Love in the Time of Cholera

Sierra Leone has been in the news recently because of the cholera epidemic spreading throughout the country.  It started in Freetown but cases have now been documented in all the districts except one.  Our hospital has not been immune. 

A couple weeks ago I was down in the OB ward, getting ready to go home at about 9:30pm.  I was literally walking out the door when one of the nursing aids came and asked me to see a patient that had just come in. I walked down to the ER (ie the bench outside the nurses station) to see what was going on. 

The guy in front of me was a young, healthy looking guy, but was in rough shape.  He said he had just arrived from Freetown that day, and had been vomiting and having diarrhea since that evening.  As soon as he said he’d come from Freetown, a little light went off. I’d just come from Freetown myself and had seen all of the signs posted and heard the radio announcements about the cholera epidemic, what people should do to prevent it, when to go to the health center, etc, so it was higher on my radar than it usually would have been.

Of course I’ve seen plenty of diarrhea and vomiting cases….but this guy seemed a little different.  During the interview he had leave a couple different times to go vomit and or use the bathroom.  When the cholera episodes first started appearing, I took to ole’ Google and researched the signs as well as how to treat it.  It’s actually a simple treatment of IV fluids and/or oral re-hydration salts.  Oftentimes people will add an antibiotic because although it isn’t curative, it has been shown to decrease the duration of the diarrhea and vomiting. 

I admitted the guy and started him on IV fluids and the antibiotic and called one of the docs to let him know what I was suspecting.  He agreed with my plan so we put the guy in a private room and started his treatment.  I went down to see him the next afternoon and was doing much better. The day after that he was discharged.

We didn’t see much else that we suspected could be cholera until about a week or two ago.  At this point we’ve had four confirmed cases and others that were probable cases but we didn’t have the testing to confirm it.  We’ve made some changes to the hospital now and have moved all the women down to the OB ward so we can have the womens medical ward for the male cholera patients and the womens surgical ward for the female cholera patients. 

While cholera is relatively simple to treat, it can be extremely deadly. The fluid loss is just so extreme that if it’s left untreated for 24 hours, it can kill.  Since patients aren’t always quick to come to the hospital (see other bazillion posts about patients coming too late) it can easily kill. It’s also very easily transmitted (oral-fecal transmission….yum!) 

It turns out that trying to contain cholera isn’t easy!  Now me, I hear cholera and I think hmm…I don’t want to go anywhere near that!  When we realized that we were seeing multiple cases, we decided to limit visitors and only allow one visitor per patient.  We went up and down the wards kicking patients out, but they kept finding their way back in.  My friend explained that if you ask a family member to leave the patient, they automatically think that the patient is dying and so will do whatever they have to to be near the patient.  He had one family member that he had repeatedly asked to leave, but kept coming back.  Later when he asked this family member if the patient was drinking the ORS (oral re-hydration salts) like he was supposed to the family member said that yes, he was drinking it, but the family member had also started having diarrhea so was drinking some of it as well.  Frustrating!!!  We’re currently working on getting some better security and educating the community on the various dangers.  The WHO came a few days ago to see how we were handling things and the government is supplying free IV fluids to the hospital for all the cholera patients.  We’re very grateful that we haven’t seen any deaths (although we were fearful for one guy in particular!) and our patients are improving. 

Ironically, last week was a red letter week for me, as I received 3 different marriage proposals.  It had been awhile!  To be fair two of them were by one person who initially wanted me for his son but when I said he was too young offered to marry me himself.  This was of course after I’d already met his wife.  It must be true what they say.  Cholera is in the diarrhea….love is in the air. 

Spoke too soon....

The last post I did was about the successes that we had in the OB ward.  I’m sad to say, I spoke too soon.  One of the success stories I mentioned, the woman who’s baby was breech and had a c-section, died yesterday.

She was discharged.  She’d stayed her 7 days and was ready to go home.  But the bill wasn’t paid in full yet.  Her husband came to visit her almost daily, always promising to come with the money and always drunk.  On the patient’s last admission he threatened to beat one of the nurses because he was upset about the bill.  He is a policeman.  Yup.

So she was ready to go.  She had been having vague complaints throughout her stay.  Every day it was something different.  Her head hurt. Her back hurt, etc.  She spent a lot of time in bed and we had to keep encouraging her to walk.  Those of us in health care have had these kinds of patients before.  The best thing for them is to get out of the hospital, get back into their routine and they start feeling better. They forget to be sick. 

Such was this patient.  Needless to say, when we were doing rounds on this patient on her 3^rd or 4^th day after being officially discharged, I wasn’t overly impressed when she said, “I torment, I torment.”  What does that mean?  “I just don’t feel well.”  Well, we all said.  You need to get home, get back to your routine, etc.  Your blood pressure is fine, your incision looks good.  You’re on the mend. 

About an hour after this conversation, she said she was feeling cold so we took her temp.  102.6.  Huh. That’s weird.  Something really is going on.  I called the doc and we ordered some labs.  While the labs were cooking, she started becoming delirious, talking but not making any sense.  The family also said that she wasn’t moving her right hand very much. 

While we were waiting for the labs, we called another doc to come look at her and see if this was a complication from her surgery.  I’d listened to the abdomen and didn’t hear a whole lot in there, so it was possible.  The doc came, looked her over but decided that this wasn’t a surgical problem.  Darnit. Back to square one.

The labs came back and she was malaria positive.  Upon admission, she’d been negative but had been given the treatment anyway (we can only test for one strain of malaria so if they complain of symptoms we often treat even if the test is negative).  Ok, now it was starting to come into focus.  Cerebral malaria.  I’ve never really been with someone it came on so while it seemed pretty fast to me…maybe that’s what happens?

Now our dilemma.  We use quinine as our injectable anti-malarial for adults when patients aren’t conscious.  It’s not the best medicine because the malaria in this area has developed a resistance to it. It also has some pretty nasty side effects.  But it didn’t matter because we don’t have any.  We have recently discovered injectable artesunate.  This is the drug we use as first-line treatment for malaria.  Unfortunately our supply is limited so we’ve been using the artesunate in the kids, the quinine in adults.  But we don’t have any quinine. We have 30 vials of artesunate.  Kids, depending on their weight will use 1-2 vials. She would need 4 vials for every dose.  It would burn up our supply pretty quickly. 

