Wednesday, March 23, 2016

A Tale of Two Stomachs


 “Drag your thoughts away from your troubles...by the ears, by the heels, or any other way you can manage it.”  ― Mark Twain


A/N: As usual, these patient scenarios are composites of my experiences. No one person is represented. As the movie disclaimers read: ‘Any similarity to any person living or dead is merely coincidental.’ The essence of the dilemma remains the same.

“Ohhh… doctor! My stomach!” the young woman cried clearly distressed as she moaned and rolled disturbingly close to the edge of the exam bed on which her generous body habitus nearly flowed off.  “My stomach is paining.” She clutched her abdomen to emphasise her point.

“Where is it paining you?” I asked as I tried to write a coherent history in her medical book at my desk, making observations as we spoke. I checked her vital signs; all were rock solid and normal. (She wasn’t dying at least.)

“All my stomach!” she groaned and winced as another wave of abdominal cramps overwhelmed her. “Owww…”

“Do you have any fevers?”

“No.”

“Any diarrhoea?”

“No.”

“Vomiting?”

“Any belches, pain when you pee, vaginal discharge?”

Essentially, in the end, she wasn’t having any problems except excruciating abdominal cramps. I stood up and went over to the examination table where she looked over at me with tear-brimmed eyes. “Please doctor, the pain is too much.”

I checked her eyes. Not pale. Good. She wasn’t having internal bleeding. A thorough palpation and auscultation of her ample belly did not reveal anything life threatening.

“But, doctor, the pain is too much.”

“We’ll give you some medicine for the pain and check for any infections,” I reassured her. “Your stomach pain will cool soon. Be patient just a little longer.”

She nodded.

In the interim while waiting for her malaria smear (standard on almost anyone in Africa) and typhoid test, she received a dose of IV Spasfon (an anti-spasmodic) medication to calm her cramping. When that wasn’t enough, we gave her a second injection of Novalgin IM, basically an injection form of a drug in the category of NSAID (same category as ibuprofen). My nurses took her over to the hospital where she gradually calmed down on one of our unoccupied patient beds.

This wasn’t the first time that Ms H had come to the hospital with the problem of acute abdominal pains. The first time she’d come, one nurse took me covertly aside. “Doctor, Ms H has been having this kind of pain in her stomach for a long time. Her mind ‘de over worry’.”

“So what usually happens?” I queried, curious to hear what my predecessor had done in the past. Had the former physician done a work up on her to find any signs of celiac disease or an inherited autoimmune inflammatory bowel disease or gallbladder stones, pancreatitis, diverticulitis, kidney stones, pelvic infections, dysmenorrhoea, endometriosis, giardia, amoebas, etc. After all, the list of diseases that might cause abdominal pain in a young woman is infinite.

“She usually just checked a few labs and gave her tablets for pain,” my nurse explained with a shrug.

“So she never figured out what was causing her stomach pain?” I hoped perhaps she might have come up with a diagnosis.

“No,  she just gets better after a few days.”

“Ok. I think I am getting you,” I frowned. I was still a little confused but marginally reassured that Ms H has survived similar attacks in the past without any apparent long-term detrimental effects. I moved forward with my treatment plan.

There are a limited number of tests one can do in a mission hospital, especially on a woman with limited financial resources. Certainly she couldn’t afford to see a specialist in the big city of Douala. She didn’t seem to be in such serious condition as to necessitate a CT scan of her stomach. And the value of an X ray  to diagnose her problem was questionable enough to tip the balance in favour of cost outweighing benefit.

In the end I checked the malaria and stool analysis. We did a rapid blood test for typhoid.

“It looks like you have a little infection in your stool,” I sat down next to her at her bedside in the hospital where she was resting much more comfortably. After a few hours of spasmodic abdominal pain, she could smile. The nurses had found her clean hospital sheets and she was resting comfortably.

“I can’t say exactly what infection might be going on, but there are some white blood cells in your stool that could mean you have an infection.”

She nodded.

“We’ll give you some ORS (oral rehydration salts) with zinc and ciprofloxacin along with some more anti spasmodic medication and paracetamol to help with the pain. You’ll be ok in a few days.”

I smiled at her. Part of medicine is letting the body heal itself. In this case, I wasn’t sure the antibiotic was essential but given the inflammatory white blood cells in her stool, it might help.  The odds of an infectious form of diarrhoea is high in Africa where sanitation is less than ideal sometimes. The good news was that her symptoms were improving.

She would get better – of that I was certain. Time was my biggest alley. Her labs and my physical exam assured me she wasn’t dying. With a little magical ‘tincture of time’ she would soon be back to normal.

Ms H gave me a tired smile. “Thank you so much, doctor.”

“You’re welcome. Just be patient, you’ll be fine.”

As Ms H gathered up her things and headed home from the clinic the following morning, she saw me and rushed over. “Doctor, thank you!” She hugged me and then as a parting gesture, she placed her hand on my shoulder and gazed into my eyes, “God will bless you,” she earnestly bestowed this tender and honoured gift upon me and the ministry.

A warm glow filled me.  I had contributed very little and yet her gratitude was immense.

******

And so, it was with a sinking feeling that some time later I saw Ms H sitting disconsolate in the waiting area of our clinic.

“It’s paining again, doctor,” she cried. “I’m sure something else is wrong inside my stomach. Can’t you do an echo (ultrasound) and look?”

