When all else fails...

About a month ago, a young boy arrived to our outpatient department (OPD) in severe respiratory distress. He was gasping for each breath, and we were fairly certain he was going to die. Based on the initial history (a few days of URI symptoms), he was immediately placed on oxygen and treated as an asthmatic (he had essentially no air movement and a prolonged expiratory phase). However, despite a full court press (back-to-back and then Q1-2H nebs, SC epinephrine, IM magnesium, IV dexamethasone, and aminophylline), we made almost no headway. He persisted to have essentially no air movement. A few days into his course, he became acutely more distressed and developed massive subcutaneous emphysema and a large left tension pneumothorax, requiring an emergent needle decompression on the floor, followed by placement of a chest tube. Once the tube was placed, we could finally hear some air movement, and we were able to hear a fixed, monophonic wheeze emanating from the trachea. He had a foreign body! We rushed him to the OR for a bronchoscopy... and no foreign body was found. At this point, one week into his stay, he had shown no improvement with asthma treatment and although he clinically looked like a foreign body, there was no foreign body on direct bronchoscopy. What was the next step?

He was presumptively placed on antibiotics with risk for super-infection, and then we waited. Our ENT was out performing surgeries at a different facility, but was due back in town in a few days. So we weaned down on our asthma medications, but continued high dose dexamethasone to prevent further airway edema. When our ENT returned, 3 days later, he went back to the OR for a second look. This time, we weren't even able to pass the vocal cords because of the edema and inflammation. What was our next step? On repeat history with the family (which, by the way, is next to impossible to obtain), we "confirmed" our suspicion about a foreign body as mom indicated he had been eating peanuts (called "groundnuts" here) prior to the onset of respiratory distress (although this was the fourth completely different history obtained in as many attempts).

We continued the steroids and antibiotics and removed the albuterol, and waited for a third attempt to localize the foreign body. He made small improvements with the steroids, but a few days later, he again acutely decompensated, becoming cyanotic and struggling for each breath. Our ENT, who had again been out at surrounding facilities performing surgeries, had just come back to Mbingo about 10 hours prior, and was called to take him back to the OR at 4am. This time, he found what we were looking for - numerous pieces of groundnut in both mainstem bronchi. Once the pieces were out, his respiratory status stabilized, and the patient rapidly recovered.

We did everything we could for this patient: we treated him as best we were able given the history and the clinical presentation, but despite our efforts, he didn't improve. Even though we knew the underlying problem, we were helpless to effectively intervene. Then when the patient was seemingly making small steps towards improvement, he acutely decompensated and almost died. When all else failed, however, God came through. It was no coincidence that our ENT had just come back from working at outside facilities in time to rush him to the OR. And even though the vocal cords were too edematous to pass previously, Dr. Acha now had clear passage to remove the pieces of groundnut. Princewill is alive now not because of what we did, but because God decided to intervene and saved his life. When all else fails, God comes through. Thanks be to God that despite our limitations and bumblings, He is able to bring healing when there is seemingly no solution.

Princewill - post the third bronchoscopy and removal of the groundnuts

Provision

The past few weeks have been full of mountaintops and valleys, and have truly highlighted the ups and downs of medicine and life. Lindsay and Cathen flew back the United States to attend Rory's wedding, which provided an awesome opportunity for them to see family and celebrate. Of course, being here alone without my two ladies has been difficult.

We had an incredible recovery of a young boy who had aspirated a groundnut (peanut), and a teenage girl who presented with a massive anterior mediastinal mass and SVC syndrome is responding to her chemotherapy (and we were able to make an "official" histologic diagnosis of Burkitt lymphoma by sending pathology slides to Dr. Bardin to review while he is on vacation in the US). These were tremendous highs.

Those successes have been tempered by the busiest week of our 6 months here in Cameroon - while the hospital is short-staffed (we are currently missing 6 of our 10 expatriate physicians), and feeling helpless as patient after patient gets admitted to the ward and we are unable to diagnose or treat the problems. We have had more deaths in the past week than in the past two to three months combined.

