The gift of a safe delivery

As Dinya, the clinical officer, prayed, I quickly pushed the ketamine into the patient’s IV. I watched her carefully; she was struggling to relax.  After thirty seconds or so her face began to relax. Dinya began pinching folds of skin on her abdomen, while I watched her body language for tension, to ensure she was numb enough to begin the c-section.

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Five months in, it was my first time running anesthesia for a c-section independently. Since we’ve moved here, I have been working at the hospital on Thursdays. Matthew stays home with the kids and I am grateful for a husband that’s willing to jobshare a bit so I can be part of the action. It is true, though, that coming in only once a week has made for a slow onramp to feeling anywhere close to confident. Anesthesia in particular feels like something a nurse should have, oh, at least an additional Master’s degree in.

My preceptor, Kitty, poked her head into the OR. “You ok?” she asked. But I was; I was feeling like I could anticipate solving several problems independently before I’d call her for backup. It had helped that we’d been together with some difficult cases. “All right. Let me know if you need me.”

I turned back to the patient, and I watched the monitor as her oxygen level promptly dropped from 100… to 96… to 92… to 87. Right. I propped her jaw forward to open her airway further. Nothing. Time for oxygen. I watched her oxygen saturation rise again, and offered a quick prayer of thanks.

It was clear even a few minutes in that she was metabolizing the ketamine quickly. She began to grimace a little, to sing a little. I watched her carefully and prayed; sometimes ketamine just makes you talk. It can also cause uterine tension and make baby a little slow to start breathing. I really didn’t want to have to give her any more if I didn’t have to.

The blood pressure machine was broken, so I assigned a midwife student to take the patient’s blood pressure every few minutes manually for me. I also decided she needed a little more ketamine, explaining to the visiting doula who was shadowing why I was hesitant to do so.

A few minutes after that, Lo and Dinya pulled a 3-kg baby out. The cord was wrapped around the baby’s neck three times. “Right,” Lo said matter-of-factly in her Irish accent,. “this one definitely wasn’t coming out normally.”

In America, having a c-section can be a mark of shame for a woman. My first child was delivered via cesarean; when the doctor announced that, at the eleventh hour, Naomi had flipped into breech position, and with my water already broken, a c-section was our only option, quiet tears rolled down my face. I remember talking a friend through feelings of disappointment that she wasn’t able to deliver her baby vaginally, receiving positive e-mails from a VBAC (vaginal birth after cesarean) support group listing tips for talking to your doctor, reading in a childbirth book about ways to delay c-sections, and trying to drum up as many suggestions as possible for convincing your doctor to give you more time to do it yourself, as it were. To be fair, there are reasons why c-sections are not preferable to vaginal births. I pursued a VBAC with our second child, and was glad for the easier recovery. But as the baby’s cries rang in the air, indicating health and liveliness, I was reminded, again, that having a c-section available to me, done by competent health care professionals was, and is a gift.

It was a gift that multiple competent doctors were ready at that hour of the morning when we went into the OR for Naomi’s delivery. It was a gift when Dave, the scrub tech, walked into the OR and cussed audibly because I was sitting on the table getting my spinal block put in. It was a gift when Rose, labor and delivery warhorse that she is, kept a close eye on my heartrate when it dropped into the 40s after surgery. And my anesthesiologist, Tom, was definitely a gift, as he explained to me what was going on behind the curtain– despite the fact that I had been in c-sections as baby nurse before, being the patient was a little scary for me. He walked me through it with a caring manner and kept me pain-free.

I took the bucket containing the placenta and blood out to the pit behind the incinerator. Emerging from the OR into the sunshine was a breath of fresh air. I made a mental note to bleach my shoes the next day. What a gift.

 

 

Malaria, Typhoid, or Both?

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:

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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!

Writing Roundup: Baltimore

At the risk of being self-indulgent, here goes: I don’t live in Baltimore anymore, though I miss it and our community there quite fiercely. At this one-year mark of the events that centered around the neighborhood Maggie and I lived in for 6 years and will always love, I’m reposting below several articles I wrote before and after. There are many other good things written at the time which I tried to link generously to therein, and you should follow these links.

A few things have changed and I look forward to seeing how people who are willing to learn from the past might change the future of Sandtown and places like it. The people who were committed to Sandtown long before it became newsworthy are still there and still doing the long, slow, grueling work of rebuilding foundations. They’ll keep working as long as they can and they still need prayers, support, love, and fellow travelers. I wrote these things mostly to help communicate their perspectives and wisdom, which have shaped me in ways that I am still trying to discern.

Faith, Fatalism, and Freddie Gray– A broader historical take that looks at the role the church can play in healing the wounds caused by civic neglect and structural racism.

