Saturday, July 1, 2017

Meet Charity...

*Note: Charity has given me permission to share her story, name, and photograph with my supporters and friends of Evangel VVF Center*

Meet Charity, a lovely young woman in her late 20s. She's a mother of four--including a 6-month old little boy, she and her husband are farmers to provide for their family, she speaks Hausa, and identifies as a Christian.

Charity came to Evangel VVF Center in April because she was leaking urine since her last childbirth in January. She had labored at home, just like with her previous three children, but this time she felt that the baby was not positioned correctly for delivery. She attempted to turn the baby herself, and was able to deliver a healthy baby boy. But then she started leaking urine uncontrollably and was unable to walk. She'd been to several traditional healers that had given her herbal medications, all without any improvement.

When her aunt who lives in Jos heard about Charity's condition, she arranged for Charity and her husband to come to Jos to see us at Evangel. So that Tuesday in April when she came for clinic, her husband came with her, actually he carried her. Our physicians examined her and identified that she didn't have a fistula (an abnormal passage between the bladder and birth canal as a result of prolonged obstructed labor, resulting in uncontrolled urine leakage), and referred her to me to diagnose and treat her legs and potentially her pelvic muscles to see if she could regain her ability to walk or to normal bladder function.

As soon as I started performing a neurological screen to assess sensation, reflexes, and voluntary muscle contractions, I realized she had a central nervous system injury--likely some sort of spinal cord compression at the lower thoracic level. I also discovered that her urinary incontinence stemmed from paralysis of the normal pelvic muscles that assist in bowel and bladder control. I had access to AP and lateral view spinal x-rays, but that gave me no real helpful information, just confirmed that she had a malalignment of her lower lumbar vertebrae, which might have been there for some time and due to its location, I doubted that it was the cause of her symptoms. I didn't understand what exactly had happened during her home birth, but somehow she'd damaged her spinal cord. We do not have access to an MRI or CT scan here in the city of Jos, nor is there a neurosurgeon that we could refer her to. Even if she was a surgical candidate, Charity's family probably could not afford it. It was up to me to do whatever I could for her.

Here at Evangel VVF Center, we have a hostel where patients can stay if they're receiving long term care (but don't need to be in the patient ward), waiting for a subsequent surgery, or are enrolled in the skills training program. Charity and her infant son decided to stay to receive physical therapy treatment, and were given beds in the hostel. Charity quickly became friends with the dozen or so other women that were staying there, and her son was well taken care of by the myriad of women who were eager to help. Mama Esther oversees the hostel and also made sure to keep an eye on Charity.

I don't have access to a huge closet of adaptive equipment like in the US, but we made do! Charity was able to borrow the one wheelchair that the VVF center had to transport patients between the operating room and the ward, one of the nurse aides found a smooth wooden board Charity could use as a sliding board to transfer in and out of her wheelchair by her herself, and she borrowed one of my gait belts to use for ankle stretching exercises.

I went to the hostel a couple of days a week; first, to show her how to use the wheelchair and maneuver around to open the doors, get in and out of bed, and not have to rely on someone pushing her. Later, I taught her stretches to help with the night cramps she experienced and to reduce the risk of contractures from prolonged sitting. We did a lot of standing with her holding onto the bunk beds and me assisting at her hips in order to stay up, and later I found that the other women were helping her with this exercise several times a day!

After two weeks of therapy without any changes, I knew the day had come. I couldn't keep her at the hostel forever, and she'd been asking to return home. I've never had to break the news to a patient that they would likely never walk again. Usually in the United States, the doctor does that. He or she will go in with that look on their face, explain all the radiology reports and diagnostic tests, break the news, and then answer any questions the patient will has. Yes, sometimes the physical therapy team has to reiterate the prognosis and help the patient through the various stages of acceptance of their condition, but we aren't usually the ones to make that call. But that is the US, and this is Nigeria.

Charity and I sat down with her aunt who spoke English, our two hospital chaplains, and the Nigerian head of the VVF deparment--Dr. Sunday Lengmang. We explained to her that we had done the best testing we could and concluded that she'd damaged her spinal cord. Because of that spinal injury she would likely never walk again and she would need to have a catheter permanently to drain the urine. Typical to the Nigerian culture, she took the news well, but the chaplains stayed to speak at length with her and pray with her. They also spoke with the family about contributing whatever they could towards to the cost of purchasing a wheelchair. While my heart wanted to just pay for it outright, I knew that it was best to follow the advice of these kindhearted Nigerian chaplains and ask the family to pay whatever they could.

