patient stories

I went down to the office last night after Zoe was in bed, hoping to tackle the pile of Smile Train charts in my box. I've got my system down to a science now, which is good because the end of the outreach means lots and lots of cleft lips.

When I pick up a new chart, the first thing I do is go into our database of before and after photos to pick out the pre- and post-op photos that I'll need to upload along with the patient's information. It's my first contact with the patient, and I love watching the little faces that pop up. Alseny was no exception.



Big brown eyes and a milky mouth; my kind of baby. Alseny was here to have his cleft palate repaired, but when I opened the chart, another photo fell out, one from before his cleft lip surgery. As I started to look through the rest of his paperwork, Alseny's beautiful story unfolded in photos and graphs and page after page of careful notes.



This is Alseny and his twin when he first first came to be admitted to our Infant Feeding Program (IFP) on November fifteenth. At four months old, he weighed just over six pounds, his cleft lip and palate preventing him from getting the same nutrition as his sister. It's one thing to see a tiny baby, malnourished because of a cleft. But put him next to a twin, next to a baby who is getting all the same milk he is, just without the broken lip and palate, and the true impact of this birth defect is thrown into terrible, sharp focus.

Thankfully for Alseny, his mama loves him. She saw past the curse, past the lie her culture would seek to tell her that one healthy baby is more than enough, and she fought for his life. Instead of letting him starve to death, she brought him to us, and Jess, our IFP coordinator, got to work making a specialized plan for fattening little Alseny up.

Twelve days later, Alseny weighed in at over nine pounds.



Let that sink in for a minute. He gained over half his body weight in less than two weeks, simply because his mama was taught how to feed him and provided with supplements that she wouldn't otherwise have had access to.

And it didn't stop there. Over the next two months, Alseny kept on growing until he was more than ready for his cleft lip surgery in February.



In case you're wondering, that's him on the right, putting his formerly big sister to shame with those rolls.

In just two months, we went from not knowing whether Alseny would survive to walking him into the OR for his lip to be repaired. And because he did so well, we were able to admit him for a second surgery to close his palate, too, something that wasn't even on the radar when we first met him. We serve a God who does more than we can ask or imagine. And in Alseny's case, we actually have photographic proof.



Surgery finishes on Friday, and the hospital closes next week. This Field Service is coming to an end, but when we sail, we leave behind stories like Alseny's, the promise of life when the future looked anything but hopeful.

I love this place.

I've been feeling increasingly disconnected from the work going on downstairs over the past couple of weeks. Zoe has been sick and I'm pretty sure she's hitting the dreaded four-month sleep regression a little early (it figures that my child would be an overachiever), so my life has been consumed with keeping her happy when she's awake and putting her to sleep without her screaming her little head off. Easier said than done, apparently. I know amazing things are happening down there, but it seems so far away.

The other day I had to go downstairs to pick up some medication, and instead of taking the aft stairs down to Deck Three, I used the forward ones, the ones that would mean I had to walk the hospital hallway before crossing over to the starboard side where the pharmacy is. I'm not ready to have Zoe in the wards yet (we're going to wait until she's had another round of immunizations and is a little older before we let her get passed around among the patients and caregivers), but I just wanted to at least be near the patients, if only for a few steps.

When I hit the telltale green floor on Deck Three, Rebecca, one of the hospital chaplains, was leading a straggling group of VVF women on their customary walk. Catheter bags in hand, they were a ragtag bunch as they shuffled slowly down the hall. When Rebecca saw me coming, she started herding them to one side so I could pass. Enyo, I told her, It's good. Don't worry. Her face broke into a wide grin and we started singing together as I caught up to her.

Enyo, enyo, enyoto
E-enyo.
Nussya nussya Mauwa,
E-enyo.

It's good, it's good, it's so good.
God has done it,
and it is good.

The ladies turned as I passed them, drawn to the sleeping baby on my chest. Their eyes were full of hope and pain and despair and joy, empty hands unconsciously reaching out to her. I slowed when I reached the head of the line, matched my pace to theirs and sang with them as Rebecca started the next song.

Il est la.
Il est la.
Il est la.

Over and over they sang it.

He is there.
He is there.
He is there.

I don't know where their faith comes from. So many mamas without babies, mamas who have suffered the cruelest loss. Zoe nestled her head deeper into my chest as we all sang together and I just don't know if I could be that strong if I had lost her and had my life so horribly shattered.

I reached the aft stairwell, my cue to turn and go about my day. I waved farewell, and as I crossed over to the other side of the ship, their voices followed me.

Il est la.
Il est la.
Il est la.

My friend Deb, one of the charge nurses down on D Ward, has written an update about the patient I mentioned last week.

