Sunrise

sunrise

 

We’ve been seeing some pretty beautiful sunrises as we make our early drives to the screening site each morning.

Tana Screening: Halfway Point

Tana HMP

We are mid week through our second week of screening patients here in the capital.  The first days were long and very busy with crowds of over 2000 people showing up.  The numbers tapered later in the week and we managed to not be quite so overwhelmed.

We are seeing all sorts of cases that our surgeons should be able to help with and our slots reserved for this location are filling up and our waitlist is growing.

The mornings are cold, usually in the 40’s, and often a few dozen of the first patients we see in line have slept outside overnight.  Often they huddle together in small groups, make a simple fire with scrap wood, and layer up as much as they can.  It’s certainly a different experience here than in West Africa as we screen patients.  There, I never had to wait for a patient to disrobe six layers of clothes before showing me the burn contracture on their arm.

We’ll finish screening here on the 7th of August and then most of our team will head to Toamasina where the ship will meet them their the following week.  I’ll head on another assessment trip to two cities, Antsiranana and Morandava.  More about that trip some other time.

Screening Schedule

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This is the poster our Communications Team made advertising all the screenings we will have this field service.  It should give you an idea of my itinerary and where in the country I’ll be during the following months.

First Impressions

Just a day and a half after I arrived in Madagascar last week I took a three and a half hour flight down to the very southern tip of the country. So began my first assessment trip – 9 days visiting two cities, Fort Dauphin and Manakara – where we will have patient selections in September.

The flight was extraordinary. We flew over such a vast swath of this large and geographically diverse country. Waterfalls cascading down rugged mountains. Tiny villages dotting the landscape every so often. The majority of them having nothing but a footpath leading to them. I was struck with how wild it all appeared. My guess is so much of the terrain is untouched. Still in 2015 there is land that is untouched, never set foot on. I sat in awe as we flew over that especially considering not just a few days before I was in Chicago were we lived stacked on top of each other.

When I arrived in Fort Dauphin I set about having meetings with representatives from the Ministry of Health and some other agencies. We spoke of the patient selection, of course, trying to work out the plans and details. And the first thing that came up was the size of the region we were trying to pull patients from. The remoteness of these villages deep in the bush. The concern was so apparent – it would be nearly impossible for patients to come to Fort Dauphin not matter how much they needed the care and free services we were offering. For the next few days we met and devised a strategy to meet the challenge before us.

I thought it was cool how my travel down to Fort Dauphin tied in so well with the meetings I had. I don’t think I would have appreciated their concern about how hard it will be to reach the entire region if I had flown to Fort Dauphin on a commercial flight, for example. Flying at a higher altitude above the clouds I wouldn’t have seen the landscape, the difficult terrain, and the fact that so many of the people really do live in such remote areas.

 

Southbound

Poster

I just arrived to Madagascar yesterday and already tomorrow I get to take a jaunt down to the south of the country and prepare for the screenings we will have in two cities down that way.  These are the posters I will come bearing, announcing patient screenings in 11 cities across this nation.  Thanks for all the love and support that has been sent my way.

Fitia

Patients wait to be seen at a Mercy Ships screening. Mahajanga, Madagascar. January 2015.

The last time I did any kind of update on my website was back in February. I want to reconnect with you by telling a patient’s story that impacted me in a very powerful way. This post looks long and it is. But I’ve timed it and it’ll take you just a quick 8 minutes to read.   I hope you continue.

You may know that from November to February I returned again to work with Mercy Ships, this time in Madagascar. There are a lot of things to sum up the three short months I was there, but nothing really as important as sharing about Fitia.

On our final day screening in Mahajanga one of the last patients to present to us was Fitia, a two and a half year old who was burned from an accidental scald burn in the kitchen in September 2014. I was the one pre-screening patients as they were trickling in late that afternoon. I remember a mother holding a shirtless, frail, and scared Fitia in her arms. She stood in front of me just holding her and not speaking. It was that all too familiar scene I have witnessed so many times as a nurse working in the developing world. A loving parent thrusting their sick child in my direction with desperation in their eyes. I worked in a Burn ICU for five years so I knew what I was looking at yet at the same time I had never seen anything quite like it. The burn happened five months prior and was massively infected. Fitia was clearly suffering and as her mom brought her closer to me so I could get a better look her whimpers grew to a full on cry.

