The Pfennigers – Fred and Lydia

We continue to be amazed and the “ball of energy” that God has blessed us with!  From the time when came and we were concerned about him being able to get up and down the stairs to now when we can hardly keep him off of tables and other high up places! (You could pray for him as he has no fear of gravity as of yet.)

He’s also quite the “talker;” though we have as of yet to understand what he is saying!  But he definitely understands quite a bit! 

One of his favorite books is called “God gave us you.”  We truly believe that for Noah to us!

Luke 18:16  Then Jesus called for the children and said to the disciples, “Let the children come to me. Don’t stop them! For the Kingdom of God belongs to those who are like these children.

See our updated prayer requests, click here.

In August we were asked to write a blog about our experience here in Togo for Samaritan’s Purse.   Today it got published.  We hope you enjoy.  To read the blog click here.

God Bless

I read an article today where the Prince of England said “I dream of Africa”.  It is not the first time I have heard someone express their heart for Africa.  I too am attracted to Africa not only as a place to live but as a place to practice medicine.  I am left to wonder why, why Africa?  The obvious answer, it is different.  The not so obvious answer, Africa is still a “hunter / gatherer society”.

In Africa, food is not a given.  Yes it is available, but not to the same extent as it is in America.  Here in Africa there are no large grocery stores at every corner filled to the top with perishable and non-perishable items.  Also, refrigerators and freezers are rare in Africa.  Yes we have a fridge/freezer set up here on the compound, but this is unusual.  This is not common to every household.  As such, time is spent every day “hunting” for and “gathering” food.  Thus we are connect to and are reminded of our morality every day.  Meals and or no meals become a celebrations of our “daily” success and failure.  They are not routines that become lost within the 24 hour day.  They do not become “bottle necks” within our “productive days of work”.  Eating has meaning and is a celebration.  I am successful today not because I got a promotion, finished a work project and or visited some friends.  I am successful today because I was able to “hunt/gather” three meals.

In medicine, the idea is similar.  We do not have rooms full of medicine nor offices full of doctors. Our medicine and doctors are limited.  We prescribe medicine and do procedures not out of routine or habit and/or experience, but out of necessity . . . if we do not do it the patient will die.  We do not read and study medicine for the details of whether the new studies support or refute a new and or current treatment course.  We study medicine to understand the big concept of treatment.  We study medicine to figure out what we can do with the medicine we do have and when to tell the patient we have done all we can.

This is an exciting process when we are successful.  It is a ground shaking, demoralizing process when we are not.  Failure makes you question your role, purpose and ability.

A week ago one of our newborn babies at 36 hours of life had a bilirubin of 32, normal is less than 13.  Bilirubin can cause neurological brain damage.  Treatment is dependent on level.  Phototherapy is indicated at levels higher than 13, and a transfusion is indicated at levels higher than 23.  Working with Dr. K, the pediatrician, I placed a central line through the umbilical vein and we did a double volume blood transfusion.  All and all we spent six continuous hours treating this patient.  The patient then got 3 days of phototherapy.  Prior to discharge, the baby had a bilirubin around 5.  We felt good.

About 7 days later we admitted a 13 day old baby girl born at another hospital.  She came to us with a fever and a bilirubin of 74.  Working with Dr. K again, we did a lumbar puncture and we struggled to place a femoral central line, after which we started a double volume exchange.  Unfortunately, we lost the line after transfusing only 60 ml of blood, our goal was 400 ml.  By this time, we had spent five continuous hours trying to treat this patient.  Our other work was piling up and I was both hungry and tired.  We decided to call it a day and treat solely with phototherapy.  After getting the baby placed under lights, saying a prayer, our day and night continued.  The next morning, after a night on lights, the baby’s bilirubin was 18 and I felt bad . . .  I gave up on this baby!

Despite me, this baby got better.  Remember, I gave up on this baby.  I chose sleep, food, and other work over this child.  Granted I did not sleep much during that shift which saw me later resuscitate a 30 week old newborn.  By God’s grace, this child who I gave up on is better.

The balance here is tough . . . I cannot work 24 hours a day and I cannot simply say “it is in God’s hands now” to every patient who walks in the door.  Where is the line between give it your best shot, persistence, futile stubbornness, and God’s grace?  I believe in God, and I rely on God, but I am not sure what this means practically.

