Sunday, April 24, 2011
I’ve had five maternal mortalities in my first 4 months of living in Tchad. It’s somehow harder for me to bear when a young woman here dies of a complication related to pregnancy and childbirth. Maybe it’s because my specialty is to help women here, and when I don’t or can’t, I feel a sense of failure.
I wrote about the first 2 already. The last 3 I didn’t know as well, but they were still my patients. They all came late and very sick. We had 2 die just last week. When you do all you can here, it’s of out of your hands.
I kept thinking this was so preventable as I sat by her bedside listening to her struggle to breath. She was gurgling. It’s the sound that I’ve heard all too often here. The sound of death coming.
What could I have done differently?
I should have pushed the issue of finding someone to donate blood on rounds this morning.
She came in for agitation after delivering at a local health center 4 days before. Her baby only weighed 1.7 kg (an all too common weight here). She wouldn’t breast feed her baby and was acting psychotic. She got admitted to medicine (Olen’s service).
They said she didn’t lose that much blood at her delivery, but her conjunctiva were quite pale. She got a unit of blood that was donated from a family member. She also had malaria and was started on quinine.
Olen transferred her to maternity.
Yesterday she looked better but not good. Her conjunctiva still looked pale, so we ordered another hemoglobin (takes a long time). I explained to the family that she needed more blood and that someone needed to donate more. The lab guy came and showed me that he had checked it already before the donation and her hemoglobin had been 2.7!!! Why didn’t I know this? Now it was 4.3.
Please someone donate blood! Her heart will give out if it works like this for long. It’s already been too many days!
She is the rare O negative blood type. We don’t even have any units of O negative right now in our bank.
She was eating. I helped her start to breast feed her tiny dehydrated baby. Her sister-in-law had been breastfeeding him some, but apparently not enough because his skin was all dried out and he was weak.
After a long discussion, two family members said they would check their blood types and try to donate blood. One was her mother, so I thought I had a good chance of getting an O negative.
Okay good....plan figured out. More blood, she’ll be better. I didn’t follow up on it, but Sandrine (the French Midwife volunteer that’s here for 10 days) helped the mother continue to breast feed her baby. She was producing milk and the baby was eating much better. I’m happy, this baby may live.
This morning I quickly did maternity rounds. Dr. Marc had already done surgery rounds and we were getting ready to start my vaginal hysterectomy.
She didn’t get any blood yesterday? Why not? No one was the right blood type. Please look for someone else to donate.
We did a hernia, then removed a lipoma. Dr. Marc is a great teacher in the OR. I’m excited about learning. At noon I ran into Tex (an aviation volunteer, really his name is Jonathan, but he’s from Texas). I remembered again about needing blood. He thought he was O negative. I asked him to donate.
No luck... he was O positive.
A couple more surgeries in the afternoon. Finally at 4pm we wrap things up and are about ready to go home. A nurse comes to say my anemic patient needs some attention.
I go to her bed. Wow, she looks awful. She is not breathing well. Her mother was already holding her mouth shut as they often do right before they die here.
What? She was eating and drinking this morning.
We must have waited too long with her anemia. Now she’s in cardiac failure from her anemia.
We still have no blood. It’s probably too late anyways to give blood. Her heart’s already shot. She’s probably in end-organ failure. My mind goes crazy. I should have pushed the issue harder this morning. We should have FOUND someone who was O negative.
I ask the nurse to get an IV and run to the OR to steal some fluids so we can start quickly. Her breathing is really loud and she’s making gurgling sounds in her mouth. I try to open her airway. Not really helpful.
We push a 1/2 liter of fluid in. We explain the gravity of the situation to the family again. I call Olen. I think it’s too late, but maybe he has an idea.
He and Dr. Marc came. What can we do? I say a silent prayer. Can you call Noel (the chaplain)? Simeon (anesthesia nurse) walks by and we ask him if he can bring the oxygen saturation.
She starts to breath quieter. No longer gurgling. She’s probably just tired of breathing.
Olen goes through a list out-loud of things that cause obtundation.
That’s weird, her oxygen saturation says 99%. I would think that if she were in cardiac failure from anemia, she’d be hypoxic.
Olen asks someone to find the lab guy to get a glucose level.
“The machine won’t work right now because it’s to hot,” the lab guy responds.
Can we get a hemoglobin?
Meanwhile the nurse working the guard tonight says that he is O negative. I beg him to donate blood, and he agrees. I don’t think she’ll survive long enough to actually get his blood.
Olen stays with the patient. I go to the office to finish some gyn ultrasounds fully expecting her to die soon. Olen says he’s seen too many gyn patients while I was in the OR.
I start with the first gyn patient. She’s had 3 pregnancies. All of her babies died at 7 or 8 months gestation. Very frequent here. I can’t figure out if they died before or after delivery.
Text from Olen: Oh no, I think, she’s died. “Bring me D50 (glucose).”
