Avoiding Caput Medusa - or - Try and Keep Your Cross-Cultural Teaching Simple

(from Eric)

We are in the throes of clinical teaching here at Kibuye.  In French.  To a group of Burundians.  Who are on their first hospital rotation.  And we're still learning how to do it.  So we try out some new things.

I asked my students what some topics were that they wanted to learn about.  Perhaps that was the first mistake, because it is certainly possible to be too early in your education to know what you need to know.  They said psychiatric disease, liver failure, kidney disease, and hypertension.  I would have only picked one of those things.

But, I did ask, so I tried to follow through.  The next day, I sat down to try and do a little extemporaneous talk on liver failure.  Every time I try and do this, I discover that I don't know significant amounts of vocabulary necessary for the topic.  And I discover that when it is too late to turn back.  So you just try pronouncing the word with a French accent.  If they repeat it back, you're good.  If they don't, you give it a second try for good measure.  Third blank looks gets an attempt to explain it.  Fourth blank looks abandons the topic.

We started with a list of symptoms of chronic liver disease.  They got a few of them.  Ascites.  Jaundice.  But they weren't getting anything associated with portal hypertension.  So I asked them:

(in a French accent) "Hypertension Portal?" (it's also good to try and reverse the orders of words)

Flash of recognition.  Good.  Success.  "OK, can you name any signs of portal hypertension?"  Blank stares.  OK, I should explain it to them.  "So, when the blood going to your liver gets backed up, the blood gets sent on alternative pathways in various parts of the body, and that leads to varicose veins there and possible bleeding problems."

If you are impressed that I could explain that in French, then you shouldn't be, since, though I got an "E" for effort, they obviously didn't really understand me.  OK, moving on:

"Esophageal varices?"  OK, good, they've heard of that one.  "The same problem in another place?"

No response.

"Hemorrhoids?"  I think they get the word, but they seem more confused.

"Caput medusa?"  Very confused.  "Medusa, do you know her, from Greek mythology?"  Nothing yet.  "A lady with snakes instead of hair."  Mouths agape with astonished stares.  "Uh, yeah, I guess it does sound a bit frightening..."  

This is where I realized I had certainly gone too far, but now, with the totality of their interest directed towards me, what am I to do?

"Well, picture a face with a bunch of snakes coming out, and then picture the belly button with dilated veins sort of coming... out... instead..."

One of them ventures boldly:  "You can see that, just by looking?!"

Uh, yeah, but I don't think it's as dramatic as you are thinking...

Medusa

Caput medusa

Another day in our lives.

 Wikipedia France has informed me that "la tête de Medusa" is, in fact, the French term.

Valentine's Day

by Jess Cropsey

It's been a little while since we've given an update from the "home front".  Kibuye Hope Academy just finished its 24th week of school last week and we closed the week with a smashing Valentine's party!  (We like to do holidays as big as we can here!)  Thanks to the advanced planning and generosity of Grandma Cropsey, there were plenty of crafts, decorations, and goodie bags.  (She's already scheming how to get post-Valentine's sale items to us for next year!  Can you tell she has a little experience with this?)

The McLaughlin family brought some delicious sugar cookies with sprinkles and frosting which everyone enjoyed. 

The kids worked hard on cards for each other (and for the adults too).  

 Each of the older kids got a special sticker/coloring book, courtesy of Carolyn Bond (our new World Harvest colleague in Bujumbura).  She also brought special Valentine's M&Ms and Dove chocolate hearts.

In the evening, we had a team potluck dinner for Carlan's missions pastor who was here for a short visit.  We all enjoyed our traditional homemade pizzas, although this time there were a few heart-shaped ones!  

Sending our love to all our friends & family on the other side of the ocean!  Hope you had a special day with those you love.  We missed you! 

