Wednesday 18 September 2013

A prayer to the God of my life...

The backyard of a local church compound
Psalm 23:1-6
The Lord is my shepherd; I shall not want. He makes me to lie down in green pastures; He leads me beside the still waters. He restores my soul; He leads me in the paths of righteousness for His name's sake. Yea, though I walk through the valley of the shadow of death, I will fear no evil; for You are with me; Your rod and Your staff, they comfort me. You prepare a table before me in the presence of my enemies; You anoint my head with oil; my cup runs over. Surely goodness and mercy shall follow me all the days of my life; and I will dwell in the house of the Lord forever.

Psalm 42
1-2 As the deer pants for the water brooks, so pants my soul for You, O God. My soul thirsts for God, for the living God. When shall I come and appear before God?
5-8 Why are you cast down, O my soul? And why are you disquieted within me? Hope in God, for I shall yet praise Him for the help of His countenance. O my God, my soul is cast down within me; therefore I will remember You from the land of the Jordan, and from the heights of Hermon, from the Hill Mizar. Deep calls unto deep at the noise of Your waterfalls; all Your waves and billows have gone over me. The Lord will command His lovingkindness in the daytime, and in the night His song shall be with me - a prayer to the God of my life.

Psalm 27
1 The Lord is my light and my salvation; whom shall I fear? The Lord is the strength of my life; of whom shall I be afraid?
4 One thing I have desired of the Lord, that will I seek: that I may dwell in the house of the Lord all the days of my life, to behold the beauty of the Lord, and to inquire in His temple.

Monday 16 September 2013

Serenity

I captured this photo on an idyllic afternoon last week. It's hard to discern the features unless you zoom in but if you do, you may see in the centre a little boy pushing a huge tyre (as big as himself!) with a stick. It's one of the favourite games the kids here play.

At any rate, last weekend almost broke me, mentally speaking. I was so tired that I slept from 9pm last night till noon today - 15 hours of bliss. Let me give you a taste of what confronted me over the past week:

Paediatric ward:
In bed 1, we've an 11-day-old female who presented with 48 hours of seizures. She had a home birth and the mother had not received any antenatal care prior to delivery. Diagnostic dilemma: febrile convulsion vs cerebral malaria vs meningitis vs neonatal tetanus. Malaria smear was negative but we had otherwise no way of proving any of the other possibilities so we ended up covering with ampicillin, gentamicin, aciclovir and metronidazole as well as phenobarbital and diazepam (no neuromuscular blockers, paraldehyde or chlorpromazine). At any rate, over the course of her admission, neonatal tetanus became more and more likely as her seizures were tetany-like and were provoked by touch. Pray for us as we'll be deciding in the next few days if treatment should be withdrawn depending on what we think her neurological outcomes could be (which is going to be a challenge since no one can besides God can foretell that with certainty).

In bed 2, we've a two-year-old boy with gross generalised oedema (swelling) and 16 hours of anuria (no urine output). The anuria was later found to be secondary to urinary retention as he had one of the worst cases of penile and scrotal oedema that we've seen and he required a suprapubic tap to relieve the post-renal obstruction. We've finally got the ability to test electrolytes (hallelujah!) but the machine was playing up; our first specimen gave a potassium of 14.2mmol/L (!!!) and the second was so high it could not be recorded. The troubling thing about this was that both samples were arterial in source since none of us could get venous access due to the oedema. However, it's doubtful he would have lasted this long with such severe hyperkalaemia.

In bed 3, we've a one-year-old boy with the same presentation but less severe.

In bed 5, we've a fourteen-year-old boy with worsening dyspnoea and chest pain as well as abdominal pain and distension. Found to be febrile and on examination to have massive hepatosplenomegaly as well as cervical and inguinal lymphadenopathy and CBC showed severe anaemia (Hb 4.9) and thrombocytopenia (Plt 21). Treated for presumptive malaria and transfused one unit but the Hb post transfusion actually dropped to 4.8g/dL and there was bilirubin and urobilinogen +++ in his urinalysis, indicating an ongoing haemolytic process. CXR did not show any obvious cardiomegaly, effusions or consolidation, his WCC was normal, LFTs were only mildly off and both ESR and triglycerides were elevated. At this point, our differentials were leukemia/lymphoma, autoimmune haemolytic anaemia, autoimmune lymphoproliferative syndrome +/- Evans syndrome, haemophagocytic lymphohistiocytosis and macrophage activation syndrome. We started prednisolone on Saturday night but unfortunately, he developed worsening respiratory distress overnight and passed away this morning.