Run Towards The Pain– This essay focuses on the role of minor leaders in mediating the work of community advocates who have remained or returned to struggling neighborhoods.

The Need For Neighbors– Perhaps more relevant now than it was then, as efforts to “revitalize” have multiplied, this piece discusses the importance of knowing and caring for one another as neighbors willing to bear risk together.

From Reaction to Action– City Paper was kind to publish this “Op-Alt”, with a lot of specific suggestions for community organizations and churches doing good work in Sandtown.

Let Sandtown Speak For Itself– I found too many opinions about Sandtown last year were assuming a fairly monolithic “voice of the community”, so I tried to highlight some different voices.

The Policing Baltimore Needs– I doubt this piece had anything to do with it, but I’m happy to say that many of the suggestions here have gained some traction in the past year. We’ll see how they work out in the years to come.

Is Black Lives Matter Overblown?– I took on more about policing and how we might think about a more positive construction for how to fight for public safety in tough places.

Why Bernie Sanders Shouldn’t Call Baltimore “Third World”– More on the struggles of universalizing particular narratives in regards to Baltimore neighborhoods.

 

February/March Writing Roundup

Things slowed down in February but lately a bunch of things I’ve written (some quite a while ago) have been making their way out, so here you go!

Needing My Neighbor– I wrote this one for Plough Magazine, a quarterly dedicated to faith in action, about my struggle with pornography and how my ideals about being a social justice-y Christian were driving me further into addiction. Fortunately, my friends and mentors in Sandtown were there to help me find a way back into healing and along the way I learned some more things about what a more holistic approach to mental health might be.

Building the Virtuous Neighborhood– There’s been some debate lately (and some assumptions for a very long time) about the importance of cultivating virtuous behavior in fighting poverty and reckoning with the sense of victimhood. I wrote about how we can’t assume that virtue and economic self-sufficiency are a closed system and how we can go about promoting the sorts of responsibility and care we want to see flourish.

How the Church Heals– My second Christianity Today column, about the role of the local church in public health.

How The Wingfeather Saga Reshapes Our Imaginations to Love Others– I love the Wingfeather Saga books and I’m thrilled that they’re doing a Kickstarter to bring the stories to the screen. I wrote about how the series slowly builds to a powerful message about loving foreign invaders– yes, even the ones who want to kill us.

Social Justice is Boring– The rhetoric around missions and social justice is often quite charged and exciting, but the work of actually serving and loving others is usually a bit more boring. I wrote about how we can rethink our approach to be more comprehensive and inclusive.

 

Slice of life: chicken edition

Robirda is our chicken. We have been working on adding to our flock, so far to no avail. No matter. She has enough sass for a whole brood of hens. (Sassy seems to be the only type of woman we keep around the Loftus homestead…)

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Robirda has one flaw, and that is that she likes to hang out at the hospital all day. One Thursday when I was working she casually sauntered onto the peds ward. The patients got a good laugh at me chasing her as she ducked under beds. Someone did help me catch her, and I took her home and kept her penned up for a few days. It didn’t really stick, though. The next day that I worked she was hanging out at the patient waiting area. I  joked to Anna, the nurse I was working with in antenatal clinic that I like to take my pets to work with me. She laughed and said, “Me too”– her dog had been sleeping in front of the clinic all morning!

On yet another day, Matthew carried Robirda home, looking a little harried. The health department had just arrived for an inspection. I don’t think they would have been very happy to see Robirda hanging out with the lab technicians…

Robirda likes to roam the whole hospital. Multiple people have told me they are ready to take her home and eat her. I hope not– she just started laying little eggs with bright yellow yolks (the other eggs you can get in town have very pale yolks, suggestive of low nutrition).

But maybe she does have something else in her future. Short term nurse Lydia has had several heart-to-hearts with Robirda in the administrative office at the hospital, which led her to text me one day about “prayerfully considering Robirda to CO (clinical officer) school.” Well. Medical education is certainly a passion for us. We’re not ruling it out.

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Robirda and her benefactor enjoying a nice swing.

Cuttin’ for the very first time

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!

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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.

