Pick-Me-Up

Our family was recently in the capital city transferring from our MAF charter flight to a commercial flight so we could get away on a much needed vacation. I always smile at what I can fit into the layover time between flights. In this case, a local charity organization called Nehemia Madagasikara had organized two patients for me to see at their office. Organizational partnerships are so important and I appreciate Nehemia for helping poor families access healthcare. I had already been sent a WhatsApp photo of a young boy who had been brought to come and meet with me. 

He was 8 years old and as I walked in I could smell a pungent odour in the room. There was a colourful sheet overing his thin body on the table. I was told this boy had sustained a petrol burn 3 months prior. He lay on the table in the fetal position he had been in for 3 months, pus oozing from the infected necrotic tissue covering a wound over his entire chest, abdomen and arm. I was not surprised at his condition or the fact he was in the state he was. Burns are challenging and expensive to treat. His body was puffy from lack of protein, evidence he was losing the war to the infection of this massive wound. He lay motionless and scared to talk as I asked him his name in Malagasy. “He is going to need a lot of work,” I told his family. Firstly he needs nutrition starting today and we need to get him to the hospital where he will spend a number of months. While there are hospitals in the capital, our hospital fees are significantly cheaper and we can ensure his care does not stop due to lack of funds, or nutritional support. A quick call to our friends at Mission Aviation Fellowship and we began arranging a flight for him so he didn’t need to take the 1000km trip by road.

My heart ached for this young boy. Thanks to Nehemia and MAF, we were able to get him started on high protein nutrition and then flown to our hospital to get him healthier in anticipation of grafting.

If ever I needed an emotional pick-me-up…it is after seeing such suffering! 

The next patient came to see me. Alida is an 18 month girl who made a 1000km journey by road to our hospital this June to see me for her hydrocephalus. She could not talk and could not see prior to surgery in June. The pressure from the fluid inside her head was slowly stretching the nerves controlling her eye muscles, driving her gaze perpetually down. Her thin brain was being sandwiched between the excess fluid and her skull. She was losing neurologic milestones by the week unable to sit or even keep her head up. Her mother had continued to try and care for her not knowing what to do about the ever increasing head size. What struck me about Alida was how unbelievably happy she was. She smiled all the time despite not showing evidence of being able to see. I wondered if this was because of the obvious care she felt from her mother!

We operated urgently in June placing a VP shunt. Her head won't shrink with the shunt but the head growth will stop allowing her brain to expand and heal and eventually her head will look smaller when her body catches up in size. 

Of all the surgeries I do, this one causes me a lot of angst during the operation because any infection of the tiny tube placed through her brain under her skin and into her abdomen can cause catastrophic complications. Her mother was beaming as I examined at her. "She is talking," she told me in Malagasy. She was holding her head up, her eyes were tracking and she grabbed my phone! Vision and coordination were working! All her incisions were healed. 

In that moment, Alida brought me so much joy!

Her mother told me the people in their village are astonished! They didn't think there was any hope for her!

As I got back to my family and our flight, we headed towards our vacation, I couldn’t help but thank God for all those who help give patients like these a chance at life. Thank you to those who financially support our ministry which helps cover surgical costs for families like these. 

I love my work, but it was fantastic to get away and spend some time with my mom and her husband who came to visit our family. Our kids were thrilled to have grandparents come see and experience what their life is like. Madagascar is literally the farthest location in the entire world from where they live so we appreciated their very long journey which included missing a flight due an airport closure from a massive forest fire in Canada... JESH

I think she may have given ME an ulcer!

At 5 years old, it was an unusual combination of symptoms. Fever, black stools and abdominal pain. Initial bloodwork showed a low blood level less than half of normal and malaria positive. Malaria explained the fever and low blood but the dark stools and abdominal pain were more of a mystery. Black stools are often a hallmark for bleeding. But malaria doesn’t cause bleeding… Bleeding AND malaria would be an unusual combination. 

I asked her if her tummy hurt and she indicated exactly where. After further assessment, she was subsequently taken to the operating room and found to have a 3cm hole in her stomach. This made sense as to the source of the bleeding. All else seemed normal. A straight forward repair was performed. Post-operatively she was put in the intensive care unit. She was a tough little girl and was not afraid to tell me when she didn’t want me examining her abdomen or wound. When I asked her questions she would reply with a silent but definitive nod or shake of her head.

