Celeb Status

The first week we were here Domoina told us we had been invited to the installation of the president of Madagascar's Lutheran Church. She said it was a big deal and we needed to wear something nice. Seeing as neither Megan nor I are Lutheran we didn't really understand what this event was or what his position entailed. All that was relayed to us was "it's like he's the pope of the Lutheran Church of Madagascar". Um okay?

So fast forward a little... a family friend named Pastor David and his wife came in town to stay with Dr Harison and Domoina this past week. Scarlet has met both of them before bc he used to be the Bishop of Antsirabe so it was fun to have a mini reunion every morning at the kitchen table! We slowly put two and two together that Pastor David was the one who was being installed as the new president this weekend. He seemed totally normal and we frequently saw him lounging in his PJs so I didn't think that he was too big of a deal.

 The installation was in Tana so Domoina helped Meg, Scarlet and I get everything ready last week. We bought Meg and Scarlet dresses at the local market and then the three of us all borrowed shoes from Domoina and her mom. Somehow we all found shoes that fit perfectly!! We were packed and ready to head to the capital on Sunday. The event started at 10am and it's a 3-4hr drive so we left Antsirabe at 5am so that we would buffer any potential problems! 

As we got into the city, it started to become apparent that this was a bigger event than I expected. Domoina told us we would be sitting up front as guests of honor "bc we are white" and there were two other US pastors coming in town for the event. Pastor Jeff and his wife recently moved to Kenya for mission work and then Pastor Albert lives in the US and travels to events like these to show support. 

**side note: her comment about why we are guests of honor was translated wrong and we later found out it was bc we are foreigners and so our attendance would elevate the event and make it more important in the minds of the Malagasy**

We arrived outside a large outdoor amphitheater where people were swarming in and we were told to walk down the road to the side entrance. There were lots of Boy and Girl Scouts helping to direct traffic and I found out that this was how Domoina and Dr Harison met back in the day! They were both Scouts! We walked down the road to the other entrance and that's when I realized it was the VIP entrance...

The stairs were lined with Scouts staring at the vazahas and when we got to the bottom we were escorted into the amphitheater by ladies dressed in very fancy dresses. As we turned the corner and saw the crowd I knew this was much bigger than I ever imagined. There were at least 6000 people or more filling into the seats. 

We were escorted to our seats which were literally front row center. Our posse included Midera and his girlfriend, Dr Harison, Pastor Al, Pastor Jeff and his wife Michele, Domoina, myself, Eleanor (here to translate), Scarlet and Meg. The installation started promptly at 10am and lasted a mere 4.5 hours.... 

The service began with a long explanation of the voting process bc there is so much corruption in politics here and the vote was a close one. You have to have a 2/3 majority to win and it took 4 times before Pastor David finally came away with the victory. Then they also spent a while justifying the secretary position bc a women had been elected. She was the first women ever elected to be in the governing board and it was clearly a hot topic. 

There were lots of speeches to congratulate the new board and then the Lutheran church service began. In Madagascar, the typical Sunday service lasts 3hrs so fortunately they modified it so the event didn't last too long... but they didn't cut back on the singing! There were probably 600 choir members who were behind us and did a fantastic job with the hymns and songs. Eleanor and I used Domoinas hymnal to sing along and I was able to practice my Malagasy!

The event ended with the benediction of Pastor David and his wife. They received metals and certificates while paparazzi snapped all of the pictures. 

Which reminds me... the entire service was broadcast live nationwide. So every time the press would run up to the front to snap a pic of the action on stage, they would also turn around and snap a picture of us! We're waiting to see if we make it into the local newspaper but Domoina got lots of texts saying we were on TV several times during the live broadcast!! 

Since we are VIP and now apparently famous, we loaded up in the cars and drove across town to the reception. WHOA SO FANCY! This place looked like it belonged in a country club in the US. The building itself was beautiful and it overlooked the city. 

The reception was catered with a delicious 4 course meal and we were entertained by the full choir. They sang traditions Lutheran songs in Malagasy and then all of the sudden turned it up and sang gospel music the rest of the night.

About midway through the reception, Pastor David got up to make a speech and to introduce the two visiting US pastors. After he introduced them, he also decided to introduce Scarlet, Meg and I BY NAME! He knew our names!! I'm shocked bc we his English is limited and we maybe spoke a handful of times, mostly about food! He explained we are students working in Antsirabe and providing free healthcare to the Malagasy people.