You should read it.

I dare you to picture what she writes about without getting choked up. Or maybe that's just me. Maybe her words have such a strong impact on me is because they remind me of a similar scene at the end of the last field service, right before I boarded a plane to go home on maternity leave. I know so well the wave of emotion that washes over you in moments like that, and while I'm not spending time swimming in that ocean these days, reading her words at least lets me dip my toes in again.

This ship is an amazing place to live.

I'm sitting here laughing to myself as I read back over that last entry, the one where I said I had no idea how I was going to walk away from all of this. I really should stop saying things like that, because this time it resulted in a couple of twelve-hour work days, ever since I hit publish on that entry.

This week, we have a German cranio-facial surgeon on board, Dr. George. When I looked at the surgery schedule last Friday, the boxes marking out his days for yesterday, today and tomorrow were nearly empty, each one saying simply All Day Case. We were waiting to see if we'd be able to get the one neurosurgeon in Togo to come and operate alongside Dr. George and make those cases possible, and right up until Monday, we weren't sure we'd be able to say yes. But those boxes have names now. Rudolph and Maurice and two more waiting to find out whether they'll be able to go to the operating room tomorrow, and as a result our ICU is busier than it has been all year.

Rudolph is four and was born with extra space between his eyes and two holes in the front of his skull where his brain and spinal fluid poked out. Yesterday, Dr. George took apart Rudolph's head and put it back together again correctly, an admittedly meager explanation for an incredibly complex, a ten-hour operation. Rudolph spent the night breathing with the help of a ventilator, but as of this morning we've removed his breathing tube, and now we're just trying to walk the fine line between letting him wake up and keeping him calm enough that he doesn't hurt himself in his quest to get out of bed (something he'd very much like to do, apparently).

In the next bed, three month-old Maurice is snuggled up in his mama's lappa, all seven and a half pounds of him. He was also born with the hole in the front of his skull, but because of the placement, his surgery was much more straightforward. All Maurice has to show for his long morning in the operating room is a little incision curving around his nose, held together with steri-strips and a few IV lines giving him fluids and medications for pain, but he still needs to be monitored very closely to make sure his brain agrees with its new, smaller living space.

Tomorrow at least one of the babies who wait next door in D Ward will join Rudolph and Maurice in the ICU, having also had surgery to reshape their skulls. And I sit here and shake my head, because who would have ever thought that such a thing were possible here in Togo?

I used to work in an incredible PICU back in New Jersey where we had a neurosurgeon who would do cases like these on a fairly regular basis. In fact, when I saw the screening sheets for tomorrow's patients, I just had to smile because craniosynostosis isn't just a jumble of letters to me. But when I quit that job, when I got on a plane to come to West Africa for the first time, I had no idea that I'd be part of that type of surgery over here.

Just outside the ship are dirt roads and tin-roofed houses with no running water. There are six million people in Togo and one neurosurgeon. One, and even if our patients could have found their way to him, the cost alone of an operation like this would have put that dream to death.

Down in the ICU are two little boys who have been given the impossible blessing of having surgery that will give them a chance at life, a chance to look normal and to grow into young men who don't have to worry that their lives will be cut short because of the way they were born.

For once, we get to thumb our noses in the face of that often-repeated lament, that where you're born shouldn't determine the reason for your death. For once, we get to hold out the promise of life to the ones we'd normally have to turn away. I love that I get to be here for this, that in my last days on the wards I get to bear witness to transformations like these.

Esther went outside to Deck Seven for the first time since her surgery today. I can't wait for Rudolph and Maurice to join her out there.

When I opened up the nursing schedule this morning to check staffing for the upcoming week, I glanced up at the top line. It’s the one where my schedule is posted, and I never really look at it because my schedule is the same every week. Monday through Friday, day shift. It’s simple.

Today, though, I looked at my own schedule and it hit me like a fist in the gut. Five shifts left. After four years down in the wards, I have five shifts left until I pack up and fly home for maternity leave. And when I get back, my badge is going to read Primary Caregiver, not Pediatric Nurse or Team Leader.

I’m not saying it’s a bad thing. I’m more than excited about this new chapter in our lives, about the little one growing inside me, about finally getting to be a mama after dreaming of it since I was a teenager babysitting the neighbours. But this morning, looking around D Ward, the thought of leaving it all was a bitter pill to swallow. I’ll still be involved in little ways down in the hospital once we’re back on board with Poppy, but it’ll be nothing like it is now. I get to be there every day, now. I get to work with every patient that comes on board for maxillo-facial surgery. I get to hear every story.

