Kinshasa Highlights

After our wonderful weeks in Vanga, it was difficult to return to a complex, crowded, traffic-congested city. But we have had some very beneficial and meaningful experiences here. This is what we have been up to- the highlights.

Monday we worked at the Compassion Clinic in a very poor neighborhood in Kinshasa. Someone quoted ~80% of Kinshasa functions as a village within the city. Certainly, walking along the road with the graywater running along the side as children play there, looking down over the immense Congo River and realizing there are "houses" crammed along the edge, or realizing a drainage ditch is a large village market makes me realize that most of Kinshasa is not like the Art Market or the downtown avenue with stoplights and wealthy residents. The clinic was started in conjunction with New City Fellowship (in St. Louis). There is a small church on the same property, and this church definitely has an outreach to the orphans in the area. Each church we visited took orphans into their own homes or cared for them in some way. The nurses at Compassion Clinic seem like they are doing a good job for the most part. Our role while we were there was to supervise the clinic process and do some minor education of the nurses and give suggestions. Of all the conversations or patient encounters we had this week, we realized that one of the most important was with our interpreter while we worked. Briefly, it was a very meaningful conversation regarding eternity, and the good news that Jesus does not ask for more "religion," but He loves us as we are and wants a real relationship; He does not care as much about the rules as He cares about our heart. The actions necessarily follow in response, not vice versa.

Yesterday and today, we taught in one of the medical schools. Fortunately, they all speak some English, so we were able to have meaningful presentations and dialogs with the students. We had lectures and practical hands-on teaching about proper presentations, complete physical examination, labor and delivery, ob and gyn emergencies, and differentiating between rheumatoid and osteoarthritis. Paul did an excellent job as my pregnant patient, and I acted out various neurological disorders for Paul. Tim was the master at the opthalmoscope. Our hope is that our small contribution will help them to become better physicians for the future of Congo. This medical school is the same that is in charge of the residency program we were involved with in Vanga, so there is continuity of relationship. The Dean of the medical school is very active and has good vision of the future. They will graduate their first medical school class next year I believe.

We walked through part of Kinshasa to find a place to eat several days this week. Yesterday, we (as in Tim) decided to be adventurous and try to find a shortcut back. It was getting dark quickly, but we felt we had one shot to make it. Otherwise, we could go by the main road which, although full of diesel fumes, is also better lit. We turned down a side road, and another, and another, and finally came to a dead end... we thought. There was a wall to our left, a wall in front, and a large gully with village housing to our right. But there was a sentinel at the gate in front of us who pointed us down into the front yard of the village house. In short, we went through several "front yards" with children playing, down a very steep drop, over a wall, across a small stream, turned right, went past the tent someone was living in under a tree, took a sharp left and went straight up the other side, then through a few fields and finally over a (large) wall to get back to the road in front of our hostel. On second thought, guess that wasn't so short... my description nor our journey. At any rate, it was good to see once again, the village within the metro area which is Kinshasa.

We visited the oldest functioning church in Kinshasa. It was sobering to see the grave site of a 38 yr old missionary who died after only 3 yrs in Congo. Perhaps it was malaria or a snake bite. Whatever the reason, this underscores the major differences between the older generation and ours. They came to Congo prepared to die. We come for 4 weeks (some years), but most of us can retain contact with loved ones and return to our home country to die.

We connected with several other ex-pats here in Kinshasa. The American School of Kinshasa (TASOK)  is literally across the street from our hostel. Saturday afternoon we were able to play softball with several Canadians/Americans who work for MAF (Missionary Aviation Fellowship- our pilots!) and Korean and Congolese. It was a grand time, even if Tim's team did win. We walked through the campus of TASOK which is quite large and has the largest portion of rain forest left in Kinshasa. 50 foot bamboo, a thick thick forest, canopy trees over 100 feet tall, mango trees, papaya and avocado: it was beautiful.

Our week in Kinshasa is coming to a close, as is our time in Congo. We leave tomorrow evening on our long journey home to waiting spouses and families. I think it is safe to say that we are all anxious to be reunited with our families but are immensely grateful to God for the experiences we have had here in Congo.

