Wrapping up

The countdown is on! We will be back home in less than 3 weeks now. It doesn't seem like 16 months since we came here together, but here we are!

We've entered a very lovely season here in Nepal, much, I'm sure, to the jealousy of those of you still battling snow and wondering if spring is ever going to arrive. The days are starting to get hot, but the mornings and evenings are very pleasant. It's sunny almost every day. We could actually use some rain to fill up our water tanks, as there is a severe water shortage at the moment. We have run out of water a few times in the last few weeks. Surgeries had to be cancelled over the weekend because of a lack of water. There are fights breaking out at the local water taps, where people who don't have running water in their homes go to stock up. Our large storage tanks are less than 30% full, even with getting tankers of water to truck water in and pump it into the tanks for us. Send the rain, Lord!

This is an issue every year at this time, and the solution isn't obvious. Trucking water in is expensive and not sustainable, as more and more people move to the community and also rely on the town's water supply. Our rainwater storage tanks are a great idea...when there is rain! In a couple months, the monsoon will start, and the tanks will be full to overflowing, and most will forget that we were in a crisis just weeks earlier. There are plans to build an even bigger rainwater storage tank (over 1 million litres of water), which will certainly help, although it still may not be enough during the dry season. Drilling for water may be a better long-term solution...assuming when we drill there is actually water to be found (which is not a guarantee). It is an issue that has very much been on our hearts and minds since we came to Tansen, and we continue to pray that God will make the way for us to have an abundant, clean supply of water, not just for the hospital, but also for the surrounding community.

As Jessica goes on maternity leave, the hospital is facing even more of a shortage of surgeons than there has been. This challenge is compounded by a new policy that medical licenses are not being granted to short-term visitors, so our usually steady stream of short-term surgeons coming to help is also not happening. She is leaving the department in the hand of 1 Nepali surgeon who has worked here for the last 3 years, but may be leaving in the next few months to go do further training, and 2 newly graduated Nepali surgeons who had some significant gaps in their training and are still learning the ropes. Please do pray for the surgical service and for provision of adequate coverage and support, both as we are away, and when we come back.

Our new Nepali surgeons operating together

Paul's building projects are coming along, though disappointingly, it is likely that neither of the 2 major projects will quite be finished before we leave. He's working hard to try to get them to a place where they don't need his oversight anymore. They're getting close, but we're still waiting on shipments of supplies that should have been here ages ago, as well as some other things that are outside of our control. He is sad to be missing out on the satisfaction of being able to survey the finished project, but trusting that it's all in God's hands. 

The nursing station in process

With the challenges and suboptimal circumstances we're leaving behind both on the surgical side and the building side, we're reminded that this is indeed not our work but God's, and that we need to hold onto things loosely, allowing Him to use as as He sees fit, but remembering that we are only a small piece of a much bigger puzzle. "Unless the LORD builds the house, those who build it labour in vain." (Psalm 127:1)

Our current plan is to be home for about 6 months, and then to return to Nepal in late October. The baby is due on July 11. Do please pray for us as we wrap up the last couple weeks here in Tansen for this season and prepare for the next chapter of our lives.

Leaving our comfort zone

With the increasing availability of specialists in Kathmandu who provide a reasonable quality of care, we try not to do things here in Tansen that are too far out of our realm of expertise and comfort when we can help it. These days, it seems that more and more patients are able to afford to go to Kathmandu when needed and pay for the care there, and so we often refer more complex cases there. However, Nepal is still a very poor nation, and there are many patients who could never afford to go to Kathmandu for care. In fact, their hospital fees here get paid for with charitable funds. In those cases we do the best we can, even when we are pushed beyond our usual scope of practice.

We have a visiting pediatric surgeon here right now who has been here many times before. He was asked to help with a little 6-month-old girl who was born with an encephalocele. For those of you non-medical types, that is where a portion of the spinal canal doesn't properly form, so there is a connection between the spinal canal and the surrounding tissues, and causes a leak of the fluid around the spinal cord and brain (CSF, or cerebrospinal fluid) into a fluid-filled sac outside the spine. This little peanut had a big mass, about 30-40 cm in size, coming out from the back of her neck, filled with CSF and connected to her spine and brain. Normally this would be operated on by a neurosurgeon, but this family was dirt-poor, and couldn't even afford care in Tansen, let alone go to Kathmandu. So we sent the MRI (which we sent her elsewhere for and paid for out of charity funds) to this surgeon over e-mail to get his opinion. Not being a neurosurgeon himself, and never having done a case like this, he consulted a neurosurgery colleague back home, who thought that this was probably doable, and told him how to do it.

We did the operation on Monday. Aside from some nervous anesthetists (and surgeons!), everything went well. The mass came off easily, and the hole in the spinal canal was closed off. Baby did well. We were pretty pleased. The next morning we heard that she was doing "Dherai ramro" (very well), and we were excited to hear that. But on rounds we noticed that her fontanelle (baby's soft spot on their head) was a bit full and bulging (a sign of increased pressure in the brain). She looked okay otherwise, though, so we just watched her closely. By later in the day her level of consciousness had deteriorated, and her breathing pattern was abnormal. We knew there was a potential for this to happen. We decided to remove some of the excess fluid with a needle and hope for the best. (We understood from the neurosurgeon that sometimes it takes time for the CSF balance to sort itself out after an operation like this). But the next morning she seemed worse. Now her right eye was not focusing, and she was even less alert. A quick SMS/e-mail consultation with the neurosurgeon and we decided the best thing was to send her to Kathmandu ASAP for something called a VP-shunt (where they insert a drain that drains the CSF into the abdominal cavity). If she deteriorated in the meantime, we could insert a temporary drain here in Tansen before sending her to Kathmandu. He told us how to do this.

