An African Gentleman

This really is just an random rural African man waiting to be seen in clinic. Believe it or not, the temperature at the time this picture was taken was somewhere between 80-100 deg. (roughly).

I puzzled at the frequent sight of men walking along the roadside on a hot, sunny, 100 degree day in a full suit, until a Zimbabwean friend told me that the saying here is "The Gentleman has no weather."

Good day, gentlemen...

Today

I hope you’ll forgive me for the massive number of blog posts today in such a short time. The internet here is generally very slow, but for some reason this afternoon it’s blazing fast. I write a few blog drafts off and on, but so often don’t upload them because getting the pictures online is torturous. Somehow this one ended up as a very long rambling post about my day. In any case, here goes.

This morning  (a few days ago) our friends from Ashland, KS, left Karanda to return home. They had been here for ten days installing screens in the Karanda Mission Hospital Guesthouse where we and other volunteers stay. 

The building is quite large, and they designed and built wood frames with screens for approx. 50 windows. Toward the end it became apparent that only 4 of 12 boxes of staples needed for fastening the screens made it into the luggage, but God provided through Dr. Stephens who happened to have wood staples at his house. They finished with about 50 remaining. It reminded us of Jesus’ feeding 5000 with the loaves and fished. The crew consisted of three- Ben and Kaila Anderson, he is a hospital administrator and she is in school for social work, as well as Chance Wilkinson, who works in maintenance at the Ashland hospital. All three are great people who love Jesus, and have hearts willing to travel halfway across the world to serve us and the people of rural Zimbabwe.

After breakfast with Lisa and Jude, I headed off to devotions for the nursing students at 7am. There are usually 60 or so in attendance, plus miscellaneous other staff. Thursdays have been my day to lead, so this morning I spoke about Jesus teaching that we should be salt and light from Matthew.  Many of the nursing students are believers, but not all.

The next item of the day was hospital rounds. The last week or two we have noticed that the census is dropping off, both in the number coming for outpatient clinic visits as well as inpatients on the wards. A few weeks ago the wards were full and we were working until 6pm every night, but since the rains have started it feels like a different place. The local staff say this is because, with the rains, people are now working their fields, and travel is more difficult due to high rivers.

Each of the medical providers here takes a different ward each month, and this month I am rounding daily in female ward. Each day brings a mixture of patients waiting for or recovering from surgery, older patients with chronic illnesses, acute infections or illnesses, and then many patients with HIV and/or Tuberculosis and the opportunistic infections that accompany HIV. Accurately diagnosing and treating these conditions here is the most challenging medicine I have seen, as the infections are complicated, and the available laboratory and diagnostic tests are very limited. Nonetheless, we do our best, praying and trusting God to give us wisdom and use the treatment resources to the best of our abilities.

After rounds, I stopped by theatre (OR) and scrubbed in to a VP shunt surgery that was in progress with Dr. Stephens. These are the kids I wrote about earlier with the “big heads,” swollen with cerebrospinal fluid that their bodies don’t drain correctly. We broke for teatime and them came back to finish another VP shunt placement on another child.

Each day  at 10:00 am we break for “tea,” a religiously observed custom in Zimbabwe carried over from the days of British colonization. Some days we actually drink tea, but most days it means a 30 min. break to walk home and see Lisa and play with Jude for awhile. This is one of those elements of Zimbabwean culture that I wish I could transport to America, since we’ve so much enjoyed the extra family time each day.

The rest of the day held an assortment of other surgeries and procedures. For some reason the hospital water system was turned off at 1 pm, so after that we had no running water. I walked out of an operating room, taking off my gloves to find that there was no running water to wash off the latex powder. There were still several procedures to be done and patients to see, so this meant no hand-washing in-between. There is a large trash can filled with clean water that can be used if needed, but I left that for the scrub techs who were dipping into it for water to clean dirty surgical instruments before sending them to the sterilizing machine.

We finished up in theatre mid-afternoon, so I headed to the outpatient clinic to help out by seeing any remaining patients. There I visited with a young male patient in his early 20s, complaining of blood in his urine as well as genital warts. He was well-dressed and from Harare (the capital city), but had ridden the half-day bus-ride to Karanda seeking treatment, not uncommon here. After a urine analysis we discovered he had Schistosomiasis, a tropical disease contracted after swimming in freshwater lakes or rivers infested with this parasite. They burrow through the skin, into the blood vessels, and this particular form eventually live in the bladder lining, where they cause inflammation leading to blood in the urine, and if left long enough, cancer of the bladder.