With treatment and procedure successes I feel a part of this place, like I have a role.  With failures I feel the weight of this place, and question my ability.  This weight becomes sharp and digs deep when I am asked by a nurse a simple and honest question, “Is there nothing more you can do?”  The answer is complex . . . “yes” is the response if I can look beyond myself – the hunger, the fatigue, and the other patients; . . . “no” if I realize that we cannot do it all and that God has a role too!

“But he said to me, ‘My grace is sufficient for you, for my power is made perfect in weakness.’”                                 2 Corinthians 12:9

God Bless

As from about 17 months ago, Noah continues to be a blessing in our lives!  Though he has his moments as all kids do –he continues to bring a smile to our faces, especially after a long day at the hospital!

One of the missionary families, who have 4 young children of their own, had adopted an abandoned young monkey, who is about a year old now and seems to have taken a liking to Noah.  And don’t worry this is not Noah’s only friend!

And as from the beginning, father and son continue to have fun moments together!  And what can I say, “Like father, like son!” 🙂

Thank you truly for all your prayers for Noah during this time.  He has adjusted well.  He has developed good relationships with the gardener and househelp and some of the other children who live here.  And thankfully, except for one day of fever, he has stayed healthy and has only had a few mishaps that were nothing serious –boys will be boys!

God bless

“Your mission should you decide to accept it . . . “

Mission impossible, this is how it feels most of the times.  During residency and fellowship in the States I used to get tired of the routine cases such as hypertension and diabetes.  Now I have a craving for them.  Do not get me wrong, we do get routine stuff here, however, it is the minority.  The strange, bizarre, and “too late to treat, but I will try” feels like the norm.

On Friday night, after having finished a very busy week on OB and after having cleaned out the labor deck, I headed home with the goal of getting some sleep.  Just as I laid down I got a call from the labor deck.  A transfer from an outside clinic had come in with elevated blood pressure.  “Je viens” I said.

As I walked to the hospital I reflected on the “most likely diagnosis” of elevated blood pressure and the work up that needed to be done.  Twenty minutes I thought, twenty minutes and I will be back in bed.  Nope, try five hours later.

This 22 year old lady who was by her last period 38 weeks pregnant had high blood pressure, but this was not all.  She also had 4 plus protein in her urine which gave her the diagnosis of severe pre-eclampsia, a potentially deadly disease of pregnancy that warrants the delivery of the baby ASAP.  Her history was not impressive, however, her physical exam opened up a can of worms.

First and foremost her fundal height, which is the distance from her pubic bones to the top of her belly, was only 29 cm.  This height should equal her gestational age in cm, which was 38.  Why is it so small?  Are her dates correct?  In reviewing her pregnancy record from the outside clinic it became clear that her dates were correct and that up until her last visit at the outside clinic which was the end of June the baby was growing normal.  However 8 weeks later and the baby appears to have stopped growing.  What now?  I need to see the baby myself.  To the ultrasound machine we go.  I fuddle through the exam noting the condition of the placenta, the position of the baby and measuring the baby’s age.  I think the baby is about 33 weeks in size.  Diagnosis, intrauterine growth restriction.  If there was any doubt to how sick she was before, there was no doubt now.

Second, this 22 year old lady could not move her legs and was unable to maintain a sitting position.  What?!  A detailed neuro exam with Dr. W revealed a loss of motor function of lower extremities, weakening core muscles, but good sensation and good rectal tone.  And a urinary cath showed she had been retaining urine.  Out come the books, the phone and a prayer.  There is no option, I accept the mission.

What is the cause of this?  Does she need steroids?  Does she need antibiotics?  Does she need a lumbar puncture?  Can she deliver vaginally?  Will she be able to push effectively?  Should we just do a c-section?  What is actual age of the baby?

 “As always, should you or any of your IM Force be caught or killed, the Secretary will disavow any knowledge of your actions.  Good Luck.”