We stood there…two doctors, three nurses, trying to figure out what to do…what decision to make.  We have plenty of oral anti-malarials.  Can we give that rectally?  Will it still work as well?  We have no idea.  No study to help us decide.  What if we gave a lower dose, didn’t use as much?  But then what’s the point if it’s not a therapeutic dosage?  Does she really need the injectable artesunate?  Her family said she seemed to be getting a little better, moving her right hand now.  Could we get away with saving it for the kids?  Finally one of the other nurses suggested putting in an NG tube (tube going through her nose into her stomach) and giving it orally.  Perfect.  The oral anti-malarial we have works really well…and this way she doesn’t have to be awake to take it.  Seemed like a good solution.  I had high hopes she’d turn around.

When I came in the next morning and asked the night nurse how the night had been, she told me it was very rough because the woman was “tormenting” all night.  She hadn’t come out of it.  When the doc came by for rounds she listened to her lungs and said she was full of fluid.  They were now suspecting that she threw a pulmonary embolus (little blood clot into the lung) and this put her into pulmonary edema.  We threw a whole slew of medicines at her…..although it was frustrating because we just don’t have the testing capabilities or monitoring capabilities to do everything we would in the states.  We continued on like this for the day.  When the doctor came by in the afternoon she was hopeful that if we just gave this lady one more day, she would probably turn around.

Over the next 2 days there was no improvement.  This woman lived nearby and was well liked so the family and friends started coming by.  The crying began.  She has three children.  Two girls, age 10 and 6, and this new little baby boy.  The older girl began to see that her mama wasn’t getting better and became hysterical.  Some other family members took her home.

Yesterday she started seizing.  The family had once again begun complaining that she wasn’t moving her right hand, so we thought she must have had a stroke. Again, no way to confirm.  We got the seizures under control but now her oxygen saturation was dropping. We put her on oxygen.  We tried to suction her lungs, but there was nothing to come out. 

The ward was full of people! The rumors had started that she’d died and the nursing assistant working with me was fielding the calls to find out if it was true.  Her family came and asked me if they could take her.  They wanted to take her to her home town about 6 hours away.  This town is the center of all things “magical” “occultic” whatever you want to call it.  They said that her sickness wasn’t a hospital sickness and that her twin brother had taken something from her that they needed to go to this town to get back. 

I didn’t see any reason to keep her.  She began doing the “guppy breathing” that people often do at the end of their life, and I knew there wasn’t anything else we could do for her.  It was heartbreaking to see her two daughters sitting by her bedside.  The older one knew that something was going on, but the little six year old had no idea that her life was about to change forever. 

I couldn’t do anything to stop this woman from dying.  For some reason, her little daughter just got to me. I wondered if she would remember her mom. I wondered if she would remember the week and a half that she spent in the hospital, only to leave with a new brother and no mother.  I wondered who she would live with.  What was her life going to be like?  I mentioned above that she and Kadiatu had become quite good little friends.  They often played with Kadi’s “baby” (a black baby doll that was sent over on the container).  People freak out over this doll because it’s pretty life-like. I’ve had tons of people stop to see if it was real, touch it, etc.   And I had another one.  The dolls came as a set of twins. I’d given the first one to Kadi on her first night with me but the other one was sitting in my closet. I’d been saving it for….something.  I ran up to the house to get it and had Kadi give it to this little girl.  She was so excited.  I felt like crap.  A baby doll?  Really? It was such a small thing to give when I knew what this girl was about to lose.  I knew, but she had no idea what was coming. 

I left that afternoon and she was still alive. I found out the next day that they had taken her that evening and she died three hours after leaving the hospital.  Leaving three beautiful children behind.

I wanted to remember the feeling I had, remember her, so I snapped she and Kadi with their babies.

 The faces are real. It is so common here to meet people who have lost their mother, their father or both parents.  While I always feel bad, I generally meet these people as adults and the wounds have had time to heal, at least a little bit.  This was the first time I watched it happen.  It sucked.  

Success!!

A lot of times it seems like the things I post on this blog are very dramatic, and oftentimes sad.  In an attempt to balance the sad with the not so sad, I thought I’d tell you about the OB ward right now.  I’m not sure what happened 10 months ago that kept people from baby making, but for the past few weeks the ward has been pretty quiet.  One contributing factor could be that it is “hungry season” right now.  This is the time of the year when planting is going on and the harvest hasn’t begun yet.  People have run out of the food/money from last year's harvest and are trying to hang on until they are able to harvest what they’ve planted this year.  For this reason, there are very few if any elective surgeries and people wait until it is very late to come to the hospital. They will also try to deliver at home to save money.  That being said, our ward for malnourished kiddos (which is free) is overflowing right now.

For the last few days we have had 4 patients in the ward.  Patient number on is a woman who had a previous c-section.  Although that baby was born alive, he/she died soon after beginning to walk.  Mom said he had been having fevers, vomiting, etc.  Stupid malaria.  Anyway, she was told after her first c-section that she would need to have another one for her next pregnancy. (No attempts at VBAC’s here (vaginal birth after c-section. Too risky).  She lives far away but came to stay in this village with relatives about a month before she was due so that she would be able to come to the hospital quickly.  Because she acted quickly after her labor started and came when we asked her too, she and her baby are both doing great and are just waiting to go home.  Success!

Patient number 2 is also a c-section.  This was her sixth pregnancy.  I walked into this delivery soon after she’d arrived. She had been laboring at home for awhile but the baby just wasn’t coming. The nurse before me had started some oxytocin to see if she could move things along.  After a while she did her second vaginal exam and said, “Um, Emily.  I’m not sure what this is, but it isn’t the head.”  We confirmed with ultrasound that indeed, this baby was coming rump first.  Although it is possible to deliver these babies vaginally (especially if they’d had many pregnancies before) this particular presentation gave us a high probability that if we tried we wouldn’t be successful.  To the OR we went and she now has a beautiful, healthy baby boy.  Success!

