Challenge Accepted

It seems that South Africa misses me just as much as I miss it!
Earlier this week, Joe and I were asked to take on a new, temporary assignment.  We accepted.  We are now the Durban Advanced Team!
Typically, since the ship returns to the same shipyard in Las Palmas / Tenerife, there is no advance team.  We have contacts there that we have been using for years.  However, we will not be traveling back to Spain this year.  We will be going into dry dock in Durban, South Africa.  The organization sends an advanced team into the country next, or the next field service location, and countries in which we do not customarily dock.  The advanced team secures local contacts and works with local authorities to ensure a safe, hassle-free entry into the country.
We will be traveling to Durban on May 13.  The ship will be arriving approximately June 15.  The following are a few of the tasks we need to accomplish before the ship arrives.
Housing.  While the ship is in dry dock the children are not allowed to stay onboard.  This is for their safety.  So, the families will need to live off ship for several weeks.  We will locate housing close to the ship.
Medical.  We will locate a clinic, emergency center, dentist, eye doctor, and pharmacy within a reasonable distance from the ship.  We will not have a doctor, dentist, or pharmacist onboard while we are in shipyard, so we need to have locations already selected in case the services are needed.
Cell Service.  The managers and engineers onboard need a reliable cell phone network while we are in shipyard.
Transportation.  We will arrange for rental vehicles for use during the duration of shipyard.  It is more cost effective to rent a small number of vehicles for the seven weeks than to import and register our own vehicles.
Customs and Immigration.  We will work with customs to ensure that any of our containers arriving to Durban are not delayed.  We will also make sure our crew onboard and incoming crew have the necessary paperwork to clear immigration.

There are other tasks as well.  We will be busy, but it is an incredible opportunity.  This is an unusual way to serve God and support the mission.  But after meeting with the Operations Director, we realize just how much prep work is needed in order to ensure a smooth entrance into a country. We look forward to the challenge.
 I will be leaving the hospital about two weeks before it closes.  I am a little sad that I will not be there to see the last of my VVF ladies go home, but I am incredibly excited to be back into South Africa.  I love a good challenge and love making lists.
Since we are not taking our vehicles with us, Joe is free to be part of the team.  He is making a plan as to how the vehicles should be stored in Madagascar until our return.  The transportation mechanic is still here and will be onboard during the sail, ensuring that the vehicles are in good hands.

Please pray for us as we will be alone in South Africa.  We will have the support of the organization, but we will be living and working alone.  Please pray that God helps us to complete all the tasks well.  Please pray that God grants us divine encounters with the right people.

Words From a VVF Surgeon

I wanted to share a letter we received from surgeon Jerry Putman.  He and his wife, Marty, left Friday after four weeks onboard.  Dr. Putman is a VVF surgeon.

Dear Crew,
I just wanted to take a moment before Marty and I depart to thank you all for a great 4 weeks of fistula and gynecologic surgery.  As of March 31st we have done 43 surgeries.  The people of Madagascar are gracious and fun-loving, a testimony that poverty alone does not destroy the human spirit.
I want you to know I have witnessed the many hours you all have loved and prayed over these women, counting the endless milliliters and sometimes drops of urine, flushing catheters, giving endless doses of lactulose, and putting up with my wearingly constant reply of please keep the catheters flowing.
It is a privilege we all share that these ladies have invited us as strangers into the most private parts of their lives, allowing us to share their shame, frustrations and embarrassment of a loss of dignity as they have lived lives being soaked in urine and odor.  It is a sacred responsibility God has granted to us to care for the vulnerable and be used as He heals their physical and emotional pain.
I have never worked in a fistula environment with such a competent staff.  So far I think 2 of our ladies will to come back for a 2nd surgery, though there may be more.  That means many will go home happy and dry.  The reason is because of your diligence to not allow catheters to remain blocked and repairs to open up.  Thanks to excellent and safe anesthesia, diligent and professional ward nurses.  What an amazing organization!  Putting the fistulas together is the easy part.  Keeping the catheter flowing requires hard work.
As we leave, you all will be in my prayers as you continue your labor here.  I am deeply indebted to you for your commitment.

