Homeless

Jesus replied, “Foxes have dens and birds have nests, but the Son of Man has no place to lay his head.” Matthew 8:20

I’m tired.

I want to go home.

What home?

Oh, yeah, right, I’m homeless.

Jesus' comment to the potential recruit in Matthew has new meaning for me:

Over the past couple months, Bill and I have been dependent on other people’s charity. Now don’t get me wrong. I am deeply appreciative of the generous hospitality shown to us. It’s not easy inviting two people that you might not have seen for a few years, or at least a year, into one’s house and having them invade your privacy, disrupt your routine, and block your vehicle in the driveway. I am very much indebted to the wonderful welcome so many of our friends and family have shown us. In fact, I am so thankful that I am also struggling with guilt. Why am I so unsettled and tired of living from house to house when so much kindness has been floated my direction? I feel ungrateful.

I should be more thankful. Less unsettled. Less grumpy.

Guilt and loneliness has a way of sneaking up and rearing its sinister little tongue in my ear at the most inopportune moments. For example, driving down the speedway from Zion National Park to San Bernardino California after a fabulous camping trip. And when I say fabulous, I mean it was perfect. Great weather. Great company. Delicious food. Inspiring views of nature’s beauty. It was a flawless get-a-way. I couldn’t have asked for a more perfect adventure.

It’s over now. We’re driving away toward the smog of the L.A. West. We’ve packed up the little red Honda Fit once again. Although our clothes smell like campfire smoke and items might have “shifted” a bit making the piles in the back more ‘poofy’, everything is settled enough that one can view out the rear-view mirror. Our temporary tent shelter is cleaned and packed and now a distant memory. We are driving onward to another yet another temporary shelter.

Our yellow duffle bags contain most of our clothes. Our two backpacks contain the other essentials, like a laptop computer, documents, and electrical wires for charging the mobile phone and iPad. The camera and day planner are in my shoulder bag. Bill and I can carry all our necessities in two hands.  We don’t need much: deodorant, toothbrush, clean underwear, pyjamas, and a nail clipper. Our life on the road is pared down to the bare essentials. And yet, with all our comforts more than amply supplied, why do I feel so “homeless”? Like a vagrant or a gypsy?

How many more WiFi network passwords can our MacBook remember? McDonalds, Starbucks, Panara, and even Zion National Park have public Internet access now. I’ve used them all. The downside of daily changes in my IP address was that my Google account locked me out. It noticed "erratic usage patterns" in my account!

How many different ways of brewing coffee can we learn? Instant…Drip… Pods… Press… Fancy machines and not so fancy machines…

How many varieties of soaps and shampoos will our skin adapt to?

How quickly can our bodies adapt to the ever-changing time zones and schedules?

How many different brands of washing machines and dryers are available in the U.S. these days? The fully automated ones practically require a PhD to be able to utilize. I never new laundering a pair of wool socks was such a complicated science!

Our new Honda Fit has driven over 16,000 miles in under 4 months and passed through 26 different U.S. States. Our Visa company is almost on speed dial so we can let them know we’re in yet another country.

I have one address on my driver’s license. Another address for my Visa Card. When someone asks for a mailing address, which one should I give? My Amazon account contains over 20 potential addresses for shipping.

Oh, and a phone number, you ask? Well….I have  a new mobile number this year. A Trac phone. One of those pay-as-you-go phones. Great for avoiding the FBI if I were a secret agent spy; not so great when others want to contact me or I want to look up a friend in my phone’s contact list.

Want to confuse someone? Try scheduling a doctor visit or a dental check-up with the receptionist. The conversation can be a bit awkward:

“I can put you in for an appointment with the doctor on Wednesday, December X,” the receptionist pauses, waiting for my affirmation.

“Um… I won’t be in Virginia then. We’re only in that State for the last week of November. Might you have another appointment slot open, please? We only come back to the U.S. for a short period of time for our annual holiday, you see. Sorry for the confusion.” I apologize. Sometimes one can make appointments more in advance but then one risks misunderstandings through the crackling, unsteady Skype connection.

The receptionist (rolling eyes on the other end of the line most likely) finally answers after a significant pause, absorbing the information, “Well…let’s see…” I wonder if she thinks I’m making up the situation to entice her to try for a more urgent slot. I have no idea.

~o~

One day it will be nice to have a home address again. A home to ship our belongings to that are scattered all over the world. Some cartons are waiting on the dock in Douala tagged to cross the Atlantic soon -- we hope. Other boxes are shelved in our longsuffering parent’s basement. Our dog is lodged temporarily with my parents while we drive across the country like migrant workers in search of a permanent position. Our cat is distributed to a friend of a friend until we have a final destination. Other mementos are stored in at my husband’s relatives. And the rest of our things -- those little essentials that we can’t bear to part with -- like our guest book, a favourite pillow, and my husband -- are nestled ‘fittingly’ into our Honda Fit.

One day Bill and I will have our own bed again. One day we’ll be able to set our toothbrushes down on the bathroom counter and not worry about forgetting them when we pack up again. One day it will us giving out the password for our own WiFi network. But, for now, we’re homeless and on the road. Two days here. Three days there. House to house. Friend to friend.

I am thankful. I am grateful. I am blessed by the interactions and the opportunities. I wouldn’t trade this unique experience of transitioning from Cameroon back to the U.S. for anything. I won’t forget it.

And yet… I  think I will be glad to finally unpack…one day. At least for a while.

~o~

Lord, I cannot fail to see the spiritual lesson in all of this. What a reminder that yes, we are pilgrims and sojourners on this earth. We cannot get too settled. Earth is not the final home; heaven is our destination. Heaven is our home. Until then, we keep travelling.

And I do ache for that heavenly home. These past few weeks have demonstrated that more than ever to me. Home is heaven.

 The hymn in church last week seemed fitting. It is probably a familiar hymn for many of you. The words have been filled with additional meaning for me recently. Here they are: (the YouTube version is quite nice, btw).

This world is not my home, I'm just passing through.

My treasures are laid up somewhere beyond the blue.

The angels beckon me from Heaven's open door

And I can't feel at home in this world anymore.

O Lord you know I have no friend like you

If Heaven's not my home, then Lord what will I do?

