How was Africa?

How was Africa?

I usually say “good”. Here is what I mean.

It’s been a challenge to switch back to a different life so quickly. There are so many things about our time away that I think are tucked in the back of our mind / stuffed down in our souls. 

In addition to the joys and sorrows of the patient care there that I have already written about here, these are some of the elements that impacted me the most.

1) Taking a class in French language as a family was so eye opening in terms of how we learn differently, what each family member enjoys and despises and how we adjust to change. 

2) Every place has it’s unique beauty. France is historic and idyllic. The semi-arid climate of sub Saharan Africa has a dry desert look at times and a green savannah feel depending on when you are there. Now I am surrounded by lush grass and mist over open fields in the mornings in Indiana. The Europeans have a confident and sophisticated air about them. The Africans can pull of any color combination and have unmatched brawn, smooth skin and the highest cheek bones. The Americans all seem to wear cool tennis shoes, give lots of hugs and have the most colorful and cool hair styles. 

3) There was so much growth and valuable independence for our kids there. We can’t send our oldest sons to market to get groceries for us here. They can’t free-range their chickens in our subdivision. We’ll probably be more nervous here if we can’t find a kid at dinner time, but that was a common occurrence with our middle son off playing with his buddies. (We probably should have policed that a little closer - ha). There are some once in a lifetime things you just have to try - like bribing a 4 year old with a teddy bear and convincing your wife that she can climb the Eiffel tower with a baby carrier. 

4) There are people out there that you have never heard of that might just end up being you closest friends who change your life when you paths cross for a common endeavor. (No pics here for security reasons).

5) Some things take a leap of faith to get started. The scariest times are some of the closest times with God. If you cry out for help after taking a leap that God has called you to, he shows up in powerful ways.

Terminal 5 - so many emotions coming and going here.

If anyone reading this ever wants to hear more about our trip, get involved in the work there or something similar, let's grab lunch or send me a message or an email. Thanks for following along.

Mercy

While there are plenty of sad outcomes at a hospital like this - it's the surprisingly good ones that I want to remember.

Last week we closed our Lassa ward as the rainy season has begun and this lessens the interaction between the rats who carry the terrible virus (in search of water) and humans. Based on prior years' trends, it seemed like a long shot to ask God to protect our hospital entirely from the disease but he did! We had several suspects but all eventually tested negative and we made it through this dry season without any confirmed cases here.

The first suspect (based on symptoms and a screening questionnaire) set off the procedure of setting up an isolation ward, making concentrated bleach water wash and all the needed contact precautions. She was a young girl with a persistent fever of unclear source and recent hospitalization elsewhere - both red flags. You can imagine the terror in these kids who are isolated in a room away from their family and approached only by nurses cloaked in plastic protective gear. After she eventually tested negative and we were able to do more diagnostic studies, we found that she had a perforated esophagus. When we had her drink contrast it flowed freely into her chest behind her heart. In the absence of a stent to cover the hole or complex reconstructive surgery - this would often be fatal. 

Initial leak on right, follow up swallow study on left.

She had a coexisting pneumonia and was coughing up an unreal amount of pus. It’s unclear which process came first - the esophagus issue or the pneumonia. All I could do was place a chest tube to drain the fluid around her lung and a feeding tube in her stomach for direct nutrition. She wasn’t allow her to drink or eat by mouth for weeks. 

Through the amazing mercy of God, her esophagus healed. Many weeks later - after a negative leak test and then proving she could eat again - I got this photo of her the day we took out her feeding G-tube and discharged her from our care.

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I probably spent more time with this guy than any other patient in my time here. He recently lost both of his parents and then was badly burned in a field fire in Ghana. His chance of survival in this setting was low but so many people spent so much time in his care. I lost count of how many trips to the OR and how many skin gratings we did. I dreamed of the the day that he could come back to clinic. 

Here he is on the day we discharged him back to Ghana, giving me a high five which means his burn scar contractors are not too severe.

Thanks for praying for us and our patients. We see God a work here!

Dirt Bikes - by Avery

In West Africa, the cheapest form of transportation for the average Joe is the small motorcycle (aka “moto” ). These are used both for personal transportation and as taxis. These bikes are very often from Chinese companies who make extremely cheap scooters and motorcycles with an engine of 125cc or less, which is pretty small. 