Jerry Putman, M.D.

This topic is difficult to talk about simply because my heart breaks for the women who come through our ward.  I was working the first evening when two buses arrived from up country with seventeen women diagnosed with fistulas.  This first group of women were referred to us by another organization within the country.  You can see the hope on their beautiful faces.

I interviewed five ladies, taking a detailed history for the surgeon to review.  Only one of these ladies had family to list as an emergency contact.  The others had been completely abandoned by everyone they loved.  All of these women developed fistulas after giving birth.  Due to the long days in labor, the women were left broken and most of their babies died.
**I am a nurse and am constantly fascinated by how complex the human body is; how completely wondrous God made the many parts to work together…so the following is a bit of an anatomy lesson**
In labor, the uterus contracts, pushing the baby down through the birthing canal.  Obstructive labor occurs when a baby is unable to pass through the pelvis.  Healthcare is expensive, so many women seek help too late or not at all.

Many of the women who experienced obstructive labor are very tiny.  Their bones are small, including the pelvis.  The baby's head is too large to fit through the small opening of the pelvis.

In this picture, one can see where the baby's head pushes against both the bladder and rectum during the labor process.  This particular picture shows the baby's head after it has passed through the pelvic opening.  Note the pubic bone.  If a head is unable to get beyond the bone and the contractions continue to push the baby downwards, the baby's skull will continuously compress the bladder and rectum.  Under so much pressure, the bladder and/or rectum tears.

The vagina shares a wall with the bladder on one side and the rectum on the other side.  It is more common to develop a whole in the bladder or urethra, the tube connecting the bladder to the outside world, than a whole in the rectum.  This photo shows the whole, or opening, between the bladder and the vagina.  Once this whole develops, called a vesicovaginal fistula (VVF), urine constantly leaks from the bladder through the vagina.  A whole in the rectum-bladder wall is called a rectovaginal fistula (RVF).


The repercussions are terrible.  The smell is pungent and constant.  Most women are abandoned by husbands or lovers.  Many are also abandoned by their family.  These women are filled with shame and despair.  Humiliated and disowned, these women feel hopeless.
We give hope.  The wholes are usually repaired vaginally so there is rarely an abdominal incision.  Foley catheters are placed to empty the bladders so that the bladder does not stretch out during the healing process.  It is vital to the healing process that the foley catheters not get blocked.  If the tubing placed within the bladder does get blocked, the bladder slowly stretches as it fills with urine.  The stretching pulls on the stitching and may cause the repair to fail.
We strictly monitor the patient's intake and output to make sure that the foley is functioning properly.  Even after the foley is removed, we continue to strictly monitor the patient's intake and output.  There are blue pads on every bed, which we monitor every few hours for any sign of leaking.  If we can spot leaking early, we may be able to stop the repair from breaking down.
While their bodies heal, God is restoring their spirit.  These ladies arrive onboard and suddenly realize that they are not alone.  Then, with each day they are dry, relief and self-worth start to replace the shame.

On March 27, we had our first Dress Ceremony. This ceremony is to share in the joy of those patient's who are considered healed.  Each lady is given a new dress to symbolize her new beginning.  In most of western Africa, there are dresses specific to each tribe or country.  However, there is no single dress typical to Madagascar, but there are Malagasy hats.  Our hospital chaplaincy team spent eight hours going from shop to shop in Tamatave looking for dresses, accessories, and hats.

We have a few more weeks of surgeries.  A surgeon from west Africa has arrived to continue the good work Dr. Putman started.

A documentary movie was made about a VVF clinic in Ethiopia.  The following is a link to watch the video on You Tube: https://www.youtube.com/watch?v=TPTA4g5rGrs

Maternity Ward

****DISCLAIMER: This blog may not be appropriate for young children.  There are no graphic pictures, but labor and delivery is discussed.****

No, the ship does not have a maternity ward.  However, the local hospital, Hopital Be, does.