It’s not within our scope of practice on the ship to accept patients with non-healed burns let alone ones with large infections. We have been very strict with this policy over the years because of cross contamination of infections in the ward. But that day in Mahajanga I found myself pausing before telling the mother that unfortunately there would be nothing we were going to be able to do to help her daughter. I paused for a long time. I sighed. I held back tears. This burn was beyond giving advice on wound care. There was no possible way she was going to let anyone touch her and without IV pain and sedative medications that would be torture anyway. Her only option was surgical debridement under general anesthesia. The other option may likely have been slow death from sepsis. Fitia was already malnourished and weak. So I paused. I considered calling the ship and asking the hospital director for an exception realizing it was highly unlikely that one would be granted. Ashamedly, my pride began to creep in. I didn’t want the leadership thinking I was incapable of making difficult decisions and asking about something that I clearly knew better than to ask about. Were they going to lose confidence in my ability to do my job? How could I even think about myself when these two people were standing before me, their last shred of hope fueling their long journey to Mahajanga to see if there was anything at all we could do to help. Fortunately my pride did not prevail and my colleague and I decided we would call back to the ship to ask about Fitia’s case. The director quickly convened the hospital leadership and the plastic surgeon and then called us back with an answer a few hours later.

We accepted the patient and she and her mom flew with us in our 10-seater charter plane back to the ship the next day. Two days later she had her first surgical debridement. The wound began looking so good that she was skin grafted not long after that. Just a few weeks later she was discharged from the ward once again a healthy, plump child.

Honestly, there is a lot of heartache in the work that we do. During screenings we meet all sorts of people that we cannot help and for whom we cannot make exceptions. Often after pausing to decide what I will do I have to tell a patient standing in front of me that we are not able to help them. They tell me how long they traveled to come see us and often that we are their last hope because they either cannot afford to pay for a surgery at the local hospital or simply because the service isn’t available. These cases, these individuals weigh on me heavily. However, Fitia is one of those beautiful success stories and so I celebrate her. She is one of the most memorable in my career with Mercy Ships. Her story is not mine alone and that’s something that I love so much about working with this organization. The shared purpose. The teamwork. The hands on compassion in each step of the process that results not only in lives changed for the better but sometimes, like in this case, actually saves them.

Our chief medical officer and long time max fax surgeon talks about how the work we get to do on the ship is like inviting people back to sit again at the table of humanity. Many of our patients have such drastic deformities that they have become outcasts in their communities. Many go into hiding, only coming out at night as to avoid ridicule. They don’t participate in normal, daily life activities. I remember as a teenager not wanting to go to school because of a small pimple on my face. Can you imagine what it would feel like to walk out into your neighborhood with a 5 pound tumor hanging off the side of your face? These disfigurements are so drastic and ostracizing. Not by their choice these patients have lost their seat at the table of humanity. And the privilege we have in the screenings, operations, rehab, post-op care we do is getting to invite them back to full participation in community. To look them in the eyes after no one has done that to them in years. To remove the scarf covering their tumor and throw it away because it is no longer needed.

You have heard me say this often but I’ll say again what a great privilege and honor it is for me to work with Mercy Ships. I have found my stride being a part of the wonderful team and community on the ship that gets the pleasure of inviting the poor and marginalized back to the table of humanity. I’ve committed to working with Mercy Ships for two more years starting in July 2015. I’ll take on a new position called “Field Screening Coordinator.”

And now, here comes the plug:

Together with Mercy Ships, I have set a budget of $1225 / month to cover my crew fees (room and board), insurance, flights, and various small living expenses during these years. I’ve happily poured a lot of my savings into this work over the years and I will continue to do that as much as needed. For this to be sustainable, however, I’m asking for help as awkward and uncomfortable as that sometimes can be.