I gave him a prescription to treat the parasitic infection, and then took him to a procedure room to remove his genital warts. During the procedure I asked him what his plan was to prevent himself from getting HIV. (He hadn’t yet been tested, but I was being optimistic). He said circumcision (a new finding in recent years that is being promoted here in Africa) as well as “not sleeping around. I told him those were both good ideas. We finished up and I headed home. As I walked away from the hospital, we met on the sidewalk again, so I walked with him out to the parking lot. As we walked out, he thanked me for his treatment and asked, “So what should I do about her?” I asked who her was, and he said it was his girlfriend. He said he had had sex only one time, and was concerned about sexually transmitted diseases. I told him the best thing they could do was both get tested for HIV, wait to have sex until they were married, and then be faithful to their spouse, since that’s the way God designed it to be. I asked if he had any spiritual beliefs, and his reply was, “I am a Christian,” and “I read the Bible.” He then said, “my girlfriend called me recently and wants to go to church.” I encouraged him to be a leader and take her to church soon. He seemed encouraged by the entire interaction, and asked for my Zimbabwe cell phone number. I told him that I was only in the country for a few more weeks, but if he had a reason to come back to Karanda during that time I would be here. Unfortunately we only had a short time to talk, as he needed to catch a ride back to the city.

Interactions like this make me wish I was here longer, as medicine is a great avenue to meet people during their time of need and provide encouragement toward living a healthy life, as well as to introduce them to Jesus, who created them, loves them, and alone can truly bring the fulfillment they are seeking for their lives. This is difficult to do with the short amount of time available with each patient in the hospital, but from time to time opportunities arise to move beyond the physical condition at hand to the inner issues that are often plaguing patients just as severely.

I headed home a little after 5 pm, feeling the need to wash my hands after going an entire afternoon without running water. Thankfully there was water left in the hot water tank of our house that served the purpose well. At that moment I realized that I’ve adjusted to the intermittent/lack of electricity without much of a problem, but running water is something I’ve rarely been without, and I’m finding it harder to let go of, especially in a hospital setting. Thankfully this doesn’t happen very often, even here, but it raised all kinds of questions when I realized that running water is still a relatively new invention in our world, and even more so in rural Africa. There are in fact numerous families living without running water or electricity barely 100 yards outside the hospital compound. It’s one thing to see others live that way, but it’s different when the experience becomes personal.

 
Just the night before we had eaten dinner with Ben, Kaila, and Chance (our friends here to install window screens) in the home of Mai Kedere, who lives with her two sons and niece in a mud-brick house about a mile from the hospital.  

She gets her water from a hand-pump about ¼ mile from her house, and her electricity come from a solar panel on her roof, which powers a small radio and a single bare light bulb in the living room. Nonetheless, the food was excellent, and her hospitality was great as always. Her husband died ten years ago from HIV. He passed it to her before he died, but she is healthy and doing well on medication, and working hard everyday to expand her gardens and subsistence farm to the point that she can sell crops to support her family and send her kids to school. One of the local missionaries has become a good friend of hers, and often provides her with bags of fertilizer and seed to help support her farming endeavors in ways she could not on her own. Whether you visit in her home or see her walking past the hospital, she is always quick to greet you with a big smile and a hug, and talk about how the Lord has blessed her and been good to her even to today.

So, I arrived home to find that Lisa and Jude were out visiting friends, and decided to go for a run. I headed uphill toward the airstrip (Karanda sits on the side of a small mountain/large hill) to see a beautiful sunset beginning over the top of the hill with massive clouds trailing the sun. Looking out over the landscape from up on the hill I could see a sea of African scrub forest, with occasional clusters of huts dotting the landscape. I was struck again with the strangeness of my surroundings, but also with how familiar they’ve become after almost four months. The run was refreshing and tiring, and I arrived home to find Lisa and Jude returned and supper in process. After supper I put Jude to bed while Lisa went to a prayer meeting that is held every Thursday evening for the missionaries and senior hospital staff. It is a time of prayer regarding any issues occurring in the life of the hospital, and we usually take turns going or staying home with Jude. The electricity was off, and when Lisa returned she found me fast asleep on the couch in the dark.

It’s hard to believe we’re coming down to the final weeks of our stay here. We’ve met many wonderful African friends here that we will miss. I don’t think I’ll know what to do with myself when I have fast internet that doesn’t require waiting several minutes for my email to load and make uploading pictures a huge exercise in patience. At the same time, I think I’ll actually miss not having electricity at nights, which means eating supper by candlelight and finding ways to spend the evening that include mostly reading and relaxing with friends and family. This pace of life has been much healthier for our family than residency was, what a blessing.