Mission Impossible, this is how it feels most of the time.  During residency and fellowship, my treatment plans and courses of action were reviewed and approved by attendings and specialists.  All actions taken were in due process questioned and discussed.  This process stopped me from making a bad decision and protected the patients from my inexperience.  That does not exist here.  I am the attending.  I am the specialist.  It is uncomfortable, but yet I feel comfortable.  I feel at peace and am left to question why.  I think there are two answers.

The first answer is the “shoulders we stand on” being Christ and our colleagues.  We have been blessed with a great set of colleagues that are answering our emails and phone calls, giving us directions and pointers.  There is no doubt that these colleagues are helping to bring us peace in the decisions that are taking place.  The other and more important answer is Christ.  In openly praying for our patients two things are achieved, a glorification of Christ and not only an openness to the uncertainty we face, but also an openness of our love and desire for the patient to get better.  Here it is OK to say “I am not sure what is happening, but here is what we are doing for you” and “let us pray”.

The second answer is the Togolese’s people.  Unlike patients in the US who demand perfection and have unrealistic expectations of what a doctor and or medicine should do for them; the Togolese do not live under this delusion.  It is almost the opposite.  In discussing a patient’s condition and the options at hand with patients here in Togo, the response is for the most part “whatever you think is best doctor”, “please do all you can” or “it is in God’s hands”.  And when failure in the form of death comes they morn and cry like anyone, but they also take the time to thank you for what you have done.  It is an interesting contrast.  I feel burdened/weighted down by the expectations of the American system, but feel energized and motivated by the grateful Togolese.

Update

Jesus looked at them and said, “With man this is impossible, but with God all things are possible.” Matthew 19:26

After 46 hours of induction, the 22 year old lady delivered a healthy baby girl weighing 1.95 kg.  The baby today is doing well, breast feeding and eating like a champ.

Mom continues to get stronger.  After the initial deterioration of motor function that spread from the legs to the core muscles, the patient started to regain strength.  Prior to the delivery she was able to sit up and move her lower extremities.  Today she is able to walk with assistance.  Our last challenge is fever.  She started developing a fever just before delivery.  She has had three fever spikes over the last 4 days, the last one being more than 24 hours ago.  We unsure of the source, but do have her on rocephine, flagyl and cloxacillin.  The overall good news is she is healthier today than she was a few days ago.

Lord God we thank you for this mom and the safe arrival of her child.  We pray for mom’s recovery, her salvation, and that she can spend many more years here on earth with her new child as a testimony to you.  We pray for the child, this new life that she is called by you and that she will grow up surrounded by love and peace.  We pray this in Jesus’s name, Amen.

Once again thank you for your prayers and support.  With respect to this case in specific, thanks to Dr. Stocks and the attendings/OB doctors at St. Elizabeth Family Medicine Residency Program for taking our calls.

God Bless

“Do not be anxious about anything . . .”

It had been a short night for both of us.  Especially for my husband who had been on call that night for OB.  But as of yet, I have not been able to sleep well when I know he’s in the hospital and dealing with difficult situations.  As I was coming on for the next 24 hours he was updating me on what had happened over night.  He’d had three more women come in during the night in addition to the two I left him from my last shift –two first time moms and one who wanted a vaginal delivery after her last delivery via c-section (making her high risk for uterus rupture).  In addition, he’d been working all night with another patient that I’d admitted the day before whose baby had probably died anywhere from one to three weeks ago and she was about six weeks shy of being full term.  This was a very difficult situation, not only emotionally, but also medically as this baby was breech (butt first) and her last delivery was a c-section.   We had made several phone calls to talk with other OB’s in the US that we had worked with to ask them their opinion on the best way to work with this patient and her baby –there was no easy answer.  Our biggest concern was that her uterus would rupture and we could potentially lose mom, in addition to having already lost baby.

Thoughts:  How do you not worry when it is someone’s life and their baby’s life that is in your care?  The quality and/or quickness of the decisions you make can make a difference for them of life, death, or disability.  These decisions also affect them financially –if they have enough money to buy food or clothes.  Worry has always been a struggle of mine and here it seems to have amplified.

“. . . but in everything by prayer and supplication with thanksgiving let your requests be made known to God.” 

