And at the end they travelled again.

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The past month feels like a whirlwind. We are sitting in the Entebbe airport, eating samosas and drinking coke (with sugar, not high-fructose corn syrup) out of glass bottles and waiting for our flight to Doha, Qatar, which leaves tonight at 6:30 pm. Alex points out that the Entebbe airport seemed pretty run-down when we first came through (the power just went out as I was typing that sentence), but after 3 weeks in Yei it feels like NASA HQ. Currently we are sitting at the café and he is explaining to us the difference between, jacked, ripped, cut and shredded. I can’t tell if this is about working out or violent crimes. The flight is about 7 hours, and we are hoping the kids will be wiped out enough to sleep for a few of those. We only have an 8 hour layover (midnight to eight am), so no airport hotel this time through; our plan is to pay for pool access only, which means we will be able to swim with the kids, Alex will be able to lift at the gym, and we will be able to take showers in the locker rooms; everything we need except a place to actually sleep, which neither of the children made use of last time anyway. After that it’s just a 15 hour daytime flight to Dallas with Aubrey and Caleb in our laps. Can’t wait.

Alex just called somebody on instagram a “monster” and said he must be taking drugs. It could still go either way.

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It’s been an eventful few days since our last weekend. I finished my last day of call at His House of Hope Hospital on Saturday to cap a final week on maternity. It has been 3 weeks of deliveries, c-sections (both performing the surgeries and helping to teach and assist the senior CO’s. Dinya, on of the CO’s that has been here the longest, did his first case from start to finish, or “skin to skin,” on Friday night), OB ultrasound, pre-term deliveries and newborn care, malaria, typhoid, very sick children, death and mourning, recovery and hope, tea at 10, lots of teaching and arguably more learning. I am returning to the relatively quiet life of supervising interns at Hillcrest Hospital (trips like this sure give you perspective), while the hospital goes on and new people come in. On Saturday Dr. Perry’s friend Dr. John Waits came, and brought two of his residents from Cahaba Family Medicine Residency in Centreville, Alabama. My final day’s responsibility consisted of orienting the new residents to the hospital. At the end they seemed a bit shell-shocked, like I was on my first day less than a month ago. It was good closure.

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If you can’t beat ’em, join ’em

Outside of the hospital, we tried to cram as much into our last week as possible. Alex walked to town several times and made friends with a group of Boda drivers (apparently they are some sort of mix between a motorcycle gang and a taxi company). The younger Perry girls had a slumber party with Aubrey on Saturday. We followed this with a game night on Sunday and a dinner with just us, Alex, Jeff and Elizabeth on Monday while the Perry kids watched Aubrey and Caleb. The Perrys are coming home in April for home assignment (the term furlough has fallen out of favor, since long-term missionaries are generally travelling and working hard while back in the States), and we are excited that we’ll get to see them again in a few months, instead of 2 years.

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This morning we had a special birthday breakfast for Given, who turned 8 years old. We were delighted to bring a Doc McStuffins toy with us from the U.S. as a special surprise present from us and her parents. After that we loaded up the landrover and half the family drove us the 30 minutes to the airport on the other side of Yei. A note on logistics; our plane was scheduled to depart at 8 am, but Elizabeth insisted on us leaving from their house at 9:20! We got to the small building, unloaded our bags, checked in, stamped out of the country, and went through customs in time to walk out and watch the plane land at 10:22 am. We waved goodbye and got our small plan back to Entebbe. The mood was a bit somber; 3 weeks just isn’t enough time to live around people like the Perrys and Loftus’s and the rest of the team there at Harvesters, and work at a place like His House of Hope Hospital. We all felt like we could have stayed another month at least.

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We’ll likely be writing more in the next few weeks about our time in South Sudan, as we process the trip and think about the future. Perhaps the most wonderful thing has been watching the kids go from being scared of everything to feeling comfortable and at home in that small missionary compound in the heart of East Africa. Just now Aubrey told us, “I want to go back to our house in Africa!” Please pray with us that when the time comes, we would be faithful in following God’s call to make those words a reality.

All the Little Things

I think this post will just be a simple human interest piece with a culinary focus. I’ll try to fit in several of our favorite moments and the laughs in between. I have been amazed at how well Aubrey and Caleb have just continued with who they are in this very different place. There have been mentions of home between TJ and I as we plan out this last week, trying to fit in all the things we want to do (namely a few more family walks, more time with the Perrys and another game night with Maggie and Matthew), and Aubrey, always a keen listener to conversations she isn’t a part of, picked up on it. I’m not sure if she had wondered about going home at all or was too busy learning about life here to think about it, but she started just yesterday asking about her house in America and her friends there. Caleb of course is fully in the moment and it is interesting to see how acclimated he is now. He does bring up some things about home though! Someone said the word hot tub in a story today, and Caleb started yelling, “hot dog pees! Peessss, hot dog!!” He was very sad when I couldn’t give him one. Other than a few moments like that, this is his new home and life as far as he is concerned. What will a real move to the field look like? TJ and I continue to process this question as we find our rhythm here.

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Elizabeth and Jeff

Last week we had a double date with Jeff and Elizabeth while Aubrey and Caleb stayed with all the Perry kids (their oldest, Lilly, is 16) at their house for a movie night. It was wonderful fun. Hazel, Given, and Winnie were beside themselves excited about getting to give Aubrey and Caleb a bath and put them in pajamas; they helped me pack up a little back pack of all the things the kids could possibly need and walked us over to their house. TJ and I had a great time getting to talk to Jeff and Elizabeth without interruption.

