Published by Matt Spreadbury i Tesfa newsletter Rwanda · 18 desember 2021
Tags: Rwanda, English, 2021
Tags: Rwanda, English, 2021
Welcome to newsletter number nine from the Tesfa team in Rwanda, and my fourth! There are so many experiences that it would be impossible to convey everything in four newsletters. As it is with life we remember just fragments of the stories we are involved in. My last week in Kibogora was filled with patient testimonies as they came to the outpatient clinic for their one month post operative check up. There were so many smiles, sighs of relief and shouts of joy. It was humbling seeing these ordinary men, women and children, restored to health enjoying life once again.
Fig 1: A patient who underwent a risky and life saving procedure. Smiles all round!
A good friend mentioned to me that so far I've only shared the success stories and not the tragic ones. Well on a point of information, all the success stories have come from hope born in someone's own tragedy. However there are some events which are purely tragic and injust when judged from a worldly view. Life in Kibogora is full of contrasts that hit you whenever you least expect it. For example one can enjoy the satisfaction of completing an acute operation to then be hit right in the solar plexus with a desperate situation. Sindre wrote about this in his newsletter (www.Tesfa-hope.org) which is well worth the read!
In the west we are told to have a professional distance with our patients.
Dont get emotionally involved. Even the process of operating is geared towards impersonalising the patient laying on the table. Drapes cover the entire patient's body from the surgeon (of course this is also practical due to sterility) so that they are not visible. It's much easier to operate on an organ than it is a person.
Fig 2: A young girl who had been hospitalised for two months finally plays outside bouncing a tennis ball
Professional distance means that you can think logically, remove the emotion and thus in theory do a better job of treating a patient. To prevent one caring too much so that one doesn't get too emotionally involved. Then again in the West we only treat the physical, sometimes the mental and rarely, if ever, the spiritual. As an example of western practice each ailment of a particular organ is directed to the subsequent specialist and a team of five doctors could treat a patient without ever having a conversation together. The only trace of their presence being their individual notes in patients electronic journal. Western medicine is so impersonal.
However if we talk to patients, get to know their family, lay hands on them in prayer, hear their stories then we are by nature emotionally involved. I think it's the way God designed healing to be on Earth, ministering to the body, mind & spirit. If we only treat the physical we leave the soul spiritually wanting. If suffering does indeed have a purpose, - and I by no means claim it does - well one aspect would be to show us our need for others and for God, to call on His name and duly be comforted and healed by His presence. Healing was designed to be in fellowship with Him that heals, through a surgeon's knife, a doctor's medicine and the Holy Spirit.
Fig 3: The same girl above, but 2 months before, critically sick with a typhoid perforation of her bowel. The team covers her in prayer.
Sometimes we are living our lives blissfully in the day to day when our world gets turned upside down.
Zaustin is 32 years old, the breadwinner for her family of six. During the day she carries rocks or does manual labour to provide for her loved ones. She earns around a dollar a day. She has a newly born daughter and a husband who is currently unemployed. One evening after payday she went to the marked and had a meal with some friends, a group of guys assumed she had money. They beat her up, stole her money and left her for dead. One week later as Sindre and I were swimming at Kumbya we got the call saying a trauma is going to the operating theater. An one week old trauma that needs an operation? This sounds strange. We came straight away, bouncing along the dirt roads in a Toyota pickup. As I saw Zaustin laying on the OR table I placed an ultrasound probe on her abdomen and saw a lot of free fluid. This could be blood or something else, either way she needs an operation.
Fig 4: Venuste (my surgical brother) and I thanking each other for help after a case.
Venuste and I opened the abdomen and 2.5 liters of dark blood were sucked out. I thought I felt a laceration in the mesentery. The bleeding had stopped. We sucked out the fluid, examined the bowel and satisfied we washed and closed, but i didn't have a good feeling. Two days later she had a fever distension, low urine output and tachycardia., I repeated the abdominal ultrasound and she had copious amounts of free fluid in the abdomen. We operate again and there is gushing brown, black fluid (old blood?) coming out near the stomach. Stress ulcer perforation? The gastrohepatic ligament has a hole in it, and when palpated I felt a hard pancreas below. Hmm. At this point I scrubbed out due to fatigue. I had been operating for 9 hours so far that day. Scrubbing out during a case is something that a surgeon never does. You finish when the patient is in a better state than when you started. Not even breaks for peeing. Whilst at Kibogora I scrubbed out a couple times; once as I had fever and now as I felt that I would pass out from dehydration with the heat of the operating theater nearing 28*C under the thick cotton operating gown I had sweat through. I am all the more impressed by the stamina of my Rwandan colleagues Bernard and Venuste who carried on operating for 3 more hours.
Fig 5&6: The residents in Kibogora: Venuste, Francois and myself.
Later Bernard called me to say they found that the entire pancreas was necrotic and they had to remove all the dying tissue. Surely the mesentery and pancreas were injured in the same forceful kick to the abdomen. This condition -traumatic necrotising pancreatitis- carries with it a 50% mortality rate. After two laparotomies and on day 14 after the injury I joined Erik, a hospital chaplain on “pastor rounds” on the surgical ICU. The chaplains have an unique role in the hospital. They don't only minister to patients in need but they sometimes have the means to go the extra mile to help patients in whatever they might need. Since Zaustin wasn't working, she didn’t know how her family could afford to pay for her treatment. They might have to sell their land, bankrupting the family. The worry was spread across her face, she cared more about her family's welfare than even her current pain.
