Special Need: the shortcomings of human interventions

Meet Chrystabelle. She is a beautiful 13-yo female who presented to MBH two weeks ago. She has the unfortunate reality of living with congestive heart failure, a disease that typically effects the elderly, but that she developed as a young girl, likely secondary to rheumatic heart disease. She now also has kidney failure and is dependent on peritoneal dialysis to filter the body's waste products. It is because of her kidney failure that she showed up to Mbingo.

Chrystabelle

Chrystabelle was slated to undergo a valve replacement for her heart this June at a nearby, Italian-run, cardiac hospital - Shisong. However, before she could go for her evaluation, she began to have difficulty urinating and by the time she presented to us had been unable to produce any urine for 3 days. She was in renal failure (BUN 280 and Cr 10) when she arrived. We quickly placed her on peritoneal dialysis - which is a new therapy here at MBH that allows us to do the work of the kidneys in an acute setting, allowing the kidneys time to recover from the immediate insult - and began to filter out the waste products from her body. The difficulty in this setting is that her heart with its failure, feels that the body has too much fluid in it - it can't effectively pump against the pressure. The kidneys, on the other hand, feel that there is too little fluid in the body because the heart is failing to pump the blood forward. So, we are stuck either helping the heart and damaging the kidneys, or helping the kidneys and damaging the heart. This is quite a conundrum.

Betrand & Ivor.
Betrand is Chrystabelle's neighbor in the dialysis ward, and
Ivor is one of our newly trained PD Nurses

Medically speaking, what she needs is a heart valve transplant to allow for improved cardiac function, and then a chance at restoring her kidneys to health. This is where Shisong Hospital comes in. However, Chrystabelle's story becomes more bleak. A cardiac surgery at Shisong will likely cost the family approximately $5000, which is roughly the equivalent of 5 years of salary (a typical laborer makes $50-100 per month). This seems cost-prohibitive, and for many it is. However, as families by and large do not have medical insurance in Cameroon, they tend to unite together in emergent situations and provide for one another. It is miraculous to see how families join together to provide when need arises. This, however, is where Chrystabelle's story again becomes more desperate.

Chrystabelle is one of four siblings. Her father passed away about 4-months ago, and as per local custom, her only surviving paternal uncle, Valentine, has become the sole provider for Chrystabelle and her siblings, in addition to his own wife and children. Valentine is a kind and gentle man who loves the Lord, but this is quite a new burden to suddenly take on - four new children, and one who has medical needs that cost more than you can earn in 5 years of work. Because of the cost, many families would simply choose to take the child home - not only is the chance of survival low, but paying for the surgery would preclude their ability to care for the rest of the family. This is quite the dilemma for the family.

This is also quite the dilemma for the physician. What is my aim in serving Chrystabelle. In medical school and residency we learn to advocate on behalf of the patient. When does advocating for the patient at the expense of the family become inappropriate. Our resources are such that the daily decision of whether or not to send a child home from the hospital has ramifications not only for that immediate patient, but for the ability of the caretaker who is with the child to provide for the other five siblings that are at home without a parent and without any means of earning an income. Justice and mercy and love seem to take on a new meaning in these shades of grey.

During medical school and residency, my aim was always to "heal" the patient. Working here I am daily reminded that I cannot heal the patient. In fact, God's purpose for me is not to necessarily heal anybody. Rather, I am called to provide compassionate care to my patients in a way that shares God's incredible love, and to let God do the healing. Sometimes knowing how that plays out is easy. Other times, it is not.

In this instance, Lindsay and I have felt called to help Chrystabelle in any way we can. Specifically, we want to continue her on dialysis until August when the next Italian cardiac surgeon is coming to Shisong, and to help the family pay for her valve replacement at that time. We aim to raise $5000 to offer Chrystabelle the best chance she has at a healthy life, a new heart so to speak, and in the process, to show God's incredible mercy and compassion for those in need. If you would like to partner with us in this endeavor, please make a donation to our Samaritan's Purse Project Account, and we will use the funds accordingly.

We serve an almighty God who is able to do immeasurably more than we can imagine. We are eager to see how His love is poured out on Chrystabelle and how His perfect plan is brought to fruition. Thank you for prayerfully considering making a donation on her behalf.