The constant swing of emotions begins to take its toll, and the last couple days have been difficult. However, I was greatly encouraged last night as we were reading in Luke chapter 9 at our weekly Bible Study. After being sent out on a mission to heal the sick, the disciples return and Jesus takes them off to a desolate place to rest and recover. Rather than rest, however, they are swarmed by the masses. Jesus' response was that he "had compassion" on the crowd and "healed their sick" (Mt. 14:14). The disciples ask Jesus to send the people away to go and find food, thinking logically and knowing that they were unable to provide for them. Jesus instead replies - "You give them something to eat" (Luke 9:13). The feeding of the 5,000 ensues and what appeared a disastrous scenario turns into something miraculous.

The last week has beaten me down and I have felt unable to provide for the barrage of patients. However, even when the disciples knew their inability to meet the needs of the crowd, Jesus provided. He had called them there, and He would not let them flounder. Likewise, we've been called here for a purpose, and although I often cannot provide for my patient's various needs, God can.

Thank you for your prayers and support, for encouraging me, and for joining us as we try to bring healing to the sick.


Here are some photos that we took shortly before the girls left town:

Cathen & Gracia

(Gracia is Dr. Francine's daughter)

My Two Ladies

Marching Ants

Catching Up

Our internet was down for a few days, which allowed for some time to catch up on life. A lot has happened since we last posted, so I will try to give an overview in brief snippets:

Graduation: the culmination of many years of hard work came to fruition for two of our fine residents a couple weeks ago with our first CIMS (Christian Internal Medicine Specialization) graduation. Drs. Divine Jam and Francine Kouya are the first two graduates of the four-year program, and will be serving at Banso Baptist Hospital and continuing training in South Africa in the field of oncology, respectively. The graduation ceremony was well attended by members of the Cameroon Baptist Convention in addition to the expatriate medical missionaries that are training the residents here at Mbingo. It was an honor to be part of the ceremony, but more so to be part of the training that is occurring here at Mbingo Baptist Hospital (MBH). We are excited to continue to work on the pediatrics curriculum (the CIMS program is ~ 15% pediatrics training) and to further the education of the residents.

Dr. Divine Jam & Dr. Francine Kouya with the Attending Physicians
(Chuck Barrier, Rick Bardin, Angela Barrier, Dennis Palmer, Divine Jam, JR Young, Francine Kouya, Kaye Streatfeild, Lindsay Young)

Ward Changes: nursing here at MBH works on an antiquated system where rather than assign nurses to individual patients, each nurse on duty manages a particular skill set for the shift – vitals, oral medications, IV fluids, etc. We have found that with the current system, the comprehensive details surrounding each patient sometimes get lost. As such, we have spoken with the head nurse of the hospital and are hoping to try a pilot of sorts, revamping nursing on the children’s ward to have each nurse care for about 5 individual patients. The hope is that we will be able to have a more complete picture of what is occurring with the patient when both the resident and the nurse have ownership of individual patients. Change is never easy, but we hope and pray that we can really improve patient care by implementing this change on the children’s ward. If all goes well, we will then promote change on the other medical wards as well.

Comings & Goings: many of our friends and colleagues have recently left for furlough. The Palmers (Dennis created the internal medicine program here, and his wife Nancy, is the administrative head of the program and a doctor of psychology) have gone home to the US for 5 months. Keith and Kaye Streatfeild (anesthesiologist and internist, respectively) have returned to Australia for 10 weeks. The Sparks (Steve heads up the PAACS [Pan-African Academy of Christian Surgeons] program at MBH) have returned home to the US for 6 months. The Bardins (Rick is our pathologist and Debbie is a nurse working in the HIV Clinic) are leaving in July to return to Nashville and Colorado for one month. In addition to the faculty that have returned home to raise support and to reunite with family, we have graduated our two senior residents, and two of our house officers (essentially interns) are transferring to other CBC facilities. In their absence, we are all filling in as best as possible and trying to divvy up the workload. Pediatrics (which was created just 5 months ago here at MBH) is now the best staffed of the services with three attendings! We will miss our friends and colleagues, but we are excited that they have the opportunity to return home, to relax with family and friends, and to raise support so as to continue their work here in the coming months.

Fortunately, we are blessed with frequent visiting physicians to help lend a hand on the wards and to teach. We currently have two wonderful couples with us: Robert & Melissa (Neurologist and Pediatric Nurse) and Dorothea & Drew (Psychiatrist and Anesthesiologist). They have been a wonderful addition to the team and have really helped to smooth things out with many of our colleagues out of town.