Stories like Esther’s, who, at sixteen years old, came to us from Nigeria with tumors that Dr. Gary ranked in the top five that he’s ever seen. It wasn’t the size of them, although they were impressive by any standards, but the fact that they invaded almost her entire face. Usually we see this type of thing in either the lower or upper jaw, but not both. Esther’s disease had taken over both her jaws almost entirely, and in a marathon, nearly twelve-hour surgery last Thursday, Dr. Gary and two local surgeons took apart Esther’s face and put it back together with metal plates and screws and hundreds and hundreds of sutures.

Esther has been slowly recovering, first in the ICU and now back on the ward, and today I went to stand at the foot of her bed while her nurse changed her bandages and removed the drains from her incision lines. It was the first time I had seen her new face without the bulky layers of gauze and tape, and I couldn’t stop the tears that filled my eyes.

Oh, Esther, I told her, You are so beautiful.

Maybe I’m seeing her through the eyes of a nurse, looking ahead to the future, after the weeks it will take for all the swelling to go down, the months that still need to pass before the extra skin will retract back and tighten. But the little girl lying in that bed is beautiful nonetheless. She no longer needs the scarf that she wrapped herself in when she was admitted, the cloth she’s been using to cover her shame all these years.

Esther’s eyes widened and the hint of a smile crossed her lips as Alana (her nurse) brought her a mirror. She peered into it, just like she has every day since waking up free from her tumors, and dropped it to look back at me. What do you think? Alana asked her. Is it good?

Esther nodded once, that one tiny gesture speaking more than words ever could, and then settled back on her pillows, content to let us care for her.

This is what I’ll miss when I go. I’ve been a part of incredible things like this for so long that I have no idea how to be anything else. And for once, I have no answers for myself, no neat little platitude with which to sum up this entry. Just, I don’t know how I’m going to walk away from this next Thursday.

Today marked fifty-six days since Papakey's first surgery, the one to create a nose to cover the hole left when robbers with a machete made their indelible mark six years ago. Just before rounds, his nurse and I peeled away the dressing on his leg that covered the place where they took the skin that was used to cover the place on his head where they took the nose. (Confused? Everyone is when they first hear about this particular surgery.) What we saw led to much rejoicing. Papakey, self-proclaimed Captain of the Ship (but don't tell the real captain lest I be accused of fostering mutiny) was ready to go home.



We celebrated all morning, wide smiles on everyone's faces every time they looked over to his bed to see him slowly beginning to pack his things. We printed out the pictures we've taken to mark his journey while he's been here. We made sure he had the supplies he needs to keep his new nostrils clean and open.

And when the Patient Life team came into D Ward, we had a party.

The drums were pounding as we clapped and danced and worshipped together, nearly blowing the roof right off that place. As we came to the end of the singing, I felt very strongly that we should pray over Papakey, and the team agreed. They pulled a chair to the centre of the room and had the dear old man sit in it while we gathered around him and laid hands on him. Together we raised our voices and prayed life and protection and continued healing over him. He sat quietly, palms clasped in his lap, nodding solemnly as he caught words and phrases among the cacophony of requests going up around him.

When we finished praying for Papakey, Kodjovi, a patient from the other side of the ward, approached and asked if we could pray for him since he was having some pain. He sat in the chair, we gathered around him and we prayed for him, too. One by one the patients came forward, settled themselves in the centre of the group and voiced their requests. Healing. Safe travel. Encouragement.

Dame got out of his bed, feeding tube pinned to his gown, and told us how he had stopped going to church a while ago, how he couldn't see the need for God. Rebecca translated quietly to me as he spoke. And then I came here. I saw how you care for each other, how you care for each of the patients. I saw the way you love, and I can see the way Jesus loves. He dropped into the chair and looked up at us. I want you to pray for me so I can love like that.

After Dame, it was my turn. The Patient Life team prodded me towards the chair and told me it was time to pray for me and for the baby inside me. I sat in the middle of my ward, surrounded by nurses and translators and counsellors and patients and they all put their hands on me and started lifting us up to God. As they started to pray, Poppy, who had been quiet all morning, responded, jumping around inside me with a strength I've rarely felt before.

I left that chair filled with a joy that's impossible to put into words, no matter how hard I'm trying right now. When I head for the States in just two and a half weeks, this morning is a treasure I'll have tucked deep into my heart, something to carry with me when I'm far from this place.

Because there's something so right about the way God made us to live in community with each other, to rejoice with each other and to carry each others' burdens as we walk towards the Kingdom. Today, down on D Ward, I caught a glimpse of what it'll be like when we're all finally Home. I honestly can't wait.

