News!

So I arrived in Rochester at the end of March and never quite got around to posting at that time.  Now that I am preparing to return, I thought it was time for an update.  Besides there is so much to share!

I knew that leaving Shisong would be difficult, but it is not easy to describe that in a blog post.   The last week there was busy.  We operated on six patients, all of whom were doing well at last report.  One woman came from Nigeria after having been refused surgery in Dubai.  Moving back home and into my job here went fairly smoothly, but processing my time in Shisong was a little more challenging.  My thanks to all who are so supportive both while I am there and while I am here.

Sister Jethro and Doctor Sister Helen were in the US for 3 weeks in July and August to attend the Cameroonian Professional Society annual meeting in Houston on August 1-2.  They spent time in Lacrosse, WI on July 20, spend 2 days in Rochester on July 28 and 29 where they visited the University of Rochester Medical Center and spoke at my home parish of St. Marianne Cope in Rush, NY, then on to Houston and Dallas, and finally to Washington, DC.  Please pray that the many contacts that they made lead to collaborators in advancing cardiac care in Africa and serving the poor.  Unfortunately, I forgot to take any pictures of them speaking in Rochester but here they are at Niagara Falls where we made a brief stop:

In October, I will spend about 2.5 weeks in Shisong giving anesthesia for cardiac surgery.  Fr. Herald Brock, CFR, from the Franciscan Friars of the Renewal, will also visit the Cardiac Centre during this time.  We are hoping that Franciscan Mission Outreach will be able to assist us in fundraising to improve the access of cardiac surgery to the poor in Cameroon and the surrounding area.  Fr. Herald has done much work with the poor in Honduras and in what is now South Sudan, and we are very grateful for his support of this work in Shisong.  You can visit him on Facebook here: https://www.facebook.com/franciscanmissionoutreach.

Clinical Judgment

In the beginning of medical school, we learned the scientific and humanistic foundations of medical practice.  It isn’t far into medical school, however, before students are introduced to “clinical judgment.”  I think of this as the decision-making process used to decide on a course of action based on the information available, which is always incomplete.  Even within well-studied conditions, it is not possible to know with certainty to which population of patients the person in front of you belongs, and even if the diagnosis is certain, the response to treatment might not be.  Add to this the necessary cost-analysis and the inherent conflicts of interest, and the practice of medicine can suddenly become quite challenging.  Usually within one’s own practice, a physician becomes accustomed to the various considerations that are required, so that only the rare patient is enough out of the ordinary to require extensive additional concern.  In the US, it is likely that your patient is actually in a population that has been studied, that any relevant guidelines apply to him or her, and that if you are wrong you will have an opportunity to follow through with another decision.

Although western physicians have contributed greatly to the care of the poor in developing countries through mission teams and individual efforts, I have always found this judgment issue to be quite challenging in a new location and culture.  It is difficult on a short-term basis to know what options the patient has available, what the risks are in that patient for the procedure or treatment that you want to give (given the differences in equipment, sterilization, and so forth), and how complications will be addressed.  Here in Shisong, we have the opportunity to provide, in many ways, “first-world” medical care to cardiac patients on a long-term basis; yet the judgment issues remain challenging and the uncertainty, while not paralyzing, is disconcerting at best.  In western countries, rheumatic heart disease is not defeated but it is rare, and to see severe rheumatic disease in a very young person is nearly unheard of.  [This is the point at which the issue of prevention is usually raised.  Everyone who treats advanced rheumatic disease in developing countries is aware that the problem should be preventable.  How to prevent it in this cultural setting is less obvious, and in the meantime it does not seem appropriate to refuse to treat the patients in whom the disease has not been prevented.]
 