I myself have a Yamaha YZ85 dirt bike, a higher quality bike imported from Japan. My dad was awesome to buy it for me, and we hope to sell it to another missionary kid here when we leave. This bike is a LOT of fun as it’s a 2-stroke competition bike with an amazing amount of torque. Even though it’s pretty small, I’ll say it’s way better and way faster than many bikes here. 

Although it’s a great bike, Yamaha is a Japanese company. Since it seems like 99% of all bikes here are Chinese, fixing a Yamaha/finding parts here is nearly impossible. There is a TON of dust in the air because of the desert and winds, so wear and tear on engines happens pretty quickly. Getting something like this here and keeping it running is quite an adventure. 

Garage David in Dapaong

Here are the steps we took:

1. Arrive in Mango and quickly figure out that our “car” is at the end of its life. It is clear that we need a few motorcycles to get to the market, for dad to go to and from the hospital quickly, and just for having fun (not much else to do for fun here).
2. Talk to “Uncle Adam”, the go-to missionary for logistics here,  about what motorcycle he would suggest we get. He says that Chinese bikes would get beat up pretty quickly and that we should instead consider a bike that he’s “had his eye on” in the capital city. He was, of course, talking about the 2014 2-stroke race bike at a place called “Garage Petite Japon” in Lome. He told us “that’s the bike I would get if I was you” and that it was “a great learning bike”. 
3. Take delivery of the bike from a taxi sent up from Lome (9-hour drive). It cost 800,000 CFA francs, or about 1,600 USD.  Who knows how many owners it’s been through; the cost of a new one at home is more like 5,000 USD.
4. Dad takes it for a test ride. When he comes back, we tell him that he did a small wheelie while starting out, and he didn’t know it.
5. Finley and I learn to ride our first motorcycle, which is in fact a competition motocross bike:0
6. Run out of gas and discover that 2-stroke oil isn't sold in our town. We borrow 1 liter of it from the construction shop on compound and promise to pay it back with an order of oil from Lome.
7. The bike manual says that some pretty serious maintenance has to done on the bike “every fifth race”. We don’t take it too seriously, but we do order some parts for the bike to be sent here when our Grandpa visits.
8. Grandpa’s flights get thrown out of whack because of weather issues, so instead of easy travel here, he has to fly from Indianapolis to Atlanta to Amsterdam to Casabalanca, Morocco to Conocou, Benin, and THEN to here. Almost before he even took off, we knew the luggage with our parts probably wouldn’t make it here because of all the switches.
9. Grandpa gets here with none of his bags. A few days later, we receive two of the three bags, and OF COURSE the most important parts were in the third bag. We highly suspect the bag was stolen because of the fact that Delta claims the bag was said to be delivered to the airport here..
10. Right after Grandpa leaves Togo, the ol’ YZ starts to have problems. Unburned oil starts to leak out of the muffler, and the bike has a rapid loss of power. Troubleshooting online says that it’s likely because of a worn piston, rings, or cylinder. Just so happens that those were the parts to be brought with Grandpa.
11. We do actually have the piston rings, which are usually the first thing to go bad in a motorcycle engine. Another missionary guy kindly offers to take us and the bike to Dapoang, a city north of here with a certified Yamaha workshop. We stuff the bike in the back of his Landcruiser. The people there do a nice job of putting the new rings in.
12. The bike runs great again….for about a day. It then starts having the same problems as before.
13. An older missionary kid here helps me clean out the carburetor, as that can also be a problem with these things. No improvement.
14. We order an engine rebuild kit on Ebay and ship it to Iowa City  to be sent to a visiting medical student who will bring it out here. There isn’t good enough internet on the hospital compound, so I have to go into town to another house to order it.
15. The medical student arrives with all his bags! We send the to Daopong along with the parts laid in the back of a station wagon taxi and receive it back 4 days later.
16. After 3 months of sitting in the garage on a stand, it finally works!

Brothers

Plenty of fun places to ride here!

Ride to the Ghana border

Some noise and air pollution :)

Because

As I think through the potential “why” answers in my previous post,  I have been trying to journal my personal answer. Here are my top 5 reasons based on my 6 months away so far.