Escargot Without a House

Sometimes, a language/cultural barrier can be quite hilarious. Over the past 3-4 weeks, we have worked with people whose mother tongue is: German, Swiss German, French, Kituba, Lingala, Hindi, and Canadian :) Here are the highlights.

"Escargot without a house." - Swiss Brother who was trying to think of the word "slug"

"So, what does it mean when another guy starts holding your hand?" - Paul, as we walked through a village. We then noticed he was holding hands with our male guide. (It means nothing except friendship here)

"She is walking her feet so they don't get tired from sitting." - Kituba-speaking woman, explaining why we were just going for a walk in the countryside.

"Hello together. Goodbye together." - Swiss lady who took Kituba/Lingala greeting of "Mbote na bano" and directly translated it to English, "Hello to everyone"

"The bladder is taking a voyage away from the uterus." - English translation of how I used the few French words I know to describe why I am making a bladder flap during a cesarean section.

"Change your pants." - The Congolese doctors in the OR telling me to use a different instrument, mixing English with the French word for clamp, which sounds like pance but is spelled pince.

"My God is your God and your God is my God."- song in English and sung by the Congolese about the community. Then continuing with, "my child is your child and your child is my child." And then going overboard by making up a third verse, "my wife is your wife..." Yeah, that one didn't work.

"It has been 2 days since my last Kwilu" - my confession after I had to shower instead of bathe in the river.

"Just a minute, I need to put my shoes AND socks back on." - Oregonian Tim who found it necessary to become BAREFOOT while eating in a nice restaurant here in Kinshasa. He's a missionary kid already!

"Hommes" - prominent sign on the men's outhouse. Saying "my homie" takes on a whole new meaning when it seems you are talking about a men's restroom. It really is pronounced, "ohm," much to my disappointment, and simply means "man" in French.

"Yes, yes." - good natured Congolese Dr. Joseph in answer to an obsurd question like "Are you female?" This would cause peals of laughter in his friends who knew he was faking his English more often than not.

"You are speaking Congolese English" - Congolese OR personnel, when trying to insult their friends. They were talking about the differences between British English and American English when I piped up, joking, and said, "Yes, and you speak Congolese English." They took that and ran with it. So when anyone was having difficulty with their English, they would taunt, "he/she speaks Congolese English," or if really rudimentary, "he/she speaks Vanga English."

"Friedhelm, try English." - our team to poor Dr. Friedhelm, the German Brother, who would oftentimes change from Kituba to German to French when addressing us.  

Post Traumatic Passenger Disorder

Tim wrote about this briefly in his blog, "He drives like my dad," but I would like to reiterate our experiences last Tuesday. This is our story.

Our mission: to visit, observe, teach, and experience [even more] rural health care taking place in Congo.
Our vehicle: a 4 wheel drive 2001 Toyota Landcruiser- quite a survivor considering the conditions.
Our driver: Jamaican Crocodile Dundee- laid back, Dundee hat, aviation sunglasses, arm out the window, chewing on a blade of grass, no fear.
Our passengers: Tim, Paul, myself, Katherine, Dr. Lay (health zone director), Dr. Ji' May (resident), 4 or 5 health zone nurses and an infant- couldn't see well beyond the giant packs of mosquito nets, medications.
Our destination: Kingala, located 80 km away as the health center furthest from Vanga of the 52 centers it services within the health zone.
 
We left early in the morning and stopped by another health zone along the way. We met the 4 staff members which consisted of a nurse, a midwife, a lab tech, and a sentinel/guard/go-fer. They gave us a tour of the clinic, lab space, and surveillance areas within the first building. The second hut was for maternity with an exam table and a small amount of instruments as well as a birthing room/postpartum room. Outside, under a large tree, people were gathered for the start of preschool clinic. There are special days of the week for preschool clinic and for prenatal clinic so it is more organized and people know when to come. As we walked out of the huts and toward the throng of people under the tree, I noticed there were many women dressed in the same material for dresses. All at once, they began chanting and singing, complete with motions. As Katherine interpreted what they were saying, we understood that they were sending health messages out. They sang about the importance of vaccinating your child. (Incidentally enough, they have better vaccination rates than we do in the US! Good for them!) They sang about STDs (would love to have that running though my head). They sang about coming to prenatal clinic for maternity care. It was the highlight of my week to be among these health ambassadors. The nurse had community support from this volunteer development team, and the people were getting a message which was memorable in their oral culture. Preschool clinic began and, like an assembly line, children's names were called, they were weighed (in a sling hung from a scale mounted on a wooden frame under the tree), they were given vaccines, and this was recorded in an orderly fashion. We left with a gift of bananas and joy in our hearts at what an impact this small group of people is doing for their villages/communities.

