Did you know?

Did you know that:

• South Sudan has the highest maternal mortality rate in the world?
  The UN quotes a 1 in 7 chance of a South Sudanese woman dying during her lifetime from pregnancy-related causes (2,054 per 100,000 live births).
• It also has one of the highest under-five mortality rates in the world?
  According to the World Bank & WHO, 1 in 8 South Sudanese children do not live to reach their fifth birthday (121 per 1,000 live births).
• The average life expectancy in South Sudan is only 62 years?
• Nearly 1 in 3 South Sudanese kiddos are malnourished?
• Merely 25% of the South Sudanese have access to any form of health care?
• The poverty rate in South Sudan is over 50%?
• Less than a third of South Sudanese are literate?
• South Sudan was the epicentre of Africa's longest running civil war (over the greater part of the 50 years between 1955 and 2005)? Cost: 1.5 million deaths (population: 9 million).
• South Sudan is the youngest nation on this planet as of 9 July 2011? It celebrated its second independence day just three weeks ago!

Sources:
United Nations Development Programme: Millennium Development Goal 5
United Nations Development Programme: About South Sudan
World Health Organization: Under Five Mortality
The World Bank: Under-Five Mortality Rate
Save the Children: South Sudan
BBC - Sudan Country Profile

Why did I ask? Because all these stats, these numbers that seem so overwhelming initially, means that the work we do at my hospital here is not for naught. The photo is of the foundation that is being laid for our new special care nursery as well as an expanded labour/delivery suite. Improving the health of South Sudanese women and children is our daily bread (and butter - not that we get that here!). So I'd urge you to prayerfully consider giving towards this service; all the missionary staff here (including yours truly) work free of charge so rest assured that the money isn't going to fund our imaginary Lamborghini sports cars or Hermès Birkin handbags :)

Operating Funds Goal: $238,217 ($19,850/month) - $33,249 raised so far
Capital Funds Goal: $105,844 - $37,225 raised so far

Find out more here: Bet Eman - His House of Hope Hospital for Women & Children
Donate here: Harvesters Reaching The Nations

Waiting in the dark of the night

Well, it's 11.18pm and I'm sitting on my bed safely under the cover of my mosquitto netting (double layer for the win! The one provided with the room was full of holes). Waiting for a primigravida to progress to the second stage of labour and hopefully deliver her baby uneventfully in the next few hours (wishful thinking?).

At any rate, this is my second or third night on call solo and it's been pelting rain the entire evening, which means slippery mud, clothes that won't dry and fewer patients than usual (which makes perfect sense when one considers that there are no tarmac roads and the primary form of transportation here is either by foot or by boda [motorcycle]. Only 'kawaja's' [the Juba Arabic term for white men] and the wealthy South Sudanese own cars - or more appropriately for this environment, four-wheel drives). Hats off to the long-term missionary docs here; I can't imagine doing this - being constantly on call without a break - for years! Just a few months will soon wear me out without the help of God's Spirit.

It calls to mind this particular verse from the Bible:
Jeremiah 12:5 "If you have run with the footmen, and they have wearied you, then how can you contend with horses? And if in the land of peace, in which you trusted, they wearied you, then how will you do in the flooding of the Jordan?"

I've often pondered on this passage and wondered what it means in my life and how it can be so pertinent in situations like these. Ever since I started medical school, and now even more that I've graduated and have entered the work force, my default modus operandi seems to be one borned out of tiredness (it's became a joke in my family that whenever they ask how I am, I reply, 'Tired!'). No, I'm not anaemic (had my haemoglobin level recently checked when I donated blood and besides, I always feel rested so long as I get my beauty sleep). It's quite easily explained due to a combination of bad sleeping habits (sleeping past midnight even when I used to start work before 7am back home) and a multitude of activities always running in the background (severely trying my multitasking skills). Sometimes, I think it's a good thing I'm single because I think the degree of my fatigue would be at least doubled if I had a family of my own.