Of the five patients he had worked with during the night, he was leaving me three after one delivered vaginally and one required a c-section secondary to fetal distress.  The question now became if the other three would be able to deliver as well or were we looking at three more c-sections?  As the morning progressed so was the progression of labor of the mother whose baby had died inside of her.  After a few more hours, they called me letting me know that she was wanting to push.  Ok, now the hard part comes for me, delivering the baby, not only breech but with the uncertainty of what kind of condition the baby would be in. I prayed asking God for help and wisdom.  As the butt came out I had more difficulty then I had anticipated delivering the legs, but was able to do so.  Ok, take a breath, we have time . . . pray.  As the baby’s torso came down I kept reaching for the arms to help deliver them but they were not within the “easy” reach that I thought they would be.  Breathe, pray, ok, tell her to push again.  I was finally able to reach the arms and deliver them, all the time praying again and knowing that the head was going to be a difficult challenge and praying that God would give me the wisdom to be able to deliver this baby.  Breathe, pray, pray, mentally think it through, and ask her to push again.  But the baby’s head is not coming.  As I struggled in my thoughts of how better to work with this and prayed for God’s guidance, in through the door, unexpectedly, walks my husband (who I thought was sleeping) asking me if I needed any help –how had he known to come in? He hadn’t. . . but God had!  We were able to deliver the rest of the baby.  For the mother this was a very difficult situation –this was the second baby that she had lost like this in the third trimester.  At that moment, though grieved by the loss of this child, I was very thankful to God for the life of this mother and that we had not lost her or caused any injury to her in this whole process.  When I asked her if we could pray and thank God for her safety, she declined for the moment.

Thoughts: It’s not always easy to be thankful.  Sometimes we may not always realize the way God is intervening in our lives or protecting us.  It can be easy to ask God for things but not always easy to thank and praise Him, especially when we don’t yet know the outcome! I’m very thankful that God knows my needs and knows my words before I even say them! 

“And the peace of God, which surpasses all understanding, will guard your hearts and your minds in Christ Jesus.”

The day was yet to be over. On finishing up this delivery and making sure mom was stable, I went to see the other first-time mom who was laboring.  Her cervix had not changed in over eight hours and she was feeling exhausted and asking for a c-section, I consented given her current condition –second c-section for the morning.  Before going back to the OR, I was called to see the lady who’d had the previous c-section because the baby’s heart rate was dropping.  After a few interventions, baby stable, and discussion with mom, it was decided that she also needed to have a c-section done –third one for the morning.  Wow, did we really have to do three c-sections?  As, I left the OB floor to head home for a late lunch, all three mom’s were stable and doing well and the two live births were also doing well and stable.

Thoughts: I was exhausted as I headed home –both mentally, emotionally and spiritually.  I was crying inside for the mom who had lost her baby but I was also feeling blessed that all three moms and the two babies were all doing well without complications.  It’s during these times that sometimes I wish I had a simple job.  But I have to believe and trust that God has brought me here for a reason that He knows what He is doing even when I feel like I do not!  It is in resting in this that I find peace.  I still get anxious and worried but it is a peace that my soul has to stand on and stay anchored to, otherwise I will not stay here long –my heart can’t take it.  I felt very blessed the next day as I got to pray with this mom who had lost her baby –she had also found her peace in the “storm.” Thank you, Lord. 

We continue to need and appreciate very much your prayers for the patients (for physical and spiritual healing) and for wisdom for us as we work through some very difficult situations.

 God bless.

You can find the 2013 Summer Newsletter under the Newletter tab and or click here.  Thank you for your continued prayer and financial support.

God Bless

If one thing is true for missionary medicine is that there is no shortage of interesting cases – hepatitis B, miscarriage, ectopic pregnancy, sepsis, mandibular mass, congestive heart failure, placenta previa, severe pre-eclampsia, hyperthyroidism, new onset atrial fibrillation, colles fracture, tib fib fracture, etc. –and this is only day #16.  The theme over these last two weeks seems to be congestive heart failure and strokes.

The difficulty of the cases are compounded by the fact that the Togolese seem to come to the hospital only if they are really sick.  Having high blood pressure is not sick.  Having a stroke is not sick.  Having a stroke and not improving over the following 12 to 24 hours is sick.  Having a diagnosis of congestive heart failure and being on meds is not sick.  Having a diagnosis of congestive heart failure, being off of meds for months and having difficulty breathing is sick.