Dr. Mve Mvondo and I have written an article for submission to a journal which addresses the issue of repair vs. replacement of diseased mitral valves in sub-Saharan Africa.  Although the article addresses primarily the treatment of mitral valve regurgitation, several of the concerns are general.  I outline a few of them here for your understanding (for my non-medical readers, some of these are not unique to Africa and apply to the decision-making process in our own lives in the US, especially if you have faced a rare disease or a treatment not covered by insurance).  Most of the patients who present for surgery are young (between 10 and 30).  Patients who are young who require valve replacement almost always receive a mechanical valve, because their durability is much better than current tissue valves.  There are several issues associated with living with a mechanical valve, but the most important one is the need for anticoagulation.  Lifelong anticoagulation is necessary to prevent strokes and to maintain valve function.  In the US, this is a burden because of the need for on-going monitoring as well as the risk for bleeding.  Athletes and people with high-risk jobs occasionally refuse this treatment rather than change their lifestyle.  Although there are modern valves which might require less anticoagulation, it is not yet certain that it is safe to forego anticoagulation in most circumstances.  Here in Cameroon, there are numerous additional considerations to subjecting a patient to lifelong coagulation.  First is the understanding of the patient that this is a necessary commitment.  It is not uncommon for a patient to stop their medication because they decided that it was unnecessary.  Another consideration is cost; neither the medication nor the monitoring is free, and most patients do not have insurance or much money.   The need for many patients to travel long distances to get their medication and monitoring also impedes successful therapy for many people.  Even where there are roads, most people do not own cars, and travel is also not free or easy.  Pregnancy is an important issue for many of these patients.  It is possible for many women to safely bear children, but it requires intensive prenatal care, careful drug management, and hospital delivery because of the risk of bleeding as well as the underlying poor cardiac function present in many of these young women.  This is a culture in which bearing several children is desired and expected.  Recommending against this is difficult, and in many cases impractical, so even if a patient agrees with all of the recommendations it is unwise to assume that she will follow through.

The alternative, then, in the case of mitral valve disease, is valve repair.  Although this is not meant to be an extensive discussion on mitral valve therapy, I will point out two important issues.  The best methods of valve repair in the setting of inflammatory disease, especially mitral stenosis, are controversial, and in western countries this is not routinely attempted.  Secondly, a failed valve repair here is even more of a problem than in the west.  Many patients will not return for follow-up, most patients cannot afford a second operation, and the risk of repeat chest surgery in this setting is significant given the limitations and costs of blood products, monitoring, and advanced supportive therapies.

An additional consideration here that is somewhat different than my practice in the US is the advanced stage of disease at which most patients present.  There are evidence—based guidelines in Europe and in the US recommending the stage at which the benefit of surgery will outweigh the risk.  Even if the risk of surgery is slightly higher in this setting (and I am not sure that it is), most patients present well past the recommended time of surgery.  Even if they come for consultation early in their disease, they wait a long time for surgery due to fear, lack of support, and financial considerations.  And of course, the options that Americans and Europeans have of heart transplant or artificial hearts are not available at all without travelling abroad.

One final area that looms large, that I have mentioned above, is cost.  In the US, cost is something of a general issue, and we do not often consider it as a deciding factor in the treatment of individual patients.  At the cardiac center, we can overcome the cost issue for the in-patient care of many patients.  However, this does not make the issue go away.  Some patients have co-morbidities or suspicion of co-morbidities, and additional evaluation could be beneficial.  We do not have a CT scanner in Shisong (although hopefully that is coming), so if a patient has a problem best evaluated by CT scan, they must travel several hours and pay for the CT scan, and bring the results back to us.  There is other testing and treatments for which patients must travel and pay additional fees, and we must decide whether to proceed without the tests or not.  In the US, there is always a point at which further testing is not cost-effective, but that moving target is even more difficult here.  From an anesthesia standpoint, deciding to proceed now versus advocating waiting until different drugs or supplies are available is not something that often applies in my practice in Rochester.

In the US, we often over-test, over-treat, still fail to have optimal outcomes, and assume that someone else will pay for all of it.  Here, the answer is frequently, “you can’t have that,” and we are still left to make decisions with the information that we have based on our discussions with the patients and hope to honor their trust and dignity.  I am confident that we always act with good will and that the personal conflicts of interest are minimized.  The rest remains difficult.


From today’s liturgy: “They ate and had their fill, and what they craved the Lord gave them; they were not disappointed in what they craved.” (Cf. Ps 78:29-30)

Mi-Do

Once again, there are a number of organizations who are supporting the work of St. Elizabeth’s and the Cardiac Center.  One of these is based in South Tyrol, Italy and is called Mi-Do, which is for Micro Donations.  They can be found here: www.Mi-Do.org.  Andrea Zeller and Dr. Claudia von Lutterotti were here in Shisong in November to explain their approach and to learn how best to support the work here.  Unfortunately, somehow I never took their picture while they were here, but you can see them in the advertising flier below:

Their concept is to collect small donations from many donors in order to support individuals in need here in Shisong.  There are several children living at the orphanage here (someday I will write about the orphanage).  Mi-Do has committed to providing their school fees until their families are able to provide for them.  There are also numerous patients awaiting funding for heart surgery.  Some of these are profiled on the Mi-Do website, and you can choose one to support if you wish.  Recently they completed raising the support for one of the patients on the website, and she will be scheduled for surgery in January.