Enter the next set of problems. In Kathmandu at the moment, all the doctors are on strike. In fact, this is nearly nationwide, though it hasn't affected us yet. I don't really understand all the reasons for it, but only true emergencies are being cared for. Everything else is on hold. Thankfully, one of our Nepali doctors here has a brother who is a pediatrician in Kathmandu. He contacted him, and arrangements were made that we could transfer this little one today (Thursday) and someone would care for her there. I think they even agreed to do the surgery for free. Social services agreed that we would cover the cost of her getting there and for any medicines she would need.  All well and good, provided she was still alive by today. (Did I mention that we have been praying up a storm over these past few days?)

As the day progressed yesterday, she grew worse and worse and we knew we needed to put this drain in or she was going to die. Unfortunately our anaesthetist doctor is away, so we only have nurse anaesthetists right now. They are very good and very experienced, but they were understandably nervous. Fortunately (??) for them, by the time we got her to the OR, she was so deeply unconscious that we didn't need to give her anaesthesia other than a bit of local anaesthetic. We then used a central line (special kind of IV) kit...expired, by the way...as a drain. When she got to the OR she was only breathing (gasping, really) maybe 3 times a minute, and I really thought she was going to die in front of us. (Insert more fervent and desperate prayer!) We got the drain in, and a LOT of fluid came out, obviously under high pressure. We waited....

After a few minutes, she started breathing on her own. Her heart rate normalized. She started making a few...just a few...movements. We all realized we'd been holding our breath and all started breathing a little easier. She was coming back to us in front of our eyes. It was amazing...truly miraculous! Over the next several hours she started moving more, opening her eyes a bit, and her pupils, which hadn't been reacting at all, started reacting. She wasn't totally awake, but she was getting there. This morning at 5 am she was put in the ambulance and they left for Kathmandu. We pray she made it there safely and that she is able to get the care she needs. We pray for a full recovery for her. We pray for her parents to enjoy many years with her. And most of all, we pray for her and her family to come to know the One who really has saved her life. We serve, Jesus heals.

Why it's hard to get things done in Nepal

Paul has been diligently working away at a couple different building projects here in Tansen. One of them is coming along swimmingly...the one that involves a dedicated team of skilled workers from Kathmandu who have a deadline after which they will lose money on the contract. He is more of a consultant for that job. The other project, the building of a new nursing station for the medical ward, is being done by the hospital workshop staff, and it isn't coming along quite so quickly. Paul gets asked regularly how much longer it will be before it's done. If he could keep workers there for more than an hour or two at one time, it would really help!

That isn't to say there isn't progress being made. A few months ago they were working at chiseling away (by hand!) the extensive rock that needed to be removed before the building could even start. Eventually someone figured out that if they held a blowtorch to the rock for a few minutes and then poured cold water on it the rock would break faster. It was a little frightening to see the fragments of rock start flying everywhere, but thankfully there were no injuries!

 Now the foundations have been laid, the walls built (the gaps are where large windows will go), and the roof trusses built, welded, and secured in place. The bathrooms have been tiled, and the tiles for the rest of the nursing station have been ordered. There remains the installation of windows, tiling the whole place, designing, building, and installing the cabinets, countertops, and shelves, as well as some other things. Theoretically this is doable by the end of April (when we come home for a few months...more on that later), but given the challenges along the way, we're not sure what will happen.

A typical day for Paul:
-9:30 am go down to the job site, where 2 or 3 workers are ready for the day's work. Instructions given, as best as he can give in Nepali, and work started.
-10:00 am - one or more of the workers gets called away for one reason or another. Perhaps they need to haul some oxygen cylinders somewhere, or repair a leaking pipe, or paint the house of someone who will be moving in the next week, or any number of other things. Paul is left with one worker (if he's lucky!)
-10:30 am - Paul gets called to a surprise meeting that could have been planned in advance, but advance planning doesn't seem to be a familiar concept here in Nepal. The meeting takes the rest of the morning.
-12:45 pm - Paul goes back to the building site to check in before lunch. The workers have left for lunch 15 minutes early, and Paul sees that the tiles, which had been going in straight while he was directly overseeing the tiling, are now uneven and crooked and need to be re-done.
-1-1:30 pm - Lunchtime, during which we often pray desperately for some kind of progress to be made for the rest of the afternoon
-1:45 pm - the workers come back from lunch (10-15 minutes late). Thankfully there are now 2 of them. The other one is busy with something else for the rest of the day. Paul explains to them that they need to redo a lot of the work they had done in the morning. The funny thing is, they KNEW the tiles weren't level...but maybe they thought it didn't matter.
-1:45 pm to 5 pm - Amazingly, they are able to focus on work for the afternoon (okay, so perhaps not so typical a day!), and so after removing the crooked tiles and replacing them, they are able to make some progress with the tiles.
-5 pm - Paul is explaining what the plan will be for tomorrow, when one of the workers tells him, "Oh by the way, I'm taking leave tomorrow." Again...advanced planning is a non-concept here. No wait...that IS advanced planning - they told him the evening before!

It is no wonder Paul's hair is greyer than it was when we arrived! Ideally, this project needs to be done before we leave in late April. Without his direct supervision, it may never get done. Pray that they are able to meet the deadline.

Why the deadline? Well, our exciting news is that we're expecting a baby in July, so we will be returning home for a few months to have the baby and adjust to being a family of 3 before coming back to Nepal, Lord-willing, in late October. Jessica is now into her second trimester and is doing well. We do appreciate prayers for this time of transition, and for a safe and healthy pregnancy and delivery.

