Every once in a while someone asks me what it is like to work in Africa. Granted my trips are very short and only snippets of the reality of what actually occurs on this continent. But today was bit of a smorgasbord.
After rising early to have a fresh banana, banana bread muffin, bowel of oatmeal, and a cup of Via Starbuck’s coffee (brought with me) I left for the office with the PAACS director. I was going to assist in practice oral examinations for the Chief residents. It is their opportunity to prepare for their final exams coming up in a month or so.
We waited 15 minutes before their late arrival, which meant shortened question time and no feedback for them before weekly Grand Rounds for the hospital began.
The Pediatrician for the hospital gave a superb lecture on Measles after which there were no questions - just silence - followed by enthusiastic/polite applause. Some appeared genuinely appreciative. But I seriously wondered how many were actually listening. I find it very difficult to tell when people here are actively engaged in life/learning vs going through the motions. Reminded me of some of my meetings back in the US!
Then conference with the surgical residents. A chief resident gave the remainder of his lecture on the Liver as Keir and I interjected comments. New surgical scrubs were handed out. I presented the two OB-Gyn textbooks donated by Dr. Renee’ Knutson - and the guys were VERY grateful. She received a cheer :-)
The OR team started working on cases as the 2nd yr surgical resident and I started “lightening rounds” together to see all of the surgical patients (? 24). Shortly after we started the mid-wife showed up at the door to one of the rooms with at least 2-3 assistants in tow. I think they were there to learn how to “talk to the surgeon”. She proceeded to lay out the difficulty with a certain patient who was at term, in labor for the past 20 hours, labor had stopped, she was bleeding, and the baby appeared to be in distress. We agreed we would come see her in a bit.
After we made it about 1/3 of the way through, Amanda came to tell us one of our patients was in trouble. After some hesitation (on our part) she re-stated the situation - she really wanted us to come with her immediately, i..e, now. Two of our paraplegic ladies, one of whom has HIV/AIDS, have been declining. Both have been moving towards death, only one a bit quicker than the other. It was the “healthier” lady who had become rather unresponsive, hypotensive, with decreased oxygenation, and lost all IV access.
The difficulty - the surgery team knew she was dying. It was only a matter of hours or at most days. Now her husband was insisting that he was taking her home immediately. Minimal blood pressure, rather incoherent, and increasing fever, unable to take anything by mouth...and it was at least two hours to the closest “hospital” (if you want to call it that) near their home. A death sentence.
After a bit of persuasion, via multiple persons, he agreed to allow an IV to be re-started (by our Med/Peds physician - thank you!) and IV fluid. After she started to respond to the fluid bolus, it was another round of discussions before he agreed to at least one dose of abx to tide her over till she was closer to home. She was gone later this afternoon.
Why the difficulty? When someone dies, often no one will transport the body away, and if they do, they charge exorbitant prices because they have to hire a witch doctor to “clean” the vehicle. Without an exorcism no one will ride in the car again. So, our patient went home to die so her husband wouldn’t be responsible to pay for cleansing a car.
Simple.
Back to rounds -
We made it out of the adult side of surgery and started into Peds. Thankfully all the little ones are doing great! The 5 y/o boy who drained >500cc of pus out of his hip from TB was walking a bit better. Decided to leave his drains till Friday. The 3 y/o boy who has lost >1/2 of one of his clavicles to osteomyelitis is looking much better. The 2 1/2 y/o girl who burned her hand after being knocked into an open fire is able to make a fist (sort of) again. She wasn’t scared of us today :-) And the little boy after a hernia repair looked perfectly happy!
Then to maternity...
We had stopped by there after the discussion and IV start re: lady dying, and decided that our patient at term needed a C-section. Probably ruptured uterus vs abruption. She was in the OR being prepared for a spinal as we rounded Maternity. There was another gal in labor who had a prior C-section, then delivered next at home. We were waiting to see how she would do.
Eventually we started the C-section on our first pt. Baby born in distress, meconium/blood/amniotic fluid. No rupture, but looked like a possible early abruption. The baby perked up fairly well with aggressive resuscitation. Mom did well. And the 2nd year resident, Fabruce, did a fabulous job! Fun to assist young surgeons who are doing well.
