Trauma Stewardship

I recently read Trauma Stewardship - An Everyday Guide to Caring for Self While Caring for Others by Lipsky and Burk. It wasn't an easy read and is not a particularly well written book, but it did shine a light on challenges of staying healthy in the midst the heartbreak that is so prevalent here.

It’s not that any one scenario has been overly traumatic, but there is a steady dose of suffering, death and frustrating experiences in this type of work. The most beneficial section of the book was the list of “trauma exposure” responses, as I recognized some of my own tendencies in the list. Here are the ten that resonated the most with me including my personal examples and each with a supporting comic illustration from the book.

1) Feeling helpless and hopeless - thinking that what you are doing doesn't really matter in the end (systematically).

2) A sense that one can never do enough - but that you must still try to do enough.

3) Hyper-vigilance - double checking and micromanaging.

4) Inability to embrace complexity - preferring the simplistic explanations in my mind like "they just don't care" over "there is probably   a cultural explanation for their lack of urgency."

5) Minimizing - My wife and kids can out me on this one whenever I ignore their complaints and explain they "don't know how bad some people have it."

6) Chronic Exhaustion - I am trying to give myself space on this, learning from a senior surgeon that you just don't have the same stamina in this climate (I take 12 minute power naps after lunch almost every day).

7) Inability to Listen / Deliberate Avoidance - I am prone to this when facing patients who I can't offer a quick solution to and prefer to have someone else deal with them or make the interaction as short as possible.

8) Sense of persecution - thinking that my credentials back home carry little weight here, I just have to "fit into the system" and I don't get respected if I can't communicate well.

9) Anger and Cynicism - I really try to avoid this but I suspect this tendency is proportional to time spent here. New people come in and see the beauty and the hope. The long-term teammates buried their founding colleague out by the soccer field....life is hard... there is opposition around every corner.

10) Grandiosity: An Inflated Sense of Importance Related to One’s Work - I want to take credit for good outcomes but not bad ones.

Joyeux Noel

We miss family and our culture and Christmas cards from our friends these days - especially the increasingly rare white Christmas! It felt cold this Christmas morning here too - down to 69 degrees overnight.

It has been refreshing, even if feels odd, to take a breather from some of the holiday hassle which allows us to focus on the deeper meaning of Christmas. "God with us" is a global phenomenon indeed!

Here is the latest picture of our clan.  It seems like a long time ago since our we sent our last Christmas photo referencing a summer surprise - he has been a highlight of our year and is perched on my lap in this photo.  It has been a year with plenty of moving and packing for us as we sold our home in March, lived in a rural rental home for the summer, crammed into an apartment in France for language training time and are now settled into hospital compound life in Togo. We are enjoying our friends, the people here and all the ways these experiences make us think.

If you sent us a Christmas card - hopefully it was forwarded so that we can view it when we return to the US (scheduled for June) and we can update you on our new address with a mailed card next year.

Wishing peace and togetherness and joy to all our friends and family back home!

Love,

The Hubers

Big Radius Surgery Group

Healthcare organizations think strategically about their catchment area - the population they draw their patients from. Along these lines, I came up with a “name” for our small, two-person surgery group here - Big Radius Surgery Group. 

Dr. Nattier is the kind of guy you just want to bust through walls with. It is good to be here to work with a close friend. I hope he doesn’t get tired of me because, as the surgery roster shows, we are slotted to spend a lot of time together over the next 1/2 year.

We have seen our fair share of challenging cases lately, many in pediatric patients from as far away as Nigeria and with advanced stages of disease. We alternate call every other night and often end up with our “own” patients which is efficient and much like my practice back home. However, we tackle the more challenging cases together.

A lady presented to our clinic recently with Grave’s Disease - an autoimmune disorder that results in the thyroid gland enlarging and overproducing thyroid hormone. This can be treated with radioactive iodine but that isn’t available here. 

This patients had the characteristic bug eyed appearance of the disease and all the signs of thyrotoxicosis - pulse in 130s, profuse sweating, an enormous thyroid taking up the entire width of her neck and with so much vascularity that you could feel the bruit hum of blood flow when you touched it. We started with medications to slow thyroid hormone production and slow her heart rate. When she didn’t show for the next appointment, I fretted that she had died and regretted not admitting her at that first appointment. Thankfully she resurfaced with many of the symptoms under control and desiring the risky operation of thyroidectomy in attempt for cure of her hyperthyroidism and to relieve the pressure that her enormous thyroid placed on the other structures in her neck. 