Patient number three is a woman who is pregnant for the first time.  She is 7 months pregnant and came to us with a complaint of fevers and dizziness.  Her hemoglobin was 4.  Very, very low!  We gave her two units of blood and are looking for a third.  But she’s doing better.  I’ve seen malaria kill multiple babies in the womb so that fact that this baby is still with us and mom’s doing better….I’ll say, Success!

Patient number 4 is a baby who came to us at 23 days old.  He was born here and they brought him back after he was crying all day and night and wasn’t breastfeeding well. His scrotum was also very swollen.  Thanks to the skill of our Super Docs he was diagnosed with a strangulated inguinal hernia.  This is where there is a weakening and hole in the wall of the abdomen and a small amount of bowel is pushed through the hole….. in this case into the scrotum.  The hole is so small and tight around the piece of bowel, that the blood supply is actually cut off and if it isn’t fixed, the patient will have some dead bowel and if left untreated will eventually die from the infection.  We see these all the time (especially in men) here, but almost never in a baby this small.  Our OR team came to the rescue and today they said he could go home.  Success!!!

Our OR team working working on the smallest belly ever.  You can barely even see the patient on the table!

There is a lot of heartbreak here in Sierra Leone and we thank God that He is with us in the midst of our pain.  But we also thank Him for the times when things go the way we want them to! J  

Three weeks already!!

Little ham cheesing it up for the camera

Today marks my 3 week anniversary with “my” little one.  As an ode to that, I thought I would jot down a few things I’ve learned/ways my world has changed/things about Kadiatu. 

1.        There’s a commercial for a TV show that was on for a while that always made me laugh.  It was a cartoon and the mother was in bed sleeping. The little kid walked into the room and said, “Mom. Mom. Mom. Mom. MOM. MOM. MOM! MOM! MOM!!!!!!!!!!  Finally the mom yells WHAT!?!??!?!  The kid quietly says, “hi.”  Ha! That is my world now.  Emily. Emily. Emily. EMILY. EMILY!!!  Fantasies of her sitting quietly in the morning eating her plumpy nut while I read my Bible are just that….fantasies. I’m SURE I never needed all that attention when I was that age. Right Mom???  J

2.       I never knew that someone could pee so much.  During our first few days of adjustment there were definitely times when I did something Kadiatu didn’t like, she looked right at me like she wanted to beat me…..and promptly peed on the floor.  That was a bit frustrating.  We’re still having lots of accidents, but I’ve decided that it’s most likely due to the fact that her belly is really big and we’re getting rid of all the extra fluid in there.  Also, like a pregnant woman with those big bellies, when she has to go, she has to go NOW!  Laundry days can’t come soon enough! I think I shall forever smell like urine.

3.       I have never ever thought it was cute when little kids cop an attitude and get mad.  But with her, sometimes I just burst out laughing because the expressions she gives me are just hilarious! I think some things must get lost in translation because sometimes she will just turn on a dime and be happy and laughing, then in the next second shooting lasers at me with her eyes.  She will also look right at me and blink really slow.  One of my friends said she reminds him of the girl on “Mean Girls.”  Attitude!  Pick your battles, Emily. Pick your battles.  

4.       After 3 weeks, I have finally definitively determined the word for “poop” and “pee” in little one’s language.  Three weeks.  To learn 2 words.  Important words.  There’s a chance I don’t really have an ear for languages…..

5.       This girl is spoiled rotten.  Since I take her to the hospital with me all the time, everyone gets to know her. That, along with the fact that she’s just really cute makes people want to give her all sorts of things.  She’s quite the ham and I think she’s up to about 15 husbands and is constantly coming to me with things people have given her.  She’s just so stinkin cute. Who can resist??

6.        Kadiatu is not a morning person.  Oftentimes it takes her about 45 minutes in the morning for her to get out of her funk and be the happy little girl that she usually is.  It’s a long 45 minutes. Especially when you’re trying to keep her from waking your roommate up.  There is a moment though, when she first wakes up and I go to her bed to free her from her mosquito net that I love.  As she crawls to me and reaches out to hug me….precious. Just precious. 

7.       Kadi is definitely a girly girl.  She likes wearing dresses more than pants (which is nice with the “lots of urinating” problem and loves having her fingernails painted.  She would repaint them every day if I’d let her.  Also, she loves pockets.

8.       She’s an African girl! I love when she “plays house” and it obviously has it’s Sierra Leonean twist.  She’s brooked (handwashed) her baby’s clothes, walked around with my bread on her head yelling “HOT BREAD” trying to sell it , built a fire to cook (no matches of course), and pounded various leaves to “cook.”  So cute!

My life has changed pretty drastically over the last 3 weeks. I can’t say there aren’t times when I can’t wait to have my life back, but praise Jesus it’s getting better. We’re learning to communicate better and even though I have no idea what she’s saying about 80% of the time, I’m fortunate that a simple “uh huh!” will usually do. 

Today Kadi’s mom came to visit the hospital to get the nutrition supply for her son.  I went down to the hospital to take Kadi to her and when we saw her mom, she got really shy and hid behind me.  When I went to leave to give them some time together she started following me. I told her to stay with her mom and made myself scarce for awhile.  When I walked by later she was sitting there chatting with her mom and brother.  It made me a little nervous because we’re only 3 weeks into the 8 weeks.  I don’t want to scar her and I don’t want to hurt her mom. I know that in the long run she’ll adjust fine to being back home.  She has adjusted well to coming here, and it’s completely different, so I know she’ll eventually be fine back in her village. Today just made me start to pray already for her adjustment back.  

Now for your viewing pleasure (or maybe just my viewing pleasure).....here's some pics of the little darling.

She made this little bed for herself so she and her baby could relax and watch my neighbor wash her clothes.  So helpful. 

Enjoying rainy season.  When we have to walk to the hospital in the rain I  chant "Are we afraid of the rain????  NO!!!!"