Currently, donations to Mi-Do are in Euros, but they are able to accept donations via credit card from US donors.  We are working on ways for them to have the donation amounts appear in dollars and for them to be a 501c3 organization so that donations will be tax deductible, but since they are primarily seeking small donations we are hoping that these barriers will not impede potential US donors in the short term.

By the way, South Tyrol has an interesting history.  It is a semi-autonomous region of Italy that is primarily German speaking.  The Tertiary Sisters of Saint Francis that work here in Shisong have their origins there where their foundress, Sr. Maria Hueber, was born.

Christ the King and His Rain

Sunday was the Feast of Christ the King, which is also the last Sunday of the liturgical year.  In this region, it is common to have Eucharistic processions to celebrate.  Here, Sacred Heart Parish in Shisong had a procession from the parish to the cathedral.  

Below, you see Maribel encouraging the young people to sing about the kingdom of God as they walk and dance, and the priest carrying the Blessed Sacrament in a monstrance.
 

 

 

I have been getting lots of weather reports from home.  It seems that it is unseasonably cold and there is an expectation of snow.  I thought I would include my own weather report, since there is not much weather available on-line for Shisong.  It is currently the dry season.  Usually this season is aptly named, as I have never really seen rain here when I was here in the dry season.  This year there is rain.  On Sunday after the procession, the skies opened up with heavy rain, thunder, lightning, and even hail.  This keeps the dust down and of course is good for growing things and for the water supply, but not good for those trying to do dry season activities such as build (which often includes making bricks from the local soil) or travel.  Oh well.  I do not get to order the weather.  Here are some picture’s of one of the convent gardens (“farms”) which is benefiting from the rain but also from diligent watering by the sisters, as well as the nearby hillside which I find to be particularly pretty. 
 

Possible, but difficult, revisited

We have been able to operate on the two patients that we delayed last week due to a lack of blood, plus one more Wednesday.  The blood bank went out and had a very successful blood drive in the surrounding villages on Sunday.  There is another patient (17 years old) awaiting surgery who has been acutely ill and requires further evaluation prior to mitral valve surgery.

Many of the readers of this blog (if there are many readers of this blog) know for the last 8 years I have been the director of the Quality Improvement and Patient Safety program in my department at the University of Rochester.  This was challenging and often frustrating, and along the way I learned many lessons and developed an interest in errors and their prevention.  Although when I arrived here, I was relieved to be able to work and “not have to fix everything,” I guess I should not be surprised that I cannot just turn off the constant thinking about how to make things better.  The cardiac center does many things well, especially for a place that has only been open for four years.  Like every place, though, there are opportunities to improve communication, reduce the risk of error, and provide more patient-centered care.  There are many challenges for me in this environment.  These include but are not limited to: an incomplete understanding of the medical-legal environment of Cameroon, an incomplete understanding of the culture as it pertains to working on improvement, significant language barriers at many levels, a different education process for the nurses and staff, and significantly more limited resources than we had at Strong.  Even in the U.S. it is always challenging to identify the resources to implement our ideas for improved safety; here it is even more difficult to improve infrastructure to make care safer.

In the news I saw that Great Britain appears to have taken a step backwards in safety by criminalizing certain failings.  I am hoping that they will be very clear about what behavior is criminal and not include errors in these prosecutions as many places have done.  I have been reading Sydney Dekker's The Field Guide to Understanding Human Error.  It will be interesting to think about how to apply his ideas to medicine in Cameroon.

Day by Day

When I was in high school attending youth retreats, our retreat leader used to play a mix of music during the morning while we were eating and getting started.  I still remember this mix as being uplifting and relaxing, while motivating me to participate in the day.  One of the songs in this mix was “Day by Day.”  The song was from Godspell, but it is based on an ancient prayer.  The words of the chorus are:

     Day by Day

     Day by Day

     Oh, Dear Lord, these things I pray:

     To Know Thee more Clearly

     To Love Thee more Dearly

     To Follow Thee more Nearly

     Day by Day

It is still a good prayer.

