Pivot

This post might be a bit text-heavy, but I promise I'll make up for it at the end.

A woman of child-bearing age in Benin has a 20% chance of dying from a complicated pregnancy.

Infant mortality as a result of a complicated delivery is among the top 10 causes of death.

Another common outcome of these complicated deliveries is the obstetric fistula (OBF) or Vesico-Vaginal Fistula (VVF).

OBF is an epidemic, but its victims are a nearly invisible population. Many will become a shadow of their former selves; the ever-lingering odor of urine making them undesirable as a wife, an employee, or even sometimes as a member of the community. Most are relegated to small, makeshift dwellings outside their former home, and rely either on the pity of their family, manual labor in open fields (where the smell is less noticeable), or just plain begging. In many places, certainly here in Benin where Vodun is so prevalent, the condition can be seen as a curse for some great wrong the woman must have done. Perhaps the child was conceived through an extra-marital affair, and this is punishment for her adultery. They are forced to watch the world they used to be a part of from the sidelines. Finding them, letting them know there is help, and that that help is free, can be a challenge. We know there are more women out there, but we had to cut our OBF service short as we simply couldn't fill all our slots.

I've said it before but I'll say it again: the change that happens during the weeks these ladies are in our ward is impossible to miss. Healing a fistula is not simply about repairing the physical damage, but also the emotional, psychological, and social wounds.

Yvette, who had lived with a fistula for over 30 years.

We cannot undo the years of shame and stigma these women have endured, but we strive to show them that they have value, they are loved, and they can be part of a community again. Watching them slowly break out of their shell, sharing their stories with each other, nervous skepticism turning to cautious optimism and then joyous confidence... It is a blessing to be able to witness the transformation. They realize they are no longer trapped in a nightmare - their time here is a pivot point on which their whole story may hinge.

This week our Women's Health program is winding down, and we will soon be transitioning to general surgery. The last few fistula patients will receive their new dresses this Sunday, and have an opportunity to share their stories. It is a joyous occasion, but my heart breaks thinking of the few patients we were unable to help. The damage may have been too extensive, leaving so much scar tissue that the repair cannot heal. What's left of their urethra and the surrounding muscles may have been too little to ever regain any bladder control. Countless factors are working against a successful repair, and unfortunately about 10-15% of the time the first attempt fails. The failure rate only goes up with subsequent attempts, as there is now more scar tissue to deal with.

I had a patient this week who left us unhealed. I shared some tearful moments with her - both of us wondering what her future holds. It is difficult to be honest sometimes. And difficult not to give someone false hope. We encourage them to continue practicing pelvic floor exercises, which has a small chance to improve their continence, but is no guarantee. There is also a hospital in northern Benin which performs fistula repairs for "a low cost," but again, with repeated attempts, there is a poor chance of success. I know it is impossible to fix everyone, but my prayers are clinging to the sliver of hope that remains for these women. And sometimes hope wins out - one woman whose repair we thought had failed just had her catheter out today and has been dry! The next few days will be telling.

While I carry sorrow for those we couldn't help deep in my heart, the present events call for rejoicing. Every healed woman is getting a brand new start in their life, and our symbolic presentation of a new dress is a momentous celebration that cannot be truly conveyed through pictures or words.

Nonetheless, I'll try.

Leontine getting her first look at her stylish outfit.

I must say, the loud and vibrant West-African styles are certainly more memorable than the dresses we had in Madagascar! Fabric is sourced at the local market then sewn and fitted by a Beninoise seamstress. The result could be worn on the runway - the ladies are gorgeous!

Singing their way into the ceremony!

Rose thanks her surgeon, Dr. Andy Norman. A man with a Texas drawl and a very big heart. 

How they get those headwraps to stay on is beyond me. 

Our B Ward nursing team, along with Dr's Andy and Carron, and our first three "graduates." All smiles!

Thanks for sticking with me; I told you it would pay off. :)

Well I'd better go - my laundry slot is coming up. Thank you all who are reading this again for your support from afar. Ivanna (pictured above on the front left) and her husband were saying to me just yesterday, "It's just impossible that this place works at all. Yet it does! It always does." The odds are never in our favour, but there is a bigger force at work that is.

Must go now so I don't miss my laundry slot!

Till next time,
-D

Underbelly

Last week I had the opportunity to tour the engineering decks of the Africa Mercy - areas normally off-limits to most of the crew.

I wish I could remember all of the statistics our guide shared with us, they were all mind-boggling, but I'll include the few I know for sure.

