This post has been completed in the relative peace of a conference in Addis. I’ve been working on this little project for a few weeks now. It is very challenging to communicate about life here because it is so hard to figure how where to start. So I’ve decided to be a little more exhaustive, and give a lot of information about a discrete period of time. Though no one may believe it, there are actually quite a few things left out; but I’ve tried to give a better feel of the pace.
As I read back over it, I am a little depressed at how busy and medical it sounds, and how little the Christian ministry seems to take central stage. But I think that actually gives a more accurate picture of the challenges here. There are so many things demanding your attention that it is a constant struggle to go about the important work of sharing the good news in the midst of the urgent work of medicine. This narrative starts almost three weeks ago after we spent a weekend pursuing strategic planning for the hospital. This included about eight hours of meetings on Saturday and another few hours on Sunday.
I’ll warn you. This is long, even by my standards (18 page Word document). I will also warn you that this is pretty medical. It’s not unlike what one surgeon would share with colleagues while sitting in the surgery lounge. I apologize if much of it doesn’t make much sense. But if you’re interested in what-in-the-world medical missions is like, here you go…
November 18, Sunday
On Sunday evening I got a call from the on-call resident and we operated on a guy with a huge incarcerated groin hernia. Excuse the imagery, but his scrotum was the size of a small pumpkin. It was huge because of the loops and loops of bowel that had fallen out of the abdomen through the abnormal hole. Unfortunately, the bowel had been strangled of its blood flow. He ended up having nearly half of his small bowel dead and it required an extensive resection. We finished in time so that I was able to join the community for our home church service. It was a good time together.
November 19, Monday
The next day on rounds, we talked with the patient from Sunday about how close to dying he came and we talked with him about Jesus. He wanted to hear more, so we split up the team, leaving one of the residents to talk further with him while we continued seeing patients. He put his faith in Jesus that morning.
I couldn’t sleep Sunday night out of anxiety over a big operation on Monday. The patient is a woman with tuberculosis of the spine and a collapsed vertebral body, with weakness of both legs. I had to expose the front part of her spine, which involved opening her lower chest and detaching her diaphragm from the back of her body to find the affected area. I have never done or seen this before, but I was armed with advice from two of my previous partners from Dallas, Drs. Mike Foreman and Matt Lovitt. I had also done a literature search for additional intraoperative advice. We spent nearly the whole day in this operation. Bjarte Andersen, a visiting Norwegian general surgeon, helped with most of the procedure. It was his last day in Soddo and I was thankful for the help. The case went well (I think) and she is recovering well. The anatomy was pretty well jacked by the tuberculous process. Her spine was encased in an inflammatory abscess that obscured everything. On a good note, it has pushed her aorta (very large, scary, main artery to the body from the heart) away from the spine. Once we broke into the abscess cavity, the bones were already pretty well exposed above the collapsed level. We had a dicey hour pulling the diaphragm down and trying to expose the affected level and just below it. All of it was foreign territory and there was the constant anxiety of severing a necessary artery to her spinal cord, which would have left her permanently paralyzed. By God’s grace, we were able to get the thing exposed. I then worked with a visiting orthopedic surgeon, Alan Johnson, as he removed the collapsed vertebra and fashioned the bones above and below it to accept a reconstructive graft.
We don’t have the proper hardware, so he harvested her fibula (the smaller bone running outside the shin bone). He carefully cut it to size and we were able to wedge two struts in, with Alan slipping it into the two fashioned cavities in the bones above and below while I flexed her very unstable spine by pushing from her back. The whole time, we were both rather marveling at what-in-the-heck we were doing, understanding we were in way over our heads. In the end, it looked pretty good and seemed quite stable. After a meeting of the ignorant minds, we decided on a drainage scheme and got everything closed. As of right now, she is doing well and all her drains are out. The orthopods took her back to the OR and put a body cast on her. She is relatively stable regarding up and down movement of the spine, but very unstable regarding rotation. Praise God, she seems to be moving her legs much better than before the operation. This just might work. Now begins the slow and difficult process of building her nutrition and strength. She hasn’t walked in about eight months.
