Tuesday, January 30, 2018

Life as a Missionary PT Part 3: Clinic Visit and Diagnostic Testing

This is part 3 of a series of posts about what my ministry is like.

Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.

When I get to the center on Tuesday mornings, I change into scrubs (us women can only wear scrubs during Tuesday clinic and while in the operating theater. The rest of the time we wear long-ish skirts as is culturally appropriate) and make sure there are enough copies of all the forms we'll need in clinic.

I love sitting in on clinic because 1) I can dialog with the physicians about which patients might need therapy, and 2) by filling out forms and scheduling patients in the surgical schedule, I can keep clinic moving faster.

As we're getting set up, one of the aides will bring in water to fill our instrument sterilization containers. While there is an autoclave and sterile instrument packing protocol for instruments used in the operating theater, we use a system of bleach water and soapy water with timed immersions to sterilize our instruments used in clinic.

This is what our clinic room looks like. It's not big at all, but it works for us. I love the fact that the VVF center is built up about 8 feet above ground so that we can keep the windows open for natural light (and to help us get a better view of the fistula), but no one can see in. We do have one tiny ceiling bulb and a ceiling fan we can use when the electricity or the hospital generator are on, but it doesn't do much good.

I sit in the corner (back left in this photo) so I'm out of the way and can fill paperwork.

Later, one, two, or all three of our fistula surgeons will trickle in, as well as one of our nurses who serves as an assistant during examinations. Ladi will poke her head in the room and hand me the patient's brown card as well as the intake questionnaire form she's filled out. I get started filling out their examination finding form, we'll call in the first patient who's sitting out in the hall and clinic begins.

Fistula is an abnormal opening between the bladder and the vagina through which the woman leaks urine uncontrollably (because there's no sphincter to stop the urine as there is in the urethra), but that fistula can occur in many different locations. The most common cause of fistula is prolonged, obstructed childbirth where the baby's head presses on the mother's internal tissues for a long period of time, cutting off blood supply, and resulting in that tissue dying off--causing the hole.

In order to get a good idea what the surgeon will encounter during the operation, and to decide whether the surgery can be done through the vagina or must be done via a more complex abdominal surgery, we have to actually see where the fistula is. To do that, we insert a catheter into the bladder and then fill the bladder with purple dye. Usually, it's pretty easy to see where the dye is leaking out. 

Then we drain the rest of the dye out and the exam is done. As she's getting re-dressed, we'll discuss when to book her surgery, I'll fill out the scheduling book and her reminder slip, and one of the physicians will fill out the exam findings form. We hand the reminder slip to the nurse who either explains to the patient in Hausa or if she speaks a tribal language, we call in the family member to translate for her. Often, the exam is done in less than five minutes and the whole visit is less than ten minutes. 

If the fistula isn't immediately visible with the dye test, we may ask her drink water and come back in an hour. If she's recently delivered her baby and the fistula is fresh, we might just leave the catheter for two weeks and hope the bladder can heal on its own. Or if her case has failed all surgical attempts, we may send her the head nurse and to the chaplains to discuss a radical and permanent solution that diverts the urine from the kidneys elsewhere. Thankfully, this center has surgeons who are trained in performing the more complex cases and our team works together both in clinic and while the patient is in surgery to come up with the best solution for our patients.

Sometimes, a woman will come back and say that she's still leaking. We may find another fistula that we missed or, as is often the case with the larger fistulas, has converted to a pinhole fistula. We schedule these women again for repeat repair surgeries.

We also have patients that come for their 3-month or 6-month followup visit that say they're dry! We're always happy to do a quick exam and make sure the surgical site looks good, answer any other health questions they have, and clear them to "meet with their husbands again."

If, during Ladi's interview, the patient is complaining of urine or stool leakage but we can't find a fistula with the dye test, then we start thinking about using medication or sending her to me for pelvic physio. Often those patients leave the clinic room a bit discouraged because they thought they'd get another surgery, but yet we're saying there's no structural reason for the leakage. 

