Heresy and Hearsay, October Update

Greg was trying to help his students understand the Trinity and the Incarnation in Systematic Theology class last week. Unlike most classes in Malawi, he facilitates discussion in a seminar-style format and tries to keep everyone talking. “What happens to God when Jesus, who is fully man and fully God, dies?” He asked them. “It was a fake death.” one student offered. “That’s a great answer,” Greg replied, “But that’s not what Christians believe. Saying that it was a fake death would be a heresy, probably under the umbrella of Docetism (They say that Jesus did not have a real human body). Great job in getting to that conclusion!” The class laughed at being congratulated in coming up with its second heresy of the day. Greg continued, “It’s great because you are taking the problem seriously and trying to think about it, and just by doing that you got yourself to one of the firmly-held positions that the Church had to fight against.” Throughout the class, the students brought up a variety of issues that the Christian Church has struggled with for hundreds of years, and they were able to sort through some understandings and misunderstandings, while still arriving at the conclusion that the Trinity is a true mystery of the faith. At the end of the class, like every Tuesday, Greg takes a couple of his students out to lunch, exploring their questions and discussing their career plans more in-depth - whether they are planning to become pastors or pursuing education or employment somewhere else after graduation. We’ve also found ourselves having meals and tea with students at Nkhoma University. More often than not, we end up discussing ideas of prosperity. So many pastors in Malawi emphasize the blessings promised to Abraham – descendants, land, wealth – and preach those as a Christians’ inheritances. Greg and I try to challenge these young people to consider other types of prosperity, and the possibility that following God in this life might not lead to material blessings. It’s not a popular message, but an important one as we are serving in a low income country. And just last week, Greg started facilitating a Bible Study for long-term volunteers at Nkhoma. He’s leading the group through Mark, as he has done for a number of groups before, but this time it is fun to view stories of Jesus’ healing through the eyes of missionary doctors, and to talk about Jesus’ purpose among people who are trying to live out their callings through employment in foreign contexts.

Although we haven’t even been in Malawi two months, it feels like we have grown, adapted, and achieved so much. In Nkhoma’s Blood pressure clinic, for example, we’ve seen a doubling in the number of patients who have their blood pressure under control. Greg has arranged building a fence for the dogs, a gate for the house, shelves for the kitchen, and a screen to keep mosquitos off our porch. Political demonstrations continue, threatening business and safety about every two weeks. And patients continue to die on the medical ward every week – sometimes every day. Nkhoma Hospital has lost more than half its providers in the past 2 months, and in 3 weeks, my fellow Family Medicine consultant Catherine will be returning to the states for 4 months.

A Day at Nkhoma Mission Hospital

(so many people ask “what’s an average day like? Do they really want to know?)

6:00 Wake up (actually, I woke up at 5:00, that was a good day, it’s been closer to 4:00 or 4:30 lately; but this time I stayed in bed until 6. I was going to get as much rest as I could!)

7:30 Bible study; Breakfast of oats, granola, mac nuts, coconut; cup of tea (I tell Greg we need to get more creative about things to do together. Life these days seems so monotonous, so draining)

7:00 Handover (I wanted to shrink away when they asked about a medical patient I didn’t know. Lately I’ve just been checking in and consulting about the patients the clinicians ask me about. But the group seems to hold me responsible for knowing everyone on the ward. Embarrassing) Instead of teaching about medical topics after handover today, the chaplain talked about pain and suffering, using Job and the teachings from Jesus. I thought that was nice. The community is still recovering from the death of so many children and adults in the accident last week.

