Finishing Strong

There is a friend of mine who always tries to make sure that he ends a project with at least as much enthusiasm as he started it. He likes to say he wants to “finish strong”. A good attitude. I am hoping I can achieve this in my final 24 hours here. Trying to have plans in place for all the patients I am
leaving behind, and thanking everyone here for making me feel at home even though I am a “Short Termer”. Did you know they consider anything under 2 years to be short term? Doesn't sound like it to me. I am also on call today, so we will see how my night goes. There may be some last minute hand over rounds Wednesday morning. I must admit, I will not miss the 0500 call to prayers. I have not needed an alarm clock the whole time I have been here. They are even up before the roosters! I suppose it is like living beside the train tracks, after a while you get used to it.

On rounds today I was able to make some plans for the patients I am leaving behind. Christopher has the list of patients and it should help with the transition. I also spoke to Joe the General Surgeon, and he is happy to look after the complicated surgical cases. We had a bit of a debrief of my time here, and it was good to put it in perspective.

I will leave a few things behind. Some clothing, some personal
OR stuff, and of course a lot of friends. Several times the question has come up as to whether I will return, and I would like to. There are some things that I would need to have better organized at home to be able to do this.

This may well be my last blog, as I have 2 travel days after this, so if it is, I hope you the reader enjoyed it. It is my first time bogging (as I said at the very beginning), and I learned some things about it along the way.

Someone just posted some videos of Galmi Hospital here:

https://vimeo.com/user45679319

2 Timothy 2:15

Do your best to present yourself to God as one approved, a worker who has no need to be ashamed, rightly handling the word of truth.

PS: I am going back - look here: 

So much left to do, so little time

I am in to the final 48 hours of my stay here, and there are some things left unfinished. I only know a few words in Hausa – Gaisuwa (pronounced Sannu) means Greetings – Sai wata rana means good bye – Ciwon means pain - Babu ciwo means there is no pain. Definitely not enough to work without a translator! My french has improved, but there are still words I have forgotten, and words I never new. On the other hand, I did get another hysterectomy done today, and got some more patients seen in the clinic. I was very glad for the surgical equipment that I was given to take along as I was able to use some of it the case today. It made a difficult case a little easier. I almost have the outpatient protocols figured out, and Saadi doesn't have to remind me too often what is routinely ordered for each trimester of pregnancy. I also wrote out a list of all the patients and their diagnoses and treatments so it will be easier to hand over to Christopher on Wednesday.

Part of the Nigeriens (it is with an “e“ not an “a“ in Niger) being able to earn money is some of the women cleaning house and doing laundry. It is sort of expected that you will have someone do this at your place to allow then to earn a wage. The women that comes to my home on Mondays and Thursdays has a small child. Today when she said hello in french, I started to ask her about her daughter and how old she was. Then I realized that she knows as much french as I do Hausa. It was OK, I got to say hello to her daughter. Later when I went to go out and get the laundry of the line, I realized she was using Grasshopers to pin the clothes up. Just joking, she was using clothes pins, the Grasshopper was just along for the ride.  He looked like the type that I saw roasted in the market place!

The Orthopedic Surgeon is also leaving soon, and he was lamenting the fact that there will be cases He cannot get to because of time limitations. The power saw is broken (no not the makita kind) so he is having to do it all by hand, and that has slowed him down a lot. Also there are some cases that will just take too long, and won't fit in to the schedule. He comes back every year to do more.

Speaking of power saws, I walked by the maintenance yard and the shop today. They were working on the hospital trucks, and were building something that looked like shelving in the shop. There really is room for everyone to get involved here.