There is one large hospital in Tamatave - Hopital Be.  Even its name means Big Hospital.  This is one of only four teaching hospitals in the country.  There is another smaller hospital in the area, but it offers very few services.  The majority of people needing a hospital go to Hopital Be.  As part of our capacity building programs, we partner with local doctors and nurses offering mentoring programs, education, evaluation of medical practices, and more.

We never go in and tell hospitals how they should run.  Instead, we let it be known that we are willing to partner with local facilities.  Hopital Be invited us into their hospital.  Medical teams went into the hospital, spending time in each ward, learning what resources are available and what practices are being followed.  In addition, our local nurse educator, Amy, surveys the nurses to find out what areas they feel could use improvement/education.

In Hopital Be, we have being focusing on one ward at a time.  Right now, I am working with the maternity ward.  There are about six nurses onboard with labor and delivery experience.  There are four local midwives involved in the exchange program this year.  The midwives here, or Sage Femmes, do everything.  There are no maternity nurses.  The Sage Femme admits a patient (though their history and physical is practically nonexistent), starts an IV, determines which medications are given, gives the medication, delivers the baby, performs newborn resuscitation, and makes any repairs to the mother.  There is a gynecologist that is consulted only for emergencies.

So, how can we have an exchange program when we have no maternity ward?  Well, the midwives spend time on the VVF/Gyn Ward.  In this ward, about 90% of our surgeries are vesicovaginal fistula repairs.  The other 10% are rectovaginal fistula repairs and gynecological surgeries, such as a hysterectomy or repair of prolapsed uterus.

Almost all VVFs and RVFs are a result of obstructed and prolonged birth.  The midwives see firsthand the damage that can occur.  I worked with a midwife, Evelyne, this past Tuesday.  She was surprised at how many ladies were on our ward - about twenty at the time.  She was even more shocked to learn that there are about 50,000 women living with VVFs in Madagascar.  She witnessed the beginning of the long process of healing.

Each Sage Femme will spend two days on our ward and another day following a single patient on the day of surgery, including observing the surgery.  Each Mercy Ship nurse will spend two days in the maternity ward at Hopital Be.  Yesterday, Thursday, I spent the day there.  I witnessed three births and observed one hysterectomy in the OR.

The health care system is so very different than any first world system.  The patient or their family must provide all the basic medical equipment and medication.  Women are given a list of recommended items to be purchased.  This list includes the following items: IV cannula, medical tape, IV tubing, IV fluids, several syringes and needles, Oxytocin (uterine stimulant), corticoid steroid, dexamethasone (anti-emetic), latex gloves (for the nurses to wear), alcohol (to swab areas of IV site and injections), cotton balls, linens (for the patient's bed), towels, laundry soap (for the nurses to wash their hands)...and it is possible that I have forgotten something from the list.  The equipment that the hospital has includes a baby scale, a suction machine (for vacuum and nasal suction), and a cardiotocograph machine.  The cardiotocograph machine measures fetal heart rate and contractions, though they do not have the paper to monitor contractions.  For an additional fee, the Sage Femme will listen to the baby's fetal heart rate with the machine.  If you do not have the money, which most patients do not, the Sage Femme will use a fetal scope.  This is a fetal scope:

I found this picture online of a suction machine.  The one on the left is very similar to what is on the maternity ward here.

The ward has outdated equipment, except for the cardiotocograph which is a newer donation to the ward.  However, if it breaks, there is no one who is trained to fix it and no easy way to get parts for the machine.  Also, many of the practices are outdated.  In some cases, this is due to ignorance.  In other cases, it is due to a lack of resources.  For example, the acceptable method for stimulating the newborn immediately after birth is pouring alcohol on the baby's chest so he will breath the fumes - sort of like a smelling salt.  Or the Sage Femme will hold the baby by the feet, upside down, and vigorously slap the feet several times.  Or a suction catheter is inserted deeply into the baby's nose and nostrils several times and wiggled around.  This are not practices recommend in the US.