My cabin is in the forward section of Deck 2, but the rest of Deck 2 and all of Deck 1 make up engineering. Our tour started around Deck 2 midships, where most of the monitoring and control systems for the ship are housed.

Generator control panels

The ship has been retrofitted with 4 generators, two of which are running at all times to provide power. At sea, the engines would normally power the ship, but in port they only run the engines every few weeks for a brief test. 

Main engine controls

Bridge command indicators and throttles

Thousands of litres of fuel are consumed each day to keep the generators running. 

Two types of fuel, along with drinking water and waste water, are stored on Deck 1, and their levels are monitored and controlled from this room as well, in order to keep the ship from listing too far to one side or the other. 

List indicator - seems quite stationary at 0 even when the ship is noticibly rocking.
I can't imagine what it's like when it gets over to 5 or 10 degrees!

One of several drinking water tanks.

The ship can hold up to 1 million litres of fresh water. Our supply in port comes from ashore, but it is filtered, chlorinated, and filtered again before it goes into circulation. 

Our waste water must also be processed before it can be released into the port's waters. Ordinarily, waste water cannot be dumped so close to shore, but since we're sitting here for 10 months, there's really no where else for it to go. Thus, the AFM is outfitted with a more intensive treatment system than most ships.

One of two very large treatment tanks.

Rubber boots for scale.
And for removing things that aren't supposed to be flushed. 

The fire suppression system is pretty impressive. The sprinkler system runs throughout every area of the ship, of course, but down in engineering there is also a CO2 foam system - that will kill you much faster than a fire if you happen to be trapped in the same compartment. There are indicator lights throughout engineering that tell you if there is a phone call, or if you need to put on your breathing apparatus.

Sprinkler system tanks - along side a portable fire extinguisher.

There are areas in engineering, namely, where the fuel is stored under pressure, where if there was ever a fire you'd basically be insta-dead. 

Here is the most important thing in engineering:

Air conditioning.

Obviously most ships have to be self-sufficient when they are sailing, but most end up at a major port city (in a developed nation) more often than the AFM. So there are quite a few engineers dedicated to maintaining, repairing, and sourcing replacement parts. Most parts can't be supplied by our host countries, so if we need something we don't have, it'll take 2 - 4 months to arrive on the next container shipment. Our guide Charlie's main job is managing Stores; ensuring we DON'T end up in that situation, and we always have what we need.

Maintenance & Repair Workshop

Another important role that engineering plays is medical waste disposal. In the hospital, the amount of waste we generate is minuscule compared to a western hospital. We sanitize and re-use as much as is conceivably possible, destroy anything that should NOT be re-used (such as IV bags, medication bottles, etc), and dispose of most of it in a dumpster in the port. Sharps and glass vials are turned over to a reliable local disposal company. So what remains? Any waste that is contaminated with blood, body fluids, or tissue. This is usually 2-4 double-bagged bins of waste per shift, per unit. Probably more than that in the ORs. Here is a whole day's worth:

Although, I think this pile was bigger when we first walked through.

It takes one of the engineering crew ~ 4 hours a day to manually drop each bag into the incinerator, which burns at 850 °C.

Incinerator peep hole. AKA the window into the fiery abyss.

I mentioned the generators before - here's one of the 4 with me for scale:

Here's a little clip to give you an idea of how loud it was down there:

And now for the thing you've all been waiting for...the engines.

Actually, I lied. These are just the oil pumps for the engines.

 THESE are the engines:

It's awkward posing when you can't hear anything the photographer is saying...

This is one of the ship's 4 engines, each with 16 cylinders, which together power 2 massive propellers.

One more artsy shot before we climb through the 8+ decks up into to the "funnel;" the blue tower housing all of the exhaust stacks, including the engines, generators, and incinerator.

For reference:

The funnel. Mmmm...smell those lovely fumes.

Before you fret, the incinerator burns quite hot enough to ensure nothing toxic remains in the output. Nothing beyond your standard carbon smoke, in any case. The stacks also rise quite a ways above where we were standing, and compared to the oppressive heat of the engine room, the funnel is a lovely breath of fresh air!

A different perspective on Deck 8! You can see our lifeboats, radar, and bridge comms tower.

Well, that's the tour, folks!

It certainly gave me a huge appreciation for the conditions the engineering crew soldier through every day...often working below the engine room floor in cramped access crawlspaces. And it is HOT down there. At least as hot as the mid-day African sun.

Meanwhile in the hospital...

A Ward is now full of young cataract patients, who, unlike the adults, require a bit of anaesthesia and recovery for their procedures. Some developed problems due to poor nutrition or injury, while others were born with the condition. They are as curious as any kid, but they sense with their ears and their hands - and will get their hands on anything they can - including your face!