COTW: Pancytopenia and God With Us

(from Eric)

A few weeks ago, I rounded on the Pediatric service, and was told about a 10-year old boy named Emmanuel, who had been in our hospital for several days with some fever and confusion.  We see this a lot, and by far the two most common reasons, which are Severe Malaria and Bacterial Meningitis, didn't appear on his tests.  But the tests aren't perfect, he was still being treated, but stubbornly not improving.  Then his nose started bleeding.  A lot.  And he started vomiting blood.  Needless to say, it was disturbing for everyone involved.  

It was a pattern I had seen before, several times in Kenya.  I asked for a Complete Blood Count ("CBC", but it's "NFS" in French), and it confirmed my suspicion that his platelet level was practically nothing.  And he was anemic.  And his white blood cells were decreased, which made him overly susceptible to any kind of infection.  We call this pancytopenia.  His bone marrow has stopped many all of the major components of his blood.  What causes it?  Lots of things.  Can we figure that out here?  No.  Could we treat the problem even if we could uncover the cause?  No.  Can we just give him a big blood transfusion and consider it fixed?  Malheursement, No.

Along with the medical student taking care of him, we talked to the mom about the situation.  We did give him a transfusion as a temporizing measure, but the situation did not look good.

Every night before going to bed, Maggie and Ben pray for sick people.  The following night, Maggie wanted to pray for "that boy at the hospital that might not be able to get better."  I wasn't sure what she was talking about.  Apparently, she had overheard us discussing the case and wanted to pray for him.  I told her that his name was Emmanuel.  Fresh off the advent curriculum, Maggie's eyes lit up.  "Emmanuel, that means 'God With Us!" 

It was hard to pray for him, in a sense.  My technical mind knew that the prognosis was grim.  I could pray for his healing, but what are his odds of survival when he is actively hemorrhaging, and we have no tools to stop him?  And here's Maggie, praying to her Heavenly Father for a boy named "God With Us".  What am I going to tell her if she later asks what happened, and the truth is that he has now gone to be with God.  There is life and hope even in such discussions, but I wasn't quite sure it was a conversation I wanted to have with my 4-year old.

For many nights in a row, she prayed for "the boy whose name means God With Us", and I prayed with her.  Alyssa is running the pediatric service, and she told us that he had woken up, stopped bleeding, and she was sending him home.  (Yes, this is, in fact, the same boy from Rachel's hunger post.)  Unlooked for, Unexpected, Afraid to Hope.  God is with us.  We will continue to pray for him, since he is far from cured, but there is hope kindled, and maybe the surprise of it will be enough to teach me to hope a little bit more.

Book of the Month: A Praying Life

(from Eric)

The current McCropder team book study is on "A Praying Life" by Paul Miller, who helped to found our mission agency, World Harvest Mission.  We've been enjoying it immensely, and I still think the most succinct way of getting at the heart of the book was the first comment I ever heard about it: "Amazing, here is a book about the importance of prayer that doesn't make me feel guilty!"  Though that statement may sound weird to someone who is not a Christian, I would imagine most Christians would have no trouble identifying with the idea.

But to frame a description in positive terms, Paul Miller founds the idea of Christian prayer on the idea of dependency on God, our Heavenly Father.  We pray and we ask like little kids ask their parents, constantly and unashamedly, because we realize how powerless we are.  As our knowledge of our insufficiency increases, we will naturally pray more.  We stop praying when we (mistakenly) think that we are up to the task.  Thus Jesus prayed all the time, because he was supremely aware of his dependency on his Father.  Paul Miller says that he does his best parenting in prayer, which is to say that there is so much in his kids' lives that he cannot control, regardless of his efforts, so what better thing can he do than to bring his needs and concerns to his loving Father, who actually is able to help?

Since starting work at Kibuye Hope Hospital, the percentage of our life over which we have no control has increased.  (And, truth be told, it wasn't overwhelmingly high before that)  To put in another way, the illusion of the degree of control I have over my life has been partially undone.  I can't treat this problem.  I have no way of knowing what is going on here.  This system seems indecipherable to me.  I can't figure out how to explain this adequately in a foreign language.  I don't even know what I don't know, so how do I move forward?  I can't do this.