Possible, but difficult

On the last night of the Italian Mission, Drs. Giamberti and Cirri shared the story of the beginning of the mission.  They were always cognizant to try to speak English if Falan or I were present, even if they were primarily speaking to their own Italian-speaking group.  Early in the relationship between San Donato and St. Elizabeth’s, patients would be transferred for Italy for surgery.  There was a desire to perform surgery on these pediatric patients here in Cameroon.  The first year they decided to operate on 3 patients with patent ductus arteriosus.  For my non-medical readers, this is a condition in which a structure that is necessary for fetal life fails to transition to life in which oxygen is provided by the lungs instead of by the placenta, creating too much blood flow to the lungs, and too much work for the heart.  If it does not close spontaneously shortly after birth, it can be closed surgically.  The reason that this procedure was chosen to begin heart surgery in Shisong is that it can be done without the use of the heart-lung machine.  Dr. Giamberti said that they wanted to show that it would be possible to perform cardiac surgery here in Shisong, but that it would be difficult.  They then proceeded to share the adventures that occurred during this first mission.  Although we laughed at how silly the problems seemed and marveled at the genius of some of the problem-solving that occurs here in Cameroon (this is not so different than occurs when we look at the history of medical advances in the U.S.), the fact of the matter is that many barriers remain to high level care here in Africa.  It remains true that it is possible, but it is difficult.  The Italian mission organizations have built a beautiful, modern facility for the delivery of high-level cardiac care.  We do not have to worry about having to cancel an operation because the operating room is full of butterflies, as happened during that first year.  There are automatic generators to provide constant electricity so that the perfusionist (the specialist who runs the heart-lung machine) does not have to choose between keeping the patient alive and providing the surgeon with suction, as happened during that first mission because the person whose job it was to start the generator was not immediately available.  There is water, and commercial scrub solutions, and sterile instrument pans for each case.  What is keeping patients from accessing necessary heart surgery today?  Today the problem was a lack of blood availability for a patient with A+ type blood.  There is a volunteer donor program, but it is still in its infancy.  The patients must bring family members with them to donate blood.  This blood might not be appropriate for the patient having surgery, but it is expected that they will contribute to the blood bank.  The blood bank will go out on Sunday to the surrounding villages to encourage blood donation and have what we would call “blood drives.”  The blood bank is also establishing a component program.  Currently only whole blood is available.  The component program will allow us to be more selective with the way that we use blood, and reduce exposure to antibodies in patients who only need red cells, as well as treat coagulopathy (bleeding) more effectively.   I have already described the financial problems that many patients face in preparing for surgery.  Soon I will describe another organization that is raising funds specifically for these patients.  I am hoping that they will soon have 501c3 status in the US, as well as a US donation website.  In the meantime, I would like to encourage my readers who pray to continue to pray about these issues and particularly if there is a way to support these needs.  For my readers who don’t pray, you can still think about whether there is a way to support these needs, and if you are thinking about giving prayer a try again, here is a place to start.

In the pictures, you see Mr. Thomas who is the director for the blood bank, and the chairs for the volunteer blood donors.  There is also a small lounge where they can have snacks and drinks after donating.

Lifebox

One of the gratifying things about becoming involved in international missions is the number of people you meet involved in other programs.  The number and magnitude of the problems can be overwhelming, but becoming involved does not mean that you have to solve all of them.  In fact, it may not be possible for any individual to solve any of them.  However, many different organizations teamed up with the local populations are managing to make an impact.  I would like to continue to draw attention to some of the people and programs that are active here in Shisong.

Lifebox (www.Lifebox.org) is a program founded by the World Congress of Anesthesiologists and and the World Health Organization and promoted particularly by the American Society of Anesthesiologists and the Association of Anaesthetists of Great Britain and Ireland.  In many developing countries there is a serious deficit of anesthesia safety and a high incidence of morbidity and mortality related to anesthesia and surgery.  There is a significant relationship to maternal, infant, and child mortality as these populations are disproportionately impacted by the needs and the deficits in availability of expert care.  There are numerous causes of these problems, not the least is a lack of trained personnel.  However, in trying to identify problems that can actually be addressed, the WCA and the WHO identified the availability of monitoring, particularly pulse oximetry, as an area that can be addressed in an organized way.  Lifebox seeks to make pulse oximetry available in operating rooms world wide, as well as to promote the use of the Surgery Safety Checklist (http://www.who.int/patientsafety/safesurgery/ss_checklist/en/) and education in other areas related to safe surgery.

In the small world category, it turns out that the anesthetist leading much of the work of Lifebox is a nurse anesthetist here in Shisong, Mr. Benson Nfon Tanjong. Additionally, Dr. Falan Mouton from our residency program at the University of Rochester, currently on a rotation here in Shisong, has become a leader in the Lifebox organization at the level of involvement of residency programs in fundraising.  As I mentioned in an earlier post, I was able to participate in the Lifebox distribution program in early October in Yaounde at the National Congress of Anesthesia and Critical Care.  At this program, one hundred pulse oximeters were distributed along with checklists.  Below, you see Mr. Benson presenting the Lifebox workshop and me passing out pulse oximeters at the end of the session.