When her bowels started to function several days after surgery, her black stools persisted. This seemed odd given the recent stomach repair. It would be unlikely for this to fail or bleed but not out of the realm of possibility. But she did have a lot of residual blood in her bowel seen at the time of the surgery. Perhaps this blood was still working its way out. 

Further blood work showed another significant drop in her blood level! 

This was NOT normal. She had to be still bleeding from somewhere. 

As a surgeon, if you do enough surgery, complications are inevitable but they are devastating in children and even more so with limited resources and ICU capacities. How could I have messed up that gastric repair I thought to myself. (actually it was my resident who did it… but I was supervising him) I have done many in my career. I teach them!… I explained the situation to her mother and suggested that if the dark stools didn’t stop, she would need another surgery. 

I was annoyed. We had just got her through this first surgery. 3 days of no eating,  an irritating tube in her nose, lots of IVs and needle pokes and not to mention trying to explain all this to a 5 year old. I dreaded the idea of having to operate on her again! 

Without pediatric endoscopic capacities, it is hard to evaluate the inside of the stomach and intestine. Not totally convinced the stomach repair was the problem, I used a brochoscope (normally used for lungs) to look into her stomach before committing her to another surgery. The stomach was clean. No blood! The repair was intact. No issues. Further down into the intestine (with some difficulty given the bronchoscope doesn’t navigate totally well in the stomach, I saw evidence of some ulceration but no active bleeding. This could explain the bleeding but she was already on anti-ulcer medications. I increased her dose and decided to continue to observe and transfused her again. The scope seemed reassuring.

Within an hour, a 30 year old lady arrived vomiting profuse amounts of fresh red blood. This year, we received from Samaritan’s Purse, an endoscopy set that allows us to do upper endoscopy in adults. We can put a camera in the mouth into the stomach and esophagus and place “elastic bands” around bleeding vessels called varices. People develop this bleeding due to a parasite which is endemic here called schistosomiasis. This is the only effective treatment here to treat bleeding esophageal varies. Prior to the arrival of this lifesaving equipment, patients would get transfused endlessly (or until they ran out of funds) with the hopes the bleeding would stop. Many people died. Blood transfusions are expensive and not often definitive. In fact, the cost of one transfusion is roughly the cost of doing this procedure so it is very much worthwhile for many reasons.

The young woman was very unstable having vomited perhaps 2L of fresh blood. Luckily we had a transfusion running. We intubated her to protect her airway. As I place the gastroscope down her esophagus, multiple juicy dilated veins were seen one of which was bleeding. 13 bands later the bleeding was stopped. I thought wow, that was a lot of blood. Surely this day couldn’t get anymore red. I left the OR staff to clean up and went to check on the little girl from earlier.

To my horror, the little girl was laying in her bed surrounded in fresh blood and vomitting more. I said to myself what is going on today with blood and vomit?…. Given her weight, she had an estimated total blood volume in her body of 800mL and there was probably close to that much on her bed with more coming. We quickly worked to stabilize her. She needed an operation emergently. If she was bleeding this much and this fast, not even transfusing her as fast as we could would save her.

Where was all this blood coming from when I just seen the stomach clean not 3 hours earlier!

She was taken to the operating room and surgery revealed lots of clot in her bowels. Her previous stomach repair was intact. Finding bleeding outside the bowels is easy. Finding it on the inside is more challenging because it is like looking for a bleed inside a pipe that you can’t see in! An adult bag of blood was hanging. 

We needed to get this sorted out or she was going to die. 

Using our donated Thompson abdominal retractor (thank you Thompson for this awesome tool!) I opened the duodenum deep inside the abdomen where I had seen evidence of an ulcer on the scope. To my shock, it was clean inside. There was no blood. 

What is going on I asked my resident? 