Another example...The nurses expressed a lot of interest in learning neonatal resuscitation.  Twenty to twenty-five Sage Femmes, OR nurses, and pediatric nurses have attended our neonatal resuscitation class.  We will be holding another one or two classes in the next few weeks.  In the class, the Sage Femmes stated that they did not have a neonatal resuscitation mask or bag.  Mercy Ships was able to donate two bags and masks.  After one delivery, the baby was not breathing, and Franz, a Sage Femme who attended our class, used the bag and mask to revive the newborn.  It was awesome to see that she was putting into practice what she learned.

I look forward to continue working with the Sage Femmes and, hopefully, helping to provide education that will improve their practices within their resources.

I must say that the Malagasy women are amazing.  They have no epidural, no pain medication at all, yet they do not utter a sound during delivery.  I do not know if it is culturally inappropriate to do so or if it is because the Malagasy are a stoic people.  Even when the Sage Femme performed an episiotomy (cut the perineum), no sound was made.  When the Sage Femme was stitching a torn cervix, the mom grunted a single time.  They are so amazing!

To close, I want to share an interesting Malagasy custom I learned about yesterday...if a man sleeps with another while his wife is pregnant, it is believed that she will likely have a complicated labor.  However, if the husband wraps his clothes around his wife's belly during labor, it is said to ward off complications!

Not Your Ordinary Plastic Surgery!

We have just finished almost two months of plastic surgery!
For those of you who are put off by the words "plastic surgery," do not be alarmed!  We are not performing tummy tucks or nose jobs.  Our plastic surgeon, Dr. Tertius Venter, helped many patients by performing a variety of surgeries.  With each patient, I will explain the types of surgery performed.

This is Ben Ali - he totally captured my heart!  He is a two-year-old boy who got burned over a year ago.  As the burn healed, the skin contracted.  Rigid scar tissue formed over the arm, elbow, and wrist.  His right arm contracted, and he was unable to straighten the arm due to the scar tissue.  In surgery, the scar tissue was removed and the arm straightened.  A layer of skin was removed from his thigh and placed over his arm over where the scar tissue previously laid.  The thigh, his donor site, and his arm, the graft site, are closely monitored to ensure that the wound is healing properly.  At a certain point in the healing stage, a physical therapist started working with Ben Ali to use and strengthen the muscle and tissue of his arm.

Once his wound was healing, Ben Ali was trying to use his arm more and more so physical therapy gave him a splint to keep his arm straight.  It was torture for a young boy!  He only took it off for his physical therapy (PT) exercises.

But he did not let the splint stop him from having fun!

The surgery to release a burn contracture has two purposes:
First, to restore function to a limb.  Ben Ali will have so many more options with two fully functioning arms.  One day, he'll be able to provide for his family.
Second, to restore normalcy to a person's look.  Dr. Gary Parker said it best - we believe that a person has the right to look human.

Meet Melina.  She had an extra digit on each toe, protruding at a 90-degree angle from her foot just below the big toe.  The only shoes she could wear were flip flops!  She was not able to hide her deformity.  This simple operation took away the extra toes along with any sense of shame she felt.  You can see the suture line on her right foot.

This little man is Finoana.  He is a five-year-old boy who was born with syndactyly.  This means two or more of his digits were fused or webbed.  In his case, the fourth and fifth digits (ring and pinkie fingers) on both hands were not separated.  In the OR, a small skin graft taken from his groin, the crease where his leg and torso meet.  The skin was placed in between the newly separated fingers.

He had a very big personality for such a little boy!

