What Should I Specialize In to be a Medical Missionary

What Should I Specialize In?

I used to think that the only useful specialties for the medical missionary were Family Medicine and General Surgery. My ideas have broadened a bit since I have had some real experience on the mission field.
One area I never thought of was Anesthesiology. Without an Anesthesiologist the surgeon is extremely limited in what he or she can do. They are limited to minor procedures or trying to put the patient to sleep, and more importantly, wake her up again, all alone. Additionally, since the anesthesiologist put people on ventilators all the time, she is the doctor best prepared to manage patients on a ventilator in the Intensive Care Unit. One or two patients in the Intensive Care Unit can keep an anesthesiologist without a good night’s sleep for a week.
In general, the broader the training, the better one is prepared to be a missionary physician. The three most useful specialties in my mind are Family Medicine, General Surgery and Anesthesiology. In my opinion, combined Internal Medicine/ Pediatrics is a close fourth, followed by Internal Medicine or Pediatrics alone. In Shell, until we had a Pediatrician who cared for hospital patients, the Family Practice doctors were caring for sick Newborns. All we had to work with was two weeks of NICU training in residency and the Harriet Lane Handbook. We were practicing way over our heads, but most of our patients did alright because the handbooks were well written and God was gracious.
There is a role for specialists and sub specialists, but that’s mostly in teaching in short term stints in the large medical centers in a country. The Christian Medical and Dental Associations and medical schools regularly have groups that go to developing countries to teach local specialists at the big medical centers. The specialists will teach new procedures or do an update on information to the national specialists.
Another place for specialists in developing countries is on one to two week medical brigades. Long term missionaries able to treat most anything that walks through the door, which means a generalist who is able to find information or know where to send a patient is best equipped to greet the patient at the door. The problem is than when a specialist is needed, one specific specialist is needed for one patient right now, not in four months when the brigade is coming.
In Ecuador every year a group of Ear, Nose and Throat surgeons from Operation Hope would come for a two week intensive caravan to repair cleft lips, cleft palates and ears that never grew. They did a lot of great work, but they were US doctors fifty weeks a year and US doctors who worked overseas two weeks a year. They would take an entire crew of surgeons, anesthesiologists, nurses, translators and helpers. The only part of third world medicine these doctors experienced was the beds the patients used post-operatively. I was always grateful to Operation Hope, but I also knew they would be gone for fifty weeks once they left.
I took a group of children from the jungle to the Operation Hope Brigade every year. I would translate for the doctors and bring them my patients. The surgeons would teach me about what they were doing, what criteria they would use to make their decisions and how they would do their miraculous surgeries, and let me bring my patients to the front of the line. The more they taught me, the more I could prescreen patients for them and make their time more efficient. They did a great work but they weren’t International Doctors in the way I want to be, but my patients and I were very grateful for their work.

It's Official, We're Staying Another Year

Since we returned to Malawi in September, we have been praying about how long we should stay. Logic has a number of reasons to stay through June 2012 and a number of reasons to leave in the summer of 2011. But the Lord says,

Isaiah 55:8-9
8 “For my thoughts are not your thoughts,
neither are your ways my ways,”
declares the LORD.
9 “As the heavens are higher than the earth,
so are my ways higher than your ways
and my thoughts than your thoughts.

Human logic is nice, but God has a plan for our lives that at times defies human logic, but is always the best plan. So we prayed. We prayed for three months.
As we prayed, it became apparent that God wanted us to stay until June 2012. The logical reasons to stay are that Andrew will graduate high school From African Bible College Christian Academy and we will stay be here while our director spends a year on furlough. Those reasons are nice, but they pale in comparison to the most important reason, God directed us to stay.

We’re excited about staying. The time in Malawi hasn’t been easy, but it has been a time of tremendous growth for each of us individually and as a family. We are a happier, closer family for working through the hard issues that Malawi brought up. If nothing else good happens, we’re grateful to the Lord for bringing us together.
How did the Lord bring us together? Our time in Link Care helped us to talk about what each of us wanted from the family and work on setting goals as a family. That time also taught us that “You are who you are, not what you do.” Try reading the Gospels with that thought in the back of your mind. It seems like that is much of what Jesus is saying.

So, we are here following God’s will, asking for your prayers that we will follow His perfect will joyfully, and that He will give us direction for our next step in June 2012.

