Have you ever visited one of those countries where you can’t drink the tap water? Honduras is such a place (Try to keep your 1 year old from drinking any shower or bath water sometime – it’s pretty much impossible).
Fortunately, for us, we have clean tap water at our hospital (our patients are always a little awestruck when I tell them- not only can they drink the water straight from any hospital sink (without boiling or filtering it), but that my family and kids do so every day.
But for the rest of Honduras, there is a difficult choice: one can buy a Sprite or Coke at the corner store or bring river water to one’s house, boil it, wait for it to cool, then drink it. As you can imagine, it is a pretty easy win for the Sprite. Even though they can buy a bag of water cheaply (instead of boiling river water), its like convincing yourself to get a water when your combo comes with a drink- it is a hard choice. (Coke, to my shame, generally wins – fortunately for me I live 2 hours away from any fast food restaurants.) Given this reality, and the strong link between sugary drinks and diabetes, you can understand that diabetes and its complications make up a lot of our patient visits.
I was recently laying down the law, with a lovely elderly woman with mild dementia whom I had brought out of diabetic coma (thanks be to God). Her coma was the direct result of what we call poor compliance (a fancy way of saying the patient is not doing what we want them to do). Her blood glucose had been approaching one thousand- meaning she had so much sugar in her blood that is was becoming a syrup and shutting down her brain.
So as I was explaining to her, for what felt like the 10th time, how important her insulin was, I went for the straightforward simple explanation: if she did not allow her adult children to check her glucose and give her insulin on a regular basis, she would shortly die. She giggled a bit, and said, “Well I don’t want to die.”
“Doctor, I need something,” she said with a shrewd look.
“Okay.” I replied with slight hesitation.
“I need you to give me your phone number, so I can contact you any time I have questions or problems,” she gave me her most winsome geriatric smile and may have even winked at me.
I explained carefully but firmly why I would not give her my phone number, about 3 times before she gave up on charming me (for that time). Afterward she gave me a big hug and I discharged her home.
On the day of her follow up visit, her family was hanging around right in front of my door while I was trying to work through a extra long list of patients. I had seen several patients already, and was bringing back a different patient to discuss some bad news. Now, hanging out in front of my office door is a common strategy to try to get seen before others. So I was a bit short with them when I said, “Buenos dias.” And tried to slip around them without further ado.
“Doctor, can we have a moment of your time?” Hondurans can be maddeningly indirect.
“Si.” I replied trying to make it obvious that I had a list of patients queued up to be seen, they would be seen in that order, and this would all go much faster if my process wasn’t interrupted. (It sounds like I may not have had my coffee that morning)
“You remember my mother, she had the sugar coma and you saved her.” The daughter stated, leaving a pause for me to acknowledge.
“Yes, I remember.” I replied tersely.
This seemed to deflate the daughter, who said, “Well, uh, here.” And with that she thrust a large feed sack in my direction.
I eyed it questioningly. I did not want to take it without more information, but I didn’t want to be too rude either. So I moved closer to the bag and cocked my head to prompt a bit more explanation before I accepted.
“Its a chicken.” She stated with an uneasy smile, trying to regain her enthusiasm
“Is it alive?” I asked with morbid curiosity. She shook the sack a bit as if to find out for herself and the lump began moving and clucking indignantly. At this point the patient whom I was trying to bring to my room start laughing quietly at my predicament.
“O, thanks! Um, Could you hold it for a bit while I finish talking with this next patient?” I motioned to indicate the laughing patient I was trying to bring into my office.
“Yes, I can… But just so you know, its kind of hot, its a little hard for it to breath, and it pooped in the bag already. It really needs to be let out quite soon.” She stated awkwardly still holding it out for me.
“Okay. Thank you so much. I’ll take it as soon as I can.” I said as I retreated to my room to try and have a serious conversation with the patient I was bringing back.
After I had seen my next patient Bethany and the girls came down and somehow got the chicken up the hill to our house, out of its bag, and tethered to a bush.
Later that day, at their mom’s appointment, after thanking the family for their chicken and telling her it wasn’t necessary but was very appreciated (the poorest of the poor are often the most generous of people). We revisisted the importance of medical compliance (them following my directions regarding insulin). The family and little old lady who was sweet on me, broke down for me why it was sometimes hard to give her the daily insulin. First off it’s expensive, but they were choosing to make the needed sacrifices to purchase it. Secondly she was sometimes stubborn and decided she wasn’t going to let anyone stick her with needles. But mostly it was difficult because they have to send someone, usually her grandson who is 12, every other day to get ice to keep the insulin cold. Her grandson takes the horse to the pulperia (little store) where he can buy ice. Unfortunately the closest pulperia with ice is a 30 minute horse ride from their house. They then put the ice in the thermos (they were very proud to show me their insulated thermos) which keeps the insulin cool for another day or so.
“Do you not have a neighbor with a refrigerator?” I asked. Because typically, at least for medicines, neighbors will share refrigerator space with those around them who do not have a fridge.
They laughed good naturedly, “No, we don’t have any electricity in our community.”
And so I was humbled twice in one day by the same family. First for assuming they were trying to selfishly cut in line when really they were trying to selflessly give me one their best chickens. And second, when I tried to get the family and patient to take more responsibility and be better about giving insulin regularly- only to realize they were already taking this responsibility very seriously and putting more effort into their mom’s care than I had ever expected.
Prayer Request & Praise
Pray for my two little patients with kidney problems that are not responding well to medication (steroid resistant nephrotic syndrome):
Axel, 3yo, is stable and taking a medicine that will hopeful remove or decrease his need for steroid.
Maritzah, 2yo, is gradually worsening. She had an infection a few weeks ago, and nearly died. She has no clear options, and continues to have almost no response to medicines. She is very swollen. Pray for her comfort, our wisdom, and her mother’s breaking heart.
