Journal Entries from Dr. Clarke

1 March 2012 

As we finished rounds today, the last patient was a 9 year old girl admitted the night before.  She looked ill.  In fact, she looked apprehensive, as though she sensed something bad pending.  I pointed out her apprehensive look to one of the students standing beside me.  A different student was examining her at the time.  But when I examined her, I was reassured.  She did not have fever.  Her heart rate was high, but not dramatically so.  She was alert and though she did not enjoy bending her neck, it was not as bad as other joint.  She really resisted me moving her joints (particularly elbows and knees), but there was no warmth or redness.  She had a big spleen. 

            I knew that she was quite ill, but I felt comfortable that this was malaria.  The question I had was whether to change her from ACT to Quinine, but we elected to continue the ACT as the fever was down.  Later this morning the patient became much sicker and started frothing at the mouth.  The nurses quickly put in a line and started the Quinine, but the child died before the Quinine was completed. 

            As I was writing this, Samuel Ireri came to me to tell me a second child died today.  This child also came in during the night.  She was a 15 month old child who came in with high fever.  The child did appear to be a bit cloudy, but what impressed me mostly about her on rounds was her low tone.  In biology there was a time when we would pith a frog, that is stick a needle up the spine, thus destroying the spinal cord.  You could then dissect a life frog and see the heart, lungs, and other vital organs working.  This child looked like a pithed frog.  There was little tone in the extremities.  Indeed, one of the neuromuscular disorders entered my mind, though she could sit up (or at least stay up once put in position).  At rounds she did not have fever.  She had been started on Quinine.  Though she did not have a big spleen, I thought malaria the most likely diagnosis and I did not alter her therapy.  When the nurses came back from lunch today, the child had died. 

            I realize that two deaths in a day do not constitute a wave, but it is discouraging in our small hospital.  I have been in hospitals when deaths seem to come like waves and it is disheartening.  Appropriately, there is a close examination to make sure we are not doing anything to cause the death or missing anything.  There is discouragement about the work.  Superstition sets in among the patients.  Today I saw a child with diarrhea and vomiting.  The child was not that ill, but the mother and older sibling also had the same thing, so for the family’s sake, I put them into the hospital.  When that second child died, the father took his family home.  Even more ominously, this could be the start of an epidemic of either meningococcus or a more virulent form of malaria.  We will be diligently looking. 

2 March 2012  

We have a five year old on the ward who came in with high fevers for three days, then started with vomiting and diarrhea the day before admission.  When she came to us, she had a low-grade fever, a distended abdomen, severe pain in the right lower quadrant (RLQ).  I felt this was fairly classic for typhoid fever.  Typhoid fever is caused by Salmonella typhi, a first cousin to the Salmonella that causes a lot of food poisoning.  It does cause vomiting and diarrhea, but typically there is high fever for 2-3 days prior to the onset of the gastrointestinal problems.  It can cause major problems, including rupture of the bowel, and the girl was sick when I put her into the hospital.  The drug of choice for Typhoid Fever used to be Chloramphenicol, and in my book, it is still the favored drug.  There are areas of the world where Chloramphenicol has been sold over the counter, and that includes South Sudan, but it is not a favorite.  People tend to prefer Penicillin here for injections.  For oral drugs, they tend to prefer Cipro.  Both of those drugs feature prominently in the GoSS supplied drugs and therefore tend to be found in the market place for sale.  My estimate is that Chloramphenicol is used much less often in that context and therefore organisms from the community should be less prone to resistance. 

            This morning on rounds she was fairly cheerful.  She did vomit once yesterday, but not again through the night and her diarrhea has slowed down.  On exam, the abdomen was less distended than before, the RLQ perhaps a bit less tender, but now I can feel the spleen.  Could this all be malaria?  The experts from America differ as to whether malaria causes any gastrointestinal problems.  Those who take care of malaria regularly are convinced that it does.  But I do not think the primary issue in this child is malaria, particularly with the response we have seen to the Chloramphenicol.  I think it very possible that it could be contributing to her illness and we did start her on ACT. 