Intensive Care Unit

Of all the cases one sticks in my mind today, the 47 year old mother who was cooking dinner the night before, sat down and fell over.  Family helped her up and immediately noticed drooling, left sided weakness and loss of speech.  We saw her the next day at around 10 am.  A quick physical confirmed the family’s observation and added two additional findings, unequal and non-reactive pupils and decreased consciousness.  She was sick, really sick.

In the US there is a well-established stroke protocol that includes CT scan, neurosurgery consult, TPA, symptomatic treatment including sedation, hyperventilation, risk reduction and last ditch efforts.  Here we have only symptomatic treatment and risk reduction.

Within a short period of time, the 47 year old mother’s blood pressure started to rise, her pulse started to slow and she stopped breathing.  Things were going in the wrong direction.  As she changed we did what we could.  We attempted to treat her blood pressure with labetalol and hydralazine, we gave her mannitol and we bagged her (breathed for her).

As we are resuscitating her, I know she will not survive, but I am uncertain.  I know the problem with her is cerebral pressure, but I am uncertain.  I know we are doing what we can for her, but I am uncertain.  I know what she needs above all is a craniotomy/external ventricular drainage to relieve the pressure in her head, but it is too late, I think, I am uncertain.

After 30 minutes of resuscitation that include a bedside prayer, we stopped and she stopped.  But I could not.

Now comes the questions and tears again, what did we do, what didn’t we do, should we have done something different, are we competent, and should we be here?  With every loss we are left to ponder our contribution.  We are left to wonder if the outcome would have been different in the US.  We are left to ponder the difference between missionary and American medicine.

Resources is the obvious answer.  Certainty is the other answer. 

Going to the doctor in the US with a problem will result in tests, consultations and follow up visits.  At the end of it all you will be given a diagnosis and/or prognosis with certainty.  This process can take a matter of hours to weeks to months.  The speed at which it is done is directly related to how sick you are.  The sicker you are, the quicker the test and consults are done.  Built into this process, unintentionally, are the results and time.  Doctors and families alike, through results and time, come to a peace –a general understanding of the prognosis of the patient at hand.  And when a patient dies the doctor and family can reflect and justify that they did all they could.

Missionary medicine is different.  We have uncertainty.  Did the 47 year old mother with a stroke have a general diffuse bleed that could have benefited from an external ventricular drain and or a focal bleed that could have benefited from a simple burr hole?  I do not know.  Can we do it here and should we have tried?  I do not know.  Had we started the mannitol sooner, would we have made a difference?  I do not know.  Would time on a ventilator have made a difference?  I do not know.  Did I give up to early?  I do not know, I am uncertain.

Lord we pray for strength and peace in the encounters and decision we make.

We pray for understanding and wisdom in the disease process we treat.

We give thanks for the people you have surrounded us with.

We are standing our Your Shoulders

We would like to take this time to say thank you to everyone for their kind words and support.  Yes we are in Togo, but we here only because we are standing on your shoulders.  We could not be here without your support.

A special thanks to the attendings at Tacoma Family Medicine Rural Fellowship Program in Tacoma Washington, Saint Elizabeth OB fellowship in Edgewood, Kentucky, and Dr. Stocks in Missouri for continuing to take our calls and answering our questions.

A special thanks Dr. Evans (Quincy Illinois) for putting us in contact with Dr. Sullivant and for the Nephrotic Syndrome consult.  Thanks to Dr. Sullivant (Quincy Illinois) for a crash review of stroke and the treatment there of.

A special thanks to Samaritan’s Purse for giving us this opportunity to serve overseas through their Post Residency Program.

God Bless

One of our supporting churches back home sent us some questions that they were interested in knowing.  So we had fun recording our answers to their questions and thought you might enjoy watching too.

If any of you would have questions or something that you would like for us to try and do please feel free to email us and we’ll see what we can do!  Sorry we don’t do any singing and dancing!

God bless!

We’ve updated our prayer page and will be adding new pictures shortly.

10 days ago was orientation.  5 days ago was our first days of call.  3 days ago was our first c-section.  2 days ago was our first cast.  Today was our first death.

