The Pfennigers – Fred and Lydia

Where’s dada?!

I love my job. This is bizarre considering the fact I am scared / afraid when I meet a new patient. I am afraid of failing. I am afraid of failing to make a good diagnosis. I am afraid of being incompetent. I do not want to be responsible for the life of somebody. In the same breath, I want to be there in time of need. I want to do the treatment whatever it be, a c-section, a central line, an intubation, etc.

You can imagine then how I felt – happy, afraid, angry, excited, depressed –when the phone rang and it was the OB nurse. She said my wife was requesting my presence. It is rare for my wife to call for help, but when and if she does, it means simply one thing . . . things are not going well.

In helping my wife I have come to realize a couple of things. First she does not need my help. She is a competent, compassionate doctor. Yes we make suggestions to each other that neither of us thought of. But that is beside the point. Second, her call for help is a call for support usually because of a difficult case and or of being inundated by patients. I find my role in these cases as being someone she can pass work off to, trusting it will get done in a timely / efficient / competent manner. I am too her as she is too me in these same circumstances, a security blanket, a thing of comfort, someone to get things done and bounce ideas off of. I do not change the outcome for my wife and or her patients but I provide, as she does me, a source of comfort, a familiar face in a stressful environment.

The call came in at 7 am that morning, 30 minutes before the end of her shift and the start of my shift. Her shift was long. It started at 8 am the day before. All though we live less than 5 minutes from the hospital, I saw her for a short lunch only and then at 3 am. When she crawled in to bed, I could feel the weight of her day, the hopeless admits that had come in too late. Topping them off was a 55 plus year old man coming in with hypotension, bilateral lower extremity edema, tachycardia, urinary tract infection and pancytopenia – platelets 8 (normal 150), WBC 500 (normal greater than 5000), Hct 7 (normal >35%). We know he will die but we try to save him anyway. At 6:30 am she headed back over to the hospital to tie up loose ends. She did not want to leave me a mess.

After hanging up the phone, I pick up Noah and head to the hospital. I try to run, but cannot, I am out of shape. I walk as fast as I can. Passing the OB desk I hand Noah off to a nurse, “Please watch him” I say. I enter our four bed labor suit. There is crowd. My wife is easy to find. She is the white person leaning over, what appears to be, a young pregnant person, doing CPR. Our eyes meet. I know my role. I ask her what she needs. “We need to intubate her, Fred, and I need a line.” I call for the nurse anesthetists, search out equipment and request a central line kit. She is intubated by the nurse anesthetists, and I place a subclavian central line. We hook her up to the monitor and attempt to resuscitate her. Her story is strange. Did she throw a clot? She came in this morning at 7 am complaining of abdominal pain which started the night before. She had not felt the baby move for 16 hours. My wife had just determined there were no fetal heart tones when she stopped breathing and went into cardiac arrest. Forty-five minutes later we stop. We are unsuccessful. Mom, 14 years old, and baby, 39 week gestation age, are both dead.

I am angry. I am hungry. I missed breakfast. My shift has started. I cannot go home now. My wife will clean up the OB deck. I will start rounding on the medicine patients. Midway through rounds my wife informs me that Togo culture dictates that mom cannot be buried with a baby and that family is requesting we do a c-section for the baby. We comply. We deliver a normal looking infant with a normal placenta. The only odd thing we notice is the smell. I think the baby has been dead for a while.

This is not the way to finish and or start a shift.

After proof reading this blog my wife asked a question, for me, what is the learning? I think it is clear but now am unsure. It is the title, it is HELP, but I am unsure. Maybe it is just a story of events past and my random thoughts there of.

God Bless

PS Do not forget to see our updated prayer page and picture page

This is a simple but very true statement; one that I know, but one that I needed to be reminded of on many days.

It all started with a phone call.  I was home taking care of Noah, and Fred was working at the hospital covering OB.  A pregnant young lady had come in complaining of leaking fluid.  On exam it was confirmed that her water had broke.  By ultrasound and dates she was only about 18 weeks (the baby needs to be at least 23-24 weeks in the US to be considered “viable” –meaning the baby can live outside of the mother; here it is closer to 26 weeks).  Fred called me to discuss her case and what our next steps should be.  We decided on keeping her in the hospital on bed rest and with IV fluids.

This is a complicated case even in the US.  It became even more complicated a few hours later when my husband was asked to come and re-examine the patient as she’ was feeling something different.  He called me to discuss that he’d seen a good portion of the umbilical cord protruding through the cervix.  There were still strong fetal heart tones at this time. But a bleak situation became even bleaker for the chance of survival of this baby.  We discussed with the family the very low chance of survival for the baby.  It would need to survive until at least 26 weeks in utero and then it would still have a rough way to go –the baby would need many supportive measures for weeks to follow –IF it survived until then and that was the huge looming question.

