant them at an appropriate depth and keep them well watered) that will give them the chance to sprout and then deepen their roots? Do I delight in the small, fragile green growth of my seeds long before they grow fruit or even flowers (a one-inch stem and two leaves for my zucchini were so exciting that it took me far longer than it should have to prune them back to the two plants/hill they should be)? Do I mourn the seeds that didn't sprout and vigilantly fight the enemies (weeds, slugs, insect borers, etc.) that would destroy my plants? Do I prop up the ones with weak stems like I do my tomatoes, making support for their weakness because they will then be able to grow and bear fruit?
Far too often, the answers to most of these questions are "no." I have learned that it takes oft-surprising effort and discipline to get the literal fruits of one's labors in a garden. Since I think God delights no less in good fruit in my life (and mourns the bad), may I learn to be a good gardener of my own life and choices as I likewise seek to raise a healthy garden with lots of vegetables for later in the summer. May I remember always that God works alongside me, breathing life into both me and my plants, delighting in every small growth and working towards fruit we can both enjoy.
update
So it's been a while since I posted, and I had some thoughts I'd like to share or at least have the chance to process externally. I hope to continue to do this throughout the year ahead (albeit much less frequently than during my previous travels) as I start residency. If you don't want to continue to follow along, let me know, and I'll see if I can figure out how you can come off the list. :)
I graduated from med school at the end of May and moved the same day - with much packing and hauling help from Mom, Dad, Grandma, and Grandpa - to Lancaster for my new residency training. I enjoyed starting a garden and putting in flowers and landscaping in the surprisingly large backyard of my housemate's rowhouse prior to the start of orientation June 14. I also have gotten to attend First Friday downtown in Lancaster, go to two free downtown movies (part of summer series), and begun getting to know my fellow interns (via hosting dinner and later dessert and other local activities), a couple of whom live happily about two blocks away. :) We've had a busy orientation schedule between ACLS, ATLS, EKG learning, computer training, HR paperwork, and even a day at the ropes course. I've enjoyed the chance to ease into figuring out where stuff is in the hospital, making connections with my class and other residents, and settling into the city. I start in the hospital July 1 on night float for OB (5 pm-7 am Monday-Friday for two weeks), so you can keep me in prayers for that!
I graduated from med school at the end of May and moved the same day - with much packing and hauling help from Mom, Dad, Grandma, and Grandpa - to Lancaster for my new residency training. I enjoyed starting a garden and putting in flowers and landscaping in the surprisingly large backyard of my housemate's rowhouse prior to the start of orientation June 14. I also have gotten to attend First Friday downtown in Lancaster, go to two free downtown movies (part of summer series), and begun getting to know my fellow interns (via hosting dinner and later dessert and other local activities), a couple of whom live happily about two blocks away. :) We've had a busy orientation schedule between ACLS, ATLS, EKG learning, computer training, HR paperwork, and even a day at the ropes course. I've enjoyed the chance to ease into figuring out where stuff is in the hospital, making connections with my class and other residents, and settling into the city. I start in the hospital July 1 on night float for OB (5 pm-7 am Monday-Friday for two weeks), so you can keep me in prayers for that!
Friday, April 30, 2010
calling
I went on these international rotations partially hoping that God would use them to direct me regarding my future work overseas. Where should I go? With what organization? To what people group?
To my disappointment, I didn't find a particular sense of leading from God on these issues as I was traveling. I struggled with this a bit along the way. Should I have done these rotations? Am I simply experiencing some of the hard parts of living cross-culturally (initial language- and culture-learning, minimal relationships with nationals, the adjustment phase again) with few of the rewards of staying in one place longer-term? Am I missing out on something God wants to be showing me?
As I read On Being a Missionary on the flights back home, the author talked about the issue of calling in missions. Every child of God has a calling from God, a calling to go and serve others, to love and obey God, to learn to live in healthy relationships with others where we slowly learn to put others' needs above our own, to submit to each other in the Body (Church) and to honor others' gifts and abilities and cover for their weaknesses in love. But all who go to serve cross-culturally should also have an additional sense of calling to go there, whether a gradual sense building over time or a one-time supernatural experience of calling, which is necessary to sustain them through the difficulties involved.
I do have that sense, I realized, or I have at a number of times in the past. I don't need to manufacture a new and repeated sense of calling when I don't feel particular direction from God. The choice simply becomes: will I be obedient to the calling God has already revealed to me to live and work cross-culturally and internationally at some point in my future for a number of years? This realization was a relief to me. After all, the larger question of whether I will be obedient to God's will for me is simply the question of the Christian life: will I allow God to be God and trust that his goodness will lead to His plan for me being the best possible route for my life? That is a choice I have made many times in the past and can continue to make now, trusting that the details of his calling on my life will become clear as I choose to follow wherever he leads.
from: http://www.flickr.com/photos/35692109@N03/3531523716/
To my disappointment, I didn't find a particular sense of leading from God on these issues as I was traveling. I struggled with this a bit along the way. Should I have done these rotations? Am I simply experiencing some of the hard parts of living cross-culturally (initial language- and culture-learning, minimal relationships with nationals, the adjustment phase again) with few of the rewards of staying in one place longer-term? Am I missing out on something God wants to be showing me?
As I read On Being a Missionary on the flights back home, the author talked about the issue of calling in missions. Every child of God has a calling from God, a calling to go and serve others, to love and obey God, to learn to live in healthy relationships with others where we slowly learn to put others' needs above our own, to submit to each other in the Body (Church) and to honor others' gifts and abilities and cover for their weaknesses in love. But all who go to serve cross-culturally should also have an additional sense of calling to go there, whether a gradual sense building over time or a one-time supernatural experience of calling, which is necessary to sustain them through the difficulties involved.
I do have that sense, I realized, or I have at a number of times in the past. I don't need to manufacture a new and repeated sense of calling when I don't feel particular direction from God. The choice simply becomes: will I be obedient to the calling God has already revealed to me to live and work cross-culturally and internationally at some point in my future for a number of years? This realization was a relief to me. After all, the larger question of whether I will be obedient to God's will for me is simply the question of the Christian life: will I allow God to be God and trust that his goodness will lead to His plan for me being the best possible route for my life? That is a choice I have made many times in the past and can continue to make now, trusting that the details of his calling on my life will become clear as I choose to follow wherever he leads.
Sunday, April 25, 2010
names
I have always enjoyed having a unique name and knowing what it meant (one whom God has promised) and its origin (Hebrew, the story of my birth, etc.). And part of encountering another culture is learning new names and how to pronounce letter combinations you thought couldn't go together. :)
In Zambia, I had a different problem: not smiling at people's names, picked in some cases - I am sure - for how the parents liked the way the word sounded in English even if they didn't know what it meant. Or they simply name their children Tonga words with interesting meanings. Here are some I wrote down along the way:
English: Agrippa, Cleopatra, Only, Obey, Fines, Modern, Favourite, Purity, Precious, Pritness (Prettiness)
Tonga: Linda (awaited precious one), Trouble, Change-of-sex (as in a girl after a number of boys or a boy after a number of girls), Same-sex (opposite of above)
So even our names carry something of culture in what is appropriate to name your child. :)
In Zambia, I had a different problem: not smiling at people's names, picked in some cases - I am sure - for how the parents liked the way the word sounded in English even if they didn't know what it meant. Or they simply name their children Tonga words with interesting meanings. Here are some I wrote down along the way:
English: Agrippa, Cleopatra, Only, Obey, Fines, Modern, Favourite, Purity, Precious, Pritness (Prettiness)
Tonga: Linda (awaited precious one), Trouble, Change-of-sex (as in a girl after a number of boys or a boy after a number of girls), Same-sex (opposite of above)
So even our names carry something of culture in what is appropriate to name your child. :)
patient stories, 2
Here are some patients I don't want to forget.
A 5-year-old little girl was brought in by her aunt for 15 months of abdominal distension, a cough, and headache. She was orphaned a year and a half ago when her mother died. Nothing else really came up on the history, so I took them back to the little room where we do examinations if the patient will lie down or if it requires privacy. In examining her belly, I found the reason for the abdominal distension: a huge abdominal mass in the right side with a groove between it and her liver, extending to several cm past the umbilicus and down into the pelvis. My heart just sank as I reviewed my short differential diagnosis for an abdominal mass in a 5-year-old: Wilms' tumor, neuroblastoma, possibly something renal...
I saw them several times over the course of the next few days with various lab results (a normal CBC, negative HIV, normal creatinine and LFTs) and then the ultrasound results: complex, multicystic, intrahepatic lesion. At that point, my differential failed. She had already been treated for parasitic disease, so we referred her on to the University Teaching Hospital in Lusaka. I emphasized with the concerned aunt how important it was that she be taken and seen as soon as possible. The little girl was by this time sitting comfortably on my lap as her aunt and I talked about the results and possibilities. Then we prayed together, and I sent them off with the referral letter.
Another was a 41-year-old mother of twins (G12P9). I saw her for almost two weeks on maternity waiting on the ward for the pregnancy to come to term and then waiting because her twins were breech (twin A) and transverse (twin B) and so wouldn't probably deliver at home on their own. I used my Tonga phrases for the cardinal obstetrics questions with her every few days on rounds (any vaginal bleeding? any rupture of membranes/leakage of fluid? is the baby moving well? any contractions?) and she would smile and respond with the hoped-for answers (no, no, yes, no) for almost two weeks until she finally did go into labor. Then I actually got to be there to see the breech vaginal delivery (all on her own!) of the first and internal podalic version (turning the second baby using the foot) with breech delivery of the second twin. I helped with resuscitation, assessed the Apgars, and checked the new-again mom for postpartum hemorrhage since she was high-risk with twins and high parity (number of pregnancies). She did well, and I was happy to be part of the whole process and see it through to the end!
Another maternity patient I remember was a married 15-year-old G1P0 (first pregnancy); apparently most girls go to high school or get married young, so I saw a number of pregnant 15- and 16-year-olds who were married as well as a few who were not. I was rounding in the evening and was helping to count for her to learn how to push the baby effectively (something not usually done in Zambia from what I can tell - the counting, not the pushing). She made a little progress but not much, so I ended up seeing my first Zambian vacuum-assisted delivery (when I couldn't even see the head at all whether she was pushing or not). It was successful, though, with the nurse pumping the vacuum while the doctor pulled on the head, and we were glad she didn't have to get a C-section. When I rounded the next day and checked on her and the baby, both were doing really well and she lit up with a smile to see me. She spoke a little English, so I think she had understood my counting and encouragement the night before and was happy for it.