The angels beckon me from Heaven's open door

And I can't feel at home in this world anymore.

They're all expecting me and that's one thing I know.

My Saviour pardoned me and now I onward go.

I know He'll take me through, though I am weak and poor.

And I can't feel at home in this world anymore.

O Lord you know I have no friend like you

If Heaven's not my home, then Lord what will I do?

The angels beckon me from Heaven's open door

And I can't feel at home in this world anymore.

I have a loving Savior up in glory-land,

I don't expect to stop until I with Him stand,

He's waiting now for me in heaven's open door

And I can't feel at home in this world anymore.

O Lord you know I have no friend like you

If Heaven's not my home, then Lord what will I do?

The angels beckon me from Heaven's open door

And I can't feel at home in this world anymore.

ust up in Glory Land we'll live eternally.

The Saints on every hand are shouting victory.

Their song of sweetest praise drifts back from Heaven's shore

And I can't feel at home in this world anymore.

O Lord you know I have no friend like you

If Heaven's not my home, then Lord what will I do?

The angels beckon me from Heaven's open door

And I can't feel at home in this world anymore.

X-Rays: a la Cameroon Style!

Medical care in Cameroon can be a little different as it is delivered in a culturally unique manner. Getting an x-ray in a foreign country can push one out of their comfort zone and yield surprising results.

~o~

I hate doctors.
Yes, I know. I am a doctor. That doesn’t mean I like being sick, being a patient, being on the “other side” per se. When the roles are reversed, my stomach churns with anxiety and my palms sweat with fear. I make a very good doctor. I make a lousy patient.

But, pain is an unremitting taskmaster.  Funny how convincing she can be?!

The receptionist smiled at me as I approached the radiology suite along the main road in Buea. I often walked past with my dog for our afternoon walks. Most of our client-patients utilized their radiology services for x-rays. The staff knew me well.

“Good afternoon,” I greeted the receptionist. I looked around the front room of the office. Only a couple of other young men, I couldn’t tell if they were supposed to be working or potential clients, lounged against the wall in conversation.

“I want to make an x-ray,” I addressed the receptionist.

“For you?” Her eyes startled open a centimeter.

I nodded. “Yes.” (So much for an incognito entrance).

The receptionist turned and walked into the back. I had no idea why she’d left so abruptly but I wanted an x-ray, preferably now, so I stood at the counter, waiting, exchanging uneasy glances at the young men in the waiting area. Both of us probably wondering what the other was thinking.

“The doctor says it is ok,” the receptionist reappeared abruptly to my left.

I turned to face her. “Oh, good.”

Just then, a very enthusiastic French-speaking radiology technician appeared from the back hallway.

“Vien, vien,” she motioned with her hands to follow her.

“X-ray?” I hoped that the doctor had translated the instructions for which x-rays to obtain. I had serious doubts that she would otherwise know what to do.

“Please, God,” I breathed silently as I followed her to a small room in the back with an army-grade x-ray machine. It looked as if it had survived a few wars.

“Chest,” I pantomimed as my whirling dervish technician briefly paused in her swirling activity to contemplate her next move.

She nodded excitedly. A bit too enthusiastic for my comfort, I’m afraid. How could anyone be so enthused over a black and white photograph of someone’s insides? But, what else could I do. Hope for the best.

The technician’s face lighted up and suddenly she made up her mind. With rapid hand gestures she motioned for me to strip off my shirt and hang it on the hook on the door of the room.

“Now?” like right now in front of her with an open door and curious young black gentlemen just around the corner? I hesitated.

“Now,” she nodded impatiently with a look that said she couldn’t understand why in the world I’d dawdle to take off my shirt.

So, off came the shirt, and bra. I hung them on the door. She smiled happily and quickly scooted me over to the wall and the x-ray’s photo plate board. I turned one way. She frowned and turned me the other way.

We were like a mismatched dancing pair for a few awkward moments. She’d step one way and mumble French directions that I couldn’t understand. Perhaps they were French insults but I’ll never know. She was smiling the entire time so who could tell.

She tried to direct my inept steps toward the correct arrangement. Left, no right but not that much right. Shift forward but not quite so far. She pushed and prodded me inches one way and another way. Finally, she seemed satisfied that her subject matter, me, was properly posed.

“Stay,” she motioned with her palm with a big grin, clearly pleased at her success in posing me properly for her film. I swallowed and tried to be the compliant client in spite of my misgivings. I really didn’t want to repeat this tango again.

“Should I take a deep breath?” I figured somewhere in this process, lungs should be inflated for a proper film.

The technician nodded her head earnestly. I wondered if there was anything she’d not agree to by this time. All the time she chattered away in rapid fire French. Whatever I thought she might be saying was truly a guess.

Somewhere within my asking if I should take a deep breath and hold it and her enthusiastic chatting, she took the x-ray. I still cannot pinpoint the precise moment, but she effortlessly came round from the back of the machine and indicated that I could shift from my nose-to-wall position. Not that the wall was so bad to stare at but it was a little monotonous. All white and all. The wall was probably bored by staring at me too.

Another round of tango ensued in which the French technician tilted and bent my body to her tastes, cheerfully giving out instructions in French that could have been in Klingon for as much as I could understand. In spite of my foibles at anticipating her instructions, her smile never wavered. As I practiced being a human Gumby – remaining stationary after she shifted my limbs into the correct position – she clucked encouragingly. She was pleasant, at least. Our communication abilities were less than ideal but at least she was friendly.

For the second picture, I didn’t try to coordinate the whole breathing thing. I focused on the other wall and basically tried to not stir. She stepped behind her machine, fussed over the knobs a bit, and finally re-emerged, still smiling.

“Done?” I asked hopefully. She took the correct number of films. I decided that was a promising sign that she’d also taken the correct views.

“Yes, yes,” she answered. She walked briskly off to develop the films. I re-clothed myself, thankful the place didn’t have any other clients waiting. I’m not as modest as when I was a teenager, mind you. Still, I have noticed that white-man skin tends to attract an unwanted curiosity on the part of my darker skinned community. Not the kind of attention I crave.

