Futility of Care and Fatalism

IFMF from Websmitten on Vimeo.

The above video/slideshow was made by our friend KC Morris, the lovely wife of one of our Via Christi Family Medicine Residency colleagues. I hope you like it. Frankly, the first few photos look cool, but I haven't been able to watch the whole thing.

In other news, we were on call last night. Just as I was settling down for what was sure to be an easy call night, compared to those residency call nights of old, John knocked softly at our door. He'd gone in to check on a new admission in male ward. This 35 year old patient had been panning for gold in a mine shaft, had an accident, and had a cut on his ear. He'd transferred himself to our hospital after sitting at another local hospital all day long. I thought to myself "weak admit" as I answered john's knock. I guess I had forgotten that we just don't get as many "worried well" around here as we do back home. Like, nobody shows up at 3 AM with a rash, you know? So, it turns out that this man had fallen down a mine shaft or that the mine had otherwise collapsed on him. We went in, headlamp and flashlights in hand, to check in on the man's wounds in the light of the operating room. The power had been off since early in the morning and it was now around 11 PM.

As we walked towards the dark ward where the man lay silently in agony, we passed by soft glow of candles and soft chatter of the female ward. With great effort, we wheeled the man up to the Theater (O.R.). By the light of our flashlights, and the back up lights we examined the man. His right ear, nearly severed, hung somehow to his head. His eyes were wide in desperation as his chest heaved up and down abnormally with each breath. Both of his lungs sounded terrible. given the fact that the level of oxygen in his blood was very low (02 sat 5o%) and we had no access to a radiology tech or electricity by which to take the chest x ray, we decided to take action. His lungs sounds were markedly abnormal and he seemed to even have air trapped under the skin of his neck. We, with some searching by the light of our flashlights, found two chest tubes and the necessary equipment to make them work. I inserted the first chest tube and with a WHOOSH, a huge amount of air that had been trapped in his right chest escaped. His blood oxygen levels improved, but not to our satisfaction. As John inserted a second chest tube on the other side, a copious amount of blood escaped from the man's chest. With some supplemental oxygen, the man began to speak and felt relatively good. Without power, however, the oxygen machines in the wards simply don't work. Even so, the patient seemed stable. He was even able to converse with us a little as we told him about God, man's brokenness and imperfection, and inability to be with God in that state of imperfection. He said he did not know God, all of this was fresh to his ears. We talked about how we deserve, because of our imperfections to be apart from God forever. But, because of God's great love for that man, God sent his son Jesus to receive the punishment that we deserve for our actions that are against God's laws. I told the man that Jesus says if we ask him to forgive us for our wrong doing, that if the man would just open the door of his heart, and receive Him, that God himself would make His home in the man's heart. Furthermore, that with Christ in the man's heart, God would no longer even see the man's wrongdoing, but only the perfection of Jesus, God's own son.

Here's some nice reference verses. I'm not making this stuff up:

Rev 3:20

"Here I am! I stand at the door and knock. If anyone hears my voice and opens the door, I will come in and eat with him, and he with me."

1 John 1:9

"If we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness. "

Psalm 103:12

"He has removed our sins as far from us
as the east is from the west."

At this point in the conversation, the man was awake, alert, and Chest Tubes functioning well, engaged in the conversation.

Satisfied with our teamwork and happy with our patients condition, we walked home under starry skies. The belt of orion, the southern cross, and a brilliant moon lit the way as we went through what is basically a play by play review of what we did right, wrong, and what we'd do next time. This fellowship has been an immensely good tool for team building and for allowing like minded people to sharpen each other for service to the poor in these settings.