            This girl is from Akot.  If we know anything about Typhoid Fever, it is its tendency to cause epidemics.  Episodic cases do occur, but this child could be the first case of an epidemic.  Our antennae will be up.  It gives us something else to be considering. 

3 March 2012 

My adventure today has tentacles reaching back several weeks.  We had a team from America coming, so we needed all the vehicles running their best.  We had been resuscitating and nursing along the battery in the new pickup (only five years old) and Lazarus’ battery was dead, so I decided to get a couple of new ones.  I went to the place where I generally get my parts and asked, but they do not sell batteries.  I have bought batteries in Rumbek before, but I thought these guys might have more insight as to where I should go.  Jovia is the receptionist at the parts place from Uganda and she has become a friend, so I asked her.  She pointed to a place relatively near, so I elected to buy my batteries there.  I do regret it.  I told him I needed batteries for LandCruisers.  All three of our vehicles are LandCruisers (two are pickups and the one I generally refer to as a LandCruiser we call the High Box).  LandCruisers are by far the most common vehicles in South Sudan because of the harsh conditions.  So when I told the proprietor the batteries were for LandCruisers, there was every reason to expect him to know what batteries a LandCruiser needs and whether his batteries meet the specifications.  Wrong.  He sold me a weak battery.  I explained again how it would be used and again he reassured me.  I got the batteries, the sulfuric acid, took them to Akot, filled and charged the batteries.  It was not enough.  We tried running them in the car for a bit, but they could not turn the engine over.  So I went back for an exchange.  That took some negotiating, but he exchanged one for the larger batter (N70 rather than N50), and I had to buy the second.  My dismay was compounded when these did not work either.  So now I am trying to figure out what to do and we are still using the old battery for now.  Generally once that battery has been started once, it will start the remainder of the day.  Yesterday I helped move some mudbricks and the pickup started just fine after the initial push start, so I anticipated the same thing today.

            Abraham Laat has been after me for several days to help his sister.  She, as everyone else lately, is a victim of the Agaar-Atuot violence because she lives on the frontier, the areas close to the other sub-tribe.  Her major issue is grasses.  The thatch that roofs the tukuls does not come from just anywhere.  We have tons of grass around us that looks similar, but that are not really the same.  The grasses used to re-roof the tukul often come from close to the lake or river.  The shaft is rather large (compared to our grasses at least) and there is a sturdiness about that grass that is not true of the weeds lining our paths and blocking our views when driving.  It costs about 10 pounds/bundle and a tukul usually needs 15-20 bundles, so re-roofing is serious.  But grasses are not as important as food for families.  Shelter comes before clothing but after food in the survival algorithm.  But I was committed and we bounced over mounds making a path to his sister’s tukul.  I parked the car at one side of the tukul, but Abraham directed me to the other side where the grasses were arranged.  I backed over some more rock hard fields and put the truck next to the stores.  We started loading the grasses with Abraham Laat up in the bed of the truck.  Soon we were over the sides and they got some limbs to stuff in the sides of the truck to hold the grasses in.  Soon we were well over the cab of the truck and I thought we were getting too high, too likely to fall, so I called it.  I jumped in to start the truck and got a slight groan.  The battery.  We were far away from anything approaching civilization and I did not have a phone.  I could foresee us walking back to Akot and then having to ride out in the LandCruiser to get the pickup going again.  I have push-started the car more often than I want to remember, but that is generally on fairly packed surfaces.  This was over a field.  But we had to do it.  Laat and his brother and all the women helped.  I was out beside the truck pulling/pushing.  We cleared some brush, moved forward and got some momentum, but not enough.  The engine coughed but did not start.  We had to try again.  We pushed several times without rolling at all.  We seemed past the obstacles, but we could not get going.  I looked in and the truck was still in 2^nd gear where I had left it in my unsuccessful first attempt.  Back in neutral, we got the truck rolling and the engine came to life.  The worst case scenario had been averted. 