15 year olds shouldn’t have AIDS

This week I thought I was seeing a 15 year old boy with a stomach ache, until I looked in his mouth and saw Candida (a fungus). Oops. He was there with his mother, so I had to tell them I suspected AIDS. I sent them to VCT, Voluntary Counseling and Testing, and he was positive. He probably has fungus growing all along his esophagus, which puts him at stage 4 out of 4 AIDS. That is pretty darn sick.
He had very cool shades and a very macho black T shirt, but he was choking back tears as I was telling him all about HIV. I’m not surprised. His world just turned upside down. Now instead of looking at another 60 years, he might be looking at another 10 years, 15 tops.
How did he get AIDS? There are three possibilities:
1. He was born with it. No one else in the family knows their status, so He could have been born with it, having gotten it in his mother's womb. It would be late to present, at age 15, but he is from a well-to-do family, so he could have been healthy enough all along.
2. He could have started having sex at age 12 or 13. That would be odd that he would get that sick that fast from 2 or 3 years of sexual activity, but it's possible.
3. He could have been molested. He has been at boarding school for two years, so he could have been molested by one of the older boys or by a teacher or another adult.
So, as we get to know each other a lot in the coming months, it may come out how he thinks he might have become infected. The how doesn’t matter much now. He is infected and sick. The why doesn’t matter much either. He is unlucky in a fallen world.
The only question s that matter now are “Who?” and “How?”
Who? : Not, “Who gave this to me?” But, “Who do I turn to since my life has flipped upside down?” I will humbly be suggesting that he turn to Jesus. He probably won’t make the infection go away nor will He punish the infector on this Earth, but He will be with the young man as he struggles to live a healthy life. Jesus will sustain him when there seems no hope. Jesus will redeem his soul. It doesn’t seem like much consolation from a 15 year old boy’s point of view, but it is all we have on this Earth.
How? : Not, “How do I get even?” or “How do I get rid of this?” but “How do I live with this horror?” I will also humbly suggest that Jesus is the same answer to that different question. Jesus can turn horror into hope. There isn’t anything redeeming about dying young or being sick young, but there is redemption in eventually using his illness to help others who are ill and to give glory to God.
How does AIDS in a boy who is just becoming a man glorify God? I don’t have a clue how it will happen, or even how it can happen, but I pray that glory does come out of this. I pray I can give some comfort as he starts this very sad journey.

Both Hands Tied Behind Our Backs

Professionally, I’m having a blast. I’m at the government hospital in the capital, Lilongwe, which makes Wishard look like Clarian North.

We had two kids die of rabies last week. One of the kids was bitten on Christmas Day. It was a 1/4 inch lesion on the thumb. The parents took the kid to the health center, but it was closed on Christmas day. Since Christmas was on a Friday, by Monday they thought, “It looks OK,” so didn’t take him back. He didn’t start the post bite vaccines at all and died a month later. He had hyperreflexia followed by hyporeflexia, progressive paralysis, and myoedema. The other kid, 12 y/o, had the foaming at the mouth. I’ve now seen four cases of rabies in six years: 2 in Malawi, 2 in Ecuador.

You can ask, “Why didn’t we use the Milwaukee protocol (induce a coma for 3 weeks)?” We didn’t even think about it because there are only three ventilators in the hospital, and only one can handle kids. It’s not right to use such a limited resource for a kid who has a 0.01% chance of living, even after a month long induced coma. There are also only 3 working dialysis machines in the country, all at the hospital where I'm working.

I’ve been a doc for 17 years and only encountered Burkitt’s lymphoma on board exams. In one hour I saw 15 kids with Burkitt’s lymphoma. A General Practice doctor from Nigeria has an interest in Burkitt’s & pediatric cancers, so he does the Burkitt’s kids. (Burkitt's lymphoma has mortality anywhere from 5-30%, depending on the stage when diagnosed and whether they relapse after chemotherapy.)