Then came the road. The dirt road is fairly maintained for a stretch. It is basically sand. When it is dry, it is a bit like driving on 2-3 inches of snow. We were fishtailing and careening down stretches of the road that were dry. When it rains, it erodes quickly into big gullies and potholes.The best part of the road is where it is damp, packed down, and where the ruts cut by the rain are quickly filled by the shovels of the road crew (paid for in sections by the Belgian government, to keep the roads open to export the palm oil). So when we were not careening/fishtailing, we were navigating the gullies. This is where PTPD comes in. See, when I was in Kenya in 2005, we drove in a bamboo rainforest which was uber-muddy! We were packed to the gills just like we were now. In Kenya, we drove careening through the mud and on a steep incline sideways at a 30-40 degree angle and at one point, we actually tipped over against the mud bank on my side! All "100" of us piled out and they pushed the car back upright, or I should say, back on a slant. They then drove the car and we sloshed through the mud until the car was in a more flat spot and we all 100 piled back in. So therein lies my post traumatic passenger disorder. Now, in Congo, when we were driving through the gullies at a 30-40 degree slant, I was slightly paranoid that we would tip on over onto the bank again.I was okay when my side was on the upper part, but when I was on the lower end of the slant, I became nervous. In addition, when I was small, I fell out of an old truck when the door came open when we were driving around a corner. Ever since then, I have been careful to make sure doors are locked when I am tightly squeezed into a vehicle. PTPD again. I was sure to check that the door was locked as we careened and fishtailed.

To finished the story, we made it safely to Kingala in one piece. We had a very productive and informative time there. The chiefs of 5 villages as well as the chief chief with his carved wooden staff were present as Dr. Lay talked to the village people gathered around about the importance of coming for care at the clinic. We then saw 86 patients, 30 for prenatal clinic and 56 for general medicine consultations which were over the level of expertise of the nurse. We ate the local cuisine in the nurse's hut across the road/path from the health center building and played games with the people of the village as the sun went down (this is their time to just hang out, after the work day and before dark). It was a wonderful time.

On the harrowing drive back, it was dark, yet our Jamaican Dundee was as laid back as can be in the rutted, now dark road. It was a perfectly clear night without a cloud in the sky. Tim had a great idea that we should stop and look at the stars. I say that without any sarcasm. It was glorious. We stopped on a patch of road and turned the car and lights off. We tumbled out of the car and walked down the road a bit. There was not an ounce of light pollution. The Milky Way seemed a little too bright! The moon was not out, just the stars. It was amazing to see how well lit the road was just by the light of the stars. Words are just not sufficient to describe the glory of the sky, so perhaps you can just imagine it.

On Being "In Your Element"

My perception of people is radically different when I see them in their element. Identifying “your element” is important in leadership, and when people function in this capacity, they perform the best, and the team as a whole will move forward. Similarly, when you are using the unique gifts God has given to you, that is when you shine and show His glory. Enough of the philosophical… here are the examples.

We have had the opportunity to invite various groups over to our house for dinner. We had dinner with the residents. Two are very outgoing and speak English well. They were very competitive against each other in Qwirkle, while the third sat back and was very quiet. He didn’t seem to understand the game or perhaps he was just not interested. Saturday, the doctors all meet at one house for prayer and breakfast together. Ji may lead the group. He did a fantastic job. His house was clean and table decked with a nice tablecloth and food/coffee/tea. His friends joked that “a man certainly did not set that table.” Nonetheless, he organized it and convinced a lady friend to come fix it up for him. He led a devotion time with a passage from the bible and thoughts on it. I was impressed by his leadership and had a very different impression of him after we left.