While Alan was harvesting the fibula, I took a quick break to eat some lunch and was promptly pulled into the clinic to see patients. I only had a little time before I needed to get back to the OR, so I felt the pull in two directions. Unfortunately, most of the patients were a little more complicated than the time I had to give. There was a young man with a large mass involving the right half of his jawbone. It looked like a benign tumor called an ameloblastoma. This is not something for which I was trained, but I have assisted a visiting plastic surgeon do one of these in the past. Though with trepidation, I felt we had a reasonable chance of helping him and we decided to admit him for surgery. Then there was another young man, about 24 years of age, who had a hole on the underside of his penis through which he was passing urine instead of the normal opening. Apparently he had received a circumcision five years prior and he had started leaking urine from the wound less than a month later. He had what is called a urethrocutaneous fistula, where there is an abnormal communication between the tube that carries the urine and the skin. I have never seen this before, much less treated it. I felt the weight of needing to get back to the OR and still needing to make a decision with this young man. He was ready for surgery and had travelled a long way to get here. I have gained a little experience at treating strictures of the urethra and had some experience at urethral repair. So I postulated that I could dissect out the urethra under the fistula and remove the affected segment. Then I could sew the two ends back together. So, yeah, I’ll help him. Admit him for tomorrow. There was a terrible cancer of the rectum that had filled the liver. So we talked with him about the Lord and wrote for pain medications. There was nothing we could offer him surgically. There was a three-year-old boy who had enlarged tonsils and what appeared to be a polyp in his right nostril. He had been brought to the hospital about a month ago when we had the chief of ENT at Johns Hopkins University, Wayne Koch, visiting us. We had offered surgery at that time, but the father had refused with a belligerent attitude I didn’t understand. Apparently they were ready for surgery now. The kid looked OK, no different than a month ago when the ENT surgeon had felt he would probably do well with or without surgery. I explained that I was already full for the following day and that I would have to be involved in administrative duties on Wednesday. Therefore, I would be able to do the operation on Thursday, in three days. They live in Soddo, so it shouldn’t be a problem for them to come for admission on Wednesday. The father immediately got aggressive, demanding to have the operation the next day. I confess that my own irritation began to flare and I reminded him that he was offered an operation a month ago, when I had help, and he had refused. Now I was on my own and doing the best I could. And the earliest I could operate was Thursday. He got more angry and stormed out of the clinic, citing that he would go to Addis. I had to shake my head at that, because there is no way in creation he was going to get an operation in less than three days in Addis. (Apparently he knew that too and later, when his temper tantrum didn’t work, they came back on Wednesday for admission for surgery…) There was another guy who had a non-functional kidney due to obstruction that was causing pain. He needed to have his kidney removed and was ready for admission. OK, we’ll try to do him tomorrow. Then, as I was about to leave for the OR, the resident told me that there was another patient with another ameloblastoma of the jawbone. But she was out getting a laboratory test. This one was apparently even bigger. Great.
Following the operation, we checked up on another potential challenging thoracic case in our ICU. This was a young woman with a terrible infection of her chest. We had put in drainage tubes, but her lung was not re-expanding to fill her chest. It looked like she needed an operation to fix the problem, but she was not yet willing. We put it on hold, with plans to talk further with her in the future.
By the time I got home on Monday evening, I was pretty worn out, especially given the lack of sleep the night before. Monday night was “DFN” at the Gray household, or “dysfunctional family night”. We try to host the single off-campus ex-pats once a week for dinner. So a Peace Corps worker who is living in Soddo and two young ladies who are spending a year teaching at a Catholic school in town visited us for dinner. Sophie, a nurse has been in Soddo for several years and doing rural clinic work, also joined us. It is always interesting conversation and we enjoy doing it. But I slipped out pretty early to crash out.
November 20, Tuesday
On Tuesday morning rounds, the orthopedic service offered me a gift in the form of a newly diagnosed diabetic patient who needed a toe amputation. These are always challenging wounds and it’s been a while since I’ve taken care of such a patient. Unfortunately the guy was kind a VIP sort in town, so it had a political dimension to it as well. The man with the urinary fistula was ready to go, but when we rounded on the young man with the jaw tumor, his blood pressure was really high. It was difficult to discern if this was real or just an artifact of the beat up, crummy blood pressure cuff they were using on the ward. So we decided to go for broke and see what anesthesia says. They typically err on the side of canceling the operation, so if they give it a “thumbs up” it should be OK.
I ran up to the library and revised my knowledge of diabetic toe amputations and we took off the guy’s toe. Meanwhile, the jaw tumor’s blood pressure was indeed sky-high though we had no idea why. We cancelled the case and talked with the medical service about an evaluation. This left a little to be desired since our internist had unexpectedly left the hospital for a teaching position in north Ethiopia the week prior. With the urethral fistula case looming, I finally sat down with some textbooks to figure out a game plan. The first few books I looked at had nothing about urethrocutaneous fistulae. So I went to the urethral stricture sections and read about putting the urethra back together. To my dismay, I read that it was generally contraindicated to remove a segment of the urethra from the penile part and sew the ends back together. So my very tentative plan became no plan. With a sigh, I ran up to the library and began searching through our latest edition of the four-volume Campbell’s urology textbook. I found a half-page description on this problem and read about a so-called “trap door” repair that involved swinging several little flaps around to fix the problem. This was sounding more and more out of my pay grade. So I brought the guy back to the OR and examined him one more time. Yep, it was going to be challenging. I had an honest discussion with him about my complete ignorance of his problem and that I had literally just read about how to fix it. I explained that he was completely stable, only peeing from a slightly different location, and that this could absolutely wait. I anticipated that we would have a urologist come for a visit sometime in the next year, and I would be happy to keep his phone number to call him in when experienced help was available. The anesthetists translated for me and then gave me the patient’s response. “No, thanks, doctor. I want you to go ahead and do your best, and pray.”