We looked distally and saw no blood and then looked proximal in our opening. A large ulcer with a tenuously clotted blood vessel in the center was just up from where we had made our incision. My resident dabbed it with a compress and then the arterial hose unleashed itself. "I think you found it," I told him. In a matter of seconds, the bowel was rapidly filling with blood. 3 strategically placed sutures later and the bleeding was stopped. The large ulcer had eroded into a blood vessel and given its location, it could not be seen during the first operation. This vessel is known to cause catastrophic bleeding when ulcers occur exactly over it.

Several days later in the ICU, her stools normalized and her pain subsided and her blood level didn’t drop any further. She received more than her entire blood volume in transfusions during her hospital stay. Her mom asked if she could eat chicken. I said yes. Looking at the girl she may have cracked a smile when I told her if she was going to eat chicken she might need to give me some:-)!

Both the girl and the other lady from that day are alive and well...Hurray! 

Huge thanks to our lab staff who work tireless finding donors and blood so that we can save kids and people like this. We have no blood bank. All our transfusions come from live donors!

Today the little girl was discharged from hosptial! 

I was also extremely happy though I think she may have given me an ulcer... JESH

Pouring out Hope!

“Whoever drinks the water I give him will never thirst.”
- John 4:14a

During my weekly language lesson, my very patient language instructor and I discuss many aspects of life, the hospital, and the community. 

Not infrequently, we speak about water. 

Part of the 650m hand dug trench between our new wells and the hospital property

My instructor lives in town, walking several kilometres to the hospital to teach us missionaries Malagasy. For the past few months, her water comes on randomly once a week, which means if she is working, she might miss it. If she does get to fill everything, she can manage for about a week. This means collecting water for drinking, bathing, toilet flushing, dishes, laundry etc. It’s no small task to live without water. She is on alert 24hrs a day for when it may come on.

Water is a limited resource here in Mandritsara. People spend a significant portion of their day hauling water from hand-dug wells to their homes, often over great distances, or throughout the night. One of our friends was telling us they are sometimes up half the night to gather what they need. Sometimes, they end up sharing with neighbours, who don't have running water in their homes at all. 

And many of these well sources are also drying up. 

Another friend, and department head at the hospital, shared with us last week that him and his wife were considering leaving Mandritsara. They couldn't see a way out of this desperate situation. 

The LIFT electrical team in action!

But things are beginning to change. 

This month marked a major turning point for the hospital. Until now, the hospital has been dependent on two very low-producing wells. A team of Irish electricians with an organization called Labor in Faith & Trust, arrived at the end of June and completed the final stages of a massive year long electrical upgrade. We successfully re-wired every building on the entire hospital compound and also moved the main electrical room, making it safe, efficient, reliable and expandable. A new generator, funded by our supporters, was also installed and is now providing consistent reliable power to the entire hospital. 

It has been a huge undertaking, to say the least. All materials had to be engineered in advance and shipped from 1000km away, or sometimes even internationally.  Our hospital workers spent weeks digging a total of 2km of trenches to lay the groundwork for this upgrade. 

Many trenches needed

What does all this have to do with the water shortage? New electrical upgrades were critical to providing power to the pumps and controls for the two new high-volume wells. Thank you for supporting the engineering for this water/electrical project!

Never before has the hospital had so much water.

We pumped 60,000L in 24hrs using our 3 new wells (also funded by you, in partnership with the Madagascar Water Project). This is almost 10x the amount of water we could produce before. 

Now always full!!

 In fact, since long before we lived here, the hospital tractor has hauled water from the river in town each day for months at a time in order to meet the hospital's daily needs. But now, there are plans to use the tractor to bring water from the hospital to town to assist hospital employees in receiving clean water. Thanks be to God! 

Talk about a transformation! 

In the words of the friend we mentioned above, "Now we think we can stay - we have hope". 

One of the partners who worked with us told us "you have shown me the power the prayer." We are truly grateful to God for the success of this project

Water brings life. 
Water brings hope.
And hope is what we live for!

So thank you for praying.

Thank you for contributing. 

Thank you for enabling us to help see transformational change to an area with such basic needs.

Thank you for impacting surgery and healthcare in this region.

“Indeed, the water I give them will become in them a spring of water welling up to eternal life”
- John 4:14b

Old (decommissioned) Electrical Room

New Electrical Room

New 100KVA Generator powering light for
surgeries, pumps for water, and power to an entire hospital.

