A Year in Review: Excellent Care

Chronic Osteomyelitis

From a clinical standpoint, this first year as a missionary surgeon has felt, in many ways, like being an intern all over again. In those first few months especially, I constantly felt in over my head as I tried to learn general medicine, tropical medicine, and the vast breadth of the surgical subspecialties that made up only a brief part of my residency training. The “normal” day-to-day work on surgical ward and in the operating room (“operating theatre” as it is known here) has been busy and full of many learning opportunities. In the past year, I have performed nearly 1000 operations. Only 2/3 of these cases are what would be considered within the scope of a general surgeon in the United States, hence, only 2/3 of the cases I have done have been procedures I was trained to do in my residency. The rest fall into the categories of OB-GYN, orthopedics, and urology. In fact, the most common operation I do is bilateral tubal ligation (“tying the tubes”) for women who have decided that they’re done having babies (usually after they’ve already had an average of 8-10 children), which is traditionally done by an obstetrician. The vast majority of operations I do emergently in the middle of the night are C-sections with the occasional laparotomy for sigmoid volvulus (twisting of the colon, which causes a blockage and cuts off the blood supply to the colon). I have learned procedures such as prostatectomy, hysterectomy, and how to set a variety of fractures. In addition to learning the surgical subspecialties, I am learning a great deal about HIV, tuberculosis, sickle cell disease, malaria, and typhoid and how they relate to surgical pathology.

It has been a challenge to learn to care for patients in a setting of significantly limited resources compared to what I have known in the States. Just a few examples:

*Patients come from great distances, and most do not have a car or access to reliable transportation. Many have to make a hard decision to leave fields and crops unattended or large families at home uncared for in order to come to the hospital. As a result, by the time most patients come to us, they have been living with their condition for weeks, months, and often years! 

*We often experience inadequate supply of medications and blood. When we have more patients who need blood than we do units of blood to give, we have to make difficult decisions about who will receive the precious blood available. 

*We do not have any oral narcotic pain medicines, meaning that patients going home after major surgery, with broken bones, or with inoperable cancers are given only Tylenol and/or ibuprofen for pain. 

*We lack advanced medical technology in the way of CT scanners, ventilators, intensive care monitoring, advanced lab tests (i.e. electrolytes, bacterial cultures), laparoscopy, endoscopy, on-site pathology, and the ability to provide advanced cancer care through chemotherapy and radiation.  Our ability to make diagnosis is dependent on a good history, physical exam, and occasionally an x-ray, ultrasound, a basic lab test, or even exploratory surgery.

Melanoma of the foot

*With the exception of Burkitt’s lymphoma, Kaposi’s sarcoma, and Wilms tumor, we do not have the ability to administer cancer chemotherapy here.  Many of our patients do not have the means to go to the capital city for advanced cancer care. Most with a diagnosis or suspected diagnosis of cancer will not be able to receive the appropriate medical treatment that will provide a cure or prolong their survival. Cancers often are not diagnosed until they are very advanced and after they have spread throughout the body, meaning that surgical resection is not a reasonable option. Our main focus in advanced cancer care is helping our patients be reconciled to God through Jesus Christ and in making them as comfortable as possible for however long they have left to live.

*Patients who need long-term nursing care in the way of home health or inpatient nursing facilities do not have access to such services. This means that those with significant disability (spinal cord injury, stroke, debilitation from chronic illness, major trauma) do not have the option of rehabilitation. They must rely on their families to care for them in places where there are no wheelchairs, ramps, or handicap accessibility.

Despite our many limitations, it really is incredible how much we are able to do here.  It’s amazing to see God at work when we feel like we have little to offer.  Just last week, I operated on a woman who developed multiple large enterocutaneous fistulas (small intestine forms a connection with the skin and drains its contents onto the abdominal wall) after complications from previous operations. Operating on her right away would have been dangerous because of the inflammation and scar tissue inside her abdomen, so we were forced to wait. The injuries to the small intestine were high enough in the GI tract that whole pills would come out of her wound rather than being absorbed by her intestines. Her condition put her at significant risk of dehydration, malnutrition, and skin breakdown as well as a good chance she would not survive. She has been admitted here for the last 4 months as we have worked hard to keep her alive, healthy and strong, allowing time for her skin to heal and the scar tissue inside her abdomen to become less dense to prepare her for an operation. In the States, this woman would have had multiple CT scans and a vast diagnostic work-up. She would have had home health nursing care to help her manage her fistula output. She may have even received IV nutrition (TPN) or tube feedings to maintain her nutrition and electrolyte balance. We have none of that here. Instead, she was given a bed with a hole cut into the foam mattress to allow stool to drain from her abdomen into a pan on the floor. We kept her in a steady supply of Vaseline and cotton wool to help protect her skin from the caustic intestinal contents that spilled onto her skin. Each week, we bought her a tray of eggs and a jar of peanut butter to provide her with enough protein to help her body heal and to keep her from losing weight (in 4 months, she actually gained 1 kilogram!) We spent much time in prayer, asking God to heal this young lady and to help us make the right decisions regarding her care. Her operation this week to remove the injured intestine and reconnect the healthy ends went so smoothly, and she is recovering well on the ward. Hallelujah! 