I took a sample of peritoneal fluid to the lab on January 3rd. Since I couldn’t find a lab tech anywhere in the lab, I put the sample down on the counter, right next to a sample of peritoneal from the SAME patient dated December 31st. It had been sitting on the counter for 4 days, untouched by human hands. All the crud growing in the test tube wasn’t so much of an issue because we can’t do cultures here. You are lucky to get a cell count, glucose and protein. My issue was that I had done all I could for the patient and if no one could do even five minutes of work over four days to help another human being, and the systems were so nonexistent that labs samples can go untouched for four days, there wasn’t anything else I could do. So, I just got in my car and drove home.

I did come back the next day. (That’s the difference between being fed up and giving up.)

Mind you, this is the free labor I’m doing in the government hospital to get my medical license. Tomorrow is my last day. Not that I’m counting, (20 hours).

Next week I start at Partners in Hope. It’s not a perfect place, and it has similar problems with motivated staff, but we can fire people who don’t do their work, pray with our patients and at least know that most everyone at the hospital cares about the patient.

This is getting long and might look depressing, but since most of the patients get better and go home, and we actually can make a huge difference. “We had both hands tied behind our back and STILL saved the patient.”

Three factoids before I quit.
1. There are three residency trained pediatricians in a country of 14 million, two here in Lilongwe and one at Queen Elizabeth Hospital in Blantyre.
2. Every day at morning report on the pediatrics ward they discuss the admissions and the deaths. There are 3 – 9 deaths per day. That’s one death every 3 to 8 hours. (In the US, if a child dies in the hospital, the whole building goes into mourning.)
3. No one can get reliable data about admissions and deaths, but the estimate is that the mortality rate is 9.1% of all pediatric admissions, down from 9.6% last year.

Letter from Malawi - Week 3

We’ve been in Africa 2 weeks. It looks very… African. The soil is orange red, and quite dusty, the roads are busy with pedestrians and bicycles that you have to take care not to hit on the narrow roads. The women wear colorful prints, carry babies on their backs and bundles on their heads. Others wear suits. The weather is nice this time of year, cool at night warm in the daytime. I’ve seen some beautiful birds and flowering Jacaranda trees. The Malawians we have met have all been warm and very willing to practice our greetings in Chichewa. I think we are going to like it here.
The kids started school this week, and seem to be adjusting quite nicely. They have all made a number of friends already. We have also met and been helped about by missionaries that have lived here a while, they have made the transition a lot easier. We had our first meeting with the missionaries of Partners in Hope where we prayed for the work and for each other. I’m so happy to be with a group of people who know they depend on God.
Speaking of transitions…. Please, please pray for ours. We need to find a house, furniture and a better internet connection! Pray for our language learning, and for us to be effective in our work here.
Love,
Elizabeth

Stepping Out in Faith or Running Ahead?

Things are moving very quickly here. Just as winter ended and I thought, "Great, we can enjoy spring and summer in the mid west." Then, we realized we are now 3 months from leaving, if we leave in August. August makes sense because the doctor I'm replacing leaves in July, school starts August 26th and we want to be over jet lag before the kids start. If we don't leave then, the next option is December, when it would be very hard to find someone to rent or buy our house.

We are in that area where we wonder if we are stepping out in faith or stepping out in front of God's perfect timing. Whenever we pray, God seems to be saying, "August" or is that just me? Logically, there are too many things to do before then:
Sell 2 cars
Lease or sell our house
pack a family of 5
raise 40% more support
start buying & shipping stuff we will need there
and that's just the big stuff.

Oh, did I mention I have my Board re-certification in July?

Just for fun, our kids are adolescents. They are not enjoying monster public schools after Nate Saint Memorial School. The whole school, K - 8, is the same size as most of their classes in the monster public schools.

So please pray we will receive wisdom, and most importantly, that we will be in step with God, not in front or behind. God is still on the throne, I just am not sure which way he is pointing, August or December.

P.S. Since I wrote the letter to a friend, the Lord has increased our support. It sure looks more like August.

Thank you, Lord.

Economic Meltdown and Teenage Boys

Whenever I turn on the radio or TV, I hear about how bad the economy is and how it’s only going to get worse. The unemployment rate keeps growing. The value of most people’s investments is falling. Most people’s homes are worth less than they were just a year ago. The price of gas for our cars goes up and down faster than the stock market. Trying to decide when to fill up my tank makes me feel like a futures speculator. “The price has been going up for the last two days. Is it going to go up more before I go home or will it go down by morning?” Making the wrong guess can cost me ten dollars per fill-up.