A sad day

I (Jessica) was on call yesterday and I must say it was one of the sadder days I've experienced in awhile. Started with rounds, and once again, our burn ward is full of tragic stories. On the pediatric side there was an 18-month-old boy who'd been burned by hot daal (the lentil soup that Nepalis eat every day). The burns weren't particularly deep, but they were extensive, covering about 50% of his little body. He wasn't doing so well yesterday morning, and was starting to show signs that he might not make it (unfortunately, I've seen enough of these burned kids now to start recognizing these signs which to the casual observer might not seem like such a big deal).  We did what we could and moved on. I was hopeful, but not optimistic, that he would improve.

I've already written about electric burns. Currently we have 2 patients with electric burns. One is a man I wrote about before who has huge wounds on his chest and back from the current passing through. He is actually improving, and many of his wounds have been grafted and done well. His finger, however, hasn't done well and it's being amputated today. He was discouraged about that. However, looking at the bed next to him, he has reason to be thankful. The young boy who was in that bed previously who lost one arm at the shoulder and eventually went home has been replaced by another young boy, 9 years old, who has lost BOTH arms at the shoulder because of an electric burn. He was playing in a power station! In the bed next to the kid is a middle-aged man who has a seizure disorder who rolled into the open fire in his home while having a seizure. His burns are all quite deep, and cover about 20% of his body. I think he will make it, but he has a long way to go. Finally in the corner is a young girl, about 20 years old, who poured tar all over herself and set herself on fire. Sadly, this is a common way for young women in Nepal to attempt suicide, and it is all too often effective. Just before she came we had another young girl in the same bed (incidentally with the same first name as this one) who had done the same thing, only with kerosene instead of tar. She didn't make it. But this girl seems to have regained her will to live, and is quite motivated to get better. I think she will do okay in the end.

The boy who lost one arm went home. He was a really sweet kid and always made us smile.

Metal ladder, multiple wires, bare hands...no wonder we see so many electric burns here!

So that was our morning rounds. In the afternoon I had to do an emergency C-section for a lady with twins who had "fetal distress" (indicated by an abnormal heart rate of the babies). Both the babies I pulled out were "flat" (i.e. really floppy and not showing many signs of life), but thankfully were resuscitated and seem to be okay now. Mom, however, bled a lot, and I had to resort to almost every surgical maneuver for post-partum hemorrhage that I know. Thankfully it stopped before I had to do an emergency hysterectomy. So I guess that story had a happy ending.

Not so the next C-section, which was for a lady who was 31 weeks pregnant and had come in with bleeding. Baby seemed okay, and the bleeding wasn't too extensive, and so the team had decided to give the mom steroids to help mature the baby's lungs and just observe her closely, hoping to be able to wait a couple days before delivery so that the baby would have a better chance of surviving. Things went well for several hours, but then at the early evening check, there was no heartbeat. An ultrasound confirmed that baby had died. She was breech (head up instead of head down), so needed a C-section. It's an awful feeling to pull out a dead baby! The operative findings confirmed the suspicion: that the placenta had separated from the wall of the uterus (placental abruption for all you medical types). All in all the mom seemed to take it well. I can't imagine!

Finally, just before I went to sleep I got a call that my little burned boy had died. I could hear wailing in the background while I talked to the resident on the phone. A sad day on many counts!

Thankfully the weather these days gives us reasons to smile. Daytime temperatures are lovely, and the views have been very clear. It's hard to believe that the mountains, which are so clear these days, are hidden much of the year by clouds and haze. It won't be long before it starts to get cold, but we're sure thankful for this season while we have it.

The "nice" season

One of the language teachers in Kathmandu says that there are 5 seasons in Nepal. There is the cold and dry season, the cold and wet season, the hot and humid season, and the hot and rainy season. And then there is the "nice" season, which, sadly, is the shortest season in Nepal. We THINK the monsoon is done now and we are into said "nice" season, though we were again hit with rain a few days ago. But most of the time, the skies are clear and it is sunny and beautiful. We are seeing the mountain peaks again, though certainly not every day. It's still quite hazy. We're hoping things will clear up even more in a week or two. In the meantime, we certainly are grateful for the drier weather!

The blue skies and mountain views are starting to come back!

We are also coming into festival season. Nepal's 2 biggest Hindu festivals come almost back-to-back in October and early November. Dashain...the biggest festival...is coming up next week and lasts 5 days. Tihar comes for 3 days in early November. During these festivals the whole country is shut down...including almost all the hospitals! Which means that we will likely get all the emergencies in the area, as people will have nowhere else to go. We won't be doing any clinics or elective surgeries for a few days - nobody wants to be in hospital during festival season. As far as important festivals go, it's the Christmas of Nepal. (As a side note, in contrast to this season, Christmas is really a minor occasion for most people here...it was only declared a national holiday a couple years ago, and most don't celebrate it. We will have Christmas Day off work but otherwise the hospital will run as usual)

Because of the upcoming festivals the hospital has slowed down a bit. Fewer people are coming to clinics for non-urgent problems, and most people ask to have their surgery scheduled after the festivals are done. We still have our share of emergencies, though, and the pediatrics ward, in particular, remains swamped from all the late-monsoon illnesses (typhoid, pneumonia, gastroenteritis, meningitis, etc).