But we can pray.  And we do.  We pray before we round.  We pray before we head to work.  We pray before we operate.  We pray at bedsides, in conference rooms, and in quiet offices.  We need help.  More to the point, we realize that we need help, and so we pray.

There is so much that we can't do.  But let us fill Kibuye Hope Hospital with a reliance on a good God who is indeed present with us, and who is even now working out his unseen plans among us.  To become "A Praying Hospital" is no consolation prize, and the temptation (for all us) to think of it that way is another evidence of our illusion of control and sufficiency.  Wouldn't it be better to stop praying and get on with doing something about it?  No.  Not really.  Because I can't, really.

All of this would be bad news, were it not for a Goodness and a Grace that is more solid and more real than all the evil and the darkness that is or that ever will be.  But given the reality that is ours, we will come, we will ask, and we will trust.

Hunger Culture

By Rachel

from worldmapper.org  Country sizes have been adjusted to reflect the percentage of the population that is undernourished.  Congo is the brick red country in the middle of Africa; Burundi is the lighter brick red just to its right.

Last week, Jason and I headed into Gitega to do some shopping and errand running for the team.  Several of our Burundian friends/employees came along on the ride as well.  We loaded about 5-6 boxes of food from the Indian grocery store in the trunk, along with 4 crates of sodas, and the stopped by the local grain “wholesaler” and picked up 3-25kg bags of flour, a 25kg bag of rice, and a 50kg bag of sugar for all of the families to split.  The flour/rice/sugar will probably last us 6-8wks.  And then for good measure, Carlan was hosting a party for the workers who had finished the ER renovations, so we got 5kg of potatos and some green beans and pineapple for the fete.  As we pulled onto the road heading back to Kibuye, I glanced back at the piles of food spread across the back of the van, and I looked at our Burundian friends, and I leaned forward and said quietly to Jason in the front seat, “I think there’s more food in the back of our van than the average Burundian family eats in a year.”  It was a little embarrassing.  I felt guilty about my eating habits, maybe for the first time in my life.  I mean, we almost never eat meat anymore, and rarely eat anything packaged or processed, but we eat well here at Kibuye.  Every day we have beans or cheese or eggs (or all three).  Our team splits 28 liters of milk a week (about 6-7 gallons) from local cows.  I get about 20 eggs and a huge basket of produce delivered to my door every week.  How can I justify this when so many are going hungry around me?

It’s been challenging in the hospital, too.  Last week, Alyssa took care of a very sick kid who had a disease “killing” his blood cells.  He was bleeding spontaneously from his nose and vomiting blood, and no one expected him to survive.  Lo and behold, thanks probably in large part to prayers, when she saw him this weekend he was sitting up and shook her hand.  They talked about going home.  But 10 minutes later she was called back to the bedside because he had lost consciousness.  The story emerged that he actually hadn’t been fed in three days because the mom had run out of money (the hospital doesn’t provide meals to the patients, it’s the responsibility of the family to feed the patient).  There have also been several kids admitted with malnutrition, and the families obviously don’t have the money to provide the high calorie nourishment desperately needed.  Several McCropder families have donated milk, 1/2 liter at a time, to give to these kids who have so few options.

Many families in Burundi will only eat one meal a day.  In Kenya, chai was a national institution.  Here, it’s not, because people can’t afford the tea leaves, milk, and sugar.  Sixty percent of kids are malnourished to some degree.  World Relief, an organization based here at Kibuye, does a lot of public health work and education in the villages.  They are trying to get moms to feed their kids one egg, once a week, to decrease malnutrition.  So we asked a Burundian this week why more Burundians don’t eat eggs.  They seem plentiful enough.  Too expensive.  The cost of an egg?  About 13 cents.