Burn Contractures

Burns are so much more common in the developing world than they are in America. The majority of rural people in African and in many other countries have no or intermittent electricity, and still cook over open fires. Young children are prone to falling into the fires, whether accidentally or as a result of seiure disorders. Occasionally people here use kerosene or "paraffin" stoves, which are also a major cause of burns.

Burn wounds often require skin grafting, which means shaving a strip of skin from a healthy part of the body, often the thigh, and sewing or stapling it to the burn-affected area. If a burn is severe or not treated early, it may heal with a "contracture," where the skin contracts together, and limited the normal mobility of a joint.

This young 8 year-old boy had two contractures. Here you can see that his knee joint has limited motion, as he is not able to fully extend it due to scar tissue.






His foot also healed with a severe contracture, seen below. In the picture you can see the hand of Dr. Roland Stephens, who is my teacher and mentor here at Karanda. He turned 80 years-old last year and still practices full-time full-spectrum surgery.




On this day we were able to perform a surgery to release these contractures, restoring full mobility to this boy's knee and foot. The foot portion required a small skin graft but should heal well. Very little is more gratifying than restoring function to a portion of the body that was previously limited. Surgeries like this in the U.S. are so rare that they would be done only by a plastic surgeon, but they are in fact fairly simple to do, and there is such a huge need in the developing world. This case is just one illustration of the reasons we are here at Karanda, to learn practical skills through which we can glorify God by taking something diseased and unusable, and making it functional again. What a privilege.

Clubbed Feet

I just wrote about burn contractures, and here I want to highlight another great procedure done here at Karanda. This young girl was born with "clubbed feet," as you can see from the pictures below.











By means of a fairly simple 45-minute surgery, her feet can be restored to their proper position. She may never play soccer, but she will certainly walk normally, and grow up without the obvious deformity in the pictures above. Surgeries like this in the U.S. are done only by specialists, but this surgery, just like the burn contractures I mentioned in another post, is not that technically difficult once someone has done a few. I count it a privilege to learn skills such as these, such that God may choose to use me as a simple family physician to be a blessing to children like this one in the future, who would otherwise have no chance at a cure.

Freezing patients

I have now had enough experiences with small children and objects stuck in noses to know that Ketamine is a gift from God. Awhile back I watched someone struggle for 30 min. against a 5 year old with the help of the child's father and a surgery tech., but with no success in removing the object. We came back after a break, gave him ketamine in his IV, he froze in sleep, and we had the object out in less than a minute.

Last week another small child came in with something reportedly stuck in his nose. He thrashed and screamed as the nurse injected ketamine into his IV. A few minutes later the object was removed without difficulty, and he was waking up peacefully on the bed.

This man had a posterior dislocation of his 5th MCP joint - the knuckle where the finger meets the hand. It needed to be put back into place, but this would cause severe pain if he was awake.



This picture was taken just after ketamine was given in his IV, and shows how patients tend to "freeze" in whatever position they receive the medication. While he slept we put the finger back into place and applied a splint. Oh, and he also woke up singing.

Crocodiles and land mines

You never know though what might come through the doors of Karanda Mission Hospital.

This guy came too close to a land mine.




The Mozambique border is not far to the north of us, and there are unfortunately many land mines remaining from the civil war in the late 1970s.


Recently a 16 year-old girl was brought to the theatre (surgery) with the report that she had been bitten by a crocodile. She was with her brothers using mosquito net to fish in a river when she was attacked. The report was that it was a small one, which is why she escaped.







The incident had actually happened the day before, so by the time she arrived to us her wounds were already infected, with pus and dead tissue that needed to be removed. The pictures above unfortunately don't do justice to the multitude of puncture wounds. We didn't count but guessed at around 50-60 that had to be cleaned out and packed, meaning we stuffed sterile gauze in the holes to allow the wounds to drain. She did have two puncture wounds on her face unfortunately, but they should heal if the infection can be controlled.

Patient updates

I thought it would be a good idea to write updates on a couple of patients I had written about previously.

Clayton Mufambi is the guy who had a large mass resected from his face. He returned for a follow-up visit and is doing well.





He did require another small skin graft. Before he left I gave him a Shona Bible as I had promised, with verses written in the front cover regarding topics we had discussed during his hospital stay. He expressed his gratefulness for how God had blessed him through Karanda.


Another update on a smaller patient - the 2.5 lb. baby of the HIV positive mother is now over 3 lbs. She still has another couple of pounds to go before she gets to go home.