I'm looking forward to the next celebration of sight - it should be a fun one.

Five more ladies participated in the Dress Ceremony on Sunday! Most are now home or resting at the Hope Center until their follow-up appointment, but they are DRY. One of them for the first time in 30 YEARS.

Those smiles bring tears of joy to my eyes every time.

Please pray for the 5th lady who is still on board to receive IV antibiotics. She has a very tiny hole remaining, and needs all the help she can get to be completely healed and free of her burden. She also speaks a dialect that very few of our Day Crew or other patients speak, and though we do the best we can, she does not have the benefit of the same friendship and community that the other ladies form. The psychological healing is just as essential as the physical when it comes to obstetric fistula.

I'll keep you posted.

-D

Chow

I think one of the questions I get asked the most about the ship is, "what is the food like?"

So, I thought I'd try to answer that question this week.

Once a week or so, you might catch a bit of of this chaos going on as fresh, locally purchased produce is brought on board; carried up the gangway and into the lift, up to deck 6 where the galley is.

Other, less perishable food arrives every 2-4 weeks on containers from the US and Holland. It's usually brought aboard with a crane, saving a lot of backache. This also usually includes some goodies like chocolate and cookies that we can purchase in the Ship Shop, and coffee for the Café. 

In the galley, a team of more wonderful volunteers, alongside local day crew, work their butts off to prepare food for the ~400 crew, ~100 day crew, and ~100 patients & caregivers that are on board every day. 

There's also a bake shop where all our bread and the occasional treats are baked:

How I wish I could take credit for that photo! The galley is, however, off limits to most of the crew. All we see is the end result. After food is prepared, it is lowered down to the dining room on deck 5, where the lovely serving team loads up the buffet.

My lovely friend Ruth, a Norwegian teacher, who just
 finished her time here on the dining room team. Miss you!

Meanwhile, another team is carting food down the lift to the wards on deck 3 for the patients. They are served more traditional food, meaning the galley has to cook separate meals for all of them! My parents will tell you how much that can complicate things.

Every Tuesday, however, the entire ship shares a traditional meal on "Africa Night," often something like this:

Rice, fried plantain, beef with spicy tomato sauce

Other meals are more "western," although they do a good job of trying to cater to our international crew's variety of tastes. There is ALWAYS rice, even at breakfast! There's also always fresh veg and fruit, cheese, bread, and condiments if you'd prefer to make a sandwich or "toastie" (this is British for "grilled cheese"). Which is good when your stomach is feeling a bit sensitive, and casava leaf mash just doesn't sound like a good idea.

Most of our meals, however, look something like this:

Chicken breast with mushroom sauce

Or this:

Slightly over-done roast beef with au jus

But I have to say, my favourite meal is when we get breakfast for dinner (which we did last night): 

Baked French toast with berry cream, scrambled eggs &
creamed spinach, fresh pineapple, hashbrowns, and sausage. 

Sorry, I may have taken a few bites of this one before I had the sense to take a picture. IT WAS JUST SO GOOD. 

Here's this week's dinner menu, where you can see some of the other meals we can look forward to:

There's also always coffee, tea and "milk" in the dining room, which is definitely a blessing on night shifts. I say "milk" because it's actually UHT - milk that has been pasteurized at such a high temperature it doesn't need to be refrigerated. But hey. It tastes the same. :)

Hope that answers some questions!

Well, gotta go before I miss lunch! 

-D

The Story of Many

Today is an important day.

Now, don't worry. This is not going to be a feminist rant. In fact, the word "feminist" makes me shudder. In my mind, that word conjures an image of a reasonably well-off woman who feels she has been "held down" by patriarchal colleagues/employers/politicians/etc. And feels she must scream to let them know how wronged she has been. How wronged because she was passed over for a promotion. Or because she must work two jobs to afford her very nice house and car and daycare.

I know there is some merit to these claims. I work in a female-dominated profession, where not so many years ago nurses were expected to say, "Yes, doctor, sir. Right away, doctor, sir." I know nurses have come a long way to establish themselves as a respectable, educated profession in their own right. We collaborate with physicians for the best possible patient care, rather than simply doing as we're told. And, though there is still a long way to go, the ratio of men to women in the ranks of doctors and nurses is becoming more and more balanced.

That's great and all. But that is not what Women's Day is about to me.

