If one thing is true for missionary medicine is that there is no shortage of interesting cases – hepatitis B, miscarriage, ectopic pregnancy, sepsis, mandibular mass, congestive heart failure, placenta previa, severe pre-eclampsia, hyperthyroidism, new onset atrial fibrillation, colles fracture, tib fib fracture, etc. –and this is only day #16. The theme over these last two weeks seems to be congestive heart failure and strokes.
The difficulty of the cases are compounded by the fact that the Togolese seem to come to the hospital only if they are really sick. Having high blood pressure is not sick. Having a stroke is not sick. Having a stroke and not improving over the following 12 to 24 hours is sick. Having a diagnosis of congestive heart failure and being on meds is not sick. Having a diagnosis of congestive heart failure, being off of meds for months and having difficulty breathing is sick.
Intensive Care Unit
Of all the cases one sticks in my mind today, the 47 year old mother who was cooking dinner the night before, sat down and fell over. Family helped her up and immediately noticed drooling, left sided weakness and loss of speech. We saw her the next day at around 10 am. A quick physical confirmed the family’s observation and added two additional findings, unequal and non-reactive pupils and decreased consciousness. She was sick, really sick.
In the US there is a well-established stroke protocol that includes CT scan, neurosurgery consult, TPA, symptomatic treatment including sedation, hyperventilation, risk reduction and last ditch efforts. Here we have only symptomatic treatment and risk reduction.
Within a short period of time, the 47 year old mother’s blood pressure started to rise, her pulse started to slow and she stopped breathing. Things were going in the wrong direction. As she changed we did what we could. We attempted to treat her blood pressure with labetalol and hydralazine, we gave her mannitol and we bagged her (breathed for her).
As we are resuscitating her, I know she will not survive, but I am uncertain. I know the problem with her is cerebral pressure, but I am uncertain. I know we are doing what we can for her, but I am uncertain. I know what she needs above all is a craniotomy/external ventricular drainage to relieve the pressure in her head, but it is too late, I think, I am uncertain.
After 30 minutes of resuscitation that include a bedside prayer, we stopped and she stopped. But I could not.
Now comes the questions and tears again, what did we do, what didn’t we do, should we have done something different, are we competent, and should we be here? With every loss we are left to ponder our contribution. We are left to wonder if the outcome would have been different in the US. We are left to ponder the difference between missionary and American medicine.
Resources is the obvious answer. Certainty is the other answer.
Going to the doctor in the US with a problem will result in tests, consultations and follow up visits. At the end of it all you will be given a diagnosis and/or prognosis with certainty. This process can take a matter of hours to weeks to months. The speed at which it is done is directly related to how sick you are. The sicker you are, the quicker the test and consults are done. Built into this process, unintentionally, are the results and time. Doctors and families alike, through results and time, come to a peace –a general understanding of the prognosis of the patient at hand. And when a patient dies the doctor and family can reflect and justify that they did all they could.
Missionary medicine is different. We have uncertainty. Did the 47 year old mother with a stroke have a general diffuse bleed that could have benefited from an external ventricular drain and or a focal bleed that could have benefited from a simple burr hole? I do not know. Can we do it here and should we have tried? I do not know. Had we started the mannitol sooner, would we have made a difference? I do not know. Would time on a ventilator have made a difference? I do not know. Did I give up to early? I do not know, I am uncertain.
Lord we pray for strength and peace in the encounters and decision we make.
We pray for understanding and wisdom in the disease process we treat.
We give thanks for the people you have surrounded us with.
We are standing our Your Shoulders
We would like to take this time to say thank you to everyone for their kind words and support. Yes we are in Togo, but we here only because we are standing on your shoulders. We could not be here without your support.
A special thanks to the attendings at Tacoma Family Medicine Rural Fellowship Program in Tacoma Washington, Saint Elizabeth OB fellowship in Edgewood, Kentucky, and Dr. Stocks in Missouri for continuing to take our calls and answering our questions.
A special thanks Dr. Evans (Quincy Illinois) for putting us in contact with Dr. Sullivant and for the Nephrotic Syndrome consult. Thanks to Dr. Sullivant (Quincy Illinois) for a crash review of stroke and the treatment there of.
A special thanks to Samaritan’s Purse for giving us this opportunity to serve overseas through their Post Residency Program.
God Bless
Fred and Lydia,
I don’t know what to say….except “Yes, you are competent, and yes, you are where the providence of God has led you. It is difficult to trust in God’s providence when things don’t go as we hope or as we expect. My daily prayer for both of you is that you find joy and beauty in each day and don’t get too discouraged. All of your friends at St. Elizabeth are so proud of you both and we’re here when you need us!
You all are there for a reason doing God’s work. We will continue to pray for strength and wisdom. Keep up the good work.