Someone gave her this piece of cloth and she wore it like this almost all day. We weren't sure if she was  Mary Magdalene or showcasing her Muslim heritage.  Either way, she went around bowing and greeting everyone in her native language all day.

Like a good mother, she is breastfeeding her baby.  You may notice that her form is perfect.....

Taking advantage of her 50th invitation to join one of the patients families for chop time.

It's a dangerous thing......

I would like to preface this post by saying that if you are not medically inclined it might be a little too boring.  And gross.  Sorry.  You were warned.

Last night I was working during the evening.  When I got to work we had zero OB patients….the first time I’d ever seen the ward empty.  I was hanging around, just in case something came in.  Kadiatu was having a bit of a rough time and at about 6 I went up to the house to change my clothes after she’d peed on me.  Again.  I was just about to jump in the shower when I got a call that they needed the ambulance to go out.  I grabbed Kadiatu and we ran down to the hospital.  Fortunately the rest of the hospital was quiet so my friend agreed to watch her for me while I went out. 

We were going to an area that isn’t served by any health center. It’s kind of in the middle of nowhere and neither of the closest health districts will claim responsibility for it.  For some reason (impassable roads?) we couldn’t go directly to them but were going to meet them at an arranged meeting place and pick up the woman.  The ambulance driver told me it was going to be 2 hours one way.  Oh dear. 

The road was pretty bad the whole way, oftentimes barely resembling a road.  We ended up reaching in about an hour and 15 minutes and the woman was just sitting on a bench (the driver told me he said it was going to take longer so I would be pleasantly surprised when we got there sooner.  Nice call. Very un-Sierra Leonean!)  She was weak but was able to walk. The story we got was that she’d been in labor since the night before. She wasn’t bleeding and hadn’t urinated or had a bowel movement in a long time.  It was her first baby. 

When I first started going on the ambulance I would always want to do some exam. Do a vaginal exam, listen to fetal hearts, etc.  I’ve come to learn though, that usually what we need to do is just get to the hospital quickly. If the woman’s not bleeding, really weak/unconscious and/or seizing, I usually just scoop and run.  That’s what we did with this lady.

After going back over the wonderful road again (can’t even imagine doing it when I’m in labor!) we reached the hospital.  (This is where I may be a little too graphic for some of you so….sorry).  We took her into the labor ward to get her checked out. Her blood pressure was fine, the baby was full term.  I listened with the Doppler but didn’t hear any fetal heart tones.  Honestly, I would have been shocked if I had.  When I did the vaginal exam the baby’s head was almost crowning.  When I stopped to look at the woman, I noticed that she wasn’t contracting very much.  If she’d been in labor for that long, her contractions should have been coming hard and fast.  I decided to start an oxytocin drip to see if we could strengthen her contractions. I also attempted to insert a foley catheter to drain the urine since they said she hadn’t urinated in a while.  The only foley I could find was huge, but I decided to try.  It was difficult because the head was so far down. I pushed and pushed but got no urine, just started to get some blood.   Huh.  Well, I left it and decided to let her try for awhile and then use the vacuum to try to get the baby out.  Since this was her first pregnancy I wanted to avoid a c-section for a baby that wasn’t alive. 

That’s where I was when the cavalry showed up.  I love having a cavalry here!  In addition to the two doctors we have here who are pretty much on call 24/7, right now we also have a Sierra Leonean doc who’d doing a surgery residency and a doctor hanging out with us for 7 weeks.  Anyway, they came in and one of them immediately mentioned an odor.  Huh.  I hadn’t really noticed.  I felt bad, but honestly there are so many smells in this country that are unfamiliar to me…I don’t always notice the bad ones from the really bad ones.  Opps.  Anyway, I told them what was up.  I couldn’t find any fetal heart tones but asked if we should use the ultrasound to try and confirm.  They confirmed that indeed, the baby was already gone.  Next we looked at getting this baby out.

They tried to use the vacuum but agreed with me, that her contractions just weren’t coming very strong. There was also the problem of the full bladder. We tried using two other catheters but couldn’t get any urine to come out.  They could feel the bladder and it was really distended. It could have been what slowed down some of the progression in the first place.  We also started to suspect a ruptured uterus.  Although her hemoglobin was fine, something just didn’t seem right.  When her uterus was contracting, it was firm at the top, but not at the bottom.  But was that just because her firm bladder masked the firmness of the belly, or was it indeed soft?  In America they tell us that one of the ways you know that a woman has ruptured her uterus, is that she is writhing around in pain.  Not so much here. It’s very difficult to tell.  You can try to use the ultrasound, but it can be difficult to see.  We decided that since we were no questioning a ruptured uterus and couldn’t seem to get the baby out with the vacuum anyway, we would head to the OR for a C-section. 

OB can be such a fun place to work…when everything goes like it should. But cases like this, where we already knew the baby was gone….no fun.  Also, because of the smell we were suspecting that the baby had been gone for awhile and had started to decompose. 

The first thing they had to do after opening her up was to drain her bladder. They couldn’t even get to the uterus, it was so full.  They ended up using a large bore IV catheter to put a hole in the bladder to drain it.  She probably put out about a liter of urine.  After that was getting the baby out.  One of the docs told me I needed longer gloves to help them.  Wait, what?  Because the head was so far down, I needed to go under the sterile field and help push the head up through the vagina to help the doc break the suction and be able to pull the baby out.  When my time came I got down on my hands and knees and started to push.  I wasn’t confident in what I was doing because I’d never done it before and the doc who had his hand at the other end started saying, “Push. Push, Emily.  Emily Push!!”  It was on the tip of my tongue to comment that it sounded like he was trying to get me to deliver…but didn’t think it was the time.  Thank you social filter.

The baby came out and it had definitely been gone for awhile.  I took it into the other room, cleaned him up a bit and went back into the OR.  When I came back in the room they were looking at a badly ruptured uterus.  At this point I usually leave but since it was a pretty rough surgery I stuck around in case they needed me to go grab stuff. 