One of the pediatric patients "namaste"-ing me in clinic

On another note, I (Jessica) have decided that there are few injuries that are worse than electric burns. I wrote about Sonu a few months ago. Hers was by far the most extensive and devastating of the injuries we've seen recently, and she eventually succumbed to them. But we've had several other bad ones, and each time I see them I find myself angry that these injuries happen with such regularity, and to young people. Recently I cared for a 27-year-old young man, an electrician, who was handling wires when something happened and he was shocked. He lost his right arm, up to midway between his elbow and his shoulder. He has a wife and a child, and probably won't be able to do electrician's work again. He had the most incredible attitude of any patient I have ever cared for, I think...much better than I would have had in his situation. Because of this, I really enjoyed seeing him every morning on rounds, but his right arm stump was a constant reminder of the tragedy he had suffered.

Then there is a 10-year-old boy currently in hospital who also suffered an electric burn. How does a 10-year-old get a bad electric burn? Well, if you saw the complete jumble of electrical wires that we see around Nepal, you might not find it such a surprise. He was climbing a wall and grabbed a wire, and was frozen to the wire for almost 1 minute before he was released from it. His right hand immediately was in a "frozen" position, never again to move. We had to amputate his right arm all the way up to his shoulder. He also has severe wounds on his abdomen and chest, which will need to be grafted. Thankfully he's doing quite well, but his life will never be the same.

This morning there was another patient who had arrived...a young man in his 30s. I don't know his story, but I do know that he has huge, very deep wounds in his chest and going through to his back, as well as in both hands. We are hopeful that he will be able to keep his hands, and that his heart and chest haven't suffered too much damage from the electric shock. Time will tell.

I would sure love to see some prevention going on as far as electricity is concerned, but I'm not even sure where you would start. In the meantime, we continue to see these devastating injuries, and I am grieved every time. It's hard to make sense of it all sometimes, but I am grateful for the chance to care for these ones, and pray that in the midst of their suffering they would come to know the God who loves them and cares for them far more than we ever could.

Catching Up

Our apologies to anyone who believes we have fallen off the blogging planet. How is it September already?

After a short but good trip back home for a family wedding, we have been back at it again here in Tansen for a little over a month. There was no time for jet lag, either going or coming back here. Things continue to be extremely busy, and we find ourselves being involved in many different things and being pulled in many different directions. The challenge remains finding a balance between the many very real needs here, and knowing what we're called to take on.

Monsoon

The rains continue here in Nepal, and we're all getting pretty tired of it. There are definite perks to the rain - like a more abundant water supply and greener fields - but for most people the constantly damp, mouldy clothes, the constant need for an umbrella, the mud and puddles everywhere, the grey skies, and the unsafe travel, are enough to make them look forward to the end of monsoon. A few weeks ago the skies cleared and for 3 days we even saw the mountains! But then the clouds and rain came again, and we're still in the thick of it.

A few weeks ago...a brief hiatus

The same view. Are there really mountains out there?

Paul

Paul has a few major projects on the go, and is also regularly being called upon for input into one or another building or maintenance issue. A few of the main things he is working on are...

A 3-storey residence and classroom building. Fortunately there are outside contractors who have been hired to do the work, and so Paul is mainly there to ensure things are getting done properly and that things are moving along smoothly. There have been many bumps and hiccups along the way, and we're still looking at approximately another year's worth of construction and work before it will be finished inside and out.

A new nursing station for the medical ward. Paul designed this building, and is overseeing its construction. The first (and perhaps biggest) challenge has been to break up the rock that is where the nursing station will be. There are no jack-hammers or dynamite, so this is being chipped away at painstakingly by guys with hammers and chisels. Amazingly, they're almost done...after more than a month's worth of work! Notice the tarp over the area to allow for work to continue in the rain.

The project that has consumed most of Paul's time in the last few weeks has been a cart to house our new laparoscopic equipment for the Operating Room. (We recently received a high definition camera, LCD screen, and light source to replace the very outdated ones we have been using) We are looking forward to actually being able to see what we are doing when we are doing laparoscopic surgery, or cystoscopy, or arthroscopy! Of course, the equipment that arrived needed to be assembled along with the old pieces that we will still need to use. It is still a bit of a hodge-podge, but it will be a huge improvement on what we've been doing. Paul had to design and build this cart from scratch, with the help of some guys in the workshop. It should be up and running by tomorrow. We're both excited...Jessica to finally be able to use it, and Paul to finally be done making it (everything takes longer than anticipated here)!

Before (minus the machines)

After

Jessica

With only 2 general surgeons here currently, life is very busy, and Jessica often has to work late or go in when she isn't on call. We are excited to report that 2 new Nepali general surgeons will be arriving later this month, and they plan to be here for a few years, at least. They have just completed their surgical training, and haven't yet been registered as specialists with the Nepal Medical Council. As such, there will still be a few months where they cannot work as independent surgeons, but we look forward to their coming, and hope that it will help make the workload a little less.

Jessica has spent a lot of time on various administrative activities lately: organizing the surgical teaching for interns and residents, designing and implementing new paperwork and updating the protocol for the burn ward, putting together a teaching schedule for our daily morning reports, and most recently, working on creating an evaluation form for us to use for our trainees.

The burn ward has remained quite busy, but thankfully no patients have died recently of burns. We have had a few success stories. Two young ladies who were both burned on approximately 30% of their body surface area, who both required skin grafting, both did well and have been discharged. We still need to work on their mobility and preventing the stiffness that is so difficult to deal with in burns patients, but we are making some progress. There was a gentleman in his 40s who had both his hands badly burned, requiring grafting. He did really well and has gone back home with relatively normal hand function. We've had children who have also done well, including this little one who burned his hand and needed grafting. There is a sad story of a 27-year-old man, an electrician, who was electrocuted while working with wires and had to have his right arm amputated as a result. Electric burns are awful!