November 6, 2013

There are several hospitals that have entered into collaboration with the cardiac center here.  These hospitals send teams once or more than once per year to serve the cardiac surgery needs of adults and pediatrics, and several have done so since prior to the opening of the center in 2009.  One of these teams was here last week, from Modena, Italy.  We performed 5 successful operations on adults ages 15-27, and including mitral valve/aortic valve replacement, Bentall procedure, and pericardial stripping for severe constrictive pericarditis.  The patients have all been discharged from the ICU to the cardiac ward and some have gone home.   This week there is a pediatric team from Milan led by Dr. Alessandro Giamberti and Dr. Sylvia Cirri.  This team has been extremely committed to this project and is significantly responsible for the existence of the center.  They have trained most of the clinical and support staff and see to it that they receive ongoing training.  They will perform around 15 operations for congenital heart disease including atrioventricular canal defect, Tetrology of Fallot, and hypoplastic left heart syndrome, and perform a number of diagnostic and interventional catheterizations.

A side benefit of having an Italian team here was the dinner invitation.  Dr. Giuseppe Gramegna prepared his special sauce and pasta from Rome and the local cooks prepared the rest of a delicious meal.  After the picture below, Carolina (a perfusionist from the Modena team who stayed to assist the pediatric team) did agree to share.

November 2, 2013

One of the Italian Mission Teams was here this week for a very successful mission which I will write more about soon.  I thought it was time for some lighter fare and to share some of the beautiful scenery around Shisong, as well as an opportunity to show the people I have been spending time with. 

This dog apparently lost a friend who left the weekend that I arrived.  She was very sad, and started following me everywhere.  The sisters call her “Rambo.”  I do not know the origin of the name since it might be the most docile dog I have ever met.  

Sr. Ruth, who is an ICU nurse, and Dr. Daniel (pharmacist) and I went “trekking” to the St. Francis Comprehensive College and had a tour of their dairy farm.   

Another day, we “trekked” to the bishop’s house on a hill near the village of Squares.  We stopped in at the convent there to greet the sisters, and found them watching “Sister Act.”  On our way down Sr. Ruth decided to try out flying. 

Logan and Eric Horne and their 5 children live in Squares above the bishop’s house at St. Augustine College.  You can follow their mission here:  http://hornefamilymission.blogspot.com.   You can see that Logan has mastered the art of carrying her daughter the African way. 

If you arrive for 2^nd Mass (9 AM) before the 1^st Mass ends (begins at 6:45 AM), you have to wait in this not-so-disappointing setting. 

Dr. Falan Mouton is a senior resident in anesthesiology at the University of Rochester.  She is here on a one month rotation at the cardiac center and in the main operating room of the hospital.  We have found some nice places to walk.

By the way, in my previous post I mentioned the NGO's and generous donors that make the Cardiac Center successful despite multiple challenges.  One of the founding organizations and driving force behind the effort is Bambini Cardiopatici nel Mondo, whose English language website can be found here: http://www.bambinicardiopatici.it/english-website/the-association.php.

October 28, 2013

Okay, so I think the blog issues are sorted out and I should be able to post a little more often.  The last couple of weeks have been somewhat quiet as we have been trying to get patients ready for the operating room.  The primary issue is financial.   There is great need here, for treatment of the usual acquired and congenital heart diseases that we see in the US, in addition to a significant burden of rheumatic heart disease.  Thanks to some NGO’s, there is funding for many of the pediatric congenital cardiac patients.  There is much less funding, though, for the adult patients.  These “adult” patients may be as young as 9 years old or may be the parent of many children who will be left without a parent without the necessary cardiac surgery.

I used to rationalize that in countries where there is significant or extreme poverty (recall that a large portion of the world’s population lives on less than $2/day), that things are less expensive.  In my experience in developing countries, this is generally untrue.  Things of similar quality are as expensive or more expensive than they are in the U.S.  Local produce is generally inexpensive, but comparable with public markets in the U.S.  Anything that is packaged or imported is quite expensive.  What is different is the way that people live when they are living on a very low income.  Houses are built without building codes and frequently without electricity or running water.  Cooking here is often done on a wood fire (indoors or in a separate building near the house).  Protein sources, including beans, are expensive and therefore not eaten every day.  Schools all require tuition, so if a family is able to generate an income a significant percentage goes toward school fees, books, and uniforms; if the breadwinner gets sick the children may have to withdraw from school.