I ask the pharmacy to charge it to my account because it’s urgent and run it to Olen. Then I go back to continue my consult.
Text: “Bring me another D50.”
I pass off another one to a family member who was outside and continue my consult again.
Text: “She’s sitting up, eating and drinking now.”
No way. I’m so excited. It was hypoglycemia. I have to go see this.
She’s sitting up and drinking water out of a bowl. Praise God! We say a prayer in thanks with the family.
Meanwhile her hemoglobin is still 4.1, but she is getting a precious unit of O negative blood now. Her heart is somehow fine. Her sugar was too low, which can happen easily while on treatment with quinine.
Olen gave the husband the empty D50 bottle. He explained carefully that if this happened again in the night to demand that the nurse give a new one to the patient.
“I will extol the Lord at all times; his praise will always be on my lips. My soul will boast in the Lord; let the afflicted hear and rejoice. Glorify the Lord with me; let us exalt his name together.” Psalm 34: 1-4
Saturday, April 23, 2011
Relief can come in many ways. I am grateful for all of the ways!
The first: Dr. Mark and his family.
Samedi (our nurse who is a surgeon) is on vacation this month. Yeah for him. Boo for me. His vacation started a week ago. He’s mostly just staying at home because it’s expensive for anyone to travel here. We worked out a plan that if I needed to call him in for help, we would pay him extra. But....last weekend he went to the capital, N’DJamena for 5 days. So...I was stuck here knowing I had no other surgeon to help me. No hospital to transfer a patient. No one to call to consult. Olen and I are a team, but he hasn’t done very many surgeries.
So it felt a little overwhelming last weekend. I had a kid who had a hernia. I thought I’d have to operate on him, but he turned out to have meningitis. There were a few other cases that I managed to put off. There were some postoperative complications that I wished I had a surgeon to consult with too. Tuesday evening I had to bring a patient to the OR for a presumed ectopic pregnancy. Olen scrubbed with me. I really thought she had pelvic infectious disease (PID). The day before her ultrasound showed no intrauterine pregnancy....then Tuesday her pregnancy test was positive. So I couldn’t sit on her with how much pain she was having.
I never did find the ectopic pregnancy. She was very inflamed in her abdomen from her infection. I also did my first appendectomy by myself because it looked inflamed too. One salpingectomy and an appendectomy later, and we closed her.
Needless to say, it can be overwhelming doing tasks that are not your specialty.
Then Tuesday night Dr. Mark and his family came. What a relief! He is a general surgeon who specializes in Oncology from France. Double relief! He speaks French better than us! He has experience in all types of surgery. His wife is a Midwife and has been helping out in maternity too. His two oldest girls are here and are a breath of fresh air also. They out balloons to all the kids at the hospital.
Wednesday night Olen and I slept quite well. No one came to knock on the door after 10pm. We later found out that the nurses had found Dr. Mark and he went into the hospital for us twice that night.
We are learning much from him. I’ve decided to call Air France and cancel their tickets! I know I’m being selfish. But it’s nice to have more help around here. Don’t tell them that their tickets are being cancelled. We’ll just surprise them.
The second relief:
It’s been soooooooooooooooooooooo hot here! It’s 10pm as I’m typing this blog. It’s still 100 degrees F in the house. Sweat is poring down my neck. I don’t think anything of it. It’s normal. When you are not sweating it’s just because you’re not drinking enough. It’s really too hot to do anything. I was going to write another blog named “too hot.” But....it’s too hot to write another blog. I’m told April is the hottest month here. So luckily it’s almost May. I think we are going to freeze when we go back to the states and have air conditioning. Oh, how wonderful it will be to freeze.
Yesterday evening we went to Tammy’s to pick up Lyol after working another hot day. We were chatting in her house like we do sometimes because we were too lazy to walk the 20 feet to our house (I’m going to blame that one on the heat too).
Cory yelled out, “Rain!”
We all ran outside to feel large drops of rain fall on us. Huge gusts of wind blew through the mango trees on the compound. What a relief! Instantly it was cooler. We were all happy and excited. Lyol was running around naked and playing in the newly made mud, splashing in the puddles. It didn’t rain that long, but long enough to provide the first signs of relief to a hot and dry season.
|Samedi and I after a "hot" operation, and that is with air conditioning!|
Thursday, April 14, 2011
First of all, we’d like to thank everybody for the kind words of support we have received. We’re still getting several emails a day, everything from quick notes to personal testimonies. To those of you who have lost children after spending months and years raising them... I have no words. Continuing on takes a strength that few possess and I’m humbled by you.
We’re still trying to make sense of it all. We’ve heard all the explanations (from God killed him to stop him from becoming a murderous thief to... well... to better, more comforting explanations). We’ve gone through numerous stages of grieving. Piece by piece, we’ve started to put back together our house and put away painful memories and leave happy memories to be revisited in the future. We are able to smile, laugh and joke again.