A final patient was a 6-year-old boy I admitted to men's ward (the cutoff for peds being six years due to high rates of disease/malnutrition in younger kids). I was worried about nephrotic syndrome (post-strep GN) with complaints of a sore throat two weeks ago, facial and feet swelling, abdominal pain, and headache. The urinalysis turned out to have only trace protein, though, and the child continued to spike fevers through penicillin and then amoxicillin and looked sick, never smiling at me whenever I came up to check on him. So we ended up deciding to do a lumbar puncture (spinal tap) to make sure he didn't have meningitis. I did my first pediatric LP, which was relatively direct (for which I was grateful), and we started him on stronger antibiotics (cefepime, having run out of ceftriaxone for meningitis). By the time I was leaving, he looked a bit better and gave me a crooked smile. :)
A 5-year-old little girl was brought in by her aunt for 15 months of abdominal distension, a cough, and headache. She was orphaned a year and a half ago when her mother died. Nothing else really came up on the history, so I took them back to the little room where we do examinations if the patient will lie down or if it requires privacy. In examining her belly, I found the reason for the abdominal distension: a huge abdominal mass in the right side with a groove between it and her liver, extending to several cm past the umbilicus and down into the pelvis. My heart just sank as I reviewed my short differential diagnosis for an abdominal mass in a 5-year-old: Wilms' tumor, neuroblastoma, possibly something renal...
I saw them several times over the course of the next few days with various lab results (a normal CBC, negative HIV, normal creatinine and LFTs) and then the ultrasound results: complex, multicystic, intrahepatic lesion. At that point, my differential failed. She had already been treated for parasitic disease, so we referred her on to the University Teaching Hospital in Lusaka. I emphasized with the concerned aunt how important it was that she be taken and seen as soon as possible. The little girl was by this time sitting comfortably on my lap as her aunt and I talked about the results and possibilities. Then we prayed together, and I sent them off with the referral letter.
Another was a 41-year-old mother of twins (G12P9). I saw her for almost two weeks on maternity waiting on the ward for the pregnancy to come to term and then waiting because her twins were breech (twin A) and transverse (twin B) and so wouldn't probably deliver at home on their own. I used my Tonga phrases for the cardinal obstetrics questions with her every few days on rounds (any vaginal bleeding? any rupture of membranes/leakage of fluid? is the baby moving well? any contractions?) and she would smile and respond with the hoped-for answers (no, no, yes, no) for almost two weeks until she finally did go into labor. Then I actually got to be there to see the breech vaginal delivery (all on her own!) of the first and internal podalic version (turning the second baby using the foot) with breech delivery of the second twin. I helped with resuscitation, assessed the Apgars, and checked the new-again mom for postpartum hemorrhage since she was high-risk with twins and high parity (number of pregnancies). She did well, and I was happy to be part of the whole process and see it through to the end!
Another maternity patient I remember was a married 15-year-old G1P0 (first pregnancy); apparently most girls go to high school or get married young, so I saw a number of pregnant 15- and 16-year-olds who were married as well as a few who were not. I was rounding in the evening and was helping to count for her to learn how to push the baby effectively (something not usually done in Zambia from what I can tell - the counting, not the pushing). She made a little progress but not much, so I ended up seeing my first Zambian vacuum-assisted delivery (when I couldn't even see the head at all whether she was pushing or not). It was successful, though, with the nurse pumping the vacuum while the doctor pulled on the head, and we were glad she didn't have to get a C-section. When I rounded the next day and checked on her and the baby, both were doing really well and she lit up with a smile to see me. She spoke a little English, so I think she had understood my counting and encouragement the night before and was happy for it.
A final patient was a 6-year-old boy I admitted to men's ward (the cutoff for peds being six years due to high rates of disease/malnutrition in younger kids). I was worried about nephrotic syndrome (post-strep GN) with complaints of a sore throat two weeks ago, facial and feet swelling, abdominal pain, and headache. The urinalysis turned out to have only trace protein, though, and the child continued to spike fevers through penicillin and then amoxicillin and looked sick, never smiling at me whenever I came up to check on him. So we ended up deciding to do a lumbar puncture (spinal tap) to make sure he didn't have meningitis. I did my first pediatric LP, which was relatively direct (for which I was grateful), and we started him on stronger antibiotics (cefepime, having run out of ceftriaxone for meningitis). By the time I was leaving, he looked a bit better and gave me a crooked smile. :)
culture, take 2
On my flights back and in layovers, I started reading a book I have owned for a number of years but never got to read, On Being a Missionary by Thomas Hale. His chapter on culture shock/stress made me think again about my entry on cultural differences. I recognize much of his symptoms of culture shock in myself over the past eight weeks particularly: discouragement, critical spirit, self-pity, pessimism, etc. I know and knew at the time that I was experiencing some stress from the difference in cultures. It simply costs more emotional energy to do simple things like going to market when you have to say no to several people who want money or a job, ignore some propositions or comments, try to figure out what I'm going to do with the few vegetables available that my stomach won't reject, and then gauge whether the price I'm offered is a fair one or whether I should barter a bit and if so how much to offer and whether the seller speaks English...
Hale goes on to talk about what to do for culture shock. His steps include recognition, praying for God's grace and enabling, adapting to the nationals except for ethics and faith, making a circle of friends, cultivating an attitude of exploration/adventure, maintaining friendships with other expats, and not taking yourself too seriously. I was struck as I looked over this list by how little of this I did. I was much quicker to judge and criticize than to ask God for his enabling to love those around me. I was much quicker to relate to the simpler relationships with expats than to invite over Zambian friends, even for the little hospitality (tea, games) I could offer. And this is me, who prides myself on enjoying the challenge of cross-cultural relationships and cultivating a good number of them, including among my closest friends. Have I been deceiving myself and simply requiring my friends to respond in ways that fall within my expectation or do not require challenge or change for me?
Hale speaks of the way in which Jesus gave up so much to be with and for us, to die in our place, to rise to give us a victory we could never earn but in which we are welcomed lavishly, generously, joyfully, grace-fully to share. He reminds the reader of how love is shown forth in one giving his life for his friends, and how those of us who serve cross-culturally in an attempt to show Jesus' love for others have a unique chance to give up our lives (our things, our culture, our status, our privileges, even sometimes literally our lives) to demonstrate that love. How little of that was present in my thoughts and attitudes, although I hope a bit more of it was present in my actions...
So this is my confession. I have far to go in learning to be like Jesus, who willing and without complaint gave up a place in heaven to be born in a stable, to work as a carpenter, to be rejected and ridiculed, to be humiliated in death and misunderstood in life. I do not love my neighbor well. Lord, help me to grow in this, particularly when dealing with the additional stresses of cross-cultural relationships. Am I willing to be misunderstood, to be rejected, to be unappreciated or ignored? Am I willing to have my medical judgment questioned, my competence doubted, what little knowledge I have worked to earn ridiculed? Am I actually willing to follow where Jesus leads and expect nothing in return?
I am reminded of 1 Corinthians 13, the so-called love chapter. Verses 2-3, 8a: "If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but have not love, I am nothing. If I give all I possess to the poor and surrender my body to the flames, but have not love, I gain nothing... Love never fails." Lord, teach me to love like you do.
Hale goes on to talk about what to do for culture shock. His steps include recognition, praying for God's grace and enabling, adapting to the nationals except for ethics and faith, making a circle of friends, cultivating an attitude of exploration/adventure, maintaining friendships with other expats, and not taking yourself too seriously. I was struck as I looked over this list by how little of this I did. I was much quicker to judge and criticize than to ask God for his enabling to love those around me. I was much quicker to relate to the simpler relationships with expats than to invite over Zambian friends, even for the little hospitality (tea, games) I could offer. And this is me, who prides myself on enjoying the challenge of cross-cultural relationships and cultivating a good number of them, including among my closest friends. Have I been deceiving myself and simply requiring my friends to respond in ways that fall within my expectation or do not require challenge or change for me?
Hale speaks of the way in which Jesus gave up so much to be with and for us, to die in our place, to rise to give us a victory we could never earn but in which we are welcomed lavishly, generously, joyfully, grace-fully to share. He reminds the reader of how love is shown forth in one giving his life for his friends, and how those of us who serve cross-culturally in an attempt to show Jesus' love for others have a unique chance to give up our lives (our things, our culture, our status, our privileges, even sometimes literally our lives) to demonstrate that love. How little of that was present in my thoughts and attitudes, although I hope a bit more of it was present in my actions...
So this is my confession. I have far to go in learning to be like Jesus, who willing and without complaint gave up a place in heaven to be born in a stable, to work as a carpenter, to be rejected and ridiculed, to be humiliated in death and misunderstood in life. I do not love my neighbor well. Lord, help me to grow in this, particularly when dealing with the additional stresses of cross-cultural relationships. Am I willing to be misunderstood, to be rejected, to be unappreciated or ignored? Am I willing to have my medical judgment questioned, my competence doubted, what little knowledge I have worked to earn ridiculed? Am I actually willing to follow where Jesus leads and expect nothing in return?
I am reminded of 1 Corinthians 13, the so-called love chapter. Verses 2-3, 8a: "If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but have not love, I am nothing. If I give all I possess to the poor and surrender my body to the flames, but have not love, I gain nothing... Love never fails." Lord, teach me to love like you do.
Friday, April 23, 2010
Zambia slideshow 5
I am home safely. I am also starting to lag, so more blogging stories and thoughts later.
Saturday, April 17, 2010
blog
Linda's computer also recently died, so I will be on a blogging hiatus (except for borrowing Heidi's right now) for a few days. I'll try to blog some patient stories when I'm in Livingstone on Wednesday, and I fly out Thursday, Lord willing, to arrive back in Philadelphia Friday. Yay! :)
Monday, April 12, 2010
update
Just some details on life here. I'm on my fourth and final ward starting this week, male ward. The usual person who covers male ward is off studying right now for an exam, so it is covered by a resident from UPMPC St. Margaret's who is here starting this week. I will have a day off tomorrow or Wednesday, though, to go to Choma to get my visa renewed for the last week-plus that I'm here.
In the mean-time, life at the hospital and with friends continues. Abby, the American nurse here who went to Jefferson, had a group of us girls over for pancakes/crepes on Sunday, which was fun. Linda and I have been watching a number of movies and reading books in the evenings when we're not on call. I was happy to get to talk to my family a few times over the past couple weeks (amazing how easy it is to take that possibility for granted in the States!). That's about it.
In the mean-time, life at the hospital and with friends continues. Abby, the American nurse here who went to Jefferson, had a group of us girls over for pancakes/crepes on Sunday, which was fun. Linda and I have been watching a number of movies and reading books in the evenings when we're not on call. I was happy to get to talk to my family a few times over the past couple weeks (amazing how easy it is to take that possibility for granted in the States!). That's about it.
culture
I've been thinking about how I don't post about Zambian/Tonga culture like I did about Indian culture. I think there are two primary reasons for that. One is that, although it's new in my remembered experience, much of Zambian culture is not surprising to me since I grew up hearing about it from my parents. So the fact that I curtsy when shaking hands, that one shows respect for the person greeted in shaking hands by placing the other hand below your own outstretched arm slightly distal to the elbow, that women carry the heavy loads and the children, that we eat nsima and relish with our hands, etc. simply don't strike me as novel.
The second reason is the more difficult for me to acknowledge and process. There are parts of Zambian culture that are difficult for me personally, particularly as a woman. In many small ways, I am treated differently because I am a woman. Different things are expected of me. I think women and men also have similarly different roles and expectations of behavior in parts of India, but those roles/expectations didn't apply to me as a foreigner. Because of this, they didn't bother me personally so much. I feel half ashamed of this; should I care more about these different expectations only if they impact on me? Then again, their impact on me may be greater at least as far as my adjustments to them than on the people who grew up in this culture and so have their own expectations more shaped by it. But maybe I'd just like to think that so that it makes me feel better that I don't mind the cultural differences as much when they don't affect me.