I can’t seem to keep enough sugar in the house...it disappears at an almost alarming rate.  I was initially worried about the sugar going into my families’ bodies, but then one week realized that over half of our sugar consumption goes into chai for 6 different Burundian workers (some hospital employees that work on our property, some our employees).  I was so frustrated.  I came up with plans to limit the amount of sugar I put into the canister, thought about talking to the person who made the chai every day, grumbled to myself and to Eric.  And then one day I realized that the amount of money I spent on that sugar (and milk, and tea for that matter) was less than $10/week.  For six people.  Who make less than $50/month.  And the calories they consume in that cup of chai might be the only calories they get all day until they go home for dinner (and who knows how much they eat for dinner).  And I was ashamed of my stinginess.

What do we do with this?

Give us this day our daily bread.  Or in Kirundi, give us to eat that which is sufficient for us.  How many times in my life have I gone to bed hungry because I didn’t have enough food or money to buy food?  Never.  How many times have I sat down to eat and been truly TRULY thankful at the gifts provided in front of me, provided by grace and not because I earned it?  And when I am tempted to grumble and complain at all the things in my life that are not going the way I wanted them to, how many times do I stop and thank God that He never ceases to provide for my most basic needs?

I’m not here in this place to provide handouts, and that probably isn’t in anyone’s best interest long term.  But what does a world full of hunger and famine mean to me, a relatively rich American Christian with plenty to eat?  Does it mean less Starbucks lattes?  Less lunches at Panera?  No more Reese’s PB cups?  Become a vegetarian?  Donate all my money to some organization that goes around and drops off food to hungry villages each week?  I don’t know.  This is something I’m just really starting to struggle with, and I don’t have any good answers.  I know that some people who eat out three dinners a week are far more generous with their money than I am.  Eating less in order to save money to hoard it, or spend it on myself, is missing the point.  Maybe, being more grateful for what I have, and recognizing it for what it is instead of wishing I had more of something.  Being more generous with what I’ve been given.  Being aware of what is happening in the world around me.  Working, somehow, for mercy and justice, to care for orphans and widows and starving families, and praying that God continues to fix what is broken in our world...

A Fanta to End the Mourning

(by Eric)

Last week I received a text.  It was from our friend Pastor Luc, who is the assistant administrator at our hospital.  It said that he unexpectedly lost his mother that morning.  I was saddened for him, and touched that he would think to text me at a time like that.  Luc is a very solid guy.  When we first arrived, he drove us around to introduce us to the local administrators and the chief of police.  In light of our coming, he convinced them to add two new police officers to the Kibuye campus.  During a rain storm a few weeks ago, I was trying to get an urgent message to him, but the cell connection was cutting out.  Next thing I knew, he was at my door with a big umbrella and some rainboots.

Sunday marked the seventh day since her passing, and we were invited to a traditional gathering to mark the end of the initial mourning period.

An aside:  As I share impressions of Burundian culture, I'm sure that I'm getting things wrong sometimes.  I'm sure I will be able to re-read this in years to come and think "Wow, I really didn't understand that at all."  In a sense, I hope I will, since that will mean that I've grown in my understanding of this world around us.  But I will share it as I understand it, nevertheless.

We drove out in a little caravan of about 5 vehicles at 1pm.  Everyone was in a suit.  We left the tarmac after a few minutes, but the dirt road remained good.  Luc was in the car in front of us, and was frequently stopping to pick up more passengers.  It was obviously getting full up there, so we signaled that we could take some as well.  We arrived at the parish church, which has a gathering area.  A young mentally-handicapped guy came out and immediately hugged the three white guys in suits, and insisted on introducing us to various even-now-unidentified people.  There were a lot of hospital acquaintances there, and so we chatted a bit.  After a while, they showed us to a shaded area, and gave us the benches of honor, to the side of the head table where the family sat.