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They took us to the Bishop’s compound (they have a great chef) in town after a quick trip through the open air market. We got a neat curry take on American hamburgers with chips (French fries) on the side. And an almost cold coke. Such a luxury! Date night second edition happened last night and we went to the only other restaurant. I didn’t catch the name, but it was Ethiopian. I will say, TJ and I had never eaten Ethiopian food before and we were both shocked when Elizabeth tore the white spongy looking napkin the food was served on, dipped it into the sauce and ate it. For anyone who doesn’t know, it’s called injera and is a sourdough flatbread (thanks, Wikipedia!). It reminds me of a crepe just a little.

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Our delicious Ethiopian injera

We thoroughly enjoyed our time together. Driving to the restaurants (and everywhere else) is really more like off-roading it. I wish I could have taken a picture of the gullies and sometimes waist deep trenches all through the main dirt roads. I was too busy hanging on as we slowly lumbered in their range rover over the rough terrain! I am going to have to gain some serious courage (and learn how to drive a stick) to get behind the wheel on the mission field.

Filling the hours of the day has been more challenging after the first week, but having nowhere to be promptly means we can stop and enjoy things like a long trail of huge pale orange ants climbing up a tree (Caleb stuck his hands right in the trail and there was a slight frenzy on my part to swipe them off),  random wide short logs that are fun to try to roll, and any small green weed daring to grow during the dry season (Aubrey likes to pretend she planted them and yells out, “Look Mommy! My seed is growing! We need to bring it water!!”).

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Log rolling for fun

During walks, Aubrey likes to make dust trails for us to follow by dragging one foot or shuffling both feet in the inches of dust everywhere and asking Caleb and I to only walk in the “path” she made. We have managed on several occasions to take thirty minutes to walk to the Pyatt (a one minute walk without kids) and I usually don’t mind. We have visited Maggie and her two kids, Naomi and Leo, multiple times and switch off houses. Our latest favorite, as it has been getting hotter, is playing in the water tubs (yes, the same dread water tubs that Caleb would not go near during our first week). Lots of busy pouring from one container to another and then episodes of intense splashing fill the afternoon nicely! This has cured Caleb of his fear of baths and now he wants to climb in one every chance he gets, clothes on or not.

 

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Sushi with difficult to find cucumbers, lots of avocado, and home made cream cheese!

A favorite has been lunch with the Perry family. We have had homemade sushi, thai soup and pad thai. They often eat later (around the kids nap time) so twice my kids have slept at our house (with an eager Perry helper or two hanging out just in case they wake up early) while TJ and I have enjoyed lunch kid free with the rest of the family. This usually includes Alex and that makes TJ and I happy. Alex has all the older kids laughing at his antics and stories within a few minutes of sitting down. Elizabeth has endeavored to find a way to make all their favorite dishes even on the mission field despite limited fresh vegetables, not very much meat, and very different dairy products. When the power went out for several hours the first week we were here, Elizabeth had been in the middle of baking 9 loaves of bread that would last her family the next week and a half and had to switch all those pans to the wood fire oven outside the Pyatt! Three hours later, they were done and still turned out great! She and Rebecca (the Canadian doctor here for three months) just made cheddar cheese the other night and are waiting for it to age. I think I should go to a cooking from scratch class with a focus on creative substitution in recipes prior to moving somewhere without grocery stores.

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On our field trip walk

I have missed being able to take the kids to a park or library or Mayborn, until we discovered the pig farm! Just a small walk away down the big dirt road outside the compound, there is a small wooden fence enclosed pig sty with four large pigs. They are owned by someone the Perrys know and Elizabeth pointed it out to me on a run one morning. Never have we been on a better field trip. Maggie and I teamed up with the Perry girls extraordinaire (including two other MK toddlers they were watching) and led our little troop, munching on digestive biscuits on the way, to the destination. The Perry girls hadn’t ever stopped to look at the pig farm so they thoroughly enjoyed it as well.

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Pig farm!

We ooh’d and aww’d over the stinky dirty pigs and their big rubbery looking noses, and the kids’ eyes almost fell out of their heads when they saw the pigs getting fed “slop.” We walked back to our house and promptly colored pig pictures to hang on the walls. Since that first trip, we have been two more times!

 

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burger and fries night

Oh, one other highlight I can’t forget to mention was the night we ordered “delivery” from the EPC compound (the same one we went to on our date night). Alex paid 450 pounds (about 22 dollars) for five hamburgers and five orders of chips. He had also gotten us cokes and REAL ketchup in town earlier that day and we had a feast! The kids were so excited they had a dance party around the table.

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Aubrey leading the dance party and Caleb loving it!

Neither one of them actually ate anything but fries and lots of ketchup since the burger meat was a bit spicy, but that didn’t matter. We had just finished eating (thankgoodness!) when Caleb stood up and turned around in his high chair, and TJ said, “What is that all over his back?” Yep, poop explosion. We hadn’t had to deal with one of those since before the 1 year mark! Not even that could put a damper on our fine dining evening.

To find some sort of conclusion to this random assortment of recaps, I will say the Lord has so richly blessed us during this trip by providing fast friendships, good fellowship, and time for long conversations. The kids are thriving, and TJ and I love the adventure of new and different together. The sobering thought is once the newness and excitement wears off, underneath there will be a depth of confusing cultural differences, language barriers, and very difficult medical work wherever we end up going. We are praying for grace to see us through the “Dancing Elephant” stage on our own foreign mission field and His energy to stay the course when we become weary. Only three more days before we fly back! Thank you for all of your prayers and thoughts!

Medical Culture Shock (part 2)

After years of conditioning and institutionalization, many residents have a hard time adjusting when they are not on a strenuous schedule. Even though we commonly work 80+ hour weeks, we still feel like we are stealing from the clinic or getting away with something when our schedule gives us an afternoon off. In the hospital, life begins at 5 am; that’s just the way it is. Life does NOT begin at 5 am at His House of Hope Hospital in Yei. The day begins with a staff devotional from 9 to 10, followed by tea until about 10:30.  After tea there is either teaching rounds or case presentations, after which the work of rounding (finally) begins. There are important reasons for this. Many of our staff walk for miles to come into work, and starting the day shift while it is still dark isn’t possible for them. Also, rounding is generally more helpful if you already have lab results available for patients who need them, and since our main source of power is solar (and solar power doesn’t work as well at night), having all of those labs finished by 7 am is pretty much impossible.