It comes back to bigger questions about culture, too. For the most part, I enjoy cultural differences and learning about other cultures. But I don't think other cultures or my own are above moral judgment. Just as there are things in my own culture that I wish were different (e.g. materialism, time-focus over people-focus, prizing status and influence over character and inner worth), there are things about other cultures I wish were different.
What is hard is making judgments about another culture from the outside rather than my own from the inside. Am I simply more sensitive to things that are right and wrong here because they are different? How can I learn to be more sensitive to what is right and wrong (and not above judgment) in my own culture from being within another? How can I balance suspending judgment here while learning more about why things are the way they are and trusting that some things are value-neutral and simply different with acknowledging that some things simply should be different here as well as in my own culture? I don't have any easy answer, certainly not for how I live it here and now or in the future, but I suppose it's good to be asking the questions.
The second reason is the more difficult for me to acknowledge and process. There are parts of Zambian culture that are difficult for me personally, particularly as a woman. In many small ways, I am treated differently because I am a woman. Different things are expected of me. I think women and men also have similarly different roles and expectations of behavior in parts of India, but those roles/expectations didn't apply to me as a foreigner. Because of this, they didn't bother me personally so much. I feel half ashamed of this; should I care more about these different expectations only if they impact on me? Then again, their impact on me may be greater at least as far as my adjustments to them than on the people who grew up in this culture and so have their own expectations more shaped by it. But maybe I'd just like to think that so that it makes me feel better that I don't mind the cultural differences as much when they don't affect me.
It comes back to bigger questions about culture, too. For the most part, I enjoy cultural differences and learning about other cultures. But I don't think other cultures or my own are above moral judgment. Just as there are things in my own culture that I wish were different (e.g. materialism, time-focus over people-focus, prizing status and influence over character and inner worth), there are things about other cultures I wish were different.
What is hard is making judgments about another culture from the outside rather than my own from the inside. Am I simply more sensitive to things that are right and wrong here because they are different? How can I learn to be more sensitive to what is right and wrong (and not above judgment) in my own culture from being within another? How can I balance suspending judgment here while learning more about why things are the way they are and trusting that some things are value-neutral and simply different with acknowledging that some things simply should be different here as well as in my own culture? I don't have any easy answer, certainly not for how I live it here and now or in the future, but I suppose it's good to be asking the questions.
Thursday, April 8, 2010
epidemiology
It's been interesting what diseases occur here and don't occur here. I have seen no coronary artery disease and no lung, breast, or colon cancer, although that may be partly because we lack the imaging or procedural technology to catch the cancers early (CT scanning, mammography, colonoscopy). However, I have seen multiple women with cervical cancer, something I never saw in the US. It is on the differential diagnosis for any woman with a watery vaginal discharge, especially if she is HIV-positive.
Pap smears, the common screening tool used in the developed world to detect early pre-cancerous cervical changes, are hard to do on a regular basis here since it requires sending off the obtained scraping to Lusaka for pathology results some three months later. It requires an infrastructure for following up and treating abnormal results as well, which is hard to put into place. And it simply isn't part of women's thoughts for health maintenance when they're more likely to be thinking about how to make it through till the next harvest or whether their malnourished fifth child is going to be hospitalized for this episode of diarrhea or fever. On top of this, immunocompromise (as with HIV, a relatively common infection here) makes cervical cancer progress since its pathophysiology is related to the viral HPV infection, and cervical cancer actually is one of the determining criteria for which stage of immunocompromise an HIV-positive patient is in.
So these musings amounted to the fact that last OT (operating theatre) day we told two women in their fifties that they had stage IIIB cervical cancer (extending to the lower third of the vagina), which has a 40% 5-year survival rate in the best of circumstances with radiation therapy. These women will most likely not get in at the University Teaching Hospital (UTH) in Lusaka, the only place where these types of services are available in the country, in a timely manner to enable them to get the radiation. So they're sentenced to living and dying with advanced cervical cancer as it metastasizes through their pelvises, bringing difficulty passing stool and urine as well as pain. Even the pain of advanced cancer is difficult to treat where we have limited supplies of one opiate, pethidine. If any place in the world needs the HPV vaccine, which has caused such controversy among some communities in the US, this is certainly one place I would distribute it!
We had an interesting though sad case on rounds a few nights ago. The patient was being evaluated for lower abdominal pain, hematuria (blood in the urine), and amenorrhea (no periods) for three months. They did an ultrasound to rule out an ectopic pregnancy and found instead a large renal mass, palpable on re-examination of her abdomen. Again, there are no resources here to do a nephrectomy (removal of the kidney), and it is unlikely she will get in at UTH soon enough to make a difference in her prognosis...
On a positive note, I had a conversation with the ultrasonographer, a young Zambian man who is pastoring a local church while doing perhaps 200 ultrasounds a month through his job at the hospital and is in further training for ultrasounds. He mentioned the offers he has received to go to Botswana or elsewhere to earn more money for his job. His ultrasonography course is through some place in Canada, so that also opens doors. But "if you want to see change in your country," he said, "you have to be patriotic." Knowing there are other options available to him, he is choosing to stay here where he is needed and can make a difference. And make a difference he does since ultrasound and X-rays are our only imaging technologies. Thank you, God, for people who choose to give up what they could have for the longer-lasting reward of a life lived faithfully and well in service to those in need. May I remember his example.
Pap smears, the common screening tool used in the developed world to detect early pre-cancerous cervical changes, are hard to do on a regular basis here since it requires sending off the obtained scraping to Lusaka for pathology results some three months later. It requires an infrastructure for following up and treating abnormal results as well, which is hard to put into place. And it simply isn't part of women's thoughts for health maintenance when they're more likely to be thinking about how to make it through till the next harvest or whether their malnourished fifth child is going to be hospitalized for this episode of diarrhea or fever. On top of this, immunocompromise (as with HIV, a relatively common infection here) makes cervical cancer progress since its pathophysiology is related to the viral HPV infection, and cervical cancer actually is one of the determining criteria for which stage of immunocompromise an HIV-positive patient is in.
So these musings amounted to the fact that last OT (operating theatre) day we told two women in their fifties that they had stage IIIB cervical cancer (extending to the lower third of the vagina), which has a 40% 5-year survival rate in the best of circumstances with radiation therapy. These women will most likely not get in at the University Teaching Hospital (UTH) in Lusaka, the only place where these types of services are available in the country, in a timely manner to enable them to get the radiation. So they're sentenced to living and dying with advanced cervical cancer as it metastasizes through their pelvises, bringing difficulty passing stool and urine as well as pain. Even the pain of advanced cancer is difficult to treat where we have limited supplies of one opiate, pethidine. If any place in the world needs the HPV vaccine, which has caused such controversy among some communities in the US, this is certainly one place I would distribute it!
We had an interesting though sad case on rounds a few nights ago. The patient was being evaluated for lower abdominal pain, hematuria (blood in the urine), and amenorrhea (no periods) for three months. They did an ultrasound to rule out an ectopic pregnancy and found instead a large renal mass, palpable on re-examination of her abdomen. Again, there are no resources here to do a nephrectomy (removal of the kidney), and it is unlikely she will get in at UTH soon enough to make a difference in her prognosis...
On a positive note, I had a conversation with the ultrasonographer, a young Zambian man who is pastoring a local church while doing perhaps 200 ultrasounds a month through his job at the hospital and is in further training for ultrasounds. He mentioned the offers he has received to go to Botswana or elsewhere to earn more money for his job. His ultrasonography course is through some place in Canada, so that also opens doors. But "if you want to see change in your country," he said, "you have to be patriotic." Knowing there are other options available to him, he is choosing to stay here where he is needed and can make a difference. And make a difference he does since ultrasound and X-rays are our only imaging technologies. Thank you, God, for people who choose to give up what they could have for the longer-lasting reward of a life lived faithfully and well in service to those in need. May I remember his example.
Monday, April 5, 2010
communion liturgy
I loved the liturgy used at the communion service and found something with significant overlap online and wanted to share it. After a period of introspection preceding the service in which I had to acknowledge to myself a number of areas in my life where I was not depending on and submitted to God, I was fully aware of my own unworthiness of the price Jesus paid to be in a relationship with me. Thus, this communion's invitation to share in God's hospitality at his table was particularly welcome, and the pauses after each short phrase for translation to Tonga made it particularly poignant.
"Come to this sacred table, not because you must, but because you may;
Come to testify not that you are righteous, but that you sincerely love our Jesus Christ, and desire to be his true disciple;
Come not because you are strong, but because you are weak;
Come not because you have any claim on heaven's rewards, but because in your frailty and sin you stand in constant need of heaven's mercy and help;
Come not to express an opinion, but to seek a Presence and pray for a Spirit.
Come not because you are fulfilled, but because in your emptiness you stand in need of God’s grace and assurance.
Come, sisters and brothers, to this table to partake and share.
It is spread for you and me that we may again know that God has come to us, shared our common lot, and invited us to join the people of God’s reign.
And now that the Supper of the Lord is spread before you, lift up your minds and hearts above all selfish fears and cares; let this bread and this wine be to you the witnesses and signs of the grace of our Lord Jesus Christ, the love of God, and the communion of the Holy Spirit. Before the Throne of the Heavenly Father and the Cross of the Redeemer make your humble confession of sin, consecrate your lives to the Christian obedience and service, and pray for strength to do and to bear the holy and blessed will of God.”
- attributed on one website to John Hunter
http://oneyearbibleimages.com/lords_supper.jpg
"Come to this sacred table, not because you must, but because you may;
Come to testify not that you are righteous, but that you sincerely love our Jesus Christ, and desire to be his true disciple;
Come not because you are strong, but because you are weak;
Come not because you have any claim on heaven's rewards, but because in your frailty and sin you stand in constant need of heaven's mercy and help;
Come not to express an opinion, but to seek a Presence and pray for a Spirit.
Come not because you are fulfilled, but because in your emptiness you stand in need of God’s grace and assurance.
Come, sisters and brothers, to this table to partake and share.
It is spread for you and me that we may again know that God has come to us, shared our common lot, and invited us to join the people of God’s reign.
And now that the Supper of the Lord is spread before you, lift up your minds and hearts above all selfish fears and cares; let this bread and this wine be to you the witnesses and signs of the grace of our Lord Jesus Christ, the love of God, and the communion of the Holy Spirit. Before the Throne of the Heavenly Father and the Cross of the Redeemer make your humble confession of sin, consecrate your lives to the Christian obedience and service, and pray for strength to do and to bear the holy and blessed will of God.”
- attributed on one website to John Hunter
Zambia slideshow 4
We also went to a wedding coming-together celebration on Saturday afternoon, so this includes some pictures of that to give you a taste of Zambian cultural life as well as one of our modes of transportation (the back of a truck!) in addition to the Easter weekend pictures.