Praises: Cristofer Daniel is doing great, eating well, and putting on some healthy fat.
P.S. We will be in United States for most of July. As of now our plans are:
Sunday July 4th – Chattanooga Valley Church of the Nazarene, Flintstone Georgia
Sunday July 11th – Judson Baptist Church, Nashville Tennessee
Sunday July 18th – Reallife Church of the Nazarene, Murfreesboro Tennessee
Recently, during missionary fellowship, I asked all the children to share just one prayer request. Elizabeth seemed to be carefully weighing her options, then chose, “That Daniel will get to go home soon.”
“Good news!” I said, “Daniel went home today, your prayer was answered and now it’s a praise.” Elizabeth, Lydia, and Ruth were delighted.
Praise be to God, Daniel was able to advance his diet to solid foods, and keep everything down and working. For several days of post-op observation.
His family’s bill for their prolonged stay, TPN, surgery, and meds, (about 3,000 USD) was largely taken care of by your many generous donations. Thank you all for your help.
Please continue to pray that Daniel is able to keep gaining weight, and avoid future bowel problems.
Also be in prayer for Axel who is 3 years old and Maritzah who is 2 years old. They both have nephrotic syndrome, which is a kidney problem that crops up in some kids for no clear reason. Almost every time this type of problem responds to simple steroid treatments. But when it doesn’t, as in both of their cases, things become significantly more grim.
For Axel, pray that the new medication that we’re going to try will help put him in remission. For Maritza, pray for a miracle, that God might heal her kidneys, and barring that, that he would shower his love and grace upon her and her family- transcending their suffering.
Dr. Dave, Daniel’s surgeon, spent a lot of his day yesterday cutting back adhesions (old internal surgical scars) and confirming the anatomy, cause, and best solution for Daniel’s intestinal blockage.
By the grace of God, the power of prayer, and Dr. Dave’s meticulous skill, we found what seems to have been the problem and a new route for things to flow through was created, bypassing the problem.
Daniel is recuperating, but for now he can’t eat or drink- until it’s clear that his bowel has woken back up and started functioning after the shock of being pulled out and cut open. It will be several days before we can do the ultimate test of letting him try solid foods.
Above is a picture of me, drawn by Daniel. As you can see, I apparently have no problem getting nourishment. To the left of the picture, you can see Daniel and his sister. He gave me this right after his operation.
Thank you for your prayers.
And thanks to all of those who reached out and sent donations to help cover some of the expenses of Daniel’s stay.
On Easter Sunday my patient with the belly problems, six year old Cristofer, came to church with us and his family. During Sunday School after 3 weeks of spending hours each day caring for and getting to know him, imagine my surprise when he introduced himself to the Sunday School class by his second name, Daniel.
So let me give you an update on Daniel. After almost three weeks on TPN (a customized liquid nutrient solution that is put directly into the blood stream), Daniel gained nearly 10 pounds, has lots of energy, and has become a professional at getting various hospital employees to buy him popsicles and ice cream.
In the days leading up to Easter, all of Honduras goes on vacation. During that time it became nearly impossible to get the TPN delivered across the country so we were forced to try and see if Daniel could absorb his nutrition orally. Unfortunately, although he has been able to mostly maintain the weight gain that was won through the TPN, his belly has become distended again and proven him unable to handle any non-liquid diet (and it’s really difficult to get a healthy mix of protein in a kid-friendly liquid diet).
Despite this setback, he is remains very happy, playful, and much better than when he arrived.
Tomorrow (or today if you are reading this on Thursday morning) Daniel will be going to surgery. Please pray:
That Daniel and his family will have peace before, during, and after the surgery. (Daniel is feeling a bit scared because of all the bad experiences he has had.)
That Dr. Dave, our surgeon, will have wisdom, insight, dexterity, and divine guidance in the midst of what could be a very complex surgery.
That Dr. Isaac, our anesthesiologist, will be able to help Daniel get to sleep, keep him from vomiting/aspirating, and wake Daniel back up again without problems.
That Daniel’s body will heal well and recover quickly, such that he can get back to eating normally and have no further obstructions.
That Daniel and his family will experience Christ-like love in a way that transforms their lives forevermore.
If you thought you might want to give to help cover some of Daniel’s rather large inpatient bill, but have not yet done so, please consider doing so now. You could Venmo or Paypal us, or give through Samaritan’s Purse. We’d be happy to send you directions for how to do so – just email us: firstname.lastname@example.org
So far, outside of the regular support that we get, we have not had any funds given specifically to help Daniel. The main reason he is a special case, with an unusually high bill is because we had to give him TPN for 3 weeks, which is a very expensive and time consuming process.
Christopher Columbus, as you may have heard, opened up the Americas to European exploration with the patronage of the Spanish monarchy at the end of the 15th century. What you probably did not know, is that on his fourth voyage in 1502, he sailed along the very coast that I look over every day from our porch.
Legend has it that after exploring the area between the bay islands and the mainland he proceeded southeastward, where the water become very deep immediately off shore. There he was caught in a tropical storm (something we are very familiar with of late). Finding refuge in a eastern cove he exclaimed “Gracias a Dios que hemos salido de estas honduras! [Thank God we’ve escaped these treacherous depths!]. From that exclamation, the area where he took refuge became the Departmento known as Gracias a Dios and the entire territory, later an independent country, came to be called Honduras.
Now you know how Honduras got its name. Which probably has something to do with why the name Cristofer is popular to this day in Honduras. In fact, the six year old boy currently on my inpatient service for the last week and a half is named Cristofer. And he, like his namesake is going through a harrowing time. I would like to tell you his story so you all can pray with us, help support him as you feel led, and hopefully in 3 or 4 weeks be able to say, “Gracias a Dios – Thanks be to God, he has made it out of danger!” as we send him on his way home.