Several hours later I was awakened by a knock at my window. The bundled up security guard (they do this here when its in the low 70's even) brought me the dreaded news that our guy wasn't doing so well. Now 4 AM, I walked into male ward. By candle light, I could see that our patient was declining rapidly. With much duress, nurses went to collect equipment to monitor oxygen saturation in the blood, a bag to assist the patient in breathing, and oxygen. The tank of oxygen did not work correctly, and no on knew how to make it do so. The power was dead, so the oxygen machines were still of no help. Finally, a nurse showed up with the kind of portable oxygen machine that old smokers drag around casinos while playing slot machines. It had a little battery life left on it, so we quickly but it to use in conjunction with my bagging efforts. Still the blood oxygen registered dangerously low (50-60). He'd been like this for hours, but now the patient was listless, I was told in a flat tone by the nurse on duty. As I bagged and bagged and tried to fix the oxygen tank, a bat flew around the dimly lit ward over my head for several minutes. A large frog hopped between the beds. A different man died a few beds over. These things combined with the cries of old mental patient in the corner made for the strangest candle lit quasi code blue I've ever taken part in by myself. For an hour I pushed air into his bruised and bloodied lungs. Despite my efforts and the old-smoker-goes-to-Vegas oxygen setup, the blood oxygen levels did not rise and I deemed treatment futile. I gave the man a low dose of Morphine to keep him comfortable (but not too much), prayed silently and went home, the man still thrashing and gasping. With no power, no ventilator, and so many catastrophic injuries, designating this "futility of care" seemed appropriate. This was among the most helpless times I have experienced as a physician to date.

This morning, I walked down to his bed, fully expecting him to have passed away during the night. I was wrong. He continued to lay there, thrashing about, his oxygen now even lower- the battery on the oxygen machine now dead. I was unable to help him, despite drawing fluid from around the heart with a needle. I intubated him, but without any power for suction, his throat had filled with blood and I had no way to remove it. It was at that time that the full extent of his jaw and rib fractures became more apparent. Shortly thereafter, he died in our arms.

I was kind of in a funk today over this whole thing. One thing that people struggle with around here is the idea of fatalism. "What will be will be, so why try to intervene." Maybe that's why nobody called me for three hours after the guy had already had severely low oxygen levels. Because he was going to die, and they knew it. No sense in fighting it, right? So, I ask myself, why was I up all night with this guy? What is it in me that makes me pull out all the stops for a dying man? I mean, I certainly felt like those hours of care could have been but to more pleasurable use (i.e. sleep) if the he was just going to die anyhow. And how far can you extrapolate this idea of fatalism? Why lift a finger to care for anyone? Why intervene in any disease process, especially when survival may mean severe disability? This is especially enticing when the people we are caring for smell badly, are different than us, or even have been overtly mean people.

The reason, as it became clear to me this moring, is because:

1. People are made in God's image and have inherent value. The way we treat them directly reflects our feelings towards God and His worth.

2. Our actions go on forever, and ultimately we are responsible for them. This man is, as is everyone else, a human with a soul. I firmly believe that his existence did not stop this morning. I do not know what impact our conversation during the man's lucid interval had, but I don't believe in meaningless circumstances. It is the highest honor to care for a man in his last moments and to hold out hope for him.

3. Because this is how God is with us. Constantly in denial of His person, his greatness, even his existence, or constantly impressed with ourselves and our spiritual rightness, we are offensive to God. But, he continues to hold out hope for us. Patiently bearing with our futile case, which in a matter of a few years will be over, he works on us- attempting over and over again to rescue us from our self destructive tendencies and restore us to Himself- that is to a state of total and real health. All this, because he loves us.

A Restful Sunday

Abbi closely examining her new friend, Froggy.
Enjoying some sidewalk chalk with Dad

I'm laying here in bed, the electricity having just turned on. Our fans are abuzz and a cool breeze now runs through the room as April naps and I lay here typing. I feel a little bad, skipping out on the church service- the songs of which, we can hear through the window of our room. Abbi got grouchy and went down for a nap about 10, which happens to be when church starts. This became a really convenient excuse not to go, which i didn't really mind, as the service is 2 hours long and is in Shona for the most part. The people are great. and things singing/dancing in worship is great, but hey, my kid is sleeping and my Shona is worse than bad. Instead, i read through a sermon by Matt Chandler. The ones I've been going through lately include

Games People Play (Part 1)Luke (Part 43)Matt Chandler

Games People Play (Part 2)Luke (Part 44)Matt Chandler
Games People Play (Part 3)Luke (Part 45)Matt Chandler

These three sermons are the last three done on a 2 year long series on Luke. I thought these were phenomenal. The green icon above is the mp3, the red is a written format, and the SG is a study guide.