Fred and Lydia, I forwarded your email to my friend, Walt. He left a lengthy encouraging message for you on your email address. I got a copy. I hope you are encouraged and feel you are doing exactly what you went to do there. Feeling your frustration and joie de vivre as you serve Christ Jesus there. Margie
While mulling your blog over dinner. I struggled to find words to respond to you. Then while washing the dishes and asking the Lord what is it that I can say to Fred and Lydia. I started laughing then crying realizing WOW! I am going through the same thing…. Well, sort of. At least the same question and response is the same. Only, this is a daughter struggling with how her mother is being treated in the States. After mom was diagnosed with bi-lateral pneumonia in May, she has rapidly declined. About two weeks after her diagnoses, it was evident that her speech was progressively becoming slurred. I talked with my sister, who kept saying mom wasn’t like this in person, only on the phone. My thought, are you sure Lisa, are you doing every thing you can for mom? A month is to the slur, I called the Assisted Living Facility and spoke with the DON, who said she had noticed a difference in my mom’s gate as well and they made an appt. with the in house dr. in 4 days! REALLY, this is my mom, and I have to wait 4 days for her to see a dr. . Why (toward Assisted Living) did it take you a month to notice this? Are you doing enough for her? Should we go up and get her and bring her down to Kentucky? Can I take better care of her?
Four days came and I got no call. (Very Typical) I called and they said mom had a UTI and was dehydrated. I requested her to see a neurologist, which they said they would make an appt. She started her course of antibiotics and three days later fell twice in one day. She gets transported to the local hospital, they run a CAT scan, ran her blood and hydrated her. Her CAT scan showed now sign of stroke and they released her 3 days later. Her slurring had almost stopped after she had been hydrated. We waited for 4 hours for the hospital dr. to come and do a meeting, with my sister and myself. He never showed up. My questions, Did he do enough? Is she not getting the care she should, because they see she’s on Medicare, even though she has secondary insurance from my dad working for the Federal Govt.? Shouldn’t they have done an MRI? Do I need to be there?
Toward the end of July, she went to the neurologist and they ran nerve tests on her arms, legs, back and did an MRI. Their findings and diagnosis
Her MRI showed no signs of her ever having a stroke. However, she has mild chronic microvascular ischemic disease. She also has moderate central and cortical involutional changes which have progressed since her last MRI in 2009. Realizing that this means her brain is shrinking, the direct result of which is her dementia. Her speech, swallowing difficulties, and coughing are all related to this. The doc also said hydration would also contribute to this. People her age tend to be dehydrated because they don’t want to wet themselves. WOW! Again, do I need to go up there and get her? What else can I do to help her from here? There is a constant desire to flee to Chicago!
Now we’re in August, her speech is VERY bad and the Assisted Living sends her to the hospital again for an evaluation. No sign of stroke. They performed a swallow test, which she failed. her prognosis, she needs to be given pureed food and the dr. says all though she’s in fairly decent health, are her affairs in order? Breath Anne… Breath…. I keep thinking OK Lord, what can I do, what can I do… Pray for her! Yes, but Lord, I want to do more…
Ha! No answer from Him! I am 352 miles away Lord. You have placed me here in this state and I can’t do anything. I am struggling with not being able to do anything.. Control is gone… There really isn’t anything we can do for her.
Then, He shows me the eternal perspective… What is certain…… God is still on the throne… Our days our all numbered… The Lord has me where He wants for such a time as this…. The Lord has given me all I need to help her….
I still have to fight these thoughts… So, I have to take my thoughts captive and ask the Lord to once again, help me with them.
So, Fred and Lydia, we’re in this fight together. Your work is eternal! That prayer you prayed has eternal value. You may not know what the Lord will do with that prayer, but He does!
Roman’s 8:18 says “I consider that our present sufferings are not worth comparing with the glory that will be revealed to us.”
Our prayer is that God show you that “all things work together for our good… according to His purpose.
We’re here for you, we LOVE your blogs and we LOVE YOU!
Anne and Chuck
AYe, Fred and Lydia …
You do what you can do as limited by your resources. It is a hard lesson of how little control we physicians really have. And at least some of the time, the illusion of control in the US is just that – an illusion.
I’m sure Russ Ebersole has been in your shoes many times …. and what counts in the end is that you tried .. and patients know that you did something to help them. In the end despite the dismal outcomes, the families of your patients will have more gratitude for what you tried and failed than the majority of relatively spoiled US citizens from what was tried and succeeded. From that you should take comfort …. eh?
God bless, John and Irene
Boy you have been put in a real medical storm of outrageous proportions and I am so thankful that you are there by Gods grace helping them. I can imagine you feeling overwhelmed but Gods almighty hands are guiding you. Praise God that He never gives up and so Christ will continue to give you Wisdom from high as you labor for Him. In Christ Alone you stand . Love Deanna Walker
Hang in there. Bob and Evelyn