8:00 – 12:30 Seeing Patients in the Medical Ward and Outpatient, with multi-purpose tea break at 10:00-10:30 (Okay, so first I had to corral the four medical students so they could do their observed consults with Dr. Miriam who drove up from Lilongwe. Then I popped into general medical ward but didn’t have time to help because I was called to private ward to see some VIP patients. Sent one home, one is getting better. My resident didn’t come to work today which made my job of discharging the first patient difficult. And I wasn’t able to teach him that he shouldn’t give two of those medications in someone over 60. Next time? I stopped in my office to grab my things - and drink 2 cups of tea, and pray - when the charge nurse came by to tell me that the accreditation committee was here and wanted to review our charts and death audits, had to break into Amos’s office to use his copies since we couldn’t find the others. I was heading back to the general ward when I got a call from outpatient to see a patient – his blood pressure was improved but gout was worse and sugars were worse, probably because he didn’t like taking his medication. I was just about finished with him when my clinical officer intern came in to tell me about a patient who was really sick on the medical ward. It sounded bad so I wrapped things up and went to see him He had swelling – fluid everywhere in his body except where it was supposed to be – in his blood and his bladder. What could we do? Maybe the surgical team could tap into his bladder and get fluid out? No such luck. They said it was a medical problem. Darnit. Next patient had terrible meningitis, wasn’t getting better after a week of our strongest medication. He looked close to death. I had to check with the HIV specialist around here to see what we could do next. Turns out steroids and stopping the HIV meds for now. Who knew? Had to tell the family that they shouldn’t take him home just yet. Give us an other day. Then another patient walked in with hepatitis, we weren’t sure why, My resident ordered the tests but he wasn’t around. Called him, he was supposed to be back by now. He called me right then to tell me he would be another few hours. I had to hang up on him because they rolled a patient in who had stopped breathing, no pulse. We did CPR for 10 minutes, but she never came back. Greg texted me, asking when I was ready for lunch. “when I stop CPR and pronounce this woman dead” I texted him back. That woman had a fight with her husband and then poisoned herself. I couldn’t think of anything else to do for her. I had to tell the family that we had tried but things weren’t looking good. Then I pronounced her dead 30 mins after she arrived at our facility, 15 mins after she was on our ward.

12:30-1:30 Lunch with Greg – The private restaurant on Nkhoma hospital campus is keeping us alive. $1.50 for a plate of rice, veggies, and today, crispy BBQ chicken. (today was really nice because Greg was visiting with 3 pastors, and we talked about the Bible and about healthy eating, the amount of sugar in their staple food nsima. Only later did I realize that two of the pastors were high-up in the CCAP, which runs our hospital. As they were leaving, I joked that they should of told me sooner, that I would have told them they could eat anything they liked. After saying goodbye to Greg, I wanted to go to my office and reflect until starting again at 2:00, but I was intercepted by a nurse. He had borrowed $15 from us last month, and I told him he was free to keep it and not worry about repaying, but if he wanted to borrow from us again we might not be able to help him next time if he didn’t repay this time. That led to a 15 minute discussion about his business idea which he might be asking us to help with. It sounded like a good idea, but I told him, if he wanted another loan, he probably should repay the first beforehand.

2:00-5:00 Patient care and Quality Assurance (actually we spent the first half-hour reviewing the death before lunch and talking about what we could have done differently. I didn’t realize that she was agitated when she arrived and received a sedative in our outpatient department. What if that was what tipped her over the edge? Should I have given epinepherine when we were doing the resuscitation? I’ve never given those meds without watching the heart rhythm first. Maybe I should have just gone for it. Was it my fault she died? Was it the one who dosed the sedative? Could this have been prevented? These death audits are always such fun. But out team is pretty awesome and we got through it. Then I went with my students and interns and saw some more patients. Swollen bodies, scarred lungs, possible tuberculosis, so many who weren’t getting better and I’m not sure what I could do to help. Well, the guy with the swollen joints was getting better at least. The new clinician came to me with a question about a patient, that was great, she usually doesn’t ask me. Chest pain for a month. I thought it was from acid reflux, but WOW – that ECG sure looks like a massive heart attack. Do we have a protocol for that? Sure we do, but we don’t have the medications or the testing listed in the protocol. Sigh. Time to cut a nitroglycerine tablet into quarters and dissolve it under a patient’s tongue – will it fall out because she doesn’t have teeth? Then I have to check in on the private patient again. I have a medication that could help him, but his blood pressure is lower now, is it still safe? Stop back in at the general ward, need to make sure that patient with a heart attack is doing OK.