Cristofer came in to our emergency room a little more than a week ago. His parents were at their wit’s end and knew with a parent’s intuition, that something was very wrong with their youngest son’s abdomen and that his time was running out.
The story of Cristofer’s abdominal problems began when he was 2 years old, Cristofer had to have an abdominal surgery due to an intussusception, a problem caused by bowel sliding back into itself and getting stuck – like a telescope collapsing down. The surgery was successful and he went on to live and grow normally till he was 4 years old. At that time, his intestines became knotted up due to the scars left by the first operation. This required another surgery, and the removal of some of his intestines. Once again, the surgery was successful and he went on to live and grow up normally for a further 2 years -until about 2 months ago.
2 months ago, he started to have belly pain, nausea, and vomiting. He was hospitalized and found to have another knot or bowel obstruction. this time the surgeon told his parents that part of his intestines had turned black. Further bowel had to be removed, and the surgeon was confident that he had removed the problem and repaired the remaining bowel. Cristofer was discharged home. But over the intervening weeks he never seemed to get better. He continued to have vomiting and belly pain, and then he started to lose weight.
When he was brought into our Emergency Room, he was still able to walk and talk, but it was clear that his body was very malnourished. His body had consumed whatever fat stores he had, and now had begun to consume his own muscles.
After talking his case over with our surgeon and other doctors, and doing several tests including sending him to the nearest large city to have a CAT scan, it became clear that Cristofer has a small bowel obstruction that almost completely blocks his food from going more than a few feet past his stomach (the small bowel typically absorbs nutrients over the course of about 20 feet of looping intestines).
All of this means that Cristofer needs yet another operation. But with an abdomen that has a proven track record of forming problematic scarring and a very recent surgery – the chances of long term or even short term success are not good. If we were to operate immediately, cut open the problem portion of bowel and stitch it back together; at his current level of nutrition he would be unable to heal the wound before the sutures dissolve, at which point he could die from a bowel leak. To improve these odds, our surgeon has asked that we buy Cristofer time (so that the abdomen can heal up and calm down from the most recent surgery), and give him the best chance to respond well and recuperate after the next surgery.
To that end we have begun the arduous process of giving Cristofer TPN (Total Parenteral Nutrition- nutrition put directly into the bloodstream). This is a sterile custom mix of the basic building blocks of proteins, sugars, fats, and electrolytes recalculated every 2 days to meet Cristofers day-to-day nutrition needs. Our TPN has to be ordered from San Pedro Sula (half-way across the country), made up and shipped on ice via busses and couriers and whoever we can beg- so that it can be hung in a chilled box and pumped at a set rate through a UV proof tube.
Rather than belaboring how time intensive, detail oriented, and relatively expensive this process is- simply understand that my children and my wife think that I have adopted a fifth child named Cristofer with whom, or on whose behalf I am spending more time than I am giving any of them.
I am writing this to include you in the ministry that we do here. To ask that you pray for the upcoming surgery in 2-3 weeks. And to ask if any of you would like to help us pay for some of his care. Each bag of TPN costs a little more than $200 USD, and a bag lasts for 48 hours. So we are probably looking at around $5,000 USD just for the TPN.
Nevertheless, please don’t take this as a desperate plea for help- Cristofer will get the TPN, and our hospital will figure out how to eat whatever cost his family cannot pay. But if you feel led to give, we’ll be happy to put your money towards this or similar direct patient care projects. If you already give to support us, know that you’ve already taken a massive chunk out of all our patients’ bills – because they didn’t have to pay anything to their doctor.
In other news…
I am sorry to tell you that the little boy Alan, who I wrote to you about previously, died a few day after my last blog. We believe that his brainstem- which controls things like heart rate and breathing rate was severely damaged during one of the times when he stopped breathing, and so he continued to worsen until he finally passed away.
Axel, the 3 year old with the life-threatening kidney problems, has had mixed results. His kidneys seem to be doing better sometimes and then go back to letting protein slip through. He is on a medicine that is not good for him long-term, but cannot be decreased or stopped unless his kidneys stop letting protein slip through. Please continue to pray for him.
Today I received my first ever live chicken gift! (I have long dreamt of this day.) He was given to me by a very thankful, and very poor family of a patient that I took care of in the hospital a few weeks ago with a diabetic coma.
Hannah Faith Gilley, our little baby girl, born here in Honduras several weeks after we came here, is turning 1 year old this week!
Grace and Peace to all of you. May the Lord richly bless your upcoming Holy Week and Easter.
Yesterday, my 4 year old little girl, turned 5! And we celebrated that blessing with a sticky bun breakfast and promise of further celebration when I would be off call.
Yesterday I rocked my two year old to sleep in our hammock, and then went down to the hospital and held the life of a 1 year old in my hands as I kept him breathing by squeezing and releasing a bag over-and-over, during my 4 hour turn with a little boy named Alan.
I’d like to give you glimpse of what our days here are like. It’s hard to capture the differences, the beauty and the pain that we see here each day. But maybe a simple run through my clinic list can give you some insight into what we do here.
Yesterday in my clinic…
I saw a 3 year old girl with a cough and fever.
A forty year old man recovering from falling off a roof and landing head first on a machete (he had a large scalp laceration and a severe concussion- those are improved, but his left sided facial weakness may be permanent)
A boy who has been having dizziness and headaches at school, that could be secondary to struggling in school or to an anti-tuberculosis medicine that he has to take until his father completes the full treatment course for tuberculosis (that usually takes about 6 months)
A 16 year old, pregnant with her first baby, who came in for a routine visit, and on my ultrasound was found to have too much fluid around the baby. This puts her at risk for complications, and means we have to do further testing to see if there is a reversible cause.