“But an echo won’t show everything that could be wrong?” I explained.

“There might be something though. My stomach keeps paining. Can’t we make sure everything is ok?”

Perhaps it was the curly eyelashes and liquid brown of her pleading eyes, or perhaps I was feeling a bit more generous than usual that day, I’m not sure, but, in the end, I caved to her pleas. “You’ll have to wait until I finish seeing the other patients, then we’ll do a little echo, ok?” I bargained with her.

“No problem. I’ll wait,” she eagerly promised.

She spent the next six hours waiting in our hospital compound, chatting with my nurses and other patients, while I continued my day-to-day consultations. At last there was a break in the flow, “Come on back, Ms H, we’ll check your stomach.”

“Everything looks ok,” I cheerfully proclaimed as she watched anxiously at the moving grainy black and white pictures on the ultrasound machine.

“Then why do I keep having this pain?” she sat up and dressed.

“Well, there are many reasons for the pain that don’t show up on the ultrasound.” I helped her down from the exam table. “The inflammation can take time to clear up completely in your stomach and the pain to cool completely? You’ll be ok. We’ve made sure there is nothing else that we need to treat.”

“Ok, doctor. Thank you so much for checking. God bless you. You are so kind.”

“Just remember, try to relax your mind and not worry. You’ll get better soon.” With much reassurance from me, reinforced by our nurses, she eventually went home.

Over the following week, the local community visited Ms H and comforted her with a plethora of ‘ashias’ and distracting company. She unburdened her troubles through countless conversations with her friends. Although she lacked family support, neighbours and church members stepped in as her surrogate family and talked her through her panic over the future.

A few weeks later, I ran into Ms H at the market. “How are you?”

“I’m fine, doctor,” she smiled. “It wasn’t easy. I really suffered.” She shook her head at the memory. “But, now I’m fine.”

“Praise the Lord.”

“Oh yes!” she agreed with enthusiasm. “Without Him I couldn’t have survived. God is good.”

“Amen.”
 *********
Ms H would go on to have other attacks of her mysterious stomach pains. The attacks had a habit of occurring during times when there were increased stressors in her life – worries over finances,  schooling, or children. Each time she came to visit us, she received compassionate care. She found a hospital where nurses prayed with her and gave her prompt attention. Although I doubt we will ever find an organic reason for her pains, we do a standard examination of her with a physical and basic labs to ensure nothing out of the ordinary is suddenly attacking her body each time.

Friends often pray with her and come and sit with her at home when she has these pains that typically last a few days. Eventually they always go away – probably more due to her own body’s inherit healing rather than any medications we administer. She’s always grateful and later comes with fruit or vegetables to share with hospital staff. My predecessor was correct in her diagnosis of her abdominal pains: ‘over-worry’. 
 *********************

Stomach 2 (Ms T)

Ms T was a 20 something year old female who came in with her stepmother. She gave me a fleeting soft smile that could immediately put the most anxious at ease. Clear blue eyes shown out from under a mass of unruly red hair. Outside of being having a high BMI, she appeared healthy. That is, until one opened her medical chart!

Pages and pages of doctor visits, blood tests, procedures, tests, and even surgery. She was barely 20. How could someone so young already have such a medical saga?

I sat down across from Ms T.

“What can I do for you today?” I began our interview.

“It’s my stomach,” she answered flatly.

“Oh?” I left my sentence open for her to elaborate.

“Pain.”

“Ok?” I tried to give her free rein to continue her narrative.

She sat silent in the chair in the exam room. I wasn’t sure what to do. I looked over the list of various problems in her medical chart and felt mildly overwhelmed. What was wrong with this young lady with such a complicated medical history? Perhaps I was not the right doctor for her. Why wasn’t she seeing her specialists?

“Why don’t you give me a little recap about your stomach pain since this is the first time we’ve met?” I encouraged.

“Well, I’ve been having pain in my stomach and it’s still there.”

“OK. How long have you been having this stomach pain?” I decided to be a little more directive in my queries.

“Years.”

“More than five years or ten years? Can you be a little more specific?”

“Since I was in school,” she shrugged without emotion. “No one can seem to figure out what’s wrong.”

“Oh? So you’ve had a lot of tests already? Have they found out anything?” I attempted to ascertain what her own understanding of her medical condition was.

“Well, first they said it was stomach ulcers but the medicine didn’t do anything.”

I nodded, listening. “And what else?” I prompted after she fell silent.

“Well, then they said it was Celiac and put me on a gluten free diet but that didn’t really help.”

“OK,” I still wanted her to continue her narrative.

“Then they said I had asthma.”

That explained the inhaler prescriptions in her chart.

“But they didn’t do anything either.”

“I see you’ve also been diagnosed with depression too,” I prodded.

“Oh yeah, they keep telling me I’m depressed but the drugs they give me don’t do anything,” she answered. From her lack of interest in her health, I did wonder if this might have been more accurate than she gave it credit.

As we went through the litany of various diagnoses that she’d been labelled with such as depression, anxiety, cholecystitis, pancreatitis, acid reflux, peptic ulcers, gastritis, gluten sensitivity, asthma, angina, irritable bowel, chronic pelvic pain, etc. I could sense an aura of fatalistic opposition. Ms T expressed a confusing puddle of passive victimization. She had a mysterious ailment of her stomach that doctors couldn’t figure out. When she mentioned the complementary and alternative providers that she’d been to see, I began to wonder what I was going to contribute. In my few minutes allotted to our interview, what would I discover that so many before me had failed to address? She gave the impression of having lost all faith in the medical community. I wondered what she hoped to gain by her office visit today.