Easter in Zambia
It was certainly a weekend full of festivities here. Church services Thursday, Friday, and Saturday nights were followed by a 5 a.m. Sunday morning Easter sunrise service, 9 a.m. communion service, and 10:30 a.m. Easter morning service. The Easter sunrise service was particularly neat since I remember going to these as a child (and being disappointed by an 8 a.m. "sunrise" service in the States that was after sunrise and inside!). It was neat to be there with mostly women and be reminded of how the women were the first ones to the empty tomb and the first witnesses to the Resurrection. This is a culture in which women are definitely second to men in priority, and the culture of first-century ancient near east was no different. So the honoring implicit in the women's primacy in this central event of the Christian story is particularly special.
All the services involved much singing and rejoicing. There were some culturally specific ways of celebrating that were unique. The women go to the sunrise service wrapped in sheets (or old mosquito nets!) to commemmorate the linens which had wrapped the body of Jesus that the women found forsaken in the empty tomb. I forgot mine, but I did manage to remember to borrow a scarf to wear to cover my head so that I would be allowed to participate in the communion service later. I come from a church tradition often associated with head coverings - Mennonites - and some people in my home church do wear coverings, but I had never worn one before. It was an interesting experience, thinking of doing something I don't consider necessary to partake in this community's celebration of faith in equal standing. Then again, I wear skirts every day (something I don't think necessary for women) so as not to offend and to participate in the local community's life as much as possible on the same level...
After the services, we went over to the Thumas for lunch, which included some visiting friends. We ended up chatting for the afternoon and went home briefly only to join up with Abby and Heidi, two other expat young women, to go for a walk to see the sunset. So the day which began before sunrise ended with the sunset - altogether, a very satisfactory day. :) Pictures to come.
All the services involved much singing and rejoicing. There were some culturally specific ways of celebrating that were unique. The women go to the sunrise service wrapped in sheets (or old mosquito nets!) to commemmorate the linens which had wrapped the body of Jesus that the women found forsaken in the empty tomb. I forgot mine, but I did manage to remember to borrow a scarf to wear to cover my head so that I would be allowed to participate in the communion service later. I come from a church tradition often associated with head coverings - Mennonites - and some people in my home church do wear coverings, but I had never worn one before. It was an interesting experience, thinking of doing something I don't consider necessary to partake in this community's celebration of faith in equal standing. Then again, I wear skirts every day (something I don't think necessary for women) so as not to offend and to participate in the local community's life as much as possible on the same level...
After the services, we went over to the Thumas for lunch, which included some visiting friends. We ended up chatting for the afternoon and went home briefly only to join up with Abby and Heidi, two other expat young women, to go for a walk to see the sunset. So the day which began before sunrise ended with the sunset - altogether, a very satisfactory day. :) Pictures to come.
Friday, April 2, 2010
clinical update
Over the course of the week, I finished my first week on maternity which, due to the maternity doctor's absence in Choma getting his car fixed for three days, has included exactly one day of rounds and one day of OB- and gyn-related outpatient visits. But I've done more cervical exams on women in labor (albeit inaccurate ones, according to the nurse-midwife) here over the past few days (three) than in almost two years of clinical rotations in the US. We do also have rounds tomorrow, and hopefully the doctor will be back. I've been doing some reading and learning relevant OB-related Tonga in the meantime (baby moving? vaginal bleeding? contractions? leaking fluid? nursing well? milk?).
I also rounded on women's ward again, seeing some patients I knew as well as some new ones, and did my first paracentesis (for fluid in the abdomen) without ultrasound guidance, of course, and attempted several lumbar punctures (or spinal taps - 1/3 successful). For procedural-related things like those, sometimes it's nice not having residents or interns to allow to go first when there is something to be done. But we'll see how I feel about it when I become an intern in a few months!
I do think that I am gradually gaining something of a team feel as I work here. The people with whom I work seem more open to me doing things, although I think I've started asking to do more, too. I feel my judgment on some things is trusted more than previously. I remember more often to order HIV tests on practically everyone I see. I can conduct a very basic interview in Tonga as long as the answers consist of yes (ee-ee), no (pay-pay), today (sunu), a little (ashonto), or a lot (meningee). That's gratifying, too. We'll see what the next few weeks bring.
I also rounded on women's ward again, seeing some patients I knew as well as some new ones, and did my first paracentesis (for fluid in the abdomen) without ultrasound guidance, of course, and attempted several lumbar punctures (or spinal taps - 1/3 successful). For procedural-related things like those, sometimes it's nice not having residents or interns to allow to go first when there is something to be done. But we'll see how I feel about it when I become an intern in a few months!
I do think that I am gradually gaining something of a team feel as I work here. The people with whom I work seem more open to me doing things, although I think I've started asking to do more, too. I feel my judgment on some things is trusted more than previously. I remember more often to order HIV tests on practically everyone I see. I can conduct a very basic interview in Tonga as long as the answers consist of yes (ee-ee), no (pay-pay), today (sunu), a little (ashonto), or a lot (meningee). That's gratifying, too. We'll see what the next few weeks bring.
Holy Week
I realized last Sunday in Livingstone that it was Palm Sunday when we saw a larger parade of brightly dressed Zambians coming out of the church near Jolly Boys Backpackers carrying palm fronds and singing. I was sad to miss the day's celebration in the Macha church but began to look forward to seeing how the rest of Holy Week's events are marked in this place.
Last night was Maundy Thursday, the night prior to Jesus' crucifixion on today, Good Friday, a time to remember the Last Supper and all its significance, his suffering in the Garden of Gethsemane, his trials, and his desertion by his disciples. Linda and I traipsed off a bit late for the service at 1830 to the church after our dinner at the MIAM cafeteria. Upon arriving, the church was dark and no one visible. We were about to turn around when Mrs. Spurrier, wife of Dr. Spurrier with whom we work in the hospital, came up from the dark church. Cheered by each other's company, we decided to wait a bit longer to see if the advertised service would happen.
After about 15-20 minutes, about 10-15 people had assembled, so we entered the sanctuary. The power was off, so we sang some hymns (including some I knew the tunes and the words in English) by flashlight and candlelight. Despite the small group in a T-shaped church that usually seats about 800, I've been told, the singing was hearty, lovely, and inspiring. We then heard a short, bilingual message about Passover and Jesus' institution of the new covenant and fulfillment of the Passover salvation of the Hebrew people in Egypt by becoming our Passover lamb. As we were preparing for the closing song and prayer, about 20 more people came in. They joined us for the last part of the service, and then we left.
I've been to a number of Maundy Thursday services, often called Tenebrae (service of shadows), which start out in light and end in darkness (either by the gradual extinguishing of candles or lightbulbs). This one started in the gathering darkness of late twilight as we walked to the church, proceeded through the companionable sharing of flashlights and candles to read Tonga song words or Bible readings, and ended again in darkness lit by the Milky Way as we walked home. We'll have another service tonight, tomorrow night, and two on Easter Sunday.
As Linda and I read the events of Thursday night from the account according to Matthew, I was reminded of light and darkness in the story. The lights of the upper room where Jesus breaks the bread and passes the cup. The darkness of the garden of Gethsemane. The lights of approaching torches that allow visualization of the betraying kiss. The lights on His face as he is silent under accusation on trial first before the Sanhedrin and then Pilate. The dim light of early morning and fading night fires on Peter's tear-streaked face as he mourns that he has betrayed his Lord thrice before the cock crowed. The darkness behind the blindfold from which Jesus was mocked and asked to identify those beating and taunting him. The utter darkness of mid-day on Good Friday as the One who is the Resurrection and the Life breathed his last, crying, "It is finished."
And I look forward to celebrating the shafts of bright early morning light that lit the empty tomb on Easter Sunday. But for now, I wait. I wait in a world in which innocent people suffer, in which the one truly innocent Man was brutally flogged, forsaken, and hung on a cross. I wait in a world in which we don't live up to our best hopes for ourselves - hopes of courage, faithfulness, sacrifice, a world in which we may even betray our very best Friend. I wait in a world in which God's call for you, for me, may include walking through pain to achieve his ends; it did for his Son. I wait.
Last night was Maundy Thursday, the night prior to Jesus' crucifixion on today, Good Friday, a time to remember the Last Supper and all its significance, his suffering in the Garden of Gethsemane, his trials, and his desertion by his disciples. Linda and I traipsed off a bit late for the service at 1830 to the church after our dinner at the MIAM cafeteria. Upon arriving, the church was dark and no one visible. We were about to turn around when Mrs. Spurrier, wife of Dr. Spurrier with whom we work in the hospital, came up from the dark church. Cheered by each other's company, we decided to wait a bit longer to see if the advertised service would happen.
After about 15-20 minutes, about 10-15 people had assembled, so we entered the sanctuary. The power was off, so we sang some hymns (including some I knew the tunes and the words in English) by flashlight and candlelight. Despite the small group in a T-shaped church that usually seats about 800, I've been told, the singing was hearty, lovely, and inspiring. We then heard a short, bilingual message about Passover and Jesus' institution of the new covenant and fulfillment of the Passover salvation of the Hebrew people in Egypt by becoming our Passover lamb. As we were preparing for the closing song and prayer, about 20 more people came in. They joined us for the last part of the service, and then we left.
I've been to a number of Maundy Thursday services, often called Tenebrae (service of shadows), which start out in light and end in darkness (either by the gradual extinguishing of candles or lightbulbs). This one started in the gathering darkness of late twilight as we walked to the church, proceeded through the companionable sharing of flashlights and candles to read Tonga song words or Bible readings, and ended again in darkness lit by the Milky Way as we walked home. We'll have another service tonight, tomorrow night, and two on Easter Sunday.
As Linda and I read the events of Thursday night from the account according to Matthew, I was reminded of light and darkness in the story. The lights of the upper room where Jesus breaks the bread and passes the cup. The darkness of the garden of Gethsemane. The lights of approaching torches that allow visualization of the betraying kiss. The lights on His face as he is silent under accusation on trial first before the Sanhedrin and then Pilate. The dim light of early morning and fading night fires on Peter's tear-streaked face as he mourns that he has betrayed his Lord thrice before the cock crowed. The darkness behind the blindfold from which Jesus was mocked and asked to identify those beating and taunting him. The utter darkness of mid-day on Good Friday as the One who is the Resurrection and the Life breathed his last, crying, "It is finished."
And I look forward to celebrating the shafts of bright early morning light that lit the empty tomb on Easter Sunday. But for now, I wait. I wait in a world in which innocent people suffer, in which the one truly innocent Man was brutally flogged, forsaken, and hung on a cross. I wait in a world in which we don't live up to our best hopes for ourselves - hopes of courage, faithfulness, sacrifice, a world in which we may even betray our very best Friend. I wait in a world in which God's call for you, for me, may include walking through pain to achieve his ends; it did for his Son. I wait.
Tuesday, March 30, 2010
life...
I found out today that the smaller 28-week-old twin who was gasping away with lungs too young for air on Friday died over the weekend.