We have a urologist visiting us at the moment, who is helping us to update some of our urology protocols, as well as teaching us a few new skills that we will hopefully be able to use after he goes. He was also helpful in the operation on a 70-year-old lady who was having quite a lot of pain when passing urine. No wonder. Here is her X-ray showing a 7 cm stone in her bladder...and the stone, which we removed yesterday!

Please continue to pray for us, for strength for the many demands, for wisdom to know what to take on and how to prioritize, and for ongoing grace for living in a culture that is not our own. There are days where it is very challenging and frustrating, and other days where we love it. But we know that this is where we are to be at the moment, and so we carry on.

Monsoon

It’s been awhile. I suppose sometimes the more mundane things in life overshadow the “blog-worthy” stories, and so here we are in the middle of July already! Amazing how time flies.

It’s monsoon season right now, which means that everything is wet and everything (including our clothes and towels) stinks like dampness and mould. Our feet are often wet and muddy from walking outside. You can't leave home without your umbrella, as it could start raining at any time. Fortunately the sun does come out now and then, so we do get a bit of a respite at times. This is the only time of the year that our water storage tanks are overflowing. They sit dry for much of the year, which leaves us with a water shortage a lot of the time. But right now the tanks are bursting at the seams, and for now we enjoy abundant water. As you drive along the road, all the rice fields are flooded...perfect conditions for growing this Nepali staple.

The sun does come out occasionally. Last week it brought this rainbow with it.

In the hospital, monsoon brings a bit of a slow-down of patients, as travel is a bit of an issue (more on that in a minute). However, it also increases the number of admissions for things like meningitis, snakebites, typhoid, and other GI illnesses that all seem to come at this time of year. This doesn’t tend to affect the surgical side of things too much, though we do remain quite busy in surgery, as well.

Travel is always an adventure during monsoon. Flights are unpredictable, as the weather often causes delays or cancellations, sometimes at the last minute. Recently, someone we know was almost in Bhairahawa (the airport near Tansen) before the plane turned around and went back to Kathmandu because of poor landing conditions! Fortunately, the 2 visitors we have had during monsoon made it here with no problems.

Then there are the roads. The rain often makes them very muddy, makes potholes worse, and the roads can be very slippery. Add to that the risk of a landslide, and road travel also provides no guarantee you’ll be able to get where you want to go. Landslides happen more frequently as monsoon progresses. You just hope you aren’t directly under them when they do happen! And if one happens, the traffic can’t get through, resulting in more delays. We came across this landslide the other day while out for a walk. 

We are thankful to have the opportunity to take a break from monsoon, as we are on our way home for a couple weeks for a family wedding. We made it out of Tansen without any problems, either on the road to the airport, or on the flight itself, and we are enjoying a day of rest in Kathmandu before heading on the long journey home tomorrow. We are ready for a change of scenery. As much as we love Tansen and know that it's where we're to be right now, we are tired, and looking forward to being home where (barring unforeseen disasters), you have consistent electricity and an ample supply of water, you can drink the tap water and eat what you like without worrying about getting sick, speak English, drive a car, go out for coffee, see friends and family, etc. The time will go quickly, but we are thankful for it. Please be praying for our safety, as we have a lot of travelling to do in the next few weeks. We will be back in Tansen in early August.

Sonu, Part 2

Sonu died last night.

I knew earlier on in the day that this was likely to happen. She has deteriorated and bounced back several times before, but this time it was different. Her breathing was becoming more and more laboured, and she was lapsing into unconsciousness. I knew it wouldn't be long.

She had continued to hang on since my last post, and in fact had perked up again. I really wondered if she was going to surprise us and make it after all. We did end up amputating her one leg a few days ago. Her mother knew this and had given us permission. Sonu had given a head nod that day to say that we could do it if we had to, but I don't think she realized after the fact that it had been amputated. But she did complain of a lot less pain after that. In a way I'm glad that she didn't realize that her leg was gone - she had been so against that from the start.

I don't usually go into the hospital if a patient dies in the night. The residents are usually very capable of handling it, and Nepali people have their own customs for mourning. But last night I wanted to go in and see her once more, and (much more importantly) to give her mom a hug, sit with her if need be, and pray with her. Sonu's family lives very far away from the hospital, and I knew it would be awhile before any other family member would be able to come. I didn't want her mom to feel alone, and I also wanted to connect with her for the sake of my own closure.

Nepalis are very community-oriented people, always very interested in everyone else's business. Whereas we tend to be quite private about our personal lives and our health issues, they are very open, and like to show off whatever medical test results they have, talk about their problems, and be involved...even with total strangers. In fact, there have been times where I've thought I was giving discharge instructions to a child's parent (and they nod very interestedly as I do so), only to find out later that the person I was talking to is with some other child and not related at all to the one about to be discharged! At times this interest in everyone else's business is amusing, and at times it's frustrating. But last night, it nearly melted my heart.