“It looks like you’ve had a pretty thorough work up for you problem,” I commented. “Colonoscopy…”

“Yeah, that was no fun,” she muttered.

“Endoscopy (tube down the throat). Rheumatology work up (lots of blood tests). Electrocardiogram. (lots of wires) CT scans (lots of IV sticks and scary machines)… Quite a lot of tests.” I turned to her. “And you had your gallbladder out too?”

She nodded to the affirmative. “It didn’t help though.”

I looked at Ms T. Really, there was nothing left for me to investigate. Every conceivable test had been done. Already she’d been exposed to enough risks associated with invasive procedures, anaesthesia, and surgery, and radiation. Her chart was riddled with a long list of problems from psychological to biological but way too many for one patient just barely out of high school. Every time a medical professional opened her chart, he or she would be inundated with a mountain of extraneous labs, procedures, and specialist reports without really understanding the true issues or the person underneath the burden of medical reports.

“Why don’t you describe for me, in your own words, all about your stomach pain? How it began? What it feels like? What makes it better or worse? How you’ve treated it in the past? That kind of thing,” I rewound her story and decided to let her start the slate clean. I prayed for wisdom.

She blinked and stared at me for a few moments. Finally she shrugged and in her characteristic monotone that I’d started to get used to told me the details I needed for my history. It was not as complicated as I was afraid of at first. In fact, her history was rather similar to another young female patient – a Ms H.

As I reassured myself that I was not missing anything life threatening with a thorough physical exam, I inquired into her own understanding of her illness. “Is there anything you’re particularly afraid you might have? Something you are concerned that could be wrong? You’ve had a very comprehensive work up for all the dangerous things that could be wrong,” I reassured. “But perhaps there’s something that you’ve read about or heard on TV that you’re concerned about?”

Ms T sat up and thought for a few moments. She shook her head no and shrugged. “Not really.” she leaned back in her chair as if challenging me to come up with a new diagnosis for her to defy. Another label for her symptoms, another pill for her to proclaim useless, another reason to distrust the medical professional community.

“Ok.” I sat and gave her some time to think. I didn’t have a new label for her. She’d been labelled with everything already. I was at a loss of what else to do for her. I typed out the history she’d given me in the computer while she sat with her arms crossed, watching me tap away on the computer keys.

Mid keystroke, she decided to speak up. “Doctor, do you think this could be due to panic attacks?”

“It’s possible,” I answered hesitantly. “Why do you ask?”

“Well, I always get them when I’m stressed out, like when I have a deadline at work to meet.”

“Why don’t we have you keep a diary of when your stomach pains occur and see if we can correlate them to certain stressors?” She agreed to our plan.

At the end, she left with a promise to reinvestigate what stressors might be triggering her pain along with a refill of a mild anti spasmodic to use at times when her pains were particularly interfering with her ability to work.
***********************

So now I sit back and reflect on the contrasts between these two young women with stomach pains. Similar situations in regards to life transitions and stress but different countries and different cultures. Both boiled down to stress-induced stomach cramps or ‘over-worry’.

Ms H had multiple doctor visits, stool tests, and one ultrasound. She recovered with a tincture of time and community support after each attack. She was an honoured member of society and went about her business between attacks. She knew most of our staff at the hospital and was always welcomed when she needed treatment. She made her own decisions and was content with the treatment given.

Ms T, in a similar fashion, had multiple doctor visits and stool tests. She also had multiple specialist consults, invasive diagnostic procedures, radiation-filled imaging, blood draws, and dietary restrictions. She is dependant on the charity of friends and family for housing. She distrusts the medical community and yet remains apathetic regarding decisions about her health. The real person, that disarming blue-eyed lady with a kind soul, is lost under a mountainous medical record. She is unhappy with her medical care and hopes that one day she’ll find the magic doctor or test that will diagnose her pain and alleviate it forever.

Is there a moral to this comparison? You choose. I simply make the observations.


Wednesday, March 9, 2016

Reflections on the Past and International Women’s Day



“Does the walker choose the path, or the path the walker?”   ~ Garth Nix

Technically, I should have written this about 3 ½ months ago, my one-year anniversary from starting a new job in the U.S. after completing a 5 year mission term at Buea 7th day Adventist Health Centre in Cameroon.

One year would have been December 15, 2015.  That date was a day overflowing with memories. Good memories from Cameroon but paralysing fears regarding the future. 

I used to have goals to work toward. There was always something in the future that infused meaning into the present labour.  There was a confidence that the present trouble was a stepping-stone for reaching higher and better accomplishments.

And now?

Now I wonder if the past five years in Cameroon were the pinnacle? Will my identity culminate with living overseas for five years? Was service in Cameroon my destiny? Is there anything left for the future?

The Pacific North western culture is different. The art of medicine is different here as well. I haven’t seen a single case of malaria. There’s been only a small handful of cases of traveller’s diarrhoea, none of which were Typhoid.  A typical clinic visit might be exemplified by Ms Ariel:

Ms Ariel is a hybrid that represents a commonly encountered scenario that occurs on a daily basis in my office. In the interest of privacy, I have created an amalgamation that preserves the essence of my work in American healthcare but doesn’t identify any personal details of one individual.