It also underscores the importance of keeping a consistent quiet time and of being disciplined in seeking rest in God and God alone. As Jesus once said,
Matthew 11:28-30 "Come to Me, all you who labour and are heavy laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and lowly in heart, and you will find rest for your souls. For My yoke is easy and My burden is light."

Of all the promises He's made, it definitely ranks as one of my favourites. And it's one that I have to remind myself over and over to practise, rather than trying to find escapism in trivialities such as the latest TV series, a good storybook or even the higher pursuit of time spent with loved ones. It is in Christ that our souls will find repose. As St Augustine aptly puts it all the way back in the 4th century AD, "Thou hast made us for thyself, O Lord, and our hearts are restless until they find their rest in thee." (Confessions).

Babies and more babies

Well, it's official! The English royal family has a new prince. In other news...

1. Primigravida with ruptured ectopic pregnancy
A 23-year-old primip presented to our hospital mid last week with severe lower abdominal pain on a background of 6 weeks of amenorrhoea. My colleagues did a quick ultrasound scan of her belly before admitting her and saw a possible right adnexal mass; however, it also looked like there was an intrauterine gestational sac (?heterotopic pregnancy) without any signs of peritonism or guarding. I saw her on the ward in the evening and she was haemodynamically stable, smiling and appeared comfortable. The next morning was a whole different scenario; she was on her knees in obvious pain and a repeat scan showed a definite fetal pole in her right fallopian tube with an empty uterus.

Rushed to theatre, we were waiting for induction when my colleague took a peek around the drape, saw her suddenly turn pale and made the (correct) call that the ectopic had ruptured. Proceeding to laparotomy, we found massive haemoperitoneum. It was rather scary as she continued to bleed profusely even after the ectopic was removed; there was a question of whether the blood was tracking down from other parts of the intraperitoneal cavity following the initial rupture or whether it was from another source (she also had smear-proven malaria and the possibility of splenic rupture was considered). Ultimately, we decided to close the abdomen, estimating blood loss of at least 1.5 litres. Thankfully, she recovered very nicely. Her postoperative Hb did drop to 6.6 from an admission Hb of 12+ despite intraoperative transfusion (with just one unit of whole blood - this is South Sudan, after all) but she remained clinically stable and was discharged home after three days with a discharge Hb of 7.8.

2. Yet another case of postpartum haemorrhage
Another of our patients, this one pregnant with twins at 36 weeks gestation, represented one day after discharge in active labour. The first one delivered fine but CTG showed fetal distress with the second bub (known to be breech and smaller in size - 500g difference from memory). Thank God, he delivered soon after; Apgar score at 1 minute was 4/9 and he was initially bradycardic and floppy but a couple of minutes with positive pressure ventilation quickly fixed that.

Everything seemed hunky dory in the next few hours until I did a quick evening ward round and the mother told me that she was concerned that there was more lochia (vaginal bleeding and discharge after birth) than expected. Alarm bells went off in my head since she had a multiple pregnancy and a second-degree perineal tear that was left unrepaired, both risk factors for PPH. Say what you will, I think it was the Holy Spirit that prompted me to take her back to the labour ward to properly examine her, and I am so grateful to God that I did. There was quite a bit of ooze from the perineal laceration, which we repaired without further ado. What was more concerning was how we subsequently uncovered large amounts of clots coming from further up (i.e. the womb). In fact, we had to then sedate her with ketamine to manually evacuate the uterus.

This time, the haemorrhage was managed in a more or less controlled fashion, and better still, we had a satisfactory outcome for both the mother and her twin babies. In other words, the stark opposite of the case of PPH we had just a short two weeks ago!

Psalm 127:3-5 Behold, children are a heritage from the Lord, the fruit of the womb is His reward. Like arrows in the hand of a warrior, so are the children of one's youth. Happy is the man who has his quiver full of them...