There is a lot of give and take conversations in these two person operations - 

“Do you think that’s the nerve?” as we search diligently for the recurrent laryngeal nerve that moves the vocal cords…. “Oh - there is the parathyroid gland!” as we try to preserve the body’s calcium regulating gland that sits right next to the thyroid…. “I think you got it” when the bleeding stops after a delicately placed suture.

She is recovering well after her subtotal thyroidectomy. We tried to leave enough thyroid gland behind to minimize her need for thyroid hormone replacement and we continue to monitor her for that. When she removes her head covering her neck looks a lot different now. Her bug eyed appearance (proptosis that is due to Grave’s disease) is waning. She has a strong voice and can breath and swallow normally. These are little things that we sweat over before surgery and rejoice to see afterward.

Another challenge was this million dollar smile boy from Benin with a huge mass (sarcoma) in his right thigh. It had been growing for many months and was starting cause pain and affect his gait. We weren’t certain from examining him that it what relation this mass had to his femoral artery or if we would be able to salvage his leg. Thankfully - we were able to get what appeared grossly to be a complete resection, sacrificing a significant part his quadriceps in the process. 

The pathology results aren’t available yet but we do have some chemotherapy options here for these types of tumors so we are prayerfully optimistic about this little boy’s life! He is walking and smiling with his adoring mom. 

The big radius encompasses many wonderful people. It is a joy to be here among them.

Typhoid

After finishing a C-Section during one of my first call nights here, the pediatrician on call asked me to see a young boy she had admitted with a four day history of abdominal pain.  He had significant pain, most localized to the right lower abdomen, and a fever. She had started antibiotics and was asking about my opinion about his need for surgical intervention. 

These kids are stoic and hard to read. Many don’t know French and I don’t know if they understand my simple inquires about their pain. This boy was silent and still but grimaced and grabbed my arm when I palpated his abdomen. Here in Togo the most likely cause of severe abdominal pain and fever in children is typhoid fever caused by a Salmonella bacteria from contaminated water.  This infection predominantly affects the last part of the small intestine before it joins the colon. Appendicitis is always another possibility for children with these symptoms. I didn’t know which problem we were dealing with and obviously couldn’t just check a CT Scan of his abdomen to find out.  We decided that an overnight trial of powerful antibiotics was a reasonable first step.

The following morning he was worse and surgery was clearly necessary. We encountered a lower abdomen full of pus and 5 holes in his small intestine. Salmonella typhi creates abscesses in the wall of small intestine that then open and create full thickness holes that contaminate the entire abdomen with bowel contents.

The surgical options included trying to repair all the holes or removing the severely diseased segment of intestine that contains them. Because these kids are often not well nourished at baseline and present here in an advanced stage of the disease - they don't always heal well. There is a significant risk of bowel repairs breaking down and leaking within days of the original operation - recreating the infected abdomen scenario. However, I thought that the risks of him not healing an intestinal anastamosis or not surviving in his village with an ostomy (either one or the other would be required if an intestinal resection was done) were higher.

I think hard about these sorts of decision - not really knowing the “right” answer. I decided to do the best repair of each hole that I could, closing them in layers and trying to not narrow his intestines too much or cause an obstruction in this process.

Thankfully, he improved steadily with fevers resolving, pain decreasing and the output from the drain I had left in his abdomen showing no signs of subsequent leak. By the fifth day after his operation he was eating again, tolerating oral medications and ready for discharge. He was still very weak and wore a consistently blank expression on his face, but I felt he was safe in the care of his mom.

I was so happy to seem him walk into clinic like this- looking much more bright eyed and happy and without signs of infection!

We see many people who we can’t help from a medical standpoint, often times it is hard to prove the diagnosis and we see death occur all too often. These kids who come in sick and then are restored back to health are special. We thank God for his mercy on them. We tuck them away in our memory, learn from them and keep trying when the next patient like them comes in.

Citizenship

Our U.S. Embassy’s vice consular was here at the hospital compound yesterday to discuss a wide variety of topics. A former marine with a Master’s Degree in political science from a University in Moscow, he was a very effective communicator with a broad perspective and I am glad I and my older boys could learn from him.

The Embassy includes a much bigger contingent of Americans and Togolese workers than I realized with a primary mission of serving Americans who happen to be here. I really appreciate their efforts.

