Culture Clash

Last week, I ran smack into a very difficult culture clash that broke my heart.  I arrived at the clinic to start work.  We began to see patients when Dr. Sana got a call to run to the next village to see a patient.  He left me there to continue on my own. As he was leaving, he said, there is a pregnant girl out here who is suffering with pain.  Her paper was already in the stack of waiting patients.  I saw another patient, but then decided to move her ahead in line. 

I wasn't super worried about her.....We see lots of pregnant women with low belly pain due to STDs.  She was only 17 years old, 7 months along and this was her first baby.  I called her into the office and registered her in the book and began asking what the problem was.  Her pain seems more intense than an STD and she said it had started the day before.  As she lay down on the exam table, I asked if she was having any "white water" - the term we use for discharge.  Yes, she replied.  A lot? I asked.  Yes, like I peed.  That had me concerned. 

I checked her stomach and she seemed to be having contractions.  Baby's heartbeat was nice and loud.  But mom also had significant edema/swelling in her legs, she was complaining of a headache, and her blood pressure was 160/110.  I did an exam and she was dilated 1 cm.  Since no one here checks for that during prenatal visits, I had no way of knowing if that was new.  I wasn't sure what to do....I kind of wanted to send her to the hospital, but that was a 2 hour motorcycle ride away on rough roads.

I called her husband (about 18 years old) and father in and told them...I want her to start taking medicine and rest here for the afternoon.  We will see if her stomach calms down - and then we will have a better idea of what to do.  They were good with that and the dad went back to their village to work on the farm until evening, when he would return to pick them up.

I started her on antibiotics and gave her a shot for the pain.  We mixed up Gatorade and she started drinking it.  I had her lay down in a quiet room, and continued to see other patients.  I checked on her throughout the morning.  The pain wasn't getting better, but it wasn't getting worse either.

By this time, I was way past my time to go home (most days I only work in the morning), but Sana wasn't back yet and I felt uncomfortable leaving her alone.  I continued to see patients until everyone was seen.  Still no Sana.  I was getting fussy.  I was hungry and had a boatload of stuff that I had been planning on doing that afternoon.  I thought about leaving her at the clinic and running home to grab a bite to eat.  Sana's wife was there (their house is right beside the clinic) and she could call me if there was a problem. 

Something told me to stay put.  It was 3:30 pm at this point and I knew that we were going to make a decision about what to do with Dyama (the patient).  Her headache was worse and the pain shot wasn't working.  I finally was able to call Sana to ask where he was.  He said that he was on his way -which means anything from....be there in 10 min to showing up several hours later.

Thankfully this was a 10 minute delay.  He pulled in on his Moto and looked at me with a question on his face.  I pointed to mom, who was standing in the hall.  Is she in labour, he asked?

I think so, I replied....but she is only 7 months along.  And I think she has pre-eclampsia.

He headed over to his house and I decided to check and see if she was dilated more.  As I went to get gloves, I heard a loud scream from the other room.  Not good, I thought.

I grabbed gloves and laid down an old plastic tablecloth - our attempt to reduce tetanus.  I told mom to lay down.  As she did, I could see the umbilical cord sticking out.  I ran out and told Sana that I needed help.

We discovered that baby was breech when the first body part we could find was a foot.  Sana's wife Dena came in to help when she heard the screaming.  What followed was about 20 exhausting minutes of.....

-Dyama screaming and begging us to stop....having never had a baby, she had NO idea what was happening....she wouldn't lay still, making our job SO much harder.

-Dena chastising her...telling her that there were men outside the clinic who could hear her screaming

-Sana and I taking turns trying to reach in for feet and arms to try to get baby out - his little arms were stretched high above his head....and the cord was part way out so his blood supply was cut off.  Sana said...no way this baby is going to survive...but I was hopeful.

Finally we got baby delivered - strangely, the placenta came out with baby- having already detached.  He was a good sized, beautiful little boy.  He was not breathing and had no heartbeat.  I was going to try to revive him, but my delivery bag was at home with my ambu bag and I felt certain it was already too late.  I reached for him, deciding to try anyway, but Sana stopped me.  I knew he was right.

So there we stood, looking down at the mom and her baby...I had no idea what to say or how to handle it.  I was opening my mouth to tell mom how sorry I was when I saw her looking at the baby.  She said something about whether or not it was breathing yet...and I realized that she didn't know it was not alive.  Ok, I thought...let's see how Sana breaks the news.  But he just brushed her off and said, we will take care of it.  Wow, that was not what I was expecting.