I saw Grace yesterday. Her feeding tube had fallen out at home, so Esther and Anthony made the long trip from Benin back to the ship three days early. Our feeding program coordinator, Jess, stopped by D Ward to see if there were any pediatric nurses around who could place a new tube and I was quick to volunteer. I gathered my supplies and headed out to the dockside tent where Grace's small family was waiting. I got huge hugs from both of them and quickly got the nasty part over with.

Once Grace's new tube was taped firmly in place, I stole a quick snuggle. With her tucked my arms, I got the chance to ask her parents how things were going. It turns out little Grace isn't quite as little as she used to be; she's gained a whopping two hundred grams since we last saw her. It doesn't change the way her heart looks, so it doesn't mean that we can do surgery, but it's more than we expected. We caught up on family news, learned how excited the other girls were to have their sister back, and sent them home again. I'll keep you posted with her story if I hear more about how it's unfolding. Anthony would like me to thank you all for praying. He was speechless for a moment when I told him about all your comments and e-mails and then just ducked his head and said, You need to thank them for me.

Down on the ward, Bernice had a new blue cast put on yesterday and went home today, her caregiver laughing and hugging her thanks to all of us.



It's hard, sometimes, to let them go. Harder still when you know they're going back to an orphanage with sixty-one other kids who all need love and care. Hard to trust that they'll watch over her vigilantly enough, clean her mouth well enough, make sure she eats the right foods. I found out today that Bernice actually does have a mama, but that her real mama wants nothing to do with her. She rejected beautiful Bernice when she was born with a cleft lip and palate, unable to see past the deformity, unable to imagine that her child could ever be worth anything.

But Bernice is anything but unloved. She's had affection poured into her little soul from every angle over the last week and she's been soaking it up. It was finally my turn for a cuddle today during morning worship. I had her in my arms, her head on my chest, her bum resting comfortably on Poppy's head, apparently, if my own kiddo's wild dance moves were any indication. As the drums beat and the music swirled around us, her tiny hands patted my back in time with the rhythm, her fingers soft as little feathers.

Eventually the singing slowed and I handed her off to the next willing set of arms so that I could finish writing her discharge orders.

There's a rhythm to this place. They come, we fall in love, and they go. As Bernice's caregiver was collecting their things, four year-old Mounira rolled back into the ward from the recovery room. The steri strips on her lip mirrored Bernice's, and I saw Bernice's caregiver nod knowingly.



Here's another one saved, that nod seemed to say. Saved from a lifetime of rejection and ridicule before she's really old enough to realize that she's different. Mounira's papa stood by her side, his own smile wide as he looked down at his sleeping daughter.

Here's another one who doesn't have to hide her face, another one who gets to look like all the rest of us. This is how it should be.

Each Friday I print out the list of possible admissions for the upcoming week and write a quick e-mail to the photographers about which of them are going to be Smile Train admissions so that they can make sure their pre-operative photos are taken. Smile Train is a charity that funds cleft surgeries around the world, and we partner with them here in West Africa. We provide the doctors and nurses and the hospital in which the operation takes place, and Smile Train provides the finances. It's a win all around.

Smile Train patients are one of the highlights of my work here on Mercy Ships. I absolutely love the transformation that takes place in a patient before and after cleft surgery, and it definitely helps that the majority of them are babies and small children. (Except for one gorgeous, tiny old lady who had her lip fixed on Friday after living with a face split wide for more than fifty years. She wasn't a child, but she was still pretty cute.)

Unfortunately, many of the patients who were screened before the ship arrived are from up north and many of them have been failing to show up on their admission dates. Some arrive late, others have phones that no longer work, and the most heartbreaking ones are the few we've called who tell us that they can't come because they simply can't find the money for transport.

It just makes us cherish the ones that do make it to us, and among those Baby Bernice has a special place in all our hearts.



She's two and she has no mama or papa. She lives in an orphanage and the woman who brought her to us is one of the workers there. On Thursday, Bernice was scheduled to go to the operating room when Melissa, her nurse, found that her leg was hot and swollen. Little Bernice sat in her big bed, staring up at us with big, wide eyes, surrounded by a whole team of us as we talked through what might be wrong. We decided to hold off on surgery until we could figure it out and I felt my heart sink at the prospect of having to cross yet another hopeful patient off my list.

An x-ray of the sore leg made the path forward much easier for us. Bernice's little femur had been fractured, probably a couple of weeks ago judging by the film, but there was no reason she couldn't have surgery to fix her cleft lip and palate. In fact, as we discussed our options, we realized that yet again, God had placed the right people on the ship at just the right time.

The general surgeon who has been operating on hernia patients in A Ward just so happens to be a pediatric orthopedic surgeon, too. Except that we're not doing orthopedic surgery this outreach; six months just isn't long enough to ensure good physical therapy follow-up afterwards. There was no reason for an orthopedic surgeon to even be on board, but God made sure we had not only the correct specialty, but also one who is trained in pediatrics.