The whole series can be found here:

http://hv.thevillagechurch.net/sermons?kw=luke&type=sermons&match=any

I find Chadler's practical application of scripture, sense of humor, and general mocking attitude towards the prevailing religious silliness of the bible belt to be really great. The Truth of scripture, as presented by these sermons, has cut right through me and changed me at a deep and real level. I recommend them to anyone who hungers for depth and truth in their life, especially those disillusioned by religious hobbyists and religion in general.

April and some of her friends at Kid's Club

We're on call this weekend. So far we've only had two C sections. One of them was yet another transfer from the local district hospital. We've come to refer to this as "the Mount Darwin special." We get lots and lots of transfers from District and even Central hospitals here. It's definitely a commentary on the state of the medical system in Zim. We've also had a bunch of random admissions. It gets a little tricky around here because, oh, 50% or so of the time I'm definitely in "never seen this before" territory, but I guess that's one reason why we're here. Additionally, there's no lab when the power's down, no x ray on weekends, etc. So, we just have to get a little creative sometimes.

I'd write more, but John and Shea have just announced to us that they are babysitting Abbi and that I have a hiking/picnic date with my lovely bride. Gotta go...

Date Night!

It's difficult around here to find time for dates. And if you did have time, there is really no where to go. So, John and Shea informed us on Sunday night that we were having a date! They made us dinner, set up a nice movie "theater", and John even acted as our own personal waiter!

Today was a relatively light day. After rounds and an early morning C section, we all went for a quick run before clinic began. Yes, even Abbi went with us. We picked up a BOB jog stroller a few months before we came. Even though it was sturdy, we just thought we'd never use it. Wrong. The thing is built like a tank and we use it daily- it takes the abuses of rocks and trail ruts in the African bush with flying colors- and allows Abbi to run with us. We enjoy running several miles every day that we can. It is a great family time together!

Following a fairly uneventful clinic time, I was walking by the pediatric ward. April, Abbi, and our friend Nicci happened to be there handing out stickers and candy to the kids. I had brought Eric Carle's "From Head to Toe " for such an occasion.

With our friend Miriam translating, I read the book to the kids. They didn't know what to think. I think they enjoyed it, though. I know if I had my leg in traction for three weeks (as four of these kids do) I'd enjoy any form of diversion.

Tomorrow is "Theater Day," which is Zim speak (AKA British) for "a big day in the operating room." Tomorrow we'll be doing

-exploratory laprotomy

-Hysterectomy

-Open Reduction Internal Fixation Radius

- Prostatectomy

-z plasty wound revision

hmmm...There's probably double that number of items, but you get the idea.

here are a couple of the kids we operated on today. The fist is the worst case of hydrocephalus I've ever seen. The head measured 72 cm around. This is maybe 20 cm bigger than any of the other kids I've seen. Unfortunately, this child will likely suffer profound disability because of the delay in surgical treatment. He's six months old and the hospital in the capital city has apparently put him off for about that long. Very sad. See the kiddo in the second picture to see how these kids usually present to us...pretty normal, except the crying and all. I guess white people are just a little scary for the little ones. The third is a strange neck mass on a 10 year old little girl. She's a cute kid and her neck looks good as new now. Forgive me for the blurry photos, I just like to try not to use a flash when I'm photographing patients. I figure I'm a little less intrusive that way.

Luke 18:15

^"15People were also bringing babies to Jesus to have him touch them. When the disciples saw this, they rebuked them. ¹⁶But Jesus called the children to him and said, "Let the little children come to me, and do not hinder them, for the kingdom of God belongs to such as these. ¹⁷I tell you the truth, anyone who will not receive the kingdom of God like a little child will never enter it."

I've been running the pediatrics ward here lately, so this passage took on new meaning. If you get swamped with people when handing out stickers, just think how ear splitting the situation must have been when the Son of God showed up to hold and love the kiddos. I bet he was just inundated by loud requests from all the moms. I have more appreciation for his patience and love for these little ones, now. Especially now that I am in a culture that does not particularly value children, much like the culture in Jesus' time.

It's hard to believe that our time here is nearly halfway over. For me, that creates a sense of urgency to learn as much as I can while we're still here- that is to learn as a husband, father, friend, and physician.