Zeke’s clothes (really Lyol’s hand-me-downs), Zeke’s pacifiers, Zeke’s swaddling cloths (which he loved, despite the heat), Zeke’s bottles, Zeke’s formula and Zeke’s diapers have all been put away, ready for the next child we fall in love with, biological or otherwise. Zeke’s baby footprints (made posthumously) rest on the dresser. I keep thinking that I will move the toy chest, since it’s the first thing I see every day when I walk into the house, and it’s also the place Zeke spent most of his final morning. Zeke’s picture slideshow is all ready on our computer for anybody willing to take the time to get to know him. Our eyes still well up frequently, but the tears don’t overflow multiple times a day anymore. It still hurts to see babies.
Lying in bed this morning, I realized it’s been one week today since Zeke died. Although nobody has demanded it of us, we feel an update is appropriate.
The week has flown by instead of crawling, helping us to put some emotional distance between us and Zeke’s death. Gary and Wendy Roberts are the ones mostly responsible for that.
Gary and Wendy brought us ‘Olive Garden’ the night after Zeke died (homemade, there’s not actually any restaurants here). Pasta and salad. It was wonderful. Gary is a pilot for Adventist Medical Aviation just a couple kilometers down the road. Gary had to fly to Zakouma Wildlife Refuge on Friday, two days after Zeke’s death. He had a job there to work on an airplane.
Thursday, the day after Zeke died, Danae and I went to work and told the staff that we would be gone for the next three days. After working a full day Thursday (to make up for not working at all on Wednesday), we took off at 8AM Friday for Zakouma, about a three hour flight away.
Friday, Sabbath and Sunday, we had a four-wheel-drive car at our disposal to tool around the game park anywhere and at anytime. Gary was our tour guide and we saw lions, elephants, giraffe, antelope, buffalo, birds, crocodiles, warthogs and everything in between. It was wonderful.
Monday morning we flew home and started work at noon. By now we’ve caught up with all we missed at the hospital, and it’s back to the daily grind.
However, I remember why I’m here. I’m at my dream job. I have my dream wife. I have a wonderful son. And I had the opportunity to get to know another son. My wife will soon deliver what we believe to be another healthy child. Life is good. God is good. All the time.
Please hug and kiss your children tonight. Once for me and a million times for yourself.
The following is nothing that I wrote, but was given to me by one of my most deeply cherished friends and confidants:
“I love elephants. I love their ability for compassion and empathy. When a member of their community is ill, they patiently wait for them to heal. When one is falling behind, they all slow down so their lagging member can catch up. And when a mother elephant loses her baby, they stand in a circle around her and allow her all the time she needs to grieve and mourn. They don't hurry her along, or push her to abandon the body. They stand in a circle and gently touch her with their trunks, a silent show of unwavering support.
“Elephant mothers will stand with their babies for weeks, not eating or drinking, just holding them close and letting the reality that they are gone slowly settle in. And they are allowed that time by their family members.
“We don't do that. Humans I mean. We do not rally around the bereaved, or allow the members of our community to mourn on their own time. We push, we prod, we offer helpful statements like ‘it must not have been God’s will’ or ‘things happen for a reason.’ Grief is like some embarrassing condition - a cold sore or an unseemly rash - and we hasten to hide it from view.
“In this time of heartbreak - for I am heartbroken, even as I start to crawl from the wreckage and accept the fact that this whole process did not, somehow, manage to kill me - all I want is for the people in my life to stand around me and put their hands on my back, and let me take the time to heal. I begin to realize we are not, as a society, capable of such a thing.
“Parents and elephants never forget...and I will try to remember how this feels the next time someone in my life has suffered a loss. I will try to be the circle of support they need.”
You are my elephants.
We are receiving many offers of financial support. At this time, it’s hard to think of money and projects and everything else. Furthermore, we’re frankly a little creeped out at the thought of benefiting from Zeke’s death like this. Perhaps after a little time, we will put together a list of projects. We don’t want people to lose that generous spirit, but... well, we feel icky about receiving money due to the loss of Zeke (even if it benefits the hospital, and not us personally).
For the time being...
You will notice on our blog, missionarydoctors.blogspot.com, that we have a link for donations. This is through Adventist Health International’s website. We believe strongly in the mission of AHI. We feel that AHI is an organization worth supporting. By donating through AHI, you can be reassured that there is a strong measure of accountability following your donation. Just mark the donation for ‘Bere.’ And remember that your gift is 100% tax-deductible.
Olen Tigo: +235 98 07 46 28
Olen Zain: +235 62 16 04 93
Danae Tigo: +235 98 07 46 27
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Thursday, April 7, 2011
Your mother delivered you too early. You weren’t ready to be born yet. You were supposed to stay in your mother’s tummy another month or two, but your mother came to the hospital with eclampsia, which is a very bad disease. She was seizing and had a very high blood pressure. She would die without an immediate emergency C-section.