Breath of life

This little girl has been with us for almost two weeks on oxygen - such a cutie, right? :) Poor little bub had a bad case of bronchiolitis and it was an epic struggle to get her off the oxygen. Anyway, most of you would know that I aspire to be an anaesthetist (or anesthesiologist for the Yankees among us). It's not an accident that in cardiopulmonary resuscitation, A (for airway) comes before B (breathing), which in turn precedes C (circulation). An obstructed airway kills within seconds (at most, minutes), and hypoxia (poor oxygenation) is more lethal than hypotension (low blood pressure). Of course, in reality, these three factors are often interlinked and rarely occur in isolation. In my current hospital, the greatest amount of oxygen that we can deliver is 5 litres via an oxygen concentrator (compared with 15L on a normal ward back home). And things in the capital aren't much better, as I recently found out; apparently the concentrators in the main public hospital in Juba goes up to 8 litres (only!).

It reminded me of the story in Ezekiel 37 where God breathes life into a valley full of bones. In the passage, God commands Ezekiel to prophesy to the bones, saying, "Surely I will cause breath to enter into you, and you shall live. I will put sinews on you and bring flesh upon you, cover you with skin and put breath in you; and you shall live. Then you shall know that I am the Lord...these bones are the whole house of Israel. They indeed say, 'Our bones are dry, our hope is lost, and we ourselves are cut off!'...Behold, O My people, I will open your graves and cause you to come up from your graves, and bring you into the land of Israel...I will put My Spirit in you, and you shall live, and I will place you in your own land." (vs 5-6,11-12,14).

No matter how long we have been dead in our hearts (as indicated by how dry the bones were), God is (as some preachers are wont to say) in the business of resurrection. One of my favourite verses in the Bible is Ephesians 5:14, where the Apostle Paul writes, "Therefore He says: 'Awake, you who sleep, arise from the dead, and Christ will give you light.'" Note the sequence: just like the Creation account in the first few chapters of Genesis, rhema (the revealed Word of God) anticipates life. It was His breath that made it possible for us to live; once at our birth into this world and again when we are born of the Spirit (John 3:6). Don't you think it makes a rather nice parallel - how breath is vital to life both in the earthly and spiritual sense?

When it rains, it pours...

Remember my previous post about the little boy dying? Well, the days that followed made that a week of horrors, really. What's about to follow is a series of clinical vignettes so feel free to skip ahead if you're non-medical (or even if you're medical and don't want to hear any more about our work that seems all too pervasive at times!).

1. Postpartum haemorrhage
A multigravida lady presents just before dawn having delivered a stillborn infant at home and is now in the throes of delivering its previously-undiagnosed twin. Sadly, the second bub is also stillborn. Just after our morning staff devotions are completed at around 9am, my senior colleague receives an urgent phone call from the nurse who was at her bedside as the patient is now unresponsive. Apparently she had been slowly bleeding out the entire time and her uterus remained boggy despite an oxytocin infusion and methylergometrine. On examination, she was found to have a ruptured (!!!) uterus.

Rushed to theatre, the anterior tear (which I never got to see since I was on the other side of the drape doing "anaesthetics") was successfully repaired but it was rocky to say the least. She kept having periods of apnoea when we had to bag her and periods of bradycardia requiring boluses of adrenaline (without concurrent ECG monitoring due to our not having metaraminol, ephedrine or even just plain atropine). Maintaining blood pressure was a nightmare since the only intravenous fluid we have is normal saline and 5% dextrose (no Hartmann's, let alone gelofusine, voluven or albumin - 4%, 20% or otherwise). She did have two 16G IV cannulae, thank God, so we had blood running through one drip and normal saline through the other. Even obtaining the blood was a complex process since we didn't have any of her blood type left in our fridge and we had to find a suitable donor, bleed him/her and then get it to the patient (which takes at least 15, usually 30, minutes).

