Honor and shame dominate many cultural interactions here. High-status positions within medicine bring honor and occasionally a sense of entitlement. Correcting anyone in front of other people is felt to be shameful, which makes the back-and-forth of medical education quite difficult. In my residency training, the best teachers were the ones who interrogated my diagnoses and treatment plans until they had found holes in my reasoning, pointed them out for everyone to see, and challenged me about how to think differently about clinical problems. Even changing previously written orders while on rounds together can bring shame to the clinician who wrote the now-abrogated order. (To be fair, my experiences in the American medical system had plenty of hurt feelings over honor and shame!)

Our challenge is to work within the existing culture and recognize its strengths (America is learning what can happen when you keep saying “anyone can be President!”) while encouraging people to take on Christlike humility. It is not easy to be humble in any culture, but it’s particularly challenging in a place where saving face is more important than getting things done and throwing one’s weight around is often the only recourse for maintaining a high standard of care for our patients.

I wasn’t really thinking about this at 4AM on a Sunday morning when poor Graham got roused from sleep to come help me with a surgery, but he was.

I had already been awake for two hours, trying to get the c-section done quickly enough to go back to bed before church. It seemed fairly routine, though I was having trouble controlling the bleeding after I got the baby out and I didn’t know why. I’ve now been doing c-sections on my own routinely, trading off cutting and sewing with some of our clinical officers so that they can grow in experience, too. I hadn’t called for help from one of the more experienced doctors in over a month, but after I had already done all I could do, I felt like I had no other choice but to call for assistance.

One of the great strengths that both expatriate doctors who have both been here for years share is their sense of calm in life-and-death situations. (Read more about Jeff here and Graham here.) It was no different this early Sunday morning as I held pressure and Graham ambled into the operating theatre, putting on a mask and leaning over to look into my surgical field as I threw my hands up in exasperated fear that I had done something wrong.

In a manner meant as much for the staff gathered in the room as for me, he mentioned a time when he had made a mistake at the step in the operation I was stuck at. After a few minutes of looking around, I realized that I had followed in Graham’s footsteps and made exactly the same mistake!

This was my first time that I’d had to cut my own sutures in the middle of an operation. It was not a pleasant experience to undo my very thorough (and very wrong) work, then keep the rest of the surgical team up for an extra half hour while I fixed my mistake. The patient and her baby did fine, but I was of course ashamed and discouraged because I’d made such an ugly mistake.

When I got home, Graham had already written me an email. It was a perfect example, he suggested, of how peers correct each other and accept correction while maintaining mutual respect. While I would personally like to have opportunities to be a light and a witness in ways other than “models humility when wrong”, I was really thankful that we were able to have that interaction as an demonstrate something that the long-term workers have been talking about for years.

Every medical team, no matter where they are practicing, will make mistakes. And no matter where you are, the people involved will feel the urge to save face and resist correction instead of being honest and working together to find a solution. We need good systems and protocols in place to catch mistake before they cause harm, but we also need humble-hearted clinicians to take responsibility and change course, even if it might mean admitting you were wrong in a culture where doing so brings shame. I don’t know when my next opportunity to learn something the hard way will come (hopefully at a more reasonable time of day), but I’ll certainly look at it as an opportunity to teach, too.

All four of us have had malaria now– mild cases for everyone, fortunately, but I can assure you that it’s no fun. It’s particularly vexing for our family because we use an awful lot of precious Nutella and jam to get the kids to take their awful-tasting Mefloquine every week, and we aren’t the only family taking prophylaxis faithfully to get malaria this year– several other folks here on campus who take medications ostensibly to prevent us from ever getting it have had to settle for “at least we didn’t need to be admitted for it”.

Sadly, children in the community without the luxury of living right next to the hospital or taking prophylaxis haven’t been as fortunate. The rains seemed to have started a little earlier this year, and whether the parasite itself is getting more virulent or the mosquitoes are biting more, we are seeing more cases requiring transfusions and deaths several times a week in young children.

With very little data to work with besides our own overflowing wards (and similar stories from other clinics and hospital all over town), we can only conclude that transmission of the parasite is more frequent and the best we can do is test as early as possible and treat as quickly as possible.

Fortunately, malaria is one of the few diagnoses we can reliably make in the hospital because you can see it on a blood smear. The lab tests we can order all fit nicely on a half-sheet of paper, and half of these we rarely order anyway:

However, malaria shares a number of clinical features with typhoid– both cause fevers, headache, dizziness, abdominal pains, vomiting, joint and muscle aches. The main differences when taking a history are that typhoid tends to cause constipation while malaria can sometimes cause more diarrhea and malaria tends to be much faster in onset– but that’s about it, at least in the first week of illness.