They passed out your choice of soda: Fanta Lemon, Fanta Orange, Coca Cola, or Schweppes Tonic Water.  We all enjoyed a beverage, and sang a few hymns.  Then Luc made a short speech, as did another guy from the crowd.  Then they passed out the envelopes.

The envelopes are for donations.  The donations, as I understand it, are for the payments of the debts of the person who has passed away.  In a sense that seems harsh, to come knocking for a debt after a death, but in a land of a lot of debt, and no small amount of death, it's probably necessary to have some security in the lending process.  We were told that, for older people, there is usually a second such ceremony during the dry season, since other people will then come from further away to collect further debts.

This is still uncomfortable territory for us, and probably will be for a long time.  As Americans, the purest friendships are void of financial matters.  We just like "being together".  Africans tend to value interdependence and solidarity in lieu of independence and "freedom".  So, being a part of this process assures them that they are integrally linked into the broader community.  That being said, we're still Americans, and so we feel the discomfort.  However, we took an envelope and tried to guess what would be appropriate for our friend, comforted by the fact that his character assures us that he will steward whatever gift well.

People came and brought them up to a little conical basket which is typical of Burundian style.  Then, before we knew it, they were closing the basket, and we three had to rush up and put in our donations before it was too late.  Thus ended our dream of inconspicuously participating in community life.  There was gentle laughter, and we sat down, chatted some more, shook a bunch of hands, and made our way home.

Case of the Week: Acute Flaccid Paralysis

(By Alyssa)

I met Claudine on one of the first days I rounded on pediatrics. She was 4 years old and I was immediately struck by how sick she was. She had been admitted severely anemic (Hemoglobin of 3) with a diagnosis of malaria. As she was comatose and had had several seizures, she was also treated for meningitis. She had already received a blood transfusion and a couple days of IV medications by the time I saw her but she was still completely unresponsive. She required intubation and mechanical ventilation but that’s not possible here. I spoke with the family explaining the gravity of her condition and we prayed with them together as a team. I alerted the on-call doctor and asked him to keep a close eye on her - he was called to evaluate her several times due to high fever, difficulty breathing, and seizures. I really didn’t expect Claudine to survive. But each morning I came back to pediatrics and found her still there. She began to open her eyes and look around the room. But she still didn’t speak or move. We discovered one day that she actually could follow commands with her eyes. But she was completely paralyzed to the point of being unable to swallow or speak. Possibly a post-infectious Guillian-Barré syndrome, possibly something else. We needed to give her nutrition somehow as it had now been over a week since she had been able to eat or drink anything. I discovered some pediatric nasogastric tubes in the back supply room. The nurses had never placed or used an NG tube before, so I inserted it and explained it to them. But then I realized we didn’t have any formula to put in it nor was there any milk available (cows produce very little milk here) and the family couldn’t afford to buy milk. So I talked with my teammates and the families agreed to donate milk each day for this little girl. Anna even helped me deliver it to her one day. And we taught the mother how to put the milk in the NG tube. After a few days, Claudine regained the ability to swallow, so we removed the tube and she was able to eat. The last day of her hospitalization she could speak very softly and barely move one hand. 

She came back today for a follow up visit and I feared she would be emaciated and still extremely weak. But, amazingly, miraculously, she looked like a completely normal 4 year old girl! Walking, talking, active - I wouldn’t have even known it was her if I hadn’t recognized her mother. I loved sharing this excitement over her healing with the pediatric team as the medical students and nurses rejoiced with us. We praise God for bringing healing to her and for reminding us in this way of His love for these precious children. 

On a Thursday Afternoon

Today the kids and I (Heather) were wondering what goes on up at the hospital on a Thursday afternoon.  We walked up with a camera in case any of you faithful readers were curious as well.

Thursdays at 4:00, Alyssa teaches the medical students how to do pediatric physical exams.  Abigail happily sat in today so that the medical students could practice checking her ears and eyes.

Then we found Carlan as he was walking between buildings on his way to examine a patient.