Raising support/funding my “salary” through donations from family and friends is a rare concept and strange for many people. It’s still a bit weird even for me who has done this before. This unique model that Mercy Ships uses not only helps offset the massive cost of operating a hospital ship but also has some cool, positive aspects to it.   Since everyone on the ship is a volunteer I’ve found a lot of the crew to be highly motivated. It’s inspiring to be in that kind of community. But the part I like most, and the part that I want to do my best to relay, is that donors have a sense of being partners in the work themselves. I’ve been humbled by the amazing support I’ve had over the years and truly mean it when I say that all the people that have supported me financially and in other ways over the years feel like trusted colleagues in the work I do on the ship and the work we do as a whole in Mercy Ships. It’s such a privilege for me to share this with others.

I’ve rambled enough. If you have stuck with me this long you are probably ready for me to tell you how I need help. I’ve had a website at www.nateclaus.com for a few years now. This remains the “go-to” place to find all sorts of information about the work and about how to support it. There’s a “donate” link that will take you to a Mercy Ships funding page specifically for me. If you are from the US and donate through that link you’ll get a tax receipt for any donation made. As I mentioned before, my goal is to raise $1225 / month during my next two years with Mercy Ships. There’s an option to do monthly donations. In fact, if I can find 60 people to donate just $20 a month I’ll have hit my goal (hint, hint). But donations however large or small, including one time donations, go such a long way and means so much to me. And I will do my best each of these years to return to the US to work for 2-3 months to try and supplement this support and contribute to my monthly budget. I’m still working with Mercy Ships to make this a reality. As always, if you have any questions about these financial things I would be happy to answer them.

Ok, finally. I mentioned my website and I mentioned how what I like about raising support is getting to share my work with others. So, how will I do that in the coming years?

At a minimum I’ll commit to:

-blog post every other Wednesday (biweekly)

-more in-depth Newsletter (every six weeks via email)

-some kind of snail mail (every six months)

If you don’t already receive email updates from me and would like to, please send me an email or message. You can find contact details on the “about” page. And whenever I am in town I’d love to have a visit and share face to face. Just drop me a line!

Well, this is long-winded enough. Thanks for reading and thank you for your partnership. I’m honored to have it and look forward to the years to come.

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Toliara

The second week in January we took a screening trip to the southwest city of Toliara and stayed almost a week to screen and select patients. At the end of three days of screening we selected a total of 86 patients.

We ended up staying a day longer than planned because at the end of our second day of screening we still had not given out all the appointments we saved for this region. Also, our contacts in the city urged us to stay as long as we could because they kept telling us that it takes time for news to travel and to reach the small villages. Often these remote villages are where the need is the greatest and so our team of eight was all happy to stay an extra day to receive more patients. We gave appointments to just 6 patients on that extra day but three of them were from a village over 300 km from Toliara and they had traveled more than two days to get to us.

A child with bilateral club feet who started the first round of casting this week with our rehab team.

A teenage girl with burn contractures to her left axilla.

A teenage girl with a bulging tumor extending from her left mandible.

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I’ve been organizing transportation for the last month or so for all the patients that we will select from Toliara and Mahajanga (another city we went to in January). This isn’t something we normally do for our patients because in the past it has never been a major issue. We’ve helped some patients on an as needed individual basis in other countries but Madagascar is uniquely a very large country. From north to south the distance is about the same as from Buffalo, New York to Jacksonville, Florida. However, our patients here don’t travel on 4 lane interstates or take 1-hour flights on jets. They cram into a “taxi brousse” and take winding and sometimes very bumpy two lanes roads to get from town to town. Our first bus journey happened that extra day we were in Toliara so it was very special for me to be there in person and see our patients climb on the buses I’ve organized (more spacious than the taxi brousse) and get to wish them a “bon voyage” to Tamatave. I saw them two days later on the dock as they came for their surgeon screening and diagnostics. All of them but one were scheduled for surgery.