As I was seeing the patient that morning in the hospital and explained again to them the gravity of the situation, the family asked a question that at first surprised me.  They wanted to know if we could terminate the pregnancy.

This was a hard but very valid question.  The chance that this baby would even survive was slim to none and the costs that the family could incur by waiting things out could mean food or clothes or other necessities for daily life.  The problem: this baby was still alive!  At first my immediate reaction was, “No way can we end things now.”  But then I started talking with some of the OB nurses and some other missionaries and the question came back to me, “Are we being selfish by wanting to preserve our own conscious for what could be a few days to a week or two in possibly sacrificing this family’s basic economic ability to meet daily basic needs?”

I felt like Jacob when he was wrestling with the angel in the Bible.  I wrestled with this question; I came to the point of tears many times –being tired after many days of working didn’t help.  I talked with other missionary physicians and had gotten different opinions on what direction we should go.  I felt confused.  “God,” I prayed, “I need help.”  I sought out one of our hospital pastors.  In my broken French I explained the situation to him and then asked him what his thoughts were as I sat there broken and weary and at the verge of tears again.  I honestly don’t remember too much of all of what he said but the one thing I do remember was that he reminded me that God is in control and I should not worry about it but let Him handle it.  It was as if a sudden wave of relief washed over me as I passed that burden off of my shoulders and on to God’s.

It is hard being a physician sometimes when everyday we’re asked to “be in charge” –to make decisions for patients’ care, medications, etc, to remember that ultimately it is not us, but God who is in control.  We do the best we can and then we need to leave it in his hands.  It is very true that if by “worrying we cannot add a single hour to our life, why then do we worry about the rest?”(Luke 12:25-26). God did answer.  During that night, fetal heart tones were lost and she expelled the pregnancy with only a little help from us.   We talked and prayed with the patient and the family before they went home the next day.  Thank you God for reminding me of who is ultimately and in everyway is in control.

God bless.

See our updated pictures and prayer requests!

Fred with our wonderful bunch of OB nurses

I am changing.  I am lost for words.  I have rambling thoughts.  How do you process events that pass?

We do good work here.  Lives are saved. But we also make unintentional mistakes.  We contribute both to life and to death.

Is it is someway easier to work in the States.  There we have technology such as ventilators and dialysis machines that give us ley way in dealing with very sick patients.  We do not have to be exact.  Here we do.  Dosing a drugs every 12 hours versus every 72 hours can and will make a difference.  We have no room for mistakes.  We cannot breathe for a patient.  We cannot pee for a patient.

When I first came here, I could only see the end result.  I could only see life or death / failure or success.  Now I am starting to see the moments, the smiles, and the decisions with in the treatment process that are successful despite the end result of life or death.  I now look for these moments and I wonder at times if the “effort” and the fact that we try to help in time of need is more important than the end result.  It is as if the end result is not mine to control, but the moment is.

The young mother at 28 weeks gestation who passed away 12 hours after her emergent c-section (see Three days at HBB) had smiled at me in recovery while struggling to breathe as I told her all went well.  Her face stays with me.  She knew her fate better than I.  Today her 27 week old daughter, now 3 months old, continues to survive.  She has left the hospital.

The 60 plus year old grandma, recovering from “a stroke, in her birthday suit while receiving a bed bath by family.  She tried to cover up but couldn’t.  I tried to hide the fact that I noticed her.  I was not quick enough.  When our eyes met, she knew the “white guy” was caught off guard and lost for words.  We smiled, stroke patient 1, doctor 0.

The young man admitted for renal failure on a Friday in poor condition.  Further testing diagnosed him with a urinary and intestinal tract infection.  By Sunday he was better.  I laughed with him and the family.  We were talking about getting him out of the ICU.  On Monday he died.

The young lady who came to the OB floor around 32 weeks pregnant complaining of vaginal bleeding.  We cared for her for three days, monitoring her and the baby.  Follow up ultrasound and heart tones at 4 pm on the third day showed a good baby.  Heart tones 2 hours later at 6 pm were absent.  There were no smiles in this case.  We at HBB were there for her, we tried.

The 70 plus year old alcoholic who ran out of money and thus he’d been without alcohol for two days had been seizing, according to family for 12 plus hours.  Using high doses of valium, phenytoin and phenobarb we were able to stop the seizures for short periods of time.  However, he died 12 hours later.

The third code I’d ran, in 3 days, on kids less than 5 years of age.  All were brought to the hospital with no respiration and or heartbeat.  The kids did not have a chance.  The nurses gained valuable experience running codes.  I enjoyed the opportunity to share my experience with them.  The families were understandably sad.

Can I smile and laugh in such a setting?  I think so.  And is it OK?