They finished the surgery without any major complications and took her back to the ward. I headed up to bed.  When I got there the next morning and asked the nurse how she did overnight I was pretty surprised to hear that she wasn’t doing well. I kind of assumed that she was going to be doing fine. Apparently they had called one of the doctors down at five thirty when the nurse couldn’t find a blood pressure or feel a pulse.  They did everything they could for her which included giving her a mask for oxygen.  That’s pretty much it. Her hemoglobin that morning was fine, but she just wasn’t doing well.  The doctors came by a little bit later to do rounds and we sat around trying to think of anything else we could do. We suspected that she was in septic shock.  The baby had been gone inside of her for so long that the infection had spread to her bloodstream, making her incredibly sick.  We gave her some more antibiotics and hoped for the best.  None of us were very optimistic.  At 10:04 this morning I was turning her to get her cleaned up a little bit and she stopped breathing.  That was it.  She was gone. 

Of course the doctor from America and I were going over the things we could have done if we were home but it really only served to make us frustrated at the lack of resources here.  Her first baby…and it killed her.  With one in eight women dying in childbirth, Sierra Leone has one of the highest maternal mortality rates in the world.  The hospital where I work does an incredible job in saving so many lives….but it still hurts when there are ones we can’t. 

"Mama?" Part III

The time came and I headed toward the car. Her mom was carrying her and handed her over to me.  She was talking to her in her tribal language.  Kadi started to get a little teary eyed and her mom told her she was going to come see her tomorrow (little lie there) and Kadi stopped .  She was silent the whole way to my house.  Watching me, watching her surroundings in the car.  As we pulled up to the house she continued to be silent, just watching.  I took her into the house and she promptly peed on the floor.  Poor thing, who knew how long she’d been holding it.  I decided to go ahead and get her cleaned up at that point so I heated up some water for bath time.  I spoke to her in Krio the whole time, not knowing how much she was understanding.  She just nodded her head yes to everything I said.  Always watching me.  After a silent bath time I gave her some plumpy nut to eat and made a sandwich for myself.  My mom had sent some cartoons for some of the missionary kids and somehow they had ended up in my stuff so we watched cartoons while we ate.  I was really thankful for that mistake!!  Some kids came over and wanted to watch a movie but since it was her first night I begged off until tomorrow.  I did some dishes and cleaned up a little and the whole time she was just watching me. She started exploring a little, picking up some crayons but not brave enough to actually color yet. 

At about eight o’clock I decided it was probably time for bed.  Please keep in mind that I’m not a mother.  I haven’t even babysat in forever and my friend (shout out Kaysie) and sister have both fired me from babysitting their children after a couple incidents involving falling over in the crib and eating gravel that were absolutely and completely not my fault!!  Ok, mostly not my fault.  So I have no idea what time 4 year olds are supposed to go to bed.  It’s especially confusing since she’s a Sierra Leonean kiddo.  I’m not sure if bedtimes really exist here,  as I’ve had a 2 year old at my house at 10pm before.  Anyway, it was dark, so I figured we could try to go to bed.  Since I figured co-sleeping was what she knew, I had her sleep in bed with me.  I got her in bed, tucked her in, prayed with her, laid down beside her and turned out the lights.  After a few minutes I turned on the flashlight to see if she was asleep yet.  She was just laying there.  Staring at me.  After a few more minutes I did it again.  The stare again.  Now, this little girl is one of the cutest things ever, but it’s still a little disconcerting to have someone just stare at you while you’re pretending to sleep.  Always staring.  After a few minutes I decided to get my computer, put in my earphones and watch an episode of Lost. (I know I’m a little behind, but I’ve been saving it!)  After a couple minutes she turned over and was asleep.  Thank you Lord!!

That night was another pretty restless one for me.  I was so afraid that something was going to happen to her.  Did she fall into the crack between the wall and bed? Was she too hot? Was she too cold?  Was she still breathing?  I woke up about a hundred times.  It didn’t help that Little Miss Thing likes to make noises in her sleep. I kept turning the flashlight on expecting her to freak out but she was just talking to somebody while she was sleeping. 

The next day was my first full day with her. I had a plan to ask one of the ladies I know and trust to keep her for me while I was at work but I wanted to keep her with me for the first few days. Ideally I would have taken a couple days off of work but we’re so short staffed that it wasn’t really an option.  Now Mothers, don’t hate me for this, but I never really understood what you meant when you were late and said it just took you forever to get out of the house.  Why don’t you just allot the amount of time it will take you and your kids to get ready, and plan accordingly.  Now I know. I repent.  The was so much crap I had to bring with me…potty, blanket, toys, change of clothes, snacks, water, etc. that I could barely carry it all out of the house, let alone do it on time.  Finally, we were ready and headed down to the hospital.  Kadi was again, just taking it all in.  She hadn’t spoken yet, just nodding her head to everything I asked.  We got to the OB ward and I set up camp across the hall in the part that we’re not using right now.  There wasn’t a lot going on at the time so we sat out in the hallway for awhile to people watch.  That was a bit of a mistake.  I guess the sight of a white girl with a little black girl is quite the sight because everyone kept stopping and asking if she was my child, pinching her cheeks, and generally making quite a fuss.  Eventually I got tired of it and was afraid it was overwhelming to Kadi so we went inside the ward and people watched from inside, where we weren’t so obvious. 

The day was long, but good.  The OB ward was really quiet which I was utterly thankful for because I could spend most of my energy focusing on Kadi.  I did everything I could to keep her occupied and she tried to be a good sport but was mostly….just watching.  At the end of the day we went to the market to get a couple things.  Again, it was impossible to keep a low profile and we literally had a crowd following us around.  They were all asking if she was my child, if she was sleeping with me, etc.  I thought that being white made me stand out here, but having a little black girl with me made me even more conspicuous.  One of my missions in the market was to find some more clothes for her.   When I was praying about whether or not to have Kadi come live with me, I told my mom about it and had her send some clothes….just in case.  I was so so so thankful for these, as Kadi literally came with the clothes on her back and nothing else.  But I needed a few more things.  Our lack of communication and history of just peeing anywhere ran us through 7 pairs of underwear in one day.  While I was hopeful that it would improve, I knew I needed some more backup things.  The crowd that was following us was very helpful in their many, many opinions. 