To keep the grasses in, we use ropes.  I put one around the posts, but fairly low, so the poles were sticking out the side, much like a shrimper lowering its nets.  I planned to come around again high, but Abraham thought going over the top more important.   I anticipated some problems.  We snaked our way to the tukul through some fairly tight squeezes, so I knew it would be difficult getting back out.  Twice in the first quarter of a mile, we had spillage from a tree limb catching a bundle or one of the posts hitting against a tree.  We decided to repack.  We had to keep the truck running, which is frustrating when fuel is 8 pounds/liter, but I dared not turn it off.  This time as the boys handed up the grasses, I roped in the poles at the tops to keep them from leaning outward.  And like a building built squarely, the pressures on the poles were not too great and poles stayed upright.  One bundle from the top spilled about half of its grasses, but we arrived intact.  One more down and one more lesson learned.

4 March 2012 

I come from a family of attorneys, and my father has a humorous story about a classmate badly misusing the legal term eminent domain, so I must be careful here.   Eminent domain is when the government takes over the property of an individual for the good of the community.  An old house on Main Street is condemned to allow the construction of a new courthouse.  In America, when that occurs, the individual has the right to demonstrate an equally effective way to meet the goal as an alternative (my father did that at his property and won) and the government must compensate the individual fairly.  I have complained in the past about the failure of eminent domain in the Dinka culture.  An individual decides he wants to extend his field into the road and he throws down a couple of sticks and declares the road closed.  I have thrown away many such locally imposed detours.  But yesterday I heard something from the other end of eminent domain abuse.  I was taking Deborah, one of the students working in the hospital with me, to her sister’s house in Rumbek.  As we turned down the street where she lives, a bulldozer was knocking down a mango tree.  We went some ways down the street and Deborah was excited.  “They did not knock down my sister’s house.”  This was another home owned by her sister and brother-in-law that they rented out.  What looked to be the new road came within a few feet of the house, a nice one by Dinka standards, but the house appeared to be spared.  Later, though, the sister informed us that the house would be destroyed so that they could widen the road.  They would lose the house and property, and there would be no compensation given.  “If they are fortunate, the government may give them some land outside the city, but nothing for the house,” Deborah informed me.  Nor will there be any insurance to help them.  I can imagine the protests that such an approach would generate in the US, but in South Sudan, it is just part of life.  I heard Deborah and her sister talking about the problem.  Though I made out few of the words, it was obvious that the sister had resigned herself to what was going to occur.  I often complain about government interference; I am for a smaller government, but I like the US form of eminent domain far more than the South Sudanese equivalent.  

5 March 2012 

Our first go at having Rumbek nursing students in our hospital tanked.   Shortly after their arrival I snuck them out of Akot, fearful that Malek might be the target of the malignant revenge of the Dinkas (see 28 February).  So I was pleased that CISP elected to continue the program even after the disastrous start.  Two more nurses, John Umbali and Kuotca Paulino came to spend a few weeks with us.  They are both from the Nuba mountain region.  Much information has come to the US about Darfur, but in fact, Khartoum has been guilty of similar abuses in various regions of the country all along.  The Nuba Mountains and South Kordofan are geographically located in northern Sudan, but the people are black.  Again, I have some difficulty distinguishing the Arabic black from the African blacks, but Khartoum obviously does not.  Throughout both Anyanya I and II, the wars of Khartoum against blacks of southern Sudan, the Nubians were also under attack.  Khartoum labeled the wars as jihad, religious wars against the infidels, but as the atrocities in Darfur suggest, the real explanation that fits the facts is attempted genocide.  The Khartoum government apparently hates sharing the country with blacks.  When the CPA (comprehensive peace agreement) was reached in Jan 2005, the Nuba Mountains were also to be allowed to vote on separation.  Instead, in the April 2010 elections, the governor of South Kordofan was selected by a large margin, but somehow Khartoum refused the man and sent Bashir’s handpicked crony instead, leading to unrest and eventual bombing of the civilian population.  I am unsure of the events in the Blue Nile region, but the referendum was again blocked and bombing and killings have followed.  Since the independence of South Sudan, it is as though Khartoum does not believe world opinion matters.  The little restraint the CPA engendered has evaporated and Khartoum is again bombing and committing all kinds of atrocities against its citizens in the Nuba Mountains and Blue Nile, though it usually goes unnoticed by the US.  The Upper Nile region of South Sudan is loaded with refugees who choose to face turmoil and possible starvation in refugee camps rather than the fears and potential for death from Khartoum’s military activities against her own citizens.  But these nursing students are committed.  They are from the Kauda region of Nuba Mountains, a place somewhat less affected than others parts of South Kordofan,  but still quite hostile.  Once they compete their education, they will return to Nuba and continue the struggle that so much of the world has ignored.  I am glad we can play a small role in assisting them. 

