March 2022 Details

Month Highlights:

Training: We partnered with Pathways to bring a vision casting workshop to pastors and Sunday School Superintendents in the Lilongwe area. We continue to make plans to bring transformative trainings to all 200 communities in our region, including plans to follow up on Community Health Evangelism and Transformational Development. The local has identified leaders to attend the CHE Training of Trainers with World Challenge, which is now planned to be in Blantyre at the end of April.

Teaching: Christina spoke at a Pastor’s Wives retreat (see the story in our March Update). After 5 years, church leaders in our area are starting to become leaders of health and healing as well. Partners have joined with us to help sponsor a total of 3 church leaders to complete Community Development training at NTCCA and another Lilongwe college.

Patients: Christina cared for some very sick patients this month. So far, God is bringing incredible healing in all cases, but as some patients needed longer hospitalizations, Christina learned to rely more on her team members and handovers of care. Patients have been booked with overwhelming frequency as Christina prepared to leave for the month, so please pray with us as we consider cutting back on clinic hours in order to do more in the community.

Dzaleka Refugee Camp: Christina is working with YWAM staff and volunteers to develop a system for helping individuals with disabilities and sicknesses within the refugee camp. She is also re-connecting with the government clinic leaders in an attempt to help understand existing healthcare structures and improve communication and perhaps repair some broken trust between the refugees and the clinicians assigned to serve them.

Mentorship: Christina continues to assist students, residents, and physicians find sustainable work fits. This month she has completed reports necessary to renew California-based training in Preventive Medicine as well as embarked on a new grant opportunity to improve research into Maternal/Child outcomes in San Bernardino

The AAFP LPW and Physician Wellbeing Conference One of the reasons we are splitting our furlough into two trips this year is because Christina was selected to participate in the American Academy of Family Physician’s program Leading Physician Wellbeing. This 10-month program includes personal wellbeing measures and organizational improvement strategies which aim to help doctors become leaders in preventing burnout and promoting physician thriving. The program required attendance at two conferences, including the Physician Wellbeing Conference in Naples Florida (thankfully the program paid for the conference.) As a guest, Greg has been able to attend some sessions with Christina which deal with concepts like letting go of perfectionism, being more mindful, and not allowing negative emotions to take over. We are finding this a safe space to discuss some of the things that have brought stress over the past years and how to build in healthy boundaries so that our work is more sustainable. Please pray with us as we consider how content from this conference might benefit our organization at CHSC as a whole.

Well Babies and Sick Kids

It was a busy Monday morning. I had half a dozen kids scheduled to see me for vaccine advice, but by the end of the morning I had seen or coordinated care for more than twice that number. One little boy had an appointment to get a polio vaccine to help protect him from the new epidemic in the country. But he wasn’t looking great when I saw him. His breathing was fast and he was putting in too much effort to move the air in his lungs just a little. His oxygen was okay, but I didn’t like the effort it was taking for him to get there. He only had a fever for one day, but I didn’t like how fast his heard was beating. I noticed some wheezes so I gave him a breathing treatment, which opened up his lungs but then increased the wheezing I could hear in both of his lungs now. The chest x-ray showed a diffuse pneumonia and the full blood count was consistent with a bacterial infection. So I gave him the strongest antibiotics we had, gave the family a pulse oximeter to check his oxygen, and sent our clinic’s pediatrician a thorough note about the case. I told the family that they could go home if they agreed to monitor him closely and bring him in the next day for a checkup. I wished I could do more, and questioned whether I had not been cautious enough when I let them go home.

I hope that I treat every patient equally, but I will admit that it is hard for me when the patient is also my friend. Greg and I work closely with this child’s grandparents in bringing training to communities. Greg attends Bible Study with the father and I get hair advice from the mother. It’s an honor that I’m their doctor, and I think I do the best I can, but sometimes it is hard when I wish I could do more, when the outcome is not what I hope it would be from the start.

