"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    

On Malagasy Time

We stayed overnight at the Ivato Hotel in Tana bc JillRae, Chesley, Dr Joel, and Maureen didn't fly out until this afternoon. We spent the morning at the Faza mall (white people mall) and then went to the Gastro for lunch. The Gastro is the big "fast food" restaurant in Madagascar that serves really good pizza! Normally I try to avoid eating American food while in other countries but this was an exception! So good and so interesting to try Madagascar's version of pizza... soft thin crusts, light sauce and lots of yummy cheese mixed with herbs!

We dropped JillRae and Chesley off at the airport for their safari in South Africa. Pizza ran a little late and we didn't think it was gonna be a problem to arrive 2.5hrs before takeoff but we ended up cutting it real close! Checking in the bags and people took over an hour and they finally got everything squared away 30min before having to board the plane! So we learned the 3hr buffer is a mandatory in 3rd/4th world countries! We're definitely going to miss JillRae these next couple weeks bc our dream team is now down to two! 

Our journey back to Antsirabe should've taken about 3hrs but a few unforeseen events transpired that drew out the journey to over 7hrs. About an hour into the trip, Pastor Honey had to pull the van off to the side of the road bc the engine was overheating. Turns out the electrical wire had shorted and we had no power in the car. This means no lights, no power steering or breaks, and no way to cool down the engine. We were about 15min outside a semi large town of Ambatolampy and therefore coasted into town as the sun was setting. We tried to find a mechanic but no one was open. 

While waiting for a solution, the town power went out and we were completely surrounded by darkness. The only concerning part about this was that our car had no lights and we were a sitting duck on the side of the road. Cars and trucks roared by causing our van to shake multiple times. Pastor Honey made some more phone calls and got in touch with his uncle-in-law who lives nearby. The uncle loaned us a small car to use to get to Antsirabe since it wasn't very safe to stay in this town. 

7 people with overnight bags + 1 small sedan makes for a tight squeeze for 2 more hours! Pastor Honey drove with Domoina and her mom in the front seat and Scarlet, Njiva, and I in the backseat with Meg laying horizontal across us. The car took a second to start and the dashboard didn't light up but it had 4 wheels and working exterior lights so we were good! We didn't know how much gas was in the car bc the dashboard didn't work so Pastor Honey went to find a gas station. The first one was closed bc there was no electricity in the town. The next one was in the process of pumping gas and therefore we couldn't fill. And the 3rd gas station we passed was about 20km away from Antsirabe so Pastor Honey didn't stop bc we were so close to home.... 

Well we made it to the Antsirabe city limit sign and then all of the sudden sputtered to a stop and we were stranded yet again! Fortunately we weren't in the bush anymore so it was a little safer but still not the ideal situation bc we were on the side of a dark road where trucks and vans were flying by. Dr Harison came to our rescue with gasoline and we filled up the car and made our way to the hospital! I've never been more happy to make it home than I am tonight!!!

 

We like to move it move it!

This weekend we traveled up to the National Park of Andasibe to see the lemurs. The park is 3-4hrs east of Tana so on Saturday we loaded up the vans and drove north to the capital. We stopped at several small markets along the way to pick up souvenirs. We ate lunch at the mall in Tana before continuing east to the national park. It was a total of 6-7hrs of travel (290km) that included lots of CME learning, Disney singing, and sleeping. 

On our way there, we saw a 3 car train on the tracks and all the Malagasy interpreters got very excited! I had noticed earlier in the week how the train tracks always had a lot of people walking on them but didn't really put two and two together. Eleanor explained to me that the government built a lot of train tracks across the country but the trains aren't used very much so now people use the tracks as pedestrian walkways. 

We arrived at Hôtel Feon'ny Ala around dinnertime and got settled into our thatched bungalows. There were 4 twin beds nestled in the loft and 1 full bed on the main level of the bungalow. JillRae, Yolanda, Meg and I took residence in the loft while Chesley was able to enjoy the main area without our craziness bothering her! The hotel is appropriately named to mean "Song of the Forest" bc the bungalows literally sit on the edge of the Réserve Spéciale d'Analamazaotra and we woke up to the roar of the lemurs calling out to each other. 

The next morning we packed up our things and headed to Vakôna Lemur Forest. The lemurs live on an island separated from the mainland by a small strip of river. We had to get on a canoe to cross and then we were surrounding my fun-loving lemurs eager for bananas! The most surprising part of the lemurs was how light they are! They would gently jump onto your shoulders and begin climbing all over you for fun!! We got some great pictures and videos and JillRae had a lemur friend follow her back to the boats, clearly asking to go home with her to America. 

Our group was so large that the Malagasy guides couldn't take us all out on the canoe adventure to the other lemur islands at the same time. But several of us who have been canoeing before volunteered to paddle so the whole group could go together! We found several other pods of lemur families and even a couple babies hanging onto their mamas! 

The ring tailed lemurs were the last ones we saw bc they are secluded from the rest of the lemurs. Apparently they can get a little feisty and don't play well with others...

After the lemur park we drove west to Moramanga for a birthday surprise! Today is Ebony's 29th bday and yesterday was Pastor Honey's bday so we ate lunch at a French bakery where they had custom cakes made for them!! Both were so surprised and the cakes were delicious!

We continued on to the chameleon and reptile reserve to see some of the native reptiles. We saw geckos, snakes, chameleons, and more! The chameleons were beautiful colors and ranged in size from a few cm to over a foot.