The rest of the evening was pretty uneventful.  I cooked my first African meal by myself and I was nervous that she wouldn’t eat it.  I’m not super in love with African food so I can’t tell if it’s good or not. But she chowed it down. Yeah!!!  I gave myself a little pat on the back there.  Just a small one. J  When it was bedtime she went down without a fuss. Some kids even came over and watched a movie and she didn’t stir.  I was so so thankful at how things were going and the thought crossed my mind that this was easier than I thought it was going to be!!  Then began what I have coined “The Dark Days.”

“The Dark Days” were 3 days where I didn’t think I’d make it. I picked Kadi up on a Wednesday and the Wednesday and Thursday were pretty easy.  Friday morning she woke up and was pretty clingy, kind of whimpering a lot.  I had to work so we headed down. At around 10am she was so clingy, whining, rubbing her eyes and yawning, I knew she had to be exhausted. I tried to lay her down and she flipped out.  I tried the ole’ “crying it out” thing but she just kept screaming and becoming more frustrated and I was at the end of my rope. I knew that she needed sleep, but she wouldn’t cooperate.  One of the other nurses who speaks her language came and started consoling her.  She would barely look at me. I was a failure. 

The next three days proceeded much the same way.  She seemed so tired but just wasn’t sleeping well.  Each day seemed to be getting worse and she started fighting me in everything.  Bathing became an issue.  Sleeping was an issue. Taking her medicine was an issue. I felt like everything was a fight and I was exhausted.  (Keep in mind that I hadn’t slept much in the few days leading up to taking her and the sleep since having her was still small in interrupted).  Praise the Lord so so much for my neighbor Bethany.  Kadi loves her and would spend some time at her house and be comforted by her when I made her do something awful like take her medicine (she was being treated for malaria, worms, a respiratory infection and an infection in her belly….lots of medicine).  It was hard to be “the bad one.”  But I told myself that I wasn’t there to be her mother.  I wanted her to get well. If I had to be the bad one to make her take her medicine, etc. I was willing to take that roll….as long as she had someone to comfort her. 

The most painful thing was that it just seemed so hard on her.  She was an emotional rollercoaster….fine one minute, having a meltdown the next.  It felt like I was living with a time bomb and was constantly on edge, waiting for the next fit.  I started crossing off every day that she was with me.  The total was 62.  When that didn’t give me enough satisfaction I went through my calendar and counted backwards from 62 so I would always know exactly how many days were left.  Yes, it was different having my whole life changed and taking her to work was especially challenging, but my real countdown was for Kadi.  When she would be fussing and looking pretty miserable I would remember that this was just a short time and we could get through this. We would get her healthy and then get her back to her village where she was happier. 

I took her to church Sunday morning but ended up leaving early because she was just so fussy and was inconsolable.  By Sunday evening I was at my wits end. I was about a fraction of a second away from breaking down in tears at any moment.  My friend came down to the hospital and was talking with her and took her on a little walk. I had 10 minutes of peace and it was incredible. I wasn’t sure how much longer I could go on like this.  I wanted to take her back to her village.  It didn’t seem to be working for her.  She was miserable.  Probably the only reason I didn’t was because I had signed that contract and didn’t feel like I could break it.

Monday morning we woke up and it was the worst morning to date. Usually, the only way to console her was to wear her on your back, but this morning even that wasn’t working.  I had planned to take her to her village that morning to see her family. I wasn’t sure if that was a good idea. Did she just need more time to get adjusted? Was seeing her family and village going to make it harder on her?  Lord, what do I do?!?!?!  I decided to go ahead and go.  It didn’t seem like it could get much worse.

We left that morning and actually met her mom coming to bring her other child to get some nutritional supplement from the hospital.  When Kadi saw her mom she was initially surprised like she wasn’t sure what was going on and then she was SO SO happy! She just started smiling, talking, and wouldn’t take her eyes off her mom.  If she thought her mom was leaving, she started to cry.  We went to the hospital and I left them alone for awhile.  When I was around, Kadi would barely look at me.  They did their business at the hospital and then I took them back to the village. When we got to the village I played with the other kids for awhile while Kadi visited with her family.  Finally, it was time to go.  I 

was on the brink of tears the whole time we were in the village because I knew what was going to 

happen.  I went to turn the car around so I could make a quick get-away.  Her auntie started to bring her to me but when she realized what was happening she started kicking and fighting.  Her dad took her and brought her to the car. By the time he reached the car I had lost it.  I was utterly exhausted and my heart was just breaking for this little girl.  I started bawling.  He looked surprised like he wasn’t really sure what to do and told me to “bia” (be strong).  Her mom came up to the car and looking slightly horrified as well said, “Emily don’t cry. Don’t cry Emily!”  I nodded my head although I couldn’t stop.  I took Kadi and we headed down the road, both sobbing.  She was kicking and fighting and I just kept whispering “Bia, bia, we just have to bia small. We’re going back. You’ll see them again.”  After a few minutes I must have let out a big sob because she all of the sudden looked up at me and saw that I was crying as well. She immediately stopped.  She didn’t cry the rest of the way, but I still couldn’t seem to stop.  She kept watching me. 

When we got back to the house I’d pulled myself together and the kid that got out of that car was a different one than the one I’d taken.  She went into the house and was playing, singing. I was in shock.  The next morning she woke up and was in a great mood, talking, talking, talking. 

Something happened on that trip and I don’t know if I’ll ever know exactly what it was. But since that time she has had an almost complete turn around.  I’m learning which battles to pick and she’s learning that there are certain boundaries she has to respect.  She still has little melt-downs but they are much less frequent and she rebounds quickly.  I started working evenings which is nice because it’s not as busy and there are several kids that hang around at that time that speak her language and she has a great time playing with.  Everyone down at the hospital loves her and when it has gotten busy there are always people (staff, family of patients, people selling things outside the hospital) who are happy to watch her for a little while.  In two more weeks I plan to start working days again and put her in nursery school during the day. Then she won’t have to go to work at all with me, which will be a little bit of a stress relief. 