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Approaching the landing strip in Toliara

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Sunset on the west coast

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our plane to Toliara

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The first group of patients from Toliara in front of their bus transport

Blood Donor

blooddonor

One of the many unique and fun parts about living on a hospital ship is the fact that our crew is our hospital’s blood bank supply.  We have very limited space to bank blood so if a patient needs blood and you’re a donor then you get a call in your office or your cabin asking you to come down to the lab to donate blood.  My blood is some that they actually do bank before I leave each time because of my type.  This is a photo of me donating 400 ml of blood yesterday.

Last Two Months Recap

Tana screening team - 18 December 2014 - Antananarivo, Madagascar

Tana Screening Team – 18 December 2014 – Antananarivo, Madagascar

I arrived to the ship on 7 November. My first week back I got to be a part of screening patients Monday through Friday at our Toamasina Screening Center. This is the first field service in as long as my Mercy Ships history goes back that we have not had one day of a massive “main screening” when we first arrive in a country. The screening center was open for the entire month of November. Our team saw a huge influx of patients the first few days and then a good, steady amount for the remainder of the month. Having more than one day to see patients allowed us to give more time to each patient. We were able to better explain how we could help them. Even more, it allowed us to give a better explanation of why we could not help, instead of just a quick “sorry” and having to move on to the next patient.

Just over a week after arriving I was tasked with setting up, organizing, and running our screening in the capital city, Antananarivo (Tana, for short). I spent four weeks there working with the Ministry of Health, doctors from 5 different hospitals in the city, and partner NGO’s coming up with the best way to find and screen patients.  We ultimately settled on a registration system via the 5 local hospitals, which meant I spent a good amount of time training doctors at these hospitals about the Mercy Ships scope of practice.  I discovered I really liked that.  For me, it is always special to partner with others in our work and it was especially encouraging to me to see their eagerness and excitement in what we do.  We all have the common purpose of helping the Malagasy people.

We held an open registration for two days for any patients interesting in being treated by Mercy Ships. My colleague and I then reviewed all the registration forms and selected those that fell within our scope of practice.

The last week I was in the capital, a small team from the ship joined me and we saw in person all of the patients who were registered at the hospitals.  Those were two great days as we got to see all those weeks of prep work come together and patients standing in front of us. I think it all went really well and we found a total of 178 patients that will come to the ship to see a surgeon and likely get surgery.

Another project I have been tasked with is a Patient Transportation Project. We will screen for patients in two coastal cities this month – Toliara (southwest) and Mahajanga (northwest). From all of our conversations with our partners and with the government we have been told over and over again that patients will not be able to afford the travel cost to come to the ship in Toamasina. It’s our goal to reach those most in need so we have brainstormed several ways to reliably help our patients reach the ship for surgery. I’ve been partnering with the Ministry of Transportation and a transportation company to work out the many logistics needed for this. We will transport a total of about 400 people (200 patients + 200 caregivers) over the course of the next five months so the logistics involved have not been a breeze but I’ve found that I really like the challenge. I learned a lot doing this type of logistical work in Congo-Brazzaville a little over a year ago. It proved very frustrating yet also quite rewarding when the patients finally arrived to the ship after their long journeys.

Evening Stroll

Today I did a training with about 20 doctors from 5 Hospitals in and around Antananarivo.  On Thursday and Friday these doctors will register patients who are interested in being treated by Mercy Ships.  This is all part of the unique method we have developed to screen for patients in a very large city hundreds of miles from where the ship is docked.  We of course discussed the specific scope of Mercy Ships and which type of patients we can treat but also went over in depth the whole registration system which has multiple detailed steps.  I feel like it was a success and I am eager to see how the Registration goes on Thursday and Friday.  Looking forward to hearing feedback from the doctors as well.

Later in the afternoon I headed out of my hotel to a store to buy some more credit for my mobile phone.  The short walk to run a simple errand turned into quite a long evening stroll.  I winded up and down the streets of Tana, through several neighborhoods, and finally ended up on the tallest hill overlooking the city.  It was a  beautiful view and it somehow feels like a perk of the job to get to experience stuff like this.