We had a total of five premature infants last week, four born at 31 weeks! Sadly, two died.
- The first died on the night of admission: I wasn't on call that night but the little two-day-old boy (~35 weeks' gestation born at home a/w possible meconium-stained liquor) had been tachypnoeic since birth and apparently had frank haemoptysis/haematemesis before passing on. We still can't figure it out but one hypothesis is the nasal cannulae causing epistaxis which bubs normally swallow and then cough out and another possibility is meconium aspiration syndrome but his respiratory distress seemed more severe than expected if that was the case.
- The second died on Sunday morning; the one-week-old boy had been noted on Friday and Saturday nights to have reflux associated with apnoeas and bradycardia. This was a particularly vexing case for me since the sequence of events was that at 5am, the mother notified the night nurse on duty that he seemed to be in a bit of strife; by the time the nurse arrived, there wasn't any cardiac output but I was only called about it 18 minutes later! By which time, it was way too late. Argh...so frustrating, especially since his twin later developed the same problem that afternoon but we got there within a couple of minutes and basically brought him back, thank God. The poor mum, a 15-year-old primip, was crying into my lap for an hour and a half.

Obstetrics ward
In bed 1, we have a HIV-positive mother who is two weeks post elective C-section (four previous scars) with acute right hemiparesis and facial droop as well as mild dysarthria and confusion. She had only one documented fever, was normotensive without any signs of pre-eclampsia, and had a normal ECG but was surprisingly neutropenic (0.8). Was it a stroke? Cerebral toxoplasmosis/TB? Some autoimmune disease? CNS lymphoma? She was asymptomatic and well besides these neurological deficits so it's a bit of a mystery. We covered with cotrimoxazole and sent her back to the local antiretroviral treatment centre to hopefully be recommenced on HAART.

In bed 2, we had a 20-year-old primip who delivered twin girls; one a stillbirth (foetal death in utero at time of presentation) and the other one of the prettiest babies I've ever set eyes upon. Both mum and baby had malaria and received adequate treatment but the mother was persistently anaemic (with Hb levels < 5.0g/dL!) despite four units, which is a lot in our context (most patients get only one unit even with Hb levels as low as 1.9g/dL). She was later found to also be Hep C positive and had massive splenomegaly; no retained tissue on ultrasound examination. DDx: FDIU-related coagulopathy, hyperreactive malarial splenomegaly (aka tropical splenomegaly syndrome), Hep C-related cirrhosis and some form of autoimmune haemolytic anaemia. None of it was ever proved or disproved but my money's on the first two.

On Friday evening, a two-year-old boy arrived in status epilepticus, later found to be secondary to cerebral malaria. On Saturday morning, we had another primip who proceeded to C-section for foetal distress followed by a VBAC with unproven pelvis (first child was delivered via C-section for breech presentation) that eventually required a vacuum. That evening, a lady arrived near-collapse a day post septic miscarriage at 10 weeks' gestation. And in the early hours of Sunday morning was the death of the second premmie.

Amidst all this madness, we were also taking care of one of our nurses who had the misfortune to be in a hit-and-run pedestrian vs motorcycle accident the week before. He almost certainly had a base of skull fracture (bleeding from both ears and nose as well as left sided LMN facial nerve palsy) but thankfully has gradually recovered with conservative management (the only option available to us considering there isn't a CT scanner or neurosurgical service in this country) and is now fully oriented to TPP with mild persisting dizziness and no further headaches.

God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And wisdom to know the difference.
- Reinhold Niebuhr, 1943

Amen and amen, brother.