A 70 year old woman with severe arthritis in both knees and severe high blood pressure.
A 52 year old woman who began to have a severely itchy rash around her eyes 8 days ago, and despite seeing several doctors and receiving multiple treatments has continued to suffer.
A 2 year old boy who was feeling totally better after receiving an anti-parasitic medication 1 week ago. (Unfortunately I never think to take pictures of the well and happy children I see and discharge.)
A 30 year old with a stomach infection called H. pylori, who also suffered from hemorrhoids.
A 15 year old young lady, pregnant with her first baby, coming in for labs and an ultrasound that showed normal development and no complications thus far.
It is unusual that a day goes by when I don’t diagnose cancer or diabetes, and the deadly complications thereof, but yesterday was one such happy day.
Below are some of the dermatologic problems that I’ve recently seen (avoid looking too closely if you are queasy). Medical people challenge: can you name the weird warty lesion in the top middle position. It was on a 40yo man’s abdomen, RLQ, itchy, persisting for months, no inciting event.
Thank you so much for your ongoing support. We love the work that God has given us to do here. The needs, great and small, are countless. But the people here are gracious and thankful for any help.
Grace and Peace, Nathan & Family
Please be in prayer for:
-Axel, a 3 year old boy with something called nephrotic syndrome, which will likely destroy his kidneys unless he begins responding to the only medication we have.
-Alan, a 1 year old boy who is currently not breathing on his own, due to a large amount of inflammation in his lungs, that is likely due to something he swallowed that went down the wrong way.
-Our family, as we look to the future and pray about our long-term plans.
We are well. We are in Nashville with family for a previously scheduled vacation. We had planned to fly out today, but by the grace of God we had to move our flights a few days earlier due to hurricane Eta flooding the main airport that we use (San Pedro Sula). This was good because flights are probably grounded throughout Honduras due to the latest incoming hurricane.
Pray with us for our hospital, community, and Central America as they are faced with a second hurricane, Iota, making landfall today and tomorrow.
This year has been blow upon blow against the already tenuous Honduran economy that was largely based on tourism followed by agriculture (industries deeply affected by covid and hurricanes respectively). Our hospital has been increasingly busy as the strain of COVID, travel restrictions, and various sector shutdowns have left many Hondurans without access to healthcare for everything from diabetic management to cancer resection.
Pray for our missionaries and our national staff, who continue to model incarnational Christ-likeness by being physically present to care for and minister to our patients (despite the risk of COVID and the hardships and dangers that hurricanes bring).
Pray for our family as we rest up, and spend time with family- that we would be blessed and a blessing as we visit and rest. Our children are now 8 months, 2 years, 4 years, and 6 years old- pray for them and for the challenges that they face as our family seeks to follow God through all this.
We plan to be at Chattanooga Valley Church of the Nazarene for Christ the King Sunday (November 22nd) for the Sunday morning service and an informal evening gathering.
We also plan to be at Judson Baptist, Nashville on the first Sunday of Advent (November 29th) for the Sunday morning service.
Bullet Prayer Request:
-For all those in the path of the incoming category 5 hurricane, Iota.
-Hospital Loma de Luz’s water, electricity and internet supply (and their respective back ups)
-Pray for our return trip, especially with all the uncertainty of hurricanes and ever changing COVID restrictions.
-The hospital’s food supply (the roads and bridges to La Ceiba)
-The safety of our patients and staff who have to come in to the hospital during this storm (think of women going into labor, children with epilepsy, and our essential nurses and lab technicians, as well as doctors who have to come in terrible weather or no).
-The long-term recovery of Honduras, especially the poor who are always hit the hardest by these types of events.
-Our family and especially our children as we seek to put God first, and rightly prioritize their formation and education.
-Thank you to all of you who have and are supporting us financially. If you would like to send aid to the hospital and surrounding community to help with hurricane relief, we would make sure that 100% of what was given goes to the local needs. See our support page or email us if you’d like more information about supporting us financially or making a one time gift (please send as an email specifying what your gift is designated for if relevant)
-Also, for those of you who might prefer a different avenue, I’ve put together a short Amazon wish list of things that are needed or would be helpful in our hospital and clinic (that we can bring back in our luggage).
Warning: The following story may prompt incredulous laughter and children to ask uncomfortable questions.
Maybe I should have followed in your footsteps and become a better baseball player, you know, to make me a better doctor.
Nevertheless, I am happy to report that the secret playroom kickball matches that Jerod and I played allowed me to develop the skills necessary to become a competent physician. You see, just a few weeks ago, as I started my morning rounds, my very unpracticed sliding-into-homeplate manuever was put to the test:
I heard a yell in the hallway leading to surgery and went to investigate.
Arriving there I saw a pregnant woman, waddling towards me. Her eyes were wide with the shock and terror of a person betrayed by their own body. And as I ran forward to assess the situation I quickly saw the reason; upon seeing my querying expression she hiked up her hospital gown to reveal her baby crowning.
Her family and a few nurses were trying desperately to help her get to our labor and delivery room. But I determined this baby was going to come before we could possibly get her to a bed.
“We’re going to need to deliver the baby here,” I said with authority.
With relief the mom stopped trying to move forward and immediately began to sink to the floor. Fortunately her family members promptly stepped up to support her as she began sitting back. Unfortunately, as soon as her knees bent and she began to squat, her baby took advantage of the more open pelvic outlet as well as the increased abdominal pressure generated by her squat.