At the counter, I paid the customary 5000 XAF ($10) for the x-ray. Turns out one of the young men lounging against the wall was supposed to be the cashier. X-rays in Cameroon are probably a bit cheaper than those in America. Granted, of course, there was no electronic data file available. And, although the radiology technician was happy with her work, the quality of the black and white film was a bit fuzzy in areas with some developing fluid drips staining the lower portion. The good news, the pictures were adequate. I didn’t have to repeat them.

And the other good news?

The electricity went off just AFTER my x-rays, not to return until the next day.

And the x-ray pictures results?

Well… the radiologist’s interpretation is at least unique. I doubt I’ll ever get another read on a chest x-ray that says, ‘…small heart!!!’. Not sure if the triple exclamation marks were necessary…

~0~

 “Suffering has been stronger than all other teaching, and has taught me to understand what your heart used to be. I have been bent and broken, but - I hope - into a better shape.”
― Charles Dickens, Great Expectations

Amputation

Amputated.

Severed.

Cut off.

Well, perhaps not cut off literally, but cut off figuratively. Unexpectedly and suddenly terminated. Like most traumatic accidents, I was unprepared and caught off-guard. I wasn't happy about the loss either -- to put it mildy!

Last week my longsuffering, elderly Macbook computer shut down - and never woke up. A permanent siesta of sorts.

I went through the typical stages of grief that are defined by Kubler-Ross:

At first, disbelief. "What?! This must be a fluke. Surely my computer will reboot. I just need to try it again and give it more time. It's not really broken, just acting out..."

Then anger. "Why God?! Why now? What I have done to deserve this? If you're trying to teach me a lesson from this loss, please teach it another time. I don't want a lesson in patience and endurance without complaint now. No, no, no!"

Third, bargaining. "Please, please, please, God! Just make my computer turn on this once. I need it. You know I need it for work, for staying in touch with my husband and friends, for my sanity. Please make it reboot. Please let me know what you want of me and I'll do it. Just let my laptop get past its grey screen of death."

Fourth. Despair. *sob* "Why?! Why oh why? It's not fair, God. You take away my husband. You take away my health (I had a stomach flu and mild case of malaria at the time) and now you take away my only means of communication with the outside world. I'm going to suffer in loneliness. I don't want to by like Job of the Bible." (At this point, my attitude was more along the lines of Job's wife, 'curse God and die', than anything).

Finally, Acceptance. "C'est la vie. What will be, will be. Everything will sort itself out in the end. I'll survive. Somehow I will manage."

Tumultuous thoughts such as these tossed around wildly in my mind. Back and forth. Just when I might think I had come to a full acceptance of my loss, another situation would present itself and I'd realise afresh how much I missed using my laptop.

How does one know when they've truly given their problem over to God and "let go". As the verse in 1 Peter 3:5 says, "cast all your cares upon Him for he cares for you." This sounds good in theory.
Or how about the popular saying, 'let go and let God'? When can one know they've actually truly and meaningfully 'let go'? Sometimes I think there is a rather extended period of give and take. Letting go and then grasping back at our problems - not quite sure we can fully trust God to handle the problem just yet. It is a process.

During this period of angst, I attempted every means possible to resurrect my Macbook and trick it into rebooting. At the local public internet cafe, I searched and found a blog about what to do when 'good Macs go bad'. I added some new terminology to the linguistic  centre of my brain. Terms like 'safe mode', 'verify disk and repair disk', NVRAM, along with a whole lineage of Mac feline operating systems: Mountain Lion, Leopard, Snow Leopard, Lion.. A regular jungle of Mac cats! Did  you know, there is even a computer code can typed, 'fsck-fy' -- it seemed rather appropriate at the time.

In spite of my best efforts at reanimation, my computer stubbornly remained in suspended animation - a persistent vegetative state - not quite alive but not dead either. "Mostly dead," as they say in the film, Princess Bride.

But mostly dead is for my intents and purposes, dead. My 'technological right arm', my 'second brain' is gone. A traumatic amputation.

My primary means of international communication is gone. My data bank of work files is locked away. My encyclopedia for looking up medical questions is frozen. My television screen for watching shows is finished. My library for reading books is closed...

I am sure you get my gist. It was a major operation. A significant disruption to my normal daily routine of life. It wasn't pretty.

The Bible says that if your 'hand causes you to sin; cut it off.' I am not going to say that my computer was causing me to sin although the thought did cross my mind somewhere within my Kubler-Ross grief striken state. I am still searching for meaning behind the whole fiasco though. My humanity is seeking to find a reason why. Perhaps that is human nature? I cope with loss by trying to find a reason behind it. I'm not looking for a silver lining but I find that seeking to find a reason is somehow comforting, perhaps. Loss without a reason or a purpose seems so much harder to accept, oddly.

Maybe one day I will look back and discover a reason. For now, I can only hope that the searching will lead to something positive. I wish my computer would start working again but I believe I have reached the point of a more steady acceptance. I don't identify with Job's wife anymore. I may not have the patience of Job yet but I feel more comfortable saying, 'the Lord gives and the Lord takes away; blessed be the name of the Lord'.

I think about how intimately connected I was with my computer. Consider all the vital funtions it had in my day to day life. I used it multiple times a day. I connected with it for knowledge, entertainment, relationships, communcations, problem-solving, even just to tell the time of day sometimes. I logged onto my computer to read the news at least once, usually many times, in a day. My computer really was like an extra data storage memory bank. My 'second brain'. My life doesn't feel complete without my computer.

Today I read John 15. In that chapter, Jesus speaks about connecting to himself, the true Vine. "Remain united to Me and I will remain united to you. A branch cannot bear fruit by itself; it can do so only if it remains in the vine. In the same way, you cannot bear fruit unless you remain in Me." John 15:4

Perhaps instead of a vine, one could use the modern analogy of Jesus being the master computer. Like my computer used to be my access point to the world wide web, Jesus is my access point to all knowledge, heaven and His Holy Spirit. Jesus is my life. He should be such an integral part of my day to day life that I will go through withdrawal and grief, just like I did with my Macbook, if I am unable to connect and boot up with Him.

"Without Me [Christ] you can do nothing." John 15:5

I cannot function as smoothly without my Macbook. Life is inconvenient having to borrow another person's computer or use a public computer at the outside internet cafe. Life is inconvenient but not impossible. But, without my connection to Jesus, life is more than inconvenient; it's impossible.