“5 billion people do not have access to safe & affordable surgical care” (The lancet commission on global surgery 2015).
Patients undergoing surgery shouldn't face bankruptcy to pay for it. Such is human injustice that exists today, while there is enough wealth in the world so that nobody has to be hungry. Its a heart issue.
As Eric and I prayed with Zaustin I felt moved to tell her not to worry, we will somehow find a way to cover the costs of operating and her postoperative care (social services, myself, the Church or use donated funds). This definitely breaks some unspoken rules of the traditional doctor-patient relationship. You can't help everyone, but here is a patient who I can help. We are blessed to bless others. That comes with a moral responsibility (James 4:17). Zaustins relief of hearing this was visible on her face. We are not talking a lot of money either, 15-50 dollars perhaps.
The next day she was in agony.
I had doubts her pain was being managed properly. Her breathing was fast and shallow between a moan of pain. Her oxygen concentration in her blood was around 80% (for you or me it's 97-100%). The hospital had run out of IV paracetamol and morphine. I don't think you could imagine her pain after 2 laparotomies and necrotising pancreatitis. This is not just agony, it amounts to torture by association.
Fig 7: This was the chest x-ray. Simplified, normal lung should appear black, this is pretty much all white.
Her pain meant that she wouldn't breathe deeply, thus her lungs won't expand fully, worsening her own oxygen uptake. A condition called atelectasis. I doubted this was the whole story. She had ARDS - acute respiratory distress syndrome- where the pancreatic enzymes had leaked into her systemic circulation and caused a massive systemic inflammatory response leading to fluid leaking into her lung tissue. She needed CPAP. Positive pressure to inflate the lungs and two weeks in a fully equipped intensive care ward but even then the mortality rate is still 50%. Our neonatology ward ironically uses adult CPAP machines but the hospital doesn't have adult CPAP masks. Something I find very hard to believe. Someone started performing lung physiotherapy (brisk pounding on the lungs) and Zaustin screamed uncontrollably as she coughed up fluid and sputum.
I had to do something. I paced to anesthesia to get ketamine/diazepam and rigged up the infusion myself. At least she was more comfortable and relaxed now. That was the limit of my efficacy, in the system I am working in with the resources available. I asked Thomas, an experienced nurse, what he thought “For her, transfer”. We tried, but the referral hospital refused. Early in the evening she was saturating at 40%. You know that burn you get in your legs when you run? That's due to oxygen debt and lactic acid being produced. As Zaustin’s oxygen level was so low she would have felt the same burning pain in her entire body. She was scared and diaphoretic with beads of sweat covering her exhausted face. Bernard, Gilbert an experienced nurse anesthetist and I pondered what to do. The truth was there was very little in our toolbox. We only had the box, a now empty one. Our only hope now was to try and transfer her again. The larger hospital would not accept this transfer unless she was intubated. That means having to give general anesthetic, placing a tube into her trachea and using a machine to breathe for her. This in itself could kill her. Then she might die on the journey as someone had to hand ventilate her on the 6 hour car journey.
I took in her situation again. The oxygen monitor, the anguish on her face, her wide eyes imploring me. “Let’s pray”, Bernard stood at the end of the bed and I closed my eyes and lay my hand on Zaustins shoulder. She looked at me, nodded and closed her eyes as well. “Comfort oh God, be with her, cast out the fear, we need you now…” As I continued I heard a softly spoken voice join in prayer to my left, Gilbert the anesthetist “Jesus hold her, never let go, bring your peace Father..”
When there is no worldly hope, all it takes is a step of faith, to change everything.
Our two voices became three as Zaustins nurse lifted her voice to heaven on the other side of the bed. People saw what was happening and felt moved to join, even the patient in the next bed started praying! The ebb and flow of prayer changed beautifully when a family member sang out in the spirit. Out of nothing, the spirit moved. My voice blended into a melody of others where there is all hope and we declare things as if they are.
Not too long afterwards, Zaustin passed away in the embrace of the Father. Her body was failing, but her soul abiding & secure. She is now at peace and in a final moment of divine healing she is in a place where she can breathe deeply again, where there is no pain and is at rest.
By treating as God intended, we are emotionally involved, thus the joy when a patient survives and is restored to health is all the sweeter when shared. We celebrate the success stories with our friends and colleagues and when a patient passes we grieve, together, in fellowship. We shout, cry and console each other - together. Not just with our Rwandan colleagues but also as a Tesfa team. Through our vulnerability it feels healthier this way. By sharing our grief with our brothers and sisters in Christ. It's one of the beauties of living out faith with others.
Two steps away, in the next bed lay our little boy with burns, Uway (newsletter 3). He had been trying to wave at me the whole time I was with Zaustin. I smiled, held his hand and gave him a bottle of juice. He had been asking for juice the last few days. Here in the space of two physical steps I have mounting sorrow and overflowing joy. I know God is present in both.
Fig 8: Paradise? Absolutely
Fig 9: The Tesfa OR team
Christmas is upon us, Christ came to Earth, his light shone in the darkness. I pray you all are filled with hope, peace and joy during this season.
Luke 2:14 “Glory to God in the highest heaven, and on earth peace to those on whom his favour rests”
Obs we will have a webinar in January for everyone who would like to join a Tesfa mission trip. Get in touch with me or Bjarte and stay tuned!
*All pictures are taken with consent from the patients, where applicable stories and names may have been changed to protect patient confidentiality*
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