Noting this, I dove forward, my arms reaching out to catch the slowly falling baby and mother. The amniotic fluid on the tile floor helped me to slide easily into position at the mom’s feet. With my right hand I worked to catch the baby that was slipping rapidly out for a head first dive. And with my left hand I tried to push up and away on the mom’s buttocks that was coming down to land on top of her baby.
When the proverbial dust settled, we’d managed to all land safely in a somewhat slippery and slightly bloody pile, with a joyfully screaming little baby cradled in my arm connected by his umbilical cord to his mom who was slightly shocked and somewhat on top of me.
All we needed was an umpire to stare down at our strange pile and then after a pregnant pause, dramatically yell, “Safe!”
Love, your son, Dr. Nate
Remember one New Year you asked Dad, Jerod, and I to each tell about a miracle that we’d seen. Ultimately that led to a discussion about miracles, because for you, every day was filled with miracles: from rainbows to children to happenstance meetings- you saw Divine fingerprints everywhere; for Dad, Jerod, and I the world was a significantly less miraculous place. We weren’t sure we’d ever seen God reach down and definitively perform a miracle.
Well, I’ve decided that your view of the world is the better one, and I would like to tell you about a miracle I recently witnessed.
You see, the little baby that I caught in the story above (Yes, the story above is totally true, and yes Jerod and I did secretly play kick ball in our playroom, frequently, and without ever breaking a window), that baby started to turn yellow 12 hours after he was born. Now that’s not too uncommon, he was jaundiced, and we can treat that. We put him under some blue lights that convert the yellow, problematic bilirubin to a form that can be disposed of by most any liver.
I say, “most any,” because on rare occasions the drainage system of a liver is incompletely formed or the infant’s liver cells are genetically incapable of doing some basic function that causes excess production or diminished disposal.
I say all that because, after we put the baby under lights, instead of turning a beautiful Honduran brown and going home, he turned green. He turned green because his liver had one of the two problems detailed above.
When I investigate what could be done to help this little fellow, I found myself running into dead ends (grim pun intended). In Honduras, you do not want to be a green baby. Most likely you are stuck looking for an expensive, risky surgery that only a handful of hard to get to surgeons can do (to repair your drainage system). The other, equally tragic etiology, for our low resource patients, is that this disorder could arise from a super rare genetic problem that will be almost impossible to diagnose and likely will be equally untreatable.
As I often find myself doing, I first explained the poor medical prognosis. In this case I explained to baby’s mom that from strictly a medical perspective her baby had a serious and life-threatening problem. As stated above, the most likely cause was a problem with the liver’s drainage system. Untreated, this often results in death after a few months. So we would do further investigation and begin reaching out to arrange for treatment if necessary and possible. (We would also be reaching out for help from our donors because just the trip to see the surgeon in the big city would have been cost prohibitive)
Then, I concluded with your perspective, mom. I reminded this mother that we believe in a God who is all powerful and can do miracles. So even as we do everything we can medically, we also pray. The mom and I prayed for healing multiple times, specifically for God to allow this little boy’s bilirubin to get out of his system.
I have prayed many such prayers, and most of the time God either answers those prayers through the medical care being provided or the patient dies. But, occasionally, Divine fingerprints are a little more overt. Like this time, where visit by visit the little boy’s color, weight, and labs improved with no treatment beyond earnest prayers of hope and thanksgiving. A few days ago he came in for a check up and was totally normal.
Whether this was God directly altering the baby’s physiology or not, I do not know. But one thing I do know, he was a sickly-appearing, green baby and now he is healthy and brown.
And at that visit I praised God with his mother for the miracle of her son’s life.
It was the best of times, it was the worst of times… it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair…
These are some of the opening lines of Charles Dickens’ classic novel, A Tale of Two Cities. They capture the not infrequent juxtaposition of very good things and very bad things in our lives, without giving either more weight than the other. It reminds me to hold the two in balance – and allow myself to feel and know the bitter sweet reality of life between the first and second coming of Jesus Christ.
Case in point, we have recently had two babies who required intensive care in our hospital; one has done very well, and one did not do well. The first baby is named Estephanie, and the majority of her medical care was provided at the direction of Drs Anne and Isaac Hotz. This is also the infant that I previously mentioned for whom Bethany has supplied breast milk. She was born premature. And while that may not seem like a big deal – it is.
Imagine being in a rocket ship, and telling ground control that “All systems are not go for launch, repeat, multiple critical life-sustaining systems are not functioning.” Only to hear, “We are go for take off.”
Premature delivery shares a similar level of disaster potential as the above scenario. Our lungs, skin, eyes, brain, gut, and fat reserves, are all essential systems that don’t come fully on board till late in a pregnancy. And being born without anyone of these systems can result in a cascade failure reminiscent of Apollo 13.
With Estephanie, we knew from her mom’s first prenatal visit that she was at risk for early delivery, because Estephanie was sharing the uterus with a birth control device called an IUD.
Anyways, with advance notice that the baby might be born premature we were able to give the mom timed steroids to rush the baby’s lung development. We do this whenever we suspect preterm delivery because once a mom’s body goes into true labor, there is precious little that doctors can due to stop the process (especially in rural Honduras).
Ultimately, Estephanie was born at 29 weeks and 3 days of gestational age. At that stage of developmental, with our resources, it was a Herculean task to keep baby nourished, breathing, and avoid sepsis. Remember the brain and fat reserves that aren’t fully developed yet? That means that most premature babies don’t have the coordination or energy to consistently breath or eat independently. So we place a tube down the mouth to allow us to put food directly into the baby’s stomach, and a CPAP over their noses to augment and remind them to keep breathing
But tasks such as feeding, breathing, and keeping baby warm are easy compared to the biggest hurdle that Estephanie faced. About a week after birth, when the basic problems inherent in preemies began to seem surmountable, Estephanie suddenly started showing signs of sepsis or an abdominal emergency called neonatal necrotizing enterocolitis (nicknamed nec). The only known preventative medicine: breast milk (having had Bethany’s milk may be one the reason this baby went on to survive).