When the surgery started, I was in the operating room waiting for you. I checked, and I had everything I would need to try to protect you and save your life. I had a bulb suction to get all of the mucous and snot out of your nose and your mouth. I had a special Delee suction device to suck bad stuff out of your lungs too, if necessary. I had a bag to help me push the air into your lungs in case you weren’t breathing well enough. I had a suture to tie up your belly button. I had sugar to give you in case you were too weak. I was ready for you.
As soon as you were pulled out of your mother’s tummy, we rushed you over to the table and started our work. We sucked the snot out of your nose and mouth. We did everything! But you weren’t breathing very well at all. Your normal oxygen should be 100%, but you only had about 60%. It’s really hard to live with less than 80%!!! You were going to die. But we started blowing air into your lungs with the bag. We started to put sugar into you. And after about thirty minutes, you turned from blue to pink, you started to move, you started to breathe and you even let out a single solitary whimper. God had saved your life!!!
Even though you were too tiny (only 1.7 kilograms, less than half the size of a normal baby!!!) and very weak at your birth, you got a little stronger every hour. You were a good eater when your mother breastfed you, but it was very hard for her. She was still very sick, but she wanted to look at you and see you.
The next day, your mother got even sicker. She couldn’t breathe very well. Her blood pressure was very high. Despite all the medicines, she died. Your father was so sad that he couldn’t even look at you.
When they went home to bury your mother, they left you with us for four days, so we could continue to give you antibiotics and feed you.
When I heard you were coming home, I pulled out a swing, an activity mat, a bouncy chair, an outfit, a hat, a bottle and formula to get ready for you.
We loved you. You were so cute and so adorable (and so little!!!). In fact, everybody loved you. People would fight over who would get to watch you during the day while we worked. Your little body was perfect, just too small.
Each day, you’d get more strength. You ate well. You’d even wake us up at night to feed you and give you your round-the-clock antibiotics with your crying. You were pooping. You were peeing. You were acting like a normal, healthy baby! Just too little still.
After four days, your family came back to get you. I was surprised to find myself feeling a little sad, knowing that you wouldn’t be sleeping in our house that night.
While we were walking with the family to get you, I asked what they would feed you.
‘That’s all we have.’
Isn’t there somebody else in the family or in the village who could give breast milk?
Is it possible for the family to buy formula?
What will happen if you only give the baby water.
‘He will die.’ It was your paternal grandmother talking (like a biological Gamma). She looked so sad. She didn’t want you to die. She also believed, like everybody else in your mother’s culture, that babies born a month too early (like you) will die, but that babies born two months too early will live.
Well what do you want to happen to the baby?
‘We don’t want him to die. Maybe you could take him.’
I should admit, I immediately felt a little excited.
Well for how long do you want us to take him? Days? Weeks? Months? Years?
‘Maybe you could take him permanently. Your family could give him better food, clothing, education and many other things that our family wouldn’t be able to. God has blessed your family and put you in a position to help us.’ It was your grandmother’s brother talking (like a biological great-uncle David).
This was a big decision! It’s not a decision you can make so quickly! Was it the right thing to do for you? Was it the right thing to do for our family? We already had one son and we were about to have another baby! And we work so hard! Who can watch you during the day? And what would the villagers think? Would they think we’re running an orphanage? Would they think we’re letting patients die so we can take their children?
We told your family to go home and pray about it for two weeks and we promised that we would do the same.
The next day your father sent a message to me. He wanted to know how you were doing. He was interested in you! He wanted you to be healthy and strong. I told him that you were. In fact, your father would send me a message almost every day to ask about you and your health.
We thought about and prayed for your future every day until your family came back. What was the best thing for you? We prayed and we prayed and we prayed. We decided that if your family wanted to take you home, they could. We also decided that we couldn’t let you die. If your family didn’t think they’d be able to take care of you, we would adopt you. Above all else, we felt at peace with the knowledge that God would work all things together for good. We left your life in His hands, and trusted that He would make the right decision for you.
We were getting very excited about the idea of adopting you. I even started having dreams about you!!!
Technically, it’s illegal for Americans like us to adopt Tchadian babies. And since it’s illegal in Tchad, America won’t allow it either. But we agreed that we would try our best to adopt you if your family wasn’t able to take care of you.
I started this letter to you March 26, exactly one week after you were born. I thought it would be cute to give it to you someday ‘when you’re old enough to understand.’ But I can’t wait. Below is the rest of your letter:
We talked to lots of people about the adoption process. As it turns out, Americans CAN adopt Tchadian babies!!! We were so excited. We began to think about all the possibilities: Where you would sleep (with Lyol or with the new baby), When we’d be able to take you to America to meet all the rest of your family, If we’d try to surprise your family in America and just show up with you without telling them about you first, If you’d become somebody great, like a teacher or a preacher, If you take care of us when we got old... The imaginations ran wild. We loved to think about our future life with you.
We started to prepare to meet with your biological family. We wrote up a contract in French, outlining our commitment to raise you to love Jesus, to give you nothing but the best of available medicines, food, clothing and education as well as many other things.