We also invited 3 of the Congolese supervising doctors over for dinner. Again, two were outgoing and spoke English well. We have gotten to know Dr. Fina and Dr. Mpoo very well during our time here. But Dr. Lay and his wife were quieter except when they were able to tell the story of how they met and were married. However, we were able to spend a day with Dr. Lay visiting a couple of health centers in the Vanga Health Zone. Boy was he dynamic! We sat underneath a tree with 5 chiefs of surrounding village and the chief chief of them all who was sitting with a carved wooden staff. A group of village people were standing all around us. Dr. Lay then began telling them why he continued to come from far away to supervise this health center. “We care about you. If you do not use the health center or the nurse we provided you, why should I come here? If there are very few people coming for visits, why should I bring more mosquito nets or more aspirin? But if you use this health center, you can be well and your wives will have a better chance at a good birth by going to prenatal clinic and your children will live because they get vaccines and information about nutrition.” Rough translation. But all around him, the village people and the chiefs were nodding their heads in agreement. One asked, “When will you fix up our health center?” (the building is not in the best condition, made of local materials but with a rusted roof and some of the walls are leaning a bit). Dr. Lay turned to them and said, “This is YOUR health center. If you want to have a new building, you should build it! Have each family bring 2 bricks and you would have enough material for the walls.” Brilliant! What makes Dr. Lay so effective is that he was a nurse in the health center prior to becoming a doctor and then taking over the job of oversight of the Zone. So he knows what the nurses are going through. He knows the frustrations they probably have when people don’t come for prenatal clinic or preschool clinic for vaccines.

The third example is just of my perceptions of missionary kids (MK) when I was growing up. I looked at the children who came with their parents on furlough and saw them as shy and somewhat awkward. Then, in college there were many MKs and some were quite different… running around everywhere without shoes, etc. But when I have been on the mission field, what a difference it makes to see them in their element! They speak multiple languages, run around with the village kids in bare feet, and have a more expanded worldview than most. 

For me, I certainly don't shine when the conversation revolves around popular music or "name that artist." I have an appreciation for music but don't pay attention to the artists. But when I have been working in Congo, I feel like I am in my element. I enjoy my work, laugh with my coworkers, love to teach, enjoy bathing in the river, etc. Speaking of which, the Kwilu is calling my name.

From Scarlet Fever to Pott's Disease- Paul Tuttle

Working in an inner city academic hospital for the last three years has exposed me to many very sick patients.  However, working in Congo with the significant malnutrition, lack of routine medical care, extreme poverty, and existence of tropical diseases has given the term “pathology” a whole new meaning.  I have felt more enlarged spleens and livers here in one day then in the last year at Saint Louis University.  

A few days ago we saw a child who complained of a sore throat for the last few weeks.  She had been seen in an outlying community health center and only took a few days of amoxicillin due to a rash that started after the initiation of amoxicillin.  She still complained of a sore throat and had a faint rough nonerythematous rash on her trunk with a few areas of desquamation.  We were suspicious for scarlet fever from what sounded like an inadequately treated strep throat and told the patient to return the next day after starting a course of erythromycin.  The next day she had significant desquamation of her distal extremities as well as her axillary and inguinal folds that was accompanied with a “strawberry” tongue.  This was a textbook presentation of scarlet fever, a disease process that we do not see in the United States due to the widespread use and--some would argue--overuse of antibiotics.  

Then there was the 2 year old child who slowly lost her ability to walk.  She was seen by a doctor in the capital city and given medication for malaria without help.  Her mother brought her to the countryside hospital of Vanga for further evaluation with its reputation as being one of the best hospitals in the country.  She had a small kyphotic deformity of her upper spine with signs of upper motor neuron injury and was subsequently diagnosed with tuberculosis of the spine otherwise known as Pott’s disease.  She is responding well to treatment and is a very cute little girl!  We are praying that she will recover her ability to walk as treatment progresses and the infection is better controlled.

On the internal medicine service, we saw a middle aged female who had presented with shortness of breath.  Her chest xray showed a heart that filled up almost two thirds of her chest cavity with an echocardiogram showing a very large pericardial effusion that was found to be due to tuberculosis.  Then there was the middle aged women with an amoebic hepatic abscess being treated conservatively with anti-parasitic medication or the man who was paralyzed from the waist down after suffering a spinal compression fracture from falling out of a tree while collecting food.  To make the situation even worse for this gentlemen the local custom is to put the paralyzed person’s feet in the fire in order to try to regain the ability to walk.  He now has a third degree burn on his foot with exposed bone and will probably need an amputation in the near future due to the infected bone.