When I went into the burn ward, Sonu's mom was sitting on a stool, holding her young daughter who has been with her this whole time. Around her sat the other 2 female burn patients in the ward (who are both doing quite well), as well as their family members. There is a young woman, 22 years old, whose skin grafts have taken well and will be going home soon. Her husband is with her. They were clearly concerned and sad for Sonu's mom, and the husband was making multiple phone calls from his mobile phone to try to contact a family member, or at least someone from Sonu's village, to pass on the news that she had died. The other woman, who is also doing well, was sitting up in bed and trying to offer comfort to Sonu's mom. Her granddaughter (maybe 15 years old) was sleeping when I came in, but she later woke up, and immediately went over and hugged Sonu's mom, held her, and let her cry on her shoulder. She then took 500 rupees out of her pocket and gave it to Sonu's mom for mobile phone recharge cards or other expenses. Later, they took the baby from Sonu's mom, and the husband of the young woman held the baby (below) while Sonu's mom cried. It was so touching to see the love and care that they showed for her. The poor woman is still all alone. Her husband is supposed to arrive tomorrow. It's a long way. In the meantime, she has nowhere else to go, so she is sleeping on the burn ward with the only "family" she currently has. I'm so thankful that they're caring so well for her.

I took one last look at Sonu before they wrapped up her body and wheeled her away. She looked peaceful and had a little smile on her face...the first smile I've seen on her in weeks. I had been told yesterday morning by one of the members of our Pastoral Care team that she said yes to Jesus a few weeks ago. I believe she is with Him now, and her suffering is over. Thanks be to God!

Yesterday evening, before she had died, Paul and I were praying for her in our home. I was initially crying tears of sadness for her and for the whole situation. But then I felt like Jesus showed me that His arms were going to be open for her that night, and that the next time I see her, she will be whole. Then I heard His words: "Whatever you did for the least of these you did for me." The tears that followed were tears of gratitude. Gratitude for the opportunity to care for Sonu and show her the love of Jesus in the midst of this tragic situation. Gratitude for His love for her, which far surpasses mine or the love of her family. And gratitude that He made a way for us to be with Him forever. Death no longer has to be the ultimate enemy.

Welcome Home, Sonu!

Dipesh

I should have taken his picture, but I didn't think of it in time. The beautiful smile he flashed for me today was priceless. It was the first time I had seen him smile since I met him a couple months ago.

5-year-old Dipesh was another one of our burn patients. We treated him a few months ago in hospital, and I have seen him in clinic a few times since then. He was one of those kids who screamed every time you even looked at him, let alone made any move to touch him. While in hospital he had been quite sick with high fevers for awhile, and we had wondered if he would make it. Many in that situation don't. But he did, and he eventually went home. He still had some wounds that we thought would need grafting, but for various reasons he went home without that being done.

When I saw him in clinic a month later, there was still a wound that needed grafting, so we brought him into hospital and did the surgery. Only some of the graft took, but we decided at that point to send him home and see him again in a month, hoping the wound would have healed, or at least gotten smaller.

Today, as usual, he started crying as soon as mom opened the door to my clinic and started to walk in. I looked at him, smiled, put my hands behind my back, and said, "See, I'm not going to touch you. You lift up your shirt and show me." Reluctantly he did. The wounds were all healed, and I told him so. I asked to see his leg, which almost made him cry again, but I promised not to touch. That wound was healed, as well.

When I told him he didn't need another operation, he looked at me with the kind of disbelief you don't usually see in a 5-year-old. And then, cautiously he flashed me a smile. I then said, "No more surgery, no more hospital, no more injections. You can go home." Then he smiled a big smile, showing his beautiful huge dimples in the process. I proceeded to hand him a frangipane blossom, which for some reason I had brought with me to clinic today. They are a favourite flower of mine, and are blossoming beautifully right now. Their fragrance is amazing. When I handed it to him, he actually laughed. Mom looked me in the eye and said, "Thank you for saving his life."

There are many days when I cry out of sadness or frustration over one patient's story or another's. I have plenty of patients in hospital right now who are worth shedding those kinds of tears for. But this time I shed tears of joy.

We serve, Jesus heals!

Sonu

They teach us in medical school not to get emotionally involved with our patients. We are taught to stay professional and objective so that we can best care for them. There is certainly wisdom in this. If we were devastated every time we cared for someone really sick we would never be able to keep going. Having said that, it's impossible to stay completely unattached, and there are some patients who really get into your heart. Sonu is one of them. For privacy reasons I won't post a photo of her.

She is a beautiful 16-year-old young woman, newly married (yes, girls, especially poor girls, marry early in Nepal). Her husband can't be more than about 18, but I don't know his age for sure. She comes from a family of 8 children - 6 girls and 2 boys. The youngest girl is 1 year old, a spunky, very cute, curly-headed little girl, who is staying here at the moment while her mom cares for her sister. About 2 months ago, Sonu was holding some kind of metal rod in both hands, when it touched a live electrical wire. The current went in through both hands, travelled through her abdomen, down out both her legs, exiting, I suspect, around both knees, though also affecting her below the knee. When she came to us, both hands were completely black and shriveled. She had a huge, gaping abdominal wound, with some bowel exposed. Her legs weren't charred, but they were also badly burned, and bone was exposed and infected around her knees.

When she came in, we could see immediately that she needed both hands amputated. She knew this, as well. We couldn't see the rest of the damage because she was covered with blankets and dressings. I took her to the minor procedure room, sedated her, and took a look. When I took the dressings down, all I could do is stare for about 10 minutes. We usually measure burn severity in terms of percentage of body surface area burned. Her total percentage was only about 35%, but it had so badly affected her arms and legs that the injury was devastating. I stared, prayed, and wondered what I could do for her...or more to the point...what I should do for her.