I knock on the patient’s door.

“Come in,” she answers absently from the chair she’s seated in scrolling through her Face book alerts on her iPhone.

As I seat myself on the stool in the room and log into her electronic medical record on the computer, she eventually tucks her phone away in her purse and turns to face me.

“Cool hair,” I comment on her recently dyed tri-coloured hair, transitioning from royal blue to aqua turquoise. It is eye-catching and somehow seems to fit with her multiple body piercings that compliment her tie-dye skirt and tall leather boots.

“Thanks,” she smiles.

“Did you dye it yourself?”

“No, my friend wanted to practice,” she shakes her head. “She’s going to cosmetology school.”

Now that I have her attention, I glance down at the paper in my hands on which my medical assistant has written the main concern today, “palpitations”. The paper also reminds me to ask Ms Ariel to schedule her pap smear and get her flu shot while also filling out the questionnaires to screen for alcohol abuse and depression.

“Yea, in the past few weeks I keep feeling like my heart is going to jump out of my chest,” Ms Ariel begins. “I feel like I can’t breath sometimes.  I can feel my heart flip flopping like a fish inside my chest, especially when I’m in bed trying to sleep.” She stops.

“Anything else you notice with these feelings of your heart beating too fast?” I prod. “Other symptoms that seem to be associated or bring them on? Did anything change in your life recently before these palpations began?”

“I get headaches sometimes,” she replies. Her iPhone rings and she reaches over to retrieve it and turn off the ringer.

I wait. “Is there more stress in your life recently? Have you ever had these palpitations in the past?

“I recently started a second job at the service centre,” she remembers. “My boyfriend and I broke up after that. I haven’t been sleeping well either. And, that’s another thing I wanted to mention, doctor,” she looks at me. “I need something to help me sleep at night. I can’t fall asleep until after midnight and then I wake up after a couple hours. My friend gave me one of her sleeping pills and it helped. I want to see if you can give me a prescription today.”

I nod in recognition of her change in topic. “And has your lack of sleep made your palpitations worse?” I try to steer her back to her original reason for consulting.

“Yes, I think so,” she answers after a pause. “I had palpitations before when I was a teenager, I think,” she continues. “The doctor gave me some kind of medication and eventually they went away. I stopped taking the medicine. I don’t remember what it was now.”

“Have you ever fainted during these spells? How long do they typically last? Do they just go away on their own eventually?” I attempt to garner more information to assess the severity of her palpitations.

“No, I have never passed out,” she answers, “except for that one time when I was really sick with some GI virus and I was vomiting and having diarrhoea. I was headed to the bathroom when all of a sudden the next thing I knew I was on the bathroom floor. I couldn’t remember how I got there. My mom says I fainted. I don’t know how long I was out. Probably only a few minutes. I guess I was sicker than I thought. I was also feeling dizzy at that time too…”

I take a deep breath and interrupt her meanderings to direct her back to our original problem. “So what do you think is going on with your palpitations? Do you think they might be related to the recent stressors in your life?”

“Probably,” she answers after a thoughtful pause. “They don’t really bother me except that one time when I was at work and my boss had just brought me back to tell me I needed to meet certain deadlines. She was upset and it made me upset and then I started having a panic attack and I couldn’t breath and the room was going all dark and my heart was beating too fast. I actually had to take the rest of the day off, doctor.” She looked at me for a moment then continued. “Usually these episodes I feel now go away in a few minutes. Really I haven’t tried anything for them because they’re not that much of a bother. I know I can be a bit of a hypochondriac about my health but I just don’t want things to get worse, you see.”

I nod while she continues her monologue.

“Honestly, I think the palpitations will go away on their own. I don’t think they’re really dangerous, do you doctor?” Without waiting for a reply she continues, “Anyway, I don’t want to take any medication. I don’t like having to be dependant on a pill every day. Maybe you could just write me a prescription for that sleeping medication that my friend let me try? That way I could use it as needed when I can’t sleep. I tried melatonin already and then my naturopath suggested some teas and meditation techniques but really, they’re not the same as taking that pill when I really just need to knock myself out.”

Attempting to reorient myself to her new concern, I answer. “So, you think your palpitations are related to more stress and not sleeping. And, if you can sleep, you feel your palpitations will go away?”

Ms Ariel nods and taps a reply on her phone. “My friend just texted me the medication name, “She says it’s called lor-az-e-pam. I’m sorry if I didn’t pronounce it correctly.”

“You did fine,” I reassure her. “I understood the name.”

“And what kind of things do you think will help you manage your stress better so you can avoid the heart palpitations, the panic attacks, and the sleeping pills?” I query as we negotiate the safety concerns of a benzodiazepine.

Ms Ariel shrugs. “I don’t know.

“Would you be interested in talking with a counsellor to learn some strategies for handling stress better?”

“I don’t think I have time, doctor.”

“I’ll give you some things you can practise at home with deep breathing and progressive muscle relaxation,” I add with a resigned nod regarding her thoughts on stress management. “You might also find yoga helpful. It’s good for the brain and your muscles, particularly your core back muscles. It could help the lower back pain you’ve had before.”

“Oh, that’s another thing I wanted to ask you,” Ms Ariel suddenly remembers as I type my orders into the medical record and complete her printed visit summary. “Can I have another referral to my chiropractor? I’ve been having pain in my neck recently.”