The Final Countdown

 It's been a bit of a stretch of no communication, and we thought we would double the fun this month!

In actual fact, projects are in full tilt, and we would love to not only update you on the happenings, but ask for your prayer in the process. Progress can be a test of patience, and even with deadlines looming, many key details have yet to be sorted out. Naturally, this brings with it a fair amount of stress. It think our heart rates might be reading as if we are doing a steady amount of cardio exercise these days. 

As many of you will recall, last fall we ran the #WithoutWater campaign to bring more water to our hospital. The campaign was a roaring success, and we successfully raised nearly $60,000 to support obtaining more wells and infrastructure to support bringing more of this life-giving resource. 

Little did we know that this past January, our water levels would reach an all-time low. Rainy season didn't come to our part of the country, and water restrictions began - 7 months earlier then usual. 

Thanks to #WithoutWater, the hospital has been surviving off the added well. 

God knew what he was doing when you all pitched in to make that project a success. Even with the additional well, our maintenance team are trekking to the dry riverbed daily to dig holes and supplement the hospital's water needs. 

But we aren't done yet! 

Pump houses surrounding the wells from 

the #WithoutWater project last fall

Our maintenance team has been digging trenches
(for weeks!) so we can connect the pipes
and electrical to the wells in the fields.
Still a ways to go!

This year, we have continued to move forward to finish up the projects that began last fall. While our electrical overhaul began, we were unable to finish it...until now. At the end of June, a team of 9 from Ireland and Australia will come to help us run wires, upgrade the current transformer, add a new generator, and (Lord-willing) add a power conditioner to the hospital grid. 

This is a lot of technical jibber-jabber. Basically, we hope that by July, we have more water coming in, and more, better quality power. 

As we speak, Jesh is in the capital city trying to source equipment needed for the electrical upgrades (Don't even get us started on that - why is the power company not doing this, one might ask?). The container with the necessary cables for the electrical team is stuck in customs. An important shipment from the Engineering team in South Africa is also stuck. And our power conditioner didn't get sent in time...so we don't know if it will be here while the electrical team is still here. 

Hence our call to prayer. 

We recognize that at the end of the day, there is only so much we can do. And yet over and over we have seen God "make a way where there seems to be no way". These basic resources are fundamental to continued hospital operations, and ultimately patient care, so it propels us to do everything we can to continue forward.

We are asking that you join us in praying these projects through to the finish. We know that it might not all work out perfectly, but we are just praying that some of the pieces shift so we can see progress come to this struggling part of the world. We long to bring the resources that will fuel hope, healing and encouragement to the sick and weary in our corner of the world. 

We will try to keep our facebook page updated as we move into this next month. 

Oh, and would you pray for our family as well? I (Julie) am heading out of the country (Jesh and I will pass in the air!), and it feels like the worst possible time in many ways. I'm trusting these plans are meant to be, but praying Jesh and the kids will not only survive, but mange well (and selfishly, that I don't come back to chaos??:). Additionally, that we would find ways to navigate the stress and busyness of the next month with grace and strength. It's definitely full-on, and we are readying ourselves for the (hopefully) final push on some of these things!!

Thanks for standing with us,

By Julie 

Do you Love Blood?

I have a love/hate relationship with blood. Thousands of years ago it was written that “the life of the flesh is in the blood.” There is so much truth to this. I do appreciate blood for this reason. But, I also hate it. It is often the time limiting factor to performing life saving surgery. It gets in the way of a nice dissection and can be time consuming.

In the west, blood banks provide hospitals with needed blood when a trauma patient comes in or when a patient bleeds during a miscarriage or C-section. Where I work, getting blood is a constant challenge. We have no blood bank, meaning any transfused blood must come directly from live donors. For elective surgery it means we have time to find compatible donors prior to a potentially bloody surgery. 

Unfortunately much of the surgery we perform in Mandritsara is emergency in nature. A normal blood level is around 120-140 but we see people coming into hospital frequently with levels 40-50 and sometimes even 30. 