Pastor David is the man and I can't wait to hear all about what he does these next few years! He has such an amazing sense of humor and is very humble so I pray good things come his way! (PS- pic is from brunch Monday AM when he joined us at a local cafe before his flight) 

 

Daily devotion: Isaiah 51:16

 “And I have put my words in thy mouth, and have covered thee in the shadow of my hand, that I may plant the heavens, and lay the foundations of the earth, and say unto Zion, Thou art my people.” -Isaiah 51:16

This was one of the scriptures read during the inauguration. It was meant as encouragement for Pastor David as he takes office. "Don't be afraid, God is with you and will be there the whole time. Rely on Him when the going gets hard." I thought it rang true not only for his next journey but also for anyone headed to an unknown future. Prayers go to Pastor David and his wife as they take on this major responsibility.       

Malagasy Wedding

Weddings are a special occasion that take lots of planning so that the couple can be surrounded by friends and family... and random vazahas (foreigners/white people).   Tahiri is one of the nurse anesthetist in the OR and his brother Njaka (who also works at the hospital) is getting married today. The custom for weddings and other special occasions here in Madagascar is to invite visitors to said events. Now in America I'm pretty sure most brides would turn into bridezilla if they were told to add an entire table to the reception to accommodate random visitors from another country. But here, apparently it's customary!

Food preparation began yesterday at the guest house and continued this morning. The hospital staff were in charge of the food and were cooking all kinds of meat and veggies and other delicious looking food out in the open on the big silver pots. Also FYI to the mission trip people who were staying in the guest house... we should've come this next week bc there wouldn't be any more geese to attack you/wake you up in the morning. That's bc we're apparently eating 16 of them at the reception tonight!!!

The wedding ceremony started at 12p so Megan and I spent the morning in the OR with Dr Harison to soak up every chance we get! We scrubbed in on an open cholecystectomy (gallstone was the size of a prune) and then also a c-section. It's interesting to see the surgeries we did laparoscopically in the US done open here. I'm starting to better understand the pros and cons to both!

The wedding ceremony was held at the big Lutheran church downtown. We met the 3 Norwegian nursing students at the church and had our own vazaha pew. The service started at noon, which means people were showing up from 11:45 until right before it was over. We showed up about 30min late with Domoina and her mom and no rude stares were thrown our way (mostly just confused glances on who we are).  The ceremony lasted a mere 2 hours and there was a lot of stand up/sit down and singing. The bride was absolutely beautiful and the church was decorated nicely. 

Malagasy weddings all have color themes and so whatever color the bride picks is what all the guests wear. The bride and her bridesmaids all wear white. This bride (Stella) chose a rainbow theme so we were able to wear any color and the church, car, and reception was decorated in rainbow colors. 

After the wedding, the bride and groom hop in their decorated car and everyone caravans behind them in a parade. We parade through grassy mall downtown where everyone hangs out and then also parade the newlyweds past their homes. Njaka grew up in Antsirabe so that was easy but Stella grew up in the next town so we drove an extra 20min to get to this other town. Scarlet made the comment about how did they meet bc it was a pretty far way to walk and most people stay in meet someone in their same village/town.

The reception was at a pavilion near the center of town and was decorated in rainbow colors! There was a live band, 4-course meal (including the geese...) and lots and lots of dancing! 

The surgeons and OR staff were there and they helped teach us the Malagasy dances including the Afindrafindrao (opening dance) where you dance with your partner behind you and shuffle around in a circle. There were lots of circle dances, line dances, and then just regular fun dancing! 

As expected our table was the vazahas plus Dr Harison, Domoina, Midera, and gma. Kamilla, Ingrid and Elise (the Norwegian nursing students) also had a blast and it was fun to be surrounded by 3 fellow blondes! 

 

TGIF

Friday 11/4 - There were only a handful of cases on the board today so we were expecting a slow Friday. Boy we're we wrong! The first surgery was a tonsillectomy secondary to persistent rheumatic fever (a complication of untreated strep throat). We also had a couple abscess debridements. But the big case was a young guy who came in with peritoneal signs (acute abdomen) from a stabbing that happened last night. He was very out of it and had rigidity, guarding, and diffuse tenderness. We got him back to the OR for an exploratory laparotomy and right after he was intubated, the patient coded on the table. 