Charity needs a wheelchair long term if she's going to be independent or be able to return to any of her household work. After much checking to find the fair price, I set off for a local medical supply store to find one for her. I stopped at one shop and found a foldable wheelchair with swing-away footrests, but the tires were worn and cracked from sitting in the sun. I left feeling defeated and frustrated. I talked with my neighbor, a missionary occupational therapist who's served here for 13+ years to ask if she knew a place I could buy bicycle tires and inner tubes. She asked one of the Nigerian staff who not only knew a shop that sold bicycle tires, but then went to visit another medical supply shop that had plenty of wheelchairs in stock!

So the next day, my mom (who was in town for a two-week visit) and I walked down to the store. I identified myself as a doctor at the local hospital and asked to see their wheelchairs. After a few minutes, I'd found one I thought would be a good fit for Charity but the salesgirl told me "sorry, that one is spoilt," pointing to the arm rest that was askew. I chuckled, reached over and flipped a level to pop it in, showing her that the armrest is supposed to be like that because it's removable--perfect for Charity since it'll make her transfers a bit easier. Another salesboy came over with a capful of motor oil from the shop's generator and greased up the various hinges and levers for the footrests, brakes, and folding mechanisms.

I paid for the wheelchair, then turned around to find the salesboy a bit confused. He was looking for my car to load the wheelchair in... but we hadn't come in a car. I think he was surprised to see two white people using Nigerian public transportation! He helped us flag down a keke, bargained with the driver to take my mother, me, and the wheelchair directly to the hospital for N300 ($0.84), then helped fold the chair and stuff it in the back seat. 

Back at the hospital, mom and I wheeled the chair back to the hostel and waved at Charity and the group of women who were sitting out on the porch enjoying the sunshine. Mama Esther came over to translate for me as I showed Charity the various features and how to use this new wheelchair safely. She transferred independently (remembering all the safety tips I'd taught her!) into her new chair and wheeled back out to the porch.

Charity's son was napping, but she wanted to make sure he was in the picture too!

She went home with her family later that day after discussions with the nursing staff about how to change the catheter and how to avoid getting bedsores from prolonged immobility. She took the sliding board and gait belt with her so she can continue her home exercise program. Charity knows she is always welcome back at Evangel VVF if any new condition arises, or if her condition spontaneously improves and she needs further physical therapy. But most importantly, she knows that we care about her, that we have done the best we can for her, and that we are committed to helping her get as much independence back as she can.

My motto for ministry here is "Restoring dignity to African women through physical therapy." In Charity's case, I can't do anything to reverse her spinal injury. But, I can do the best neurological screening I can to see if there's any muscles she can use. I can do a thorough sensation screening to identify her risk of skin breakdown. I can get her a quality wheelchair that will last and will help her be up and off the ground. I can teach her how to transfer safely so she doesn't end up with skin tears or get a shoulder overuse injury--and so her husband doesn't hurt himself trying to help her. I can help her keep limber so she is more comfortable and, in case her muscle function returns, she can use all of her joints. I can pray with her (even in English), and get the chaplaincy team involved so they can do home visits to encourage her in the future. I can tell her there's a safe place to get medical care in the future.  I can explain to her as best I can why she's unable to walk so that she doesn't think she's cursed or so her neighbors won't ostracize her.  I can assure her husband there's nothing further to do and tell him it's OK to stop taking her to various traditional healers (who are often expensive). I can help Charity return home where she is comfortable and where her three other children need her. All of those things I can do. And all of those things contribute to her dignity.

I have to do the best I can and leave the rest in God's very capable hands. I have to recognize the limitations of practicing medicine in Nigeria and not compare it to what I learned in school/clinicals. I have to pray for wisdom and patience with myself as I navigate the mission hospital environment. I have to remember to show love through it all.

Please continue to pray for Charity and for her family. 

I want to say a special thank you to each of my financial donors whose gifts not only cover my living expenses but fund a special ministry account for me to use on therapy supplies, assisting patients with medical expenses, and providing equipment for patients like Charity. Thank you for enabling me to help her!

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