Today

Jamie took the children outside this morning to transplant tomatoes in the rain. Abigail came in first, covered in mud. I changed her into clean clothes. After two bowls of oatmeal with raisins and two Big Franks with ketchup, she was satisfied. The men came in and ate while wearing their muddy clothes. I washed the dishes in a tiny bowl of water, so they didn't feel really clean, and that made me feel a little grumpy. But then I was happy that we had water at all. I swept the floor.

"Baa, baa, baa, baa." Mama Sheep was bleating and stomping. It was a good day, because Jamie was home to take care of them this time! "You better go check on Mama Sheep!" I said. "She doesn't bleat like that unless there's something wrong."

He walked to the ewe, then ran away from her and then ran back to her. The next thing I saw was Jamie running, followed by three sheep! More ants! He planned for the sheep to run behind him to the backyard, but they had different thoughts. Spying the ripe papaya sitting on the front step that Jamie had picked that morning, they turned and started happily munching! When Jamie ran back from the backyard, there they were! He chased them away only to return to find the chickens claiming their share! Before they departed the front step, they left a deposit.

After putting Abigail to nap, I heard, "Cluck, cluck, cluck." Three hens were sitting in my dining room chairs! Grabbing a broom I shooed them outdoors and quickly disinfected the chairs and swept the floor.

Abigail awoke, and after she ate, three more hens ran into our house, with Jedidiah and Ellie the German Shepherd giving chase. Two went back outside, but the third one took off down the hallway, right into the children's room! She ran over all of my children's scattered toys and perched on top of their wooden kitchen. When I took her outside, there was Abigail, jumping in huge muddy puddles. I called her in and changed her clothes, again. And swept the floor.

Thankfully the water was flowing by that time and I began disinfecting toys. Then Jedidiah and his oversized puppy ran inside. Chunks of soil covered the floor and muddy paw prints marked a line to the dog food. Again, I swept the floor. The children took their baths.

Then Jamie came in, and the mud was from man-sized shoes and pants that time. I swept the floor. They ate supper while I sank into a chair with a headache.

Sometimes I just want to feel clean.

Our yard today

Welcome Back!

“Doctor, there is a patient in Maternity”.

It had been a good day of administrative discussions. As part of becoming the new Medical Director, I had spent the day catching up on the hospital business. We had wrapped up nicely by 5 pm. I had told my wife that I would be “home by 5:15”. She was obviously looking forward to it. 

“She is in labor, but the baby has no heartbeat”.

After the talks I decided to wander over to the Medical Ward as I had heard it was a “very busy day”. I hesitated as I thought about 5:15, but only being back in the hospital for a day, I thought I should at least show up to support our busy troops. I arrived to see a flurry of activity with our staff admitting, triaging, and treating multiple severely ill patients all at once. Our Clinical Officer was waving admission papers in his hand feeling the pull of multiple emergencies at once. A 29 year-old patient with hypoglycemia and alcohol intoxication had just pulled out his IV, and was about to seize and aspirate. He died a few hours later. 

“She is fully dilated, but having a lot of pain. The baby is not coming down”.

This story wasn’t sounding good. I looked around for a qualified delegate, but realized all hands on deck were busy. I reluctantly said goodbye to 5:15, and we went to see her together.

She was tired and pale. Her heart rate was fast, and blood pressure was low. She was tender in the middle of her abdomen, and while fully dilated, the baby was not coming. We discussed her. “Doctor, she is having strong contractions, if her uterus had ruptured, there would be no contractions”. That sounded reasonable, but something didn't make sense.

Uterine Rupture is one of the most feared complications of childbirth. It is also a leading cause of pregnancy-related death in Malawi. The most common risk factor is a previous Caesarian Section (which our patient had several years earlier).

I did an Ultrasound of the uterus. While I’m no expert at ultrasound scans, it seemed there was free blood in the abdomen. She needed a surgery.

In the Operating Theatre, her condition deteriorated. Heart rate going up, blood pressure going down; she was starting to get confused. Pulse 150. My pulse close to 150. We commenced the operation with a prayer for help. Blood gushed from the abdomen. The small rupture in her uterus had bled two liters into her abdominal cavity. An average human being has 5 liters of blood in their body. With the additional blood loss of surgery, she had lost at least 50% of her blood. We had 200 mls of blood available for transfusion (about half a pint). We started to give it. We removed the baby -- a perfect lifeless baby -- and proceeded to sew the uterus back together. Our Clinical Officer, Mikson, performed the surgery with skill far beyond his training. Jaqueline Uy, a Loma Linda University Family and Preventive Medicine Resident calmly assisted him in the procedure. I watched with admiration as the international team work to save a mother’s life.

Fortunately, we had the equipment to perform an autotransfusion of another 700 mLs of blood we could salvage from what she had lost.

The bleeding was arrested, her vital signs gradually improved. After thanking the team and ensuring she would be closely monitored all night, I started to head home a little after 8 o’clock. Her life hanging in the balance.

“5:15?”.

“I’m sorry”.

“You weren’t on call”.

Most developed countries have a maternal mortality rate of 20 maternal deaths per 100,000 live births or less. In Malawi the number is hard to know for sure, but is between 400-600. Easily 20-30 times higher than in the United States (which is far from the best in the world).

My children were energetically going to bed when I got home. “I was taking care of a mommy whose baby died”. I couldn’t help but notice how energetic and healthy they looked tonight. Jedidiah had lots of six year-old questions about how that was possible, and what we did about it. Abigail, our spunky two-year old, just got upset. “The mommy should have her baby. I want to pray for her.” She proceeded as only a sensitive angry two year-old could, “Dear Jesus, please help the Mommy that doesn’t have her baby. I don’t like that.  Amen”.

Hug your babies tonight; hug your mommies tonight. If you live in a country with good healthcare, thank God for it, and remember those who don't.

Ready to Return

It's time to go back.
Time to go back to...

fog that mysteriously rolls across the ground seconds before the sound of rain
squawing turacos in the brilliant orange flamboyant trees
chattering monkeys perched in the blue gum forests which rise like sentries amid rolling tea fields
chitenge clad women carrying baskets atop their heads with babies tied on their backs laughing together
the bleating response of goats to the goatherd's waved stick
rainy season's odor of decaying masuku fertilizing the tree from whence it grew
roller coaster pot-holed muddy roads
mournful wailing passing my house as another villager closes his eyes for the last time
jealousy and greed and entitled demands
missionary strife and discord
a battle that is more than flesh and blood