The OR monitors are older and so they sometimes show an error in heart rate and O2 sat. So when the monitor started beeping and showing a flatline it wasn't too concerning bc normally the vital signs will pop back up in a minute or two. Around the same time the anesthesiologist was listening for breath sounds to indicate a good intubation but looked up concerned bc he didn't hear the heartbeat. That's when everyone stepped into action. Lots of Malagasy was being spoken but everyone remained calm. They started chest compressions, kept continuous breaths and pushed epi. I have no idea how much time passed but it felt like an eternity and I really thought we lost the patient. The staff started relaxing a little bit and we later found out it's bc the patient was back with us but with weak vitals that weren't registered on the monitor yet. Slowly the vitals came back to normal and the patient was starting to stabilize. It became a high risk surgery due to an unstable patient but once we opened him up we knew that continuing with the surgery was the right call. The stabbing had punctured the patients stomach and he had rice and other stomach contents floating free in his abdomen. The patient was very close to becoming septic so they cleaned out the free fluid and sewed up hole in his stomach. The surgery went smooth and we checked on the patient later that afternoon to find a very alert and oriented 20yo who was shocked to hear he almost died. 

Everyday the hospital takes a 2hr lunch break from 12-2p to go home, eat, and rejuvenate for the afternoon. We took advantage of the lunch break and headed into town to Antsena Kely ("small market"). This weekend we have two very exciting events we got invited to (stay tuned!) but needed proper attire. So off we went to go find Megan a dress and possibly shoes for me! 

We walked to the front gates and hailed 2 pus-pus to take us to the market. A pus-pus is like a chariot where you sit in cubby and a man (usually barefoot) lifts up the other side and starts running/pulling you towards your destination. Very strange concept at first but man was it fun! The men are so strong and can run so fast! The other type of transportation they have is a bike-pus which has a guy peddling a tricycle of sorts with you sitting behind. And to be honest, I think the running pus-pus actually get there faster! 

The afternoon was super quiet in the OR so the surgeons decided to practice knot tying with us and then Dali (nurse anesthetist) taught us blood replacement formulas. We had asked him about it a few days ago and he apparently went home to look up everything and came back in today to teach us! We are so fortunate to be surrounded by people who truly care about our education and want to help us learn! 

Right as we decided to head home for dinner, a young boy came in with a pleural effusion from falling(?) that needed a chest tube stat. We had been waiting on him to be NPO but his family kept feeding him water or soup. This means he couldn't be put under general anesthesia for the procedure and we could only use local lidocaine. It took a couple tries but Dr Harison got the tube into his lung and started draining blood. Before the boy left the OR, he had already drained 65cc and Dr Harison said he drained over 3L of fluid over the next day from his lung!! Poor boy could hardly breath before the chest tube!

Julie and Domoina cooked tacos for dinner to celebrate Domoina's moms birthday. It was a seasoning packet that scarlet brought from the US on her last trip and Domoina has been holding onto it for a special occasion!! Tacos have never tasted so good with all the fresh produce and meat!

As if today/this post isn't long enough, there is one more thing that must be mentioned! Midera promised to take us out on the town tonight and it just so happened one of this friends was throwing a Halloween party at a bar called Code Le 110. So even though I escaped Halloween in America, it still found me here and we celebrated big! We were given masks at the door and we walked into a fully decorated Halloween bash. The Norwegian girls met up with us a little later that night and we danced the night away! It was so much fun!! Oh and Midera introduced us to a local celebrity who is in town to perform a concert on Saturday. So if you ever hear about an artists named Rak Roots, just know that he's from Antsirabe Madagascar! 

 

"African Medicine"

When we first got here and had the power outage with a pending a c-section, Domoina told us that "this is African medicine". We didn't really notice the effects of this until we started in the OR this week....

Right now we are in the rainy season so it's like Florida and we have daily afternoon rain storms. When the storm is predicted to be more severe (like the hail storm... yes hail... that occurred yesterday) the surgeons are really rushing to get the surgeries done as quick as possible in the AM. This is bc the city power almost always goes out when it rains and the hospital generator is broken. So once it starts raining there's a high chance the power will cut out at anytime. Yesterday I was closing the femur fracture and all of the sudden the power clicked off. It was too dark to continue so the staff starting looking for flashlights or candles to help. Fortunately we were almost done with our surgery, but Megan was midway through a hysterectomy where suction and cauterization is key! They simply had to wait for power to return and fix any bleeders by hand like they did before the fancy tools. 

Another interesting part of "African medicine" (which is more like 3rd world medicine bc it's similar to what I saw in Peru's hospitals) is the sterilization process. There's a main sterilization area where everyone hangs out between cases and two ovens to sterilize the tools. The scrubbing technique includes a bar of hand soap and a sink but you still wash all the way up to the elbows. And there are open windows in both ORs. The amazing part about all of this is that the infection rate at the hospital is extremely low! So either the Malagasy people have tough immune systems or they embrace the fact that a little dirt don't hurt! The more I'm here, the more I'm convinced that Americans (including me) are wimps... 

Other funny things we've seen that would never fly in the US is people coming in/out of the OR drinking coffee, performing surgery while barefoot, and eating food in the sterilization area. 