So Bernice had a full afternoon on Thursday. Dr. Gary closed her palate and carefully stitched together her lip while Dr. Alex busied himself with her leg, correctly aligning the bones and placing a long cast from hip to toes. Instead of a lifetime crippled from an unhealed injury, she now has the chance to run and play again. She's been recovering in D Ward since then and is much happier now than she was at first. She's still a solemn little thing, but she reaches up to be held and carried, and the nurses are more than happy to oblige.

There's a phrase in Dutch that one of our nurses taught us. It translates literally to soft-cooked egg, and it's how you feel when you pick up a gorgeous baby and your insides melt and go all runny and warm. We're all pretty soft-cooked around Bernice these days.

I left her sitting on the charge nurse's lap this afternoon. She had been there the whole time I was giving report to the oncoming shift, her little hands busy with everything on the desk she wasn't supposed to touch until Melissa opened a drawer and handed her a ball of yarn.

She sat there, enthralled, casted leg sticking out at a crazy angle, steri strips on her top lip looking like little kitten whiskers, playing with her ball of yarn while her caregiver looked on from their corner, a smile on her lips. And all I could think is that Bernice might not have a mama or a papa, but God is absolutely looking out for her. And that's enough.

I am exhausted in body and soul, but I need to tell you more of Grace's story before I can go to bed.

The past two days have been hard, dark days down in the hospital. All of a sudden, it seems, things got sad. One of our long-term patients who's been with us since the start of the outreach went to be with Jesus last night. We rejoice in her complete healing, but the ache of her passing is strong, especially among the team of nurses who threw themselves so wholeheartedly into her care.

On D Ward, a shadow seems to have crept quietly across the sunshine that we've been enjoying. There is an edge of pain starting to sharpen some of the stories we've been watching unfold, but none cuts so deep as Grace's.

After her first good day, Grace took a turn for the worse. Yesterday her breathing started becoming more laboured, her little body struggling harder and harder. We took an x-ray and found something that none of us had expected. We knew Grace was damaged; we just didn't know how badly. In addition to her club feet and cleft lip and tiny bottom jaw, Grace was also born with a heart that's massively enlarged. We don't have the technology to diagnose the problem any further than that, but the silhouette on the screen confirmed the path ahead.

Grace will not be able to have surgery. Her body would not be able to withstand the anesthesia, so even if we could get her fat enough, there's nothing we can do.

We had many talks with her parents over the last twenty-four hours. Long, wrenching discussions where the truth sits between you, dark and heavy. This baby is too broken. There's nothing we can do.

Anthony, Grace's dad, came up to me around lunchtime today and told me that Grace's three older sisters were missing her, that they wanted to see their baby sister. I asked him how old they were, and he told me ten, eight and five. I asked their names, and his smile broke wide.

Testimony. Miracle. Favor. And the small one is Grace.

He asked if they should make the long journey from their home in Benin and come to the ship to see Grace, and when I told him that there was nothing more that we could offer them and that it's best if the reunion happens in their home, he paused for a long moment. So what does this mean, he asked me, hope and fear fighting in his eyes. What will we do now?

We talked again about Grace's problems, about the fact that even in America this would be a badly broken baby. We agreed together that medicine holds no more promise for Grace, especially not here in West Africa, and then I saw the hope win out.

So we will take her home and we will trust God for the miracle.

The rational, medical side of me wanted to contradict him. To shake him and make him understand that his baby might not survive the trip home, that she is very, very sick and that we will all be surprised if she is still alive to come to the appointment that they desperately want next week with the Feeding Program. To make him admit that coming back, getting another chest x-ray and finding a normal heart is the most unlikely thing in the world. That's it's impossible and useless even to hope.

Instead I found myself nodding, agreeing, speaking out words of life over Grace and her family. Because the thing is, miracles aren't miracles because they happen every day. It's not a miracle if you can plan it, explain it, expect it. The rational side of me knows that, barring a direct intervention of the hand of God, Grace will not live much longer. She has days, weeks at the most, before her tiny body just gives out. But the rest of me, the side that's seen the unexplainable more than once before? That side joins her parents in pleading God for the miracle of her healing.

And so we taught them to give her formula through the feeding tube, packed bags full of supplies and sent them home to Testimony, Miracle, and Favor. They thanked me over and over for what we've done, little as it seems to us. We prayed together for that miracle, and I gathered small Grace in my arms and walked with them down the gangway to the waiting car. Next week, they called to me as they drove away. We will bring you a fat baby next week.