And then there's usually one or two each week who come into the clinic room with a smile on their face and a bulging belly! They've come, just like we told them, to get a referral card to the antenatal (prenatal) clinic and schedule their cesarean delivery--all of which is free of charge to them because of our gracious donors. Often what caused the VVF in the first place was the fact that she had a small pelvis, so we don't want her to try to deliver naturally again. Or if she's had a VVF repair, we want to protect that repair site and not risk it breaking down again during delivery. 

We have all sorts of women come each Tuesday, each with her own history of fistula onset and her own course of treatment. We are also blessed to have a medical team that's highly skilled, collaborative, and that trains the more inexperienced members so we can correctly diagnose and treat these women.

Sunday, January 28, 2018

Meet my friends: Grace

This is Grace, or "Sister Grace" as I call her. She used to work at the Christian publishing house next door, but when there were huge lay offs a while back, she started up this little food stall outside the gate. She's a mother and grandmother herself, and was one of the first people to be patient with my poor Hausa when I was first taking Hausa lessons!

She arrives about 8:30am and gets set up. I'm leaving about that same time for work and so I call out the morning greetings as I go around the corner to catch a keke. She brings out the large umbrella, her small plastic table and a few chairs, the propane stove, and the plastic buckets that hold her dishes and water for cleaning vegetables and washing dishes. Then she'll walk to the back of hte compound and fill a few buckets from the huge water tank, go around the corner to buy vegetables from the shops there, and go the local provision shop to buy a carton of Indomie (ramen) noodles and a crate of minerals (sodas).

By about 10:30 she's ready for business and starts serving up meals to anyone who passes by. Her usual customers are the staff from the publishing house and the bookstore as well as office workers in the church denomination headquarters and the Christian guesthouse nearby. There are often many visiting pastors and Christian workers who've traveled to the city for a conference or some other meeting at the headquarters, and since they often go to the bookshop to buy Sunday School material or commentaries for their sermons, they'll find their way to Grace's shop.

Some days, I'll be home from the hospital in time for lunch. In the keke on the way home I'm thinking through what's in my fridge that I can easily reheat on the stove (I don't have a microwave, and even then, our electricity is inconsistent). If I don't like my meal options, I'll eat at Grace's shop.

As I come over, I call out the mid-day greetings and ask how the shop is going. I'll look through the plastic bucket on the table filled with cool water and bottles of minerals, choose one, and pop the top off with the opener hanging off the center pole of the big umbrella. Then I'll find an empty plastic chair, sit down, and ask her to make me "Indomie and egg."

She also serves a local salad made with cut up romaine lettuce, shredded carrots, sliced tomatoes, thin rings of purple onion, and heavily seasoned with a mix of Maggi (similar to chicken bouillon, but loaded with MSG!), crushed peanuts, and salt. I haven't tried it because I'm wary of any vegetables that haven't been bleached, but I hear it's good!

When I ask for Indomie and egg, She knows not to add extra peppe (finely ground red pepper that's in little tubs in the first picture), and will often add cut up carrots and onions to both my noodles and to the egg. Here, Indomie noodles are often served as noodles, not soup, so after the water's boiled and she's added the noodle packet, she will remove it from the stove and let it sit until the water has been absorbed.

Then she'll start making my fried egg, using two to three eggs, a healthy amount of Maggi, and a handful of chopped veggies. Once the egg is done, she dishes the noodles out into a shallow bowl, slides the egg on top, and hands it to me.

I'm halfway done with lunch--the bowl is usually overflowing with noodles and the egg is twice that big!
Sometimes, there will be a pastor or two sitting and eating lunch there too. We'll usually get to talking (always him asking me a question first, as is culturally appropriate), and invariably the conversation will turn to President Trump. I will give my customary answer of "You know, I don't follow the news so well now that I live in Nigeria. So I'm not sure exactly what is going on right now. But I do know the Bible tells us to pray for those in authority whether we agree with them or not. I pray regularly for both President Trump and President Buhari." That answer usually satisfies them and means we can move on to another topic--often the weather and how baturi (white) people like the cold, the current fuel scarcity and it's resultant high prices and 2-day-long lines, or asking about how each other's Christmas and New Year celebrations were.