Last week, there was a small party consisting of bottled Fanta and Coke with fresh peanuts and rolls.  This was to celebrate the start of a national research trial for a new medication for the treatment of trypanosomiasis, which is otherwise called “African sleeping sickness.”  African trypanosomiasis is an almost universally fatal disease if left untreated with the highest number of cases found in Congo.  There is great hope that this new medication will be as efficacious as the old medications but with less side effects.

Yesterday, we saw a very sad case of gram negative bacterial meningitis in a 5 year old.  The child is doing better with antibiotics and steroids but will likely have some neurological damage. 

There are many sad stories but there are also many encouraging stories such as the young boy with severe tetanus who gives me a big smile and high five whenever I see him in the pediatric ward or the man who praises God for his improvement after antibiotics and debridement for his extensive lower extremity necrotizing fasciitis or “flesh eating bacteria” infection.  The Lord has poured out His grace and mercy in many real and tangible ways.  The faithful hospital staff display the hope and promises of Jesus Christ everyday.  We may be limited in our diagnostic ability, limited in the availability or affordability of medications, limited in the various treatments, but we are not limited in what God can do physically or spiritually.  Jesus, the Great Physician, came into this world to not just heal physical maladies but to heal us spiritually by making us right with God.  He has promised to wash away our sins as far as the east is from the west (Psalm 103:12) and to complete the good work that he has started in us (Phil 1:6).

What is Your Life? -Paul Tuttle

What is your life?

“Come now, you who say, ‘Today or tomorrow we will go into such and such a town and spend a year there and trade and make a profit’ - yet you do not know what tomorrow will bring.  What is your life?  For you are a mist that appears for a little time and then vanishes.” - James 4:13-14

“Only one life, ‘twill soon be past, only what’s done for Christ will last” - C.T. Studd

My time here in Congo has caused me to reflect more upon this verse.  Life is short, moreover eternity is infinite and final.  The United States is a wonderful country in many respects.  The freedom and material blessings we enjoy are truly gifts from the Lord.  Our individualism and wealth can be stumbling block or an opportunity.  Jesus and the apostle Paul often spoke to the many dangers of wealth, but at the same time Paul charges the rich to be generous and ready to share in order to take a hold of that which is truly life (1 Tim 6:17-19).  Christ said much is expected from those who have been given much (Luke 12:48), and to store up treasures in heaven and not on earth (Matt 6:19-21).

It is very easy in America to store up treasures on earth rather then in heaven as we live in a society where we are bombarded daily by the materialism and death is usually something that happens in old age.  Congo is a war torn country that lacks basic infrastructure and hence is plagued by disease, poverty, corruption, and death.  As much as we Americans say we understand that death is a fact of life, the Congolese understand this much more.  The wealth disparity between the United States and Congo is stark to say the least.  Thus, the wealth disparity and common occurrence of death has forced me to reevaluate my life.  What is my life? 

The word “gospel” literally means good news.  It is good news that Jesus Christ died for us on the cross and has therefore paid the due penalty for our sins.  God gives us grace and mercy through Christ.  Grace is getting something we do not deserve and mercy is not getting what we do deserve.  Through Christ’s work on the cross, God gives us the grace of eternal life and the mercy of escaping eternal damnation. 

The more I understand the depth of the gospel, that is, the more I understand the love of God shown on the cross for a sinner like me (Eph 3:14-19), the more I will strive to store up treasures in heaven rather than on earth.  Whether we are a missionary in Congo or in our own neighborhood in the United States, these eternal treasures are found through the participation of God’s work through prayer, money, and time.  Life is short and we have been given much in the United States and much will be expected from the Lord.  To truly live means to daily die to yourself and to live for the glory of Jesus Christ.  