You can order labs for typhoid, though– the Widal test, an old serologic test that measures antibodies to the Salmonella typhi bacteria. Unfortunately, this test can’t distinguish between current infection, previous infection, or successful immunization, so in a population where typhoid is quite common there are quite a few false positives. This hasn’t seemed to slow down the test’s popularity, as it is still used quite a bit because it is cheap and quick.

When discussing patients with our clinical officers and nurses, we often have to remind them of this false-positive problem and ask if there are really enough clinical symptoms present to convincingly make a diagnosis of malaria and typhoid. Many of our patients are sick enough to justify using antibiotics to cover typhoid in addition to antiparasitic drugs for malaria, but many aren’t. We certainly don’t want to expose our patients to potential side effects or create antibiotic resistance in an area where few drugs are available. We also don’t want to waste precious resources since the drugs we do get are imported and patients pay more for each drug we order! Thus, in the midst of our current wet season with malaria popping up everywhere and causing more severe cases than usual, I prefer not to even use the Widal test unless I have a really good story that makes me think my patient has typhoid instead. (And even then, I’ll still check for malaria anyway.)

So I when started feeling achy and fatigued, I of course dilly-dallied for a day or two before finally getting tested– and I didn’t bother ordered a Widal, since I was vaccinated. My smear came back positive and I started on treatment. I was especially thankful that we had several other doctors at the hospital who could take over while I was sick– when we came for our survey trip, there were only two doctors working full-time and when one of them got sick or went on vacation, managing 40-50 patients a day was just up to one person!

I finished my three days of medication and woke up in the middle of the night, unable to go back to sleep because it hurt to roll over. I took ibuprofen and paracetamol but still felt awful and got caught up on a lot of podcasts as I gained a new appreciation for why the pediatric ward was always full of shrieking children. I spoke to our wise medical director, Graham, who recommended that with persistent symptoms, I should probably just start treatment for typhoid.

After a day of mostly sleeping and taking Amoxicillin, I felt great. I got up, jumped right back in on the wards, and didn’t take another dose of pain meds. I still don’t know if my symptoms were caused by typhoid, malaria, both, or neither– perhaps I had a virus that got better at the same time I started taking the antibiotic and just happened to have a positive malaria smear– but who knows? Here, we just have to do the best we can with what we have and continue to train enough medical professionals to assess and treat people with malaria quickly enough that they don’t require transfusions or get sick enough to die.

I still don’t order the Widal, though. And I’m trying to teach our staff to be more judicious with it, too!

When I was making my rank list for residency, we ended up having to choose between a hospital in Baltimore that would let us stay at New Song and a hospital where I could get more obstetrical and surgical experience. We ended up staying in Baltimore to finish my training and I know we made the right choice, but that meant I had a steeper learning curve once we got to Bet Eman.

I spent a lot of time in Maryland learning how to deal with polysubstance abuse, getting patients off multiple unnecessary medications, and managing complex medical and mental health conditions in the primary care setting. Here, there just aren’t very many drugs to abuse, most people have a hard time getting necessary medications, and there’s almost no such thing as primary care. (I’ll write a blog post later about what’s similar between South Sudan and Baltimore, but today we’ll only talk about the salient differences!)

To be useful in our hospital setting in the long-term, I knew I would have to get a crash course in more advanced obstetrics. I got to assist on a handful of c-sections in my training, but I never held the knife myself– until this month!

As you probably know, South Sudan is one of the most dangerous places in the world to be a pregnant woman or an unborn child. For whatever reason, there’s a certain percentage of babies that, for their sake and/or their mothers’ sake, need to get cut out. My own daughter was born by c-section. Without access to a c-section, that 10-20% of pregnancies will end in death or severe disability for mom, baby, or both. This story from MSF reminds me of a lot of the patients we see on a daily basis.

While we are passionate about preventive medicine and community health to keep people from getting sick or needing to come to the hospital in the first place (and Bet Eman sees hundreds of prenatal patients a month to keep pregnant mothers healthy!), there are sometimes when you need an operation to stay alive. Hence, I’m learning how to do c-sections so we can provide this service to the community– and once I’m fully trained, I can teach others who will work in places in South Sudan I can’t take my family.

We’ve had a lot of short-term visitors the past few months that have helped to lighten the load at the hospital, so I’ve also gotten to learn from a bunch of different family doctors as well as our South Sudanese medical officer (she trained in Uganda and has been a tremendous mentor in navigating the tough medical and cultural issues I’ve encountered so far!) Everyone does things a little differently, which is great for my education as I learn a variety of techniques and rationales for various decisions.