Ecclesiastes 3:1
For everything there is a season, and a time for every matter under heaven

Hausa Church

I am not on call today, so I can go to Hausa Church in town. It is not far, just across the highway and a few minutes walk west. You go through an entrance way that is fine for me, but if you are over 6 feet tall, you are going to have to duck. The building itself is made of panels of bamboo held together with twine. They have some tree branches that have been used for posts and beams on the inside. It is maybe 20 to 30 feet square. They have 4 or five rows of 6 patio chairs each with an isle down the middle. Church starts at 0900 with welcomes and introductions and some prayer. Then there is corporate prayers with many people praying at the same time (mostly in Hausa). Then there is singing (in french) followed by some more prayer and then the sermon. The preacher today was both tall and broad shouldered. He actually had to move the pulpit because he was hitting his head on the roof. He preached in Hausa, and a second person translated in to French. He was very enthusiastic and full of conviction. The service ended a little after 11 and we walked back to the compound.

Today was a quiet day in the compound, time to catch up on bible reading, and catch up on sleep. At 4 pm I was off to the CC to practice the worship songs for tonight's service. The Orthopedic Surgeon Graham is doing it all tonight, playing piano, giving the sermon, and praying for communion. Sunday is also the day when Mame announces the arrivals and departures for the week, so I will be saying good bye to all my new friends here.

Matthew 18:20

For where two or three are gathered in my name, there am I among them.

Early Thanksgiving

So the fourth Thursday of November is Thanksgiving in the US (no not the day before the Black Friday Sales). We are celebrating a bit early here in Galmi partly because of the guests we have, and partly because it works out well logistically. Dr. Zoolkowski quoted Abraham Lincoln to me about the creation of Thanksgiving as a National Holiday. You can read his full speech here:

http://www.abrahamlincolnonline.org/lincoln/speeches/thanks.htm

The most quoted line (I think) is:
I do therefore invite my fellow citizens in every part of the United States, and also those who are at sea and those who are sojourning in foreign lands, to set apart and observe the last Thursday of November next, as a day of Thanksgiving and Praise to our beneficent Father who dwelleth in the Heavens.

But I also like:

And I recommend to them that while offering up the ascriptions justly due to Him for such singular deliverances and blessings, they do also, with humble penitence for our national perverseness and disobedience, commend to His tender care all those who have become widows, orphans, mourners or sufferers in the lamentable civil strife in which we are unavoidably engaged, and fervently implore the interposition of the Almighty Hand to heal the wounds of the nation and to restore it as soon as may be consistent with the Divine purposes to the full enjoyment of peace, harmony, tranquillity and Union.

For my American friends:

Thanksgiving (French: Action de grâce), or Thanksgiving Day (Jour de l'action de grâce) is an annual Canadian holiday, occurring on the second Monday in October, which celebrates the harvest and other blessings of the past year. Thanksgiving corresponds to the English and continental European harvest festival, with churches decorated with cornucopias, pumpkins, corn, wheat sheaves, and other harvest bounty. English and European harvest hymns are sung on the Sunday of Thanksgiving weekend.

Thankfully for me, rounds went well this morning, and I was able to enjoy breakfast with a full table at the Zoolkowski home. The pancakes were whole wheat with corn meal – if you haven't tried it you should! There were also camel rides today (see I told you), and some people visited the shops in Galmi.

Dinner is at the CC and everyone contributes something to the meal. Remember the bread from the baker? That's my contribution.

1 Thessalonians 5:18

Give thanks in all circumstances; for this is God's will for you in Christ Jesus.

Human Development Index

So apparently (according to google/wikipedia) Niger is only the 4^th poorest country in the world.

However it has the lowest Human Development Index (HDI). The HDI is “a composite statistic of life expectancy, education, and per capita income indicators, which are used to rank countries into four tiers of human development. “ So you could probably say Niger has the lowest standard of living in the world. In case you were wondering, the countries that are poorer than Niger are: (lowest) Malawi, (second lowest)Burundi, and (third lowest)Central African Republic. I will be celebrating American Thanksgiving on Saturday, and there are a lot of things I have to be thankful for.

I am also thankful that today on rounds the baby I delivered the night before with forceps is happily breast feeding with Mom. The lady with the Cesarean from yesterday is healing well, and one of our premature babies had gained enough weight to be discharged and return weekly for follow up visits.