1) Calling / obedience - 14 years  ago I came to Togo as a medical student. A series of events that followed convinced me that one of my God-given purposes in life is to continue to help out here. While we couldn’t have known what that would look like from year to year - we have tried to make progress toward joining in what God is doing here.  Elements along the way - career change, supportive co-workers / family / friends and all the ways God encourages us through his mercy on us and the people here - keep us linked to this work.

2) I love and admire West African people. I think they must be some of the toughest people on Earth. They are very stoic in the face of suffering yet warm and gregarious in daily life. 

3) We have friends here. You get to work with amazing teammates in places like this. Many have a unique view of the world, understanding what seems like an alternate universe in terms of cultural dos and don’ts, developing world financial realities and life in the absence of basic infrastructure. Some have an unstoppable faith and commitment. Some are in the second half of life and bring a wealth of knowledge and experience to the problems at hand here. It is a close knit community in many ways - something I haven’t always experienced in life elsewhere.

4) I want to hold the big disparities in our world in my mind. Something along the lines of “to whom much is given, much is required.” A few examples of what I mean…  When we asked our guard for help killing a rat in the chicken coop - he did it fearlessly (I wasn’t about to get near the giant thing) and then cleaned it and cooked it over a makeshift campfire that same night. We spend more in a week in groceries alone than some laborers here make in months. I drive past half-clothed kids at the local dump and ladies carrying water on their heads to their homes and then shop for fully finished homes online for our return to Stateside life. Yesterday, a patient came in with this non-union femur X-ray from a nearby sizable city - the impression at the bottom means “good healing”. 

5) I want to love without fear and raise kids who do too.

Recently I had a terrifying nightmare of a terrorist attack here. I woke up with so much adrenaline release that it took awhile for my pounding heart to slow down. 

The following morning I read a BBC News story about an attack in the country to the north of us, this time on the French embassy there.

http://www.bbc.com/news/world-africa-43257453 

Later that day I was taking time on rounds to explain post-op care to a patient. I had repaired his bilateral groin hernias the day prior, the fourth such attempt for him. He had first undergone surgery at an “Arab Hospital” (later he clarified a Qatari one) in Cote d’Ivoire followed by two hernia repairs in Burkina. 

He was very happy that he had essentially no post-op pain in comparison to the pain that he described of prior operations. This was probably because I had severed a few nerves in cutting through all the scar tissue from his prior operations.  He seemed to really understand my explanation of how the hernia mesh I had placed works (my typical “reinforcing wire in concrete” analogy). I suggested he follow up in a month, at which time he pointed out that he lived north of Ouagadougou and it would be difficult to return. 

I had this fleeting thought - “What if he is one of the ‘bad guys’?”…. I asked, “If he is from so far away, why did he come here?” He said he had heard that “the work here is good,” as my translator put it. Now we were tracking together through smiles, both happy that our paths had crossed. I made him a deal - if he had no post-op problems - he didn’t need to return for follow up. I explained the 10 kg lifting restrictions. He asked about his relationships with his wives. I felt that we had a mutual understanding of his recovery plan. If I didn’t hear from him again, I’d assume he was doing well. 

Then, I asked if I could pray for him before he left. “No problem” was the reply throughout the translator…. I felt the nudge to go further. I explained that I had read just that morning about the problems in Ouagadougou and I told him I would pray for him and the Burkina people. My translator, who also happened to have trained some as a nurse in Burkina, and the patient seemed to appreciated where I was coming from. I asked God some of my typical requests for patients who I am about to discharge… thanking him for them, asking for their healing, asking that they would know Jesus better though their time here. But for this guy - I added prayer for his people, for peace and safety. 

It was a special time filled with the joy of love edging out fear.

Why

“It is worth asking why a health care professional who is capable, respected and experienced would leave his or her home, job and loved ones to go to a challenging, exhausting and possibly dangerous destination.”

This sentence leads off a very insightful section in the Global Humanitarian Medicine and Disaster Relief chapter in Wilderness Medicine, a fascinating textbook in the medical library here. 

According to the authors, providing medical relief is the primary motivation for most involved in this work. This relief first involves action such as a surgical procedure or consult, then being with patients physically and emotionally in their suffering and then bearing witness so that those suffering do not do so alone.