Congo Epic Problem

For my coworkers in St. Louis, you will understand the title of this post. For everyone else, Epic is the computer program that we use in our hospital for orders, documentation, vitals, etc. We have a love hate relationship with the functionality. We love to say that we have an Epic problem. Yesterday, I performed a tubal ligation, several gynecologic exams, and two cesarean sections. One was for presumed eclampsia. She came to the ER in a coma, seizing, and 28 wks pregnant with elevated blood pressure and edema. They gave her phenobarbital, a bolus of magnesium in her IV, Rocephin for possible meningitis, ruled out cerebral malaria, and observed her overnight. When I heard about her in the morning, I immediately went to see her. Her uterus was tetanic (contracting constantly) and I had little hope for the fetus. But the treatment for eclampsia is delivery and often the mothers will do better after delivery. I indicated a cesarean section and we delivered a stillborn infant. After the surgeries of the day were finished (Gyn-wise), I went to see the the patient with eclampsia. She had not improved. She was still tachypnic in the 50s/min, blood pressure was rising, and she had made minimal urine output. I discussed with the resident that they should give more IV fluids and minimize the lasix as she was likely dry. She did not have any crackles in her lungs to indicate fluid overload. She had only received 1 dose of magnesium the night before, and as her blood pressure was rising, I thought she likely needed it to avoid another seizure. There was no way to intubate her in this situation as we would have done in the US. The following is the process I went through to get magnesium started. To my fellow OB residents, remember how frustrated we get when we order magnesium and it is not even going 30 min later? Read on. :S

1. Asked the resident about mag. He said, "it is very difficult" and went back to the OR for more cases. 2. Looked around, and all in the room were assistant nurses or techs and did not speak English. 3. Walked around the hospital to find Dr. Rice for a second opinion. Found Paul in the peds ward who said he was at home. Walked home to get further consultation with Dr. Rice 4. Walked back to the hospital with Dr. Rice 5. Assessed the patient. Assistants were faithfully taking blood pressures. Blood pressure was 150/110. Still in a coma. Edematous eyes, face, feet, no crackles in the lungs. Responsive to pain, pupils reactive to light. Still tachypnic. Decided we should start mag. 6. Walked to OR to get back up with the supervising doctor, Dr. Fina. He agreed, sent a different resident with us to get the mag going. 7. Walked to the lab to ask them to obtain a creatinine and sodium level. 8. Walked to the patient to order the mag on the chart. 9. Resident went to the central pharmacy to get the mag 10. Lab tech came to the patient to get blood 11. Dr. Rice walked with the lab tech to find the result 12. Resident came back with a bottle of mag. I was unsure how much mag was present in the bottle or how many mL to give. 13. Walked to the lab to tell Dr. Rice I was going to the OR. 14. Walked back to the OR. (which requires me to change into different shoes and put on my scrub hat every time) Asked Dr. Fina about the concentration. 1mL = 500mg. 15. Walked back to the lab to see if there was a result. Negative. 16. Walked back to the patient bedside. Wondered how to give 2g/h by IV after the initial bolus.  
17. Looked up on Epocrates (my handheld drug reference) that I can give magnesium 4g IM q 4 hours. Calculated 8mL = 4g. 18. Dr. Rice returned to the patient bedside without a lab result. Failed. They would try again. 19. Dr. Mpoo, another supervising doctor and the medical director, came to the patient bedside. We discussed that we needed to give the magnesium IM. He agreed. 20. Walked to the maternity to find the nurse in charge. Explained to her how to give the magnesium and to check for respiratory status and reflexes prior to giving the magnesium doses each time and the side effects. 21. Dr. Mpoo wrote the order in French. 22. We decided to minimize the number of doses due to our inability to know creatinine at this time. Changed the order on the record. 23. Nurse in charge reported that there were no reflexes. 24. Walked to the patient bedside with the nurse in charge and Dr. Mpoo. Checked reflexes. They were 1+. 25. Taught the nurse to effectively check the reflexes. She was able to do this. 26. Walked home.

  

All in all, 26 steps and 2 hours later, our patient was on mag. And in the US, I write, "mag" and it pops up in an order set.  A few mouse clicks later and this is sent to the pharmacy automatically who sends the medication in a tube system to the nurse who checks the reflexes and hooks the patient up to the mag. Sadly, our patient needed intubation with the severe tachypnea and we found out she passed away overnight. This is life and death in Congo. It is my hope that these deaths can be minimized with prevention at the level of the health centers on the front lines with prenatal care and blood pressure checks monthly.