The conversation wanes by the time I'm finished with my lunch, and then I'll ask Sister Grace how much I owe her (the price can change week to week as the price of eggs and minerals fluctuates), but it's around 380N ($0.79 USD). If I don't have small change (bills less than 100N), I'll sometimes pay for the pastor's lunch as well. That often sparks a small dispute with the pastor, but I will just say "We're all God's workers and it's all God's money anyway."

I hand her back the empty mineral bottle, drop by bowl and fork in the soapy water bucket, thank her for cooking for me, say my mid-day goodbyes, and walk through the gate to my compound.

Grace will stay until about 4:30 (most of the offices close between 4 and 4:30), then from my apartment I'll hear her bringing all of her stuff back into the compound and telling the guard at the front gate "Sai gobe" (see you tomorrow).

I'm learning to love the rhythm of life here and all the people that make up that rhythm.

Friday, January 26, 2018

Life as a Missionary PT Part 2: Intake and Subjective History

This is part 2 of a series of posts about what my ministry is like.

Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.

So what happens on Tuesdays when we run clinic? Well, we have to back up to the evening of the previous Tuesday all the way until early this Tuesday morning. When women come, they are sent to the main hospital's medical records area to "buy a card." This costs 650N ($1.82 USD) and looks like this:

This history is pretty common "A woman of 41 yrs old ____ by tribe from _____. Christian P1+0 none alive no education. Leaking for 240 months in a delivery at home no footdrop no previous repairs."

A medical resident/house officer will get a brief history, take vital signs, record her main complaint, then write something like "refer to VVF for proper management" At that point, she will keep her card and will wait around for the next Tuesday morning.

When she comes into the VVF Center, one of our aides will take her card, write on it her VVF patient number (we're in the 3,600s now!) and issue her a small green patient ID card which she will show on subsequent visits so we can find and retrieve her patient card. Everything is done her by patient numbers since we have so many women named Hadiza, Ladi, Mercy, Sarah, Talatu, and Kadija!

Then she'll be shown to the waiting area. All the brown patient cards are given to Ladi, our clerk, who will call them one at a time.

While waiting here, Ladi will tell them a bit more about what fistula is and isn't (some of our women have been told it's because they were cursed!) as well as what to expect during their visit. Then one of the female chaplains will come share the gospel or read a small passage of Scripture. After that, the women who are being discharged after surgery will come in and we'll have a "Freedom Ceremony" where they dance and sing!

One of the songs that they often chant while dancing in a circle (there's not much room when all the women are there!) is loosely translated as "Now that the urine has stopped, no problems, no problems!" Another favorite is "Ni Zan Je" which goes like this in English "I will go with Jesus anywhere, no matter the roughness of the road. I will go, I will go!" Read more about that song here.

Historically, another song actually written by a patient treated here was used more often. This article gives a bit more history about it: Fitsari 'Dan Duniya: An African (Hausa) Praise Song About Vesicovaginal Fistulas

After the dancing and signing, the women who are being discharged home (or to the hostel to await another surgery) will receive a "wrapper" or a 6-yard piece of brightly colored fabric they'll use as a wrap skirt.

But for the women who are coming to see us in clinic, they'll wait until Ladi calls their name and then they'll come into this room:

Ladi will go through a series of about 30 questions to ask about their medical history, family background, marital status, history of pregnancy/sex/menses, and find out what their main complaint is. Everything used to be entered on the computer, but now it's done by hand with Ladi asking the questions (remember that most of our patients are illiterate) and recording their answers on the form. Then one of us will go and type all that into the master Excel spreadsheet/database to be analyzed later.

In recent months, we've been especially interested in demographic information on our follow-up patients, especially their rate of divorce compared to time since onset of urinary leakage (and if there's any different between if they're in a monogomous or polygamous setting), and if their risk of divorce is inversely correlated to whether they've given birth a live child before or not. It's actually rather interesting to see what's going on in these women's lives outside of the actual fistula they're coming to see us for. Expect to see some published literature on this in the next year or so!

Then the women will sit in the hall just outside the exam room and wait until we're ready to see them.

Tuesday, January 23, 2018

Life as a Missionary PT Part 1: Patient Demographics and Sourcing

Several people have asked me what it's like to work as a missionary physical therapist. They want to know things like, "What kind of women do you treat?" "How do you bill for therapy?" and "What's the typical doctor visit like?" Well, my friends, here you go!

(Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.)

Today, I want to tell you a bit more about the type of women we see and how our patients find us. One of our staff members has been keeping records for the last 5 years regarding patient age, religion, marital status, education level, parity (number of pregnancies), and live births. I won't share the exact stats here, but our patients usually fall into one of these categories:

  • Ages 1-14, never married or sexually active, some primary level education, leaking urine/stool since birth (usually caused by a birth defect), accompanied by her mother or auntie.
  • Ages 15-50, usually married young but divorced now as a result of the urinary leakage, some primary level education, her problem may have developed after the first childbirth (as is often said to be the cause of VVF) or after several successful deliveries, often had at least one stillbirth, may live in her father's house, often comes on her own or if she doesn't speak Hausa the mother/auntie/brother may accompany her
  • Ages 50-65, either started leaking after a pregnancy many years ago and is just now finding out about our center, or started leaking a few months ago (often related to a cervical cancer or advanced AIDS), accompanied by a daughter/son
Interestingly, about 51% of our patients are M**lim, even though we are a Christian hospital located in a predominantly Christian part of the country. 

I'd guess that 95% of our patients are verbally fluent in some non-English language (usually Hausa, with a few that speak Fulfulde or Tiv). A few of those patients can hear some English like simple commands or greetings, but cannot answer in English or understand medical questions. We don't gather statistics on literacy, but I would imagine that less than 20% can read or write Hausa, and about 1% can read or write in English.

How do these women find us? In recent years, Nigerian media has started publishing more stories about VVF--often focused blaming the family members and on the woman's shame that VVF causes, but there was also a well-produced Nollywood film released in 2016 about VVF. Unlike in other African countries where AIDS awareness/proper condom use/malaria information is posted on huge billboards, I have not seen any such postings about VVF in Nigeria. The Western world is starting to pay more attention to the plight of these women as we're starting to care more about social justice and women's equality... but that actually does little here in Nigeria.

There are several centers around the country where a woman can have a fistula surgery; some of the surgeons are more skilled than others, and some centers (like ours) offer more drastic procedures while other centers only perform simple repairs. Many places require payment for the fistula surgery, but some hospitals and temporary "fistula camps" set up throughout the country offer free services through outside funding like the United Nations Fistula Project or Worldwide Fistula Fund.

Our women find us through word of mouth from other patients (as is the case with many of our M**lim patients from the North), are referred here for a more complex surgery than what can be done by our surgeon assisting in a fistula camp, or are referred from a surrounding hospital (as is often the case when the fistula is fresh or was caused by another vaginal/abdominal surgery). Sometimes, we never can quite figure out how they found out about us! Googling or searching a online physician directory isn't really a thing here!

So each Tuesday when we do clinic, we never quite know how many women will come, which patients will return for their follow ups, how many new patients we'll have, or what their stories will be. 

What we do know is that we are ready to receive each woman with kind hearts, listening ears, and skilled hands. And as she has finally arrived to our center--sometimes after multiple failed surgeries at other places--she has arrived to a place of hope. We are only human, but we serve a great God who heals.

Wednesday, January 10, 2018

My Christmas Chicken

My mom tells a story about our first few months living in Singapore. While only she remembers exactly how it all went down, my version of the story--as recollected by my 8 year-old brain--goes something like this...

While we did a lot of shopping at the local grocery store, we shopped for much of our produce and meat in the more traditional way. My mom, two brothers, and I would often head out to the "wet market" (outdoor vegetable and meat market/food court that's found in each neighborhood around the country) right after Dad left for work. The early part of the day was the best time to go because it was cool, the shops were just opening, and the meat market had the best/most fresh selection.

Dragging the rolling shopping buggy, we'd trek the 2km or so to the nearby wet market. Mom would send us to various shops to buy many of our family's food staples. My brothers would usually go to the meat stalls and buy our ground meat, mom would pick over the vegetables and fruits and often buy something we'd never seen/heard of/tasted before, and I would go to the "egg lady" where I'd pay for 10 eggs (selling eggs by the dozen is a Western thing. Here in Nigeria we sell them in quantities of 15 or 30 (full- or half-crate)) and usually end up getting an additional egg for free. 