As a surgeon, when someone is bleeding we are trained to resuscitate usually involving IV fluids and then blood. Too much IV fluid dilutes your blood and impairs its ability to clot. 

So what happens when blood isn’t available? 

This is where it gets tricky. In a bleeding patient, give your patient blood and they are often in better shape to tolerate lifesaving surgery, but if that transfusion doesn’t come, then your patient is in worse shape to operate. 

So how long do you wait?

If your patient is actively bleeding, you need to stop the bleeding or they may die. But if they have lost significant amounts of blood, they may not tolerate the surgery you want to do to save them. Losing blood not only decreases your capacity to bring oxygen to tissue but it also impairs your ability to clot which makes bleeding worse. It also makes you cold impairing the biochemical processes necessary for life to occur. 

A frequent transfusion threshold is 70 in the west and sometimes higher for certain conditions. But here, depending on blood availability and how stable the patient is, we are forced to operate on patients with levels below this.

Finding compatible donors is sometimes so challenging that recently in our town, a radio station was advertising on behalf of a family willing to pay a compatible donor to give their blood for their loved one in the hospital.

I have on several occasions provided blood for patients I have operated on. This is a strange experience but one that really puts into perspective the importance of giving so others can live. 

Blood represents life in so many ways. It makes me appreciate the idea of Christ giving his blood (or life) in order to save me. It is not a stretch for me to grasp that I am hemorrhaging spiritually because of the sin in my life.

Thankfully, according to the message of the Gospel, the ultimate blood donation was given. 

This post is dedicated to our amazing lab staff who tirelessly work finding donors so that lives can be saved! JESH

Training Surgeons in Madagascar!

Thank you to SIM stories for their video production of our surgical program.

End of the World…and then a bit further

So it is a lot of travel logistics to get away from our hospital, but this month we got away to attend a surgical conference in Kenya. This conference is hosted by the Pan-African Academy of Christian Surgeons, the program that supports us educate our junior surgical trainees. Our kids were excited to come along for the ride because many of their friends would be there from the previous hospitals we worked at. Even Julie was excited to go to a "surgical conference" as she could connect with other surgeon's wives... being the spouse of a surgeon let alone in a developing country is not easy.

There are lots of programs that are trying to impact the surgical deficits in Africa. PAACS has been training surgeons for 27 years. 

PAACS:

- has surgical training programs in 11 African countries (we represent Madagascar)

- has training programs in 17 mission hospitals across Africa

- accepted 41 first year surgical residents in 2023

- trainees represent 19 African nationalities

- has graduated over 140 surgeons working in 20 African countries

- has 25% women in training

We are excited about PAACS because of our combined vision to practically address the lack of surgery in Africa but also to train men and women to live out the example of Christ in their lives.

It has been such a joy to converse with people living in difficult locations, teaching surgery all around Africa. PAACS is also are working to improve surgical care in francophone speaking countries and 3 new surgical training sites were launched in francophone speaking countries in the last 2 years including:

- Madagascar

- Burundi

        - Togo

Interestingly Julie & I have spent time at all these hospitals and we are excited to see surgeons being trained in these sites. 

Our surgical trainees are learning many new skills at this conference including much needed ultrasound training by a team of Canadian physicians. Many volunteer surgeons and anesthesia staff have come to assist and equip trainees from all over Africa. We are really grateful for their commitment. I assisted by teaching chest trauma and some orthopaedics.

These young men and women surgical trainees are the key to impacting the dire surgical need across Africa!

We are also grateful for the 40lbs of cautery pens donated to our hospital from hospitals in the US. It is very difficult to operate without cautery and we are grateful for these critical tools which will accompany us in our luggage on the way back.

While all the hospitals represented at this conference are in hard to reach locations across Africa, our hospital in Madagascar has earned the prize for “the most difficult to reach” PAACS hospital.

We have been told that we live and work at the end of the world…and then a bit further.

We work in Mandritsara at the Good News Hospital because of our faith, because we believe in something more than this life. It’s why we can live and do what we do. We believe people at the end of the earth matter. We believe these people need good surgical care and we are committed to not just providing that care but also to training national staff to accomplish this when we are gone… 

All for the glory of our Lord…. Jesh