We called in a distant relative - a woman for our town - and explained what happened.  We got mom cleaned up...baby laying next to her the whole time.  Finally we moved mom into the next room and wrapped baby in plastic and laid it out of sight.

We went to the office and Sana called the husband in.  He said, I want you to go to your village and get your family.  The husband said, you are scaring me.

Sana said, nothing to be worried about.  Just go get your family and we will wait for you here.  The husband left.

I was stunned ....nothing to be worried about? Seriously?

Sana said, they are both very young.  We cannot tell them about the baby until their parents are here.

Now, before you wonder about me and why I didn't go with my instincts to tell mom and  comfort her, you need put yourself in my shoes. We are guests here in this country and there are a million things about the culture that I don't get.  Breaking bad news to someone is one of them.  I have seen people lie to the face of another (there is nothing to be worried about, for example) until they feel the time is right to break the news.  We rely HEAVILY on Sana, Dena, and our other friends to help us know the correct cultural way to approach things like this.

So I shut my mouth and waited.

After about 30 minutes, I decided to go and check on mom.  I wanted to check her BP to see if it was going down.  I went in and laid my hand on her shoulder and ask how she was feeling.

Better, she said.  But where is my baby? Did that lady relative take him to her house?

I couldn't look her in the face.  I mumbled something and left the room, forgetting about taking her blood pressure.  It was awful.

I wanted SO much to sit with her- but I knew I would not be able to avoid her questions so I sat outside, tears running down my face.

It is cultural no-no to cry like that.....Sana asked why I was upset...Since it was God who had decided that the baby would not live. 

After about 45 min, the husband returned with his in-laws and a few other people.  I was still crying but trying to get it under control.  We all went into the office.  Sana explained how she had come because she was sick but that it had turned into a delivery.  But that baby was too small and didn't survive.

The dad was the spokesman for the group.  He said that he had heard, and that they were grateful for all we did.  He knew that we tried.  He then said something that surprised me....He said, "Gulunga (me) stayed here the whole time.  She never left Dyama alone.  And we thank her for that."

I was surprised, because the 18 year old husband was the only one from that group at the clinic that day....He must have been the one who told them that I had been there the whole time (made me SUPER glad I didn't run home for a bite to eat).  It never occurred to me that it would make the impression that it did.

Sana took the family to see the baby and then we all went into the room where the mom was laying .  There the dad officially told the baby's parents that the baby didn't survive (even though the baby's dad had been in the office with us and already knew).

The family thanked us again for our kindness and for me staying with her the whole time.  After a short while, all the men left, except the husband.  I went in to be with mom for a bit and to tell her how sorry I was.  A group of women were sitting there with mom, talking.  One of them said, was this her first baby?  When they replied that it was, she said, first babies are hard.  They are often taken from their mom's hand (meaning that they died).  Everyone agreed.

That might be reality but it made me angry.  I wanted to shout - but it doesn't have to be that way!!!!!  It is not like that everywhere.  That is not to say that it doesn't happen.....but it is certainly NOT the norm.

I was able to talk to mom for a few moments...telling her how very sorry I was and prayed for her....that God would bring comfort to her heart.

I went home broken hearted that day....feelings like I had failed my patient and her baby.

I known that in will never understand all that is involved in breaking bad news in this culture.

My hope and prayer is that the families will see my heart for them, and through me, Jesus's love and concern as well.....no matter how the news was delivered.

Conakry Business: Not For the Faint of Heart

 Recently I asked our supporters to pray for our time in CKY - as we had a lot of business to do.  I thought it might be fun to share a bit of what we did while we were there.  Remember, none of these shops is in the same place, so a trip downtown, with traffic, can be between 30 min and 3 hours - one way - depending on the day and time of day.

Grocery shopping  - I shopped for groceries to last for the next 10 weeks.  (Unfortunately, I forgot a few things - and the closest place to buy the few things that I can is a 4 hour round trip away!)  Shopping required stopping at 8 different stores.  I found most of what I needed - though almost all of the stores were out of frozen chickens - they said that they will be restocked in a few weeks.  This time, I only shopped for myself and 2 other people.  Often I have a list for more than that.

I bought 18 lb. of beef chunks and 38 lb. of hamburger - NOT all for me.

Medicine to restock the clinic and personal prescriptions -  This required stops at 5 places.  I got almost everything on my list - though the blood pressure medicine that we need has been unavailable in the country for several months.

Piano -  We sold a keyboard to some fellow missionaries.  This required 2 trips to their house - one to drop it off, and one to pick up the payment.