6 March 2012 

Robert Chekata visited us today.  He is from Mapuordit hospital.  I contacted Dr. Rosario, the head of that hospital, a few weeks ago about coordinating services for HIV/AIDS in our region.  Dr. Rosario has been in South Sudan close to 10 years and Mapuordit is arguably the best hospital in the Lakes State.  In the past, we have worked through Malteser for HIV, TB, and leprosy, but now Malteser is changing their emphasis (though continuing their work in South Sudan) and we need to either tackle this question alone or coordinate with someone else. 

            Robert told us the currently accepted incidence of HIV in the Lakes State is 3.7%.  That is still low compared to much of Africa (or even parts of South Sudan), but that is enough.  Given the level of promiscuity and the amount of denial, we will be inundated with AIDS within ten years, possibly five.  As we talked, Mary Agum said that Peter Mangar had been threatened by those in the community because they said he was lying when he told someone they were HIV positive.  Michael Marial said that a friend of his boasted that if a woman came to him telling him she was HIV (+) he would sleep with her anyway.  The wife of a man who died with AIDS refuses to get tested and now the man’s brother is sleeping with her to fulfill the role of kinsman redeemer. 

            I said I would like to get enough tests to screen all pregnant mothers and everyone coming for treatment for STD (sexually transmitted diseases).  The reason for screening pregnant women is that treatment with anti-retroviral therapy (ART) is proven effective in reducing the likelihood of the child becoming infected.  The reason for screening those with STD’s is twofold.  First, STD’s tend to run together.  Someone with one STD (say Gonorrhea) is more likely to have a second, including HIV.  The second reason is to drive home the point that sexual promiscuity puts you at risk for AIDS.  Currently we can treat most of the STD’s coming our way.  But unless I miss my bet (and I hope I do) HIV will soon become one of the most common STD’s in our area.  I shudder as I say this. 

7 March 2012 

Another baffling tragedy came in today.  It was baffling not from a patho-physiological stand point: I understood the medical issues.  It was baffling because it was beyond my comprehension of how it could occur.  A ten year old boy came to me today with pain and fever originating from his R eye.  He had been in too much pain to sleep the last two days.  Exam showed R orbit (eyeball) that was fairly hard.  The sclera (the white of the eyes) was blood red.  But most troubling, the pupil looked like pus.  He had endophthalmitis, an infection of the eyeball, a dangerous medical emergency. 

            As I got more history, I found out that the child of a friend, the younger cousin to this boy, shot him in the eye with a bow and arrow.  My friend told me that his son had the bow and arrow, but that other men told him to shoot at people.  That is like telling an obese man he can eat his way into fitness.  Of course the child started shooting everyone he saw and predictably tragedy occurred.  Had no one corrected the boy?  Had no one told my friend?  I find that hard to believe, but it may be so.  But what really baffled me was that this occurred two weeks ago.  He was seen on the day of the injury and treated appropriately and the mother was told to bring him back in 2 days.  Who knows what might have happened had they followed instructions.  Chances of the child losing vision in that eye still would have been high, but that prognosis was not as grim as it is now.  I watched the tears streaming down this mother’s face as she contemplated her son.  She is from Akot.  I have little doubt that this mother loves her child or is grieving for his loss of vision and possibly even worse, but I cannot conceive of taking such a casual interest in the child when it mattered. 