So I took a deep breath and we got ready to move forward. While they were giving the guy a spinal anesthetic, I ran around trying to gather all my weapons to win the battle: had the nurses open up the plastic surgery instrument set, got materials to place a tube in his bladder through his abdomen at the end of the operation, put on my magnification loops (one-pound horn-rimmed glasses with little telescopes sticking out from the bottom of the lenses), and went out to scrub my hands.
Meanwhile, a parallel drama was playing out. The medical service had been taking care of a Chinese national who was a bigwig in one of the construction companies working in the area. He had a pretty bad pneumonia and was not oxygenating very well. The decision had been made to transfer him to Addis and a helicopter had landed in the field besides the operating building. Jeremy Gabrysch, our emergency medicine doctor, was going to escort the patient to Addis. As I was scrubbing, I heard the rotors spin up as the helicopter readied to take off. I looked out the window and saw dozens of onlookers spread around the periphery of the field, as this is always a big event in Soddo. Maybe twenty people were just outside the operating building. I was just finishing my scrub when the helicopter took off, taking a route that would bring it right over the OR with my man with the incredible trust.
I watched with a chuckle as the twenty people outside the OR scattered like troops under mortar fire. The downwash of the helicopter kicked up a terrific wall of dirt and, as it approached, it looked like a scene from a movie with a desert dust storm. I kicked open the doors to the OR just in time to see the dirt wall come blasting through the open windows right beside our sterile equipment and completely contaminate all of the instruments. My chuckles quickly disappeared, and I left to gathered new weapons. Now I got to do the operation with big, clunky instruments and dull scissors. Sweet.
With a heartfelt prayer, we finally got started on the operation and we had the book open on the counter beside the operating table. I had to wonder what this guy was thinking as he lay there with a spinal anesthetic, completely awake, and watched me walk back and forth between his groin and a textbook while carrying a knife. God was helping us, though, and I think we did OK. It was a “textbook” case (ha-ha) and it did, indeed, look like the pictures when we were finished. He has since left the hospital and I am still awaiting his return to see if the repair held up.
I went to bed early that night, still kind of worn out. At about midnight that night, I awoke to someone pounding on the door. The on-call resident was there to inform me that he had a patient on the table in the operating room that had been stabbed. Apparently the phone network was not working, so he had to run over to our house to let me know. I quickly dressed, said a word of prayer, and hustled over to the OR. The anesthetist was in the process of putting the young man to sleep and I surveyed the sight of half his small bowel sitting on his abdomen. There were some blood-soaked straps of cloth wrapped around his torso that had tried in vain to hold his intestines inside. The resident informed me that he was a 15 year-old boy who had tried to prevent his drunk, divorced father from attacking his sister. The man had turned on him and stabbed him in the abdomen. This had occurred about four hours prior.
There was a hole in the intestine that was bleeding so I put a clamp on it while we prepped the abdomen as best we could and put on the drapes. We opened the abdomen and pulled the intestines back inside. There was no sign of active bleeding, but I could see a hematoma in the back part of the abdomen called the retroperitoneum. Since he was stable at this point, I quickly repaired the injured bowel and we evaluated the rest of the situation. The blood supply to the bowels travel to the intestine via an apron-like structure called the mesentery. The blood vessels carry blood to the intestines from the big vessels in the back of the abdomen. He had a hole about halfway down his mesentery, but it was only on one side of the mesentery. Down below, he had a lot of blood contained in the back part of his abdomen around his great vessels and extending over toward his right kidney. All of this is scary, scary territory. But we had to expose it and deal with what was injured.
So we mobilized his bowels to the upper part of his abdomen to expose the area. As we did so, lots of dark blood began welling up at us. From this point on, I honestly lost track of time. It was an absolute beast to handle, but we finally identified that the main vein in his lower body was injured, the inferior vena cava. And not just injured, the vein had been completely cut in two. By God’s grace, we finally found the two ends and I was able to sew them off, leaving the vein disrupted. It appears that the knife had gone in the left side of his abdomen, had punched a side hole in the bowel, had entered his mesentery about halfway down, had travelled inside the mesentery to the right in the back of his abdomen, had cut his inferior vena cava in half, had bounced off his spinal column, and had then gauged a big slash in the muscles travelling beside his spine and finally stopped at his ribs in the back.
This is consistent with my experience of stab injuries here. The blade typically stops when either (a) the assailant runs out of blade (which seems to be rare) or (b) it hits something bony enough to halt its progression. This is quite different than many of the stab wounds I saw back in Texas, which tended to be shallow and wimpy. I’m not sure why this is different. But my hypothesis is that Africans understand how much force it takes to plunge a blade into a person. Unlike most Americans, most Africans have experience slaughtering farm animals and they know how tough the skin and body is. Perhaps, I don’t know.