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Dr. Perry teaching for the CO’s

Patients are cared for during this time, of course, but when you are used to knowing about all of your patients and having the bulk of your work done by 8, 10 o’clock tea can be a little exasperating. Regardless, by 11 things have really ramped up… and then we break for lunch from 1 to 2. I’m no stranger to eating on the go or working straight through meals (in med school I consistently lost weight on EVERY inpatient rotation), and my first day I decided I would just grab a quick 10 minute lunch and keep working, with or without the rest of the staff. This became challenging when I returned to the maternity ward to find it deserted; almost all of my patients had left to go have lunch, too. I guess in my hurry to finish the work I could have tried to press on without even them, but a doctor must have patience.

Since those first few days, I’ve really come to appreciate parts of this schedule. The later start to the day has allowed Katie and I more time to read scripture and pray together in the morning (something that often feels impossible to maintain on hospital months at home), and gives me time to eat breakfast with Katie, Aubrey and Caleb. The devotional time itself is really quite beautiful; the hospital begins each new day with praises and worship offered to Christ through prayer and English and Arabic hymns, and a short message focuses our hearts, reminding us that we are each working for God and not for men, and relying on Him for healing.

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Dr. Loftus sharing in morning devotion

 

This reminder is important, because the other shocking part of working here is just how difficult it is to take care of patients who are so ill. Because many patients come from far away and do not seek medical care until the last resort, His House of Hope often sees the sickest of the sick. Any child here would be the sickest on our service at home, or already transferred to a specialty pediatric hospital. One night on call I had just arrived, along with my CO, at the bedside of a small child who had been admitted earlier that day for severe malnutrition, severe dehydration, severe malaria. He was 1 year old and weighed about 11 pounds. His hospital care had been appropriate so far, but I was just coming on call and wanted to see if there were measures that we could add that night. I had no sooner laid eyes on him then I was called away to a truly emergent C-Section. As my CO and I were finishing the surgery and Dr. Perry was intervening for the premature newborn baby, we heard the all too familiar wail of mourning from outside. We were informed that the small boy had died.

If I had thought about and worked with that child for that hour instead of performing the C-section, would I have been able to save his life? Or was it just too late to intervene when he had been so sick for so long? I’m not sure. But the truth of this and so many similar experiences is clear; when you are a missionary doctor in a setting like this, to be one place means you cannot be another. His House of Hope has grown so much since the Perry’s moved here 5 years ago, and now there are several full time missionary and South Sudanese doctors, and short termers like us, in addition to the CO’s, midwives, nurses and other staff. There is fellowship, there is support, and maybe most important of all, there is backup. Culture shock is one of the things that can end a call to missions prematurely; burnout is another. You have to have a break, you have to see your family; but depending on where you go, taking a day off might mean that people are going to die who might have lived if you had been there.

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Matthew Loftus (matthewandmaggie.org) and Jeff Perry (perryclan.com)  Two of the full time missionary doctors here in Yei.

I’m not sure how to process that yet. Looking ahead, I know that same part of me that worked through lunch and dinner all those days in med school and residency would be tempted to try to work night and day. That part, unchecked, would get me a plane ticket back home before we had been on the field for a year. I know the docs who are here have struggled with that and have had to set-up strict rules for themselves, to make sure they have time to rest and spend with their families. You can’t “work until the work is done” when the work is never done.

Thank you so much for sharing in this journey with us and for all of your prayers and encouragement. As we enter our last week here, please pray for the doctors, the CO’s, the nurses and the staff of His House of Hope, and for all of our patients, big and small.

Medical Culture Shock (part 1)

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Looking back, I think I may have experienced just a little bit of culture shock during my 3 weeks in Burkina Faso in 2006. It’s hard to say. On the one hand, I don’t remember much in the way of anxiety, fear, feeling homesick, a desire to withdraw, or judgment of the host culture. On the other hand, we had a deck of cards out in the Lyele villages and we played A LOT of Gin Rummy. I mean, like 200+ games. I’m not sure if it was really a form of escapism or just a way to fill the 14½ free hours each day, but it was certainly a coping mechanism. I have definitely experienced reverse culture shock, and this is one I’m pretty embarrassed about. After that trip I came back to the States and had to take a few Summer classes at Bossier Parish Community College. After registering as a student and paying tuition at the business office, I walked outside to explore the campus a bit, when nature began to call. Remember, I had been in the bush for the 2½ weeks prior to this. Without thinking, I walked up and stood facing the outside wall of the administration building, and… realized what I was about to do just in time, and quickly walked inside to find a restroom!

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Those bushes weren’t there yet in 2006

Here in Yei, I only seem to be experiencing culture shock in the hospital setting. Healthcare in much of the developing world tends to be quite paternalistic (not that we are exempt from this in the U.S!). In my practice, if I’m treating a patient for a bacterial infection I will explain the condition, what I think caused it, the treatment I am recommending and some of the major side effects, and other medical and home remedies or supportive measures the patient might find helpful while the antibiotics are treating the infection. I’ll pause for questions multiple times and assess whether the patient and I are on the same page and whether they are likely to be adherent to the treatment regimen. This process isn’t as arduous as it sounds, but even if it was I’ve been taught that this is the best way to communicate with my patients. The process here is more straightforward: “Take these pills for 1 week.” Or, if you are feeling particularly smarmy, “You are sick. Take these pills for 1 week.”