It has been helpful to read a concise list of potential answers to this “why” question, to reflect on my own motives and to understand where others involved in this type work might be coming from. Each reason listed in the chapter has merits and drawbacks and it is noted that many ideals are “mulled over” in the course of these deployments. Here are my take-home notes from the textbook on this subject.

1. Help people in need / relieve suffering - This is a laudable goal that the world could aspire toward more. One drawback is when the “helper’s high” or “doing something good” can be self-serving and used as a means to a personal end. This desire might not suffice if the culture served in has no grid for “volunteering” and assumes an ulterior motive for the service. While volunteerism is commendable it can lead to financial and domestic difficulties if not done with balance.
2. Testing oneself - In the absence of diagnostic technology or readily available specialists, an austere environment might hone physical exam skills, resurrect knowledge from medical school days or push some into learning new procedures. In contrast - skills needed in your home role might be neglected and require re-learning.
3. Medical tourism / adventurism - Our credentials can be a ticket to world travel. Having a “cross-cultural experience” has many benefits but this attitude might segue to “voyeurism and reductionism that can trivialize patients and their situation.”
4. “Check-mark syndrome” - Working in an emergency situation is just “one more box to tick off the list of having done it all.”
5. Fleeing a negative situation / finding oneself - Some may be looking to get away from personal relationship failure, professional frustration, or disillusionment with values of their home society. They might find a cause to channel their energy toward. 
6. Personal conviction, philosophy or religious belief - These ideals can serve as a sufficient motivation to serve and advocate. People of this mindset might feel that the suffering they see needs be shared with a wider audience and speak up on behalf of their patients. Local governments might not share the worker’s sense of social justice or beliefs which can limit their advocacy in the interest of patient or team safety.  Challenges arise when “there is discordance between foreign ideals and local culture, politics and traditional power structures.”

The section in the textbook concludes with an observation that we are all complicated humans who sometimes experience boredom and ambivalence in the midst of joy and fulfillment. However, we better understand the human condition when we enter into and see the “beauty and brutality” of the lives of others. This challenges our ideas about how the world works. Also, we see what we have in common can transcend great distance and our differences in language and culture.

Lassa

This is a very well-written recent article about a disease that surfaces in this part of the world at this time of year.

Lassa Fever Erupts in Nigeria - the New York Times

Because people with Lassa Fever who need to be hospitalized are often quite ill, they tend to be the more severe cases and have high viral loads that increase the risk of transmission to healthcare workers.

My friend Todd died of this illness and was the index case in this region two years ago. The date of his death (Feb 26) is actually the anniversary of the opening of the hospital that he was so instrumental in building.

Some of our teammates here have spent amazing amounts of time to get us prepared for this season. Any time a patient presents with a fever, we have to run through a checklist to profile their risk of having Lassa Fever and it adds another dimension to the stress and ethical complexity in caring for these patients. It is a gut check to consider our love for our patients and if that love is enough to conquer fear.

I remember thinking soon after Todd died that this horrible disease needs a protective vaccine against it.  So, I am very excited to learn of the funds and collaboration being directed by the Bill and Melinda Gates Foundation, vaccine companies and others toward this goal! There are two sometimes competing thoughts in my mind about these sorts of healthcare disparities in the world. On the one hand - you “change the world by changing systems” and on the other you change it “one life at a time.”

...Got the T-shirt

It was such an encouragement to host friends from back home for a brief stay earlier this month. My dad and an orthopedic surgeon friend travelled a long and weather altered route from Indianapolis - (scratch Detroit) - Atlanta - Amsterdam - Casablanca, Morrocoo - Conocou,Benin - to here….. for an 8 day stay. Predictably their luggage was lost in the shuffle but the bulk of it made it eventually. 

We worked hard to see and facilitate operations for many patients with long-standing orthopedic problems. There were times of high yield learning and fun adventures too. 

It was a rare privilege to have my dad in the operating room with us.

It is a blessing to have a wise, energetic and adventuresome dad for me and grandpa for my children. He liked off-road motor biking more than I would have guessed. I found something he is actually afraid of. Hippos!

However, I think the memory of going to see them was worth it.

Baby

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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.