We are back in the US for a few weeks with our family. What a joy! Though Betsy began to experience severe fever and chills early this morning – from malaria – that she must have picked up before departure (two week incubation). Not fun… Please pray with us…

One-year-old little Matilda arrived in Cavango a couple weeks ago, with fever for a week and difficulty breathing for several days. She was listless, not eating or drinking, and had ceased nursing. Her urine was black and her nail beds and conjunctivae were white, both indicating destruction of her red blood cells from the parasite, so we measured her hemoglobin, which was 2.1, compared to a normal of 12. Her profound anemia was symptomatic, as her respiratory rate was greater than 60 breaths/minute, because 80% (!) of her blood’s oxygen carriers had been destroyed, so she reflexively breathed rapidly to try to maintain sufficient oxygen in her vital organs. We put her on supplemental oxygen and began the tedious process of preparing to transfuse into her healthy blood.

We completely take for granted the absolutely astounding transfusion procedures that safely and remarkably save millions of lives annually in the developing world’s health care systems because of expertise, experience, technological resources, “well-oiled”, evidence-based guidelines/policies and myriads of people willing to safely donate their blood to help those in need (please donate regularly if you are able).  In the African bush, it is a different story.  We would attempt with Matilda, perhaps our 12^th transfusion over the past couple years.  There are no blood banks in the country, let alone in rural areas.  We have a special relationship with an organization in the US (based on mutual gratitude), whose owners developed kits and tests specifically for places like Cavango, lacking electricity and refrigeration.  In seeking blood compatible for a child, the best candidates are his/her parents, and Matilda was tested as blood type B(-), her mom B(-) and her dad B(+).  With a few more tests, we verified that mom had no dangerous communicable diseases (HIV, HepB, HepC, Malaria, Syphilis, etc), and proceeded to draw a unit of blood from her (about ½ liter, a pint, or 10-15% of her circulating blood). 

Because Matilda was healthy and fat, and her blood volume was diminished, IV access was challenging (her veins were buried in fat and collapsed).  We tried to place an IV catheter into her arm veins multiple times without success, but I was able to tap a vein in her neck.  We immediately sedated Matilda, so that she wouldn’t unintentionally remove her line and/or fight the process.  We began the transfusion, expecting a calm four hours of waiting for the correct volume to drip into Matilda’s system.  Because we don’t have machines to monitor the IV flow rate, we must count the drops of blood flow per minute, to make sure Matilda gets the appropriate volume over time, while protecting her heart from the stress of the supplemented volume.  We counted, adjusted, and got the drip rate within an acceptable range… but…

About fifteen minutes into her transfusion, our peacefully sleeping child developed a cough, which progressed quickly, over just a few minutes, to severe difficulty breathing. We stopped the transfusion and re-typed her and her mom to make sure we hadn’t erred, but their types matched. She was reacting to another component of her mom’s blood and we urgently gave her medications to blunt her body’s reaction. Her respiratory status improved but she was still life-threateningly anemic, so we didn’t have the luxury of abandoning the procedure.

We tested several of our nurses/workers to see if we could find a match – someone with her exact blood type or someone with O(-), the blood type which is the “universal donor”, as it can be transfused into anyone without the recipient’s immune system attacking it. We found no one… so… even though her father was not a perfect match, we made the decision to use his blood, as the risk of her dying by rejecting his blood was less than that of her succumbing to her severe anemia. Her body accepted his blood with only a slight reaction and she rested calmly and sedated for four hours while she received her father’s blood, but the rest of us were shot (!) after a full day of effort/surprise/response/effort devoted to Matilda, while the rest of the clinic was hopping!