At this point, we put in temporary packs and temporarily closed the boy’s abdomen to get him to the recovery room to try and resuscitate him. Amazingly for our setting, he got four units of blood during the operation. Unfortunately, he probably needed more like twenty. In the recovery room, his pupils were big and not responding to light. But his heart rate and blood pressure looked pretty good, so we prayed.
At that point, the resident showed me two other admissions to the ICU. One was a one-month-old baby with a bowel obstruction. Her abdomen was distended and she had not passed anything from below in several days. She had been vomiting green, bilious material. By the textbook, this is a surgical emergency. The other patient was a 40-ish year-old man also with a bowel obstruction. He had been distended for several days and was also not passing anything from below. He seemed to be in more pain the baby, though. X-rays for both patients were consistent with bowel obstructions.
This highlights one of the challenges of surgery in an environment so limited in resources. They both needed an operation, and soon. But as hard as both operations might be, the limited resources further complicated the situation at night. There is only a skeleton crew in the operating room building. There simply isn’t much help. I had already had a heck of a struggle with the vena cava injury, at one point having to leave the resident holding pressure on the bleeding vessel while I kicked open the OR door to yell for help to get the suture I needed. The anesthesia situation had me particularly scared regarding the baby. Operating on a one-month-old is dicey at any time of the day because of the anesthesia risk. But I was not very enthusiastic about tackling it in the middle of the night with absolutely no backup for the anesthetist. It was about 2:30 in the morning at this point, so I prayed for protection and decided to delay the baby until first case in the morning. I would do the older man now.
We took the guy back and put him to sleep. After opening the abdomen, I waded through the distended bowel and reached down into the pelvis. My already exhausted spirit deflated further when I felt a tennis-ball-sized rectal cancer that was blocking the bowel. It had a loop of small bowel stuck to it and involved in the tumor that was blocking his small intestine. Additionally, he had a loop of sigmoid colon stuck to it as well. Sigh… I had been praying for a quick solution, but this was going to be a several-hour cancer whack. We started with the small bowel and disconnected the bowel before and after the tumor, leaving a sewn-off segment of disconnected bowel attached to it. We then sewed the uninvolved bowel back together. At this point, the OR door opened and one of the OB nurses informed the on-call resident that they had a lady who needed a C-section – she had obstructed labor and the baby was in danger. I asked the anesthetist if they could call anyone else in, and he informed me that they couldn’t. We had one team. And they couldn’t start the C-section until I finished this case. In frustration, I asked the nurse to call Mark Karnes, our obstetrician-gynecologist, to the OR.
While waiting for Mark, I tried to hustle along. I began mobilizing the tumor, trying to figure out the fastest solution that would work. As I dissected, I found the ureter and began tracing it out to protect it (the ureter carries urine from the kidney to the bladder). To my continued dismay, I found that it too went into and out of the tumor. This was going to take several hours to sort out. By then, Mark arrived and he confirmed that the baby’s life was in danger. They needed to do the C-section soon.
I paused to pray and think. Finally I decided to bail out. We packed the guy’s abdomen and, again, temporarily closed. It was the only solution I could think of to save the baby’s life and I felt I could delay this without too much problem. Besides, I was exhausted and could use a brief nap before starting the next day. I would start with the infant bowel obstruction and then finish this guy’s operation. I was supposed to be involved in management meetings on Wednesday, but… oh, well. I walked home at 4:30 and took a quick nap.
November 21, Wednesday
A couple hours later, we rounded on the patients to get the day going. The kid with the vena cava injury looked terrible. His heart rate and blood pressure were OK, but his pupils were both fixed and dilated, consistent with a non-functioning brain. And he had not woken up from surgery at all. His breathing tube was still in place and he wasn’t doing anything on his own. The ventilator machine did all of his breathing for him. The guy with the jaw tumor still had a high blood pressure but the medicine team thought they saw a mass in his adrenal gland on ultrasound. This could be cause, albeit pretty rare, of his high blood pressure. Thankfully we had a visiting Norwegian radiologist who was pretty slick with ultrasound. So we sent him for a repeat ultrasound (turns out it was normal)
We got the baby into the operating room and got started. I did the operation with our senior-most resident (nearing the end of his second year) and he did a good job. We opened the belly and I wanted to cry when I saw a bunch of dead bowel. She had what is called a midgut volvulus, where the bowel had spun on its mesentery (blood supply). In addition to blocking the flow of stool, it had strangled itself as well. It turns out a little over half the small bowel was dead, along with the first part of the colon. We removed the dead bowel and sewed the ends back together. The big problem with this situation is whether or not there are enough bowels remaining to give adequate nutrient absorption for life. It looked like she might be OK, but it was close. So we prayed. I didn’t know if I had made the wrong decision in not operating on her in the middle of the night. I don’t know.