The crew - up early on Saturday morning before rounds to go hiking

Chickens: our first batch of chickens have grown up, fattened up, and already appeared on our dinner table… chicken pot pie, Banso chicken stir fry, fried chicken, chicken fajitas, etc., etc. The chicken coop was a huge success, thanks to Chuck, and now that the first four chickens have been eaten, we have a new batch of chicks for the kids to enjoy until they too become dinner. Chickens are rather pricey here in Cameroon (not to mention quite chewy), so raising them on our own is cheaper and it provides entertainment for the kids (and the adults when the chickens escape from the coop – one of the ornery chicks got out three times just during a recent evening’s dinner!).

The chicken coop

Hiking: it had been almost three weeks since I'd been out for a good hike, so Chuck and I got up early last Saturday morning before rounds and took a 3.5 hour hike up the mountains on the east side of the hospital. We ascended just under 2000 feet and got an incredible early morning panoramic view of the surrounding countryside. It was phenomenal, and a great reminder of the beauty that surrounds us here.

Looking back at MBH

Panoramic facing southeast

Medicine: In the past week alone we have seen a barrage of pediatrics cases on the wards and in clinic. Some of the more interesting cases included:

-       Suspected congenital adrenal hyperplasia in a 5 week old

-   Disseminated MAC 

-       Pseudomonal infection of crush injury

-       Cerebral malaria x 2

-       Gram-negative meningitis (likely H. flu)

-       Bilateral retinoblastoma, presenting with an exophytic mass (extending ~3 inches from facial plane)

-       Burkitt’s Lymphoma presenting with intraoral mass, sepsis, acute renal failure, and right cranial nerve 3 palsy

-       Hepatic mass with obstructive jaundice and ascites

-       Inflammatory bowel disease

-       Osteomyelitis with sequestrum
-       Suspected adrenoleukodystrophy

We miss you all and cherish your prayers and support. Thanks for following along. Blessings.

Picture Quiz: Does anyone know what this is? This is really random…

 

Destiny

Maybe we should have seen it coming. They really were two of a kind: rebellious but sweet, always demanding what they wanted, and succeeding in obtaining their demands. He had those rugged good looks with longish, scruffy hair that flowed in the wind, and a way with the ladies. She was somewhat of a tomboy, with short, scraggly hair and trousers as her favorite garb. And her smile – it could win your trust in a moment, and break your heart the next. He showed up one day on our side of the compound, engine blaring, with a huge smile on his face. He was courteous enough to ask, and with his charm, somehow convinced my wife that this was a good idea. Our daughter was enamored to say the least, and without a moment’s hesitation, she jumped on the back of his revved up mustang, and they drove off into the distance. They looked happy, and he was truly affectionate in his care of her… but we keep asking – “aren’t they too young to be riding off together like this? Should we have done something to prevent this? Or are they simply destined to be together… destined to ride?”

    Rugged good looks                                                        Tomboy

   

    The Asking                                                                     Jumping at the offer

   

    Enamored                                                                      Loving

   

    Destined to ride

Starring: Isaac Barrier and Cathen Young

Praises

We have settled in to life here in Mbingo. Work is steady, at times hectic, challenging, exciting, frustrating, and rewarding. We are seeing a much broader scope of infectious diseases here than we did back home, but we are also seeing first hand just how remarkable a recovery a child can make - even when we do not specifically know what we are treating. We have had a handful of children who presented altered, somnolent, and in status epilepticus - likely secondary to a viral meningoencephalitis - who have made remarkable recoveries and walked out of the ward.  We currently have a 13 yo with cryptococcal meningitis (despite being HIV negative) who presented comatose and is now asking for his older brother. God is the healer and we have seen His miraculous hand at work over and over.

Boris: 2 weeks post-operative                                                                                     Boris: heading home

The most poignant example that comes to mind is Boris. Boris is a 5 yo who came in after being hit in the head with a piece of rebar. He progressed rapidly to mental status changes and signs of increased intracranial pressure, and was rushed to surgery where they found a frontal lobe abscess. The surgeons were able to debride the area but in doing so had to resect the entire right frontal lobe. 2 weeks later, he is being discharged home looking and acting for all the world as if nothing ever happened (other than a nice surgical scar). God is good!