The treatment for Nec: no feeding, support the baby, try antibiotics, and wait. The treatment for sepsis: remove any possible sources of infection, give antibiotics, support the baby, and hope. In the case of Nec, if you have to wait more than a day or two you need to order a custom tailored formula called TPN that can be put directly into the baby’s blood stream (bypassing the gut completely which could rapidly necrose and kill the baby if food is put through it). This must be given through a central line (like an IV, but going through a major vessel dumping directly into the heart).
In the case of sepsis, any central line that you have in place is a potential source of infection. So we pulled the old line, ordered the TPN, and tried to put in a new central line. “Tried” being the operative word. Over two days, we tried every possible access point, multiple times, for hours at a time. We prayed, we dripped sweat, we got frustrated with each other, frustrated with ourselves, frustrated at having ordered and transported the expensive TPN from the across the country only to be unable to deliver it the final few inches.
Ultimately, we were unable to get a central line. Without a central line we had to decide when we would allow the baby to have tube feeds- the sooner we fed her, the higher the risk of complications from nec, the longer we waited, the higher the risk of complications from starvation. In the end because baby made a quick turnaround soon after we stopped feeding her we were able to compromise between the two ideal intervals and resume feeds after 48 hours We started slow and praise be to God, Estephanie was able to tolerate tube feeds.
Today, by the grace of God, Estephanie is doing well. She’s coming up on 36 weeks gestational age, and has been discharged from the hospital after almost 50 days. She is no longer needing help breathing and she is able to take a bottle. She is the youngest preemie to have survived at our hospital. Praise be to God.
Our second baby, would have been named Genesis. She was brought in late one evening when I was on call. I was already in the emergency room, monitoring a young boy I had just medicated for an ongoing seizure. I looked up to see a mother being shown in to our ER with a silent bundle in her arms. Typically I let out nurses locate a patient’s chart, get initial vitals, and ask basic questions, but something in this mother’s defeated demeanor prompted me to make the initial evaluation.
I quickly, explained to the parents of the boy with a recent seizure how to monitor their now sleeping son, and crossed the room. The baby’s mom seemed reticent to put her baby down, and when she did I saw a frail, pale, recently born baby girl who appeared dead. She was floppy and unresponsive as she laid in the bed, and I thought she might be dead. But on further evaluation she was taking shallow breaths had a weak pulse.
I urgently called for 2 other doctors to help, and tried to obtain vital signs and figure out what had happened.
The baby’s diaper was full of black and coagulated blood, and her mom said that her baby was 8 days old and had been doing well until she suddenly began vomiting and stooling blood that morning. Immediately her mother started trying to get her baby daughter to the hospital. (She does not own a vehicle or know how to drive, almost all taxis and public transport are not allowed to operate due to COVID, and road blocks are set up all throughout the country to decrease the spread of COVID)- so it took most of the day to get her baby to us.
When my colleagues arrived, and verified that the baby was still alive despite appearances we had enough information to determine that we had a baby on the brink of bleeding to death- who we might be able to save. We called ‘CQ Belfate – Rapid Response to the ER’ over the radio – signaling all available clinical staff to come in and help.
As help came pouring in, we inserted a needle into the baby’s leg bone to begin giving fluids and as soon as our lab personnel arrived we drew off some of her precious remaining blood to check her blood type. More than anything else, the baby needed blood, we later estimated that she had bled out three quarters of her blood volume, prior to arrival.
As we were waiting on blood typing, we gave the maximum amount of IV fluid, continued to give oxygen, and, as it seemed likely she was still bleeding internally with an undetectably low blood pressure, we decided to try for a central line (medicines that force the heart to increase blood pressure are called pressors and must be given through a central line).
This was only about a week after our failure to get a line on Estephanie. But miraculously, Dr. Isaac managed to get a blind subclavian line in with one of his first tries. The baby and her uncle were a blood type match so we drew a unit of whole blood from him and started giving the baby 4 teaspoon boluses of blood at a time.
Honestly, we were all a little shocked that she survived that first few hours, and not only did she survive, she awoke to start fussing and kicking soon after her transfusion! Nevertheless, that night I explained to her mother that Genesis was not yet out of the woods, and that if she did survive it would be a miracle from God.
On days 1 and 2, we continued to be amazed at Genesis’ resilience, and started to hope that God might heal her. After her first transfusion, we gave her her first vitamin k shot. We became more and more convinced that Genesis had gastrointestinal bleeding due to at least a vitamin k defeciency (pretty much all babies are born with some degree of vitamin k defeciency).
Unfortunately, Genesis had been born on the way to our hospital rather than in our hospital. As she was born precipitously in the vehicle before arrival and their family had no money to spare, they turned around and went home, never recieving the vitamin k shot.
The next morning showed that although Genesis’ brain, heart and lungs had bounced back remarkably well, her liver and kidneys were not so quick to bounce back. Those organs showed signs of severe shock and only time would tell if they would recover quick enough to allow her to live.
On day 3, Genesis had completely stopped bleeding into her belly, and her liver seemed to be making a slow recovery, but her blood pressure and oxygen were wavering and she still had not made any urine. Her mother was exhausted from staying by her baby’s side, and afraid to hold her daughter with all the tubes, lines, and devices we had afixed to monitor and respond as needed. At one point, while my colleagues and I were discussing her poor prognosis and worsening situation, baby Genesis had several very low blood pressure and oxygen saturations, her belly was swelling ominously, and I along with Dr. Isaac and Dr. Anne decided to prioritize allowing mom to comfortably hold and love on her baby who seemed to be dying.