The people we are going to serve in Malawi don’t have to worry about the price of gas. They don’t have cars. However, the price of gas is reflected in things they buy, like school uniforms for their children, shoes, even the little bit of food that they don’t grow themselves.

When you live on less than a dollar a day and prices go up, where do you trim your budget?

Another phenomenon is watching my son Andrew sprouting like good Indiana corn. Every morning his pants ride higher up his ankles. For his after school snack, he eats his way through half the refrigerator, and then asks, “What’s for dinner?” If you are missing a child or small pet, you know where to look.

In places where there isn’t enough food, adolescent boys must always be hungry. In Africa, rice is food for the rich. Meat is a rare treat. How does a teen ager have a growth spurt on a diet of millet and corn mush?

Times are tough in the US and the whole developed world. In Africa, where people are living on the edge of survival, as the cliff starts to crumble there is only one place to go.

Even when we feel like we have nothing to share, Jesus asks us to share anyway. I think He might say, “You really have more than you think. Plus, real giving means giving up a little of what you need so that others can have something. Please share even when times are tough, maybe even more now that times are tough. Don’t worry. I really will take care of you.” (Luke 12:22-31)

Cultural Misunderstandings Can Happen in the US, Too

After a month working with the Family Practice residents at Indiana University, I have been happy to see that they are a group from all over the world; South Asia, East Asia, Latin America and Africa. They all really like each other and are all likable people.
For these young doctors, their second or third language is English and they speak English with each other, but they also communicate well in laughter and love. I see the new residents liking each other. It’s rewarding to hear the Pakistani resident learning to say good morning in Spanish so that she can greet her classmates from Honduras and Colombia. It is even more rewarding to see the residents starting their second year really love each other and laugh at their war stories like old soldiers. They are young doctors who know how much they have to learn, are dedicated to becoming excellent doctors and are caring people. It’s really a great group.
The hardest part of the hiring process must be finding truly caring people in a one day interview. Many people can fake being a nice person for a day or two, but by judging the results, IU seems to have separated the wheat from the chaff. I saw the difficulty while interviewing residents at the University of Arizona and in Ecuador, so I appreciate how much wisdom is involved in picking this group of residents. It’s a testament to the discernment of the people involved in the process and people who refined the interview process.
Just this morning I saw that cultural misunderstandings can happen anywhere, and can be embarrassing, no matter where you are. In Ecuador and much of Latin America, it is considered highly rude to walk between two people talking. It’s easier to avoid walking between people because Ecuadorians stand closer to each other than Americans.
This morning, I was walking down the hall. Three people were talking, one of them a resident from Pakistan. Seeing a small, brown person in a conversation, I kept making little steps to try to go behind her so that I wouldn’t walk through a conversation. Apparently, in Pakistan, walking through a group that is talking is not a big deal, so she kept making small little mincing steps to allow me to go through the group, not around it. We went through this little dance for about 15 seconds, then I finally remembered that this resident, although small and dark skinned, was not from Ecuador. I needed my second cup of coffee to get my brain out of first gear.
It’s a small thing, my little embarrassment this morning. I’m not even sure the resident would remember any of it, but I remember that I am out of the culture loop after five years overseas. My children are really out of the loop, since their last time living in the USA was almost half their lives ago. I personally love learning about the little things of other cultures, except for when I make a total fool of myself. I don’t even need to be in another culture to make a fool of myself, but it’s a convenient excuse.
When you’re on the mission field, if you haven’t made a fool of yourself at least once a day, it’s because you didn’t leave the yard.
Your ego, try to leave home without it.

What I'm looking forward to in the US

As much as I’ve loved my time here in Ecuador, I am looking forward to some things in the US. Here’s an incomplete list of what I’m looking forward to in the US:

• Electric lights that turn on every time you flip the switch.
• Toilets that flush every time you push the handle.
• Not having the fear that I will go to jail for a little fender-bender. Here, everyone in or near the accident goes to jail until the judge sorts it out.
• Public restrooms that are clean and have toilet paper.
• Not having the fear that any time you get in a vehicle it could be your last look at Earth. (The drivers here love to pass on 2 lane bridges, blind curves, and going up hills.)
• Pretzels. (There is every kind of junk food available, even Sour Cream and Onion Ruffles, but no pretzels.)
• Diet Dr. Pepper (You can’t even get regular Dr. Pepper here.)
• Tunnels that you can see in, because they have lights.
• The power is on always.
• Not having to change the propane gas tank on the hot water heater to get a warm shower.
• Drinking the water.
• Newspapers and books in English.
• News in English on the radio.
• Autumn leaves.
• Seeing as many of you as possible.