New curtains and paint - We (and by we, I mean me) have been wanting to repaint a few rooms at our house and replace the curtains.  Thankfully, some colleagues had leftover paint and also some curtains - which I then had remade to fit our windows.  The tailor who did the work was working out of the mission compound- so that was great - I didn't need to track him down!

New Rug -  Of course, new paint and new curtains means needing a new rug - so I stopped by the place where they have big rugs hanging over bamboo poles.  I looked through lots of them and smelled the ones that i was interested in (since I sometimes see them hanging in the rain).  I finally found the one I wanted and bargained for a good price.

Printer cartridges -  We were out of ink for our printer - that required a trip downtown and stops at 3 stores to find.

Various other items - I needed a few random things as well - a bike pump, a plastic tablecloth for the clinic, two thermoses, rectangular plastic tubs, welcome mats, and lamps.  Most of these are found in different places (no one stop Walmart shopping here!).  If I need something, I say, “Mr Bah, I need to buy _____ .”  And he usually says, “One of my cousins sells that.”  I found a bike pump next to the place that sells apples (obviously!!!), and the plastic table cloth and Thermos were in close proximity.  We were driving by a market and I saw the plastic tubs and welcome mats by the side of the road- so Mr. Bah pulled over and I jumped out.  I have never shopped at this place before and I was immediately SWARMED by very pushy men wanting to sell me stuff.  They were a bit obnoxious.  I finally bought 3 mats and a tub.  I also saw some of the rubber shower mats that I wanted, but was feeling very overwhelmed by people and so left them.  Sadly, I never found them again.  Randomly, I also bought bug spray at that stop.  The next day, I showed Mr Bah the lamp that I was looking for and he looked at me with irritation and said, MOM, we should have gotten those downtown yesterday!  opps….

Getting and exchanging money - This requires a trip to the bank downtown.  Occasionally, they won’t let you have all of your money at the same time and want you to come back again.  Once you get US dollars, you need to change it into GNF.  The current exchange rate is 8500 to $1 - so for every $1000 use you change, they give you 8,500,000 gfn.  Makes for a heavy backpack -especially when you are trying to look inconspicuous walking down the street.  This trip to the bank took a long time because we had to reactivate one of our accounts - since our team had been out of the country for several months due to Ebola and we hadn't used the account for a while.

Paying other missions -  We often owe other missions money - or they owe us money - for things that we buy or sell or services that they do for us.  This trip, we needed to pay another mission for stuff that we had put on a container.

Paying Mr. Bah his salary -  While we are in CKY, we usually have to arrange for Mr Bah to get paid his salary.  We leave money with other mission colleagues so that he can collect it at the end of the month.  This trip, he also wanted all of his vacation and holiday pay - so we arranged for that as well.  As a mission, we also help pay for his kids to go to school, so we helped get him money to register them and pay for the first 2 months.

Internet stuff -  Internet in the capital is SO much better than the village -so we typically head to CKY with a list of websites that we want to check out, things we want to Google, internet banking, downloading files, and SKYPE appointments with family or others.

Eye clinic -  This trip to CKY required me to drive to a local hospital in search of an ophthalmologist.  I had been given his name, but he was out of the country and I was told that I needed to speak with his partners.  Unfortunately, I didn’t have email contact with any of them - SO is required an in-person visit.  I found the office and was able to ask about a baby who was born with cataracts and where I could refer them to.

Lemon grass - I was also needing to find lemon grass and was told that there was some on the mission compound.  We have LOTS of older people in the village with arthritis and I was told that I could make a solution by putting lemon grass in a jar, filling it with oil, and setting it in the sun.  Apparently it is good for arthritis pain.  So I sent Jim out to the mission to get some for me. 

Veggies and fruit -  There are several places that I stop to get a 6 week supply of fruit and veggies.  We can also buy stuff along the road on the way back home.

New kitchen cabinets - We needed new kitchen cabinets made for the GH.  So we called the carpenter, who came and measured what we needed.  We then bargained for the price.  He  arranged to make them, and then have tile put on top.  This process required several phone calls and several trips to his shop to encourage the process.  Jim then went and picked them up.  Unfortunately, after they were delivered, we discovered that a piece of the tile on one of them was chipped.  Nothing we could do about it….  kind of sad.  But they look pretty good anyway.

DVD restocking -  We have colleagues in CKY who have a whole bunch of DVDs that they loan out - so I made a run by their house to get a few TV series to watch in the village.

Phone cards -  We make phone calls by inputting prepaid phone cards -so we needed restock our supply of those.  Thankfully, these are easy to find at gas stations or with people who walk up and down the street in traffic.