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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]

 

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How to be a nurse

Each week I get to work one day at the hospital while Matthew is home with the kids. I feel like I am taking a crash course in nursing all over again, this time in a low resource setting where the language, culture, and names of medicines are different– and the acuity tends to be much higher. When we first got here it had been ten months since my last shift, as I stopped working before Leo was born. I’m slowly figuring out how things work (no weeklong orientation or orientation protocols here, though the preceptors are pretty great), and how I can be helpful. Every day can look different, depending on who walks into the hospital. One of my first mornings I worked, I shadowed Kitty, a fellow missionary nurse. In between keeping meds stocked, making sure staff has shown up and clinic gets started, dressings for major wounds get changed, the morning looked like this:

  • Starting with prayers with fellow missionary nurses
  • Joining in with staff devotions
  • Listen in on the first half of staff education hour, glad for the opportunity to refresh on the pathophysiology of pre-eclampsia20160114_100602
  • Begin CPAP for a 29 week baby just born (footling breech) who is retracting deeply. CPAP is set up using neonatal oxygen tubing that’s split– one end gets tied off and the other goes 6 cm into water to provide adequate pressure for respiratory support
  • Greet a guard whose baby was born on Christmas and ask how baby Immanuel and his mom are doing in Arabic. (I realized after I walked away that I asked how MY baby was doing, not HIS… grateful he understood what I meant!)20160114_114747
  • Assist with setting up a c-section, helping the doctor start a spinal, getting set up for anesthesia using ketamine when the spinal didn’t take, setting up to receive the baby, running anesthesia for said c-section (went well, phew!). Get patient cleaned up, transferred to the antepartum unit (which doubles as postpartum).20160114_125247
  • Head to the office to catch up with Kitty, getting intercepted by the x-ray tech, Morris, who is drying an abdominal xray for said 29-weeker to check the UVC (an IV that goes into the umbilical cord) placement. Get asked opinion on whether or not it was advanced too far, into the heart. Observe that wow, it does look like the line goes up into the chest and then curves, then
  • Snap back to my senses and remind myself that though I just played the part of a nurse anesthetist, I am DEFINITELY not a radiologist, and say, “Hmm, what did Dr. Perry think?”
  • Go to lunch. That was only the first half of the day!

December/January Writing Roundup

The pace is slowing down a little bit, but I had enough sleepless nights from jet lag to bang out a few unsolicited opinions.

Is Black Lives Matter Overblown?– There’s been a lot of discussion about the Black Lives Matter movement and a lot of people are skeptical. I tried to take skeptics’ concerns seriously and write an article demonstrating how one could– and should– support the goals of Black Lives Matter even if the tactics or underlying ideologies might make you squeamish. Tyler Burns and Drew Dixon also invited me onto the CaPC Digest podcast to discuss this article and we had a great conversation about police reform, public justice, and loving your local community.

Songs For The Fight– Music has always meant a lot to me and good music has gotten me through some dark places. I wrote about how I got to meet Andrew Peterson one time and how our conversation demonstrated how doctors and artists need one another in the Body of Christ. Also, why I wish sometimes that I could be a lawyer, social worker, or an independent singer-songwriter.

Rain For Roots: Music That Teaches Us To Wait For The Lord– One of the albums that has been getting us through the tough parts of our transition to South Sudan is Rain For Roots’ “Waiting Songs”. This was ostensibly a kids’ album, but it– like other good art made for children– can be good for adults, too.

The Christ and Pop Culture 25: #6-#10– Every year, Christ and Pop Culture does a list of their 25 favorite people & cultural artifacts. I wrote the blurb for Wesley Hill’s book Spiritual Friendship, which made it to #10 on the list. If you’ve been following me for any length of time you know I love Wes’ work and I loved this book, so if you were waiting for one more push to go buy it, here you go!

Why Bernie Sanders Shouldn’t Call Baltimore “Third World”– Bernie Sanders was thoughtful enough to make a campaign stop in Sandtown, but while there he described the neighborhood as looking like a “Third World country”. I wrote about how that mindset and language constrains our political imaginations and undermines the sort of development we’d want to see in Sandtown.

So what are you doing now that you’re finally there?

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?

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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).

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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!

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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.

Slice of Life: Burning the Yard Edition

I am learning lots about how to live in South Sudan. How to cook on a small iron cookstove, how to be a surgery nurse in an operating room with flies in it, the words to all of the ingredients I need at the market… the list is endless. But this week I learned how to set my yard on fire.

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Our corner of South Sudan is covered in beautiful teak leaves. The trees provide beautiful wood, nice shade, and soundproofing. But during hot season, the enormous leaves dry out and fall. The sound they make when they land on the tin roof and screeech their way off before making a slight crashing sound on the ground was actually mildly alarming before we realized what it was.

The side yard of the house we’re staying in has a sizeable grove of teak trees. The leaves keep on piling up. People have been seeing more snakes than usual (so I’m told– I haven’t seen one yet, which I’m fine with), and burning them takes away their place to hide.  So our girl-neighbors came over and sweetly asked if they could help me out by setting fire to the leaf piles. So we got to work.

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Sweeping

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Small girl setting things on fire. Nothing to see here.

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Gratuitous baby who amused himself on the porch far away from burning leaves