There was also a frustrating difference in opinion as I was all for pouring the fluids in asap since she was obviously in hypovolaemic shock but my colleagues were reluctant to push her into fluid overload. I had to argue that she was more likely to die at this point from an inadequate circulation rather than pulmonary oedema that we could offload later on (which we often do in ICU with frusemide infusions) before we came to some form of consensus. And the pulse oximeter wasn't working - partly because she was so shut down peripherally and partly because the actual machine wasn't functioning properly (I tested it on myself). My requests that we find one that work were repeatedly ignored since "there would be no change in management"; fair enough, but having a pulse oximeter means not having to manually measure her falling heart rate (causing us to be one nurse short who had to auscultate her chest every few minutes to get this number) and having a beat-to-beat report on at least two of her vital signs. The donated monitors that we received from an American charity also died on us due to some problem with its power inverter. Argh!

Anyway, I left to get to clinic after she was (seemingly) stabilised. However, an hour or so later I could see a crowd of people gathered around the operating theatre and hear wailing from inside. Apparently she had become apnoeic again, was intubated but then went into cardiac arrest. So in the space of four hours, the poor patient's husband had lost both his twin newborns and also his wife. In retrospect, would an emergency hysterectomy have saved her life? It's hard to tell. Apparently her uterus was still uncontracted at the end of the repair and we don't have prostaglandins or the ability to perform embolisation. Another possibility was arterial ligation. In either case, none of the staff members have ever done any of these procedures so the outcome may have been exactly the same.

2. Severe dehydration
I can't emphasise enough the importance of knowing a patient's electrolytes. We do have a biochemistry machine but we lack the trained staff to use it. A very young boy presented to us that same day in severe dehydration (the first time I've seen markedly reduced skin turgor!) secondary to vomiting and reduced oral intake (combination of severe malaria and malnutrition). As expected, none of us could get IV access. This round, having learned from the previous case where we couldn't get access as well prior to the little one's untimely death, we didn't waste any more time and took him to theatre to put in an intraosseous line. Well, things seemed to be on the mend and he survived the next two nights appearing euvolaemic. Unfortunately, on the third night, we could hear wailing coming from the hospital's direction and a quick phone call proved that he too had passed away.

Was it hypokalaemia? Hypernatraemia? Acute renal failure? Something else altogether? I guess we'll never know now.

3. Why I would never choose obstetrics as a long-term career
It's all a bit muddled in my mind now but I believe we had either an emergency Caesarean section or a complicated labouring woman (pre-eclampsia, breech presentation, floppy neonate requiring chest compressions etc) every night that week. I don't particularly find the prospect of facing yet another placenta attractive in the least, no offence to all my O&G friends.

Anyway, at the end of the week during our Pioneers (the American-Australian missions organisation that sends us) get-together, one of my nursing colleagues shared this passage with the rest of us, which was truly a timely word of encouragement from God Himself:

Isaiah 65:17-25 "For behold, I create new heavens and a new earth; and the former shall not be remembered or come to mind. But be glad and rejoice forever in what I create; for behold, I create Jerusalem as a rejoicing, and her people a joy. I will rejoice in Jerusalem, and joy in My people; the voice of weeping shall no longer be heard in her, nor the voice of crying. No more shall an infant from there live but a few days, nor an old man who has not fulfilled his days; for the child shall die one hundred years old, but the sinner being one hundred years old shall be accursed. They shall build houses and inhabit them; they shall plant vineyards and eat their fruit. They shall not build and another inhabit; they shall not plant and another eat; for as the days of a tree, so shall be the days of My people, and My elect shall long enjoy the work of their hands. They shall not labour in vain, nor bring forth children for trouble; for they shall be the descendants of the blessed of the Lord, and their offspring with them. It shall come to pass that before they call, I will answer; and while they are still speaking, I will hear. The wolf and the lamb shall feed together, the lion shall eat straw like the ox, and dust shall be the serpent's food. They shall not hurt nor destroy in all My holy mountain," says the Lord.

Amen and amen. Lord, come quickly!