Every day, people come to our hospital with a variety of illnesses and injuries, and every day, people go home healed or on the mend, having received treatment, medication, surgery, physical therapy, and spiritual counseling.  Like most mission hospitals, we operate under the knowledge that “We Treat, but Jesus Heals.” We believe this wholeheartedly here, and we see it every day as patients are healed despite lack of resources or limitations in our knowledge and ability.

Mukinge is not on the main road. It’s not on the way to anywhere, really. It’s at the end of the paved road, about a 2 ½ hour drive from the nearest city. And yet, patients come from far outside our district, making the long journey here because they have heard that if they come to Mukinge, they will be cared for. They have heard that there’s something different about Mukinge Hospital. They come all this way because they have heard that God is at work here, and they come believing that they will get better.

Over the course of medical school and residency, as I would talk with people about medical missions and about becoming a surgeon in the developing world, a number of medical professionals made comments to me about how they didn’t think they could practice medicine overseas because they couldn’t stand the thought of not being able to provide “excellent care.” I’ve thought about this a lot over the years.  What does it mean to provide excellent care in the developing world?  In Africa?  In Zambia?  At Mukinge Hospital or elsewhere?  Can a commitment to excellent practice be made in a place where the conditions seem less than ideal?

I appeal to you that it is possible to deliver quality medical and surgical care in the developing world, that it is possible to provide excellent care even when the conditions are less-than-excellent. I think we do this every day at Mukinge Hospital. I don’t think that Excellent Care means that we have the ability to provide stereotactic radiation, robotic surgery, or state of the art diagnostic imaging.  I believe that Excellent Care is providing the best care possible with the resources available in a compassionate and caring manner. It means treating patients and their families with love and integrity.  Sometimes it means knowing helping a patient to die well without inflicting unnecessary suffering through prolonged hospitalization or surgery that will not improve their quality or length of life. Here at Mukinge, we strive to provide excellent care for each of our patients. As we work under the guidance of the Great Physician, we trust that God will provide for our needs and those of our patients. He does excellent work, and it is a privilege to work in a place like Mukinge Hospital where “We Treat, and Jesus Heals.”

A Year in Review: Arriving

“One does not surrender a life in an instant. That which is lifelong can only be surrendered in a lifetime.” 

~Jim Elliot

I was sixteen years old when God called me to be a missionary doctor, although I’m certain that He has been in the process of preparing me for this work my whole life. I don’t think I ever doubted that this is what the Lord created me to do. Through college, medical school and surgery residency, I had this singular purpose in mind as God continued to give form to my vision and fuel my passion.  I graduated from residency, passed the American Board of Surgery exams to become board certified, and completed training with both Samaritan’s Purse and SIM. One year ago, after a lifetime of education, months of preparation, weeks of packing and goodbyes, and about 30 hours of traveling, I arrived in Zambia.  It’s hard to believe a year has gone by already!  So I thought I would take the next few posts to reflect on what the past year has brought, to recount the things I have learned and the ways I have grown, and to remember what the Lord has done.

Some say that the first year on the mission field is the most difficult year in the life of a missionary. I suppose this is true, although having spent only one year here, I don’t have much basis for comparison J.  It has been a good year. I have learned so much in the way of surgery and medicine in rural Zambia. I’ve taken care of hundreds of patients and have witnessed God at work in healing bodies and hearts and minds. I have become part of a community of missionaries who have been faithfully serving the Lord here in Zambia, some for as long as 40 years! I have made friends with several of the Zambian hospital staff and am slowly learning the culture and language of the Kaonde people. I’ve given lectures at the nursing school, spoken in chapel services, and have overseen visiting medical students doing elective rotations at Mukinge. In the relaxed pace of life here, I have found plenty of time to read, to rest, to go on walks and to sometimes just sit on the porch and watch the rain. I have grown in my walk with God and have gotten to know Jesus more deeply and fully than before. It has been a good year.