We're having a lot of rich time here as a family. April is really appreciating being able to spend so much time with Abbi. She is an excellent mother and finds the time at home, which this year affords her, both exhausting and invaluable. April has been cooking "sadza" recently. The local staple food, which is basically a corn meal and water mush about the consistency of dense mashed potatoes isn't much to look at. But, it goes down nicely with the various traditional local sauces April makes to accompany the stuff. Abbi keeps us laughing, she's so great. The other day she was touching our fruit basket which she knows she is not suppose to do. April looked at her and said, "Abbi, now what is our rule." She quickly responded, "Abbi don't eat playdough!" Funny kid. She's been working on potty training recently. She has been taking to it pretty well, except that she recently developed a phobia of the birds that chirp outside our bathroom window. So, she's kind of afraid of the toilet and the birds that might get her these days. She must think that they are right behind her or something.

April and Abbi are really blossoming here, especially in their relationship with the Zimbabweans. The two of them attend "Kids Club" 3 times a week. It's a "club" for kids whose parents have died of HIV. some of them walk greater than 5 miles each way in order to come and get food, medicine, and hugs from April and the others involved in the ministry. All of them are destitute. We have been really falling in love with these kiddos. The other day we had 2 kids that were sick - Praise and Wilma. These two orphans are some that just break your heart. Praise was crying the entire time, and I found out that his ear had been hurting, so I took him down to the hospital to be examined. He laid his head on April's chest and just held on like it was the only affection he would get for a long time. His mother died 3 years ago from HIV. Wilma is another one of the HIV orphans who walks to kids' club barefoot with her 4 year old little brother, Tino over 5 miles of rough terrain. These two never show any emotion and I've never seen them smile. It really makes one wonder what is going on in their "foster" home- there's just no safety net for at risk kids around here. Wilma had a wound on her big toe, so I took her down to the OR a drained it. We would have just kept the two in the hospital, but pediatrics ward was so full, that two patients were sleeping on the floor. So, we decided to fire up the Land Cruiser and drive the children home. We couldn't just drive 2 of the children home, so April ended up with 7 of the kids club kids sitting in our living room while I worked on the little girl's toe at the hospital. I guess the kids just looked like deer in headlights when they walked into the guest house where we live- they froze and just looked around amazed. Many of them just stared at the moving ceiling fan like they didn't know what to think! The kids all crowded onto the couches and had pink lemonade and each one got a gummy vitamin. It was a good moment for all of us!

We all piled into the big blue land cruiser and bounced over the rain-worn dirt roads singing childhood hits such as "Jesus Loves Me" and "Jesus Loves the Little Children." I got pretty choked up singing with those kids. Yes, Jesus does love them, but with both their mother and father dead, they are truly vulnerable kids with very few adults to protect and love them in this world. While we drove the children home they would yell out the window at people they saw that they knew - they felt like rock stars, I'm sure! As we sang "Jesus Loves Me" over and over as they would say "again, again." This is a sweet memory that will be forever stamped into our memories. We drove over the dirt roads and continued on and on like what seemed like forever - I thought at one time they were just taking us on a joy ride! But they kept saying "let's go" and pointing ahead. All the time in the car I just kept picturing little Wilma and 4 year old Tino making this trip barefoot and Wilma with an infected toe, 3 days a week, just to make it to kid's club for a meal and an hour of fellowship. It took us almost 1 hour round trip driving to get to their home and back. Tino weighs a lot less than Abbi and does not look well.

I just returned from the most challenging C section I've done here. A woman who was in labor for 2 days or more showed up. Her uterus had ruptured and we had a bear of her time putting her back together. Her baby did not do so well. We have been given more and more freedoms both in the wards and in the operating room as our time here as progressed and feel very good about our educational experience here.

We humbly ask that you pray for us in regards to the following items

1. Saftey and health for the kids

2. That we would come to know and love the Zimbabweans we are serving

3. That the gospel would advance through our work here

4. For strength in our marriage

5. For wisdom in parenting Abigail

Abbi loves coffee! She is a McQuillen for sure!

Wrestling with dad.

rounding on the peds ward with Abbi. April and Abbi love coming around and handing out stickers to the kids and then heading to Maternity Ward to see the babies.

Abbi lookin' spiffy in her rain boots and pig tails.

Nope. She's not pregnant with quintuplets. I removed 22 liters of fluid from this woman's abdomen.