We explained to the mom what we felt was inevitable and she was agreeable to not prolong her baby’s suffering. With heavy hearts we disconnected several lines and took off the blood pressure cuffs and pulse oximeter. We were able to comfortably put Genesis in her mom’s arms. Mom asked that we discontinue the oxygen-CPAP so she could just hold her baby and see her beautiful face. I prayed with mom while holding mom’s arms as she cried and gently rubbed Genesis’ head with my other hand. I prayed for God to be with us and baby Genesis. I prayed and cried, I had several words of comfort and hope I wanted to offer, but those words wouldn’t come out. So I swallowed down a sob and simply concluded, “Help us Lord, Amen.” And then waited in silence for a time with mom and Genesis.
But, about one hour after we moved to what we call comfort care (stopping everything that doesn’t make baby more comfortable including oxygen, fluid, and pressors), Baby Genesis went from gray back to pink, from struggling to breathe back to breathing comfortably, and started becoming more active. Genesis really liked being in her mom’s arms!
With such an improvement we talked with mom about keeping the priority of her holding her baby but at least giving some fluids and oxygen to keep Genesis confortable. Mom agreed and Genesis did much better over that night. But still Genesis did not urinate.
I remember coming home that evening to find Ruthie running around with a diaper so wet that it was sagging under its own weight. As I changed that diaper I thanked God that my babies make lots of wet diapers.
The next day I didn’t know what to do. Should I continue to pursue the goal of comfort care, or should I revert to full active treatment? I prayed for wisdom, but didn’t feel like I received any. Ultimately we felt we owed it to this baby who kept hanging in there to give her every chance to survive. Even though she still hadn’t urinated, we were approaching the limit for how long a newborn can survive without nutrition.
She agreed (with some relief), so we again needed TPN (baby probably had a gastric ulcer and was uninterested in eating). TPN takes time to custom formulate and ship, so we had to order it ASAP that morning. After ordering it we needed to change out our central line to prevent sepsis. Given our recent frustrations, Dr. Isaac and I decided to use a process that uses a guide wire to hold the old line’s position while the old line is removed and a new one is placed. In the midst of this procedure the guide wire slipped out of position because it wasn’t quiet long enough.
But mom was in favor of comfort care, mainly because she was concerned that her family would already be unable to pay for what the hospital had already done. (This is a sensitive cultural intersect- in the developed West we are blind to the cost of our healthcare, and never speak about money as part of developing a care plan, in Honduras people want to know how much a life saving surgery will be before they are rolled back). Trying to compromise between the two worldviews, we asked mom to give us one more day to give Genesis every possible chance and we promised to work with her to bring the cost of the hospitalization down to something she could afford. (Our prices are set to be manageable by most Hondurans, keep our lights on, and pay our Honduran staff – for instance a 24 hour hospital admission costs about 20 dollars.)
We were crushed, literally I felt God-forsaken. Once again we had TPN ordered and we’d lost access. We tried briefly to get another line in but in a baby who could not easily stop bleeding who already had a very low chance of survival, we did not feel it was safe or right to keep sticking her.
When I explained the situation to the mother she was incredibly gracious. Her response more than anything else that day assured that we were not forsaken by God. He was right there. In the mother who bore the roller coaster of her infant’s hospitalization with dignity and grace. Even though this was her second child and her first had died mysteriously a few days after birth; she was kind and appreciative of all our efforts, thanking us and praying with us. Shortly after, she asked us to discharge Genesis so she could take her home to die.
The day after Genesis’ mom returned to our hospital to tell us that Génesis had died and to start making payments, we celebrated the discharge of Estephanie to her home, in good health.
It was the best of times, it was the worst of times..
The doctors at Hospital Loma de Luz, take 24 hour call 1-2 times a week. That means that from 7am to the next morning’s 7am, any emergency or obstetric problem that comes into the hospital will be primarily the responsibility of the on call doctor. For my first 2 months here, each time I was on call I had someone assigned to back me up and show me the ropes. This is necessary because the norms of treatment, follow-up, and getting things done are so different from how things are done back in the USA that you need someone to walk you through a lot of different scenarios before you can really work independently.
For instance, if you need to give your patient a medicine through an IV at a specific rate in the US, you simply enter the order and wonder why it takes the pharmacy and nurses so long to do it. Here you go to the pharmacy, retrieve the medicine or find an adequate substitute for the medicine you wanted but don’t have, find syringes and fluid bags, then mix the medicine into solution at a concentration that will allow you to run it through a pump (A lot of moderately complicated math). Find a IV pump, place an IV if the patient doesn’t have one, hook it all up and program the pump to run at your desired rate… and then wonder what happened to the last few hours.
After about 2 months of call with back up, I recently started taking call independently. My first two independent call shifts were rough.We have an awesome team that is very supportive of one another, but we also try to take care of each other by handling anything we can independently, and only calling for help when it is absolutely necessary (especially during the night). During my first shift I had about 6 medically complex admissions topped off by a young man who came in with 4 gunshot wounds – 2 to the neck, 1 to the chest, and 1 to the abdomen – whereafter I promptly called and received help. But all of the patients did well, and were pretty clear cut from a diagnostic and treatment perspective.
My second independent call shift was not so clear cut.
Things were generally okay during the daylight hours, but as dusk settled I started getting calls.
Out of the several ER patients that I was called to come in and see, I can now only remember two. At about midnight I saw an older gentleman brought in by his son because he was having trouble breathing. I was able to determine that he was fluid overloaded due to advanced liver failure and a recent medicine change. This was based on the history that I obtained from his son and my physical exam because we do not have lab or X-ray available during the night (except for clear life or death decision points that prompt us to call staff to drive in from the surrounding community during the night). So I talked with his son about our treatment plan, his good short-term but poor long-term prognosis, and then started the treatment which I would modify based on the labs that could be done in the morning.