            I gave the child Ketamine and injected Ceftriaxone 12.5 mg indirectly into the orbit.  I also put him in the hospital.  The optic nerve is called the first cranial nerve (the first of twelve nerves coming directly out of the brain instead of going through the spinal cord) but now most experts say that is inaccurate.  It is not a nerve at all.  It is part of the brain itself.  And there is a danger of the infection spreading into the rest of the brain.  This is serious, made more so by two weeks of neglect.

8 March 2012

 Noncompliance is a general phenomenon in medicine.  Indeed, in the US, if a medication is given and half is taken the way the doctor prescribed, it is considered good compliance.  Over 25% is fair compliance.  Taking 80% of the drug is excellent compliance.  When I was in the Air Force, a pharmacist told me about taking a truck around base and collecting medications that had been given out but not completed.  There was no incentive or coercion, but the truck did not make it half way around the base before it was full and had to return to dump all the drugs before continuing.  But sometimes I think I had never seen a lack of cooperation with medical care until I got to South Sudan. 

            We have a 65 year old man who came to us with abdominal distension and diarrhea for 6 months.  He also had not urinated in two days.  Our nurses were appropriately concerned and put in a urinary catheter.  They got back a little urine and some blood.  We have treated the man for probable giardiasis with Flagyl, and his abdominal complaints are drastically reduced, and the urine output increased greatly after some IV fluids, but now is falling off again.  For several days now we have been supplying water and encouraging him to drink, but he says he is not thirsty and therefore he will not drink. 

            I had a seven year old in clinic today for cough and fear.  The cough has been chronic, so I suspect asthma and want him to take deep breaths and blow out hard to see if that will induce wheezing.  He looked me in the eye and steadfastly refused.  He complains of left upper quadrant pain in the abdomen, but will not take a deep breath, so if there is a moderately enlarged spleen, we will never know. 

            Overall, I have loved working here with the Dinkas, but I have never met a group more stubborn.  One patient was complaining of how concentrated her urine had gotten, but again refused to increase her water intake.  Routinely patients refuse to answer the questions I have asked but want to go into detail about how the worm in their kidney is eating through their diaphragm.  I see patients here going home after illnesses that would have killed them and I am encouraged, but sometimes I feel I would rather be a psychiatrist for lemmings than deal with Dinkas.

            Then I start thinking about my own disobedience.  God my Creator, designer, Father instructs me in what is for my good and I look Him in the eye and disobey.  “See, I have set before you today life and prosperity, and death and adversity, in that I command you today to love the Lord your God, to walk in His ways and to keep His commandments and His statutes and His judgments that you may live and multiply and that the Lord your God may bless you in the land where you are entering to possess it” (Deut 30:15-16).   Why do I so often choose poorly?  And why does God put up with my disobedience?   When I get so mad at Dinkas that I could spit, let me go to the mirror and remember God’s patience with me. 

9 March 2012 

We had an unusual case today.  A mother brought in her three week old girl with swelling behind the ear.  One look and it was obvious that it had to be drained: it looked like two headed boil that should have ruptured three days earlier, and there was a third spot right next to it over the mastoid process (the bone just behind the ear).  But the real question was the source.  The scalp was clean, so these were not just severe reactive nodes.  Mastoiditis is a type of bone infection, usually associated with chronic ear infections.   I did look in this child’s ear, and it was unremarkable.  I thought about TB.  Miliary TB is a severe kind of infection that the child can get from the mother, but usually the mother must be somewhat ill for that to happen.  This mother had a few complaints during her pregnancy, but nothing suggestive of severe disease.  Beside a child with miliary TB should be quite ill, but this child looks good except behind the left ear.  She is nursing well.  I gave a “whiff” of ketamine and then incised the lesion.  About 3 ml of pus were removed.  I probed down to the mastoid bone, and it felt a bit rough, though I cannot claim to have done that procedure often, particularly in 3 week olds.  I gave some Ceftriaxone and admitted the child.  This afternoon, the child looked good and was nursing well.  There was little drainage through the wick I placed within the lesion.  We will see what tomorrow brings. 