THIS is what Women's Day is about to me:

These beautiful, strong, remarkable women have had the worst lot handed to them in life, but they can still smile in spite of it. They married young. They had a limited education, if any. They spent excruciating days in active labour, desperately trying to deliver their baby, but the nearest hospital is days away by foot...and how could they afford to pay the doctor? And perhaps their family and neighbours have told them that doctors cannot be trusted. They should instead trust their traditional practices to get them through this trial. At the end of days of misery and fear, their child is stillborn. Their child is dead, and they now find their bodies have betrayed them even further; they cannot control their bodily functions. They now live in perpetual shame, grief, and hopelessness.

It is such a precious privilege to be able to serve these women; to watch them reclaim their dignity and their value.

Simply correcting the damage that has been done, however, is not nearly enough.

The challenges faced by women in the developing world every day are gargantuan when compared to those we face in our very comfortable lives. There are millions of girls who are never able to attain a primary school education - let alone the secondary and post-secondary requisites for a job where they would have to worry about pay equity.

So let's start there, shall we?

Let's start with the story of the many girls who face oppression not just in the size of their office space, but in the miles they must walk to school, the dogma that restricts their free will, and the daily threat of violence.

Let's share their story. Let's celebrate their determination. And let's work to change the ending.

-D

Bonne Travaille

Now that I've had a bit of time to acclimatize, my orientation is complete, and I'm starting to get back into the swing of things. AND, more importantly, I've had the chance to raid the promotional photo archives. So, here's a little update on what's going on right now on the ship.

Plastic surgery is wrapping up! Our smallest, 10-bed ward (C Ward) is still full of plastics patients who are here a little while longer for dressing care, but most have left to make room for the OBF patients. The plastics program focuses on releasing burn contractures - that is, skin and scar tissue from a burn that healed over a joint, limiting that joint's range of motion.

Patient M., who had massive burn scars over her
neck and upper back, can now whip AND nay-nay.

The repair process usually involves grafts, and thus can take a long time to heal, but the newfound freedom it gives is quite evident.

Maxillo-Facial and EENT surgeries are also in full force, with many tumor & goiters being removed, and cleft lips & palates being repaired.

Goiter patients waiting for admission.

Cataract surgeries are also ongoing. Just before I arrived, there was a huge "celebration of sight" for all the ophthalmology patients!

Patient J. just after her eye patch was removed for the first time!

Celebration of Sight. Hopefully I can catch another one of these!

Unfortunately for some patients, once their treatment is complete, it means they have to return to school.

Not. Impressed. 

As I mentioned, the plastics patients are clearing out to make room for the Obstetric Fistula patients on B Ward (the B is for Best)! There were only 3 of them on my first shift, but every day the ward is filling up with 3 or 4 more, and it is just beautiful to watch the friendships and community of support that is already forming between them all.

Our first few lovely ladies waiting to be admitted.

We also have several gynecology patients right now, who are having massive fibroids removed. One mass was the equivalent of a 36 week pregnancy. That patient needed some extra monitoring after surgery, so she went to D Ward (which also holds the ICU), but seems to be recovering well.

It still can be astonishing how dehydrated and malnourished some of the patients are on arrival. One patient required 3 units of blood pre-op to get her hemoglobin (iron) levels to an acceptable level...and she likely had several more units during surgery. As always, the crew of the AFM serve as the blood bank for the patients - sometimes a nurse ends up transfusing their own blood! It's a weird thing to watch a part of you trickling into someone else's veins.

In other news, two teams are heading out from the ship this week: one to visit Madagascar for follow-up, and one to visit Cameroon to start preparing for the next field service there.

Something that has been a big difference so far from my experience in Mada is the number of patients who speak French fluently (or, at least, as "fluently" as me). It makes SUCH a difference when you can have even a very simple exchange of honest, direct conversation between you and your patient with no one in between. Don't get me wrong, I have an INCREDIBLE appreciation for our Day Crew who serve as our ward aids and translators, but there is always a barrier there to establishing a real bond or rapport with your patient. Tonight, near the end of my shift, I said "Une dernière fois," to my patient (one last time) as I took her vital signs. She nodded, then said, "bonne travaille" (good job). Just that little conversation, with no middle man, was a beautiful moment for me! In Mada it was often a challenge knowing if your patients really understood what you were trying to tell them, and vice versa. Being able to have some discussion, albeit still limited, beyond "Hi, what's up?" is a HUGE deal.

And that is why, this is indeed un bon travail. Le MEILLEUR travail, in fact.     (the BEST job)

Alright. I need to hit the hay. The ship's really rockin' tonight, as there's a storm-a-brewin'. Good thing I don't get seasick!? nervous laughter

-D