I went back up my house, but before falling asleep I was called again. It was about 2am…
A 21 year old girl with abdominal pain and nausea was brought into the ER in middle of the night. Her blood pressure was too low but she was conscious and it was not worsening, her abdomen was rigid, her blood sugar was too high for our machine to read and she was becoming deathly pale. She had a strange history of going to a different hospital the previous night, going home, resting, eating, then coming into our hospital for the same unbearable pain that had sent her to the other hospital.
I began to treat her identified problems individually, but was not sure of her unifying diagnosis. As I was trying to decide if I should call for help or lab, one of the nurses asked me to come quickly. I followed and she took me hastily to the room of my patient with liver failure explaining that she had just gone to check on him and found him dead. I entered the room where the patient’s son was by his bed – unaware that anything was out of order. I confirmed the patient was dead and then tried to gently but clearly explain to the son that his father had just died unexpectedly. After taking as much time as I felt I could, I went to check on my 21 year old female patient and found that her oxygen saturation was dropping. With my confidence shaken and my patient doing worse, I promptly called for help from the more experienced physcians.
Ultimately, we determined that she had a very dangerous condition called diabetic ketoacidosis (DKA) coupled with the even more deadly condition called sepsis. As we tried to treat her, we came to an impasse. The treatment for DKA is to rapidly but carefully lower the blood sugar while simultaneously addressing the acid-base and electrolyte disturbances created by both the disease and your treatment of the critically elevated sugar. To do this right, one needs to monitor and replete the electrolyte called potassium, while monitoring and correcting the acid-base status, and constantly titrating your insulin to lower the sugar (in the USA most hospitals purchase a proprietary software uses a complex computer model to anticipate the patient’s blood sugar responses and guide insulin titration).
Problem #1: Our acid-base test is so finicky it cannot be trusted.
Problem #2: Our electrolyte machine broke 2 days ago.
Problem #3: The country is shut down for COVID-19 so getting the replacement part will take at least a week.
Problem #4: Septic shock is the body’s final, unregulated and often devastating response to an overwhelming systemic infection. It’s treatment is to give copious fluids, broad-spectrum antibiotics, and start life-support measures like pressors and a ventilator while rapidly determining the source of the infection.
This is the tight rope we were walking:
If she becomes to acidotic she will die – and both DKA and sepsis create acidotic states.
If we leave her sugar that high she will die of sepsis – if we drop her sugar too fast and she goes too low – she will go into a coma and likely die.
If we do not give her adequate potassium near the time when her potassium begins to drop due to our treatment of high sugar – her heart will not be able to keep pumping – if we give her too much potassium, well, potassium is the drug of choice for lethal injection.
With these limitations, we did everything we could to help this young lady. We prayed for wisdom and healing and made our best educated guesses on what to correct – when.
For a while the patient was stable on two forms of life-support: pressors and a ventilator. I had spoken with her mother and our chaplain about the gravity of her situation (she had already required chest compressions and life saving medicines once that morning, which decreases the odds that she would survive to be discharged). I then went and saw my clinic patients. I checked on her several times throughout the day and I started to be hopeful that she might pull through. We arranged to split shifts to run her ventilator between 3 doctors who were not on general call that night (we do not have any respiratory techs or dedicated ICU nurses). I went home, explained to my girls in very basic terms why they hadn’t seen me for so long, and we said a prayer together for my patient.
That night, my patient’s blood pressure started dropping and despite chest compressions and meds, she died.
The next morning my 5 year old asked me how my patient was doing, the one for whom she was praying. I told her that she had died during the night.
“Why?” she asked.
“I don’t know.” I answered. And I don’t know. I don’t know why she died.
Medically, I don’t know if she died from an infection for which I wasn’t covering, an electrolyte imbalance I caused or didn’t correct, or something I had no control over. Spiritually, I don’t know why God didn’t answer our prayers for this 21 year old girl, when other times he so miraculously intervenes (like in my previous shift when the man who was shot 4 times, twice in the neck and head, walked out of our hospital after prayers and surgery).
I understand the philosophical arguments for why bad things happen. Abstract discussions of love, free-will, the effects of sin on creation. But I don’t believe there is a simple or straightforward answer to my daughter’s question. I believe the best answer is either silence or “I don’t know,” followed by an example of continued faith and prayer that mourns and wrestles with what happened while faithfully doing the next right thing. The Bible says we walk by faith and not by sight. Despite what we see or cannot see around us, we keep walking in faith.
I was hurt and saddened by the loss of two patients from the same call shift. But I keep walking by faith. I trust that God is good and faithful.
Nevertheless I went into my third call shift with some trepidation and prayer that God would give me a little more time to recover before my next medical disaster. And I am happy to report that my third call shift was rather uneventful. That morning, as I was nearing the end of my third call shift, I gave thanks to God that instead of severely ill patients I had the opportunity to be on the other side of things. I helped a mother deliver a healthy baby boy into the world in the wee hours of the morning. And as I went home, I stopped at our overlook and took in this view:
Clearly to me, God is at work in our world. I don’t always understand how He chooses to work, nor do I always know how I should pray. But I hold onto the faith of Jesus Christ and trust that He will not allow us to be tested beyond what we can bear.
Blessings on you all,
Please pray for our family as we continue to settle in, push through culture/COVID shock, and the newborn phase of sleep deprivation.
And please pray for the preemie baby in our hospital. Bethany provided breast milk for her until her mother’s milk came in, and the baby has survived almost a week now, but she has several more weeks before she’ll be out of the woods.