Before they went, Anthony came to me, sleeping Grace tiny in his massive hands. He held her out, proud papa that he is, so that I could take photos of her. Show them, he told me. Show the people who are praying the baby they are praying for. Show them our little Grace.





You're praying, aren't you? You always do. I know that and it sustains me in the long nights when I lie awake, wondering whether my pager will go off, whether something tragic will happen. Pray for our little Grace. Pray for the miracle, and pray for strength for her parents if God chooses a different path.

Most days, being the Ward Nurse Maxillo-Facial Team Leader doesn't mean a whole lot out of the ordinary. I lead rounds, write orders, cover lunch breaks. I do all the same things the evening charge nurse does, just with a fancy title tacked onto my badge. Things can fall into an easy routine and I forget that I'm really in charge of anything.

Until someone comes asking for my input, because I'm one of the ones who can say yes or no.

Today, as I was getting ready to leave, one of our hospital physicians came into D Ward looking for me. There was a little baby with a cleft lip and palate waiting in C Ward. She was being seen by the feeding program and just wasn't gaining weight.

When I introduced myself to the baby's parents, they smiled up at me, eyes full of hope. I placed the oxygen sensor on her little foot, and as I bent to assess her, I asked her name. Her mama answered simply. Grace.

Grace. An undeserved blessing. At ten weeks old, she weighs just a hair over six pounds (if that), despite her parents feeding her as much as she can handle, a few drops every half hour. Too much of that formula seems to be going into her lungs rather than her stomach, and the telltale signs of a baby in distress were easy to see when I unwrapped her to check her oxygen levels. Add to all this a congenital condition that caused little Grace to be born with an underdeveloped lower jaw, further increasing the work she has to do to breathe, and it's no wonder that she's very sick.

The problem is, we're not a medical hospital. That may sound strange, but it's really more accurate to call the ship a floating specialized surgical centre. We're set up to do surgeries, lots of them, and our patients are, for the most part, perfectly healthy apart from whatever body part we're operating on. Grace is far too small for surgery right now, and this close to the end of the outreach we're not even sure we can get her fat enough to withstand the operation to close her cleft lip before the ship pulls up anchor and sails away.

It's wrenching being caught like that between a rock and the very hardest of places. Yes, we could admit her to the wards, put in a feeding tube and help her gain weight. But every day she spends in a bed is another day that someone else might not get to have surgery. New patients show up on the dock every single day with tumors and cleft lips and a myriad other conditions; we could stay here for years and not come to the end.

In the face of such overwhelming need, how do you triage? How do you decide who gets to come on board and who gets sent home? How do you choose one life over another? And, once you've made the decision, how do you sleep at night?

Sometimes it's all I can do to stop my mind from racing through the day's decisions, replaying every conversation, questioning every move. Tonight is not one of those nights.

This evening, Grace is under the watchful eye of a pediatric ICU nurse in D Ward. There's another PICU nurse working tonight who will take over her care, and one of the nurses working tomorrow morning is the one who used to run the feeding program before the current dietician took over. God knew Grace was coming to us today; it seems He set up the schedule long in advance to make sure the right nurses were working at just the right time, just like He's done so many times before. Grace's papa saw me at the gangway as he left for the night. Thank you, he said. Grace is in the room now. They are caring for her. Thank you.

Tonight I sleep easy, knowing that we made the right choice. Whatever happens with small Grace in the future, she is ours to care for now. The need in West Africa is no less overwhelming because we've admitted this one tiny baby, but I know in the deepest part of me that we are not called to fix all of West Africa. We are called simply to be faithful to the ones placed in our way.

Today, that was Grace. Tomorrow, it will be someone else. And the next day, and the next, and the one after that. Every day we will reach out to the hopeless and speak to them of God's love. Every day we will be called on to extend to them the same grace we were once shown.

Grace. An undeserved blessing.

Almost every man here in Togo wears his hair cut very short, a millimetre or two away from a smooth shave. So when I walked into D Ward this morning and saw the curly mop on Abola's head in Bed Six, I was a little surprised. I knew we'd have to do something about it before Dr. Gary could tackle the fist-sized tumor poking out of the curls on the right side of his head, and since I seem to be the one with the most experience in hair cutting this year, I ran back upstairs for the clippers.

During rounds, Dr. Gary told the patient that we'd be cutting his hair before he went to the operating room and looked at me to confirm that I was up for the task. I laughed and pointed to the clippers, charging on the desk, and he went on to offer Abola his choice of hairstyle. We can just cut the hair around the tumor, or we can cut all of it. It's your choice. Abola replied immediately. Cut it all.