Looking at it all I realized that full treatment would involve amputating both arms and both legs above her knees, a tragic circumstance, even in the west, but here in Nepal, coming from a very poor family with lots of mouths to feed and lots to do, is it even a survivable circumstance? We have funds here to pay for the medical care of poor patients, but even if she survived the care (which was unlikely), what would happen to her after she left hospital? And so I stared, and prayed, and wondered, and eventually decided that the best option would be to stick to comfort measures, knowing that she would die, but at least giving her the chance to die without (hopefully) too much pain and suffering, and hopefully being cared for in a compassionate way. As I made this decision, and for several hours afterwards, it weighed so heavily upon me that I found myself weeping, both for her situation, and for the weight of responsibility that I felt for making that decision. Then we spoke with both Sonu and her husband, and they pleaded with us to try. They said they knew her hands needed amputation. They didn't want her legs amputated - they were adamant about that. They knew she had a severe abdominal wound, but they were hoping that it might heal. They asked us to try and give it some time and see if her abdominal wound would heal, and see what happens.

This took pressure off me in terms of the decision-making. We still thought she was likely to succumb to her injuries pretty early on. She had raging fevers for the first several weeks. But she remained spunky and spirited, and it really seemed like she was fighting. After long discussions with them, we amputated her hands (which obviously needed it), and performed a skin graft on her abdominal wound, which actually was starting to heal on its own. Amazingly, the skin graft took better than almost any other skin graft I've seen! Instead of dying, she seemed to be actually thriving. She was maintaining her weight (i.e. nutrition), and was still energetic and holding on. But she still remained in a lot of pain, and there was still the question of her legs.

About 2 weeks into her hospital stay, her husband disappeared, and nobody has seen him since. I suppose you can't blame him...what a circumstance to find yourself in when you're just a kid, newly married, with your whole life ahead of you. But it added to Sonu's woes and to the tragedy of the situation. Her father came to stay with her, bringing with him a notebook in which people from his village had written their names and pledges for how much they would give to help pay for Sonu's care. The pledges were generally in the 10-20 rupee range (15-25 cents maybe), and amounted to about 5000 rupees (maybe $60) - a fraction of what her care would cost...but it was really touching to see.

Now, about 2 months later, Sonu is still with us. But she isn't herself anymore. She sleeps a lot and she's refusing to eat. We keep on putting feeding tubes through her nose into her stomach to feed her, and she cries and cries and begs us to pull the tube out. But she is losing weight, and is now looking more like a skeleton than a girl. She cries in pain whenever we touch her legs, so we have to sedate her for any kind of dressing change or wound care. She hasn't had a fever in about a week now. We don't know if that's a good thing or a bad thing...good thing because the infection is more under control, or bad thing because her immune system is so compromised that she can't even mount a fever anymore. We're not sure which.

I spoke with her and her mother the other day about how things are going. It really seems like she is going to die. But she's surprised us before. I talked with them once more about amputation of her legs, which may put more stress on her body than she can handle at this point, or it may be what is needed to save her life. But for what? They haven't made a decision yet, which means that the decision may end up being made for them soon. The other option is comfort care and letting her die. She's almost past the point of us being able to do anything more for her, and delaying this much more may put her past that point. We'll see. When I said to her mother that her daughter might die, she began to cry, and said, "My daughter is going to die?" I said - with tears in my own eyes - that yes, that was very likely. There really is no easy answer in this situation. And with my still limited Nepali, having an indepth conversation about all of this is impossible. All we can really do is pray for wisdom and compassion as we continue to care for Sonu and her family as best we can.

It has been an emotional roller coaster for me and for the other doctors caring for Sonu for the past few months. But it sure is a reminder of why we are here. She was sent away from 3 other hospitals because of both the severity of her injuries, and their poverty. At least here we have funds that we can use to pay for her care, we have compassionate staff, and a wonderful Pastoral care team who has been very much involved in caring for her. Whether she survives this or not, we do know that she has had the opportunity to hear about the God who loves her, created her, and died for her, and who will gladly welcome her into His arms if she'll put her trust in Him. We pray that she does. 

Contentment

Life in Tansen, as with anywhere else overseas, has its ups and its downs. You can't argue with the view we get from our window. We have a full-time house-helper, who not only does our laundry (by hand), cooking (all from scratch), and cleaning for us, but she is also a lovely lady. Nepalis in general are really lovely people, easy to get along with, very warm and friendly. We have a very comfortable house to live in (at least we do now that Paul has done so much work on getting it fixed up). Jessica's work is steps away from home, which means we usually get to see each other periodically throughout the day, and we can often eat lunch together. We have a great team of people here, and some good friends. And being here together is such a blessing...so much better than being here (or anywhere) as singles. We have much to be thankful for.

Still, there are many challenges. Water and electricity supply is somewhat sporadic. It is a rare day where the electricity doesn't go off at least once. We have to filter all our drinking water. Even with filtering, we still get sick regularly. We have each had Giardia (a GI infection that is very common here) - Paul twice, Jessica three times - in the last 4 months. Not to mention the wicked food poisoning that Jessica got just after arriving in Nepal in January. Even when we're not overtly sick, we still often don't feel well, and that tends to be most people's story over here. It takes a toll on your health, energy, and overall sense of well-being. Work is busy. There are many cases that are not straightforward, and even those that are take more work and energy here than they would at home. Why? A culture that is different than our own. Trying to do it in a language not our own. Not feeling well a lot of the time. Etc.

There are critters...spiders, cockroaches, snakes (not too many around here compared to where Paul was in Mozambique, but still an issue), termites, and other lovely things. The weather is not freezing cold in winter, but cold enough when you don't have heat inside and you get frostbite from washing your hands because the water is so cold. And in the summer it's hot, and soon it will be monsoon, during which we get so much rain that our 1 million litre water storage tank gets full within 3 days! You don't come to Nepal for the weather, except maybe in October!