Things that we often have to do but didn’t this trip :  Get new propane bottles to replace empty ones in the village, restock the guesthouse (we did a bit but our teammates were on their way down and offered to do it), buy plane tickets for us or Hannah, get visas or other official paperwork, buy car insurance or paperwork.

Some days, as we are sitting in traffic or running errands, I think about how simple most of this process is in other parts of the world.  But at the same time, there is not nearly the sense of accomplishment and challenge there.  Here, finding new stores and items is exciting. 

To be sure, shopping and doing business in CKY is not for the faint of heart.  We love visiting and hanging out with our friends, and then escaping back home to the village!

My Expanding Resume

Many, many times over the past few weeks, I have been invited to people’s farms to help pull (harvest) peanuts.  It is not something I have done before - and I often tease them, when they press me to come, by saying  “No problem - Let me just run over to the clinic and tell the sick people that so-and-so wants me to go to the farm with them - so you will just have to wait until another day.”  Usually they start laughing and beg me not to do that. 

Anyway, it got me thinking about the new skills that I have learned since moving to Africa.  I have NO doubt that they will greatly enhance my resumé should I ever look for a job in America….

Here is a list of some of the things I can now do:

1.     Beat rice to get the husk off

2.    Beat millet to get the husk off

3.    Dig up sweet potatoes

4.    Plant peanuts

5.    Shell peanuts

6.    Beat rice off the stalks

7.    Pick sweet potato leaves

8.    Cut sweet potato leaves for sauce

9.    Mix cooked cassava - this is a very difficult and taxing process which involves sitting down, pinning your feet against a hot pot of cooked cassava, and beating it with a wooden paddle that you keep pulling towards you - it really is exhausting - even for the women who are used to it, much less a “soft” white lady.  Also, I am NOT a big fan of the resulting meal - which is a bit like eating a big pan of glue - so it hardly makes the work worth it!

10.  Prepare fish to smoke - you take gutted fish and bend them into a circle and pin their side fin into their tail so that they remain in a circular shape - you then smoke them slowly over a fire.

11.  Make fish balls - this also a long process which produces less than appetizng results (in my eyes).  You put gutted little fish into a big wooden pestle - fins and all— and start beating it - it makes a sloshing, sucking, nasty kind of noise.  Then you add salt and hot pepper and peanut butter and bullion.  Then you shape them into balls - making sure that you don’t poke yourself with the fins and bones.  You cook them in boiling water and then place them in the sauce.  They are EXTREMELY high in nutrition and EXTREMELY hard to eat as you have to pick through the bones and fins and spit them out.  NOT my favorite!

12.  Wash rice to get the stones out (I really like this job - it is relaxing to me).

13.  Open a can with a knife - this is accomplished by gripping the can with your bare toes and plunging the knife bade into the side of the can - and continuing to work your way around the edges until it is open.  It is a bit hard for me because my husband has always stressed taking care of the knife blade - AND also I don’t want to lose a toe.

14.  Pull water from the well

15.  Start a fire

16.  Cook over a fire

17.  And my most recently acquired skill, of which I am SUPER proud!….. washing a plastic bowl and then tossing some of the water out into the air and flipping the bowl over just in time to catch the water to rinse off the bottom of the bowl.  I have ALWAYS wanted to learn how to do that - and now I can (or at least I COULD, a few weeks ago)!  It is possible that in the learning of this new skill, I became covered in water, providing MUCH amusement for Kanko and Isatu. 

I still have many, many things that I can not do yet (like fanning rice to get the chaff off) - but I am working on it.  I am thankful to Isatu and Kanko for giving me a new appreciation for how incredibly hard women work around here.  They are AMAZING!  And not only does it increase my appreciation, but it also provides entertainment for the people passing by!  Anything I can do to help, I guess.   :^)

How to see patients by yourself in a rural clinic in 20 easy steps

Recently I was reflecting on an insanely busy day in the clinic.  I looked back over the day and thought - I saw about 22 patients in about 7 hours - that is only 3 patients an hour - WHY am I SO exhausted?  But then I thought about what “seeing” a patient entails and decided that I may have unlocked the secret to why it goes slowly (though, admittedly, I have no idea how many patients a doctor in the US sees a day).