"I have told you this so that My joy may be in you and that your joy may be complete." John 15:11

'Unite to Me' -- connect to Christ. He is life. And, in that life, our joy can be complete.

I wonder if there is a Macbook heaven?

A Tiny Ethical Dilemma

A Tiny Ethical Dilemma

Life is not always so simple. Black and white moral choices. Do they even exist in such stark, contrasting colours? Seems like there are a quite a few shades of grey when it comes to ethics.  Fifty shades if you believe a certain author…

Clients old and young crammed into our clinic waiting area. Those healthy enough hung around the perimeter avoiding the sweaty, hot central node of sick bodies, nudging their way past mothers with babies strapped to their back and elderly grandparents resting against the wall grasping their walking sticks while sitting on the benches. Somehow there was an order although at the time it was difficult to conceive any sort of queue existed among the impatient patients.

My door cracked open as I sat opposite a sick client reviewing her history. “Oh, sorry,” Madam H said unapologetically. Her eyes flicked to her medical book and back to me expectantly as she pushed the door open further and shoved her book under my nose for an inspection of her lab results. She was ready for her prescription.

“Ok. Thank you,” I said, trying not to sound to exasperated. Mrs G. sat motionless and silent, suspended in animation until my intruder finished intruding on our private interview. “I will look at your labs and write the prescription after I finish with her.” I indicated Mrs G.

Madam H gave a satisfied nod and backed out, closing the door on our privacy once more. “So, you were saying you have vaginal itching but that the discharge does not have a smell….” I picked up where I’d left off in our original conversation. Amazingly, Mrs G seemed unperturbed and jumped back into a detailed description of her ailments for the past eight years.

“Yes, doctor. When I take medicine it goes but then it always comes back.”

“Any pain associated with the discharges?” I probed further into her history trying to ascertain her underlying fears and preconceptions about the problem.

“Yes, doctor, here,” she pointed to her lower abdomen.

“What is the pain like?”

She was silent a moment, trying to come up with a suitable analogy. In those brief seconds, another knock on my consultation door alerted me to the next interruption. It’s amazing I manage to get any outpatient consults done some days.

“Doc?” Nurse A poked her head into my consult room. “There’s another doctor who says he wants to talk to you.”

“Ok. After I finish here,” I nodded to Mrs G. and gave her a small nod. “Just tell him to wait and I’ll come.”

Within a few minutes, I completed my interview and examination of Mrs G. and had sent her on her way to the laboratory. I strolled out of my office and looked around. “That guy,” the nurse pointed out an average-looking middle-aged Cameroonian male standing near the doorway. He spotted me even before I could introduce myself.

“Doctor?” he held out his hand in greeting.

“Yes, I’m the doctor,” I replied hesitantly. I wondered what he could want from me. I didn’t recognise him. Why was he here? What did he want?

“Doctor, I’m happy to meet you.”

“Happy to meet you too,” I shook his hand but remained standing out in the doorway.

“Doctor, I want to talk to you.”

“Oh?” I glanced around at all the patients who were giving me less-than-patient curious stares. “I still have a lot of people to see…” I shrugged.

“It’ll only be a minute. Can we…” he indicated a more private corner, “…talk together just for a minute?”

I hesitated. There were so many people to see. Many had been waiting several hours. They were sick and didn’t feel good. Most were hungry because they had come without taking breakfast. It wasn’t fair to make them wait just because another professional colleague that I didn’t even know decided now was convenient for him to visit me.

“It will only take a minute,” he pressed his case persistently.

At last I relented. “Ok, come back here.” I indicated the bench where we do our dressing changes and injections. “Agbor, Natalie,” I called out.

The patient shouldered her purse and hurried to enter my consult room. “Have a seat inside,” I indicated the chair. “I’m coming.”

I returned my attention to my unknown, physician visitor. We sat across from each other.

“Doctor, I wanted to meet you…”

“And now you have,” I smiled.

He gave a wane smile in return. “Doctor, I work at the ___ hospital.”

“Oh?”

“Yes. I wanted to meet you so that maybe we could work together – collaborate – refer each other patients.” He paused frequently as he struggled to fish out the correct words to get his point across clearly yet subtly.

I listened. I wasn’t sure I understood his agenda yet.

“You know, doctor, I’ve been to ___ country.”

“Oh,” I nodded. I wasn’t sure why he was sharing his foreign travels with me. I’d been to other countries outside Cameroon too.

He continued. “You know, I studied many additional things.”

“Ok.”

“I’ve had training in gynaecological procedures.” He paused waiting for the light bulb to click in my mind. It didn’t.

“Knowing how to manage gynaecological problems in women is a good thing.” I filled the pause.

“You see, doctor,” he resumed his explanation, “I have additional training in how to manage bleeding in women, like after a miscarriage.”

“Like a dilation and curettage?” The light bulb was beginning to turn on.

“Yes, I can do D&Cs.” He was pleased I seemed to understand him now. He paused again.

I waited for him to continue. I wanted him to verbalise the point of his visit more clearly and confirm what I was beginning to suspect.

“Well, you see, doctor, like yourself, I have training in helping take care of women. I can help them. Sometimes you see women who come here for an echography.”

“True.”

“Sometimes they come for an echo and they don’t want it.”

“You mean, when we confirm that a woman is pregnant but she doesn’t want to be pregnant?”

He nodded.

“I can help them. You can send them to me.”

I now understood my colleague’s visit. He was soliciting referrals for dilation and curettage (D&C) for patients who came and wanted an early abortion.

“I am trained in that way.”

The light bulb was fully illuminated in my brain. I understood his request perfectly.

For now, I didn’t have any cases to refer to him. Thankfully, most women recognise that we are a church-based mission hospital and a D&C to abort an unwanted pregnancy is not possible at such a health institution. And yet, sometimes we do diagnose a pregnancy and the dilemma arises: what to do?

Does one refer a young lady to a doctor who can perform a D&C relatively safely and in antiseptic conditions in a hospital? Does one council and pray with this woman and hope that she abandons all thoughts of ridding herself of the pregnancy? Does one refuse to discuss anything outside of maintaining the pregnancy and pray she doesn’t go in secret for an abortion under unsanitary conditions by unqualified people with no training that masquerade as “doctors”?