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My clinic team, at the end of a long day

I’m not quite there. It’s always hard to find the line between ethnocentrism and “now I will show you a more excellent way,” but for now I’m going to continue to try to model intentional patient communication for the CO’s and nurses. The patients don’t quite know how to handle it. They laugh when I introduce myself, and especially when I ask if they have any questions at the end of the visit. The most confusing part for everybody is the anticipatory guidance. When I explain the warning signs and symptoms the patient should look out for, including reasons to come back to the hospital, the interpreters nod at me and say ‘ok’. When I further explain that I want them to now tell that to the patient, there’s an awkward pause. They are probably just figuring out the best way to explain what I said, but I secretly wonder if they are actually waiting to see if I am joking.

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Finally got a picture of the labor ward

Medical privacy is another area I’ve had to adapt to. Generally I sit down next to my patients when talking with them; it helps people feel heard, less hesitant to ask questions, and softens the perceived power differential. Last week on rounds on maternity, sitting across from my patient meant I was actually sitting on the next patient’s bed. We’ve had surreal moments where we are trying to convince someone that a medication or intervention is necessary; when she is hesitant, other patients and visitors in the ward are likely to chime in to convince her to listen to us (or I assume that’s what they are saying). It’s the same in clinic. This week I’ve been on antepartum clinic, and because of Yei’s size it’s not unusual to see 60 or more patient’s in a day. After they are assessed by the midwives, they are called in 4 or 5 at a time and sit in a row next to my desk. After I have seen one, she leaves and they all move to the next chair in line. This is a great system for efficiency, and necessary to take care of so many women who are in such need of good quality prenatal care; but it still feels pretty awkward to talk with my patient while my next 4 patients watch and listen from a foot away. Fortunately, as best I can tell I am the only one that feels at all uncomfortable with this.

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Antepartum clinic. I’ve still seen worse (ahem, Denver Health)

I’ll share more tomorrow. In the meantime, please pray that the God who commanded us to go into all nations would also give us wisdom once we get there, and that He would show me both what to teach and what to learn from the way things are done here.

Time with Orphans

I have so many thoughts about what we are learning here that it’s hard to know how to write them all down. That’s why it has taken me so long to blog! So the other night we were hanging out at the Perrys’ and enjoying their fellowship. I was overhearing Jeff and Elizabeth’s conversation with TJ (Caleb wasn’t interested in what they were saying so he and I were playing on the floor) and was so intrigued by the wisdom and experience they have as senior staff here and long term missionaries. Jeff was describing three types of short term mission trips. Feel good trips, do good trips, and real good trips. We all laughed at this and he elaborated with multiple examples.

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Playing next to the Harvesters huge truck on the compound

Feel good trips are when teams or individuals come mostly wanting to feel good about what they get to do or their interactions with the people here. They want a quick fix for all the hurting they see because it makes them feel better. Instead of following the advice or even instructions of the long term staff, they make their own decisions about what seems best and very unintentionally make things harder for the missionaries who live here and have to deal with the consequences after they leave. An example is when people freely give handouts or gifts, unintentionally creating expectations. A do good mission is one that provides a service or offers some good but makes a lot more work for the long termers. An example would be a specialty surgeon coming to the hospital. They offer a needed service, but also use up all the OR time (so all the normal c-sections have to be done late at night), all the supplies from the OR, and because of so much extra work and long hours, leave the staff feeling burnt out. A real good mission is when that same surgeon returns but this time, brings all his own scrub techs, assistants, and supplies and is able to provide follow up. How interesting is that? I really appreciated hearing that perspective. Especially as Jeff and Elisabeth went on to say that although short termers can be more work, when it is viewed as part of their ministry, it is a blessing they are thankful for!

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Splashing party with baby Leo in the Pyatt

During orientation Jeff had mentioned that the orphans stay on their half of the compound and aren’t supposed to come around the mission housing. He said not to give any one on one special attention or any handouts. I love kids and hearing that made me wonder why there were such boundaries. I have learned a little more since then. Establishing real relationships with the orphans, learning their names, staying the course with them, and giving them firm authority is the best, what they really need from adults. A month long short termer can’t really offer that. Fun games, ‘football’ and good laughs is a great level of interaction. Reaching beyond that and then leaving makes it harder for these kids to trust and build lasting relationships. They are also pretty street wise (precious little sinners like the rest of us) and tough survivors so they like to take advantage of unsuspecting westerners (phones have been stolen, or if allowed to play with a phone, passcodes have been changed as a trick). Several short term teams have come and passed out candy and toys and had no boundaries. It feels good to the team to love on the kids and give them special treatment. But then they leave and their actions aren’t sustainable. Do you see what I’m saying? All these kids are WORTH it and so adorable and loved by the Lord. AND we need to see them as individuals who need authority, structure and consistency. I understood a little better after Aubrey and Caleb and I hung out with a few of the kids one afternoon.

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Caleb enjoying some milk!

I had been talking to Aubrey about being brave and showing love to the kids here, so when we walked to the swing after nap and collected a following of giggling children, I was so proud of Aubrey for smiling and waving and even shaking their hands (greetings are a BIG deal here). But after a little while she got tired of being touched and patted and having her hair stroked. Caleb was in the swing at this point; I honestly wanted to get him up and out of the way because the orphans are a little rough. Aubrey was standing as close to my legs as possible and wasn’t smiling any more. Lots of sweet black faces were crowding around and giggling at everything we said. Then I saw one little girl pinch Aubrey. Just a little quick pinch on the arm, but I switched into parent mode and suddenly saw these kids through the eyes of a mother. This might have been fueled by the shocked look on Aubrey’s face. I firmly told the girl no and shot her a stern look. She returned the look with an impish gleam in her eyes and I will admit I was a little surprised. I caught them pinching Aubrey or tugging her hair several times over the next few minutes and had decided we would just retreat since I couldn’t always tell who was doing it and me saying NO wasn’t doing any good. I got Caleb out of the swing and started back for the house. Aubrey lagged behind and started playing with one of the girls on the bridge so I hesitated. Should I see what happens? Nope, there were just too many kids playing too rough. Maybe I was being too protective. After all, I had hoped we could spend time making friends with these kids. But I called Aubrey and when she tried to come to me the biggest girl blocked her way. TWICE. Momma bear came out and I stormed back towards that adorable bully fully intending to…well I don’t know what I would have done, but all the orphans shrieked and fled. Hum. Not the interaction I had imagined. I ended up talking to some long term people (ones that work with the orphanage) over lunch at the Pyatt about our interaction. They know the kids by name and addressed the issue. They also offered me advice on having a loud voice, engaging with the children in THEIR space instead of interacting with them on the missionary housing side, and taking any discipline issues straight to the head master so he can keep the expectations for their behavior consistent. Consistency is SO needed for these kids and short termers can often get in the way of that!