Our team

Here in Togo we are for the most part, not including visiting doctors, 3 family doctors, 1 surgeon and 1 pediatrician.

Our shifts

We (my wife and I) each have 15 twenty four hour shifts to work.  One works and one stays at home with Noah.  Depending on the day, the shift could start at 7:30 / 8 or 9 am.  Depending on the day, we could be responsible for just the OB floor and or the whole hospital – Peds, Adults, Intensive Care and OB – 50 beds in all.

Our patients

We see patients from all over.  People travel from the capital Lomé to see us.  We do refer patients, however, rarely.  These are patients who are beyond our ability to treat with the caveat that if for whatever reason they are unable to get help, they can come back to see us and we will try.

Saturday August 3, 2103 – A typical 24 hour day?

I started the day grumpy as rounding started early.  First stop pediatrics.

Dr. K was signing out 9 kids to me before heading to Ghana for the day.  5 kids going home, 4 staying.  The sickest of the bunch has cerebral malaria and suffering from seizures.  The night before the child had required 3 doses of valium and 1 of Phenobarbital.  Instructions: if the kid seizes give her pheonbarb.  Check.

Next stop, Miss B, a nurse practitioner.  Our task, round on the 6 medicine patients in the hospital.  The sickest patient was a 21 year old female with what is believed to be post partum congestive heart failure.  My wife had admitted her yesterday and from all reports she was on deaths door.  Working together with Dr. G (another family doctor), we had come up with a treatment plan that consisted of easing the load on the heart.  Today she looked amazing.  Win 1, Losses 0.

Next stop OB, 5 post partum patients to round on and 1 laboring patient.  In between rounding on the patients, I got to deliver the laboring patient, and I was made aware of an admit to the hospital with congestive heart failure.  His vitals were stable, labs pending, and medications given. I’ll see him after lunch I thought.  Win 2 Losses 0.

As I was leaving the hospital, I noticed a young man laying on the gurney struggling to breathe in the triage area.  I stopped by the nurses’ station to inquire who he was.  They handed me the file, 19 y/o males admitted for congestive heart failure!  This was the admit I was made aware of while on the OB floor.  He’s definitely not stable.  Lunch will have to wait.  I hit him will all we had lasix, nitro paste, dopamine, and fluids.  I called for advice.  He never got better.  I watched him die.  Win 2 Losses 1.

The evening was topped off with 4 more admits, 2 of them had HIV, 3 of them had a Hematocrit of 15% (normal is above 36%).  I got to bed around 11 pm.

The phone rang at 4:30 am.  “Hello” I said.  “This is the OB floor.  We have a transfer from an outside clinic of a lady in labor with BP of 202/110.”  “OK” I said, “I will be right over.”

Entering the OB ward I noticed there were a lot of people on the floor, more so than when I had left a few hours ago. In approaching the nurses’ station I was politely told that we have 5 active laboring patients!  2 are stable, 1 is breech and will require c-section, 1 is a VBAC that a doctor must delivery, and 1 has BP of 202/110.  Starting with the worst, I rounded on each patient assessing them and writing orders as I went.  After realizing the true scope of 5 laboring patients, 1 who was potentially very sick, I called in my wife.  Leaving Noah at a fellow missionary’s place, my wife came in and did the c-section.  Meanwhile I delivered 2 of the patients vaginally, including the VBAC patient.  I left the hospital at 9:30 am while my wife stayed to start her 24 hour shift.

Some Thoughts

After praying with the family who lost there 19 year old boy, the father simply said to me, “Thank you for all you did.”

“Naked I came from my mother’s womb, and naked I will depart.  The LORD gave and the LORD has taken away; may the name of the LORD be praised” (Job 1:21).

In thanking me, I am left wondering what I did!  Did I make the right decisions? Did I give the right medications?  Did I run the right tests?  Did I cause his death?  Am I competent?  Should I be here?

In the USA it would be different.  A 19 y/o male with CHF would not be left to a generalist with a book and a phone but with a specialist.  Would it mean that the actual treatment would be necessarily different in the end? . . . No.  It would simply mean that today I would not be crying and wondering what else I could have done.

“In their hearts humans plan their course, but the LORD establishes their steps.”  Proverbs 16:9

God Bless