She got into my measuring cups and transferred water from one
cup to another, to another and then to her baby

I love this little girl so much.  There are definitely times when I’m chanting the mantra “you can do anything if you know there’s an end in sight” (mostly it’s when she’s saying, “Emily. Emily. Emily. Emily. Emily. Emily) but there are many other times when I dread the thought of giving her back.  People are always telling me that it will be hard for her to go back.  I don’t really agree.  She will be going back to stay with her family and friends in a village that she knows, speaking a language that she understands.  Most likely she won’t remember any of her stay with me.  It will be my heart that breaks when I give her back.    

"Can't you see I'm busy washing my baby's clothes??"

She makes my heart very very happy. :)

She's definitely an African child! She loves to carry her baby on her back.  Sometimes while putting bread on her head and going around yelling "Hot bread! Hot Bread!"

"Mama?" Part II

So, I was all set to leave Kadi in her village. My mom, sister and I went up to see the hospital when they were here and stopped to see Kadi in her village and drop off the first installment of plumpy nut. I weighed her and she weighed 10kg’s which is 22 pounds. My niece weighs 22 pounds and is 13 months. Kadi is 4. The chronic malnutrition has left her about the height of a 2 year old.  I met Kadi’s dad and talked with both of her parents about my plan to bring them the plumpy nut frequently.  Since I was only staying in the hospital for a couple days I gave her a couple days worth, stopped back again on the way down to give her some more and she agreed to go to the hospital in a couple days to pick up the balance that I’d left with a friend of mine there.  The Alpha ward has an outpatient program and since Kadi had been admitted before she was used to going to get the supplement. 

I was back down in Freetown with my mom and sister, having a grand ole’ time, but was still often thinking about Kadiatu.  I called on the day her mom was supposed to have picked up the supplement to see how she was, but her mom hadn’t come. I called back a few days later, she still hadn’t come.  A week after she was supposed to come I was headed back up to the hospital so stopped to see her.  When I saw Kadi I couldn’t believe how much better she looked!  There was a life in her eyes that I hadn’t seen before and although I didn’t get a smile, I got a slight upturn of the mouth…something totally new!  After just having a week of the plumpy nut she was already doing a lot better. I was a little bummed that her mom hadn’t gone to pick up the balance because it meant that she had had it for a week and then hadn’t had it for a week.  When I talked to my Freetown plumpy nut friend, she said that if they have it for a day, don’t have it for a day, etc. it really slows down their progress. But, I was going to be in the area for the next two months so I’d just make sure she got it every day. 

At the beginning, every time I went to the village it was quite the spectacle.  All the kids (and a lot of adults) would gather around and just watch us.  Literally, just sit and stare at us.  Awkward.  I would generally feed Kadi one of the packets of plumpy nut just to see how she was eating them.  I have a little children’s Bible so would sometimes read a story from there, blow bubbles with them, etc.  One of the first times I went there I noticed that Kadi’s little brother didn’t look too well. I asked about him and they said he was sick.  Of course my initial thought was, well, I need to take him to the hospital.  But I was afraid.  I know what a floodgate that could open. So I just made the suggestion that they take him to the hospital because it would be less money in the long run if they took him earlier than if they took him later.  Nice try. 

This was a Friday. I was working double shifts on Saturday and Sunday so I wouldn’t be able to go to the village until Monday.  It was a long weekend. I kept thinking about that kiddo and was a little afraid of what I’d find when I went on Monday.  See, whenever I have kids who come to the hospital and are super sick, when I ask the parents how long the kid had been sick, the answer is almost always 3 days.  I know that this isn’t really true. The kid has to have been sick for longer than 3 days, but I wasn’t sure HOW much longer. I knew Kadi’s brother was sick for at least a week, probably longer.  Was he going to show up at the hospital in critical condition like so many others I’d seen?  By Sunday evening I decided that if I went Monday and he was still sick, I’d take him to the hospital. 

When I got to the village on Monday, I immediately asked about Kadi’s little brother.  He was still sick, but he didn’t look like the critical kids that come rushing in with their parents.   However, when I looked at his conjunctiva it was pretty pale (meaning he was anemic).  I knew if he didn’t get help soon, he would be one of those super sick kids.  I asked the parents if they wanted to go with me and take him to the hospital and they said yes. I did tell them to bring some money to buy the medicines.  So myself, Kadi, Kadi’s mom and two younger brothers all headed off to the hospital.  We tried to put Kadi and her younger brother in the back seat but they both started freaking out, it being their first time in a car, so we brought her brother up to sit with her mom and Kadi sat on my lap. Once she was there, she seemed to enjoy the ride. 

It was getting to be late and I knew the outpatient clinic was going to close soon (even though technically they were supposed to stay open for another hour). We got there and did labs on the kiddo and his hemoglobin was 7.  We don’t usually transfuse these kids but we admit them to recheck the hemoglobin in the morning.  Kadi’s mom hadn’t come prepared to stay so we agreed that I would go collect them early in the morning and bring them back to get his labs rechecked.  They also told her that he qualified to be admitted to the Alpha program for malnutrition if she was willing to do that.

This was the time that I really started considering bringing Kadi to come live with me.  I’d been holding her a lot during the day and she was feverish again.  She also had a nasty cough.  I was afraid that with Kadi’s mom now having another sick kid, Kadi would be neglected again.  I started thinking and praying about it again. That night I don’t think I slept for even an hour.  The next day I went early to pick them up and bring them back to the hospital before work.  They were going to do what they needed to at the hospital and then wait for me to take them home in the afternoon.

That day I spent a lot of time with them as the OB ward was pretty slow.  I gave Kadi a packet of plumpy nut in the morning when her mom was busy with her little brother and it took her about an hour to eat it.  Later I gave her another one when her family was around and it was gone in 15 minutes.  When she took another one later in the afternoon I physically saw it being shared with the auntie, the brother, and some other kids.  I knew for sure then, that she wasn’t getting as much as she was supposed to get in the village.  That sealed it for me.  She was sick again with that fever and although I thought she looked better, I was afraid that one more big sickness that wasn’t noticed very well because of other sick kids, farming that needed to be done and the other many responsibilities a mom with 3 kids age 4 and under had, she wouldn’t make it through this one.  By noon, I had decided to make the offer.  I felt a little sick.