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How many kids can you fit on one see saw?

After lots of conflicting thoughts and a few prayers for wisdom, we walked to the orphanage one afternoon. Maggie and I had our boys on our backs in carriers and our girls by the hand. And we brought Alex with us because he is great fun and an extra set of eyes. And we had a marvelous time. We watched the founder, Pastor Denis, working on a new cooking area for the orphanage, then we played on the jungle gym with the kids and had a crazy game of duck duck goose (though their rules are different and we were very confused at first). It was a wonderful afternoon and Maggie and I talked a lot on the walk back about figuring out healthy boundaries around the orphans (for the sake of the orphanage, our own children, and our sanity); mostly for her since she actually lives here.

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This jungle gym was built by an Australian engineer short term visitor and it is well loved!

I had a conversation with Aubrey after our first interaction with the orphans about loving people even when they aren’t kind to us. She hasn’t ever really had to practice that and my first impulse as a parent is to protect her from having to! But that shouldn’t really be my priority, should it? I discussed this with Elisabeth and it led to a deep conversation about how missionaries respond when the people they are pouring their lives into steal from them, lie to them and betray them. Tough love takes a new form in my mind now as I hear about the struggle to balance forgiveness and turning the other cheek with teaching consequences and earning respect by not being taken advantage of. Jesus was mistreated and betrayed and promised us the same when we follow him. It’s funny how I forget that and get surprised when missionaries face difficulties. Being on the field long term is starting to sound and look very different from what TJ and I had always imagined. Our prayer is that God will grow us and prepare our hearts to deal with the struggles we will surely encounter!

 

A Chance at Life

Dr. Perry is writing to the supporters that provided for the Waiting Mothers House about a patient that I mentioned in my recent blog post. He has given me permission to share his letter here as well.

 

Rebecca is a 25 year old who had one birth by C-section, then lost 7 babies to preterm rupture of membranes and delivery. In this, her ninth pregnancy, she had a “cerclage” placed, in which a suture is placed to hold her cervix closed. For almost 3 months, it kept her baby inside. On January 7, 2016, she was 27 ½ weeks along and her water broke.

At His House of Hope, preterm babies have a chance at survival if they can reach 29 weeks gestation. Rebecca was started on antibiotics and steroids to prevent infection and help baby’s lungs mature. As she had no bleeding or pain, we admitted her to the Waiting Mothers Shelter, and monitored her daily for several weeks.

When she was almost 30 weeks, she began showing signs of infection, so we removed her cerclage and restarted antibiotics. The following day, the baby’s umbilical cord fell out of the patient (a “cord prolapse”)—which is usually fatal to the baby immediately. The baby still had a heartbeat, so we rushed to C-section, and delivered a small, but breathing, 2 pound 14 ounce (1310 grams) baby girl.

As I write this, the baby girl is 5 days old and struggling with issues of prematurity—breathing, tolerating feeds, and infection that threaten her tiny body. The parents are attentive and concerned, but have yet to name her, as they hold loosely to hope, having lost so many babies before. The Waiting Mothers Shelter allowed Rebecca to remain near the hospital so we could intervene quickly when problems arose—giving this baby a chance at life.

Low-Risk Obstetrics

If you aren’t interested in reading about medical stuff, this would probably be as a good an update as any to skip. 

While we aren’t what you would call world travelers, this is neither mine nor Katie’s first trip to Africa. Katie went on short term trips to Cameroon and Uganda in High School, and I’ve been to Burkina Faso and Rwanda during college and medical school. In many ways, this is actually my least ‘adventurous’ experience on this beautiful continent. We’ve been here  for over a week now and so far I haven’t slept outside or in a tree branch (the roving packs of wild dogs made sleeping on the ground impractical), drunk water from an open well (yes, there were lots of ‘floaters’), or biked across the bush asking directions back to the village at nightfall. I haven’t hitchhiked or couch-surfed, and I have been eating at the Pyatt instead of hiking miles downhill to the village to buy food to cook for myself (this implies that I had to walk miles back uphill carrying my food, but the novelty of a white guy walking up a small mountain with a backpack full of potatoes was just too much, and I never had to wait long for a ride). We aren’t swimming or canoeing, nobody has tried to feed us any local delicacies, and with the running water here on the compound I will probably make it the entire trip without needing a bucket bath. With Katie here, I don’t have to spend 2 months separated from the woman I love (just so much bad planning and miscommunication leading up to my trip to Rwanda), and nobody is likely to call to tell me that her appendix ruptured and she almost died while I was on the plane. Yes, things are pretty great here in Yei, South Sudan.

The big difference is that, unlike those other trips, I’m a short term missionary doctor now, and that comes with some inherent adventures all its own. The work in the hospital is a different world entirely, and it’s impossible to compare with any of the very non-life-and-death experiences I’ve had in Africa in the past (unless you count riding through town on the back of a hired motorcycle, driven by a 14 year old that likes to weave through traffic and in and out of sidewalks).