Back to Maternity - now there was a young gal who looked all the world like she was undergoing a ruptured ectopic pregnancy. Thought we would check with the u/s. It doesn’t work anymore. So the junior resident walked back across the compound to the surgical clinic to retrieve that machine. Musical u/s machines are the norm around here. Out of four, I think one is working at present.
History was perfect for a rupturing ectopic. Exam was all over the place. U/S indicated intra-uterine pregnancy (by my less than perfect ability). The patient wasn’t pale. Blood pressures were good. Abdomen was still soft and no evidence of peritonitis. Only she had severe pain in the pelvis. So we implemented the time-worn method of surgery - tincture of time.
Back to the OR. I was slated to assist an upper-level resident with bilateral hernia repairs. But as I waited and hung out with Keir as he and a Chief resident performed an urethraplasty for a stictured urethra (remember - it is GENERAL surgery here) I finally discovered why the 3 hour wait. They were sterilizing more gowns!
Apparently there are not enough gowns when people like me start showing up. We have been using the same cotton gowns, patched and re-patched since I started coming in 2005. And they were at least 10 years old at that time! Needless to say they are much shorter, arms are torn in many places, and several have finally disintegrated. So...we waited.
While we waited I walked across to the endoscopy room to locate a bronchoscope for Keir to use in locating the exact location of the stricture within the urethra. He slid it through a hole in the bladder and along the urethra to see where the light ended up. We stuck the source end in the laparoscopic light machine for a light source. It doesn’t matter what you use, just make it work. Brochoscopy ( for lungs) in a bladder. Yep.
As they were sewing up the urethra, I asked about suture. No suture is wasted in marking or holding tissue. Even the type of needle is rarely considered - why? - because so many times just having the right type of suture (or any of the right size) is a miracle in and of itself. I use at least twice as much suture on my repairs at home, and I’m one of the most conservative surgeons in our hospital! Mainly because my assistant, Rhonda, keeps reminding me that I could use less - she came with me to Togo and learned the suture lesson well.
Which reminds me, we are out of narcotics here - only Fentanyl is left, which is short acting and only used sparingly. All surgical patients use Tylenal and Ibuprofen, 3 times a day. That is it. Prostatectomies, Mastectomies, C-sections, hysterectomies, hernia repairs, hemorrhoidectomies, orthopedic cases,... Pain is a matter of life. Period.
Brief consultation with Medicine about an elderly Frenchman who is dying of TB. He is coughing up blood now, and has perforated his lung somewhere since there is air coming out under his skin and up into his neck. He is a long way from home and has no family here. He will end his days on earth here, and likely soon. In the “old days” we would pack his chest with ping pong balls to collapse the lung and shut off the bleeding. No ping pong games around here. And he is too advanced to attempt it anyway.
Discussion held about the elderly man who fell and broke his jaw. We wired it shut last Friday after he laid in another “hospital” for over a week with his mouth hanging open without food/water or care. He is now doing somewhat better with his mouth shut. But to do another operation would likely kill him. If he learns to drink he may live.
We finally started on the last case of the day (which was slated for 10am) around 2. Simplice did a great job. Fun to see him making progress, and he wants to learn. I left with the Junior resident who offered to let me drive “my” old Suzuki which I first used over 9 years ago. Some things never change.
As I stepped out of the car he reminded me that I had walked him through his very first hernia surgery. He was still thankful, and had remembered our working together. It struck me that we never know, really, when God has used us to have an impact in someone’s life.
Over the course of this day I wondered what difference do we make?
Two ladies dying - one of sepsis, the other of AIDS.
A baby survives, and her mom made it through the C-section.
Little children walking again, and a little one using her hand.
I wonder what heaven will be like.
Because this life on earth often reminds me we are not made for this world. We all know it - somewhere deep down inside - we all know it. Some admit it.
I am thankful to know Jesus who made it possible to live with purpose and in reality - seeing beyond the frail vessels which hold our spirits. To be a part of His purpose even if we can’t see it.
But sometimes it takes someone like Fabruce to make a comment about learning to repair a hernia a long time ago... and I’m reminded that God is doing things outside our realm of thinking. For that I’m glad.