I did see something the other day that raised my eyebrows for a second. I expected insects (lots of them) and I expected that you would have to use something to kill them, I guess I didn't expect that force required to kill them would be quite so extreme. Fortunately they have lots on hand at the Co-op which is open Tuesday and Friday from 1430 – 1530. You can buy lots of stuff there – everything from pringles to peanut butter. They even have ice cream treats!.

Did I mention they have a swimming pool here in Galmi? Quite a luxury given how scarce water is. Well they do. Not Olympic size or anything, but they do give the staff children swimming lessons on Fridays. Water here is often sold in little baggies about the size of a sandwich bag. The nick the corner and suck the water out.

Also on Fridays is movie night. The early feature is an episode of the Andy Griffith show, followed by “A night with the King”.

Psalm 107:1

Give thanks to the Lord for He is good. His love endures forever.

0207

That would be 7 minutes after 2 am, for those that don't use military time. That is when my day started today. Dr. Zoolkowski has kindly lent me a dual sim cel phone while I am here, and that was the time that it went off. The ring tone is seagulls, so I thought I was having a dream about the shoreline. By the time I grabbed for the phone they had already hung up, but the call log said it was maternity so off I went. A lady had been in labour since last night and had not progressed well. When I arrived she was fully dilated but she was having trouble pushing and the head was only about ½ way down. The baby's heart was starting to dip with the contractions, and there were some concerns about early distress. The decision was whether to do a forceps or to go for a cesarean section. At 2 in the morning the resources here are less than what they would be during the day. Everyone has to be woken up and come in, and things do not tend to move quickly. Also it looked like this had been a problem for a while. On top of that a cesarean for a first time mom is a very big deal here. They do not always heal as well, and the uterus can rupture in the next pregnancy. Often women labour for days before coming in to hospital, so avoiding a cesarean can be life saving down the road. With all this in mind we did go ahead with a forceps delivery. It was not an easy one like the previous lady with 10 other children, but she now has a live baby girl, and she is recovering well.

After that, I decided to forgo my run this morning and sleep in a bit. When I arrived to do rounds there was a second lady who was not progressing in labour, only this time she was not as far along, and the cervix was not fully dilated. She had a few other children as well. We decided that she should go to cesarean. Because of how things work here, it was going to be well over an hour before the cesarean, so I went ahead and did rounds. There were no other significant concerns, and at the end of rounds I was able to do the cesarean for a baby boy. Mom and baby are well.

Pharmacy Department

Smells Delicious!

The plane came in today rather than yesterday, and there were several visitors along with some
supplies for the pharmacy. After we dropped off Dr. James Owens at his new residence we headed to the pharmacy to drop off some medications. Then Dr. Zoolkowski and I headed back to his favourite baker to pick up some bread for Thanksgiving dinner (I get to celebrate twice this year). You could smell how fresh the bread was, and we had a lovely aroma in the Land-C
ruiser all the way home.

Best Baker in Town

The MSF transport was by again today – I see where they have a strict “no assault rifle” policy for passengers.

I am starting to plan for my transition away, and am thinking of what I have to do make the handover as smooth as possible. Fortunately the people here have been through this many times, and the midwives are well trained.

Jeremiah 29:11

For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.

Hump day.

Hump day – the day people go riding the camels. What did you think I meant? Actually I was talking with one of the other doctors about camel rides yesterday. It is apparently the touristy thing to do. My touristy thing to do is take pictures. I'm not saying I don't want to ride a camel, just that it is further down on my bucket list. Wednesdays are however special for several reasons here: 1) they have cinnamon buns at the CC (which I think stands for community centre or centre communitaire). 2) Right after the cinnamon buns, the traveling butcher rolls up on his motorcycle to sell you meat of the back of his bike (literally). Wednesday is also market day in Galmi. All the tents are set up and you can buy any of the local produce, fabrics, and other interesting wares.a It is also often the day the SIM plane arrives with new missionaries and takes others back to Niamey. I will be on that plane next week Lord willing.