And so, after rounds, and after the customary disclaimer that I'm not a professional barber, I draped Abola in a sheet and set to work. A few minutes and quite a bit of hair later, he had a completely new look, one that was admired by everyone in the ward. I took him into the bathroom to wash off the extra pieces and give him his pre-surgical scrub, and he peered into the mirror, turning so that he could see the tumor. It stood out in sharp relief from his newly-shorn head, obvious now that his hair was gone. He touched it once, gently, then turned to let me finish my work.

As I left for the day, Abola was being wheeled from the operating room to the recovery room. The clean, white bandage was wound tight and smooth against his head, the tumor completely gone.

He won't need to let his hair grow long again. There's nothing left to hide.

I first met Nathanael when he was a patient on the wards two years ago here in Togo. He was just a little baby when we repaired his cleft lip, his mama ever-watchful by his side. We knew even then that Nathanael's life wasn't going to be an easy one. His tiny eyes and misshapen features spoke of an unidentifiable disorder, and we doubted that he'd ever walk or talk.

We did what we could do. We fixed his lip and made plans to see him again to repair his palate and we sent them home, just like we always do.

Nathanael was admitted again yesterday, his mama grinning wide as we recognized each other and shared an embrace with Nathanael sandwiched between us. His sweet face squinted up at me, smiling his benign smile, the same Nathanael I remembered from last time. Just bigger now. Just as damaged as we'd expected, badly needing the operation to close his palate to make it easier for him to eat without food going into his nose and down into his lungs.

Not long after he went to the operating room this morning I got a call from Dr. Gary. He had bad news, the kind that makes your heart sink when you look over to the corner of the room to see a mama kneeling by her bed, praying for her son.

Somewhere in the course of the last two years, Nathanael had surgery to try to close his cleft palate at a hospital in Burkina Faso. It wasn't their fault, but the operation failed, leaving the hole even wider than before. Once Nathanael had gone to sleep this morning, Dr. Gary found what he'd been dreading, that there just wasn't enough tissue to attempt a second repair. And it fell to me to tell his mama.

I took her out into the hall with a translator and I explained that what we'd hoped for hadn't happened, that she was going to go to the recovery room and hold her son while he woke up looking just the same as before. I told her I was sorry, and she looked me straight in the eye and spoke confidently.

We have been praying for so long for this surgery. If it has not happened, it must be God's plan. We cannot understand God's plan. If we did, He would not be God.

I had no answer, nothing to add to that incredible truth. I walked her down the hall to recovery, and as we reached the door she put her hand on my shoulder and spoke in English. Ali, you are in my heart, she told me, and went in to see her son.

We walk among giants, Dr. Gary told me when I found him and recounted the conversation, when I gave voice to my secret, suffocating fear that I will never have enough faith to be a mother like Nathanael's. When we get to heaven, we'll see who had the most faith, and it won't be us. And it won't matter.

We walk among giants.

Today was another in a long string of days that I'm tucking away to remember in a couple of months when I'm far from my beloved ship home. It was, quite honestly, not my best day ever. I have some sort of lingering cold that seems to have sucked every last bit of energy from me, and we were running from start to finish. The surgery schedule changed often enough that, in the time it took me to walk from one room to the next, I found myself out of the loop. Our three year-old, Alex, decided it was a good idea to pee all over the floor and earned himself a rather rowdy time out for that little gem. We admitted a one-and-a-half year-old for surgery to remove a lump on top of his head and I had to break out my husband's hair clippers and, with the assistance of the three translators it took to hold him still, shave the poor kiddo's hair. (The patient was not amused; the translators think I missed my true calling and should open a barber shop.)

Kids were throwing up and old men were stubbornly refusing to eat and we were putting in IVs and rushing patients to the operating room and D Ward was something very close to mayhem for most of the day.

After lunch, a calm finally settled over the ward. The last patient had been scrubbed and sent to the operating room, Alex had left to start the long journey home and the babies were, for the most part, sleeping.

In the middle of a quiet moment, Papakey called me over to his bed to complain about his new nose. He tipped his head back and pointed deep into its recesses, insistent that there was something bothering him in there. It turned out that one of the dissolvable sutures was still hanging on, and rather than let it take time to work itself out, we decided that the nose was healed enough that we could go ahead and cut it out to save him the annoyance.

Papakey's nurse graciously allowed me to take on the challenge (she knows how much I love being a 'real nurse') and I headed into the nose armed with a stitch cutter and a pair of tweezers. My first few attempts weren't successful, and since Papakey wanted to see everything we took out of the nose, we all learned how to say "boogers" in Ewe.

I eventually surfaced with the offending suture, much to the delight of all involved, but after a short time Papakey had another complaint. The stitch is out, but now you have wounded my nose. It hurts, he told me through a translator. I fired up my trusty penlight once again and found nothing more than a slightly irritated nostril, the natural result of all that digging around.