After proof reading this blog my wife asked an interesting question, for me, where is God in all this?  This is a complex question with one clear answer, God is here.  We are here because of God’s example.  He has not only motived us, but others and ABWE, to be more, and he has motived others to support us / ABWE and others financially and spiritually so that we can be here.  From this God has provide a hospital for sick people to come to, not only to experience his word but to hear it.  But what about outcome, if we are truly here because of God and we are doing God’s work why are people dying?  God’s love for us is unconditional and thus so must ours be to him.  In the same breath, people are dying, but people are also living.

God Bless

PS see our updated prayer list and updated picture page

1977, they say it was an interesting year.  Bury within the events of that year — the release of Smokey and the Bandit I, Star Wars Episode IV and Saturday Night Fever — was the birth of somebody.

A couple of interesting articles that were forwarded to us on Togo.

The first one is about the doctor shortage is Togo titled “Who Let the Docs Out” -> click here.

The second one is about Togo being the saddest country in the world titled “The Saddest Countries in the World” -> click here.

God Bless

P.S.  See our updated Prayer Requests -> click here

They say there are 4 stages to culture adjustment – the honeymoon stage, the hostility stage, the humor stage and the home stage.

It was 2 am and my question was simple, “Why did you come to the hospital today?”  I already knew his response as I had seen him about 10 days ago.  This was a young man who suffered a shock from an electrical outlet and was knocked unconscious for about 15 minutes.  The electricity had entered his left index finger, leaving a large hole and had exited his right chest area just below his nipple leaving a mark.  At the time, we watched him for 12 hours and sent him home with antibiotics and the message that he would most likely will lose his finger.  He was told to follow up in surgery clinic within the week for possible amputation of his index finger.  It was now 10 days out since he had been discharge, he had missed his appointment with the surgery days ago, he was in pain and it was 2 am, my opening question was a mere formality.  I did not wait for him to answer.  I let into him.  “What did we tell you to do when you left the hospital?”  “Why did you miss your appointment?”  “This is not right.”  I did not give him more time.  I was irritated.  I was busy.  It was 2 am.  I am not his father.

They say the second stage – the hostility stage – is characterized by frustration, anger, anxiety and sometime depression

In covering the OB deck, I was managing the labor of a first time mom that was progressing slowly.  Depending on the criteria one follows, one could’ve justified a c-section.  However, the baby’s heart tones were looking good, so we had time.  “Welcome to labor” was my attitude.  However I found myself explaining to the patient and family multiple times that although I could do a c-section, c-sections are not without their risks.  And this being Africa, those risks are compounded by availability to medical care.  Many of these patients live far from the hospital.  Doing a c-section is not only costly, but puts mom at a future risk of uterine rupture in the absence of access to medical care.  In the three months we have been here so far, we have seen 2 of them.  The baby died in each case.  The moms required a c-hysterectomy, but survived.  This process is not only devastating secondary to the loss of the baby, but secondary to the loss of ability to have more children.  Here in Togo a women’s identity is tied to her ability to have children.  Taking out a uterus, even in justifiable situations is not an easy decision.  The care of this mom in particular, took a lot of effort.  The good news is she delivered the following shift successfully.  When I heard this, I could not refrain from visiting her in recovering and asking her, with a smile, if she still wanted me to cut

The frustration

Frustrations come from a few sources.  First of all, we can only do so much here at HBB.  Our care is limited by available resources and the financial ability of patients to pay.  Patients who are in life threatening conditions are treated and then asked to pay a fee.  Patients who are not in life threatening conditions are asked to pay a fee first, and then are treated.  Second, we are the first and only stop for many patients.  It is hard to see somebody die who could have, in another life . . . another place, lived.  Third we have American expectation, right or wrong, in an African setting.  We are learning to think American with African expectations.  Deciding not to treat and accepting death is Ok.  Fourth, we are treating things we would not normally be responsible for in the USA.  Although this is exciting and something that interests us, we feel many times inadequate and wonder/question the contribution we are making.  We are thankful for our state-side colleagues who taking our calls and emails.  Fifth, it is hard to be on call for 24 hours and then be responsible for your son the following day while your partner works.  At times we are too tired to interact with him . . . we feel that he is getting the short end of the stick sometimes.

A Clarification

We are doing well.  We are working lots and learning how to adjust.  Based on comments and personal emails we have receive on past blogs, we are left with the impression that you, our friends and supporters, believe we are struggling.  It is tough here, but we are doing well.  Our blogs are a reflection of our experiences, thoughts, questions at a particular moment in time.  We hope, pray and ask for patience as well as wisdom and endurance for ourselves as we go through this culture adjustment.

“We now have this light shining in our hearts, but we ourselves are like fragile clay jars containing this great treasure.  This makes it clear that our great power is from God, not from ourselves.  We are pressed on every side by troubles, but we are not crushed.  We are perplexed, but not driven to despair.  We are hunted down, but never abandoned by God.  We get knocked down, but we are not destroyed.  Through suffering our bodies continue to share in the death of Jesus so that the life of Jesus may also be seen in our bodies.” 2 Corinthians 4:7-10

God Bless

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