I had another intense experience today. At the end (finally drawing to a close long after we were supposed to be in OPD at 3 p.m.) of an unusually long day in the operating theatre this afternoon, a woman came in at 19-20 weeks pregnant with vaginal bleeding and crampy abdominal pain who had been sent over from OPD. An exam had been done, finding the cervical os (opening) open, showing she was probably in the process of miscarrying. She hadn't passed any larger tissue yet, though, but it was decided to take her for a D&C (dilation and currettage to clean out the uterus) since left-in parts can become infected and cause sepsis and even death.
After we got her into the operating room, though, feet up in the stirrups and under anesthesia, she started to pass something more than blood. I realized it was the fetus and had gloves on and so happened to be the one to catch the baby and then placenta as it came out. It was a tiny baby boy I could hold in one hand with his little feet dangling off the edge towards my wrist. He was alive still, heart beating away with the impact of it visible on his chest wall and occasionally giving a visible but inaudible gasping attempt to get oxygen into lungs much too young that contracted his entire rib cage, which is probably still mostly bendable cartilage at that age anyway.
Early in my third year in medical school on my OB/gyn rotation I heard the story of a late second-trimester abortion that resulted (accidentally) in a live fetus, disturbing everyone involved (and sending me home to cry in anger and helplessness to a friend on the rotation). I remember wishing I could have been there at the time to hold the baby so that at least it didn't have to die alone as well as unwanted. The image of that little one set aside somewhere to breathe its last breath completely abandoned was more than I could take.
This baby was not unwanted (that I know of), but his mother was under anesthesia, and his grandmother was not interested in holding or seeing him when I showed him to her, including pointing out the beating heart. So in an oddly gratifying though tragic closure to my experience at the beginning of my clinical years, I ended up holding this little one, simultaneously delighting in and sorrowing over his perfectly formed ears, fingernails, tendons, visible heartbeat, and even sticky immature skin, wishing he had stayed safe inside his mother for another six or eight weeks even, until I didn't see that heartbeat anymore.
This picture (or one like it) sits on the mantle of my parents' home, and I have been told it reminds them of me when I was born prematurely and very small.
from: http://blog.cornerstorkbabygifts.com/wp-content/uploads/2008/10/premature-baby.jpg
As much as I am sorry for the parents' loss of this little one, the whole experience reminds me of Psalm 139:13-16 and God's ultimate control over the days of our lives, as many or few as they may be:
"For you created my inmost being; you knit me together in my mother's womb.
I praise you because I am fearfully and wonderfully made;
your works are wonderful, I know that full well.
My frame was not hidden from you when I was made in the secret place.
When I was woven together in the depths of the earth, your eyes saw my unformed body.
All the days ordained for me were written in your book before one of them came to be."
I had another intense experience today. At the end (finally drawing to a close long after we were supposed to be in OPD at 3 p.m.) of an unusually long day in the operating theatre this afternoon, a woman came in at 19-20 weeks pregnant with vaginal bleeding and crampy abdominal pain who had been sent over from OPD. An exam had been done, finding the cervical os (opening) open, showing she was probably in the process of miscarrying. She hadn't passed any larger tissue yet, though, but it was decided to take her for a D&C (dilation and currettage to clean out the uterus) since left-in parts can become infected and cause sepsis and even death.
After we got her into the operating room, though, feet up in the stirrups and under anesthesia, she started to pass something more than blood. I realized it was the fetus and had gloves on and so happened to be the one to catch the baby and then placenta as it came out. It was a tiny baby boy I could hold in one hand with his little feet dangling off the edge towards my wrist. He was alive still, heart beating away with the impact of it visible on his chest wall and occasionally giving a visible but inaudible gasping attempt to get oxygen into lungs much too young that contracted his entire rib cage, which is probably still mostly bendable cartilage at that age anyway.
Early in my third year in medical school on my OB/gyn rotation I heard the story of a late second-trimester abortion that resulted (accidentally) in a live fetus, disturbing everyone involved (and sending me home to cry in anger and helplessness to a friend on the rotation). I remember wishing I could have been there at the time to hold the baby so that at least it didn't have to die alone as well as unwanted. The image of that little one set aside somewhere to breathe its last breath completely abandoned was more than I could take.
This baby was not unwanted (that I know of), but his mother was under anesthesia, and his grandmother was not interested in holding or seeing him when I showed him to her, including pointing out the beating heart. So in an oddly gratifying though tragic closure to my experience at the beginning of my clinical years, I ended up holding this little one, simultaneously delighting in and sorrowing over his perfectly formed ears, fingernails, tendons, visible heartbeat, and even sticky immature skin, wishing he had stayed safe inside his mother for another six or eight weeks even, until I didn't see that heartbeat anymore.
This picture (or one like it) sits on the mantle of my parents' home, and I have been told it reminds them of me when I was born prematurely and very small.
As much as I am sorry for the parents' loss of this little one, the whole experience reminds me of Psalm 139:13-16 and God's ultimate control over the days of our lives, as many or few as they may be:
"For you created my inmost being; you knit me together in my mother's womb.
I praise you because I am fearfully and wonderfully made;
your works are wonderful, I know that full well.
My frame was not hidden from you when I was made in the secret place.
When I was woven together in the depths of the earth, your eyes saw my unformed body.
All the days ordained for me were written in your book before one of them came to be."
link to another blog
A friend sent me this link, and I felt that the blog post summed up much of what I wanted to say on Friday and said it better than I could. So for your edification: http://mccropders.blogspot.com/2010/03/cotw-10-months-old.html.
Sunday, March 28, 2010
Linda is here!
I had an uneventful (thankfully) trip to pick up Linda in Livingstone. She had managed to meet up with Macha friends Abby and Christina on Friday night before I got there, so I knew from Abby she was there safely, albeit minus her checked luggage. We found each other without problems at Jolly Boys hostel on Saturday and proceeded to the airport and then the Falls.
We enjoyed a(nother, for me) visit to the Falls, including seeing the Boiling Pot, the place at the base of the Falls where the water swirls around like crazy. I'll have to get Linda's pics of it since I left my camera safely in the Ziploc bag. Then we went through the Falls lookouts themselves, getting soaked along the way, and walked back to see the Zambezi as it drops over the edge.
Before heading back to the lodge, we braved the sometimes-aggressive artisan-sellers outside the entrance to the Falls in an effort to get fair (but not insulting) prices for things to take back to the States. We met up with the other two girls there, who had taken a different route at their Falls visit, including bungee jumping. Then we all headed back to Jolly Boys and out to eat for great Italian food for dinner. We had a smooth trip back today via Choma. Below is a pic of us eating at the Italian restaurant run by at-risk youth who are trained in life skills with work at the restaurant as their final step in the program.
My calzone (on the right) was deeelicious! We all shared around, too! What fun!
We enjoyed a(nother, for me) visit to the Falls, including seeing the Boiling Pot, the place at the base of the Falls where the water swirls around like crazy. I'll have to get Linda's pics of it since I left my camera safely in the Ziploc bag. Then we went through the Falls lookouts themselves, getting soaked along the way, and walked back to see the Zambezi as it drops over the edge.
Before heading back to the lodge, we braved the sometimes-aggressive artisan-sellers outside the entrance to the Falls in an effort to get fair (but not insulting) prices for things to take back to the States. We met up with the other two girls there, who had taken a different route at their Falls visit, including bungee jumping. Then we all headed back to Jolly Boys and out to eat for great Italian food for dinner. We had a smooth trip back today via Choma. Below is a pic of us eating at the Italian restaurant run by at-risk youth who are trained in life skills with work at the restaurant as their final step in the program.
Friday, March 26, 2010
hope
I wanted to clarify something after my last post as I thought more about it this evening. Two things. One is that my hope in the face of suffering, although based in a future hope of when all things are made right (and I do need a future hope because the present problems are pretty daunting sometimes!), is also something realistic here and now, not merely an escape from reality. It must be. Jesus came to bring the Kingdom of God - God's rule, the place where the reign of God as King is shown, where his laws are followed and his desires performed - and those of us in the Church have the privilege of being part of making that happen. So medicine is part of that, bringing wholeness to people's bodies. And so is loving people, making right broken relationships. And so is prayer, aligning our hearts with God's loves. And so is working for justice. And so many other things...
Second, for the here and now, this is my hope for me, for that mother in her grief, for the many questions and problems I don't know about or can't solve. From Romans 8:38-39, "I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord." May that love spur us on to continue to care when it would be easier to be cynical, to work for the Kingdom when it costs us, and to hope with a strong and sure hope for the day when God's rule will finally and fully be made manifest in the midst of all evidence to the contrary.
Second, for the here and now, this is my hope for me, for that mother in her grief, for the many questions and problems I don't know about or can't solve. From Romans 8:38-39, "I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord." May that love spur us on to continue to care when it would be easier to be cynical, to work for the Kingdom when it costs us, and to hope with a strong and sure hope for the day when God's rule will finally and fully be made manifest in the midst of all evidence to the contrary.
loss
I lost my first patient today. In some ways, it's a bit surprising that it took almost two years of clinicals for me to be on the team taking care of a patient that died. But I wanted to acknowledge it and tell the story. It feels like a way of doing something more, even when nothing more can now be done.
Today was my last day on pediatrics since I will be gone tomorrow picking up Linda in Livingstone. So after OPD finished around 5:30, I figured I'd go check on a few patients that seemed less stable before heading home. I checked on the premature baby on maternity ward (probably about two months early, but mom is really unsure of dates for her last period) who probably has respiratory distress syndrome due to lack of surfactant, which we don't have and can't give. She's still really tachypneic (fast breathing) with lots of retractions and a sternum out way further than her ribs, pushed out by air trapping, but she's still breathing. So I moved on to the peds ward with the room where we can give oxygen.
I asked one mother whose toddler I've seen for the past two weeks how her child was doing, and she said a little better today. So that was encouraging. But then I heard the second mother in the room crying.
I turned to see the second child on oxygen without the oxygen on but the machine still running, covered by his blanket. Apparently he had just died recently. I stood there for a minute or so, not sure whether to go over or not, when the doctor and peds nurse came in to pronounce him dead. She looked at his pupils, which were dilated and non-reactive, and left. Then the mother really started crying, and I also started crying. I did go over and give her a hug. Then more family came in, beginning the traditional wailing, and I left the room, still crying, trying to pull myself together to walk out the peds ward past the other moms sitting out in the fading sunlight of the day. I could hear the wailing escalating around the hospital campus as I walked out for the day.
I had worried that facing suffering here, especially children dying, would make me question my faith. I did ask God briefly, "Why?" but it was more of a question about suffering generally than this specific instance. And I still believe God is good and cares for us. I still believe someday all these things that are wrong in the world will be made right. I still believe that somehow, one day, the Light that shines in the darkness, breaking out in vivid brightness that allows us to see in color for second, will one day provide so much light that there will be no need for the sun, and darkness will be no more.
Today was my last day on pediatrics since I will be gone tomorrow picking up Linda in Livingstone. So after OPD finished around 5:30, I figured I'd go check on a few patients that seemed less stable before heading home. I checked on the premature baby on maternity ward (probably about two months early, but mom is really unsure of dates for her last period) who probably has respiratory distress syndrome due to lack of surfactant, which we don't have and can't give. She's still really tachypneic (fast breathing) with lots of retractions and a sternum out way further than her ribs, pushed out by air trapping, but she's still breathing. So I moved on to the peds ward with the room where we can give oxygen.