I explained this to Papakey, citing my own beak as proof that noses in general are sensitive things, especially when sharp instruments are involved. My friend, you have been six years without a nose, and you have forgotten how they work. You need to remember how to have a nose, I told him. Novignon translated my words into Ewe and Papakey threw his head back in a peal of laughter.

All the busyness of the day faded away as I joined in his laughter. I love that my life includes opportunities to tell old men that they need to remember how to have noses. That babies falling asleep on nurses' backs is the rule rather than the exception. That no matter how tired I am, there's never a single day when I don't want to go downstairs to work.

Assiwome is nine, and she had a lot of surgery five days ago. Her cleft lip and palate were repaired and her nose was reshaped, along with a fourth procedure at the same time to lift a flap from the back of her throat which was used to bridge the excess space at the back of her palate. We jokingly refer to this set of surgeries as a home run, except no one's really celebrating for quite a while afterwards. This sort of thing hurts. Think a tonsillectomy times ten, Dr. Gary says, and that's not even counting the first three procedures.

Assiwome has been understandably slow to feel better, but rounds this morning held good news for our little trooper in Bed One. Pack, bolster and tube out, was the verdict, medical speak that meant we could finally get rid of the cotton wad in her nose holding her nostril in a good shape, the several feet of thin gauze folded over and over and stitched to the roof of her mouth, and the plastic tube going in through the free nostril and into her stomach through which we've been giving her food and medications since surgery.

As the Patient Life team clapped and strummed and led worship on her side of the ward, Stefanie (Assiwome's nurse) and I approached, scissors and tweezers in hand. First, Stefanie cut the suture holding in the tube and slid it out of Assiwome's nose. Assiwome's little hands reached for her mirror and she held it up to her face, peering intently at her reflection. With a huge grin, she dropped the mirror and started swaying and clapping in her bed, singing along with the song. It wasn't long before she threw back her covers, jumped down and started her own little dance party right there at the foot of her bed while we clapped and sang along with her. Jehovah, You are the Most High God!

This went on for a while and the team had long finished worship when we eventually got her back under her covers, so it was quiet as Stefanie cut another suture and removed the cotton from Assiwome's other nostril. The mirror came up again, the same intent scrutiny, and Assiwome looked up at me, hopeful. I laughed and started singing the only Ewe song I know in its entirety. Enyo, enyo, enyoto. Enyo. Nussya nussya Mauwa, enyo. (It's good, it's good, it's very good. God has done it, and it is good.) We stood around her bed, clapping and singing and then we moved on to the final stage: the gauze sutured inside her mouth.

This is the part where small children often start to wonder why they ever trusted me in the first place, but thankfully Assiwome is old enough to cooperate without too much fear. She obediently held her mouth open, and with just a few whimpers Stefanie had cut the remaining sutures and slid the packing out. There was some rinsing of the mouth to be done afterwards, and then the traditional inspection in the mirror, and when we were all finished I turned to leave.

I was stopped by a little hand on my arm. Assiwome looked up at me, eyes accusing, and I realized I'd forgotten the most important part.

Enyo, ento, enyoto, we sang, and she stood right up on her bed, bouncing on her mattress, dancing and clapping and laughing, and these are the moments that are recorded indelibly on my heart.

Enyo, enyo, enyoto. It's so very good.

Toyi went to the HOPE Centre today. He'll come back Friday to have the sutures taken out of his scalp and soon enough he and his sister will be making their way back north to their village. Over the next few months the scars on his head and cheek will soften and smooth out until they'll be hardly visible anymore.



That's Toyi when we first met him, his eyes full of fear and suspicion and the combined weight of a lifetime of ridicule. His brows were perpetually drawn, unsure of whether we really meant it or not when we said we'd take care of him.



That's Toyi today, standing proudly next to his friend Papakey. When I came over to their corner and told them I wanted a photo of them for Dr. Gary, I figured I'd just snap one of them sitting on their respective beds. Instead, they both got up and solemnly arranged themselves in front of the linen cart. When I raised the camera, these two men who came to us without noses broke into smiles (Toyi's, admittedly the smaller of the two, although I'll take what I can get from him) and stood tall for their photo op.



Behind me sat Toyi's sister, beaming her thanks and shaking hands with anyone who came near. They sat together on his bed for one last photo and then Toyi walked out, taking the family nose with him.

Today was a good day.

And as if that weren't good enough, little Sibi came into one of the empty beds a few hours later, back for a minor follow-up procedure after her cleft lip repair a few weeks ago.



I love old man Toyi, but I have to be honest and admit that I'm not the least bit sorry that only four of the beds in D Ward are now occupied by patients over ten years of age.