Somewhere during the operation, the kid from last night with the vena cava injury died.
After that, we got started on the guy from the previous night. It was, indeed, a beast of an operation. But we were able to get the tumor out. With a little work, I was also able to free the ureter from the tumor and I don’t think it was actually involved. I did not feel it would be safe to sew his colon and rectum back together, so we planned to bring up a colostomy to divert his stool. We were just about to start bringing up the colostomy when one of the nurses told me that OB needed me in the next room.
I went across the hall and found that Mark was operating on a poor girl who had come in with a ruptured uterus from long obstructed labor. It appeared that her bladder had been blown to bits along with the uterus. I told him I needed to tidy up in the other case and that I would be back. So I returned to our operation and got the case to the point where the resident could finish the case. Then I scrubbed into the case with Mark. It was a terrible situation but they had done a good job of sorting out the problem. We put her bladder back together as best we could. Thankfully, it seemed that her ureters were OK. She would need a long time of bladder drainage with a catheter and we prayed that the repair would hole without forming a fistula.
After finishing the rest of the day, I went to bed very early.
November 22, Thursday
Thursday morning rounds revealed that the baby with the bowel resection looked pretty bad. I didn’t know if more of the bowel had died in the night. We prayed fervently at the bedside and continued the IV fluids and antibiotics.
Mr. Surly and his three-year-old son with big tonsils had indeed been admitted for surgery, despite his plans to head to Addis. As this is not an operation in which I have much experience, I was a little nervous, especially with the social situation around it. To further complicate the mix, the boy clearly had a cold, with snot pouring down his face. Sigh… I had no strong desire to tell the guy that I was going to cancel surgery. So I decided to turf to anesthesia. I would just let them be the bad guys. “Alright! We’ll get it done today!” I said with enthusiasm.
The ultrasound report on the guy with the jaw tumor was now available: normal. His blood pressure was still high. So we started talking with him about the need to send him home for a few weeks to get his blood pressure tuned up. While we were talking, he started angrily putting his shoes on and, scowling at us, pushed past us to walk out into the hall. The resident who was talking to him sort of trailed off in mid-sentence. Finally, he came storming back in. At this point, I had no more energy for such theatrics and just started examining the next patient in the bed beside him. After we finished with that patient, the other guy had calmed down enough that we could talk with him. We were able to convince him of the prudence of getting this under control before wading into a big operation
We later saw the guy who needed his kidney removed. His blood pressure looked fine, but everyone in his family refused to donate a unit of blood for the operation. We have made it standard to require a unit of blood for all major cases like this. The man was anemic anyway and might need it with such an operation. Alas, no one was willing to give. Finally, in frustration, I decided I would just go ahead and do it. The poor guy needed it and I though I could do it with minimal blood loss. So we put him on the schedule.
In the OR that morning, anesthesia came to me and gravely informed me that the boy for tonsillectomy had a bad cold. They didn’t think it was safe to proceed. Huh? What? Well, call the family and let’s talk with them. We talked with the family and anesthesia went to lengths to explain how unsafe this was to do an airway operation on a child with an active cold. I kind of shrugged with my hands held up, and the family agreed to postpone surgery until the cold had gone away. I love it when a plan comes together.
But I guess anesthesia was on a roll. They then came to me after checking out the nephrectomy case (kidney removal) and informed me that they wouldn’t proceed without blood being available. We threw in the towel and canceled it as well. Frankly, I could use a light day. In clinic, we saw a thirty-year-old woman who was four months pregnant with an advanced breast cancer. We admitted her for surgery. We saw another lady with a stone stuck in her ureter. We admitted her for surgery too. Finally, I left the residents with the remaining clinic and checked in periodically while getting some other work down.
At about noon, I was called by chief resident who informed me that the other, bigger jaw tumor case had apparently been admitted the night before to another ward and we had missed her on rounds… I told him that I didn’t have the moral courage to attempt that operation on this day. Get her ready for surgery for the morning, on Friday.
November 23, Friday
On morning rounds, Friday morning, the patients looked good. God had granted our prayers and the little girl with the volvulus was doing much better. She was breastfeeding well, passing stool, and her abdomen looked great. The guy with the rectal cancer also looked good. We talked with both patients (baby’s mother) about Jesus and prayed with them. The girl with the ameloblastoma of the jaw looked intimidating. Having only helped do one of these operations before, it was scary looking at the big thing. It would require removing the right half of her jaw bone with it and reconstructing with a metal bar. Her family had donated a unit of blood and we put her on the schedule. The other woman with the ureteric stone was also ready for surgery. Additionally, we had a woman with an appendix abscess that needed an operation and a few smaller cases.