We always pray before we start rounds in the morning. A good way to start the day. After the prayer and before we started rounds they asked

me to see a lady that had been stuck at 9 cm for 2 hours (so she was almost fully dilated). She had had 10 other vaginal deliveries and this was her 11^th baby. When I examined her she was fully dilated and ready to push, but for some reason she said she couldn't. I was able to do a forcep delivery that went very smoothly and she delivered a healthy baby boy. We will talk to her about family planning. For the most part, rounds went well. There is one lady who will have to go back to the OR because her sutures came apart, but everyone else seems to be doing well.

Then I went with a couple of the women here to see the market for the first time. They were buying fabric, but we also looked at clothing, food spices, and other interesting items. Like may other places, bartering is the norm here. One of the women spoke fluent hausa so she was able to barter well for the prices. They also bought spices and some lettuce. You can buy all sorts of fruit, and if you are so inclined roasted grasshoppers. I thought the chickens they were carrying around were dead, but then one clucked at me. I don't know how they get away with carrying them by their legs like that.

I saw another chameleon on the path between the hospital and the homes. This one moved a little bit faster, but was still pretty slow. Funny feet, funny eyes. What else can I say.

Ephesians 3:20,21

Now to him who is able to do far more abundantly than all that we ask or think, according to the power at work within us, to him be the glory in the church and in Christ Jesus throughout all generations, forever and ever. Amen.

A normal day.

Looking over SIM Hospital Galmi

What is a normal day in Galmi? Well for me it starts with a run at 0600. Then check the emails from the team leader to find out what is going on this week. Bible study is from 0700 to 0730, so if I had a short run, or slept in, I can go to that. Rounds start at 0800. We pray for the day and all the patients we are looking after and then we visit all the rooms. We start in USI “Unite Soins Intensive” basically the Maternity ICU. Check the vitals on all the patients, check the incisions on those that have had surgery, adjust their medications. Decide if any of them need internal medicine consults or surgical consults. Some of them have incisional infections and have to go back to the treatment area to have the incision opened and cleaned.

Then we go to the NICU and weigh the premature babies to make sure they are gaining weight. Usually we feed them with a nasogastric tube if they are too small to cup feed. Once they get to 1500g (about 3.3 lbs) they can go home with weekly assessments at the hospital. Once they get to 2kg they can be followed up in the out patient pediatric clinic.

Maria and Saadi

The rest of the wards are post op surgical wards and post partum care. We have 1 hysterectomy going home today and one going home tomorrow. The 2 ladies from yesterday are both doing well at the moment. There was one twin delivery yesterday, and there is 1 D+C planned for today.

Then it is off to the outpatient ward to do lots of ultrasounds. Are they pregnant? How far along is the pregnancy? How is the baby doing? Do they have high blood pressure? Do they have malaria? Those are the usual questions that need to be answered. Sometimes the questions are not so easy, and sometimes the answers are hard to come by.  The surgeries fit in wherever they fall.

Countryside around Galmi

There is usually a break from 1 pm to 3 pm (the hottest part of the day), and then the clinic starts up again from 3-6 pm. On Tuesdays (today) and Thursdays, the clinic runs until 2 pm and then we finish early. That allows for some other meetings to occur in the afternoon before dinner.

I have been invited over often for Dinner, and have had a great chance to get to know some of the missionaries here. The food is amazing (I have had pistachio ice cream among other things!) an the conversation is even better.

Then it is usually off to bed. I find that the first call to prayers in the morning (0500) usually wakes me up, so getting to bed early is helpful.  Sometimes the white noise from the fans helps, but not always.  There you have it. A "normal" day in Galmi.

Supermoon

Psalm 113:3

From the rising of the sun to its setting. The name of the Lord is to be praised!.

I thought I was having a hard day...

I thought I was having a hard day. I actually did. The original title for today's blog was even “A hard day”. Well, God had a lesson for me today. The people having a hard day were my patients. I was having the day I was supposed to have, helping them the best I could in very difficult circumstances. Perspective is sometimes hard to obtain. You have to be hit upside the head some times before it really sets in. Let me tell you about it.