I have seen some horrible complications of abortions done in shady clinics and even homes by unqualified persons. Sometimes the reason for a woman seeking an abortion can be quite compelling. Losing a job. Being thrown out of the house onto the streets to fend alone. Sent home to the village in shame while forced to abandon hope of a higher education. Pregnancy because of rape and incest. The list is long and complicated and heart-rending.  I once had a young woman of the age of 16 or 17 dragged by her auntie to the clinic – auntie demanding an echo to determine if her niece was pregnant or not. In the privacy of the exam room, the girl fell down on her knees and with clasped hands begged me, tears streaming down her dusty face, to please write that she was not pregnant. She’d had sex with a man in order to obtain money for her brother in prison. If she was found out pregnant, her family would throw her out and she would never be able to finish her education. Intense times. With little resources (not even a positive pregnancy test), she’d gone for a “backyard abortion” and yet she was terrified that the ultrasound might show she was pregnant.

Choices are not always so clear. Fuzziness lies on the edges. Greyscale predominates over defined black and white. To refer or not to refer?

Dyspnea

I’m supposed to write something inspirational. Something uplifting. Encouraging to the soul.

I don’t feel like writing anything cheery.

She’s dead.

I knew she was going to die. I could see it in her eyes. The heaviness. The weariness.

Pleading.

A resigned exhaustion.

Haunted by her existence.

Yearning for her release.

The look of death.

Yeah… this isn’t turning into a bright and happy piece of writing, is it?

Madam H was 50 years old. She came early in the morning. Too early in the morning. Concerned relatives had packed her into the car and shuffled her from hospital X to our health centre after she failed to respond to the treatment regime she was receiving.

“Coming,” my husband unlocked the front door. We were both trying to rejoin the land of wakefulness at the early hour. Jordan, our dog, had alerted us to the nurse on our front porch with her usual energetic barking. (No need for a doorbell. Most visitors don’t even realise we have one)

“It’s the nurse,” my husband called back to me.

“What does she want?” I inquired. I sighed. Already? Couldn’t the consults wait for another hour until the clinic actually officially opened?

“I don’t know. She wants to see you.” My husband relayed the message.

“Tell her I’m coming. I’ll be over in the hospital in a few minutes.” I hurried to finish dressing. Mornings come too early.

With a growing sense of trepidation, I threaded my way to the hospital through the milieu of animated visitors who invariably come along with a sick patient. It’s actually a little intimidating to walk past the crowds of them… all waiting and watching with expectant gazes for the white doctor. Their heads turned in unison as I passed them. I ducked away from their intense stares into the general adult ward in the hospital.

Madam H was positioned in a semi-upright position with the head of the bed cranked upright. She gasped like a trout out of water for air – hungry, mouth-open, inhalations -- without finding relief from her oxygen deprivation.

“What’s the story on Madam?” I turned to the night duty nurse.

“Difficulty breathing, doctor,” the night duty nurse gave me the very abbreviated version of the patient’s medical history.

“Anything else?” I pushed for more details.

“Doctor, the family says she can’t breath. She’s been taking medicines to no avail. They brought her here because of severe neck pain.”

“Oh?” I bent over and placed my stethoscope on Madam H’s chest, listening to the air enter, listening as some unseen force halts her efforts at breathing – preventing her from taking a long, deep, satisfying, lung full of air. No crackles. No wheezes. Just rapid, gasping breathes… not shallow but not deep and gratifying either.

“How long has she been like this?”

“Ten days.”

I stared incredulously at Madam’s troubled breathing. “She’s been breathing like this for 10 days?!” I raised my eyebrows, not quite believing.

The night duty nurse looked at Madam’s medical book in her hand. “Yes, doctor.”

“And what has the family been told is the problem?” I counted Madam’s respirations. Forty breaths per minute. Not as bad as I’d initially thought. Her heart was beating regular with a pulse of about eighty. She had a little swelling in her legs but not much.

“They said she has pneumonia, doctor.”

“Can I see which medicines she’s been taking? Do they have the other lab results from the hospital?” I turned my attention to the plastic sack of medications at the bedside cupboard. Augmentin. Tot’heme. Terpone cough syrup. Ventolin inhaler spray.

I addressed Madam and held out the Ventolin spray to her. “Take,” I instructed, “then tell me if it helps you breath better.”

Without wasting air to reply, she deftly took the Ventolin asthma spray and inhaled a few puffs.

“Did it help?”

“She looked at me with vague eyes and gave a noncommittal nod of yes.” I wasn’t impressed. Certainly not a dramatic improvement. She still put enormous effort into every breath.

“Doctor, she complained of neck pain and chest pain,” the nurse reminded me.

I nodded at her words. “Any fevers?”

The sister shook her head, “No, doctor.”

“Cough?”

“No.”

“Headache?”

“No.”

“Any pain anywhere besides her neck and chest?”

“No.”

“Does she have asthma?”

“No.”

“Has she ever had diabetes or hypertension?” I noticed that her blood pressure was up. The last reading on the blood pressure machine was 160/105 mmHg.

“No, she has never had high BP,” her sister looked around at the other members of the family who offered nothing to the alternative.

“Did her breathing problem come on slowly or did she get difficulty breathing quickly?”

“It just came like that,” her sister tried to explain. “It has never happened before.”

“So, she just woke up suddenly with difficulty breathing?”

“Yes, doctor,” the sister answered with hesitation.

“Has the treatment improved her breathing at all?” I looked around at Madam H and the rest of her family. Madam was busy breathing so I relied on her entourage to fill me in on the details.

They all shook their heads empathically. “No, she has only been having this difficulty to breathe, doctor.” The sister spoke on behalf of the crowd.

“Can I see her medical books and laboratory tests?” I sat down at the nurse’s station with an assortment of papers, receipts, several paper booklets, and a chest x-ray.

HIV negative.

Random blood sugar, 117.

Malaria negative.

Chest X-ray report read, ‘bilateral pneumopathy’.

‘for right breast biopsy’… huh?