John was building walls for the eye ward operating room.

And Jason was scrubbing for surgery.  In this operation he actually drained 2 liters of pus from the leg of a 10-year-old girl with pyomyositis.

So that's what we found happening at the hospital at 4:30 on a Thursday afternoon.

First Impressions: Poverty

The blog silence for the last few days is largely a result of us not being sure what to say about beginning work.  Our own processing is so much still in process that it's hard to articulate anything to share.  It's a lot to take in, and one could slice it on any plane.  So I'll pick one aspect, not because it gives a comprehensive perspective, but because it might be adequately bite-size.  The good news is that we're not going anywhere, so if you keep reading the blog long enough, a holistic picture of life at the hospital ought to emerge sooner or later.

Taking care of patients here is hard.  We understand limitations, but we are all hit by a whole new level of limitations.  One of the largest of these is poverty.  This is not new, but it is at a whole new level.  According to GDP, Burundians on average make about 1/3 of what Kenyans take home.

Example:  Rounding on the medical service yesterday, and we see a man in his 50's with urinary obstruction.  We can determine that it's due to his large prostate.  That part doesn't cost anything (ask your neighborhood urologist why).  Jason can take his prostate out.  Great!  We can help this one.  Let's do it!

Problem.  There's a decent chance his urinary obstruction has made his kidneys function poorly enough to be dangerous for his surgery.  And actually hospital policy means he needs a few labs before going to the OR.  OK.  Our lab can check those!  Let's do it!

Problem.  It's too expensive.  It's probably at least $8 to get all those lab tests and he doesn't have the money.  His family is coming tomorrow.  Maybe they will have something…

This is an illustration.  In most other cases, the problem of the grinding poverty here comes into play right at the beginning, so they wouldn't make a very interesting illustration.

Poverty calls everything into question.  "Standards of Care" are almost always income-dependent.  Everything we know of such standards is therefore subject to drastic reevaluation.  This test for this problem.  This medicine for this benefit.  Is it worth it?  Well, what does this cost mean to you?  There is often no straight answer to this question, so it gives us a great sense of "shooting in the dark".  Was that the right decision?  I think so, but how can I know?

And this, of course, is humbling.  Or maybe humiliating.  Sometimes the difference is hard to tell.  And maybe not all that important in the end.  Humility (or maybe humiliation) seems to be one of the hallmarks of our clinical beginning here in Burundi, as it has been throughout our time of language learning.

It's not a new thing.  It's certainly not a bad thing.  But it's hard.  Pray for us as we go.

McCropder Docs Invade the Hospital

(by Eric)

 

Today, January 2nd, 2014, is the official start of the hospital work of the six McCropder doctors.  We have been involved in various ways in the past couple months, even with some clinical work, operating, and consults, but our Burundian doctor colleagues (and 1 American visiting doc) have continued to work in the hospital, thus allowing us for the most part space to work on homes, community relationships, and language study.

 

My impression of the community anticipation of this is that it is high.  People are excited to see the white coats, and the influx of more advanced care into this community.  24 medical students are slated to arrive on Saturday, to begin on Monday, this group for 4 months.  There are five Burundian general doctors (no residency training) at the hospital, and for the most part, we have been teamed up with them, to learn the ropes.

 

We got together to pray last night and talk about excitements and anxieties.  Some thoughts:

 

-It's been a long break from clinical medicine.

-Are we really going to do this in a foreign language (or two?)

-There is so much that needs to change.  How do we balance being leaders with respecting what has been going on, and not changing too much too fast?

-John is opening a new department today, and will be training his small staff on a brand new type of care.

-McLaughlins' kids will be having some time alone with a Kirundi-speaking nanny each week from now on.

-O God, help us to love.  Whatever we do, let us do it with your love.

-We are so thankful to have come this far, having been shown so much faithfulness by so many friends and strangers, and most of all by a Savior who has loved us and called us to a good work.