The next morning Matilda was playful, her pink fingernail beds readily accepted a sucker with a smile, and her hemoglobin measured 10.9! Matilda will never remember anything about this day, but her Father used many hands and feet, and “mud and spit”, including many of you who support our service in so many ways… to extend her life and to give her and her parents more opportunities to know the wonder of our Father’s affection for them. Matilda went home a week later fully healthy, and she was worth every effort…

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A hideous and silent disease almost took Matilda’s seemingly inconsequential life, her body rejected life-giving blood from her mother, multiple people contributed to rescuing her from the disease and from her body’s own self-destruction, her father’s blood gave her new life, and she will never know that, but for such an enormous effort and rescue, all subsequent breaths and experiences that she might claim as “her own” would never happen, her children would not be born, their children…

Our injured lives seem inconsequential.  We are attacked subtly and constantly by destructive forces, from outside and from within.  We often reject life-giving remedy and counsel and we even reject kindness and love.  We suffer from self-inflicted wounds and we reject health, wisdom and life.  Our Father literally gave His blood so that we might live united with Him, and forever grateful to Him…  and we understand so very little of the miracles, spiritual and physical, which gave us life yesterday and which give us life today…

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Alice, 28, arrived with severe neck swelling over several days after tooth pain for about a week.  She couldn’t swallow her own saliva, couldn’t speak and could only breathe if she held her head in a “sniffing position”.  She had a condition called supraglottitis, which can lead to asphyxiation quite suddenly if the airway (diameter of your little finger) swells enough to close. She was almost there.  From her tooth infection, she had rapidly developed large abscesses in her neck and under her tongue, all of which needed incised and drained of pus.  She went through hell for about five minutes of cutting, probing and draining and was told that she must sleep with her head elevated to prevent gravity’s help in increasing swelling in the area.  Her family and she were told that in no way should she lie flat. 

When I arrived the next morning, pleased to hear that she had survived, she was lying flat on the bed and I inquired as to who had manually lowered the head of her bed.  Our night nurse, who was present when I emphatically instructed that the head of the bed must remain elevated, said he had done so about 10p the previous evening because “she asked me to.”  I won’t elaborate on my response (!), but in seeking to please and serve the patient, he could have killed her.  Alice, however, survived another awful draining procedure and continued to improve over several days, with complete resolution of her infection.  Lack of dentistry kills far more people in the developing world than most realize, as we’ve had several deaths from this condition over this past year alone.

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Rabies makes its deadly presence known in our region once or twice yearly and, each time, several people with bites wisely seek post-exposure vaccinations in Cavango, while several others each time remain in their village and foolishly “tough it out”, as “it will never happen to me”, or they seek out “all-natural” treatment from the local shaman, only to die of this 100% fatal disease two months after the suspicious bite.  To whom we listen sometimes affects us little, and sometimes it’s a matter of life and death… 

No one has died after receiving a post-exposure vaccine from us, though I have now seen several rabies deaths in people unvaccinated and it is awful, excruciating, and uniquely disturbing.  Rabies is an encephalopathy, or brain inflammation, is universally fatal, and occurs almost exactly two months after the bite of a rabid animal.  It is a fascinating disease in that it causes severe, irrational phobia of air movement and water, and both of these are quite unique to rabies and can be diagnostic by offering a glass of water or fanning the face of a person suspected of having rabies.  Both will elicit a sudden and strange sense of overwhelming panic, choking and/or inability to breathe.

A rabid dog invaded a village about 10km from Cavango last week and bit several dogs and three people, one of which protected a toddler from the charging dog. All three people had minor bites but wisely arrived specifically for their rabies vaccination. We administer our anti-rabies vaccine in a rather unconventional manner, intradermally, and using only one vial of the vaccination instead of the conventional five, with the same success rate in prevention of the disease. The method was developed in desperation by caring missionary docs in an impoverished and rural part of Thailand, as they saw so many die of this incurable illness because vaccinations were always in short supply. It is truly awful, as a physician, to have to ration limited supplies and watch some people live and some die, based on your decision… There are ethics courses in universities designed around hypothetical situations that we face often in Cavango! Our methods are sometimes not the accepted “standard of care”, but standards of care are for the “haves”, while the “have nots” must improvise as best they can with whatever resources are available…

In my first month in Cavango, seven years ago, a woman arrived with a bite she claimed was from a rabid dog (she was also protecting a child from attack) and we had no vaccines, so I drove her six hours to the closest hospital and obtained five ampules of the vaccine and gave them to her appropriately over a month. She died of rabies two months later, likely because the vaccine hadn’t been refrigerated appropriately since manufacture (a “cold chain” must be maintained for the vaccine to remain efficacious). Since then, we have been importing all of our rabies vaccines and monitoring their storage temperatures diligently. Our unique administration for each suspected case (these rural folks are excellent at identifying this illness in dogs): we divide one ampule of anti-rabies vaccine and inject it intradermally (superficially in the skin) at four sites, one in each limb. After over 40 vaccinations in seven-plus years, we have seen 100% prevention of this 100% fatal disease!