Florence is a nine-year-old girl who had spilled boiling water on her foot many years ago.  As she grew, the scar tissue remained stiff and prevented the foot from developing properly.  As the unburned tissue grew normally on the sole and sides of her foot, the burned tissue on top of her foot remained rigid.  She was not able to walk normally.  Like many people do when faced with a handicap, Florence adapted to her less-than-normal foot.  She could walk.  However, she was not able to bend her ankle much and her toes were fused together.  As she would continue to grow, the foot would continue to deform.  Perhaps later on she would have a pronounced limp, perhaps not.  Like the first patient discussed, Ben Ali, Florence also had a skin graft taken from her thigh and placed over the top of her foot where the scar tissue was removed.  She has been here on the ship for almost two full months now!  Her wound is healing slower than most, but recent reports are very positive.  She can go home soon...

This is Landrino.  He first appeared in the "Back to Work!" blog from November 2014.  Here he is waiting in line during screening.

Landrino was burned along the left side of his body.  During the operation to release the burn contractions to his hand and foot, Dr. Tertius also removed the keloids on his ear.  A keloid is a growth of scar tissue formed after an injury.  Landrino, his mother, and his sister have captured the hearts of all the nurses.  Here is Zuela, his young sister:

The Rakotoniriana twins each had extra digits.  One on the left hand and one on the right hand.

Here is one of the girls as she reaches for a toy during PT.  You can see where the surgeon removed the extra digit near her fifth, or pinkie, finger.

Below is a collection of photos from some more of our patients, both pre and post op.

 

Because the wounds take a long time to heal, our patients become good friends.  We have a lot of fun with them, both on the wards and outside.  Every day, the patients get an hour of playtime outside.

 

 

One Determined Man

Meet Sambany.

I do not know every detail of Sambany's story, but what I do know is quite inspiring.  Sambany's tumor has been growing for twenty years.  Despite living in a remote village, he heard about the first-world medical ship offering free operations.  He did not let the distance deter him.  Having nothing but hope and a very little bit of money, Sambany and his son set out for Toamasina using the only mode of transportation available to them - their feet.  After three or four days of walking, they ran out of money and stopped in a village to earn some more before continuing on.  I am not sure for how many more days the two men continued walking.  They showed up exhausted and disheveled, but hopeful, to the Hope Center.  Immediately, the surgeons onboard were paged, and Sambany was brought to the ship for examination.  The lab results showed he had a dangerously low hemoglobin - only 3.5; the normal is about 13.8 to 17.2.  He was given three or four units of blood during his first week onboard.

The tumor is so large, he was able to use it as his pillow.  The results from the CT scan came back.  The surgeons determined that the surgery was feasible, though risky.  The risks were explained to Sambany and his son.  Sambany felt the odds were better with surgery than without.  He even stated that he would be dead without it.

Sambany had his surgery on February 3.  The surgery took approximately 12 hours; the 16 pound tumor was finally out at 9:17 pm.  Our photographers captured his joy as he got his first glimpse of his face without a tumor in twenty years.  Sambany is recovering well.  Praise God!

Sixth Month Check Up!

Okay, we have been here for six months.  Literally.  We arrived onboard the Africa Mercy on August 2nd, and it is now February 2nd.  I have written quite a bit about my job and the patients.  But I have not written much about us.  About how we are doing and where our heads are at.