This was our last stop as a group before heading to the airport so naturally we had to take a group picture and video everyone dancing to "I like to move it move it". Definitely going to miss this amazing group of people!!

Clinic 5: Antanifotsy

This week has flown by! I can't believe its already the last day of clinic and the team leaves this weekend. We drove North to Antanifotsy about 1hr away and set up at this beautiful Lutheran church that had a school attached to it. I was working in Triage with Yolanda, which was so fun bc you got to meet almost all of the 300 patients who came through to be seen! 

The time in country has been like no other that I've experienced before. We have seen disease states that are so severe, unusual, or non-existent in the USA. Patients here just don't have the same access to care that they do in other countries and therefore you never know what is going to walk through the front door. We have seen:

• * Measles 
• * Hansons disease (Leprosy)
• * Cleft palate
• * Meningitis
• * Active TB
• * Mycobacteria lesions
• * Osteogenesis imperfecta
• * Cerebral palsy
• * Abscess with severe hand cellulitis
• * Healed displaced tibia fracture 
• * Scabies (full body severe)
• * Wilson's disease 
• * Klippel-Traunay syndrome

The saddest case today was a 1yo baby girl with hydrocephalus. Her head was the size of a small watermelon and her young mom was beyond distressed. Her sweet baby girl was considered a freak show and she had no access to medical care bc of cost. One of the nurses on the trip works in CHOAs neuro unit and has seen this condition before. She said that if the babies receive shunts to drain the extra fluid early, they can live much better lives but this little girl was the most severe version she has ever seen. There wasn't much we could do except try to get a shunt from CHOA and have it mailed to Dr Harison to do the surgery. But we couldn't send this mom home empty handed so we prayed for her. Pastor Mike was with us and he prayed over the little girl and her mom to send the Holy Spirit to guide their way during this hard journey. 

The drive today was the prettiest we've had all week. We were driving through the river lands so it was lush and green and beautiful! There were green rice patties and farmland for miles on every direction. And people were working tirelessly from sun up to sun down to earn their wages. Their work effort is unbelievable! 

Since we ended our clinic a little early, we had time to go by the Toby, the Lutheran psych hospital. It's a very unique place bc it provides a safe haven for psych patients and their families to live. There are no anti-psych meds in Madagascar so these patients have to suffer through their mental illnesses with just family support and some care giver help. We arrived and were greeted by one very enthusiastic patient who was very adamant about keeping our group together. As we rounded the corner, the reality of the psych facility hit us as we saw the patients in raw form. The patients who are a danger to themselves or others are actually physically restrained with chains. If the person is a flight risk, they're feet are chained. If they're a risk to themselves or others, they also have their hands chained. And if they're having a psychotic break, they are chained to their beds with family nearby to take care of them. It was absolutely heartbreaking to see that this was their best option! But it was also so encouraging to see how integral the family members are. So often in the USA psych patients are locked away in facilities for others to take care of them. It's very apparent how important family is and how they drop everything to take care of each other. 

After this somewhat draining experience, we came back to the hospital for a 180...  Dr Harison and Domoina put on an amazing BBQ for the Malagasy interpreters/staff and us to celebrate the end of a fantastic week. There was more food than I have ever seen before and it did not stop! They had tents set up outside the guest house overlooking the setting sun over the town and we had an amazing time. After dinner JillRae pulled out the guitar and bongo drum and we played battle of the bands between the Malagasy and Americans. Clearly the Malagasy won bc they're music was so much better! 

Our experience with the Medical Missions Team has been an experience for a lifetime. We saw over 2300 patients in 5days and gave out almost all the medication we brought (17+ suitcases). It's been an exhausting week and I don't think I've ever been so tired at the end of each day. I'm so sad that everyone is heading back to the US bc it has been such a dynamite team! I'm glad we have a couple days left to hang out and play with the lemurs:) 

   

Daily devotion from Megan: 1 John 4:19

“We love, because he first loved us.” -1 John 4:19

It seems only natural to end this week of mission work with Megan's favorite verse bc it has such a powerful message.  The verse 1 John 4:19 is the heart and soul behind why, I personally, choose to serve on medical mission trips, however it applies to everyone. The passage that surrounds 1 John 4:19 lays out how God defines love, how God shows His love, and how, as Christians, we are instructed to love.  To loosely paraphrase: first and foremost - God is love. And to know God is to know love. God's love is shown to us through the ultimate sacrifice- sending his only Son as the atonement for our sins. If God is in us, His love is in us. (That always stops me in my tracks. We have Gods perfect and powerful love inside of us- at our disposal to use to serve others.)  But with power comes great responsibility. Therefore, the way that we treat people is a reflection of God's love. Our actions can be a positive or negative testament of Gods love and our actions are a choice. We should choose to love without borders or limits. We should love sacrificially.  When I think about who and how I should love, I try to look in mirror first. I think of my attitude, my actions, my past and then remind myself that God loves me unconditionally, despite all of the hiccups along the way. God chooses to love me every day-even when it's hard (...which is daily). I also think of how he chose to show His love for me - he sacrificed His Son so I might live. That wasn't an easy sacrifice. That wasn't the spare change in the cup holder for the homeless man on the corner - it was thought out, it hurt, it required so much of Him. He loves BIG. And because God first loved me, I ought to love others in that same manner. I fall short on a daily basis, but the ultimate goal is to love like God. To love Big. To love all. To spread the love that I have been to blessed to receive.