While I say all these things, it should not take away from the fact that the surgeons here are wicked smart. They learn ALL aspects surgical medicine and are a jack of all trades. We have seen Dr Harison and the other surgeons perform surgeries from head to toe without a blink of the eye. They also are able to repurpose their limited supplies and provide optimal care for patients. It's absolutely amazing to watch an older, less expensive, less complicated version of medicine that provides outstanding results! We are learning so much and will be better healthcare provides bc of this experience! 

See One, Do One, Teach One - Part 2

Today (Thurs) was our first full day in the OR and we are soaking up every last second of it! We are doing our best to learn the daily schedule and rotation of surgical staff as well as make good impressions to prove our abilities as PA students. 

Every morning the hospital has devotion in the dispensary at 7:15am. Devotion lasts until 8am and then the workers, patients, and families begin the day. Megan and I wandered over to the OR to check the board for the cases today and found that it was filling up fast with the scheduled surgeries and emergency cases. 

Dr Surge and Dr Boná (the bone doctor...) were on call surgeons today and Sidraka was the on call nurse anesthetist. He was one of our interpreters during the mobile clinics so we know him a little better than the others. Sidraka took Meg and I under his wing and was following the "see one, do one, teach one" motto. He showed us how to intubate and do epidurals and let us start new IVs on patients who needed it. After showing us the skill one time, he then let us do it and would be there to help if need be. He also went over a lot of the anesthesia meds with us so we would be more familiar with what occurs on the other side of the curtain. 

Today we had bilateral hernia repairs, 2 goiter removals, a femoral head fracture reduction with plate and screws, a hysterectomy, vaginal hematoma drainage, and a toe amputation (6th toe on a infant). We also had a little boy come in with a broken elbow and Dr Harison casted the little boy in the main area while surgeries were going on since there's no procedure room. 

My favorite surgery of the day was by far the c-section due to placental previa. The baby was 38 weeks and not ready to be born. The baby was head up and had to be flipped to be born breech position. The first c-section I was able to scrub in on but this time I wanted to be there to catch (yes literally catch) the baby and see what happens on the second half of things. The doctor pulled the baby out and tossed her into our cloth towel hammock. I was terrified I was going to drop the towel and the baby would fall!! But so far so good and we took baby out of the room to clean her up, warm her up, and do an unofficial APGAR score. 

The baby was shown to mom and then whisked away to the nursery area which is 2 doors down. We weighed and measured the baby before bundling her up in layers upon layers of clothes. We put on a cloth diaper and undershirt, another shirt, then a blanket, then a sweater and hat over the blanket and finally swaddled in 2 more giant blankets. The poor nugget at least doubled in size with all the clothing!! And then we placed the newborn baby in a crib in the nursery and left her all by herself.... no family or nurses nearby!  

See One, Do One, Teach One

The whole reason Megan and I are here is to set up an international rotation for the Mercer PA program. We are essentially the guinea pigs to trouble shoot for the school as well as make connections/impress the doctors. The hope for this new international rotation is that PA students can come to Madagascar and do 1 week of mobile clinics with Scarlet and the Mercer pharm students and then 3-4 weeks in the OR with Dr Harison.

Megan and I are working on meeting all of the hospital staff and introducing them to what all a PA student can do. They do not have PAs in Madagascar (we actually can only see patients if a licensed Malagasy nurse is our translator) and so it's been an uphill struggle to communicate our role and capabilities in addition to the language barrier. However the surgeons, anesthesiologists, nurses and other staff have been more than helpful and very receptive! We are also fortunate that Joanna, a nurse practitioner from the USA, came here last year and worked as a NP for 9mo. We are able to explain that we are training to be like Joanna, which has really helped with the language barrier! 

The Lutheran hospital that we are at is a teaching hospital for Malagasy medical students as well as Norwegian nursing students. (Fun fact, Norway started the Lutheran mission here in Madagascar so their presence goes wayyy back). This is great for us as PA students bc the hospital is used to teaching and having students around! The Norwegian nursing students have the option to rotate in Madagascar during their 4th year for 2mo. The first month is spent at the Lutheran Hospital while they take Malagasy language lessons. This is bc most of the surgeons and nurses here speak at least some English and French. The second month is spent at the public hospital down the road where they are thrown into several different settings.

Megan and I started our surgical time on Tuesday and have been in the OR the past 3 days. We have seen and helped with so much already! One OR will have a goiter removal followed by a hernia repair and the other is doing a c-section followed by a fracture reduction. Each day is different and you have no idea what is coming through the doors!! We have to be ready for anything and willing to jump in at a moments notice!