My first week was spent on Maternity. The maternity wing consists of three rooms. The first is an antepartum room with 8 beds, where we keep women who are close to labor or being induced, or pregnant women with severe illness. This is where we treated the severely anemic woman that Katie donated blood for last week . By the 2nd hour of my 1st day I had already treated more malaria and typhoid than I have in my entire career. The CO’s and the longterm missionaries here are teaching me a ton about tropical medicine. The ‘special care’ room is on the other end of that wing; another room with 8 beds, where we keep postpartum women and newborns. There are 2 preterm incubators and they are hoping to greatly expand their NICU capacity when the funding and support is available. When I came on last week we only had one premie; a 29 week little boy who did remarkably well off of oxygen when the power went out for about 8 hours, before they got it up and running again, then emergently flew in the Australian engineer who designed the system and happened to be in another part of South Sudan on an install for another mission hospital. Over the weekend we added 33 week twins, a 32 week preterm delivery, and a 29 week baby born by C/S; we are really thankful the solar power system Is fixed up and the back-up generator is working. Please pray that the electricity and the machines needed to provide these kids with oxygen don’t fail.

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Between antepartum and special care we have the labor ward, where I spend most of my time and have most of my panic attacks. I’ve never been more thankful for how intense our OB experience is at my residency in Waco. The labor ward has 5 beds in a row, each with fetal heart monitoring equipment and several with working tocometry (measurement of uterine contractions). I would post a picture of the labor ward, but I’ve never seen it empty enough to actually take a picture. At one point on Saturday when I was on call, a woman came in unconscious with a 1st trimester bleeding emergency; she was having a miscarriage and had collapsed from the blood loss (she is doing well now and was able to go home). In the next bed there was a woman with a 3rd trimester bleeding emergency; she was in preterm labor with (previously undiagnosed) twins, and had a placenta previa (the placenta lying over the inner opening of the cervix). We had to rush her back to perform a cesarean section. A few beds over there was a woman in active labor with term twins; twin A was cephalic (head down) but twin B was breech. As we went to the OR, Dr. Perry and I prayed that she would hold off long enough for us to complete the other surgery, with plans for one of us to unscrub and rush back to the labor ward if she began to deliver (thankfully we didn’t have to). A cephalic-breech twin delivery is pretty complicated and requires a doctor, but most of the straight-forward deliveries here are done by the nurse midwives, who only call one of us if there is a complication. It’s not uncommon to manage these kinds of parallel crises with other babies being born all around you. Right now His House of Hope is doing something like 160+ deliveries a month.

A short walk from the hospital is the room for waiting mothers. It is a place to stay provided for women who are not imminent for delivery or acutely ill, but cannot safely go home prior to delivery. Two of our patients who delivered prematurely over the weekend had stayed there for a week prior, both with preterm, premature loss of fluids and a history of preterm labor. At 8 pm on Saturday night I was rounding on the sickest of our patients on the pediatric ward, when one of the OB nurses came and found me and very calmly stated, “come doctor, there is a cord prolapsed.” It was one of the women from the waiting mothers house, and the cord had prolapsed through a partially dilated cervix. This is an obstetric emergency and something I’m constantly terrified of on OB back home. We rushed back to the OR and emergently performed our 3rd C-Section of the day; baby and mother have been doing well.

 

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The Operating Theatre

The OR is a single room with an attached room for scrubbing before cases and sterilizing equipment. They have an older but functional surgical table that was donated and sent over on a shipping container. When Dr. Perry first got here, they were using an old hospital gurney; he says he had to carry a wrench to tighten the frame every few cases, because he was afraid it might collapse under the patient. At that time they were using head lamps for light and they didn’t have suction, so they just had to use lap sponges. He tells the stories and then says that’s the missionary doctor equivalent of walking to school in the snow, uphill both ways. Now in the OR we do have good lighting, anesthesia monitoring equipment, and suction. They even have electrocautery here, but use it sparingly because of short supply. The one case where we opened it, it felt like seeing an old friend.

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Scrub and Equipment Room

All of this high acuity, complex, life-saving work they are doing here is incredibly daunting. It’s hard to imagine going to a place where, as a family medicine doc, you’re the end of the line; the most senior and experienced person that they call when all else fails and they need somebody to do something to save the mother and the baby. OB never gets any less scary; your 100th or 1000th delivery (I am told) is just as scary as your 1st because things can go wrong very quickly and without warning. Coming to a place like this to stand between mothers and babies and all of those things that can go wrong must take either a huge ego, or great faith in the God who was born to a teenage G1P0 under less than ideal conditions. Pray that God would enlarge my faith and trust in Him, especially if He plans on bringing me to a place like this!

kicking and screaming…

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Here is a light-hearted post about what my kids are still screaming and kicking about over here in Africa and what they have accepted… and a list of my wins and losses that does not line up with what is making my kids melt down or throw a holy terror temper tantrum.

Let’s do tantrums first. Not just because we have dealt with so many today but because I always like to end on a good note, as the saying goes.

  1. Bathing in a tub
  2. Brushing teeth
  3. Washing hands
  4. Opening and closing doors

Caleb is still terrified of or just angry (I can’t tell which) about having to bathe in a tub. It’s not really a big deal, I just sound like I am MURDERING a child every night at 8pm as I try to wrestle him into a nice warm tub plenty big enough for him. One that he LOVES splashing in as long as he has all his clothes on.

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The dreaded tub

I’ve resorted to a half hearted spit bath in the kitchen sink the last two nights, but boy needs hair washed tonight so wish me luck! I would just do without washing his hair while we are here, but the thrice-daily bug spray coats their hair making it oily and just a bit sticky. And I cannot abide sticky stinky oily hair for more than two days. It helps me love them when they smell like sweet clean babies!!! Aubrey enjoys the tub, but I must remember to do her first because if I leave her in the tub to get a diaper and pjs on Caleb, she is DEVASTATED to have missed out on that important interaction with her brother. I count this struggle a win every night I successfully remove the dirty grime covering my children before putting them in bed.