With love and broken hearts,

JR & Lindsay

Work is tough. God is the perfect provider, and He provides rest for the weary.
I am blessed to be able to find rest in enjoying His creation.

Another Day at the Office

Today was just another day. It started a littler earlier than usual (3:30 am), and it hasn't technically ended yet, but it has overall been pretty "routine." Here is what a routine day at Mbingo Baptist Hospital entails:

Chapel begins promptly at 6:40am. Chapel includes most of the staff from the overnight shift as well as the incoming shift of hospital workers - probably close to 500 people. Then we have morning report from 7:00-8:00am. On Tuesdays we actually have the resident Bible Study, and Thursdays we have the joint surgery/medicine Tumor Board case presentations. From 8:00-9:30am we attend clinic and then start ward rounds at 9:30am.

This morning in clinic before going to rounds I saw 5-6 patients. If anyone thinks that he didn't go into outpatient pediatrics because it was too boring, perhaps he is simply practicing in the wrong location. I saw a 6-mo with a patent ductus arteriosus (PDA) coming for a scheduled closure with our visiting pediatric surgeon, a 4-yo with a badly dislocated right hip and inability to walk (see picture below), a 12-yo male that we are managing for his seizures, and a 16-yo M (who was admitted) with likely glomerulonephritis and acute renal failure (Cr 10.0, BUN > 250, hypertensive at 190/110, and 3+ protein and RBCs in the urine).

The ward was where things finally began to get a little more interesting... Here is a rundown of what we currently have on the pediatrics ward:

• 2 patients with malaria, one simple, the other complicated (hemoglobin < 5, unresponsive, and requiring emergent resuscitation on rounds)
• 15-yo M with suspected leukemia. Pathology results pending.
• 7-yo F with a distal radius fracture an superinfection
• 12-yo M with suspected Guillain-Barre Syndrome (AIDP) - bilateral lower extremity paralysis and loss of reflexes
• 3 children admitted with severe malnutrition and edema
• 2 burn patients
• 9-yo M with typhoid fever
• 7-mo F with hydrocephalus and meningitis 
• 13-yo M with recent admission for hypertensive crisis (BP 200/110 and vomiting), now with right-lung white out and ultrasound showing a large retrocardiac mass (see picture below)
• 2-week M with tracheo-esophageal fistula and severe malnutrition, s/p GT placement - scheduled for surgery later this week
• 14-yo F with left heart failure (likely rheumatic heart disease), now presenting with acute renal failure (suspected glomerulonephritis) and initiating peritoneal dialysis (PD) 
• 12-yo M with a likely primary bone tumor and abdominal metastases who has a acute abdomen with a left lower quadrant volvulus.

I spent a good portion of the day working to resuscitate our severe malaria case (transfusing blood, positive pressure ventilation, drawing blood, etc), and then was visiting with the surgeons regarding a number of our cases. We had our afternoon rounds at 4:00pm after the afternoon lecture. 

Praise God that we have a neonatologist and a NICU nurse, Margaret and Pat, visiting us right now. They managed the preemies and the other babies on the maternity ward today, while I continued on the peds ward, in clinic, and then later seeing consult patients. Typically the work is split between myself and either Lindsay or Angela. But the Barriers are home expecting their second child, and Lindsay is in Yaounde picking up her cousin, Greer, who is coming to help watch Cathen, allowing both of us to attend work at the same time. It will be a blessing to have them both here tomorrow afternoon.

Most of the children that we see are really quite sick, and the pathology is astounding. However, what is truly amazing is how God takes scenarios that seem completely helpless and brings healing to many of these kids. Please pray that we would have wisdom in treating these children, that we would be compassionate and caring in our words and actions, and that we would not let our work become simply "routine." Please also pray for safe travels for Lindsay and Greer tomorrow as they drive up to Mbingo, and pray for the Barriers while they are home waiting for the new little one to come.

We miss you all, and thank you for your support and prayers. 

Blessings,

JR

Right hip dislocation

Right-sided pneumonia and pleural effusion and retrocardiac mass

Cathen. She is dressing herself these days... Rain boots, fortunately, are always appropriate here.