Not enough

I'm going to be very honest: I've been putting off telling my side of the story of our life in Malawi.  One reason has been that I don't want to mistakenly portray that working as a physician in a poor country is glamorous.  Most days I don't feel like I'm "making a difference".  Most days that I spend in the hospital are just plain hard.   I struggle against the pit in my stomach, my racing heartbeat, and the tears stinging at the back of my eyes to overcome a feeling that I can only name as "dread".  It's not that I haven't faced sick patients in a critical place before; it's that I haven't faced them with so little to offer.

The government maternity hospital where I work has approximately 40-50 deliveries each day, with 5-10 of these as cesarean deliveries (This is over 4xs the number of deliveries I am used to dealing with in my residency).  We have two operating theaters, but usually only one is functional at any given time.  And by functional, I mean that it has a table for the patient, a single dim light (when the power is working), a scrub nurse, and a nurse anesthetist.   It does not have suction (to clear the blood and other fluid from the operative field).  It does not have electrosurgery to cut through tissue or coagulate vessels.  It does not have any solution to scrub my hands or any sterile towels to dry them before we operate.  When a patient has high blood pressures (usually from pre-eclampsia, which is a potentially dangerous disease in pregnancy), we have only one medication that I used before in the U.S.  We only have one medication to treat postpartum hemorrhage (I am used to using up to 4 different medications simultaneously and/or a balloon device to stop hemorrhage if needed).  The hospital and the region's blood bank is usually nearly or completely empty, sometimes for days.  We are usually out of soap in the labor ward (the one bar is kept for "scrubbing prior to surgery").  Last week, we ran out of water making infection prevention all the more difficult.

In each of the 10 labor rooms, there are 2 cots.  On each cot, lies a laboring woman on a disposable plastic sheet that looks like a black industrial garbage bag.  There is no pain medication for women in labor and we sometimes are short on the anesthetic to provide relief during repair of tears after delivery.  The usual beat I am used to hearing as background music in U.S. labor rooms is eerily absent.  We have one fetal heart rate monitor among 15-20  women laboring at any given time and so we intermittantly use a Pinard horn to determine the fetal heartbeat in labor.  There is one infant resuscitation unit in the center of the horseshoe of these 10 rooms.  When I sit in a bench in the center of labor ward, midwives rush past me with their blue plastic aprons swishing to place a newborn on the resuscitation unit.  Sometimes the infant appears blue and lifeless when it is placed on the unit in front of me.  I find myself holding my breath as I wait to see if the mask with flowing oxygen will help this little one take its first breaths. I wish I could say that these limitations lead to the resourcefulness and innovation that saves lives, but often it is quite the opposite outcome.  The lack of blood products leads to women dying from anemia, the lack of soap leads to infections, and the lack of fetal monitoring leads to a missed fatal fetal heartbeat deceleration. 

 In addition to knowing that our facility may not have enough resources to offer our patients, I face my patients with the fear that I may not be enough for them.  I may not recall the right knowledge at the right moment.  I may not have the right surgical experience to quickly removed a massively ruptured uterus.  I may not be able to mobilize the right anesthetists, nurses, or other staff due to my lack of relationship or local knowledge. 

It is this fear that hits me the hardest, partly because it is true.  I am not enough.  I am not enough to save some my patients.  When I realize this, a piece of me begins to fantasize about moving back to the U.S. to work in the lowest risk, most technologically advanced hospital I can find.  (Another piece of me dreams about leaving the riskiness of medicine altogether).  Until I am hit over the head with this truth: I am not, nor will I ever be enough.  That is not my role and not whom I am called to be.  God is enough.  Only He is big enough to carry the terror, dread, hurt, danger, fragility, brokenness, limitations, and scarcity of the staff, women, and babies in my ward.  I am to relinquish this burden to the one who is made to carry it.  

This truth is freeing, but not always easy.  There is a piece of me that still wants to feel the joy for any success and the guilt of every failure as my own.  But in seeking God as my help, my source of strength, my wisdom, and my guide, both the lives and deaths fall on His shoulders.  They are big enough to bear both without breaking under pride or despair. 

So I choose to stay and walk back into the maternity ward on each call day.  As I meet each patient, I pray for wisdom in the decisions I make and for a deeper realization and trust that God is in control.  I am still learning and making baby steps (that are occasionally backward) in this process.  But I feel that God is using this time to ask me to trust Him moment by moment.  Recently in my study of Esther, I came across this encouragement from Beth Moore: "In the times of greatest struggle when you make the Godward decision over convenience, earthly comfort, or carnal pleasure you have come to a critical moment...a defining moment."  May a God who is enough for my patients and enough for me, find me faithful in these moments. 
"Trust in the LORD with all your heart; do not depend on your own understanding.  Seek His will in all you do, and He will show you which path to take."  Proverbs 3: 5-6

Thank you again for all of your prayers, cards, and e-mails.  Your encouragement means the world to us. 

A few photos from our hike to Ntchisi Forest last weekend.

Inspiring views both up...

And down.