I asked one mother whose toddler I've seen for the past two weeks how her child was doing, and she said a little better today. So that was encouraging. But then I heard the second mother in the room crying.
I turned to see the second child on oxygen without the oxygen on but the machine still running, covered by his blanket. Apparently he had just died recently. I stood there for a minute or so, not sure whether to go over or not, when the doctor and peds nurse came in to pronounce him dead. She looked at his pupils, which were dilated and non-reactive, and left. Then the mother really started crying, and I also started crying. I did go over and give her a hug. Then more family came in, beginning the traditional wailing, and I left the room, still crying, trying to pull myself together to walk out the peds ward past the other moms sitting out in the fading sunlight of the day. I could hear the wailing escalating around the hospital campus as I walked out for the day.
I had worried that facing suffering here, especially children dying, would make me question my faith. I did ask God briefly, "Why?" but it was more of a question about suffering generally than this specific instance. And I still believe God is good and cares for us. I still believe someday all these things that are wrong in the world will be made right. I still believe that somehow, one day, the Light that shines in the darkness, breaking out in vivid brightness that allows us to see in color for second, will one day provide so much light that there will be no need for the sun, and darkness will be no more.
This was the sky on my walk home tonight. Light breaking out. Beauty in pain. Thanks be to God.
Wednesday, March 24, 2010
patient stories
I am amazingly finishing my two weeks on pediatrics in a few days. I've learned a lot (like how to read a pediatric chest X-ray) that I wonder how I didn't learn it before, and Dr. Thuma has been a great teacher (and very patient with my apparent inability to learn and remember how to do the seemingly endless calculations involved in pediatric drugs and fluid dosings). I've also seen many children with protein-energy malnutrition (PEM, or kwashiorkor), including one today who was 18 months and 7.8 kg (about 15 pounds) and another 12-month-old who was 4.5 kg (about nine pounds).
We also have a two-month-old baby in with PEM whose mother died two weeks ago. The family has been giving her cow milk because what else do you give a motherless baby when formula is either unavailable or unaffordable? In between desperately trying to remember why you're not supposed to give babies cow milk and wishing they could reasonably boil the bacteria-laden bottle and nipple, I wondered what realistic chance this little one had at a future with no mother and little access to nutritious food already at two months of age.
Mike and I gave powerpoint presentations earlier this week on acute rheumatic fever and rheumatic heart disease. He told me today that two of his patients on men's ward (age seven and up) with rheumatic heart disease died yesterday and today at around 14. There is no way for patients in this country to get valve replacements, which is what they would need to repair the damage done to their heart by untreated strep throat infections as children.
All it takes is some penicillin, the first antibiotic discovered years ago. But we almost never see sore throats in the outpatient department (I'm sure their parents have other things to worry about besides a little sore throat), and so some number of those untreated strep throat cases end up showing up a few years later in heart failure from damaged, leaky valves. Besides optimizing heart failure management, there's nothing we can do, and it sometimes feels like we can simply watch them die.
I feel that way with some of the really late-presenting, malnourished kids on peds, too. Sometimes it's just too late, and their immune systems are too far gone, and we can't intubate or ventilate anyone that might need it, and so some of them die. I haven't been there for any deaths yet, but I notice the empty beds.
One of the hardest things to face in medicine (at least for me) is finitude. I feel like I've mentioned this before, but I can't remember if it was in conversations only or in the blog, too, so bear with me if this is repetition. But I still have to grapple with the fact that I am finite. I can't learn it all, can't remember all the things I did at one time learn and know, can't save every life, can't impress or please everybody, can't know what is going on with all the patients I encounter or even sometimes make a diagnosis, can't make a difference in every life, can't pick up on every physical finding, etc., etc. It is daunting, and humbling. A resident-in-training once told me that he had grown to appreciate the fact that he could ask forgiveness of God both for sins of COmission (things he had done) and for sins of Omission (things he had left undone - forgotten, chosen to ignore, didn't know about). I am also growing in my appreciation of the fact that I do not have to carry the burden of either the things I do or that I do/can not do but can be free.
We also have a two-month-old baby in with PEM whose mother died two weeks ago. The family has been giving her cow milk because what else do you give a motherless baby when formula is either unavailable or unaffordable? In between desperately trying to remember why you're not supposed to give babies cow milk and wishing they could reasonably boil the bacteria-laden bottle and nipple, I wondered what realistic chance this little one had at a future with no mother and little access to nutritious food already at two months of age.
Mike and I gave powerpoint presentations earlier this week on acute rheumatic fever and rheumatic heart disease. He told me today that two of his patients on men's ward (age seven and up) with rheumatic heart disease died yesterday and today at around 14. There is no way for patients in this country to get valve replacements, which is what they would need to repair the damage done to their heart by untreated strep throat infections as children.
All it takes is some penicillin, the first antibiotic discovered years ago. But we almost never see sore throats in the outpatient department (I'm sure their parents have other things to worry about besides a little sore throat), and so some number of those untreated strep throat cases end up showing up a few years later in heart failure from damaged, leaky valves. Besides optimizing heart failure management, there's nothing we can do, and it sometimes feels like we can simply watch them die.
I feel that way with some of the really late-presenting, malnourished kids on peds, too. Sometimes it's just too late, and their immune systems are too far gone, and we can't intubate or ventilate anyone that might need it, and so some of them die. I haven't been there for any deaths yet, but I notice the empty beds.
One of the hardest things to face in medicine (at least for me) is finitude. I feel like I've mentioned this before, but I can't remember if it was in conversations only or in the blog, too, so bear with me if this is repetition. But I still have to grapple with the fact that I am finite. I can't learn it all, can't remember all the things I did at one time learn and know, can't save every life, can't impress or please everybody, can't know what is going on with all the patients I encounter or even sometimes make a diagnosis, can't make a difference in every life, can't pick up on every physical finding, etc., etc. It is daunting, and humbling. A resident-in-training once told me that he had grown to appreciate the fact that he could ask forgiveness of God both for sins of COmission (things he had done) and for sins of Omission (things he had left undone - forgotten, chosen to ignore, didn't know about). I am also growing in my appreciation of the fact that I do not have to carry the burden of either the things I do or that I do/can not do but can be free.
overdue thoughts
Sorry to have had so much time between the last real post and this one, which will be relatively brief since it's almost midnight here. The combination of lack of functioning internet, sharing Mike's computer with him (thank you, Mike!) since mine continues to refuse to turn on, and the recent inundation with residency-related matters to try to handle at a distance has left little time for blog postings. But here we go. I'll do it in a bullet-type format since that seems like it might be most efficient.
* I have now heard the wailing that Zambian women do when someone dies after hearing about it from my parents growing up. I don't know that I've heard a more poignant sound than the almost-musical mourning that goes up and travels with its producers around the hospital campus announcing the family's new grief. It never fails to make my throat tighten up and sometimes bring tears to my eyes.
* Bryce visited Macha last weekend after our trip to Livingstone with him the weekend before. Mike was happy to have another guy around, and the two guys, Heidi (a SALTer), Abby (an MCC nurse and Jeff grad), and I had fun playing Dutch Blitz one night.
* Recent meals with both the Thumas and the Spurriers, the two long-term expat families here, were helpful in building relationships and also in providing cultural and historical insights. It made me proud of the way the church here is national-run (and the services much different from churches in the States) and nationals and expats work together in the hospital. Their stories of long-term successes against measles, neonatal tetanus, and now increasingly even malaria were also inspiring tribute to the benefits of working in one community for years and years.
* We came back from Livingstone last week to find that Carl, Mike's cozy immobile wall spider, was gone. He hasn't shown up again, which is probably to his health benefit. That said, there are apparently still-living spiders now on Mike's side of the room. And Mike reports he barely notices the spiders on the walls in the lounge here in the dorm. Progress has been made. :)
* Mike leaves tomorrow (and with him my access to a computer for a few days) for Lusaka, and Linda arrives in Livingstone on Friday. I will go down to Livingstone to meet up with her, and then we'll meet up with a couple other Macha expats to travel back to Macha on Sunday. Hopefully that will make the apparently-inevitable taxi ride (~$50-80/trip vs. $3 for the trucks) cheaper to split up since the trucks don't run on Sundays.
* I have now heard the wailing that Zambian women do when someone dies after hearing about it from my parents growing up. I don't know that I've heard a more poignant sound than the almost-musical mourning that goes up and travels with its producers around the hospital campus announcing the family's new grief. It never fails to make my throat tighten up and sometimes bring tears to my eyes.
* Bryce visited Macha last weekend after our trip to Livingstone with him the weekend before. Mike was happy to have another guy around, and the two guys, Heidi (a SALTer), Abby (an MCC nurse and Jeff grad), and I had fun playing Dutch Blitz one night.
* Recent meals with both the Thumas and the Spurriers, the two long-term expat families here, were helpful in building relationships and also in providing cultural and historical insights. It made me proud of the way the church here is national-run (and the services much different from churches in the States) and nationals and expats work together in the hospital. Their stories of long-term successes against measles, neonatal tetanus, and now increasingly even malaria were also inspiring tribute to the benefits of working in one community for years and years.
* We came back from Livingstone last week to find that Carl, Mike's cozy immobile wall spider, was gone. He hasn't shown up again, which is probably to his health benefit. That said, there are apparently still-living spiders now on Mike's side of the room. And Mike reports he barely notices the spiders on the walls in the lounge here in the dorm. Progress has been made. :)
* Mike leaves tomorrow (and with him my access to a computer for a few days) for Lusaka, and Linda arrives in Livingstone on Friday. I will go down to Livingstone to meet up with her, and then we'll meet up with a couple other Macha expats to travel back to Macha on Sunday. Hopefully that will make the apparently-inevitable taxi ride (~$50-80/trip vs. $3 for the trucks) cheaper to split up since the trucks don't run on Sundays.
Friday, March 19, 2010
Zambia slideshow 2
here's the pics complete with labels from our trip last weekend. I think they tell better stories than me trying to detail the weekend.
Thursday, March 18, 2010
match
I matched to Lancaster General Hospital for family medicine! :) And Mike matched to Cornell for internal medicine.
Wednesday, March 17, 2010
brief update
We are back safely from Livingstone as of Monday night. Internet connectivity has been absent. I'm working on uploading photos and will tell more stories when I can post pictures, too. Adrienne, our fellow medical student, leaves tomorrow. I also find out where I will be for the next three years for residency tomorrow. So many updates to come. :)
Thursday, March 11, 2010
weather, money, and medicine
India was definitely getting hotter by the time I left, so it was a bit of a shock to come here to a week of rain and cool temperatures that made me wish I'd brought more ankle-length skirts and long sleeves. This week, though, it's been warmer and sunny. I'm back to being happy to be in short sleeves. I anticipate getting wet again this weekend, though, with some great views at Victoria Falls. I just hope the sun holds out for our anticipated trip to Chobe Game Park in Botswana.