We had spent the first week of your life calling you ‘Loaner Son,’ ‘Rental Son,’ ‘Borrowed Son,’ ‘Temporary Son,’ ‘Adopted Son,’ ‘Fake Son’ and even ‘Discount Son.’ But to admit the truth, more than once ‘Son’ slipped out on its own, with no qualifier whatsoever. It just felt so natural.
Now, we started calling you ‘Son’ or ‘Zeke,’ short for Ezekiel. It caught on and everybody started calling you ‘Zeke.’ You were ‘Zeke.’ And ‘Loaner Mommy’ and ‘Loner Daddy’ fell by the wayside, to be replaced by ‘Mommy’ and ‘Daddy.’
We had a blast. We took you everywhere. We took you to church (where we laughed at the African ladies trying to bundle you up in 100-degree weather). We took you to see the hippos. Lyol enjoyed playing with you. You were part of our family.
And you loved to snuggle your head under my chin and fall asleep on my chest. And I loved it too. It was impossible for either one of us to be fussy in that position.
Your family came to visit us. Well, they actually came to visit you. Fifteen of them walked twelve miles in 100-degree-plus weather to come and see you!!! Man, were you ever loved!!! They doted on you until it was getting dark. They didn’t want to leave, but as it was they wouldn’t be getting home until midnight.
They asked us what we had named you. We told them that it was up to them to name you. They named you ‘Koumagueyakoi,’ which means ‘God wanted.’ It’s true. God wanted you. God wanted you to survive those tough few days after delivery. Your family continued to insist that we give you a name. We told them your name was ‘Zeke,’ short for ‘Ezekiel.’ They loved your new name and called you by it.
Seeing as how it was so late, we borrowed a car, piled all your family in it and drove them back out to their village in the dark. It was so peaceful there. Not an artificial light. Not a radio. Not a TV. Not even a door to the hut! The entire family, no, the entire village came out!!! They brought us two chairs and all sat down on the ground around us. They passed you around, each one so incredibly sad when they had to give you up to the next person. Finally, we excused ourselves to go back home before it got too late. You came home with us.
April 4, Mommy sent me a message that you had a fever of 101. ‘Get a malaria test,’ was my reply. She did and it was positive. We put yet another IV in you (you had so many during your first few days of life) and started giving you quinine.
The next day the IV came out. Mommy told me that you had pooped blood a few times. My brain flashed to one word: NEC. Necrotizing Enterocolitis. Immediately, I prayed that you didn’t have that disease. Nobody’s really sure what causes NEC, but it happens in premature babies under 2.5kg who’s mothers had hypertension. You met all those risks. And it starts 1-3 weeks after delivery. April 5 was your 18th day alive.
NEC is diagnosed with an x-ray, which we don’t have. It’s often treated by a pediatric surgeon, which we don’t have. We don’t even have a naso-gastric tube to give you. We brought over the best nurse we could find to restart your IV. He tried for three hours and couldn’t. I gave you medicines by injection into the thigh. We stopped feeding you. You started vomiting bile and blood.
And you cried. You screamed. You suffered. Oh, God, how you suffered. Any time I would move, any time I would bump your belly, you would scream for minutes. You hurt so badly. Your stomach was so distended and hard.
Your intestines had, for whatever reason, gone without enough oxygen, and the walls of the intestines were dying. Eventually, the entire thickness of the wall of the intestines died. Then gas and poop from the intestines went into your abdomen. And you started bleeding into your intestines. The lining all around your abdomen got inflamed, sensitive and tender. Your intestines stopped working properly and your tummy became exquisitely painful.
You suffered. Not like a teenager suffers when her boyfriend dumps her. You suffered severe physical pain. And you started breathing quickly. An effortless tachypnea. Your body was able to keep up with breathing super fast to make up for the metabolic acidosis running through your blood on account of all the lactic acid building up in your tummy. You were suffering.
I swung you gently back and forth and held you close, up under my chin, in your favorite spot. You tried to enjoy it, you tried to settle down, but you were in just too much pain. Finally, about 3AM, you fell asleep and I tried to sleep too. At 5AM I woke up to check on you. You were still breathing, but not as fast as before. Your body was no longer able to keep up with the metabolic lactic acidosis.
Mommy and I prayed for you, as always. We talked about trying another IV versus letting you go. Mommy and I are like you... we don’t quit easily. I tried putting an IV into your femoral veins, into your external jugular neck veins and everywhere else. Your fontanelle and eyes were sunken, your lips were cracked. You were just too dehydrated. I decided to just put a big IV under your skin and let the sugar fluid run in wherever it happened to be.
After a couple more hours we got some other nurses to come start an IV on you. Finally we could give you fluid and antibiotics properly.
Around 9AM you opened your eyes. You looked at me. I’ve been told that babies that age can barely see, and only a certain distance at that, and then can’t even really comprehend what they’re seeing. But you were looking at me. You were telling Daddy it’s going to be ok. Then you started drooling blood. You didn’t even have the energy to vomit. Then blood started coming out of your nose.