Already past our appointed time, I sign back into her electronic records and we go through the requirements of a chiropractic referral.

As I type in the orders and fill in the allotted questions, Ms Ariel watches. Suddenly she blurts out, “You know, I think I might have ADHD. I can never remember anything and I can’t seem to concentrate at work. My boss is always reminding me to focus. I’m always forgetting something. I should probably be evaluated for it. I was thinking that I might be allergic to gluten too. Maybe I should get tested for that?”

I complete the entry for the chiropractic referral. “Let’s try to get you sleeping regularly and in a better place with stress levels, first. We can talk about your concerns with concentration and focus at your next visit, ok?”

As I finish typing her note in my office at the end of the day, I sigh. Ms Ariel represents a multitude of relatively young, stressed-out, women that I see every day. So many life stressors that affect their health in ways they can’t imagine, or are willing to admit. And there never seems to be enough coping skills and supportive relationships to help mitigate the affects of such stress.

From a physician’s perspective, it’s often less-than-satisfying to identify the problem and yet be unable to vanquish the problem. I cannot eliminate Ms Ariel’s stressful job. I cannot be that nurturing shoulder to cry on as she goes through the break-up with her boyfriend. I cannot find her a replacement boyfriend. I cannot force her to exercise, go to yoga class, practise deep breathing and relaxation techniques, eliminate caffeine and incessant texting, and choose healthier food options. A sleeping pill, even the less addicting option that we agreed upon today, is only a temporary patch for the real problem that keeps her awake at night. Her spinal pain will continue to plague her. I doubt she has clinical ADHD. She’s an intelligent, functioning women. She’s also distracted and under enormous stress without the time or relationship skills to cope.

I should have written this 3 ½ months ago. I was distracted and unprepared to cope though. I have a tough time concentrating and focusing. I have difficulty finishing tasks and find it impossible to sit down and actually type a complete thought. Perhaps I have adult ADHD? Haha. Perhaps I just need to turn off my technology and take a real holiday.

Happy International Women’s Day!!! (March 8)


Sunday, August 9, 2015

The Mundane Into The Glorious



Author’s Note:
I want to express my sincerest gratitude to those of you who read along with my blog stories and musings. I am often encouraged by the replies that I receive. Your comments serve to reinforce and further bless me in my own spiritual convictions.

Emily has been kind enough to allow me to share an excerpt from an email with me relating how our day-to-day humble service is important. The work that we might be tempted to consider dull or inconsequential or trivial is sacred

(*As usual: names, locations, identifying data have been altered)

Email Excerpt:

“Our small, insignificant mundane acts can still be sacred acts to God. Perhaps?"

Yes - definitely!

After my youngest started school, I was feeling a bit useless. I remember, after perhaps drinking a bit too much wine at home one time, bemoaning that I felt like a "waste of space".  I was missing the status of having a career and being needed 24/7 by small children. I didn't know what to do next with my life now that I was no longer “needed”.

Finally I got a job doing the bookkeeping in a little office next to a small joiners workshop with the wood dust and loud machines and loud blokes hollering and swearing. It felt like a big step down from what I was used to do, but the hours were convenient so I took the job, working for a lovely lady called Helen (*). The record books were in a terrible mess at the workshop. Helen hadn't balanced the bank accounts in over a year and I wondered how she could continue to operate. I slowly starting unpicking the figures and bringing things up to date.

So I worked at the joiners two days a week and spent the rest of the time helping my friend Miriam dig her garden allotment and chatting to my neighbour, Sandra, over her fence.

One week I sat in church and asked God what I was supposed to be doing. I asked Him what He saw in me and what was my purpose in life. The vicar was talking, but I wasn't really listening. I just stared at the pale figure of Christ in the stained glass.

Suddenly a question popped up. "Can you be a servant?" The question seemed to come from the stained-glass window I was staring at.

"But I don't want to be a servant,” I replied, without thinking it was just a little strange to be having a conversation with a stained glass window.

Then I remembered the words in the Methodist Covenant Prayer: Let me be employed for thee or laid aside for thee, exalted for thee or brought low for thee.

As I sat staring at the figure of Christ in the stained glass, I began to realise that the reason Helen hadn't been looking after the bank accounts for her workshop was that she was so busy attending to the needs of a sickly friend. Helen was unable to manage the accounts because she was spending her time, instead, taking her friend with cancer to chemotherapy appointments and looking after her friend’s children.  But now Helen had a bookkeeper (me). Now she could continue to care for her cancer friend without worrying over her business affairs. My humble tallying of mathematical figures in the joiner’s business accounts was a worthy occupation and was necessary for the smooth running of the business but also blessed others in ways I did not initially realise. Helen had peace of mind and her sick cancer friend benefited through my careful booking efforts as well. My “insignificant” efforts in balancing the business books blessed others in ways I never imagined.

As I let that first realisation sink into my consciousness, a second awareness dawned. Miriam, the neighbour that I helped dig in her garden, actually spent those long hours cultivating her allotment because it took her mind off a series of miscarriages. I couldn't fix these, but I could relate, and I could sit out in the sun and the rain with her while she grieved. To ‘weep with those who weep’ was an act of love that was within my capacity to give Miriam.