The recoveries like Boris' and the teaching keep our spirits up. However, the constant nagging of not truly knowing the diagnoses, of not having access to the studies and tests we would like, and feeling inadequate for the task make it hard. In the absence of cultures we are simply treating all of these patients empirically - what are the common bugs, and what are the bugs that could rapidly kill them, and what can we give to cover those processes. However, we are reminded that it isn't the medicine that matters. We don't have to have the right answer or the cure with each patient, and in fact, we cannot. Our role here is just as much to show these patients and their families that we care, to give our best effort, and to let God intervene where we clearly fall short. Thankfully, He is a great God, and He succeeds where we cannot.

On another note (and to give room for some more photos) Cathen is now a little over 9 months old. She is growing like a weed, and is active as a bunny rabbit. We are ever-thankful for the health and safety that she has been provided. Here are some new pictures that we took in our friends' garden:

Nursery

In addition to the goal of training local residents here at Mbingo, one of our main projects is to get the neonatal nursery up and running. There are many challenges to this goal, including space and equipment, as well as lack of formal training, but we are hopeful that this will become a reality while we are here. Currently there are two semi-functional incubators that can be used for premature babies that need help with temperature control and evaporative water loss. However, the thermostats do not function well, and we are having great difficulty maintaining normal temperatures for the babies (which in turn makes it difficult to assess for infection, as fever is one of the primary criteria). Despite the setbacks, a well-organized nursery would be a tremendous asset to the hospital, providing life-saving treatment to late pre-term infants who otherwise would not survive. We hope to raise some monetary support to build incubators to get things jump-started (it turns out that building simplistic, but sturdy incubators is easier than trying to maintain a new incubator with all the bells and whistles). We are also using bubble CPAP (continuous positive airway pressure) here in the nursery for babies with respiratory distress (we do not currently have the ability to intubate and ventilate neonates), which has been a great addition to the practice. The CPAP was actually started by Dr. Sara a couple of months before we arrived, and is being continued as it is an excellent adjunct to care as it offers respiratory support for babies who are otherwise well, but just need a little extra help to make it through the first week or so of life.

As an update, we recently had our first true nursery success stories: an ex 31-wk premature infant and an ex 32-wk premature infant - both of whom had respiratory distress requiring CPAP, neonatal sepsis (one with necrotizing enterocolitis), and feeding difficulties - were recently discharged home after greater than one month in the nursery. The children look great, have gained excellent weight, and are now stable without additional respiratory support or temperature control. We hope to expand the nursery and obtain more incubators to be able to provide these life-saving measures to additional children. Thank you for your support.

JR and the two premature babies and their mothers on the day of discharge

Our current incubators... which work some of the time. They are rather temperamental and do not hold a steady temperature for the babies.

Creechied!

Well, we have officially been welcomed to Cameroon, or at least that is what we have been told...

There is a small insect known as the Rove Beetle that is endemic to Cameroon (as well as a few other places across the globe), that reportedly has the most poisonous venom known to man - 12x more potent than cobra venom. It does not typically cause problems, unless you unwittingly smash the creature on your skin, causing the toxic liquid to squirt out all over you. Well, we have both been creechied. I received the bug juice on my arm (which spread to my upper arm and torso), and the infection got super-infected with Staph, so I am now on an oral penicillin as well as topical steroids. Poor Lindsay, in addition to the intense burn and then itch, developed a severe id reaction to the mess (a systemic inflammatory response that results in small red, itchy bumps and small vesicles all over) and has been frightening her patients away!

All that being said, the itch is improving, we are on the mend, and we will hopefully be off of medications within the next 2 weeks. Yikes!

JR's arm: the area spread for the first two days and became edematous as well as intensely pruritic. The actual dermatitis eventually resembles a burn wound as the toxin is so strong.

 Lindsay's id reaction

Sleep has been difficult because of the itching, but systemic steroids work wonders. Thankfully once the initial insult was over, we are not able to spread the rash to our patients, although we have had a lot of explaining to do so that they are not afraid!

Love you all.