His outreach topics included passport services, certificates of birth overseas, etc. that apply more to the long term folks here (like our friends the Nattiers who have a baby on the way). He covered security and the processes that the embassy uses to monitor the political situation here and keep us updated. He also addressed visas and immigration services which I found so interesting, particularly in light of the fact that the diversity visa program has been a focus of the news back home. 

https://www.theatlantic.com/politics/archive/2017/11/the-diversity-lottery-immigration/544850/

This lottery program has become very popular here in Africa and he stated that last year, our neighbor Ghana set the per capita record when 5% of the population registered for  a random chance to immigrate to America. Of course the program is a set up for all kinds of fraud where cybercafe owners charge people to register online an then extract additional fees if people actually win the lottery. But basically, for a small fee and with an internet connection, anyone in the world can register for a chance to win one of the 50,000 annual immigration visas to America.

In his explanation of his office’s task of safe guarding the integrity of the passport application and renewal process, the vice consular said the U.S. Passport is the most sought after document in the world. It struck me that everybody in my family gets one, just for being born.

There are so many mysteries in life. Each time we come home after dark and see our guard sitting on this bench by our driveway these questions surface in my mind. I think he get’s paid about $60 per month to watch our house and the others on our little road at night. At their school, our boys learned that during the day our guard works in nearby fields. Life just seems hard for so many here.

I read in another blog recently that privilege shouldn’t make us feel guilty but it should make us feel responsible. 

New Address

Thankfully, we have safely made it to our new home (for the next 8 months) will all of our luggage and in good health! We have been warmly welcomed by old and new friends are thankful to have a home to stay in (with a nice basketball hoop and an old Land Cruiser to use). We even managed to get 4 bikes left here up and running (yes, the bike repair guy transported all of them on the back of his moto).

Within the past 2 weeks we have wrapped up our brief language training, transported twenty some suitcases over thousands of miles, stockpiled food food for a family of 8, made some serious climate adjustments, and started new school and new work. Whew!

It is good to be here. I am proud of the flexibilty and resiliency of this team!

We thank God for protection in our travels and the kindness of people we have encountered on the journey.

Fishing in France

A very persistent 12-year-old boy’s 24-step process for catching a fish from the Loire River:

1. Order a collapsable fishing rod and mini-tackle box from Amazon at the very last minute so it arrives the day before departure.
2. Pack these items in your dad’s shoe in an overstuffed bag
3. Research fish that you can catch from the Loire River on YouTube. Start daydreaming about the enormous fish you can catch there.
4. Fly to France.
5. Take a 3 hr taxi ride to a town near the Loire River.
6. Ask your mom to look for fishing line, that you failed to obtain before departing home, when she takes a taxi to the "Marche” for groceries the day after arrival in your new town. She tells you they don’t have it there.
7. Start French language school.
8. Walk (500 feet elevation drop and climb back) to the same grocery store with your dad and find entire fishing section there that your mom did not see. Purchase fishing line.
9. Research fishing license requirements in France.
10. By the third day of French class - begin asking your teacher about local fishing and where you can get a fishing license.
11. Your teacher tells you that a “carte de peche” in France can only be obtained from a bar that sells tobacco?!
12. Ask your teacher if you can just order the “Carted de Peche” online and use the school printer. She laughs at you and tells you that this is a very funny idea… but that France is quite unlike the USA in this regard.  When something, like a fishing license, requires a permit from the Government to be able to sell it - you will definitely have to go that exact place of business with said permit to obtain it.
13. Walk with your dad to the “Bar Tabac” that your teacher recommends. Use google translator app and your collective limited French to inquire about your fishing license. They tell you they don’t sell it but refer you to a bar in the nearby town in the valley closer to the Loire River. The exact name and location of this bar is unclear after your short conversation with the bartender.
14. Walk to the tourism office and ask about fishing licenses there. The kind lady there with good English will tell you that she hopes you can get a Carte de Peche from the same grocery store that you purchased your fishing line. 
15. Hike to the grocery store again. The check out lady there confirms that they sell fish but clearly they do not sell fishing permits.
16. Have dad rent bikes so you can ride to the nearby town in search of a licence. For 14 Euros per day he rents 7-gear bikes with not totally inflated tires.
17. Ride to the larger town in the valley near the river with your fishing pole in your backpack.
18. Use Michelin GPS map app to find the Bar Tabac that you think you were referred to by the bartender in your your town.
19. They will tell you they don’t sell fishing licenses but that a bar down the street does. They point you in the right direction but it is difficult to know what distance they are describing (hope they mean meters and not kilometers).
20. Find the "Bar PMU" they referred you to just a few hundred meters away.
21. Unbelievably - when you ask “Vendez-vous carte de peche?” the bartender says “Oui!”
22. Provide your name, date of birth and address and she disappears behind a door marked "Privee" for awhile and then returns with your official Carte de Peche!
23. Continue by bike to the Loire River.
24. Real in a barbel (smaller than the ones on YouTube) on the first cast!