Sunday 8 September 2013

Faithfulness

Hymn by Brooke Fraser
If to distant lands I scatter
If I sail to farthest seas
Will You find and firm and gather
Till I only dwell in Thee

If I flee from greenest pastures
Would You leave to look for me
Forfeit glory to come after
Till I only dwell in Thee

If my heart has one ambition
If my soul one goal to seek
This my solitary vision
Till I only dwell in Thee
That I only dwell in Thee
Till I only dwell in Thee

- From the album Albertine -
http://www.youtube.com/watch?v=jRW8WV5cFaU

No matter where, no matter how, He will neither leave us nor forsake us. May this be our prayer for the world in which we find ourselves today. May we remember our brothers and sisters suffering in Syria, Egypt and countless other countries (Making sense of the Middle East). May we know His love is stronger than death and may this truth be lived out in our every word and action.

This is a faithful saying: For if we died with Him, we shall also live with Him. If we endure, we shall also reign with Him. If we deny Him, He also will deny us. If we are faithless, He remains faithful; He cannot deny Himself. 2 Timothy 2:11-13

Wednesday 4 September 2013

Home is where the heart is

The three resident cats
Psalm 137:1, 4-6 By the rivers of Babylon, there we sat down, yea, we wept when we remembered Zion...How shall we sing the Lord's song in a foreign land? If I forget you, O Jerusalem, let my right hand forget her skill! If I do not remember you, let my tongue cling to the roof of my mouth - if I do not exalt Jerusalem above my chief joy.

Being in South Sudan now for two months (three if I included the brief time I was here in March/April), I'm naturally homesick. Frankly, I get homesick quite easily (like the time in internship when I was attached to a rural clinic about two hours out of Melbourne, I would drive home every weekend I wasn't on call). This takes it to an entirely new level.

No family. No friends. No car. No Chinese food. Just to get basic amenities like soap or groceries means a trip into town, which involves catching a boda (motorcycle) and negotiating the dirt roads that turn into slippery mud in the rainy season. No international ATM machines so you better hope you brought enough cash prior to arrival. No 000/911/999 number to call in case of any emergencies; e.g. if in need of an appendicectomy, your options would be to either submit yourself to the local health service or going down the very complex (not to mention expensive if uninsured) route of organising a medical evacuation. No postal service so what you packed in your luggage is what you'll live with for the next few months or, at any rate, until your next flight out to neighbouring Kampala, Nairobi or back home.

Truth be told, it isn't all bad. I gained a new family in the other missionaries here in the compound (some of whom have been here for over a decade and have lived through the war together with the longsuffering Sudanese). I've the chance to make new friends in the people I meet everyday, be it as a doctor, kawaja (foreigner) or otherwise. I'm young and healthy - I can walk where required. I've three prepared meals a day (we have communal meals here in the compound) and I can cook (although procuring ingredients can be tricky; I'm currently lamenting my lack of foresight in bringing essentials such as oyster sauce!).

It's taught me that 'home' is a fluid concept. I guess I first learned this when I migrated from Malaysia to Australia as a teenager back in 2003. It took me almost eight years to get over my homesickness then, and I still consider Malaysia my first home. Home is such an integral component of one's identity, so much so I firmly believe that it could cause a crisis when there's an inability to shift or to reconcile a dissonance between what was and what is. Will there ever be a time when I can say that such a place is no longer home? I don't think so. It will always be a part of my heart and soul, but I believe that these can expand to include other people and other places. It has to as a matter of necessity, even if only to survive the emotional trauma.

Psalm 122:1, 6-9 I was glad when they said to me, "Let us go into the house of the Lord."...Pray for the peace of Jersualem: "May they prosper who love you. Peace be within your walls, prosperity within your palaces." For the sake of my brethren and companions, I will now say, "Peace be within you." Because of the house of the Lord our God I will seek your good.

For the sake of my family and friends both in Malaysia and Australia, I will always seek the good of these countries and uphold them in my prayers. Who knows whether this place would eventually take on a similar role one day? All I know is our final home will never change, and I choose to find comfort in that irrevocable reality.