The day started out well enough, I ran 8k and I actually got all the way through. After that is when I

started to have perspective problems. I went to do rounds this morning, and noticed an empty bed where there was a very sick patient yesterday. I asked about it, and they said she died in the middle of the night. Granted she was very unwell, and had almost died before she came to hospital, but I was hoping we could slowly get her better. This was not meant to be I guess. You hear the statistics about the maternal mortality rate, but seeing it for yourself is a whole different level of appreciation. I did not even get all the way through rounds and one of the midwives called me to see a patient who had come in with labour pains. She had had 2 previous cesarean sections and the midwife could not find a fetal heart. The ultrasound showed in fact that the heart was not beating. Because of the two previous cesareans

we had to do another cesarean to deliver the baby to avoid any chance of uterine rupture. We don't have the same type of monitoring equipment here, and any attempt to push boundaries and try to deliver vaginally usually ends up in a (worse) disaster. So for the first time in my life I did a cesarean on a patient who I already knew had a dead baby. At surgery it was clear that the baby had died more than a week ago. It was perfectly formed and just looked like it was sleeping. The only silver lining is that she has 4 children and that the uterus looked intact so she can have more if she wishes.

I was telling myself to look on the bright side, my two hysterectomy patients from last week were looking well and should be going home soon. We keep them in longer because they don't tend to come back unless they are almost dying (literally) and the practice here is to put stitches in that have to be removed (not dissolving) so that they will come back and have their incisions inspected. I guess that is what you have to do to make sure there is follow up here.

Then I went off to morning clinic and was seeing patients that are routine for here. A lady 37 weeks along in her pregnancy that hadn't seen a doctor yet. I think she was 37 weeks, measurements are not accurate at this point in the pregnancy. A lady at 33 weeks who had come in saying she was incontinent of urine. Again first visit, and again approximation of weeks pregnant based on an ultrasound today, but I noticed there wasn't a lot of fluid around the baby, and sure enough doing the Speculum exam it wasn't urine, her waters had broken.

Part way through the clinic I was called back to the ward. A lady had come in and was in severe pain.

The intake people said she had shortness of breath, but it was way more than that. She seemed to hurt everywhere. The ultrasound was really difficult. Partly because had a thick abdominal wall even when she wasn't pregnant. I couldn't see the baby well, and I couldn't see the heart at all. It looked like the placenta may have peeled away from the wall of the uterus – that was possibly why she was having all the pain. We went to the OR, and it was another first for me. The baby wasn't in the uterus. It was in her abdomen, and the placenta had attached on the top of her uterus (on the outside) and her right tube and ovary. We delivered the baby – it might have been 20 weeks size at the very most. It gave a few gasps and then passed away. Then we had all the bleeding to deal with. We did a hysterectomy and had to take out her right tube and ovary. She got 2 units of blood (when it is an emergency you don't have to wait for your family to donate!) and as of right now things are critical but stable.

At some point in that surgery is when I felt God talking to me, giving me some perspective. Who was really having the hard day here? Me – I still have all my parts (mostly), I am still alive, and I am going to be sleeping in a regular bed tonight not on an intensive care ward. No, I might be sharing in other people's hardships, and God may have placed me in a place to try to make that a bit better, but I was not the one having the hard. It is pretty clear who was.

"I complained that I had no shoes until I met a man who had no feet." -- Persian proverb

Philippians 2:3-4

Do nothing from selfish ambition or conceit, but in humility count others more significant than yourselves. Let each of you look not only to his own interests, but also to the interests of others.



Some of you will not want to see the pictures I took today, so I posted others instead.