I wasn’t really afraid that the husband would say no. At one point when I was visiting the village he told me that I should take Kadi and go.  It was her mom that I was worried about. I did NOT want her to think I was trying to take her child from her. It was important to me that I talk to her before I talked with her husband.  I know the culture here, and knew that if I went to talk with she and her husband at the same time, whatever the husband wanted would happen. I wanted her to have a say in the matter so I didn’t even want to approach her husband if it wasn’t something she wanted to do. 

I went to my friend “Joseph” and told him what I was thinking. I asked what he thought and if he could help me talk to her. Even though she and I communicate in Krio pretty well and she actually helps me “translate” from my krio to krio that people understand…I wanted this to be VERY clear.  No room for error. 

When I talked to Joseph, I explained exactly what I wanted to do. I would offer to take Kadi for two months, get her nice and healthy and then give her back to her parents.  We could come visit a couple times a week if they wanted.  Ok. Time to go talk to her.

When we called her to come talk, she looked nervous, like a kid who’s in trouble.  While Joseph was talking to her, she wouldn’t look at me.  She just kept nodding her head.  Joseph did a great job of explaining everything.  At the end, he asked her what she thought and she said she wanted to do it.  At this point I jumped in and asked if she was sure, telling her that I really didn’t want her to think I was trying to take Kadi from her.  She started getting a little teary eyed at this point and said that no, she was happy.  I took her at her word.  We decided that the next day Joseph and I would go to the village and talk to her husband. I was going to draw up a contract that I, Joseph, both Kadi’s parents and one other witness would sign.  The details would include the time (2 months) and the fact that they were voluntarily agreeing to come have Kadi stay with me for the agreed upon time and that no money was exchanging hands. (Call me paranoid, but I really really did not want to be called a kidnapper! J)  Joseph also made it clear that I was agreeing to take care of Kadi, but was not going to be able to start supporting the whole family financially (another one of my fears).

That night was another pretty sleepless night as I just kept going over things in my mind.  I had prayed so much that if it wasn’t something God wanted me to do, he would just close the doors. I prayed that if it wasn’t what he wanted that her mom would say no. Now I was praying the same thing for the conversation tomorrow with her father. 

I wanted God to just shout from the heavens that he wanted me to do this.  But I wasn’t getting that.  It wasn’t even like I had a clear inner voice telling me, “Emily. Do this.  I want you to do this.”  But I couldn’t get her off my mind. I thought about her constantly.  Oftentimes I get frustrated when I don’t feel like  I want to do what God wants me to do, but I’m not sure what that is.  So many times I’ve been grumbling to Him saying, “Just tell me already! What do you want me to do?!?!”  Then more often than not I hear the Voice say, “I already did. I gave you a whole Bible.”  This was one of those instances.  I wanted so clearly to have confirmation that I should do this, but wasn’t having that bolt of lightening.  When I turned my thoughts to the Bible, the words at the end of James came to mind.  “True religion is this.  To look after the widows and orphans in their distress, and to keep oneself from being polluted by the world.”  Kadi wasn’t an orphan.  She has two parents.  But for whatever reason, she just wasn’t getting the care that she needed.  Does that count?  Maybe?  I kept mulling over this verse and just begging God to close the doors if it wasn’t what he wanted.  And I tried to prepare myself for the conversation tomorrow.

The next day I was ready.  I was a little nervous, but I was also excited and felt peace that God would do what he wanted.  I was done with work at 3:30pm and Joseph and I were going to head to the village then.  At about 2:30 a patient came in that was going to need surgery.  Joseph was going to scrub in, but they had to wait for the surgeon who was far away.  I was frustrated because I’d been waiting for this all day and now because the surgeon (who was on call by the way) was far away, I knew there was no way they would be done by 3:30. Maybe 5:30 at the earliest.  Since we weren’t going to the village yet, when I finished work I went downtown to get a couple things I thought Kadi might need.  As I was walking, I was praying the whole time that if this was God shutting the doors, he would make it clear.  I wanted what He wanted.  My friend called me from the hospital while I was downtown and needed me to bring something to her.  Instead of going straight back to my house I stopped by the hospital.  I was literally muttering under my breath, “Lord, close the door. Close the door if this isn’t what you want” when I ran into Kadi’s father.  His wife had obviously told him what we’d suggested and he had walked the 4 miles (in the rain) to come meet with me.  Lord?

I called Joseph (who wasn’t in surgery yet because the surgeon was so far away…thank you Lord!) and he came to talk with us.  He went over everything that he’d gone over with Kadi’s mom the day before and the husband was very excited.  He kept smiling and saying “thank you, thank you.”  After we finished, I pulled out the contract I’d drafted and Joseph, Kadi’s father and I signed it.  Then we left Joseph to his surgery and I went with Kadi’s father to the village to collect her.  

When we got to the village, Kadi’s mom had obviously been preparing for our arrival, as Kadi was decked out in her best outfit.  We explained to Kadi’s mom that we’d talked with Joseph and agreed upon the parameters of the contract and needed her to sign.  She went to call someone representing her family to sign as well. As we waited for them to come, I sat with Kadi.  We waited. And waited.  And waited.  I checked a couple times to see if someone was coming and to make sure there wasn’t a miscommunication and they didn’t understand what I was wanting.  No, they knew. We were just waiting on the uncles to come.  Ok.  I blew bubbles with the kids that were just standing there. Staring. J

After 45 min. or so, three men showed up to represent Kadi’s mother.  We went through the details of the contract and one of the uncles signed.  They were all saying “thank you, thank you” and while I nodded my head saying Ok, I began to get sick to my stomach at the thought of what was coming.  Taking her.  I was dreading it.  I was dreading the screaming and crying that would happen as I took her away from her mom and the only life she’d ever known in the village.  Lord help me. 

To be continued…..