And then, as I continued to sit in church and absorb the full impact of this second act, a third thought struck me. (It was becoming a very fruitful ‘conversation’ with a stained-glass window).  I realised that the reason Sandra sat out in her garden by her fence, hour after hour, was that she was lonely. Her husband had recently died leaving her all alone but she was reluctant to go and knock on anyone's door for fear of being an "imposition". Instead she sat outside by her fence, hoping for someone to come by and talk with her. I couldn't fix the death of Sandra’s husband but I could listen and chat with her.

So, there I was in church, still staring at the pale figure of Christ in the glass window without listening to the Vicar’s message but hearing a message from God nonetheless. I’d been thinking about Solomon in the Bible when he built the temple mentioned in Chronicles. It took thirteen years with the craftsman having to make all sorts of paraphernalia out of wood and metal. Their work must have been quite boring and tedious, detailed workmanship to create such intricate temple ornaments according to the tight specifications. (In fact, just reading the story in Chronicles is rather mind numbing and a good treatment for insomnia!) Perhaps the craftsmen as they carved out yet another silver embellishment wondered why they were doing it; but, God honoured their work. When all was finished, His glory descended upon the temple and it was, well, glorious. So, too, God was being honoured by my own faithfulness to the small acts of day-to-day service opportunities. I was like the craftsmen in Chronicles with my attention to the details of my accounting, my digging, and my chatting. They were important sacred acts of loving service to God. The mundane made glorious in Christ.


“That our sanctification did not depend upon changing our works, but in doing that for GOD’s sake, which we commonly do for our own. …That the most excellent method he had found of going to GOD, was that of doing our common business without any view of pleasing men, and (as far as we are capable) purely for the love of GOD.”
― Brother Lawrence, The Practice of the Presence of God


Saturday, July 25, 2015

Don't Welcome Me Back Home

Photo: Natasha Kanji 2011
A/N: Thoughts after attending the Institute of World Mission Welcome Home Family Re-entry Seminar 2015. I'd rather have a mission than welcome home accolades. 

Don’t Welcome Me Back Home

“My desire is to depart ... But to remain in the flesh is more necessary .... Convinced of this, I know that I will remain and continue with you all, for your progress and joy in the faith, so that in me you may have ample cause to glory in Christ Jesus, because of my coming to you again…”
Philippians 1:24-26

I don’t want your welcome back greetings.

Please don’t think me ungrateful. Obviously, I won’t tell you to stop since I know you mean well. Your motives are pure.

But the greeting is erroneous. I am not  back home. Not by my definition of ‘home’ anyway.  Home doesn’t represent a permanent place on earth for me. Yes, there are pockets of space where I am best adapted, places I feel safe and abide within a relatively congenial community. These locations are familiar to me. They are a domicile where I sleep and eat my meals and where I am most relaxed and at ease. But they are not home. Instead, my heart yearns for a deeper home.

As C.S. Lewis so eloquently penned in the following quote:
“If we find ourselves with a desire that nothing in this world can satisfy, the most probable explanation is that we were made for another world.”      ― C.S. Lewis

Living for any significant period in another country, another culture changes you. Whether you were an accountant, a nurse, or a pastor, you cannot leave without permanent scars. The simple act of surviving in a foreign environment spoils naïve ideas about a cohesive, simplistic worldview.  The world is a messy place to live where chaos thrives. Submerged under the colours of a strange and different culture, you emerge with multicoloured lenses. Unlike real glasses though, you can’t remove them. There is no returning to your virgin views.

Even as your heart aches for home, a permanent resting place, travelling around the world proves there is no place completely safe, completely perfect. Heaven is not yet; it is still a hope; your heart’s anticipated future. You may have citizenship in your passport country but real homage belongs to the Lord of heaven and earth. We are citizens of another world as Paul outlines in Philippians chapter 1, verse 20: “…But our citizenship is in heaven, and from it we await a Saviour, the Lord Jesus Christ…”

And so… I remind you, there’s no need to welcome me back home. No adulations, please. Don’t put me on a pestle and treat me like a hero. Don’t try to reacclimatise me to a life of mundane mediocrity with wrappings of cultural adaptation. Instead, remind me that there is a reason for reverse culture shock.  Acknowledge that there’s a basis for why I don’t feel at home. Tell me there is value in my brokenness. Comfort me with words that give meaning to the bleeding of my wounds.

Don’t tell me everything will be ok.
Don’t tell me to ‘give it time’.

Instead, remind me I’m part of a bigger picture. These tears that flow without warning from deep recesses of my soul are reminders that the process of homecoming isn’t finished. The grand universal cosmic conflict is still ongoing and I have a part to play in it.  The epic isn’t complete. The novel hasn’t come to the last page.

When I am overwhelmed by yet another teary-eyed patient in my office with problems beyond medical solutions, remind me that I’m still God’s hands to comfort the suffering.  

When the sun has set and I’m putting in prescription renewals and answering messages while completing a hectic days worth of charting, all the while tired and hungry because I’ve missed lunch and now supper, tell me that the sacrifice is worth it.

When I fear I cannot face another unsatisfied patient seeking easy fixes for unsolvable circumstances, remind me I’m an ambassador of love and not of miracles. And when he gets angry and storms out of the room because I suggest changes in diet and weight loss to ease his aching arthritic knees or bring his diabetes under control, remind me again that I can still love without expectation or reciprocity.

I don’t need a hero’s welcome home. I don’t want a hero’s welcome.
I want a hero’s mission.
Remind me I’m part of a higher calling. I’m still part of a mission. I still have a job to do on this earth to represent Christ’s love to those I come in contact with each day.