Tuesday was actually a national holiday (All Saints Day) so the hospital was "closed" and was only taking emergency cases. We needed the extra R&R in the morning to make up for the chaotic travel day on Monday but that afternoon we had several cases show up. We were able to go on a surgical consult for a small bowel obstruction and potential c-section to determine if surgery is necessary. We then scrubbed in on an emergency hernia repair and c-section. Lastly we helped suture a hand lac and were present for a vaginal delivery all in the course of a couple hours while the hospital was "closed"...

Wednesday morning was full of patients at the mobile clinic and then we came back for afternoon surgeries. We scrubbed in on a huge umbilical hernia repair, an ovarian cyst removal the size of a cantaloupe, and a bilateral inguinal hernia repair. The last case of the day was an 18yo girl who is currently paralyzed from the waist down due to a TB infection in her hip bones. The infection has turned into either osteomyelitis or AVN (lost in translation) and required surgical removal of the femur neck to allow the girl to be able to sit upright in a chair again. Right now her lower extremities are so disfigured that she is only able to lay flat. It was a very sad case and her prognosis is pretty poor but I'm glad we were able to provide her some palliative care to allow her to sit up again. 

Daily devotion: John 5:3, 5-9

“In these lay a multitude of them that were sick, blind, halt, withered. And a certain man was there, who had been thirty and eight years in his infirmity. When Jesus saw him lying, and knew that he had been now a long time in that case, he saith unto him, Wouldest thou be made whole? The sick man answered him, Sir, I have no man, when the water is troubled, to put me into the pool: but while I am coming, another steppeth down before me. Jesus saith unto him, Arise, take up thy bed, and walk. And straightway the man was made whole, and took up his bed and walked. Now it was the sabbath on that day.” -John 5:3, 5-9

As we were talking with the paralyzed girl, all I could think of is this passage and how I wish we could help her walk again. She is a beautiful girl and it's such a shame that a disease could cripple her for life, but you must always remember there is a greater plan. We do not know what her personal and family life is like nor can we guess what God has in store for them. All we can do now is extend compassion and love to this girl and all other patients who need healing. Please pray for her today so that she may have a brighter tomorrow with less pain. And please pray that she may find God in her current situation and trust in His will.   

Conversion Rates

Weds 11/2 - Our make up clinic today was a success! We made it back to Antsontany to see the 200 patients who weren't seen at the clinic last week. Last time we were here the pastor toured us around the church and was very proud to show off their roof project. They are making their own tile behind the sanctuary to hang on the ceiling and then are also fixing some of the holes in the roof. The project will cost a total of $1.1 million aryiary ($343 USD) for the entire project and he said it would take 5-10yrs for them to raise the money. He told us about the project not as a plea for donations but instead to let us know what the community's goals are. 

Over the course of the mission week, our group also had several patients with medical conditions requiring expensive surgery that would take years to pay off but when converted to USD, it's a very reasonable amount. For example, the first night we were here when the power was out, a couple team members helped hold flashlights for Dr Harison as he performed a c-section. The baby boy was born with a cleft palate and will most likely have this defect forever. The surgery to fix it is done when the child is 3yrs old and will cost $150 USD. On the second day of clinic, we had an older gentleman come in with severe cataracts and that prevented him from working. The surgery to give him his sight (and livelihood) back will cost $200 USD. There are several other patient situations we encountered and while the amount in USD seems reasonable (in fact pretty cheap!), the conversion rate is $1 USD = $3200 aryiary. So multiply the previous numbers by 3200 and you can see the daunting cost these patients must take on...  

The patients we met really made an impact on our hearts and have stuck with us throughout the week so as a group we asked Scarlet if donations could be made to cover part of the cost of these surgeries to help people have a better future. We each gave what we felt comfortable giving and were able to collect enough money to cover the cost of all the surgeries, imaging studies and construction projects that were presented to us. This includes: cataract surgery, hand tumor removal, hydrocephalus shunt placement (little baby with the big head), church roof project, rice for the Toby psych patients, and a couple more. 

It is such an amazing experience to not only go into rural areas to diagnose and treat the "basic" health problems but also to have the resources to refer patients to a top notch local hospital and have them set up with Dr Harison to do their surgeries. As I've said many times before, healthcare should not be a privilege. It is a basic human right and the fact that we can do more than share our hearts and pharmaceuticals with these wonderful people, but also assist them in expensive life changing procedures is one of the best feelings! God is good and He will always provide!

Daily devotion: Micah 6:8

“He hath showed thee, O man, what is good; and what doth Jehovah require of thee, but to do justly, and to love kindness, and to walk humbly with thy God” -Micah 6:8