People ask us for money a lot here. Or they ask to do our laundry or sweeping for money. I tell them I do my own laundry (by hand), which is true. I haven't found the best way to deal with or think about being asked for money. Obviously, the perceptions of Western wealth on one hand are inaccurate - at least in my case, since I'm >$200,000 in debt for med school. On the other hand, I do live a life of incredible privilege in so many ways, partly shown by the very fact of my being in this country. So I simply smile apologetically and say no for the most part.
Medicine is quite different here. Not so much because we see different diseases, although we do (I've seen at least four cases of cryptococcal meningitis in a week and a half, which I never saw in the States, although I know it happens; I've also seen lots more TB, HIV, and rheumatic heart disease here than in the States). But because of the setting, even our first-line medications for common conditions are often different - for pneumonia or PID, for meningitis or CHF. So it takes some adjusting and insecurity can come with that. But I'm learning and thinking and asking questions, and I suppose that is good.
People ask us for money a lot here. Or they ask to do our laundry or sweeping for money. I tell them I do my own laundry (by hand), which is true. I haven't found the best way to deal with or think about being asked for money. Obviously, the perceptions of Western wealth on one hand are inaccurate - at least in my case, since I'm >$200,000 in debt for med school. On the other hand, I do live a life of incredible privilege in so many ways, partly shown by the very fact of my being in this country. So I simply smile apologetically and say no for the most part.
Medicine is quite different here. Not so much because we see different diseases, although we do (I've seen at least four cases of cryptococcal meningitis in a week and a half, which I never saw in the States, although I know it happens; I've also seen lots more TB, HIV, and rheumatic heart disease here than in the States). But because of the setting, even our first-line medications for common conditions are often different - for pneumonia or PID, for meningitis or CHF. So it takes some adjusting and insecurity can come with that. But I'm learning and thinking and asking questions, and I suppose that is good.
spiders, part 2
Mike has named the spider on his wall. Its name is Carl. Mike gives us daily updates on Carl, and they apparently have an "agreement" about the rules of Carl's living in Mike's room. 1) You don't move. 2) If you do move, you stay on the side opposite Mike and his bed. 3) If you do move to that side, you die. These rules have apparently been broken at least once by Carl's "son," Scotty. He is now dead. Carl remains immobile.
Despite the above, Mike is actually doing quite well with the spiders. I have heard no shrieks or even requests for help, and he has killed several spiders already (unlike me). He even got closer to one we saw when walking yesterday to get a picture. :)
Despite the above, Mike is actually doing quite well with the spiders. I have heard no shrieks or even requests for help, and he has killed several spiders already (unlike me). He even got closer to one we saw when walking yesterday to get a picture. :)
Monday, March 8, 2010
spiders and fears
Mike is scared of spiders. I knew this before coming here since he told me, and I told him that I remember blowing on the wall spiders that abound and eat mosquitoes, so we don't usually kill them. We have a difference of opinion about them - I like to blow on them to make them go up towards the ceiling and further away from me; Mike likes to leave them where they are so they don't move, even if that means they're at eye level. Thankfully, we don't live in the same room, so this doesn't come up often, but our dealings with spiders in the lounge of our dorm building do differ a bit. :) We share a fear of the camel spiders, or wind scorpions, that apparently also sometimes share our living space, and I've already decided to call Adrienne, the other med student, if one of them shows up.
The fact that I don't fear the wall spiders, though, reminds me of how conditioning affects our fears. I probably would be afraid of them if we hadn't lived here and my parents hadn't taught me to blow on them for fun as a child. The Zambians think chameleons, which I think are really cool (they change colors - how do you get cooler than that!? - and we even got to see one eat a few tiny ants) and gorgeous, are as gross as cockroaches, and I had several women gasping the other day when I wanted to pick one up. (Mike stopped me before I caused any heart attacks.)
Which of my fears are truly fear-worthy? Which fears are innate, and which are taught/learned? Do I fear things I shouldn't? Do I allow fear to control more of my actions and choices than it should? How do these thoughts extend into the less entomological parts of life - are my more basic fears well-founded? Just some thoughts. The Bible talks a lot more about fearing the LORD than it does about fearing other things. For example, Psalm 27:1 says, "The LORD is my light and my salvation; whom shall I fear?" I get the impression that fearing (living in rightful respect/reverence) the One worthy of it puts all our other fears into perspective. May it be that way for me and for you.
The fact that I don't fear the wall spiders, though, reminds me of how conditioning affects our fears. I probably would be afraid of them if we hadn't lived here and my parents hadn't taught me to blow on them for fun as a child. The Zambians think chameleons, which I think are really cool (they change colors - how do you get cooler than that!? - and we even got to see one eat a few tiny ants) and gorgeous, are as gross as cockroaches, and I had several women gasping the other day when I wanted to pick one up. (Mike stopped me before I caused any heart attacks.)
Which of my fears are truly fear-worthy? Which fears are innate, and which are taught/learned? Do I fear things I shouldn't? Do I allow fear to control more of my actions and choices than it should? How do these thoughts extend into the less entomological parts of life - are my more basic fears well-founded? Just some thoughts. The Bible talks a lot more about fearing the LORD than it does about fearing other things. For example, Psalm 27:1 says, "The LORD is my light and my salvation; whom shall I fear?" I get the impression that fearing (living in rightful respect/reverence) the One worthy of it puts all our other fears into perspective. May it be that way for me and for you.
patient stories 2
A few more patient stories have come to mind over the past few days as I've been thinking about my last post. One is a young woman (perhaps 21 to 23 years old) who came in pregnant for the second time out of wedlock to use the old terminology. Her parents are apparently prominent in the church here, and the shame of her first pregnancy five years ago resulted in her being kicked out of the house to go live with her grandmother for the duration of her pregnancy and the first year of her baby's life. She does not want to tell them about this pregnancy, which is six weeks along. She wants termination, but our hospital as a mission hospital does not provide that. She cannot afford the trip to or procedure/drugs in Choma to terminate her pregnancy there, nor could she hide the length of the trip from her parents even if that were possible. She threatened to go eat from a tree whose bark or something is lethal to commit suicide if she cannot avoid this pregnancy.
Since we have nothing else to offer, the other med student and I talked to her for about an hour and a half at the end of a day, trying to explore other options or sources of support for her while she continued to voice her one and only request. We voiced our emotional support and tried to come up with strategies for her to find resources to help her with this pregnancy and the baby that may be born. It was a frustrating experience in patient counseling, somewhat like refusing antibiotics to a patient with a viral infection except on a much larger scale.
Another patient was a baby born with probably hydrocephalus with widely separated skull sutures. I learned that parents do not name their babies here until they are sure they will live, an interesting attempt to deal with a life that must be oversaturated with loss. The baby was tachypneic (fast breathing rate), and the lungs appeared underdeveloped, which we can't do anything for even in the States. He also kept getting hypothermic, so we'd put him under warming lights and wrap him in blankets to try to keep him warm - but not too warm without a temperature sensor. I think he just had too many things wrong with im, and he died a few days later.
One of my favorite patients, a woman who always smiled at me and spoke a little English, was discharged today with a referral to Lusaka, the capital city. She was found to have pancytopenia (low white blood cells, red blood cells, and platelets - all the major blood cell lines), hepatomegaly, and massive splenomegaly to four or five centimeters below (but lateral to) the umbilicus. This is a spleen even I could not miss! One of the major differential diagnoses is a blood cancer or leukemia, or some other myeloproliferative disorder, so we referred her for the bone marrow biopsy we can't do (and probably treatment we don't have available). I hope she goes and has a good outcome; sometimes even Lusaka seems a world away for these people (and me!), so I'm not sure what will happen.
The final story I wanted to share is a four-year-old boy who came in when I was on call, having stuck a kernel of maize (the staple crop here, which is ground up to make nsima) up his nose. After we finished rounds, we took him over to the operating theatre and put him out with some ketamine. Once he was relaxed, the doctor bent a paper clip and snagged the corn kernel, dragging it out of his nose. It worked! So, note to self: when in doubt about tools for foreign body removal...
Since we have nothing else to offer, the other med student and I talked to her for about an hour and a half at the end of a day, trying to explore other options or sources of support for her while she continued to voice her one and only request. We voiced our emotional support and tried to come up with strategies for her to find resources to help her with this pregnancy and the baby that may be born. It was a frustrating experience in patient counseling, somewhat like refusing antibiotics to a patient with a viral infection except on a much larger scale.
Another patient was a baby born with probably hydrocephalus with widely separated skull sutures. I learned that parents do not name their babies here until they are sure they will live, an interesting attempt to deal with a life that must be oversaturated with loss. The baby was tachypneic (fast breathing rate), and the lungs appeared underdeveloped, which we can't do anything for even in the States. He also kept getting hypothermic, so we'd put him under warming lights and wrap him in blankets to try to keep him warm - but not too warm without a temperature sensor. I think he just had too many things wrong with im, and he died a few days later.
One of my favorite patients, a woman who always smiled at me and spoke a little English, was discharged today with a referral to Lusaka, the capital city. She was found to have pancytopenia (low white blood cells, red blood cells, and platelets - all the major blood cell lines), hepatomegaly, and massive splenomegaly to four or five centimeters below (but lateral to) the umbilicus. This is a spleen even I could not miss! One of the major differential diagnoses is a blood cancer or leukemia, or some other myeloproliferative disorder, so we referred her for the bone marrow biopsy we can't do (and probably treatment we don't have available). I hope she goes and has a good outcome; sometimes even Lusaka seems a world away for these people (and me!), so I'm not sure what will happen.
The final story I wanted to share is a four-year-old boy who came in when I was on call, having stuck a kernel of maize (the staple crop here, which is ground up to make nsima) up his nose. After we finished rounds, we took him over to the operating theatre and put him out with some ketamine. Once he was relaxed, the doctor bent a paper clip and snagged the corn kernel, dragging it out of his nose. It worked! So, note to self: when in doubt about tools for foreign body removal...
Saturday, March 6, 2010
patient stories
Some patients' stories stand out. Here are some that stuck with me this week.
One was a one-and-a-half-year-old child who was admitted with severe protein-energy malnutrion, or kwashiorkor, as well as a pneumonia. His hair was a silkier light brown instead of the curly black hair the other Zambians have due to protein malnutrition. We started him on the PEM protocol here, but his prognosis is still guarded.
Another was a seven-year-old with a broken tibia that was the first patient on whom I have put a cast, or plaster of Paris (POP) as it is called here.
I rounded one morning on TB wards this week and was struck by the number and diversity of HIV-positive patients there. It seems that nearly all of the longer-term patients with tuberculosis who stay here for treatment for a time also have HIV. I am sure that the HIV-positive people in the States are also a very diverse group age-wise and health-wise, but being in health care thus far has exposed me to a small proportion of them, so I am seeing a lot more relatively healthy young and old women and men as well as children here who have HIV than I have previously. We test about everyone who is sick enough to get admitted to the hospital for HIV.
More stories later when my friends let me borrow their computers again. I'm looking forward to going to church here tomorrow and hearing the African-style music!