This one is a fail though. I somehow managed to forget to brush the kids’ teeth for the first 6 days of our trip. I blame the travel and jet lag and constant snacking? Terrible I know. Anyway, we are back at it. Caleb must have forgotten all about tooth brushing because he’d prefer to scrub the dirty floor with his tooth brush and make me wash it with soap before using it. Then he yells out, “Torn! Torn!” the whole time because he wants it to only be his turn, not mine, to brush his teeth (so he can happily suck the tooth paste off). I also can’t find the lid to the kid tooth paste because Aubrey dropped it and it VANISHED into thin air!! How does she do that?

We are improving in the hand washing area so it’s a win….but there is still some crying involved. Mine mostly because oh my goodness give me your slippery soapy hand back Caleb (and Aubrey too) and let me rinse it off at one go instead of turning the water off with your soapy hand. Every time.

Doors are the kids’ new stumbling block. It has turned into a disciplinary issue because fingers are going to get squished and bugs are getting into our house.

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Metal door love
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Seriously, do Chip and Joanna know about these?

It started at the Pyatt because there are cool old metal doors (teal metal doors! Love!) that stay open all the time and the food is just always covered with a towel or a lid to protect it from all the flys. So the kids think it is great fun to push the doors back and forth and they each get one. But at our house and the Perry’s and every other door we encounter, Caleb wants it open so he can go out and Aubrey wants it closed after she comes in (or vice versa). It’s a drawn out silent battle that ends in Aubrey yelling instructions and Caleb defending his position with his favorite, “NOOOOOO!” Anyway. We are working on that. I’m calling it a draw for now. The bugs are the real winners, since they can come and go as they please.

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Inside the Pyatt

The kids have accepted lots of things though!!

  1. Taking anti-malaria medicine
  2. Having the Perry girls look after them
  3. Hearing loud noises all day and most of the night
  4. Getting to play in the dirt all day long

Praise the Lord we discovered honey for their bright yellow bitter tasting anti-malaria medicine that we need to give them every day. The first few times were brutal and both Aubrey and Caleb threw up after we managed to force feed them the medicine in some disguised form. I am SO thankful we do not have to fight that battle every morning!! Aubrey asks for her honey medicine and both she and Caleb thoroughly enjoy their spoonful of honey with the crushed pill mixed in.

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Caleb sitting next to Winnie and loving it!

Both of our kids are a bit on the shy side and Caleb especially is slow to warm up to strangers. The Perry clan is big in number and could be overwhelming but oh how my children have fallen in love!  Winnie (who is 6) has taken special care of Caleb, and he cried for her at nap time yesterday! I want to be careful not to take advantage of the amazing place their house is! I get to come in and sit down with lovely hibiscus iced tea and have an adult conversation while my kids disappear to go happily play!

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Caleb and Winnie outside the Perry’s house

I’m always worried about loud noises messing with how my kids sleep at night or nap. Our little guest house is right by the road and we do hear all kinds of sounds (from motorcycles to loud singing) but it hasn’t phased our kids a bit! Caleb has loved seeing all the motorcycles and bikes (he can’t tell the difference) and yells out “yoker-yiker” every time they go past . There are also mangos falling from the trees that sound like gun shots when they land on the metal roofs. It still makes TJ and I jump, but the kids have slept through it. Thankfully we were warned about that in orientation.

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Belly dust angels

The simplicity of playing in the dirt has grown on our children. Instead of being scared of walking barefoot, they are now making dust angels on their tummies. They enjoy making trails through the dust with little sticks and they don’t mind getting it all over their hair either…. The more they rub their dusty hands in their hair the better!

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Caleb giving new meaning to the term “dirty blonde hair”

Anyway, we are still loving it here. Tomorrow I get to work at the hospital while TJ manages the kids.

Birthdays and Conversations

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Headed to the Pyatt with Alex

The days do blur together just a bit. It feels like we have already been here for so long and only a week has passed! What a full week. I am enjoying this quick chance to blog and get some thoughts typed out during nap time. This post might ramble on, I’m afraid. Each day has held some new adventures, but despite the newness, we are feeling right at home here on the compound.

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All our shoes outside the Pyatt during meal time

The kids run around with more and more courage and have figured out the routines like: shoes come off at the door, hands are washed before we eat, and we walk AROUND the big piles of dried leaves and ashes (Black Mambas and King Cobras are a danger here and like to hide in the piles of leaves). Leaf burning is for snake control as well as standard ground maintenance.

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The area behind the hospital. AKA snake territory

On the subject of snakes, I was walking to the hospital by myself one of our first days here. I had just had a tour and been warned about the ongoing battle to hunt out and kill this cobra who lived between the Perry’s house and the hospital. I don’t have a skirt with a pocket so I just had my cell phone tucked into my waistband. It slipped out without me realizing it and dropped to the ground behind me onto a few leaves. I wish I could have seen how high I jumped! I didn’t scream, to my credit, but I was pretty sure it was that cobra right behind me!

Wednesday was crazy and I want to get more details from Elizabeth and blog about that separately. Power outage, no water, the looming possibility of having to med evac the hospital and emergently flying in an engineer to fix the solar generator only begins to cover it.

Thursday was Olivia Perry’s 11th birthday. We had a grand celebration that started out with a stroller walk (wearing Caleb on my back and pushing Aubrey) with the younger four Perrys as our guides. We walked out of the compound for the first time and our walk turned into a flower picking extravaganza and then bouquet arranging fun.