Mommy came. We spent some precious time with you. And you stopped breathing. We couldn’t let you go. Through heavy sobs, we gave you CPR. But every time we pressed on your little chest, more and more blood came out of your mouth and nose. Every time I gave you mouth-to-mouth, I tasted your blood, my face covered in it. Soaked with our tears, you would take the occasional agonal breath, but that was it.
At 10AM, you died, Zeke.
During your 19 days of life, we got to know you. Everybody said that you had the two most important attributes for a baby: You were beautiful and you were easy-going. We got to see you gain 1/3 of your body weight while you were with us. You started filling out. You were getting stronger.
But on day 19, April 6, 2011... this very morning... God decided that he wanted you, Koumagueyakoi Ezekiel. God wanted. That’s your name. That’s your fate. That’s your destiny.
This morning I lost a son. Not a biological son, perhaps, but a son who’s diapers I had changed for the last 18 days of his 19-day-life. A son whom I fed twice a night or more for all his life. A son I looked forward to adopting.
I miss you.
I love you, Zeke.
I don’t understand.
I don’t understand how letting you die glorifies God more than letting you live.
I don’t know.
I don’t know if you ever understood that you were loved.
I don’t know if you ever understood that I was kissing you.
We took you to your family in the village. The entire village came out. They dug a hole right beside the wall of your father’s house, but it wasn’t big enough to put the coffin in. The coffin we brought for you. So you were laid down into the ground directly, then covered over with dirt.
And that’s where you’ll stay. And that’s where we’ll come back to.
And when we come back, we’ll think of you.
We’ll look at the pictures that we took of you.
And we’ll read to you:
‘I thank my God every time I remember you. In all my prayers for you, I always pray with joy, being confident of this, that he who began a good work in you will carry it on to completion until the day of Christ Jesus.
‘It is right for me to feel this way about you, since I have you in my heart; for you share in God’s grace with me. God can testify how I long for you.
‘And this is my prayer: that your love may abound more and more in knowledge and depth of insight, so that you may be able to discern what is best and may be pure and blameless until the day of Christ, filled with the fruit of righteousness that comes through Jesus Christ -- to the glory and praise of God.’ Philippians 1:3-11.
The first time I read this to you, I wanted you to understand what I was trying to tell you. The second time I read this, I realized that it was you talking to me.
I thank God that we had 18 days with you. You were such a joy to us. I mourn that we lost you so soon.
Zeke, Son, on resurrection morning, don’t worry about finding us. Your Mother and I will already be looking for you.
With every last drop of love in our hearts,
Mommy and Daddy
Tuesday, April 5, 2011
We're desperately going to need prayers in the next few days. Email it around, post it on the blog, Facebook it, buy a billboard, whatever.
olen and danae
Olen Tigo: +235 98 07 46 28
Olen Zain: +235 62 16 04 93
Danae Tigo: +235 98 07 46 27
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
olen and danae
Olen Tigo: +235 98 07 46 28
Olen Zain: +235 62 16 04 93
Danae Tigo: +235 98 07 46 27
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Monday, April 4, 2011
Sabbath afternoon. It’s a time of relaxation, getting out in nature, refocusing our mission here, resting at the house, maybe going to the river. It’s usually NOT a time to think about the hospital. The hospital only bothers us for emergencies.
Today we had plans to go on an outing. One can get cabin fever here on the compound. Olen and I rarely go anywhere lately, though we did go to the market once this week. It’s really to hot to do anything.
Gary and Wendy were late picking us up in their vehicle. Gary has lived in Africa too long and now he’s on African time.
Just as Wendy and Gary arrived, Seraphin, one of the nurses from the hospital, came to tell me there was a patient in labor who was fully dilated, but her contractions had finished.
I went to assess her quickly before we all left. I was pretty sure this meant that I wouldn’t be going though.
The patient had just arrived.
“Her water has been broken since yesterday, “ Seraphin said, “And she has no contractions.”
“Yeah, how long has the head been here?” I said after I checked her. She was fully dilated and +2 station.
“She doesn’t know.”
“Someone had to be helping her at her house. Ask the mother how long the head has been here.”
After several translations, “The head has been like that for 1 day,” he said in French.
This was her third delivery and the first 2 babies had died.
I did an ultrasound and the baby was still alive. With my abdominal exam, however, the uterus felt malformed. I suspected uterine rupture. Unfortunately I have had 2 already here. Here in Tchad they don’t follow the normal rules of the textbook. In the textbook...Pain, loss of station, fetal distress, etc. This is the third patient who hasn’t had a lot of pain (that I could tell), I don’t think her station had been further along before, and I don’t know if she had fetal distress. Her abdomen just didn’t feel right.
The family agreed to the c-section, and I told them she may end up with a hysterectomy. I called Samedi and Simeon from home to help me, and told Olen and the gang to head on without me.