It has been a hard year too.  Hard in ways that I expected, but also in ways that I didn’t know how to expect.

The first few days and weeks in Zambia were a whirlwind of activity and excitement – taking the Zambian medical licensing exam, shopping for groceries, making the short mission flight from Lusaka to Mukinge, meeting the missionaries, moving in and unpacking, seeing Mukinge Hospital for the first time, walking through the wards, and getting acquainted with the operating room. It was thrilling and overwhelming and terrifying all at once. Here I was, finally a missionary doctor, finally in Africa, finally realizing my lifelong dream.  

It’s difficult to describe what it felt like (and still feels like) to have finally arrived at the goal toward which I had been working so hard for so long and to discover that even greater challenges were before me. Maybe like reaching the top of a high mountain, only to find a great chain of mountains waiting on the other side. Not that I was naïve to the challenges I would encounter once I arrived, but how does one really and truly prepare to move to a new country, learn a new culture and a new language, live a new community, start a new job, join a new church and engage in an entirely new way of life?  I was taken out of my comfort zone in nearly every facet of daily life. I knew that no one expected me to have it all figured out or to feel at ease right away. I didn’t really expect me to have it all figured out either. But I was not accustomed to not having all the pieces of my life fit together neatly and comfortably. This confident, independent, driven, and – let’s face it – proud young surgeon felt something she wasn’t used to feeling. I felt lost.

On Friday nights, the missionaries get together for potluck and a movie. My first Friday night at Mukinge, it was pouring rain and pitch black outside as I tried to navigate my way along unfamiliar paths carrying a flashlight, an umbrella, and a hot casserole dish. I kept a keen eye out for snakes as I walked through tall grass and slippery mud, up and down wrong roads until I finally found the house where potluck was being held.

That experience seemed to exemplify how I was feeling on the inside – I thought I knew where I was supposed to be going, and I thought I had all the right tools to get there. But once I actually stepped out alone into the dark and rainy night, all of a sudden the way didn’t seem clear at all. As I slogged through grass and mud, the hot dish burning my hands through thin potholders, and unseen deadly snakes lurking in the shadows just waiting to strike, I wasn’t sure how I would make it to potluck. Going home wasn’t really an option.  I knew that turning around and trying to find my way back to my house would be equally as treacherous.

The devil is well known for using these times of uncertainty and change to attempt to sow fear and doubt into the hearts of men. Just like his encounter with Eve in the Garden of Eden, he sneaks up in the darkness and whispers, “did God really say…?” (Genesis 3:1).  And so it was, in this time of feeling lost and uncertain that for the first time since I first heard Him say to me, “This is it Sarah. This is what I want you to do,” I questioned God’s calling.

Was it possible that I had been wrong, that I had heard God incorrectly or that I had made this whole thing up in my head?  Did He have any idea just how overwhelmed I was by the high mountains before me or how completely inadequate I felt? These questions and insecurities brought me to my knees before the Lord. He was gracious to answer, and slowly my heart was at peace.

When you pass through the waters, I will be with you;

and when you pass through the rivers, they will not sweep over you.

When you walk through the fire, you will not be burned; the flames will not set you ablaze.

~Isaiah 43:2

The short answer is that, no, I had not heard God incorrectly all those years ago when He first called me to be a missionary doctor, and yes, He knew exactly how I felt. In those first weeks and months at Mukinge, He confirmed and reaffirmed the same call I had heard as a teenager. This is what I was created to do. The Lord had guided me through many intense years of studying and training. He had given me the skills and the knowledge that I needed and the resources to learn how to care for the diseases and ailments I would encounter in Zambia. Most of all, He had given me a great passion in my heart for every person to know this great news that they are created and loved by God, that He sent Jesus to pay the penalty for their sins, and that He offers the free gift of salvation to any and all who will choose to receive it. He had never promised that it would be easy or that I would see the whole way clearly before me. But He did promise that He would be with me.

It’s been a good year. And if it's true that the first year is the hardest, I’ll say it’s nice to have that one under my belt. I am grateful for what the Lord has taught me and the ways in which He has shaped my character through the challenges of being a brand new missionary.

Lord, you have assigned me my portion and my cup;

you have made my lot secure.