At the bedside

So I am on call this Sunday, and while doing rounds we saw a lady I have been looking after who has had a lot of difficulty recently. She had a placenta previa, and had bled at home. By the time she got to the hospital her baby had died. She was bleeding heavily and delivered, but then had problems with her blood pressure and her pulse. There was also some concern that she might have AIDs and that she could have a blood infection. Needless to say she has been a concern of mine for a while, and she is very slow to get better. Another part of the problem is that she has a rare blood type, and we needed her family to donate so that we could transfuse her. This came very slowly. I had asked the Midwives to give her another unit of blood yesterday, and today on rounds the blood was there, but not running. The Midwives said she had terrible shaking yesterday when they gave her the blood, so they thought she had a transfusion reaction and stopped it. The thing is 1) She was getting O negative blood which is the universal donor, basically nobody should have a reaction to that type of blood (except in rare circumstances), and 2) what they were describing didn't sound like a typical

transfusion reaction. So ... I asked them to start it again and I would come back in an hour to see how she was doing. When I came back the transfusion was stopped again! Asked at the front desk, and they said the patient had the same reaction and they stopped it. I talked to the other doctor on call, and he said they could check the blood to make sure they had determined the blood type correctly, but that the lab tech was not back for an hour or 2. The other alternative was to sit at the bed side and start the transfusion again and see how the patient reacted. I decided on the second option, and I sat at her bed side for the next half hour and just watched her. Her breathing is somewhat laboured from the anemia, and she is very frail looking. She had her eyes closed most of the time and was quietly lying there for the whole time. After half an hour with no reaction I talked to the Midwife again and asked her to continue the transfusion and call me before stopping it if there was any more shaking. I do not know

what was going on, and I am still very worried about the patient, but perhaps she will improve now. Some times all you have to give is your time. And sometimes that is enough.

This evening is Church and I played the flute again. We had an infant dedication after church. It was wonderful, with the whole community committing to help the parents raise their child. The sense of community here is strong, and I think it is what makes this place work as well as it does.

Galatians 6:9

And let us not grow weary of doing good, for in due season we will reap, if we do not give up.

10k then 3k

I went for a 10k run this morning, and walked the last 250 metres because I was starting to feel the heat. I had thought the fun run today was in the afternoon for some reason (don't know why, maybe because a lot of things happen after work), but no, it was at 0800. So take a break for about an hour and run another 3k. That was a bit too much I think. I had to sit down a couple of times on rounds after that and then went home and drank a bunch of water and took a nap. But I am back now, and ready to move along.

It is a bit different with call here. There is no other Obstetrician, so if I don't do rounds on the weekend, the midwives have to do it themselves. Not too bad really, the load isn't that heavy, and I came to work anyways, so happy to help. I have also told the surgeons that I will do Cesareans even if I am not on call, as their work load is huge. Thursday there were 2 big MVAs in the middle of the night, and Galmi got 18 patients, many of them with multiple fractures etc. There is an orthopaedic surgeon here right now and he has been very busy!

I was thinking it was well overdue for me to talk about some of the other support staff around here. This is a real hospital, and it needs all the things a hospital at home needs. We have Nurses and Pharmacists, Administrators and IT, Maintenance and Construction, to name just a few of the jobs. There are lots of ways to help out here, and I would encourage others to consider it.

Christopher Zoolkowski who is one of the long term doctors here, was going in to the “City” so I went along for the ride and had a view of life outside the compound. It is busy and dusty with lots of

mud walled shops selling everything you can imagine (and maybe some things you can't). There were lots of livestock going through the streets as well, as you might expect in such a place. We met his favourite baker who has a firewood oven, a local shop selling soda (or pop) in anticipation of the hot work of emptying the pharmacy shipment that is coming next week,

and the local SIM card guy. I also had a chance to see where the call to prayers is coming from.

Once back home it was off to worship band practice. We did finally find 4 songs that we all new, but there will be a second practice before the service to hammer out the rest. and then a quiet dinner. Tomorrow I am on call, so I will not be going to the morning service in the city, however I hope to be able to play flute and not get called away for the evening service. I am hoping to go to the Galmi Church next week.

Psalm 119:32

I will run in the way of your commandments when you enlarge my heart!