Remind me that my mission service is not over. I am not coming home. I survived five years in Cameroon as a naïve and inexperienced physician. Through threats, thefts, fire, and tragedies, I survived and came through changed for the better. When I am tempted to forget, remind me of those valuable lessons I learned through people management, administrative duties, intercultural communication, adaptation, and flexibility. I am stronger than before. I survived adversities and adulations in Cameroon. Surely I can endure the challenges of today.

When I sigh and complain that home is tedious and dull, don’t tell me to appreciate my blessed abode. . Instead, remind me that I’m not home. I remain God’s ambassador to the world, whether here or in Africa. He hasn’t called it quits on my mission yet. There is a purpose in the pain that imbues meaning in the suffering. I can accept the frustrations, disappointments, disillusionments, and fatigue when I remember that this isn’t the end. The mission continues.


“ All this is from God, who reconciled us to himself through Christ and gave us the ministry of reconciliation: that God was reconciling the world to himself in Christ, not counting people’s sins against them. And he has committed to us the message of reconciliation.  We are therefore Christ’s ambassadors, as though God were making his appeal through us.”

2 Corinthians 5: 18-20

Tuesday, June 23, 2015

Six Months and a Carpenter's Stethoscope


Disclaimer: Pardon the hiatus. I find I am out of practise with writing down stories of life and work. 

June 16, 2015


Yesterday marked the six-month anniversary of starting a new job in a very big, primary care clinic. More than sixty doctors, nurses, and physician assistants care for thousands of outpatient in the rapidly expanding urban medical complex where I work.

Did I mention it’s big? It’s a vast labyrinth of medical services. I often find myself feeling like the mouse-doc scuttling around in a medical maze and discovering a delightful piece of cheese tucked away in a hidden corner of the system.  I am constantly greeting new faces and finding new pieces of “cheese” within the clinic.

Although my work environment is a dramatic change since relocating to the Northwest there are many additional cultural differences to decipher: Church. Local community. Politics. Socials. It’s another foreign country, in a way. Portland is a ‘hipster’ city where food that is cooked without meat is no longer termed “empty”. Instead eating establishments proudly proclaim “gluten-free”, “vegan”, and “organic”.  Being a vegetarian is not on the extreme end of the spectrum. It’s more on the moderate end of a very broad spectrum of dietary preferences.  

The vast dietary spectrum of preferences if relatively an easy cultural adjustment – instead of green leaves floating in palm oil there is organic kale salad with alfalfa seeds and thistle milk or something along those lines. The bigger struggle for me has been to find a sense of belonging and assurance that I’m still ministering to others and leading a worthwhile life. I find it challenging to feel like I’m a part of a bigger picture. I have an inner, subconscious sense of losing an exclusive membership in a noble club. I find pieces of my heart sometimes shifting around uncomfortably like a loosened shingle, pulsating against the battering of life’s storms. One end is still fastened firmly to the practical, logical area of my brain and affirms that I’m still doctoring. I’m still performing a necessary service to those suffering and sick and in need. But a portion of my emotional, irrational subconscious wobbles with uncertainty and doubt when adversity and discouragement pour down in a deluge of negativity. I waffle at the fringes, constantly questioning myself:
Am I still serving God in a secular clinic?
Are my skills as a physician needed in a country with so many doctors?
Am I utilising my time appropriately seeing so few patients in comparison to Cameroon standards?
Without the external affirmations one receives as a missionary, can I believe in my calling here?
Do I believe in my heart that I’m currently where God wants me?
Do I believe He’s called me to such a large, institutionalised office to serve as His ambassador of love?

Lately I have found my creative writing energy sapped. I don’t find it easy to outline interesting and noteworthy aspects of my work. I am not involved in the same severity of life and death struggles that clawed at my work while in Cameroon.  I am surrounded by ailing people but of a different type. Sick but a different kind of sickness.

I discovered when I first met Mr AT that he had been having ankle pain for years. It had been worse lately with all the activity necessary in his new job as a construction worker. He’s already been appropriately treated with the anti-inflammatory medications (Aleve, Advil). He had an ankle brace. Work notes that dictate modified work activity had been written. Physical therapy had been offered although he couldn’t find the time to attend such therapy sessions due his demanding daytime job schedule.  

“What are you hoping to get out of your visit today?” I searched his face for a truthful explanation. I dreaded his answer though as I was pretty sure I knew what it was going to be.

“Well, doctor, I guess I was hoping maybe you could just fix things, make all the pain go away.” Mr AT laughed nervously and gave an apologetic shrug.

I return his laugh with an echoing helpless shrug. “I wish I had my magic wand and could fix all your problems. It sounds like you already know what you need to do to fix your ankle though. You’ve just told me that your ankle is fine on the weekend after you rest it.”

He nods.

I continue. “Either you need a new job, one that doesn’t involve all the heavy labour that you’re doing; or, you need a younger body, a new ankle. I’m not sure how to give you either of those though.”