This happens over and over. My great friend who I walk with each week has an endocrine condition which isn’t the easiest to treat in this context. The lady at the front desk has hard-to-control diabetes, but lifestyle advice results in low sugars and medications result in side effects. One of my dear friends has a lapse of terrible back pain but I feel uncomfortable giving her stronger medications due to the other meds she is taking.

I’ll admit it, I want to be the one who heals, I want to be the one who saves. When I end an encounter and I don’t feel like I have reached the outcome I wanted for a patient, or especially for someone I’ve grown to care for, it’s difficult. I know all the right words and theories, but I carry the pressure on my shoulders nonetheless. I know that’s not sustainable, I know that is how doctors and missionaries burn out. And I think it’s healthy for me that I’m not in the hospital every day these days, it gives me a chance to let go and let my capable colleagues take over. It’s not always easy to realize that I don’t have control and that I can’t direct most medical outcomes, but it’s a good discipline to remind myself and others.

Pressure

The patient had a 5:30 appointment, later than I usually like to book, but was brought in at 1:30 by a colleague who used to work with me at ABC. He came with a stack of blood tests. The kidney function was most concerning, showing that his kidneys had 26% function remaining, or stage 4 kidney disease. When I plugged the patient’s information into my kidney function calculator app, the clinical recommendation was “prepare for transplant.” Of course, there are no transplant services in Malawi. We only have dialysis available for a handful of people out of thousands who would qualify for the service in America. I wanted a few minutes, letting the patient rest in a chair, before checking his blood pressure. It was about double normal, a whopping 200/120. We call that hypertensive urgency, a pressure so high that it will cause a problem sometime, if it isn’t leading to heart attack, stroke, or end organ damage already. It wasn’t clear whether the high blood pressure was causing the kidney damage (which would mean hypertensive emergency) or if chronic poor kidney function was causing the high blood pressure, but something had to be done quickly.

The trouble is, we have a very limited number of medications available in Malawi, and even in the capital city, most of the medications available can injure kidneys further. It was easy for me to stop the diabetic medication which caused kidney damage, a bit harder to optimize blood pressure medications as the patient didn’t have a record of the medications he had been taking. We don’t have the fancy injectable medications that can be used to quickly lower medications in the US, and frankly, I’m not sure his kidneys could handle them even if we did. People with low kidney function are very sensitive; a couple weeks ago I was caring for a patient with kidneys even lower functioning than this gentleman, and when he was injected a very small amount of insulin, it dropped his sugars from 400 to 60 and would have gone low enough to knock him unconscious if we hadn’t hooked him up to a bag of glucose then. So I gave quite a bit of counseling, about diet, about medications, about how soon to expect a change, about when to come back. And we prayed together. I prayed that the medications would work and that his kidneys would miraculously improve and that he would be able to get his sugars under control. We discussed a time to meet again, and I sent him off.

I would have liked to have more time to monitor him, to watch his pressure come down, to know that he would follow up at a certain time. But I was frantically busy that day, trying to squeeze people in before the holiday, and I didn’t have the full one-hour appointments that I preferred for new patients. I had to trust my colleague, who ushered him out of the office, explaining things as he went. Only time will tell if this patient’s kidneys will improve. I am confident that the right medications and habits will help his blood pressure and sugars come down, since I’ve seen several patients with numbers and kidneys worse than his improve with the right medication and drastic lifestyle change. But whether therapeutics can help his blood pressure before he gets a stroke or a heart attack remains to be seen.

Two days later, communication with my colleague showed that the gentleman had stopped drinking, confirmed the medication that he had been taking before, and gave me a chance to advise about adding back one of the medications at ta twice-daily dosing if his blood pressures were at a certain range. And I learned that the patient had stopped drinking, whereas he was drinking a destructive amount before. So whether or not his kidneys will bounce back, whether or not we can control his chronic diseases, at least this individual is taking steps towards healing and hope.