The nurse taking care of her was excited to show me a Zimbabwean method of caring for pre-term babies, called the "Kangaroo method."





Here are mom and baby kangaroo-style, skin-to-skin. They say that pre-term babies carried this way grow more quickly than other babies. It's God's natural built-in incubator.

Babies and Goats

Babies are usually born after about 40 weeks in their mothers' wombs.




This baby was born after only 28 weeks, which is early for the U.S., and extremely early for Zimbabwe. She weighs about 2.5 lbs.




Her mother sits and sleeps next to the baby warmer day and night, just as you would expect.

Her mother is also HIV positive. This brings a dilemma. Should the new mother breast feed her infant, increasing the infant's chances of contracting HIV, or... what other option is there?

This mother, like most rural Africans, cannot afford "formula" milk, so as is the case for many infants of HIV positive mothers, this young baby must either drink her mother's breast milk or starve, a decision in which this infant will have no say, but will profoundly affect her life.

It is for babies like this that Karanda Hospital has a "goat program." Goats are raised and given to HIV positive mothers, who then feed their new infants exclusively goats' milk to reduce the risk of HIV transmission.

So far the program has been supportably significantly by donations to the TEAM missions organization, but recently funding has become much more of challenge. A full grown goat sells for $25, raising a baby goat even less. I can't think of a better place to give.

Work and Play

These last few weeks have been a mix of work and play. After several weeks of uneventful work at the hospital, we took off for a few days in mid-October to drive to Victoria Falls, which is one of the seven natural wonders of the world, at the junction of four countries- Zimbabwe, Zambia, Namibia, and Botswana. Lisa's parents accompanied us, as they had just come for a two week visit. 

On the way to the falls we stopped at Hwange National Park, a huge game preserve with 39,000 elephants! We took a 2 hour game drive through the bush during which we saw giraffe, zebra, cheetah, hippos, ostrich, kudu, impala & springbuck, and of course MANY elephants. We survived a "mock-charge" by a mother elephant. I tend to think of elephants as docile creatures, but try to imagine sitting in the back of a small pickup truck about 30 feet from the largest land mammal (20 tons or so) as it is trumpeting loudly with its trunk in the air, pawing the ground, and flapping its ears at you. 

It gets your adrenaline pumping. Our driver stood his ground and revved the engine of our tiny truck, and the elephant backed down. Afterward he told us, "they usually give a mock-charge before a real one." Not sure what would have been the result of a "real one"...

We spent many hours driving on our recent vacation, and saw so many kinds of wildlife along the roadside and crossing the road that we came up with our own African wildlife road game. If you hit a cow, you earn 20 points. If you hit a goat, you get only 5 points. For hitting a donkey you get zero points because the animal is not smart enough to know it shouldn't be in the road. If you hit a lion, you automatically win the game, because your odds of that are so small, and finally, if you hit an elephant, well... you lose.

On the way home at dusk Lisa thought she saw a lion running off into the bush. Lions are rarely if ever seen on game drives, as they sleep during the day and hunt at night. Because we had to drive across most of the country to make it to the Falls, we spent a night at Antelope Park, a game reserve that breeds lions and teaches them to hunt in the wild. There we had our fill of lion interaction, as we were able to take about a one hour walk with three 10 month-old lions. 

At 18 months they release them into a large fenced in acreage filled with zebra, impala, etc. After several months of learning to hunt, they are sorted into groups and released into much larger game parks. 

Lisa loved having her mom here at the hospital this past week for encouragement and companionship. Her Dad helped us out by designing a frame to use in applying screens to the windows of the hospital guesthouse. The windows here are odd sizes and not made for screens, but with malaria, hot weather, and no A/C, screens make a huge difference. 

We also participated in a "hog butchering" with the Siamukwari's, an African family we have learned to know, and later that evening had a feast of grilled pork with them and other friends from here at Karanda.

I learned the hard way that I shouldn't have worn flip-flops to slaughter an animal in Africa. A nest of large black ants came running at the first smell of blood, and I happened to be standing right in the middle of their highway between home and a feast of pig remnants.

The weekend before Lisa's parents left Karanda, the local church invited an evangelist from Harare to speak to hospital workers as well as at the local "shops," which is a collection of bars and small stores near the hospital. 

There are small churches in the area, including one next to the hospital, however many local people practice only traditional animistic African spirituality. Alcoholism is definitely a problem here as well. The evangelist held meetings on the hospital grounds during the day, and at the shops at night for several nights, with a good turnout of local people each night. Many people including thirty hospital workers committed their lives to Jesus Christ. God is at work here at Karanda.