“Did they do a biopsy of her breast?” I was confused. Why was there a work up for a breast lump going on in the middle of a hospitalization for shortness of breath?

“I don’t know, doctor,” the sister answered with a shrug.

Strange. I would peruse her books a bit more but for the moment Madam H, her family, and the night-duty nurse were anxiously awaiting a plan of action.

“Check the Hb (haemoglobin level). She looks a bit pale.” I instructed. “Then tell the family to repeat the chest x-ray.”

Surprisingly, the Hb came back normal – 12.2 g/dl. The chest x-ray, when compared with the picture from 10 days ago, looked very similar. This time the report read, ‘bilateral pneumopathy with small pleural effusion’.

I wrote orders for IV antibiotics and furosemide (diuretic). The underlying question remained though – why was Madam having pneumonia that wasn’t responding to appropriate oral antibiotics? Where was the pleural effusion coming from? Why wasn’t she having any fevers? Was the neck and chest pain related to the lungs or the heart or something else?

Time is a funny thing in medicine. It can pass in what seems like one blink of the eye or it can drag on forever, counted second by endless second with each laboured breath.

“How is she?” I came to check on madam in the afternoon after most of the consultations on the outpatients were finished. “She’s ok, doc,” the nurse shrugged without enthusiasm. “Her blood pressure is high.”

“How is her breathing? Any better?”

“Not really, doc. She’s complaining that the Lasilex makes her chest pain more when I give it.”

“Ok,” I acknowledge this odd factoid.

On examination at the bedside, I found madam sitting up. “Does she breath better when she’s sitting?”

“Yes,” the sister confirmed.

Her oxygen saturation was 99%. Her pulse and blood pressure were relatively unchanged. Respirations were still laboured. Her lungs on auscultation with my stethoscope sounded the same. No change. And, she still didn’t have even the faintest hint of a fever. I examined her conjunctiva. White.

“Check her Hb again,” I requested.

I searched through her records again. I found evidence for a ten-year history of breast pain and a small surgery with excision of a breast lump several years ago. Otherwise, I could not find anything new. I didn’t know what to think.  Her symptoms did not add up to equal simple pneumonia. They didn’t fit a simple pleural effusion either. In spite of producing plenty of urine, her breathing had not improved at all. My mind stared grasping for other explanations. Pulmonary embolus? Heart attack? Cancer? Pericardiac effusion? Pericarditis? Parapneumonic effusion? Questions; no answers.

I felt like an idiot. The family stared at me like I was an idiot too. How come the white doctor couldn’t tell them exactly what was wrong with Madam H and fix her? Their silent stares and background animated chatter felt eerie and accusing every time I passed the hospital entrance.

“I feel like I’m missing something.” I lamented to a friend online. “What is it?”

She graciously messaged with me and helped alleviate my insecurities. I felt somewhat more confident that at least my line of reasoning was logical, medically speaking, afterward.

I plunged forward with my questions and investigations while Madam H continued to struggle to breath. She was able to sleep and relax a bit when we gave her oxygen. I left the oxygen concentrator next to her bedside. Anything to alleviate her air hunger and discomfort even though it wasn’t the solution.

I took photographs of her chest X-rays and emailed them to another friend for reassurance that the local radiologist and myself weren’t missing anything significant on the films.

An ultrasound doppler study of her leg veins failed to show any blood clots. The sonographer didn’t feel there were any signs of a dilated right heart ventricle or atrium. “It just looks like congestive heart failure.” She gave her opinion of the ultrasound study as I discussed it with her.

So… no definitive answers.

“What was the repeat Hb?” I stood at the nurses station trying to decide what else to do. Nothing seemed to be helping.

“Her Hb was 13.3 g/dl,” the nurse informed me.

“How can that be?” I asked, still not believing. “She’s white. You’ve seen her, right?”

“Yes, doc.”

Madam H’s conjunctivas were white, her tongue was pale, her fingers appeared bloodless. I searched my memory banks for anything that would make her Hb falsely elevated. And yet, her pulse was not tachycardic. Her blood pressure was high; not low. The haemoglobin metre had churned out appropriate low values of 8.7 g/dl and 9.9 earlier.

“How are you?” I walked over to Madam H’s bedside and addressed her. During her entire stay, she’d barely uttered more than a yes or no. All oxygen was savoured in favour of expending her efforts to breath.

She stared at me with tired eyes. I didn’t need her to tell me. She wasn’t better. She was worse.

I checked her oxygen saturation. Sitting straight up with her legs dangling over the side, the oxygen saturation levels rose to a meagre 89%. When she leaned back into the bed, in spite of the inclined head of the bed, her saturations dropped to the 70s. Not good.

“Can you think of anything else?” I turned to my nurses at their station.

They shook their heads. “Doctor, I think we need to transfer her.”

Wearily I agreed. She was clearly not improving.

“We’ve tried everything we can here at our small health centre…” I began as Madam’s relatives sat opposite me in the make-shift family conference room. “I don’t know what all is causing her difficulty breathing. It’s more than a simple pneumonia though. She needs to go to the big hospital in D_____ where there are more specialists and capabilities to treat her.”

“You’re right, doctor,” one of the male relatives spoke and nodded.

“Don’t waste your time going to the other small hospitals. Just go to D_____ now. You’ve already been to one other hospital and I know the hospitals here in Buea are not big enough to do anything more than we’ve done for her here. Go to D_____.”

“Ok, doctor.”

We wrote up the appropriate paperwork and helped the family load Madam H into the waiting taxi.

I was relieved that she was going somewhere that could do more for her. I was frustrated that I couldn’t help her. I felt drained and apathetic. Discouraged. Empty.

I couldn’t even figure out what the real problem was. She was dying and I didn’t have a clear picture of what was really happening. There could still be a pulmonary embolus. Perhaps it was heart failure from a recent heart attack… maybe it was complications from breast cancer…. a resistant pneumonia… anaemia (even though our metre pointed to an alternative diagnosis she still looked very very pale). Too many questions. My mind wouldn’t stop processing Madam’s case. In spite of my musings, the meagre facts of the case swirled around without coalescing into any solid diagnosis. Like a computer trying to open a bad file, my brain whirled endlessly and fruitlessly. No program loaded. No answers popped up.