Luckily I had brought my keys to the OR with me, so I opened "the bloc" (OR) to get things started while I waited for Simeon and Samedi to arrive.
The team arrived and I decided I was going to put in the foley with sterile technique. I’m tired of postop urine infections and complications. No one puts in a foley with sterile technique here. I would show them now!
I could NOT get the foley in. The head was too low and wedged in place. So much for my sterile foley insertion. I would have Seraphine or Simeon put the foley in after we had the baby out.
After the spinal, I made a vertical incision, and my fears were confirmed. Rupture #3 for me in my first 3 months! I pulled the term baby out breech because we entered the peritoneum so high to avoid the bladder. I wished for Olen to be here to help revive the baby and passed the baby off to Seraphin.
“Suction out the lungs and then breath for him, “ I struggled to say in French. I feared for the baby’s life, but decided not to break scrub this time as I’ve done in the past to help. The mom’s uterus was torn quite badly.
We assess the uterus and I was quite ready to do a hysterectomy after Honorine’s story. There was no way to get the laparotomy kit for the other tools to help with the hysterectomy because Simeon (our anesthesia nurse) was now helping to resuscitate the baby. So I wrapped both hands around the base of the uterus to block off the blood flow and waited. It was probably a good thing to do anyways to gather our bearings.
Baby wasn’t breathing, but had a strong heart beat. Seraphine continued breathing for him.
Meanwhile I reassessed and the rupture was all in the inferior part of the uterus. It seemed like it was repairable. God knew what he was doing when I couldn’t get the foley in, because the tear was all the way down right next to the bladder. With a full bladder, it made it easier to see what was bladder and what was uterus.
After a long and extensive repair job on the uterus, I thought it looked pretty decent. We irrigated like crazy because meconium had been dispersed throughout the abdomen with the ruptured uterus. We finally closed her up. The baby was still alive after 1 1/2 hours, but was not in good shape.
I had the family come into the exterior room in the block to be with the baby. It was trying to take breaths on it’s own, but was just to weak. He lived for another 30 minutes.
Mother is now doing considerably well after the operation, non-sterile foley and all.
Later that night I would end up doing a hysterectomy after (but during) another cesarean section for uterine atony. The crazy obstetrical complications here are never ending. Her baby lived though and both are doing well.
Again, please continue to pray for God's wisdom and guidance as we give medical care for the people in Tchad.
Sunday, April 3, 2011
Josephine came in the 13th of March with her water broken for 2 days. She didn’t have any contractions and was 5 centimeters dilated. I did an ultrasound and her baby had died already. So I wrote a very careful oxytocin drip protocol for the evening and night nurse. It got turned off in the night and the next day restarted when she was 8 cm dilated. After only a few hours the following day I came in to find the oxytocin drip running way to fast (under the supervision of the day nurse). No notes were written to tell me how often she had increased the drip and she couldn’t tell me for sure. Again I say oxytocin in dangerous for the uterus if not given properly.
Though she was fully dilated now, I feared her uterus could be ruptured because she had no more contractions. I brought her to "the bloc" and was considering forceps, when Samedi touched her belly and said he feared it was ruptured too.
So....we did a c-section, found a badly ruptured uterus with meconium all over the abdomen, and ended up with a hysterectomy as well.
A few days later I removed the foley catheter. The following day I found her in a lot of pain. I brought her to the "bureau" for an ultrasound. A huge cystic mass was in her abdomen: her bladder. I emptied over a liter of urine. I should have just left a foley in. I wrote and gave careful instructions to watch her next void and if it was not much, to put a foley back in. The next day. Same thing....huge bladder, no one had put a foley back in. Okay. Foley stays in for several days.
Nine days postoperative. She started leaking serosanguenous fluid from her abdominal incision. Oh no! Dehiscence: when the fascia (the strong stuff that holds the incision together) opens and lets some of the fluid in the abdomen out.
Back to "the bloc" #2. She has quite a bit of serosanguenous fluid, but no signs of infection. I opened her up, then suctioned off the fluid. It didn’t seem to be accumulating more, so I don’t worry to much more. I backfilled the bladder and the bladder was intact. I closed her up (I was the only person scrubbed) and payed careful attention to make sure the sutures did not loosen up on the fascia.
During all of this she also had malaria (yes, even a positive blood test). She vomited several times and had a fever, but that can all be attributed to the malaria.
She started to get better. She was peeing, eating, walking.
A few days after I took the foley out, she told me she was leaking something out of her vagina. Her belly started to look more distended.
Two days ago I did an "echo" and thought I saw a huge 10cm hematoma. It was liquid and had movement with it like ascites. It was definitely not clear urine, one of my biggest fears here. Great. I have to take her back to the OR. Maybe it will go away with time and antibiotics. I decided to look again the next day. The next afternoon it looked about the same size. I stuck a syringe in it and out came clear yellow colored fluid. Not what I expected. I put her foley back in. That also looked pretty much the same color. Even though the lab was closing I asked them if they could tell me if it was urine or ascites. They tried but said it was to hard to know.