10 March 2012 

I need a two week vacation—from me.  The only problem is that I do not know how to leave me behind.  I have been in the foulest mood lately without any justification.  I know that I have been the recipient of amazing, unbelievable grace.  I am the adopted child of God, joint heir with my Lord.  I am in a place where I can see the significance of my work on a weekly if not daily basis.  If I had any sense of justice and fair play, I would never leave my knees.  Instead, I act more spoiled at times than any princess complaining the three boulders in her bed.  This little gadget does not work when I want it to.  That person did not thank me enough for what I did.  This group has the audacity to question my judgment on a medical matter; that Dinka wants to tell me how to drive.  Mortal offenses, everyone.  And then instead of laughing at my stupidity, ingratitude, orneriness, I sulk because I have demonstrated again how desperately I need a Savior.  I came back from Rumbek this evening and you would have thought my favorite dog died and my children denied any connection to me, whereas in truth it was a fairly unremarkable day.  I was just engaging in a little pity party.  I am so sick of doing the same thing over and again, but I see so little progress.  I am growing old without growing mature. 

            Sorry.  I hate to unload, but I had to talk with someone, and right now I am not speaking to me.

11 March 2012 

Tin-Machar Baptist Church used to be my favorite church in the area.  Since I have been here, I have sought to go to various churches around, to not be too strongly associated with any one church or denomination.  But I would find myself under the Lulu tree in Tin-Machar church every month and sometimes 2-3 times in a month.  However, there has been some conflict with the pastor, Abraham Maper and some strain in the relationship so I have been much less frequently this last year.  However, a couple of the young men from the church asked me this week to come back to their church.  I asked Abraham and he was for it, so that was my plan for Sunday.  Dr. Rossi and the girls decided to go back to the ECS church, and Judy was going to the Baptist church in Malual.  I was going to take the pickup, but the keys could not be located.  I suspected Dr. Rossi, but he says he had not had them for 2 days.  I remembered that Samuel Maker had them, but later I found he put them on my bedside table (without informing me, I say in my defense).  By the time I found them Judy and I had made plans to first go to Tin-Machar and afterwards to Malual so she could teach songs. 

            I seem to recall more people at Tin-Machar.  There were a few men and older boys, a few more women, and an abundance of children.  As usual, there were very few there before our arrival.  The increase after our arrival was about as speedy as usual, but just not as many as before.  I told the story about Simon the Pharisee having Jesus for dinner (Luke 7).  A harlot (I think Mary Magdalen) comes to Jesus, washing his feet with her tears and drying them with her hair.  She kissed his feet and anointed them with perfume.  Simon is indignant, thinking Jesus must not be a prophet if He cannot tell what kind of woman is touching Him.  So Jesus tells a brief parable.  Two men owed money: one 50 and the other 500 denarii.  Both were forgiven their debts.  Who is the more thankful?  Then Jesus contrasts Simon’s lack of hospitality to the harlot’s show of gratitude.  I believe Jesus would have us both remember and forget our sins.  Let us forget them rather than be weighed down with them.  God has removed our sin from us as far as the east is from the west (Ps 103:12-14, one of our readings).  But He would have us remember how much we owed Him so that we respond in gratitude toward God, forgiveness of our fellow man, service for the church and community. 

            After church, we drove to Malual.  A lot of Dinkas, particularly the boys, will ride anywhere a car is going and walk back just to have the pleasure of the ride.  We had a fairly full pickup heading to the Malual church.  We were expecting church to be over, but found that they were early in the service, so we joined them.  I glanced around and saw no one that appeared ready to preach, so I found some notes from an earlier presentation of the Prodigal Son, my favorite parable.  I might have used the same sermon if there was only one repeated hearer, but as there were many, I thought it better to deliver a different message.  One thing that did impress me was how many people were there despite the lack of a preacher.  I estimated the congregation to be twice the size of the one in Tin-Machar.  We sang and had sharing times, and then I was called upon to preach.  A young man from the congregation was called to translate, but he was not used to the American version of English and soon had to step aside in favor of Mary Agum.  I felt animated and it was a fun presentation.  Amazingly, however, the major lesson of the two parables is the same.  We get more review of the sins of the Prodigal; those of Mary Magdalene are self-evident.  We do have the great demonstration of grace where the father, instead of turning the dogs out on the Prodigal, runs to embrace him, calling for a robe, ring, sandals, and a feast.  But the real lesson is for Simon and the elder brother: we cannot forgive or love our brothers unless we remember the grace that has come our way.  God has forgiven me incredible sins, and I must in turn forgive others real offenses.  There is no evidence that either Simon or the elder brother learned that lesson.  I hope I have.