I regret to inform my mother that all of that hype about playing a lot of video games improving one’s hand-eye coordination and making one a better surgeon is probably not true (although I haven’t tried my hand at laparoscopic surgery yet, so who knows? I still play computer games for fun and relaxation, though, just like I’m sure Jim Elliott did.) Both Dr. Jeff and I have vision issues, so we have to work a little more slowly and drive our nurse-anesthestist crazy by asking them to raise and lower the bed constantly.

I still love the primary care aspects of my job. I miss my patients in Baltimore and their multiple unnecessary medications. However, I also love doing surgeries (as long as they’re short!) and there is a serious need for good surgical care here in South Sudan. (If you’re interested in learning more about how surgeons are starting formal training programs to train the health workers Africa needs, check out the great work of the Pan-African Academy of Christian Surgeons.) I’m thankful that I got the opportunities I had to learn in Baltimore and that I have mentors here at Bet Eman who are teaching me some hardcore obstetrics after I’ve finished residency.

I’ve gotten to hold the scalpel about ten times in the past 3 weeks and I know that I still have a few dozen more to go before I’ll be anywhere near “independent.” Some of the cases had some pretty hairy complications and the physician I was operating with had to take over for a few minutes. But even on my first one, after I got the baby out one of our South Sudanese clinical officers took over to do the sewing. He’ll be cutting himself soon.

[somewhat bloody but tasteful picture of me delivering the baby’s head after the obligatory Weird Al video]

Continue reading →

So after 11 years of feeling called, 7 years of medical training, 6 years of marriage, 2 years of support raising, and 4 months of packing up our house, we made it!

So what we are doing with our lives now that we’re off the plane?

Not shown: the 16 pieces of luggage we’d been hauling for 3 days

Well besides keeping the ol’ home fires burning (literally), we’re mostly working in the hospital and doing language lessons. Our goals for the first two years are pretty simple: learn how to capably practice medicine and nursing in the hospital, gain a basic proficiency in Juba Arabic, and build relationships with our co-workers, neighbors, and friends. Not as easy as it sounds when you can’t just run out to the store for groceries any time you feel like it and you’re on a multi-cultural team working in a very different culture.

Maggie is working one day a week in the hospital, learning how to do anesthesia for c-sections (hooray for ketamine!) and manage a growing staff of nurses and nurse-midwives from all over East Africa. The rest of the time, she’s at home with the kids trying to figure out what she can cook from our very limited pantry on the charcoal stove in our yard while I work at the hospital. I watch the kids while she works and so far have had one other day off per week to rest; I’m on call 2-3 nights a week depending on how many physicians are around.

I’m also learning how to manage obstetric emergencies and perform c-sections since I didn’t get to do much of either during my residency. Thus, I’ll often be on backup call to get experience in these things (and some other procedures). We expect that it’ll take about 6 months or so before I’m able to work independently (which will give the long-term doctors here a little relief and help us all balance the day-to-day clinical responsibilities with administrative work, family time, and other projects like research).

I make up for my lack of knowledge with my fundal-pressing skills.

There are technically 42 beds in the hospital split between maternity and pediatric patients, though oftentimes our capacity is exceeded and patients sleep on the floor or in the procedure room. We’ve been blessed recently to have lots of Clinical Officers (roughly the equivalent of Physician Assistants in the U.S.) who see patients with us and assist in procedures, so most days I’m supervising a team of 2-3 clinicians that sees 20-25 inpatients or 40-50 outpatients together. We also have antenatal clinic twice a week where one of the physicians reviews another 40-60 pregnant patients in addition to managing one of the wards. At any time, though, rounds or outpatient visits might be interrupted by the need to perform an urgent c-section, cast a fracture, or attend to a much sicker child who has come in.

Lots of Clinical Officers (as well as a growing roster of nurses) means lots of opportunities for education! In addition to weekly lectures (which have been going on for some time), we are now doing case conferences and grand rounds where we all discuss patients together. Advancing South Sudanese medical education is a big part of what we came here to do, so I’m excited to be doing it every day I’m in the hospital!

Ward rounds with the clinical officers, nurses, and students.

This is our work and these are our days. I miss the deep conversations I had with my patients in Baltimore and the half-hour block Healthcare for the Homeless gave me to have those conversations. I miss being able to order advanced diagnostic tests for my sickest patients when here I have to say, “If you have enough money, you could go to Uganda and they might be able to figure out what’s going on.” I miss being able to eat a Deluxe Spicy Chicken Sandwich when I had a bad day at work (not as much as the other things, of course). Still, it’s good to be here and we are glad to be figuring out what God has for us here day by day.