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Olivia’s the curly blond one

After lunch, all squished together on one couch at our house, we had a viewing of the newest Cinderella movie, while my kids napped. Oh and we ate homemade doughnuts (the best I have ever eaten. I think I will dream about those doughnuts!) that Olivia had requested instead of cake.

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Drilling through the roof to mount the basket ball hoop
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Caleb and Aubrey adore their trampoline time!

That evening after supper we had an epic story time on their trampoline while the men attached their Christmas present basketball hoop to their roof. Around 8pm, Katharine (a long term missionary nurse here from New Zealand) came to ask if I would be willing to donate blood. When we had first arrived, Jeff and the nurses were excited to hear I had O negative blood (along with one other person here) and had planned on me donating at some point towards the end of our stay. Jeff said, “God sent us two short termers with O neg blood; I’m expecting to need it.” What a great feeling to be so useful!

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Donating blood

That night a woman five days out from a home delivery came in very pale and weak with a hgb of 2.9 (if the reading was even accurate with such a low blood volume). Her blood type was A neg. So TJ put the kids to bed that night and I walked with Elizabeth to the hospital to have my type and cross done. Then I donated blood just like I would in America…only on a hot African night with a single light bulb lighting a small concrete room with a fan to cool us off. Then Innocent (the lab tech) carried my blood off and they immediately began infusing it into a dying woman with her five day old infant in her arms.

Elizabeth and I talked without interruption, sitting in that little room, about marriage, parenting and serving God. She shared with me the painful journey they had just two years ago when Jeff lost his vision in one eye (after many corrective surgeries) and they almost lost their then 4 year old daughter Winnie to a rare form of Typhoid. My eyes filled with tears as she told me about the morning when Winnie turned the corner and the meds finally began helping, and as she was holding her little girl she heard the death wail at the hospital of a mother whose child had not recovered. She told me she wondered, why did God spare mine? And what else does the Lord have for me in this sanctification process? These are big thoughts for this mommy’s heart. Death and disease are so real here. And missionaries are not promised to be an exception. I am so thankful for the hard conversations. I am thankful I serve a God who did not spare His own son. It was a beautiful day.

 

Same-Same, But Different

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I’ve been using EPIC since 2008. EPIC is sort of the benchmark for electronic medical records, and eventually most major hospital systems will be using it or one of a few competitors. We had it at University of Colorado Hospital, Denver Children’s, and Saint Joseph Exempla, where I did the majority of my rotations in med school. We have it at Hillcrest and Providence hospitals in Waco. Only larger hospitals and clinic systems can afford it, but Waco Family Health Center was a beta test site for them years and years ago, so we even have it in our clinic. I think being proficient in EPIC bolstered my chances of matching in Waco a good bit, and it was a huge help adapting to intern year, which is challenging enough without having to learn an entirely new system.

I was surprised to discover that we don’t have EPIC at Bet Eman His House of Hope Hospital in Yei, South Sudan. I’m sure they are probably planning to transition to it, but the GoLive can take a while to plan and prepare for… and they’ll probably need some computers first. The medical records system here is different. There are pre-printed lab slips, and official hospital forms for tracking vital signs, meds, and H&P’s. Pretty much everything else is recorded in small notebooks that the patients keep with them; in fact, they keep almost all the medical records, except for the carbon copies of the op reports and discharge summaries, which we retain in the office. This is a pretty common system throughout Africa, but let that sink in for a moment; can you imagine if we were expected to keep up with ALL our own medical records in the U.S.? My patients (and myself, if not for Katie) just wouldn’t have records; we’d start from scratch with each new visit. (I will say though, the yellow card system they use for tracking pregnancy is remarkably similar to the purple cards we use at FHC. Not sure what to make of that).

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Radiology

You get used to a new system quickly. The first day I couldn’t even find any of my patients, and not knowing anyone’s name I just had to ask someone with a hospital ID, “Could you show me the patient who was 34 weeks with the preterm contractions?” (silence). “She’s the one with the large spleen that we are treating for malaria and typhoid.” (silence). “I think she was wearing green…” and on like that until they figured out who I was talking about or I gave up and asked someone else. After 3 days, I know the system well enough to find patients on my own, and at the bedside I can just take their green notebook and read the most recent notes (the documentation is in English, but the handwritten notes are often illegible and don’t contain much helpful information. So it’s the same as in the U.S.).

After just 3 days, I’m having to fight my annoyance with the CO’s when they present patients by reading from the green notebook instead of actually knowing the information. If you’ve ever taught med students or interns, you might be thinking, “how is that different from presenting by reading the notes from your iphone instead of actually knowing the patients?” It’s not; I get annoyed when my interns do that too (and hypocritically pretend like that’s not exactly what I did all through med school and intern year).

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The OB Call Room. I’ve seen a lot worse (ahem, Denver Health)

His House of Hope was not founded as a ‘Westerners do everything’ mission hospital; they are all about training South Sudanese doctors, midwives and nurses, and the greatest hope is for the missionary doctors and nurses to one day be obsolete. My role this month is as a sort of senior resident, rounding with, supervising and teaching the CO’s, or Clinical Officers (residents in the U.S. used to be called House Officers). The CO’s are hard to characterize; they’ve finished medical school and are now fully able to practice, but in the context of the hospital they function like residents, and experience wise the newer ones are more like 3rd year med students, just now starting to gain clinical experience.  Thinking of them in this context, they are really quite impressive. They are eager to learn and soak up knowledge. I left one of my OB/GYN reference books in the call room and returned to find my two CO’s, Kochoro and Moses, reading through and discussing it. What is this place?

I’m on OB this week. I’ll write again and share more about antenatal clinic, rounding on the maternity ward, deliveries and especially the OR. In the meantime, Katie had a big day yesterday and I’m looking forward to her writing about those experiences. Thank you for continuing to pray for us and our patients here in Yei.