12 March 2012 

Jacob beckoned me from the doorway.  There was a tall woman standing beside him.  I had seen him with her a couple of days ago, scalpel in hand.  I thought at the time he would ask for my assistance, but he did not.  I try to keep a balance between being over-bearing and being irresponsible.  I want to give our staff some freedoms, partly because I do not want to be called on every patient, but I also want those who come to our clinic to receive good care every time they come.  It is a balance I am still trying to perfect. 

            The lady had suffered with swelling and pain in the tip of her right index finger for two weeks.  She attributes the swelling to an injection at the wrist she received in Adol, but I assured her that was very unlikely.  I am not sure I have an accurate view of what has occurred over those two weeks.  Dinkas are notorious for telling you what they want you to know and withholding the rest.  But she came back in a lot of pain.  She essentially did not sleep the night before. 

            What impressed me more than anything about her exam is that there was a dead smell coming from the finger tip, as though she had been working in dead fish all day.  The finger tip was swollen, very painful, and somewhat tense.  It had a mid-line incision at the tip, the very place Primary Surgery suggests avoiding because of the potential for nerve damage.  I assumed that was from Jacob.  I did a digital block and opened the finger parallel to the nail.  There was little bleeding and no pus.  I am afraid that much of the finger tip is dead.  I am convinced she had what we call a felon, which is basically pus trapped in the little compartments of the finger tip.  The major problem is the pressure can induce ischemia, insufficient blood delivery, or even infarction, death of tissue from lack of blood.  I cannot imagine the pain she must have endured these last two weeks, but I am afraid her bravery and Jacob’s confidence have not served her well.  I did pack the finger and leave it open and started her on Flagyl.  I hope that there is enough viable tissue there to not lose the finger tip. 

13 March 2012 

I admitted Piath today, a 14 month old girl child with a short history that did not fit.  While Rebecca was examining the child, I noted that the posterior fontanel was not closed.  Fontanels are the places where the skull is not completely joined in newborns.  They are important because of the rapidity of growth of the child’s brain, far faster than the skull can grow.   The posterior fontanel usually closes by 4 months, whereas the anterior may not close until 18 months.  The lack of closure of the posterior fontanel plus the wasted limbs, particularly the buttocks, spoke of a chronic, severe process.  She was somewhat sick today with fever, cough, vomiting and diarrhea, but I strongly suspected that this child had AIDS.  I noticed, however, that Mary Agum was remaining quiet during the examination.  On examination, I found severe thrush and crackles in the left lower lobe area.  I admitted the child to the hospital to test for HIV (mother and child) and started the child on Septrim and Nystatin. 

            After they left, Mary Agum opened up.  “I was trying to catch your eye.  Do you not remember this mother?”  I confessed that I did not.  Mary remembered her very well.  The husband died in 2010.  Mary was fairly certain that the mother had been tested before and found positive for HIV.  In an ideal world, the mother would have been tested and if (+), started on ART (anti-retrovirus therapy), thus substantially reducing the risk of transmission of HIV to the child, but South Sudan is far from an ideal world.  Instead, she started spreading malicious lies about Peter Mangar, the Dinka involved in testing for HIV in our clinic.  There were several men in the area who threatened Peter to stop the testing.  Peter told Mary and advised her not to translate when the discussion is about AIDS.