So here is a step by step guide on how to “see” a patient if you are the only healthcare worker there:

1.     First, assess if they have a “carnet” or medical record.  If they brought one, it goes in a stack on the desk- so that you can see people in order.  If not, they need to buy one. 5,000fg in our clinic gets you a very nice book (a note book cut in half) that becomes your medical record.  It is very hard for people to get used to needing to bring that with them so that we can track their treatment.  (5,000fg is about $0.60 USD)

2.    Call the patient whose carnet is on the top - sometimes you have to go and look for them.  Welcome the patient and any family members that they brought with them.  Everyone can crowd into the small 8 ft by 8 ft office.  No need to worry about HIPPA violations.

3.    Weigh the patient - our scale weighs in pounds, so you need to convert it to kilograms.

4.    Record the patients name, accompanying  family member, where they are from, age (see note below), and sex in the large medical record book.  (Most of the older people have no idea how old they are - many conversations go something like this….  ME - how old are you?  PATIENT - I have no idea.  ME - ok, how many children to you have?  PATIENT responds - and I calculate from there.  I have also gotten - do you see that tree over there - it was 2 feet tall when I was born - turns out that information is NOT as helpful as it is meant to be.  My other favourite answer - “well, how old do you want me to be?” - and one from last week - “Do you know that guy named such and such in another village?” (I had NO idea who they were talking about) - “he and I are the same age”…..  ummm, ok - how about i just guess how old you are)

5.    Ask about a medical history.  This is tricky.  We usually start by saying “what and what is tormenting you right now?”  It is helpful if you can speak the language - MUCH harder if you have to have someone translate for you.  People tend to hide medical history here for some reason and it takes  awhile to pull it out.  They especially seem hesitant to share what medical treatment they have already gotten.  I have heard some interesting symptoms - here are a few of my favourites. 

            a.  There are things walking around in my stomach.

            b.  There are things walking around under my skin.

            c.  My heart is beating hard and it is sucking the life out of me.

            d.  I don’t have any “man” power.

            e.  Something is very wrong with my son - he cant walk around at night in the dark without a        flashlight.  He keeps running into things if he doesn’t use a flashlight.  (That one caught me off guard.)

6.     Examine the patient.  We have a bed in the office* so they lay on that and we assess them.  We also have a few high-tech devices like a BP cuff, stethoscope, finger oximeter to measure oxygen levels, and a Doppler to measure metal heart tones. 

* Occasionally, the midwife is there too - but she is usually tired from farm work, so she will often lay down on the bed.  So you might need to move her off the bed first.

7.      If indicated, utilize one of the 4 labs tests that we can perform in the clinic: urine dipsticks, pregnancy tests, malaria tests, and tests for anemia.

8.  Make a diagnosis and write it in the book.  Each diagnosis comes with a “code” that gets recorded as well.

9.  Write in the book all of the medicines that you want the patient to have.  Tylenol is almost always included because people don’t keep that on hand.

10.  Rewrite ALL of the medicines again in the patient’s carnet.

11.  Dispense all of the meds into little bags and draw lines on them to indicate how many times a day it should be taken and how many pills should be taken with each dose.

12.  Calculate the price of the meds.  Include a 20% fee on top, which becomes the doctors salary.

13.  Tell the family “ your family member has been seen, and the medicines have been written.  Here is the price.”  Often at this point, you all pause and look at each other and then say - did you hear?  Yes, we heard.  And often, people will ask for a price reduction.

14.  Take the money (always use your right hand - never take anything with your left).  Count it out in front of everyone.  Often, people will not have enough with them.  So they say, give me the medicine and I will bring the money later.  But that is not done in our clinic.  So we usually divide out how much meds match the money they have and they come back later for the rest - when they bring the rest of the money.

15.  Explain how to take the meds.

16. Say goodbye and bless them - saying, May God heal you and give you health.  I always tell them to come back if they are no better.

A few side notes -

-you never want to get moved ahead in line because it means that there is something very wrong.  We always go in order - no matter who it is or how very far they have come.  However, super sick or bleeding people get moved up in line.

-there is but one small window in the office - it is a blessing and a curse.  It sometimes lets in a small amount  of breeze - but also allows people to see into the office and talk with you.  We try to make them sit in the outer room - but they are always fascinated by what is going on with other people.  Also, we try not to dispense meds out of that window - but occasionally, on very busy days, it is much faster to hand stuff out that way - which I am sure is very confusing, because most of the time people get in trouble for standing there 

- but then sometimes are told to come to the window.  The window is also maddening because people like to stand there and plead their case for why they should be seen right away - all the while distracting you from focusing on the patient in the room.

-I like to start my day by sweeping up the mouse and bat poop - makes me feel fresh and clean.  Sadly, there are days that some kid pees on the floor and there is nothing to clean it up with  - so you end up walking in it until it dries.