Living water

This is the water tower that supplies our house. Due to some miscalculation during its construction, its height is apparently insufficient to generate a constant pressure - but this applies only to the shower heads and only for the hot water, something my engineering friends can explain, perhaps? Anyway, shower times have become a rather laborious process due to this quirk. Call me a princess or precious but I like being (and feeling) clean, especially in the heat and dust that characterises this country.

It's become an adventure to stand under the shower head, turn the faucet and hoping madly and wondering if some hot water would trickle out. Failing that, the next best option would be that hot water is available from the mixer tap (from which I could bend and still get a bath of sorts - a good thing I don't have a bad back!). Otherwise, it'll mean a very quick shower since I hate cold showers (hot water was my norm even when growing up in tropical Malaysia). Another part of life in South Sudan, I guess. At least we have running water that's safe and hot for part of the day (the water only gets heated between 7pm and 9pm). Most of the locals don't even have that!

In Lopez Lomong's autobiography (Running For My Life - Lopez was a 'lost boy' from the Sudanese civil war who became an American Olympian; an amazing story by the by, do read it if you can), he spoke of the need for easily accessible clean water in his homeland. Most of us would know the dangers of drinking contaminated water, be it rainwater or water collected from a river or well. What I didn't realise was that that wasn't the only danger. For instance, Lopez's sister was ambushed and raped on her way to the river. And I recall being told that gathering water was usually a job for the younger children, especially girls, and having to walk a few miles there and back every day meant missing out on school. It's shocking how something so seemingly trivial can compromise not only one's health, but also one's education, dignity and most likely, one's future.

It also brings to mind the story in John 4 of the Samaritan woman at the well and of her encounter with Jesus. She who had been married five (!) times and was currently cohabiting with a man who wasn't her husband was told by the Saviour of the world that, "whoever drinks of the water that I shall give him will never thirst. But the water that I shall give him will become in him a fountain of water springing up into everlasting life." (verses 13-14). We are told in Revelation 22 that in the new Jerusalem (i.e. heaven), there will be "a pure river of water of life, clear as crystal, proceeding from the throne of God and of the Lamb".

Without water, there cannot be life. He invites us all to partake freely of Him. When will we give up our foolish indulgences and futile desires and instead choose to live and live abundantly?
Isaiah 55:1-2 "Ho! Everyone who thirsts, come to the waters; and you who have no money, come, buy and eat. Yes, come, buy wine and milk without money and without price. Why do you spend money for what is not bread, and your wages for what does not satisfy? Listen diligently to Me, and eat what is good, and let your soul delight itself in abundance."

O death, where is thy sting?

Second day back on the job for real and I'm reminded once more that death awaits us all.

A little boy who was severely malnourished passed away today. He wasn't quite the big belly kwashiokor kids you see in pictures of Africa but almost there, complete with rib bones sticking out every which way, generalised pitting oedema (swelling) and superficial skin erosions and ulcers from micronutrient deficiencies. As was the very day I left in April, he died in front of my eyes. One minute he was breathing (rapidly) and the next he wasn't.

What made a big impression on me this time was his mum's reaction. We had placed him on our resuscitation table and his mother was seated some way away and obviously hadn't realised what had just happened. My senior colleague sat both parents down and started explaining how their son was very sick when he was admitted, gradually deteriorated over the past few days, and when he got to the part about him breathing when he was brought into the room (his mum carrying him there, mind you) but that was now no longer the case, she just stood up and left the room. Having a bad feeling, I followed her and saw her wailing and throwing herself to the ground despite her being heavily pregnant, heedless of the stares of the other patients and their visiting family and friends. I couldn't understand what she was saying and neither could she understand me when I tried to remonstrate.

Thank God one of the ladies visiting another patient managed to calm her down for a time and maybe even comfort her a little. This lady later told me that her own four children had all died and she too felt suicidal then but did not take her own life because she wanted to be with Jesus. Confronted with such grief and the stark finality that a loved one is never coming back, what can you say? Over and over again, you ask yourself if you could have done something different - whether it's in the role of a doctor or a carer. Sometimes your heart breaks so much you ask God why He didn't take you instead.