We are able to perform cardiac surgery for costs somewhat lower than the U.S. for a few reasons.  Of course, salaries are lower in general.  We do not have liability insurance, although the hospital does pay taxes on its staff.  We do not have $30,000 ICU beds, $8000 Operating Room tables, brand new equipment, or infinite disposables/single use equipment.  Due to generous donations from various foundations, hospitals, and individuals, we are still prepared to deliver high quality cardiac surgical care.  However, medications, prosthetic cardiac valves, cardiopulmonary bypass supplies, and so forth are still expensive and must be purchased if they have not been donated.  The staff must be paid regardless of the number of cases that we are doing.  Therefore, cardiac surgery is still either prohibitively expensive or a great sacrifice for patients and their families.  It is quite humbling to know that the patient that you are about to care for might have sold land or even their house in order to have surgery.

Cameroon, 2013

For a long time I have carefully considered whether I would maintain a blog of this venture, despite many requests.  My concern is that I am terribly afraid of offending my African hosts, perhaps by an unintended criticism that should not have been made publicly, or by perpetuating some kind of stereotype.  Now that I have decided to proceed, there are so many things to write about.  I thought I would start by addressing some of the questions that arise when people learn that I am going to Cameroon.





1)   Where is Cameroon?  This is why I placed the map in the blog banner.  This is by far the most common question I receive.  Cameroon is either the eastern-most West African country or the western-most Central African country.  Many Cameroonians seem to consider themselves part of Central Africa.  If you want to read about it in the Lonely Planet, buy the book on West Africa.  It is just barely, but entirely, in the Northern Hemisphere, and in the region commonly called “sub-Saharan.”  There are coastal (Atlantic) and inland mountainous regions, and it has a rainy season and a dry season.  Shisong is in the mountains around 5000 ft elevation, so the weather is cool at night and warm in the daytime.

 



2)   Do they speak English there?  Yes, and not always.  The official languages are French and English, with French being more widespread, but Shisong is in the English-speaking Northwest Region.  There are few native English speakers, however, as there are around 250 local dialects.  In the English speaking regions a lot of Pidgin can be heard.  It is interesting to read about Pidgins on Wikipedia.

 



3)   Is it safe?  For this I quote the Lonely Planet Guide:  “Cameroon’s tourist industry is a victim of geography. It sits in a tough neighbourhood, bordered by some problematic countries. But this shouldn’t put you off, as Cameroon really has just about everything a traveller could want. One of the most culturally diverse countries on the continent, its people include ancient tribal kingdoms, Muslim pastoralists and forest-dwelling pygmies.”  When my friends think that I am visiting a dangerous country, I like to remind them that the day I returned from my first trip to Israel, 8 people were shot in a mall in Omaha, and while I was in Shisong last fall, the terrible Newtown shootings occurred.  This was all over the news in Cameroon, with questions about safety in my country.  In general, the most dangerous activity in Cameroon, like many places, is road travel.



In terms of safety, I also like to refer to the parable retold by W. Somerset Maugham.  In this story, a man escapes to Samarra because he has encountered Death in the market in Bagdad.  When his master inquires of Death, he learns that Death has an appointment with the man in Samarra that night.  That story can be read here: http://www.k-state.edu/english/baker/english320/Maugham-AS.htm

Missionaries like to remind their listeners “There is no safer place than in the center of God’s will.”    The best any of us can do is not to be reckless, but to exercise careful discernment about calling and risk.





4)   What are you going to do there?  Lots of things.  Primarily, cardiac anesthesia for a wonderful project of developing cardiac surgery in Cameroon.  Help teach nurses and nurse anesthetists, and hopefully, anesthesia residents both from Cameroon and the US.  Pray with the Sisters and the community.  But most importantly, serve Christ.  The purposes of a mission hospital are to meet the medical needs of the population, especially the poor, and to let the people know how much God loves them.  Should people choose not to be in relationship with God, that is between them and Him, but I am a physician trained firmly in the doctrine of informed consent.  People should know about Christ and be allowed to choose whether or not to be in relationship with Him.

 



5)    How long will you be there? 6 months (at a time).  This is usually followed by the following response: “Wow.  That’s a long time.  Maybe you won’t come back.”  No one knows what the future will hold.  However, I have promised my partners and my chair that I will be back at the University of Rochester in April.