These types of medical cases are difficult. They drain my psyche insidiously and poison my confidence. So much effort with no return on the investment. I knew I’d probably never hear from the family again. I’d sent them off into the mysterious depths of the system of specialists in D_____. Historical experience informed me that there was a 95% chance I’d never know what happened.

Postscript:

The family took Madam H to another nearby hospital in Buea. They did not go to D____. At the hospital, they were again referred to D___ but instead chose to remain. Madam died at in the hospital the next day. The impression by the doctors at the other hospital was that she died of congestive heart failure brought on complications from breast cancer.

One may be tempted to lay blame on the family for not transporting her to a big, expensive specialty hospital where she’d have the best chances of survival. However, perhaps the family, like myself, saw the ‘handwriting on the wall’. Knowing that she was near death, they chose to let her die in her hometown and save the resources it would have cost just to get her through the front gate of the D____ hospital. Contrary to certain cultural attitudes in other parts of the world, there are financial limits and medical care is not an unlimited resource.

 “Who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves receive from God. For just as we share abundantly in the sufferings of Christ, so also our comfort abounds through Christ.”

2 Corinthians 1:4,5

Practising the Ancient Art of Bloodletting in the Modern Era of Online Communication

Blood Letting in the "Olden Days"

I can remember as a child being fascinated by the apothecary shop. The shop was a Colonial era rendition of what a doctor-pharmacy habitation might have been like in the 1700s. As the aromas of dried herbs and potions wafted round the wooden timbers and layer of sawdust strategically spread over the floor beams, the historical enactor in petticoats and apron, held up a jar of live leeches. “These were used for those with a bit of blood congestion after a long winter.” One of the black slug-like critters swivelled his sleek body in a u-shape and smirked through the glass. I stepped closer for a better view.

“Over on this table you can see some of the knives that the Dr Hugh Mercer used to cut his patients who needed to lose more substantial quantities of blood. Different sizes were used depending on how much blood the doctor felt needed to come out.”  Several smallish metal contraptions with one or more lancets, including one with rolling cutting blades that resembled a primeval torture device, rested benignly on the table. Gruesome, spine chilling, and fascinating!

Fast forward to current time period. Haemoglobin levels are measured by handheld devices now. Too little blood or too much blood have fancy technical terms like anaemia and polycytosis. Physicians are much more prone to infuse blood into the body’s veins than let it drain out although there are a few instances where blood donation is beneficial such as Polycythemia vera.  I’ve never planned to practise the art of bloodletting though! Vampires don’t seem to run in my family heritage.

Nifty little cutter for making multiple cuts at once -- improving blood letting efficiency!

NN had already met with the young mother and father of the patient, a youngster of almost 2 years. AJ clung to his mummy with his little fingers grasping at her shirt while his mother patiently consoled him by breastfeeding.

“Doctor, they’re just from hospital X,” NN informed me as I joined her in the consultation room.

“Tell me what you’ve discussed already,” I requested and sat across from AJ, still clinging to his mother.

“He was admitted in hospital Y a few days ago. He had malaria and was given quinine drips and antibiotics. He also was given one bag of blood. Now he has no more fever but he’s weak.”

“So he is taking breast well? No vomiting? No fevers? Normal stools? Everything is fine except that he’s weak?” I turned to the parents.

They looked down at their baby and nodded together. “Yes, doctor,” they chorused.

“Ok…” I wondered if there was more to the story. “Let’s examine him. Bring him over to the table.”

Mom detached AJ from her breast in spite of his protests and placed him before me. He was not happy at this separation and made sure everyone understood such.

Crying. Good sign. I mentally catalogued the information as I noted his pink conjunctiva and fingertips with a brisk capillary refill. Certainly not a haemoglobin of 5.1 g/dl anymore! After stalling for time by doing an extra long examination of AJ, all I came up with were some rough sounding lung sounds and mild oedema of the fingers and feet.

“Doctor, let me explain something,” AJ’s auntie joined the conversation. “At the hospital they gave him too much blood. See.” She pointed out some figures and written orders in AJ’s medical booklet. From her description of what actually happened versus the orders in the book, it did appear that AJ might have received more than his fair share of blood.

Although he was not critical, he was not well. AJ’s parents’ observation that he was weak was accurate.

“Is he peeing fine?” I asked his mother.

“He pees too much, doctor. He drinks plenty water.”

“More than normal?”

She nodded.

I added this factoid to the assorted observations floating around in my head, trying to align themselves into a coherent diagnosis. “Let’s check an Hb (haemoglobin level) and blood sugar,” I suggested to my nurse.

NN nodded and headed off to prick baby AJ. I headed in the opposite direction to retrieve my pulse oximeter. We met up in the laboratory. Haemoglobin is 17.9 g/dl (normal is 12-14 g/dl).  The Pulse oximetre beeped red and angry. It spit out a reading of “82%”. I waited a bit for AJ to stop crying. Gradually the oxygen level in his blood climbed up to 90%. Still low.

“Doctor, the blood sugar machine isn’t working,” NN interrupted my concentration.

“Oh, let me see.”

She handed me the machine.  I fiddled with it. Hum? She’s correct. Definitely not working. I pause. “Ok. Let’s check a urine analysis. We can see if he is spilling glucose, or having ketones, or if there is protein. We’ll be able to check the specific gravity too.”

She nodded. AJ had already confirmed his mother’s assertions that he “pees plenty!” He’d urinated all over the exam table when I examined him earlier. It took less than an hour and AJ let off another fountain. His father expertly caught it in the cup provided. Plenty urine! Analysis revealed dilute urine without anything else of significance. “Kidneys are working,” I commented to NN.

In spite of their initial protests, AJ’s parents agreed to admission to the hospital for treatment. I wasn’t completely sure what to do. Diagnosis – iatrogenic erythrocytosis with secondary congestive heart failure and its sequela of pulmonary oedema?

Thankfully, one does not always have to have a diagnosis in order to begin treatment. When in doubt, one can at least treat the symptoms. “Put him on oxygen. Give him a little furosemide (diuretic medication) and monitor his breathing and oxygen saturations. Can you think of anything else?” I gave NN a chance to add any insights she might have picked up on.