Mr AT gave a rueful smile. He understood I couldn’t satisfy his wish to make all his problems disappear. I could listen. I could empathise. I could affirm him in what he already knew. But, I couldn’t cure him of chronic ankle pain. In the end, we agreed upon the imperfect solution of partially masking the pain with pain killers while he promised to try eating healthier and losing weight – two modifiers that were controllable unlike his job duties and taxing work schedule. It was a temporary patch and not completely satisfactory for either of us. I would have loved to have taken away his diseased ankle and vanquished his pain forever. However, such was not going to happen. It wasn’t even possible under the circumstances to enact physical therapy and a different job. Those were the long-term solutions he really needed for ankle healing. Such situations leave me feeling helpless and frustration. I wonder if this is really what God is asking from me: to temporarily placate people’s pain brought on by poor lifestyles and bad luck?

Work days in Cameroon could be long and emotionally challenging. A frenetic pace from 8 o’clock in the morning with staff worship until the last patient of the day was served. Some days were certainly busier than others. It was hard to quantify the hours spent in the hospital and clinic. Now my days are more regimented. No early morning doorbell signalling a hospital emergency or midnight obstetric summons. Four days a week I walk to work, closing the door behind me at 6:30 in the morning and generally wrapping up the last of my charting and phone messages by 6:30 at night. Long days but defined “off time” away from sick patients and clinic duties. No call except the occasional urgent care shifts. So why is it that I feel less productive overall? Why do I feel like I accomplish less outside work than when I lived and breathed hospital air in the same mission compound? I am still sorting out that answer. Twelve hour days, four times a week, should give me plenty of free time, right?

Perhaps part of the reason for my lassitude outside clinic is due to the emotional tragedies that siphon off energies previously used in other pursuits.

Madam T came in for anxiety and depression. It’s a very common problem in Portland. People are “weird” here but also rather prone to worry-laden depression.  As I sat down to listen to Madam T, the floodgates opened and she spilled out a story of woe rivalling Lemony Snicket’s [series of unfortunate events].  Reflective empathetic statements of compassion are appropriate in such times and yet incapable of dispelling the sad consequences. Life is unfair. I wished for a loving community safety net that I could toss her into for that moral support she needed. Does they exist in Portland? Are there communities that have the resources to help such sad souls in need of a friend? Traditional medicine is not designed to manage the intricacies of psychiatric depression and anxiety. It’s frustrating.

“I know I need to call the mental help line, I just don’t have the energy,” Madam T laments.

I nod. “I wish circumstances were different for you. If I could change them for you, I would.” I pass her the box of tissues so she can wipe her tears and blow her nose.

By the time we part with appointments scheduled to touch base again on the telephone, I find myself relieved to escape. The atmosphere is full of suffocating despair.  I feel for her but I don’t want to absorb all the misery and bitterness she carries. I rather doubt that I’ve done anything clinically to improve her health. I’m not sure if we’ve connected at a therapeutic emotional level either. She’s still shedding tears when I exit. Is this what God has planned for me? Are these the type of encounters He wants me to keep muddling through year after year?  My emotional fatigue level leaves a huge margin of doubt on the reasonable longevity of such a plan.

And so as six days have turned into six weeks and now six months since beginning my new job in Portland, I find that the saying is true: ‘the days are long but the years are short’. It’s hard to imagine that it’s been six months. It feels like forever and yet it feels like I’ve only just begun. I have so much still to learn.

I’m still a novice with most things at work.
I am still part of the “newbie” group of primary care providers.
I still haven’t found my place in the community.
I am still a stranger at church.
I am still finding those friends that you can just “pop on by for a drop of tea and encouraging hug”.
I am still searching for a small group to nourish my spiritual fellowship needs.
I am still learning how medical services like chiropractors, massage therapists, and acupuncture work.
I am still adjusting to all the naturopaths and alternative healers available.
I still have “I miss Cameroon” days
I still refrain from mentioning my time in Cameroon for fear of being forever labelled  “the doctor from Africa”
I still worry about losing my identity as a physician with a mission heart.
I still fight against the temptation of self-pity when I work long hours without the same affirmations that come from working internationally
I still have grey days of depression and self-doubt about the future
I still am figuring out what my calling in Portland is these days.

There are a lot of unknowns. In the midst of the unknowns I have hope. God has been a guide for me in the past; I have faith he will continue to mentor me here in Portland.

Jesus spent 30 years in Nazareth, first growing up as a boy and then working as a carpenter. He spent three years in active, public ministry. Thirty years sawing wood, carving wood, pounding wood, smoothing wood, and sweeping wood dust off the floor of his tiny shop. He could have been doing spectacular, crowd-pleasing miracles like curing world hunger, walking across oceans, raising whole cemeteries, and eradicating leprosy and blindness. He could have reached more people, ministered to more sick, done more impressive feats of glory, fed millions instead of thousands, if he’d left Nazareth at 20 years instead of 30 years of age. Was it really that important to craft another kitchen table, another oxen yoke, or carve that one-hundredth window frame? Jesus spent the majority of His ministry plodding along, a faithful carpenter with the lathe and the hammer in the mundane duties of life. Perhaps I’ve re-entered the proverbial carpenter shop? Crafting another wooden stool might be compared to reassuring another sniffling American that it’s a viral respiratory infection. Hanging out in the carpenter shop chatting to a few clients over the latest design in wooden ox yokes might be like sitting next to a tearful, depressed Portland hipster and offering encouragement and a box of tissues. Our small, insignificant mundane acts can still be sacred acts to God. Perhaps?


“That we ought not to be weary of doing little things for the love of God, who regards not the greatness of the work, but the love with which it is performed.”

― Brother Lawrence, The Practice of the Presence of God