            Mary had reason to believe Peter.  In her own family, a brother-in-law was HIV positive.  Mary sought to persuade him to take ART’s so that he would have several more relatively healthy years with his family.  She also warned him about his own infectivity.  Instead of receiving the advice kindly, he and many of his extended family decided Mary was making all this up and sought to put a curse on her.   The fact that he died from the illness did nothing to persuade them that she was correct.

            When we speak of terminal cancer, we mean both incurable and the disease that will kill the person.  Sometimes I think we suffer from terminal stupidity.  “How many times can a man turn his head and pretend that he just doesn’t see?” (Blowing in the Wind, Bob Dylan).   Mary wants to keep quiet, but we cannot.  We must continue to at least try to warn them.  If they continue to ignore us, their blood is on their own heads. 

14 March 2012 

I have continued to meet with some of the pastors, teaching them from the Heidelberg Catechism.   The results are mixed.  Less than half of those who started have continued to come, but there have been some really good insights and confirmations from those who have stuck with it, and today that was even more the case.  We did not start propitiously.  I have been on time for every lesson until today.  Okay, I have been a few minutes late a couple of times, but I arrived before anyone else.  But today I was doing something in the hospital and then had to give a ride to a family who has been in the hospital for several days (the mother  8+ months pregnant, the child with severe croup), and then Rose wanted to do something along the way, meaning I then took her back to the hospital before arriving 25 minutes late.  And there were only two Dinkas.  But the discussion was very good, climaxing at Question 60: How are you right with God? Answer: Only by true faith in Jesus Christ. Even though my conscience accuses me of having grievously sinned against all God's commandments and of never having kept any of them, and even though I am still inclined toward all evil, nevertheless, without my deserving it at all, out of sheer grace, God grants and credits to me the perfect satisfaction, righteousness, and holiness of Christ, as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.

All I need to do is to accept this gift of God with a believing heart. 

It is one of my favorites from the catechism, but what I loved was when we started talking about how God “grants and credits to me…”  I asked them, “How does Isaac Bol pay your salary?  How is it that Isaac has money in the bank in Rumbek?  Has Isaac done work to get money into that bank?  No.  Ann Rao credits the account.  They take money from her account and put it in the account for Isaac.”  In the same way, “God grants and credits to me the perfect satisfaction, righteousness, and holiness of Christ, as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.”  I could watch as the truth swept over them.  It had to be earned by another and credited to me.  It is true.  I want the applause.  I want to think I have merited God’s favor, but I have not.  Yet if I “accept this gift of God with a believing heart” then God looks upon me “as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.”  It is great news and it is great to see them grasping this truth in their hearts. 

15 March 2012 

The nurses admitted a 4 yo girl last night with a three day history of fever, painful swallowing, and some difficulty breathing.  When we came to her on rounds, she still looked rather sick.  Her fever was down (it had been 39C, 104F), and she was not struggling to breathe, but she was obviously uncomfortable and drooling slightly.  The left side of her face was swollen and she had large, very tender lymph nodes under her left jaw.  She did not want to open her mouth for examination (what four year old does), but with a tongue blade I got a good look at the pharynx.  Her soft palate was red, edematous, and shifted over towards the right.  She had a peri-tonsillar cellulitis versus abscess.  The look of the exam, the response to treatment, and the length of illness strongly suggested cellulitis rather than an abscess.  They are a spectrum: cellulitis is early and will respond completely to antibiotics, whereas an abscess is later in the process and will need to be drained. 

            We have not had great success with either.  We had an adult with the same problem.  We treated him with antibiotics and he improved.  He had an abscess in the nodes under the jaw that I drained.  After about a week of antibiotics, there was still some localized swelling and I thought probably an abscess.  I was planning on draining the abscess the next day, but the family took him elsewhere (I think Mapuordit) where he died.  The other case was a 6 yo boy who clearly had peri-tonsillar cellulitis and responded well, but for some reason the family still took him to the witch doctor and he died suddenly.  I still have no idea what he did to that child, and it still makes me mad.  I cautioned the parents that it would still be several more days before we knew if this child would need surgery, but warned them not to go to the witch doctor.  I am hoping that third time will be the charm for this illness.