We started with the ureteral stone case and it went well. I then switched rooms to help another resident with the appendix abscess. He did a great job and that went well too. Meanwhile, they got the woman with the jaw tumor into the first room. This case torpedoed the rest of the day and we had to cancel the breast cancer case, though the other residents were able to finish the remaining smaller cases on their own.
So, this is a benign tumor that is derived from the cells that form the teeth. However it is locally aggressive and continues to grow, destroying nearby tissues. This girl’s tumor involved the entire right side of her lower jaw. There was virtually no bone left on x-ray and the teeth were just floating in it. Her tongue had been shoved off to the left side. To remove it, we split her lower lip in the middle and basically lifted her cheek off the tumor, extending the incision on the outside along the bottom of her jaw toward her ear and on the inside along the mucosa beside her teeth. We eventually used a saw to divide the mandible to the left of the midline, taking care to get some normal bone. We then divided the mandible in the back, again taking care to get normal bone. We were then able to remove the thing by dividing its attachments to everything beneath it. I have to confess, I got pretty nervous during the resection when things got a bit bloody. This is one of the problems of doing surgery from a textbook. There are times when the bridges are already burned and you have no choice but to push forward. But you really wonder if you’ve made a huge mistake. But we prayed and we kept going.
There is another general rule in surgery that the bleeding usually stops once the thing is out. This proved true again in our case. After removing the tumor, the operative field dried up quite nicely. Now we just had to put everything back together again. We don’t have any more real mandibular reconstruction bars – we had a few, but they were used on other cases. So Duane Anderson, our orthopedic surgeon, graciously joined us and helped us bend a small fragment plate to create a homemade reconstruction bar. Once we thought we had it in the right shape, we screwed it into place on both ends, recreating a functional lower jaw. We then repaired the muscles around the bar, giving something solid for the muscles controlling the tongue to pull against. Finally, we put her cheek, floor of mouth, and lip back together. We were very thankful for God’s help. It took all day, but He helped us get it done.
Afterwards we went and talked with the patient with breast cancer and her family. As it was Friday, since we couldn’t do the operation that day, it would have to wait until Monday. This is always a difficult situation financially for our patients, and she was no exception. But we promised them that we would not charge them for the extra days in the hospital.
We also went by to have another discussion with the woman in the ICU who needed a chest operation for her infection. When she had arrived at the hospital, she was in a bad way. She couldn’t breath and the entire lower half of her body was swollen. The fluid had actually pushed the middle of her chest, including her heart, off to the left of its normal place. It was causing dysfunction of both her remaining lung and her heart function. Now that the tubes had successfully drained her chest, she was feeling much better and was not interested in an operation. However, we explained to her that she would likely get sick again once we pulled the drains out. She needed an operation to fully recover. She was now willing to have an operation and we made plans to tackle it on Monday.
November 24 and 25, Saturday and Sunday
The weekend was blissfully and blessedly quiet. We rounded as a team on Saturday morning and held our weekly PAACS Bible study. All of the patients were thankfully doing well, and the post-operative patients seemed to be recovering well. Afterwards there were a few meetings regarding the plans for our upcoming CT machine and about our church routines are Sunday morning. I’ll spare everyone and not go into all of that. But the rest of the weekend was a blessed time with family. It was restful, but it sure felt like we could have used a lot more time.
November 26, Monday
It was a great weekend, but I still felt awfully weary and weak as the new week started. We took the young woman to the operating room with the plan to open her right chest and try to remove an inflammatory rind that was encasing her lung. She had been sick for a long time with tuberculosis and we had previously drained her chest, which was full of pus. The pus had collapsed her lung and it was now encased in a thick rind that would not allow it to re-expand even though we had now drained the fluid. This kind of operation always fills me with trepidation because of the combination of difficulty, potential for blood loss and complications, and my own inexperience. When we opened her up, I was taken aback by how developed the process had become. It honestly looked like there simply was no lung. Instead of the ton of garbage that we normally find in this situation, it was a smoothly lined cavity with very little debris. Unfortunately, though, we couldn’t find a lung. This is a very disconcerting finding for an inexperienced thoracic surgeon to find upon opening a chest. It honestly just looked like the heart pounding down there, albeit on the wrong side of the chest. I was confused enough that we even pulled out an ultrasound to look. Yes, indeed, there was collapsed lung under that leather. I took a knife and tried gain an edge to start peeling the tenacious stuff off. I was soon met with a small geyser of venous blood that increased my heart rate more than hers. So I sewed that off and tried another place… to be met with the same result. So I sewed that one off too. Part of surgery is knowing when you are out of your pay grade, and I decided to stop. She needed someone more experienced. So we drained her and closed. We did several more operations, including the difficult breast cancer case, and finished the day worn out.