Diseases fatal without exception, demand sober diligence and care! When I was bitten for no reason by a stray dog a couple years ago, lacking trust in Angolan vaccine storage integrity, I received three sets of the vaccine (!), two intradermally and one course conventionally, and I was still somewhat apprehensive as two months approached! These three people received the last of our imported rabies vaccines, and we are importing ten more doses (ten saved lives) via (unnamed) travelers from another country. We also recommended that the villagers kill all the dogs suspected of being bitten, before they manifest the disease, and remain diligent as to avoiding further contact with the culprit, who could live several days and cause many more bites, before dying from the disease.

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Perhaps ten or eleven times, over our thousands of flight miles these many years of international travel, I’ve responded to the earnest plea of “Is there a doctor on board?” The flight attendants are typically thrilled to hear of the presence of a doctor and grateful for my willingness to help. The medical concerns have ranged from serious to minor, and only twice have I diverted a plane from its course because of a medical condition that warranted urgent care. The encounters often allow me to meet some beautiful doctors and nurses who also respond to help.

On our eleven-hour, overnight flight between Johannesburg and London this week, I was awakened from about a four-hour nap, by a teen-age boy from London who passed out and fell to the floor in the aisle, directly in front of my seat. I offered my assistance as the boy’s father arrived, and he gladly accepted, while voicing concern that nothing even remotely like this had ever happened to his son before. After several minutes, the boy began to stir, he was pale-gray, and a radial pulse was difficult to palpate. I asked the nearby flight attendant for the well-organized medical kit, that is on every commercial airliner, in order to begin to monitor his vital signs and assess him for any acute concerns, but the lead flight attendant arrived on the scene with oxygen and declared that the boy just needed some oxygen and would be fine.

I got up off the floor, politely excused myself and quietly returned to my seat, hoping she was correct in her authoritative and radically stupid, three-second assessment. The oxygen level in the cabin was, of course, normal, but the flight attendant had obviously seen enough educational movies out of Hollywood about the benefits of slapping oxygen on a sick person. Transient loss of consciousness (syncope) is often benign (the common “faint”) but can also indicate something harmful or deadly, such as a drug overdose, low blood pressure because of a heart condition, a blood clot (especially on a long flight), occult blood loss (such as intestinal bleeding), stroke, or seizure disorder… Most of these causes can be dismissed with some simple questions and a brief exam by someone with some experience, but I’m sure the flight attendant had it covered (sarcasm intended)…

How many vulnerable people are injured or die every year, because someone in authority makes unwise decisions?

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There is so much tragedy, abuse, disregard, injustice and loss… nothing new under the sun…

Yet… in the midst of it all, came One to a world “with no rooms”, later mocked, beaten, and rejected by those He created, personally attacked by those in power, and slaughtered by the same…

…who said He understood, would overcome it all and could be trusted. He said He was throwing open the doors to another Kingdom, and inviting anyone and everyone to join Him, to follow Him, to know Him, to love Him, to receive from Him, to partner with Him…

I imagined this week a masterpiece on canvas, covered with muddy splatter, which tainted and obscured the beauty and purpose of the artist’s original creation.  The beauty was still there, and was still real, as was the dirt and grime… 

The Artist embraces us and our mess, washes off the dirt and grime, restores our beauty and purpose, and removes us from the mud-slingers… That is worth celebrating today…

We are the dirty and grimy, self and other-inflicted, and we are being washed and restored. We are starving beggars who taste, and then take the bread to others emaciated and hungry. We seek out others full of seen and unseen beauty… and smeared with dirt and grime… embrace them and honor their Artist-given value and the love and joy with which they were created, and introduce them to their Artist…

whose arrival and work we celebrate and remember during this season…