Well, we are okay.  Adjusting to life onboard was and is very difficult.  The only thing that does not change is change itself.  People and places have constantly been changing.  We arrived to Las Palmas, sailed to Tenerife only a day later, and then back to Las Palmas.  Then, we had a long sail to Cape Town before heading through rough waters to Toamasina, Madagascar.  We have been to four countries - US, Spain, South Africa, and Madagascar - in the last six months.  The language has changed.  Food has changed (I miss those gorgeous Spanish avocados!).
We have been in Madagascar for three months, and I feel only somewhat settled.  Only somewhat because I still feel so oddly out-of-place in town since I do not know Malagasy.  Of course, I can ask someone if they have pain, feel itchy, or if they want a balloon.  However, these do not help when we are at market.  We have been going through the phases of cultural adjustment - honeymoon, hostility, humor, and home.  I first described these when talking about the culture aboard the ship, but we also go through these phases with each new country we are in.  The ship's culture changes in each country.  For instance, in Spain, the curfew was 1am.  Here, in Madagascar, the curfew is 9pm.  In Spain, there were fewer people onboard.  Now that the hospital is running, there are twice as many crew members and a couple hundred day workers.  These details, and so many others, affect the culture onboard.
I passed through a brief honeymoon phase.  My hostility phase lasted longer.  I had high expectations for this organization.  Its motto called to me - "Mercy Ships follows the 2,000-year-old model of Jesus to provide hope and healing to the world's forgotten poor." However, I was disappointed.  I expected too much.  I forgot that the organization is comprised of humans.  Humans are fallible.  Humans make mistakes.  Humans are Christ-like, not Christ.  I have not always been the most gracious to my fellow crew mates nor the organization.  But I have expected graciousness.  I have been looking around thinking about how others should act, become better Christians, instead of looking at how I act and could become more like Jesus.  I sulked because this life, despite all the amazing opportunities it presents, is more difficult that I imagined.
I eventually found my sense of humor.  And now I am working on feeling at home.  There are days I want to pack my bags and leave, though those days are far less frequent than a few months ago.  Most days, I feel content.  I am not in love with this ship, but I do believe this is where God wants me right now.
I do not know what the future holds.  As of now, we remain committed to serving a full two years.  I have been thinking of Genesis 22 for many months now.  God tested Abraham.  God told Abraham to take his only son, Isaac, to a designated location and sacrifice his son as a burnt offering.  On the long three-day journey, Abraham remained committed; he would kill his son as God asked.  He was going to sacrifice Isaac.  As he built an altar, he remained committed.  He arranged the wood so that the sacrifice, his only son, would burn.  He still remained committed.  He tied Isaac to the altar.  Abraham remained committed.  Only when Abraham took hold of a knife, intending to slay his son, did God intervene.  God was pleased with Abraham's love and obedience.
I can only imagine what thoughts raced through Abraham's mind as they rode.  Perhaps he said something similar to what Jesus said just before being arrested - "Father, if you are willing, take this cup from me; yet not my will, but yours be done" (Luke 22:42).
I do not claim that what hardship I have endured remotely compares to the anguish Abraham or Jesus felt.  Indeed, my troubles seem petty in comparison, yet I have found myself asking God to let us come home.  There are many ways in which I fall short of Abraham, but, like him, I remain committed.  

That is where we are right now.  We are committed to serving God here on the Africa Mercy.  We pray that we remain in His will and that He continues to give us strength for each day we are far from our loved ones.  Please pray for us as well.

Meet My Patients

I would like you to meet the people who keep me so very busy.

This is Salestine.  She had an epulis tumor which is a tumor of the gums.  The tumor had grown so large, she was unable to put food into her mouth.

She was quite malnourished.  She very likely would have died within the year without this surgery.   While Salestine was in the OR for almost two hours, the surgery, from first incision to last suture took only 18 minutes.  The rest of the OR time was spent intubating her for general anesthesia.   It was a very difficult task, putting in a breathing tube.  Here she is post-op, eating one of her first solid food meals in a very long time.

 And here she is at her outpatients visit, about a week after surgery, looking so healthy and happy.

This next patient has been with us since around December 12th.  A noma had completely destroyed his nose and upper lip.  A noma is a type of gangrene or tissue death that generally effects the mucus membranes of the nose and mouth.

During his first surgery, his scalp was cut from his skull and brought forward.  A portion of the scalp was used to create a new nose.  The scalp was used because of its terrific blood flow.  A skin graft taken from his thigh or groin was placed on the scalp to replace the skin used for the nose.  A tracheotomy tube was inserted so that he could breath.  A feeding tube was also inserted into his esophagus.

In his second surgery the scalp was pulled back to its original position.  The skin graft, as seen here, is located on his left side.  The edges are still healing.  He will have a third surgery to reconstruct his lips.  Right now, his still has his tracheotomy and feeding tubes, as seen in his neck.