One was a one-and-a-half-year-old child who was admitted with severe protein-energy malnutrion, or kwashiorkor, as well as a pneumonia. His hair was a silkier light brown instead of the curly black hair the other Zambians have due to protein malnutrition. We started him on the PEM protocol here, but his prognosis is still guarded.
Another was a seven-year-old with a broken tibia that was the first patient on whom I have put a cast, or plaster of Paris (POP) as it is called here.
I rounded one morning on TB wards this week and was struck by the number and diversity of HIV-positive patients there. It seems that nearly all of the longer-term patients with tuberculosis who stay here for treatment for a time also have HIV. I am sure that the HIV-positive people in the States are also a very diverse group age-wise and health-wise, but being in health care thus far has exposed me to a small proportion of them, so I am seeing a lot more relatively healthy young and old women and men as well as children here who have HIV than I have previously. We test about everyone who is sick enough to get admitted to the hospital for HIV.
More stories later when my friends let me borrow their computers again. I'm looking forward to going to church here tomorrow and hearing the African-style music!
Friday, March 5, 2010
adjustments
I think I hadn't realized how much I had grown accustomed to things in India in my short time there. I found myself the first few days (and still now) constantly wanting to comment on how things here are different than there. Life here is just less crazy in many ways, partly because there are fewer people - traffic is less hectic and life-risking, people are not crowding walkways and towns, etc. It's interesting...
I find the juxtaposition of two foreign countries coming up in other ways, too. I was trying to ask a patient whether she had a headache after a LP (lumbar puncture - spinal tap in common parlance) and ended up combining my newly acquired Tonga word for pain with the Tamil word for head instead of my recently heard Tonga word for head, resulting in a confused patient who then asked me in English what I wanted to know. Oops.
Those adjustments aside, life here has been good so far. The schedule is approximately 7:30 a.m.-5 or 6 p.m. daily with ward rounds in the mornings Monday, Wednesday, Thursday, and Saturday and OT (operating theatre - operating room in the States) in the morning on Tuesday and Friday. We see patients in the outpatient department (OPD) in the afternoon every day. Lunch break is some time between 1 p.m.-3 p.m. Mike and I are sharing call with another fourth-year med student, Adrienne, from the States on a q4 basis, which means we go in for evening rounds (8 p.m.-10 p.m. or so) and are available for any OR emergency cases at night every four nights. Our two other fellow ex-pat students, Sarah and Beth, left today for the States. So the remaining three of us are settling in for the next few weeks.
I find the juxtaposition of two foreign countries coming up in other ways, too. I was trying to ask a patient whether she had a headache after a LP (lumbar puncture - spinal tap in common parlance) and ended up combining my newly acquired Tonga word for pain with the Tamil word for head instead of my recently heard Tonga word for head, resulting in a confused patient who then asked me in English what I wanted to know. Oops.
Those adjustments aside, life here has been good so far. The schedule is approximately 7:30 a.m.-5 or 6 p.m. daily with ward rounds in the mornings Monday, Wednesday, Thursday, and Saturday and OT (operating theatre - operating room in the States) in the morning on Tuesday and Friday. We see patients in the outpatient department (OPD) in the afternoon every day. Lunch break is some time between 1 p.m.-3 p.m. Mike and I are sharing call with another fourth-year med student, Adrienne, from the States on a q4 basis, which means we go in for evening rounds (8 p.m.-10 p.m. or so) and are available for any OR emergency cases at night every four nights. Our two other fellow ex-pat students, Sarah and Beth, left today for the States. So the remaining three of us are settling in for the next few weeks.
Tuesday, March 2, 2010
Kerala slideshow
Here's the slideshow from Kerala. Internet connection is too slow to tell lots of stories tonight, so I'll let the pics speak for themselves. Thanks to Sarah for letting me use her computer!
Monday, March 1, 2010
Zambia info
So I wanted to include some of the initial info about Zambia that I did about India, so here's the images of the flag and maps as well as some of the country statistics. All info is again courtesy of the CIA World Factbook, and the pictures are as well.
I'm somewhere about halfway between Lusaka and Livingstone, two hours from Choma.
- size: 752,618 sq km - slightly larger than Texas
- population: 11.8 million
- median age: 17 yrs (cp. 36.7 yrs)
- 35% of population is urban
- health statistics
- infant mortality:
- age structure: 45% 0-14 yrs, 53% 15-64 yrs, 2% 65 yrs and older
- birth rate: 40 births/1000 population
- infant mortality rate: 101.2 deaths/1000 live births (cp. US 6.22)
- total fertility rate: 5.15 children born/woman (cp. US 2.05)
- HIV/AIDS adult prevalence rate: 15.2% = 1.1 million people living with HIV/AIDS]
- life expectancy at birth: 38.63 yrs
- major infectious diseases: bacterial and protozoal diarrhea, hepatitis A, typhoid fever, malaria and plague in some locations, schistosomiasis, rabies
- religions
- Christian 50-75%
- Muslim and Hindu 24-49%
- indigenous beliefs 1%
- languages
- Bemba 30.1%
- Nyanja 10.7%
- Tonga 10.6% (the language of southern Zambia where I am)
- Lozi 5.7%
- etc.
- education
- literacy - 80.6% (87% male, 75% female)
- school life expectancy: 10 yrs
- politics
- 9 provinces
- capital: Lusaka
- independence: October 24, 1964
I'm somewhere about halfway between Lusaka and Livingstone, two hours from Choma.
arrival #2
Mike and I have arrived in Zambia. After about six hours (for me - four for him) of sitting and waiting and walking around looking for Mike (me for him), we found each other in Heathrow in time to head out to our gate. An uneventful flight followed, and I got to sit next to a friendly Malaysian ex-pat living in Lusaka about her life and insights into Zambia and its cultures around sleeping about six hours to make up for my one to two hours of sleep the night before.
After arriving in Lusaka and changing money, we caught a taxi to the bus station in Lusaka to head to Choma. The next available bus was air-conditioned and beautiful, and the road was also in good condition. After a month in India, I was astounded to be in a taxi and a bus with no honking and maintenance of one's own lane on the road! Mike and I met a friendly other makua (spelling? - white person) on the bus who turned out to be a Mennonite from Lancaster County living in Choma for about ten months with the SALT program through MCC. We'll see if we can manage to connect with Bryce again for a trip to Victoria Falls or a game of Dutch Blitz at some point if he visits the other SALTer in Macha.
Bryce helped Mike and I run errands in Choma and then connect with a van to Macha. The van's readying for departure was a cultural experience in itself, and I decided I was going to learn a lot about patience and waiting while here. First we waited in the van for something unknown. Then we waited for the engine to turn on, which it did after lifting the front seats and pumping something in the engine. Then we sat with the engine running for a while longer. Then we pulled out and drove to the gas station, where we waited. Then we drove to a local shop and the driver got out and did something unknown, and we waited. Then we pulled back into the original spot, loaded three more adults plus a baby in, and finally departed. The initial 45 minutes were paved and smooth, but the final hour and fifteen minutes on unpaved, pothole- and stones-ridden dirt roads, gave me renewed sympathy for my dad's experience going on the six-hour drive from Lusaka to Macha 23 years ago with a broken leg.
We are now settling into the very nice MIAM dorms. I have a room to myself with three other unoccupied bunks, and Mike (as the only guy right now) does, too. There are three other female students here, too, two of whom share a room and one on her own. They've been very friendly as we settle into the details of life here (when to eat, where to eat, how to use the internet, when to show up tomorrow morning, etc.). I'm excited and looking forward to some exciting stories in the near future whenever the internet is working. :)
After arriving in Lusaka and changing money, we caught a taxi to the bus station in Lusaka to head to Choma. The next available bus was air-conditioned and beautiful, and the road was also in good condition. After a month in India, I was astounded to be in a taxi and a bus with no honking and maintenance of one's own lane on the road! Mike and I met a friendly other makua (spelling? - white person) on the bus who turned out to be a Mennonite from Lancaster County living in Choma for about ten months with the SALT program through MCC. We'll see if we can manage to connect with Bryce again for a trip to Victoria Falls or a game of Dutch Blitz at some point if he visits the other SALTer in Macha.
Bryce helped Mike and I run errands in Choma and then connect with a van to Macha. The van's readying for departure was a cultural experience in itself, and I decided I was going to learn a lot about patience and waiting while here. First we waited in the van for something unknown. Then we waited for the engine to turn on, which it did after lifting the front seats and pumping something in the engine. Then we sat with the engine running for a while longer. Then we pulled out and drove to the gas station, where we waited. Then we drove to a local shop and the driver got out and did something unknown, and we waited. Then we pulled back into the original spot, loaded three more adults plus a baby in, and finally departed. The initial 45 minutes were paved and smooth, but the final hour and fifteen minutes on unpaved, pothole- and stones-ridden dirt roads, gave me renewed sympathy for my dad's experience going on the six-hour drive from Lusaka to Macha 23 years ago with a broken leg.
We are now settling into the very nice MIAM dorms. I have a room to myself with three other unoccupied bunks, and Mike (as the only guy right now) does, too. There are three other female students here, too, two of whom share a room and one on her own. They've been very friendly as we settle into the details of life here (when to eat, where to eat, how to use the internet, when to show up tomorrow morning, etc.). I'm excited and looking forward to some exciting stories in the near future whenever the internet is working. :)
Saturday, February 27, 2010
Chennai again
We have arrived back in the Chennai area after a couple lovely days in Kerala. I leave tomorrow morning at 4 a.m. for London and then Zambia. We are safe so far! :)
Tuesday, February 23, 2010
leaving...
We leave CMC today to go to Chennai to meet up with Swetha and catch an overnight train to Kerala, where we will be traveling for a couple of days. I'm excited about the overnight train since it's apparently a staple of the Indian travel experience. Hopefully it's a restful staple! :)
In Kerala, we will do a backwater houseboat overnight tour from Thursday to Friday morning. Then we will travel to Kochin and see whatever there is to see there until our overnight train back Friday morning to Saturday morning. We will hang out with Thenu and Nithya's families until my flight at 4 a.m. on Sunday morning to Zambia via Heathrow. Mike, I'll see you in London in a few days!
Some things I've been noticing about south Indian life as I think about leaving:
In Kerala, we will do a backwater houseboat overnight tour from Thursday to Friday morning. Then we will travel to Kochin and see whatever there is to see there until our overnight train back Friday morning to Saturday morning. We will hang out with Thenu and Nithya's families until my flight at 4 a.m. on Sunday morning to Zambia via Heathrow. Mike, I'll see you in London in a few days!
Some things I've been noticing about south Indian life as I think about leaving:
- turmeric on the hands and faces of women in the clinic - apparently it's for married women for good luck
- the different standards for space and touch here - you don't touch when greeting or saying goodbye, although some people will offer me the Western handshake, but you do sit right up next to anyone else on the bus or brush by anyone else without the expected apology in Western culture
- the temperature - it's definitely getting hotter than the warm but comfortable temperatures of our first week or two, and I'm not sure Zambia will be cooler!
- lovely colors and smiles of people in the OPD (outpatient department)
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