Over the weekend we had admitted an elderly, malnourished man who had pus in his abdomen. We had offered him an operation but the family (and the patient) had refused. Overall, I’m not opposed to this. There are times when people have lived a good life and now have a huge problem, and they just want to be made comfortable. I don’t think we need to pursue heroics on everyone. Sometimes it’s OK to let the process take its course and make the patient comfortable with palliative care. But this case was more complicated and frustrating. They didn’t really want palliative care; they wanted him to get better. But they didn’t want to listen to anyone knowledgeable either. I was informed that he was too weak for an operation and they wanted medicine for now. I tried to explain that medicine wasn’t going to work and, weak or not, if he wanted to live, he needed an operation… but to no avail. Frankly, my reserves were and are low. So, with more than a little disgust, I let them have it their way and went to bed. The following morning, still in the weekend, we discussed the situation again and their stance was the same. I tried to make it clear that we were making a choice for palliation, not cure; but I’m not sure they really bought that.
Anyway, on Monday they decided it was time for an operation. Having seen this scenario play out many times now in this country, I was pretty irritated. Of course, by the time all of the logistics were arranged, it was getting into the evening. Knowing I had another beating of a day coming on Tuesday, I didn’t feel inclined to rush this off to the OR as an emergency. So we made plans to do it in the morning.
This is one of many examples of the challenges of medical ethics in the resource-limited setting. Sometimes “ideal” simply isn’t an option and you have to choose the least crummy road. Night cases are always fraught with the potential for disaster due to the lack of help. And the lack of sleep one night has real consequences for the following days and nights. So you always have to weigh the various ups and downs for any option and try to pick the best road.
Later that evening, the on-call resident called me about another patient with a bowel obstruction. Thankfully this one was straightforward and we were able to handle it quickly and easily. She too had a volvulus, but the bowel was healthy, albeit distended. We were able to return everything back to position and get her out of the OR. We see this fairly frequently and, like this case, the bowel is often OK. It is typically a very thin patient with heavy, fluid filled bowels. I don’t understand the situation fully, but I think it is related to very little fat in the abdomen.
November 27, Tuesday
On rounds Tuesday morning, it was evident that we had a lot of work to do. In addition to the old man with pus in his belly, we had several other challenges. I had a young man whose right kidney was full of huge stones and it was barely functioning. I’ve been emailing lots of urologists about this kind of problem because I’m seeing more and more of it. Unfortunately I’m working in such a primitive environment that almost no one has any experience in tackling these problems with the capabilities available to me. I need to build a relationship with a 90 year-old urologist…. I even had the disheartening response from one urologist friend who responded, “Paul, you’ve done more of these open stone cases than me. You’re more of an expert than me.” Sweet. Anyway, the plan was to take this man to the operating room and expose his kidney. We would then clamp the blood flow in and out of it and cool it down with ice slush made from saline. I had placed a bag in our freezer at the house the night before. I would then split the kidney open along its spine, extract the stones, and put the kidney back together. Piece of cake.
We also had a patient who needed her gallbladder removed. Unlike the volvulus patient from the previous night, she was not thin. In fact, she was quite large, so large that it would really help if we could get it out laparoscopically, using a camera and small incisions. Another patient had been admitted during the wee hours of the night that needed his appendix removed. And we had two patients who needed what is referred to at SCH as “anal work”. (That’s how it is listed on the surgery price list.) They both had a draining fistula (connection between the rectum and the skin around the anus) that needed care.
So we huddled around the schedule board and worked on a game plan. We prayed and got started. We tackled the old man with abdominal pus first. After opening the abdomen, it became evident that this was going to be very, very difficult. The infection had been brewing for so long, the inflammation was intense. We were finally able to pop into several pus pockets and drain them. The bowel was stuck everywhere. As I was exploring and freeing up bowel, it became evident that there were some holes in the bowel. Though I couldn’t be sure, I was fairly confident that that the holes represented the original problem and that I hadn’t caused them in breaking up the adhesions.
The problem at this point was how on earth I was going to handle the problem. It was terrible. Intestinal contents were leaking out and all of the bowels around the hole were completely socked in. This was the closest to a breakdown as I have had in a while. Staring at this disaster while knowing everything else on the plate that day was a look into the abyss. I had to just stop the operation for a few minutes and stand there with my eyes closed. At first, though it might have looked like prayer, it was purely an attempt to not completely lose it. I was ready to just give up on the operation, cancel all remaining operations, and leave Soddo. I finally just spent a moment in actual prayer and begged God to give me the strength to continue. My temper has been awfully short lately in the OR, and I suspect the OR staff were expecting me to lose it at this point. I finished the prayer and we started working, trying to sort out the mess. Slowly, we started to gain ground and we started to get the intestines freed up.
Finally, I caught a glimpse of tissue that confirmed I was at the last part of the small intestine. This was most likely a typhoid perforation. We were able to free up enough intestine to remove the affected part and sew off the downstream end. We were then able to bring up the upstream end as an ostomy, allowing the intestinal content to empty into a bag onto his abdominal wall. There was no way he was going to heal if we tried to sew the bowel together at that operation. This would hopefully allow him time to strengthen up and recover. We could then go back in a few months and try to put him back together. I called in our chief resident and asked him to bring up the ostomy while I started the laparoscopic gallbladder removal next door.