4:50 Go Home (Actually, I’m supposed to finish my day at 4, but it’s rarely I’m home before 5:00. I am still working on boundaries. But at least I’m using discipline and not working from home as much. Whatever I don’t finish in my office, doesn’t happen. That was even true for today, I had two patients I saw yesterday who need recommendations on starting and switching their anxiety/depression medications. I resisted the urge to send them an e-mail, I knew they would be gracious waiting another day or two.

5:00 – walk dogs (actually even though we walk most days, today Greg and I decided not to do much of anything. We rested on the couch, listening to book on tape and playing puzzle games on our devices. I didn’t even get 5,000 steps, but that is okay on days like today.)

6:00 – dinner – we had leftovers from my visit to a patient’s house yesterday. It was part house visit, part social visit, and her cooking was delicious. (any day I don’t have to cook is a win. It was a great end to rough day)

9:30 – bedtime – (power had gone out yesterday and water ran out at 7:00, so after spending the evening trying to save every drop and fill up our drinking water, we figured out how to switch to our tank. Then we went to bed. What more was there to do? Glad tomorrow was a planned day off)

Trauma

Marlene came running down the hall, tears in her eyes. “There was a traffic accident, children are dying, some are already dead.” My first thought was that there was nothing I could do to help. I wanted to run the other way. But at least I wouldn’t go alone. I knocked on Amos’s my residents’ door, and called to Allison the pediatrician. She and I both looked at each other – “this isn’t my area” I said, she agreed. It wasn’t hers either. What could we do?

There were bloody bodies everywhere. Sliced faces being sutured in the hallway. A man had a towel over his eyes, I think he lost at least one of them. Fractures with bones sticking out. Mothers wailing in the hallway. Four children were already dead – a truck crashed into a minibus filled with school children. Some looked stable, but you never know. One man, laying on the concrete, was alert but his extremities were cold. His blood pressure was low and his heartrate was muffled. Oxygen wasn’t getting to his body. He had an internal bleed somewhere, but our ultrasound wasn’t working, so we didn’t know where. We didn’t have any surgeons who could operate then, so we dripped a couple liters of fluid into his veins. We crammed him in an ambulance with 4 others, not sure which would make it to Central hospital alive. As he was waiting, I dragged in the chaplain. “He has minutes or maybe hours. Please pray for him.” Olivia, an American nurse had just arrived yesterday. She didn’t want to be in the way, but didn’t know how to help. “Just pray” I said. I felt like that was about all I could do as well.

They told me a patient in the far room was stable. But his blood pressure was low, his oxygen was low – on closer exam we found he had a rupture in his lungs, or maybe his internal organs, but the air was getting where it wasn’t supposed to be, and not getting oxygen to his body. He should have been prioritized in the first ambulance, now what chance did he have? I grabbed the chaplain again. The patient was still alert, how much time did he have?

I watched as mothers came in to view the bodies of their children. They wailed and fell to the ground. I watched as ambulances loaded up to go to the hospital. I heard of mothers searching for their children afterward. Were they among the dead, or the ones transferred?

Trauma is hard. Mass casualty is hard. Triage is hard. Our team was amazing, looking for the sickest, not wasting time, providing the care we could, referring early. But it takes a toll on you. After searching the morgue and calling families in Central Hospital and finally finding a child for her parents, Catherine went home and hugged her girls. Then she had to explain to her youngest that four of her classmates were dead. Within a couple hours, it was five. Amos needed time locked in his office afterward. He seemed okay, but later texted me that he was not. Marlene has seen a lot of things in her 3 months here, nothing like this. It makes me think of how easy it would be to insulate myself from it, to live in a place where I wasn’t surrounded by hurt and limited resources, poverty and pain.

But this is where I am called. Sometimes I can help during a crisis. Sometimes I can help pick up the pieces. Sometimes I can do nothing, and there is an important time for that, too. “Each one’s work will become clear; for the day will declare it, because it will be revealed by fire; and the fire will test each one’s work, of what sort it is.” – 1 Corinthians 3:13