The boundary lines have fallen for me in pleasant places;

surely I have a delightful inheritance

I will praise the Lord who counsels me;

even at night, my heart instructs me.

I have set the Lord always before me.

Because he is at my right hand, I will not be shaken.

~Psalm 16:5-8

Atotwe

On Sundays after church, we usually meet for pancake lunch. This particular Sunday I was running a few minutes late. As I stood in my kitchen peeling and slicing bananas to take along, I heard crying coming from my backyard. I ran outside and found a little boy standing in the middle of my lettuce patch. He was all alone and was obviously very scared. I scooped him up, ran inside to put on shoes and grab my keys. Then he and I set out in search of his mother. He didn’t speak any English, and I sadly don’t even speak Kaonde well enough to converse with a four year-old. Just enough to learn that his name was Atotwe.

We went to the Kilata – the area behind the hospital where family members of patients stay. I walked up and down the rows of hostels, asking if anyone was Baina Atotwe – mother of Atotwe. With open palms raised toward the sky to demonstrate empty hands, the only reply I got was, “Kafwaako.” No one here.  As we walked along, I chattered away cheerfully at him in English, telling him about my family and my cats and how I hoped we'd find his mother soon.  He didn't say much in reply, but just clinged to my arm while we continued our search. We went to the house where pancake lunch was being held to see if anyone there knew who his parents might be. Kafwaako. I found some folks whose Kaonde was much better than mine to see if we could get any more information.

“Atotwe, jizhina Bainanji?”  Atotwe, what is your mother’s name?”

“Bamama.” Mama.

“Bagipi?” Where is she?

“Ku nzubo.” At home.

“Mwikala pi?” Where do you live? 

“Ku nzubo.”

We went to the hospital and walked through the wards to see if anyone recognized him. Kafwaako.  “Nasaka kuya ku nzubo.” “I want to go home.” I wanted him to be able to go home too!  After walking around for over an hour, the poor little guy was exhausted and fell asleep in my arms. I was exhausted too and feeling a tad discouraged. We headed toward a few of the hospital staff houses next to the hospital to see if anyone knew him, and we decided that if we still couldn’t find his mama, we’d take a break for some pancakes and water and then regroup.

As we walked up the road away from the hospital, a frantic looking woman saw us and came running and crying in our direction. Baina Atotwe! Not far behind her was Atotwe’s Nkambo – his grandmother – in an equal state of duress. Apparently Atotwe had wandered away from junior church and had traveled over a kilometer down the road all by himself before he ended up crying in the middle of my lettuce patch.  Atotwe was passed over to his mother as many joyful tears were shed and hugs were shared. A happy ending to my mid-day adventure.

Healing Rains

Be glad, people of Zion,
rejoice in the Lord your God,
for he has given you the autumn rain
because he is faithful.
He sends you abundant showers,
both autumn and spring rains, as before.
~Joel 2:23

Last month I made a quick trip home for Grammy’s wedding. I spent two wonderful weeks with dear family and friends both in Indianapolis and in Charlotte. The Lord used my time at home to refresh and encourage me – as if each encounter with friends and loved ones was like God pouring into my soul from a pitcher.

Pretty much as soon as I returned to Mukinge, the rainy season started, and we have had heavy rain most days! The corn in my garden was only knee-high when I left. It is now taller than I am and ready for picking! The rains seem to have refreshed the ground, the plants, and the people alike. Everything around me mirrors how I feel inside after such a great time at home in the States. Thank you to all of you who helped make my time there so wonderful. And for all those who I missed while I was home, I look forward to seeing you the next time!

Sweet corn in my garden

For my Zambian friends and neighbors, the rains have softened the ground and made it ready for planting. Zambian farmers are busy cultivating their fields and gardens, planting the seeds that will produce the crops they depend on for their survival. Please pray that the Lord will continue to send the rain needed to make these plants grow in order to provide the food and income that will sustain each family in the coming year.

Watching the rains on the porch with Lloyd and Ned

Lloyd working hard to stay dry during the torrential rains!

Wedding Bells!

In case you hadn’t heard the news, Grammy got married! Yes, it’s true – my dear, sweet Grammy and her “gentleman friend” Jack tied the knot last weekend. I was able to make the long journey home to stand beside her as her maid of honor. What a great time of celebration with Grammy and Jack! I am so grateful for the opportunity to be at home with my family for this exciting day!

!Man & Wife

 !Cousins

My beautiful mama

The Lantz family