And this grief turns into despair when you believe that God hasn't heard your prayers for help, or worse, that if He had, He doesn't care. Coming from a devout background, you may even try to blame yourself, saying that this is punishment for your sins (or the sins of your forefathers). Is it? Did He not say that He has "no pleasure in the death of one who dies...therefore turn and live!" (Ezekiel 18:32)? Did He not "humble Himself and became obedient to the point of death, even the death of the cross" (Philipppians 2:8) so that "death is swallowed up in victory" (1 Corinthians 15:54)? "For He must reign till He has put all enemies under His feet. The last enemy that will be destroyed is death" (1 Corinthians 15:25-26).

How to convey all this when it is not your grief to share? Sympathy and empathy are both fictional constructs in a sense; can a mind truly comprehend, understand and feel what another experiences? There will always be a wall in between one being to the next, for how else are we distinct from one another? In answer to this conundrum, the Bible has some interesting points to make. Firstly, it admonishes believers to "rejoice with those who rejoice, and weep with those who weep" (Romans 12:15). The whole book of Job is a lesson in what to do (and more importantly, what not to do) when one's family/friend/acquaintance is in distress.

Sometimes, all you can do to show that you stand in solidarity with another person is to keep company; mourn together if you can, keep silence if not. Teach me, Lord! You who know the depths of misery and pain that this life offers and that this world holds.

"He is despised and rejected by men, a Man of sorrows and acquainted with grief. And we hid, as it were, our faces from Him; He was despised, and we did not esteem Him. Surely He has borned our griefs and carried our sorrows; yet we esteemed Him stricken, smitten by God, and afflicted. But He was wounded for our transgressions, He was bruised for our iniquities; the chastisement for our peace was upon Him, and by His stripes we are healed." (Isaiah 53:3-6).

I'm back!

Just a quick note to say (as you may have guessed from the title) that I'm back in Yei. And nope, that photo isn't of South Sudan (I wish!). I was in the United States for the past five weeks; for those who weren't aware, I was in Boston for three weeks undertaking a biostats and epidemiology course at the Harvard School of Public Health. Having travelled for 48 hours to get there (I'm not kidding), I took the opportunity to be a first-time tourist to New York City and Washington DC as well. So yes, that photo is of Times Square.

One of the biggest differences between where I am now and where I had been is the (lack of) artificial light. In America (as is the rest of the developed world), we rarely, if ever, live in (literal) darkness. Even at night, lightbulbs and neon signs flash from almost every corner, strains of music (or what passes for it nowadays) can be heard from shops and cars driving past, and cities are filled with pollution - be it noise pollution, smog (looking at you, Indonesia), or rubbish-filled and pee-smelling subways (and that's for you, NYC).

But here? No. Our missions compound is one of the few places in the region with 24-hour electricity powered by a combination of solar panels and a backup generator, essential for our hospital and so convenient for the rest of us. From 7pm onwards, it gradually gets dark and when the sun has set, the sky outside is pitch dark and it's near impossible to walk outside without a lantern of some form. It's so quiet I can hear the insects outside my room (and sadly, sometimes inside too!) and almost everyone (except for the unfortunate few who are on call or worse, have an actual emergency) is in bed asleep by maybe 9pm.

It rather reminds me of what Christ said in John 12:46 "I have come as a light into the world, that whoever believes in Me should not abide in darkness" and of what the Apostle Paul said in Ephesians 5:8-14 "For you were once darkness, but now you are light in the Lord. Walk as children of light...for whatever makes manifest is light. Therefore He says: 'Awake, you who sleep, arise from the dead, and Christ will give you light.'" Without Him, our world falls into shadow and without His love, our hearts are darkened by despair and depravity. With Him, it may not yet be day, but at least we know that the dawn is indeed coming and so, we wait.