She shook her head. “Doc, the blood level… it’s too high.”

“Yes. It’s too high.”  She went off to carry out my instructions – strategically placing our little youngster in the adult ward since the electrical sockets actually convey electricity in the adult ward unlike our paediatric ward. I meandered back home to finish supper and mull over the case and figure out if there was more I should be doing.

A fluttering of dark evil-eyed doubts and fears danced across my consciousness. I’d Never had a case like this? Haemoglobin of 17.9 g/dl? Can all the patient’s symptoms be explained by such a concentrated blood level? Is there something else underlying the child’s weakness? … and what about all those other unknowns – the creatinine, the electrolytes? The evil grins on my self-doubts spread wide and showed their gleaming razor teeth. Ouch!  I was inexperienced and blinded by lack of further laboratory data – stumbling in the dark was no fun.

When one is the only physician in a foreign mission hospital, it is incredibly helpful to have online consultants, colleagues who can dialogue with you through email, Facebook, Skype…  I sent out several “feelers” hoping someone would be available.

A couple emails and Facebook message later, I found one of my dear friends (and co-conspirator in African mission work) available. “I have this 2 yo male with…. “

She and I exchanged ideas and thoughts in between several additional check-ups on baby AJ in the hospital. “He’s not really getting better,” I complained. “He’s generally stable but even with oxygen his blood oxygen levels are not getting above 92%.”

The network expanded. My friend sent off a question to another colleague working in Africa. Within the same night, he’d sent back his advice, “partial blood exchange transfusion…”

“I’ve never done anything like that before, have you?”

“No,” my friend admitted. “Makes sense technically though.”

“So many unknowns though. I don’t have a lot of back up. What if it changes the hemodynamics of her circulatory system too much? What if her potassium or glucose levels change too much? What if…” Doubts and questions swivelled in my mind. “I’ll wait until the morning and see how she responds over night to the furosemide since she’s overall stable,” I replied.

Morning came. I couldn’t eat breakfast until I’d seen AJ. “How is she doing?” I asked the night nurse, NN.

“A bit better,” she smiled.

Small better. This is really not as positive a response as most English speakers might imagine. I grabbed my stethoscope and pulse oximeter. “How is she?” I woke up AJ’s mother.  “A bit stronger,” she answered after blinking awake.

I bent over the sleeping form of AJ. Still rather rapid respirations. Auscultation didn’t reassure me either, coarse rales in the lungs, same as yesterday. The saturation reading of oxygen in his blood was 85% initially. I waited and found it wavered between 85-92%. Still not good. Essentially unchanged. Crumbs!

I spent breakfast hunkered over my laptop looking up blood transfusion complications and updating my network of online colleagues about AJ’s condition. I received a reply from another colleague. “I’ve never had a case with such a concentrated haemoglobin.”

Hum? Should I feel special that such a unique patient resided in my hospital currently or might I instead freak out because now everything was going to be “experimental and theoretical”?

“I’ll ask another friend of mine,” she emailed back. My worldwide doctor network expanded again.

I’m afraid I wasn’t completely focused on the sermon in church that morning. So many different options and alternatives rolled around in my brain. I processed step-by-step how each might play out in real life – practical? Did we have the equipment? Would my nurse be capable of such? What would be the potential complications? Argghhh!

I anxiously checked AJ when I came back from service. No change. “A little stronger,” mother and father agreed. Basically that meant she wasn’t worse. She wasn’t getting better either. A recheck of her Hb was 18.9 g/dl.

More emails. More Facebook instant messaging. I received some great information. Options. Alternatives. Things to consider. Advice. And, most importantly, encouragement. One dear friend wrote, “I know you might be nervous about doing something like that, but you might be the best trained and equipped to do it.”  The phrase stuck in my head.

Patient consultations slowed down for the day. The labouring woman had given birth to her baby and was settled comfortably in the maternity ward. There was still no change in AJ’s status. “NT, let’s talk to the parents about removing some of AJ’s extra blood.” She helped me explain the procedure to the parents and auntie.

AJ’s father signed the consent form. He seemed rather relieved that the doctor was finally doing something that made sense – take away the extra blood his baby had received from his excessive blood transfusion.

Together then, the nurse and I gathered the materials. “Doctor, my heart, ee de fear. EE de shake inside,” NT admitted nervously.

“We’ll only remove twenty millilitres of blood at a time. We’ll go slow. It will be ok,” I consoled NT and myself.

Normal saline dripped slowly into the left ante-cubital vein on AJ. NT inserted a second IV catheter into the right arm. Mother calmed AJ by breastfeeding her. AJ was surprisingly placated with sucking. The 20 cc syringe seemed huge (4 teaspoons). AJ’s blood trickled through the tiny 24-gauge catheter and finally filled up the barrel. “One good thing about a small needle…won’t have to worry about rapid hemodynamic collapse,” I watched, amused.

Twenty millilitres of blood out; twenty millilitres of intravenous fluid in. The procedure was repeated. Over the next hour and a half, we aspirated 60 mL of blood.

“Ok, check the Hb.”

“14.2 g/dl” NT reported.

“We’ll stop the transfusion then.” She turned off the IV drip and removed the oxygen. We waited.

“How is AJ doing?” It had been about an hour. Did AJ need another dose of diuretic to help his body excrete the excess fluid on his lungs? Was he still urinating freely indicating good kidney function? Questions continued to flood my consciousness.

“He’s fine,” AJ’s mother smiled.

I checked AJ’s chest. His breathing was slower, steady. I listened to his lungs. Still a little rough but improved. His oxygen saturation even without supplemental oxygen was 92%. I smiled. He was improving. He really was better.

With joy I shared the good news with my online colleagues. Baby AJ continued to improve. The next morning he went home. At his check up he was doing perfectly. His doctor is extremely grateful to God for the healing He provides. She is also immensely indebted to her team of international physicians of various specialties who provided much needed advice, expertise, and encouragement to a lonely, anxious mission doctor practicing the ancient art of bloodletting for the first time.

Thank you!

“And my God will supply all your needs according to His riches in glory in Christ Jesus. Now to our God and Father be the glory forever and ever. Amen.” Philippians 4:19,20

Hum? Sign says "talk to your doctor"... !