Today the urine in her foley looked pretty infected. I brought her to the OR to look with my makeshift cystoscope. There are several laparascopes here that have been donated. There are only bits and pieces, not a full set of anything. One scope was small enough and actually worked with the light source, but had no apparatus to put irrigation into the bladder.
I started by looking in her vagina. Her huge floppy cervix that I had left (supracervical hysterectomy) looked necrotic and dead. I cut it off. It looked better. I hoped that was only the problem. Maybe the infection spread to her bladder.
I took my makeshift cystocope (that had been dipped in bleach water as I had no means to sterilize it) and started. If I could just see both ureteral jets then I would not be worried. There are many tests I could order in the States to avoid all of this. But....we are in Tchad. I prayed long and hard about Josephine last night. I needed guidance. I didn’t know what to do with her. I didn’t want her to have to go through a third operation if it could be avoided. Maybe I would see the ureteral jets. Maybe the fluid was just ascites. There’s no one else to send her to. I injected sterile saline into the bladder with a foley first, then took it out and put in the cystoscope. The vision was definitely not clear as I held my eye up the scope. I flushed her out several times with the same process and looked again. I could not visualize the right jet. We had no indigo carmine (blue dye put into veins that makes you pee blue) to visualize them easily anyways. All I wanted was a clear jet.
Uh oh. All the clear saline is coming out of her vagina! She has a fistula where the infection had been. I don’t know why I hadn’t seen that with my vaginal exam.
Doubts swelled up. All of this is my fault. I did the hysterectomy. I didn’t find a problem with the second operation. Jesus please help me. I am NOT qualified for this.
Laparotomy #3. All in all it took 5 hours with her in the OR today. Lots of fluid in her abdomen. Now there were some pockets of pus also. Everything was adherent. Two weeks after any operation will give you a giant mess when you go back in to explore. Unfortunately it had to be done.
We found a small hole in what we thought was the bladder that was leaking a jet of urine. At least it was easier than I thought! Good. I sutured several layers over this and proceeded to repair the vesico-vaginal fistula that I somehow caused. We opened the bladder. Wow. There is quite a lot of pus adherent in the bottom next to the vagina. How did that happen? On the left I was finally able to visualize the ureteral jet right next to the fistula. Nothing on the right though. I decided to leave the fistula open because it would cause too much harm if I closed off the right ureter while trying to close the fistula (about 3 x 1cm). I would wait until someone else came to help me repair it maybe.
I put my finger in the bladder again to see if I could feel the depth we had made over the leak. It was nowhere near the leak. That hadn’t been the BLADDER that was leaking. It was the right URETER! Any GYN’s dreaded fear. This is what I had been fearing for a few days now.
I took out the stitches and sure enough was able to dissect down to a nice jet flowing out of the pelvic sidewall. Everything was adherent around it though. I took a neonatal foley and placed it to verify it was an open tube. Yes. Now WHAT? Call urology of course! And pray they don’t yell at me as I hide under the OR table or in the corner.
Well, maybe now we could repair the hole between the bladder and the vagina. I remembered seeing ureteral stents here somewhere, but ignored them because I had no tract to put them through my makeshift cystoscope. But, they would definitely help now! I put one stent in the left ureter right next to the fistula to know exactly where the ureter was. Then closed the fistula with several layers after cutting away the dead stuff.
Then we went to work on the hardest part. Connecting the right ureter to the bladder. We poked a hole in the bladder, put the other end of the stent into the bladder, and put the bladder close to the ureter. I tried to connect the tiny ureter into the bladder and then put another layer on top for reinforcement.
We were definitely not trying to be heros or supersurgeons. I think everyone in the OR was definitely ready to be done since I had kept them 4 hours past their quitting time on Friday afternoon. We were just trying to do the best thing for her. There was no one else to do it for her here. I just pray that God would be glorified through this operation. There are so many things that can go wrong.
I put her on strong IV antibiotics. Her infection could definitely come back. I don’t know how long to leave the foley in for. I have 2 ureteral stents in her. Definitely a source of infection. What if someone doesn’t empty her foley and the urine backs up? The uretero-vesicopexy (I don’t even know the correct name) will burst and then she’ll have urine in her belly again. What if the stents accidentally get pulled. Same thing will probably happen. What if the infection at her fistula site flares up again? I don’t know how she got a fistula with a c-hysterectomy anyways. I don’t think I was that careless. I know that bladder was intact during the first 2 operations. So many more things can go wrong with her.
Oh, and her hemoglobin was very low (5) today, checked during the operation. She had not lost that much blood with ANY of her operations. It had been okay after the first operation (even though it was a uterine rupture). Malaria does damage the blood cells, hard to know if it was just the malaria. She got 2 units of blood today. She is a rare O +.
Please, please pray for Josephine. She is from N’Djamena. She wasn’t even supposed to be here.