Then the community we live in, as wonderful as it is, is small. We get bored of each other. And we say a lot of good-byes, since most people that come come at most for a few years, and then leave. So far in the last 3 months we've said goodbye to 3 families that had been here for 3 years or more! Thankfully, that's it for awhile, now, I think. Goodbyes are tough! We get a bit claustrophobic here in Tansen at times, because there isn't really all that much to do, and there aren't many options for going out or getting away. If you enjoy walking/hiking, living in Tansen is a dream, but that can get old after awhile. Other than that, there's not a whole lot to do, and boredom is an issue more often than we'd like. We watch a lot of movies and TV series (on my laptop). If you want to get away, the nearest place you can get away to is Pokhara, a 4-5 hour drive on a road that makes you so nauseous you really want to make sure you are truly ready for a break before you venture on that trip. Add that to being far away from friends, family, and all else that is familiar, and at times you wonder if you really would be better off packing your bags, heading home, and forgetting this whole thing.

It's easy to think that the proverbial grass is greener on the other side. But if we're always living for the next weekend, the next vacation, the next time we go home, the end of our term, graduation, our children growing up, retirement, or whatever, then we'll miss what God has for us TODAY. At a retreat we were at recently, the speaker said that "the only time that matters is now and the only place that matters is here." This doesn't mean that we don't plan for the future, or look forward to future events. But it does mean that we choose to be thankful for the opportunities God has given us today to love and serve Him, to experience more of His presence and His love in our lives, and to be thankful for all the blessings we already have.

We've been working on contentment this week. The apostle Paul tells us that Godliness with contentment is great gain. He also said that he had learned the secret of being content in any and every circumstance. You don't need to do an extensive study on Paul's life to know that he didn't have it easy! Shipwrecks, beatings, hunger, cold, tiredness, being stoned, etc. (Makes our life here in Tansen look pretty cushy, actually, but that's beside the point). He learned that he could do all things through Christ, who gave him strength. This is true for us, too. God has called us here, and that is far more important than weighing the pros and cons of staying or going. We know that where He has called us, He will give us not only grace, but also joy as we do what He's called us to do.

And really, in the midst of the challenges, we are very blessed. We may not be able to go out for breakfast, or to Starbucks (or Tim Horton's - take your pick!), or out for a nice dinner. But we've been learning to make breakfasts that we'd say are worthy of a restaurant, and we love our weekend breakfasts together. We've also figured out how to make bagels and even some version of cream cheese! We make our own lattes, and other nice coffee. And our most recent endeavour was creme brulee...yum! It's been fun to experiment, and fun to enjoy nice food that we've made with our own hands.

Paul has dreamt of having an orchard/vineyard for some time now. While we're not sure if this will ever happen (at least on this side of eternity), around our house is a plum tree (currently full of yummy plums), an orange tree, a peach tree, and an apple tree! Our didi is currently making plum jam, since we have no way of eating all the plums, even after sharing them with many others. We grow vegetables in our garden, and we're getting some fencing ready to plant grapes in a couple months when the season comes. So we have our own little orchard here, and we haven't even really had to work for it. What a sweet blessing from the God who knows the desires of our hearts and who loves His children!

So we're praying that in the midst of the challenges, we would learn to rest in a place of contentment, knowing that God has called us here, and that sooner than we'd like to think, our time here will be over. May we not miss the joy of embracing TODAY, with all its joys and challenges, and may we be content whatever our circumstances, for that is great gain.

Outside the hospital

Most of what we've written so far has been about the work in the hospital and on our house. All of which still continues, of course, but there is more to life than work...

Pokhara

We spent a few days in Pokhara, a place about 4-5 hours from here, last month. The worst thing about going there is the road there and back, which is very twisty and not so nice for those of us prone to motion sickness. But since there aren't really places nearer than this to go to get away from Tansen, people tend to go there relatively frequently for a break. There are lots of restaurants to choose from, unlike Tansen where we have 1. There are places to shop for some of the necessities that you can't buy here in Tansen. There's a lake where you can go for a boat ride, walks you can go on to see the sunrise (if you're so inclined), paragliding (not for me, thanks!), and other opportunities for R+R. We had a great time away, and came back rested, and laden with supplies and treats.

Chitwan

Last week we went to Chitwan, also about 5 hours from here, for an expatriate retreat. Unfortunately we didn't enjoy this as much, as it was HOT (43 degrees celcius!), and Jessica got sick with strep throat and was quite miserable for a few days. But we did get in an elephant ride. Chitwan is the place in Nepal that is known for animals...tigers (supposedly, though we didn't see any), rhinos, elephants, crocs (yes, we saw a couple), and lots of birds. There is a "jungle walk" you can go on, but we were told you have to be able to climb a tree in an emergency (i.e. if a tiger comes along), so we opted out of that experience!

Tansen

Although the best way to get a break is to leave Tansen, there are options here, too. We certainly don't lack scenery and nice places to walk. We also recently enjoyed a very short visit from some good friends from Canada. Their arrival marked the inauguration of our spare bedroom (below), which was the last room of the house to be finished (we finished setting it up late the night before they arrived). There are still a few small projects Paul is working on inside the house, but the majority of the work is done, and we love our home. We especially love that we have a verandah that gets sun during the morning but shade in the afternoon. It looks out at the Himalayas (when you can see them), and is a really sweet spot to sit and enjoy some rest....and homemade lattes!

While there are options for R+R, the work here is busy and with all the demands and requests that come from many different places, we do find that we get tired. Please be praying with us that we would be able to find a good balance between work and rest, and that we'd be able to set boundaries effectively.