The hawker center part of the Bedok wet market we went to in Singapore.
After our shopping, we'd meet back at one of the tables in the "hawker center" (food court), pack our bags into the shopping buggy, and Mom would give us money to go and buy our breakfast. Usually I'd settle with hot Milo (an instant powdered malted drink that's like hot chocolate) and "dough sticks" that were fried in a wok of super hot oil. After breakfast, we'd walk back home and then start our homeschool day. 

Until one day....

That day, my mom decided to cook chicken. I don't know if she was planning on roasting it whole or boiling and shredding it for use in many future meals (we didn't eat much meat in Singapore), but for whatever reason she decided to buy a chicken. A whole chicken. At the wet market.

I guess that when I tell you Singaporeans make soup with the chicken head, neck, and feet, you'll be able to guess what happened next...

So there my mom was in the kitchen, reaching into the black plastic bag to pull out the chicken and rinse it. And the chicken's head was still attacked! It flopped around, and my mom screamed. Yes, truly. (Or at least that's how I remember it happening!)

Somehow, she got up the courage to chop its head and feet off and proceed with dinner preparations. And she never forgot to tell the meat seller to remove those parts before bagging her chicken.

Ok, so that's how my mom's story went. Now for my story...

In September sometime, Ladi (she works at Evangel VVF Center as a clerk and does all the patient demographic interviews on Tuesday clinics) told me she was raising chickens. That's a pretty common thing here in Nigeria and can be a pretty quick method of making money, especially if you time it right with Easter, Christmas, or a major Muslim holiday. Holidays are the few times that many Nigerian families eat meat. Chicken is especially prized because it's tender (or at least it is until they cook the bejeebers out of it and it becomes all dry!)

Anyway, I don't remember the rest of the conversation with Ladi, but on December 19th, our last clinic day for the year, she asked,

"When are you coming to pick up your chicken?"
"My chicken?"
"Yes, your Christmas chicken. Everyone else has already picked theirs. Only yours is remaining and  I'm still feeding it."
"Oh, I see. You raised an extra chicken for me. I didn't know that. Sorry! How much is it?"
"Well it depends. Do you want the one for 3,000N or the one for 4,000N?"
"I'll take the smaller one since it's only me at my house."
"OK. I will bring it to you because my house is a bit far. Do you want me to dress it?"
*laughing* "Yes please!"

I showed up to work the next day, the last day before I was to start Christmas break, Ladi handed me a black plastic bag, and said, "Here is your Christmas chicken!" She said that her niece had killed it and plucked the feathers just an hour or so ago. A fact I confirmed by the fact that the bag felt room temperature!

I wasn't going to head straight home, so I had to find a way to deal with it. Ladi offered to put it in the fridge in the operating room (supposed to be used only for medications), but thankfully one of my missionary colleagues offered to take it back to our compound and put it in her freezer. So I handed her this big bag and away she went in the keke, holding it in her lap.

My freezer and fridge were stuffed with food as I'd been preparing for a visitor over Christmas break and my house helper would take a two-week holiday during that time. So the chicken sat in my friend's freezer, tucked in its black plastic bag.

And then the day came that I was going to make an oven-roasted BBQ chicken. I even had Kraft brand BBQ sauce I snagged on clearance a few months ago from the one grocery store in town (I don't think BBQ sauce is a fast-mover in any Nigerian grocery store!). I was so excited! 

I thawed the chicken in my sink, then reached in the bag, and...

it still had its neck and feet! Ok, the head was gone, but the rest of the chicken was quite intact! I *might* have squealed a little!

After some sawing with my less-than-sharp chef knife, the feet and neck were tossed in my food scraps bin and I proceeded with dinner preparations.

But seriously, I should have learned from my mother.... When purchasing a whole chicken in any country outside the US, there is a very high probability that it will still have its head, neck, feet, tail, or all of the above still attached. 

Yes, the chicken was yummy. Yes, I invited my neighbors over for a potluck meal. Yes, it was worth it. Yes, I learned my lesson!

And that, my friends, is the story of my first Christmas chicken!