Festivendanges

The grape harvest is wrapping up here in Sancerre. We have learned that the hills, rocky soil and climate in our area here create a perfect spot to grow grapes.  This makes wine (and tourism) the main industry here. When we first arrived,  tractors pulling wagons full of grapes were a very common site but harvest seems to be wrapping up now. The smells and sites are refreshing breaks from class.

 


We had the, ahem, privilege of being right in the middle of the festival that celebrates the completion of the harvest - called Festivendanges. By right in the middle I mean this was the view from our kitchen window.

In some ways this was nice - free live music right into our apartment and free VIP passes for everybody b/c we had to walk through the concert to get into our own front door (after a bag search by security). Some of the bands were good. The Moorings (mix of celtic / folk / rock) endeared me to the electric violin. However, by law music / noise making is supposed to end at 2 AM. Apparently, this rule is routinely bent and the last band of the Friday night concert, The Flemish Flamingo's, played some odd form of disco consisting almost entirely of deep thumping base.

It was so awful that it reminded me of a sleep deprivation interrogation technique that could be roughly recreated by someone standing outside your closed bedroom door and pounding it every two seconds with their fist hard enough to rattle the lamps and windows. At one point my delirious wife told me she thought she was going to lose her mind.

So, at 2:25 AM I did what any man of the house would do - I got dressed, got my google translator app and waded into the concert. It wasn't pretty but I got my point across. After failing to convince the sound control guy I approached a security officer and pleaded my case. The event director took notice and shut it down for the night.

The next day we visited the event food stand stand right outside our door for lunch and managed to order for everyone in French. The goat cheese on hamburger combo here is amazing! The event director I encountered in the middle of the night passed by and we were able to communicate with some non-verbals, his limited English and my limited French. Hilarious! He was very kind and bought our drinks and really looked out for us through the rest of the festival.

Language Learning

We are settled into our small apartment, all eight of us, here in Sancerre, France. We are gradually learning our way around this beautiful historic town.

The picture above shows where we attend language school for 3.5 hours each day. We have an amazing teacher who somehow manages to keep 3 adults and boys from age 8 - 14 engaged in learning. Going to class as an entire family is a unique and enjoyable experience. The boys are quick learners and we adults have some advantage in that we have all taken some Spanish classes in the past. The younger kids fit right in and are surprisingly not very distracting. The learning is a team effort that, so far, has been good for everyone I think.

We started at the very beginning with the alphabet and numbers and have been adding pronunciation, vocabulary, grammar and essential phrases. We have been here for about a week and a half now and I am very excited with our progress. I am impressed with the immersion aspect and how it affects learning.  Our teacher teaches only in French (we can ask for English explanations when needed). Each day we go on a "mission" to places like the local brulangerie (bakery),  charcuterie (deli),  or la poste (post office), etc. to practice our French and become more functional here. We usually incorporate a game (the first one was Uno) to keep it fun and facilitate more practice. There is of course homework and all the daily life stuff of trying to keep kids (age 2 months to 14 years) sane in a small apartment.

Just to survive though - you are forced to learn quickly. The google translator app is a real life saver  at the supermarket, reading cooking instructions, talking to security (another blog post) and just understanding signs to keep yourself out of trouble. I'll write more about that stuff later :).

We are thankful to be here and think this is an essential step toward being able to help more effectively in Togo.

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The photos below show our apartment entrance (blue door with a big tower in the background), our walk to class and a pic from the first day of school.

On Time

Here we go again! This time with a bigger team and for a little longer.

We are all set to be in France for a month and then Togo for 8 months. 

We'll try to keep you updated though this blog.

We feel very loved and supported as we leave the USA today and we thank you.