See you soon.
Blessings,
Jerry

Things I'll Miss about Shell, Hospital Vozandes and Ecuador

• · Everything within walking distance.
• · Living across the street from the hospital.
• · Getting into a car maybe once a week or less.
• · Little kiosks where you can interact with a human when you buy something.
• · Serving the very poor.
• · Shaking hands with everyone you meet.
• · Saying hello to everyone every morning and again in the afternoon.
• · So little car traffic that you can walk or jog in the middle of the street.
• · The big crime wave: some lawn chairs stolen from a porch.
• · $1 lunch, $1.30 if you go to the expensive place.
• · Knowing most everyone I deal with daily.
• · Praying at the start of every work day and whenever a patient has a crisis.
• · NO INSURANCE FORMS
• · No malpractice claims, lawyers, or threats.

Big Urine, Little Urine

In Ecuador, especially among indigenous people, big urine is stool, and little urine (la orina chiquita, la orina pequeña) is urine. When people complain of problems urinating, the doctor has to be sure to specify which one.

Humorous story to remember this by: One doctor had an elderly gentleman who came in repeatedly saying, “I can’t urinate.”

The doctor gave him Hytrin, a medicine to help men with prostate trouble pee. He still couldn’t go. Finally, the doctor took him to the Emergency Room to put a Foley catheter in him. He starts to scream, “NO! I just can’t pee!”

The doctor remembered big urine vs. little urine and asked how many days since the gentleman pooped. It had been about 4 days. Milk of Magnesia cured him when a Foley catheter put into his bladder couldn’t.

A Grizzly Day by Mike Hardin, MD

Do you ever wonder if all your life’s training was to prepare you for one moment? In retrospect, Saturday, January 19, 2008 seems like that day.

The setting is our 30-bed mission hospital with a two and a half bed E.R., running on generator power since the electricity was out to our section of the country, with one doctor, one resident, one intern and two nurses on duty on a Saturday morning. At 10:15 AM a bus crashes and overturns on the road winding down from the Andes towards the Amazon, about a 25-minute drive from the hospital.

Six are dead on the scene. Bystanders begin loading other victims into pickup trucks, cars and eventually ambulances to be transported down the road to our hospital or up the road to others.

As soon as we realized the number of wounded arriving (eventually 23), we enacted the finely tuned hospital disaster plan: call everyone related to the hospital and then some and ask them to come help. The hospital ambulance trolled through town to find employees and bring them in.

Broken and bloody body after body came through the door and were placed on stretchers or benches in the hallway. It resembled a scene from a war movie. The amount of blood and gravity of the injuries were overwhelming. We made quick triage decisions as we decided one victim was too far gone to save – we stopped resuscitation and pushed the body to the end of the hallway to free up space for others that could be saved. The number of critical patients quickly outnumbered our medical personnel.

Four with severe head injuries were intubated and placed on our three ventilators. Short one ventilator, a patient’s mother-in-law was quickly briefed on how to keep her son-in-law alive by squeezing the ambu bag and ventilating him while we moved on to other patients. She kept it up for two hours before he was transferred.

Victims were labeled with tags with numbers and brief exam findings. Only later were people identified. Some of the injured had to identify their severely wounded or dead relatives for us.

One scene still plays in my head. A 21-year old Korean American girl wandering through the E.R. door with the entire right side of her face from her nose to her ear hanging off, exposing her skull, the skin held up by her right hand. A missionary took her off for treatment.

Everyone came to help. All of the missionary doctors, various spouses -- even the kitchen, janitorial, maintenance and administrative staff of the hospital were all enlisted in some way. Our administrator’s wife found herself shaving and prepping victims’ heads for suturing. Missionaries and staff donated blood that was immediately transfused into patients -- the closest blood bank was unable to process blood due to the power outage.

A call for help to the nearest hospital brought another five Ecuadorian doctors, among them a much needed orthopedist and general surgeon plus two radiology techs to help with the numerous x-rays.