The doctor literally created an entire nose for Mamisy.  It is amazing.  Although the ship brings many first world, medical advantages to Africa, we do not always have the exact implants necessary for every possible surgery.  What the doctors do with the resources we have is simply miraculous.

This little girl is Hermina.  She had a teratoma removed from her bottom.  She has been with us since late November.  The surgical wound was quite significant - both long and deep.  About one week after her surgery, she fell down while walking and opened her incision.  She is just under two years old, and, as an active toddler, she took off when her mother turned aside for just a moment.  Hermina fell down when her little legs could not quite keep up with the rest of her.  She was rushed into surgery to repair the damage.  Afterward, her mother held so firmly to her arm or gown wherever she went.  The doctors have kept her at the hospital to ensure that the wound heals well and without infection.  She was transferred last week to the Hope Center.  This is good news and indicates she is healing well.

However, having been here for so long, she made friends with other children.  It was sad to see her leave.

This young man's name is Venance.  A noma destroyed his lower lip.  The doctors removed the infected tissue during the first surgery.  In his next surgery, the doctors will reconstruct the lower lip.

This little one is Jida.  She came from the capital with her uncle.  She stayed with us for over a week before her surgery.  She was shy and distrustful of us at first.  After one week of friendly overtures, we finally won her over.  This is Jida before her surgery.

And here she is after, gazing at her new face.

And cuddling with her stuffed bear.

This next little girl is Mitia.  She also traveled quite far to reach us.  She was a very happy 6 month old. She was also quite chubby, thanks to a diet of sweetened condensed milk.  The nutritionist worked with the mom to ensure Mitia will get a better diet post surgery.

This young man is Thomas.  He had his cleft palate repaired.  Another organization repaired his cleft lip many years ago.

He really enjoyed playing with the Jenga blocks, though he did not play with them in the usual manner.

This last week, I cared for Ezra, a rambunctious 7 year old boy who was born with a foot deformity.  The surgeons repaired the foot so that he could walk normally.

In the bed next to him was a 17 year old young man, Largisse.  The surgeon released a burn contracture of his right elbow and placed a skin graft over the site from his thigh to increase function and appearance.  He is a typical teenager, always trying to bend the rules.  God has surely used Largisse to increase my patience.

And, finally, on the containers, the new special nipples for cleft palates arrived!  Here is one infant that benefitted from the new arrivals.  Although she was never my patient, I met her and her mom during a meeting with the nutritionist.  At ten months old, this infant was less than 5 kilograms (11 pounds).  She joined the Infant Feeding Program.  We provided formula and rice cereal.  The baby came to the ship several times a week for weight checks and to receive new supplies.  The baby continued to lose weight over the next month.  So, our nutritionist admitted the baby to the hospital.  With the nurses overseeing the feedings, the baby gained weight.  About a week before her discharge, the new nipples arrived.  It made the feedings much easier, both for us and the baby.  The doctors have scheduled the cleft lip repair for the end of the month.  Praise God!  Her cleft palate repair cannot be repaired until she is older.

I have enjoyed my work over the last month.  Nursing is much different here.  Sure, I still perform nursing tasks.  But I also play with the patients.  My particular favorite is a Sponge Bob memory game, though I also enjoy Dominoes - the games can get quite intense.

I hope you enjoyed meeting my patients!

However, it has not all been fun and games.  This little girl, Genesca, came to us hoping we could help her.  We performed a CAT scan and biopsy.  The results were not good.  The tumor is cancerous.  When she returned to the ship for her results, she was quite ill.  She had an infection.  We tended her through the infection but were unable to help her further.  We are not able to care for cancer patients.  We do not have chemotherapy nor radiation therapies.  The surgery would not prolong her life but would make her susceptible to infection.  With very heavy hearts, we told her family the news.  She is now back at home, though once again quite ill.  Her family is with her, loving and supporting her.  Please pray for her and her family.