In all, two patients died, six critical head injury patients were transferred for CT evaluation, several underwent major surgery for internal bleeding or extensive suturing and the remainder had lacerations sutured and fractures splinted or casted.

There were numerous heart-wrenching stories. An injured mother with a one-month old baby identifying her dead husband, her four nephews and nieces severely injured as well, their own mother later found dead at another hospital 45 minutes away. Another mother with her severely injured five-year old son at our hospital, her daughter in another hospital and her husband in even another one two hours away undergoing neurosurgery to remove blood clots from his brain. The American girl, severely disfigured, far from home and alone, in such shock she could only worry about her missing backpack that contained all her research data for her graduate thesis.

And there were bright spots. The incredible spirit of teamwork in a gruesome situation, the accidental transfer of anonymous patients (who ended up being related) to the same hospital, gravely injured patients whose lives were saved. I’m proud of a dedicated staff that freely gave their all to help in a horrendous situation.

The following day we airlifted seven more patients (paid for by the local ministry of health, a miracle in itself) to other hospitals for further treatment and discharged the least of the wounded, an 80-year old woman with a small cut on her forehead.

Missionaries contacted the relatives of the American girl, notified the U.S. Embassy, made lodging and transportation arrangements for the family, arranged for her transfer to a Quito hospital and welcomed her there with hospital visits by English-speakers. Another very determined missionary traveled to two separate towns, three different police stations and the regional transportation office in search of the backpack. She even searched the wreckage of the entire bus and found nothing. Eventually, in a locked storeroom in a ministry of transportation office in a town two hours away she found the backpack, still sealed with all the girl’s research data, cash, credit cards and passport. It arrived in Quito today.

I’m not sure how to end except to ask for your prayers for the numerous victims and their grieving families and for a shocked hospital staff that experienced a lot more than they ever bargained for.

Is This the Quiet Week We’ve All Been Hoping For?

We have four patients in the hospital. Yesterday we had seven, but two went home and one was transferred to Hospital Vozandes Quito because he had a heart attack that wouldn’t slow down.

Why are things slow here in Shell? There’s a strike. Strikes in Ecuador don’t just have people with signs walking in a circle, that doesn’t get the attention of the authorities. A strike in Ecuador is not a strike without roadblocks and burning tires. The strikers have found out that the police can pull apart a roadblock of burning tires lined up across the road with long metal poles, so now they use dump truck loads of dirt on the road so no one can pass until they decide to end the strike. Burning tires make great TV shots and blocking the roads brings capitalism to the aid of the strikers. The truckers and bus companies want to travel and make money, so they pressure the authorities to give in to the strikers' demands.

The semi-good thing about a strike for a day or two is that hardly anyone can come to the clinic, which means we don’t operate, which doesn’t affect me, but we also have very few patients in the clinic, which gives me time to catch up on my journal, emails and other important communication.

The bad thing about strikes is that travel gets bogged down. Our ophthalmologist, eye doctor, got stuck about 10 miles away. They let ambulances through, so our ambulance went to get him from the far side of the barricade. He called us to ask the ambulance driver to come get him. Thank goodness for cell phones.

Another bad thing is that the medical student who took the patient having the heart attack to Quito got stuck about 2 am ten miles away from the hospital. She tried to sleep on the gurney in the back of the ambulance, but when the ambulance driver lay down on a bench and started to snore loudly, she didn’t sleep anymore that night. She ended up walking with some patients in the rain, coming from 4 hours away to our fair hospital about 5 am. She is about 22. They are about 70, but because they walk everywhere out in the rural areas, and they have worked at manual labor all their lives, they walked her into the ground and the old folks had to slow down so that the young college student could keep up.

The worst thing is that the patients who need to come to the doctor can’t get here. The ophthalmologist is only here one week per month. Most of the patients who received operations last month can’t get in for their follow ups appointments, and patients who need to come to the clinic can’t get around the barricades. For me, the worst thing is there’s no bread and no Diet Coke in the stores. We missionaries really suffer. (Just kidding.)

Tomorrow, if the strike ends, we will be extra busy. If the strike drags on, patients who early need care won’t get it, and that could be tragic. For now, it’s just a relaxing slow day after a few weeks of horror.