Laparoscopic surgery in Soddo is a sustained beating. We had an attending surgeon when I was training that did a lot of advanced laparoscopic surgery. Though he will remain officially unnamed, we affectionately referred to him as “Yosemite Sam.” Like his animated counterpart, he had a fiery temper and, when equipment wouldn’t work during a case, he would literally stamp his feet while yelling for someone to come fix it. Well, in Soddo, “someone” is you. It is better now that I have learned some of the ropes. But it is still a whipping. I start by getting all of the instruments out, trying to anticipate every possible need beforehand. Because once I get started and am wearing sterile gloves and gown, it is terribly difficult to get something else. Next, I get all the equipment plugged in to the appropriate plugs, making sure that all voltages are correct (jack that up and it’s game over). Next, I open up the valves on the CO2 tank that will supply the gas that inflates the abdomen while I work. If there are any leaks at any of the nozzles, I have to fix that first. Next, I turn on the gas insufflation machine and make sure it is working, after which I set all the controls to where I want them, so that a nurse only has to hit the ‘start’ button when I’m ready. Then I turn on the rest of the equipment, especially the light source machine, to make sure they all work. Finally, I get the bed arranged so that I can see the one monitor and get the foot pedal in position to run the electrocautery machine during the operation to burn tissues. And… I’m ready. Off to the scrub sink.
Overall, the case went well and we succeeded with a laparoscopic operation. But it was far from smooth and took longer than I remember it taking when I was in the US. At this point, I’m no longer sure of the reasons. Having done so little laparoscopic surgery in the last four years, I’m sure my skills are degrading. But on the other hand, there’s not a whole lot of help during the operation and all of the equipment has been reused so many times it is a very duct-taped operation. Oh, well, I don’t know. But I was very thankful we didn’t have to make a big incision.
We banged out the “anal work” and then got ready to roll on the big kidney stone case. After positioning the patient on his side, we got down to the kidney by removing his 12th rib. The kidney looked very abnormal grossly, all soft and boggy with lots of palpable stones. We fully mobilized it and got control of the blood vessels. Unfortunately he had some weird veins in the back that weren’t supposed to be there (you can say that when your only experience is a book chapter). While trying to get the thing mobilized, one of these bad boys started bleeding and I had to tie it off. Then the kidney started to swell up a bit. It was looking more and more ominous to try to save the kidney. I knew he had a fully functional and normal kidney on the other side. I decided to bail out and just remove the bad one. The nephrectomy went well and I opened it up on the back table. Once we had opened the kidney up after removing it, all remaining doubts about the nephrectomy disappeared. There is no way we would have pulled that off without completely mutilating his kidney. The honest truth is I need to do one of these with a bona fide professional before trying it again.
At this point, one of the residents informed me that there was a patient in the ICU who had just been admitted and he thought the guy needed an operation. I went over and evaluated the patient with the resident. It was a young man who had crashed his motorcycle ten days before and had developed abdominal pain. He hadn’t passed anything from below in eight days and had been vomiting. Apparently he had vomited blood a few times right after the crash. Now his white blood cell count was elevated and he was definitely tender. Ultrasound of his abdomen showed free fluid, which was abnormal. We told him he needed an operation to sort out what was injured, and he agreed.
So while they got supplies ready, we headed back and operated on the kid with an abscess around his appendix. It went well and the resident again did a great job.
At about 5:30 in the evening we got started on the exploratory surgery on the guy with the motorcycle crash. We opened the belly and found a bunch of inflammatory grunge with swollen bowel. It was really socked in in the pelvis. It took a while but we were finally able to free it all up. However, we couldn’t find any specific injury. And, indeed, the inflammation, though intense, did not look like there was a hole in the bowel. I then felt in the area of his right kidney, and it was quite swollen and abnormal. Kidney injury, I wondered? Looking closer, though, we saw little yellow spots that looked like pus under the surface. Then I remember the history of vomiting blood. My heart sunk as it became more evident that he might have an injury to a very dicey part of the bowel called the duodenum. This is the first part of the bowel after the stomach and is where the bile and pancreas juice drain in. It is a notoriously dangerous place to have an injury and it is very difficult to remove.
We rotated the bowel around to expose it and it was the most difficult dissection I could remember. There was so much inflammation and infection back there. After exposing it better, I knew that I should have been looking at his duodenum. But it was just a nasty, bile-stained wad of concrete hamburger. I literally couldn’t see any bowel. I finally made a small incision on the stomach and stuck my finger into the duodenum. It was the only way I could find it. This allowed me to further dissect it out and finally I found the hole. It was huge. I got it exposed and marveled at the massive hole with mucosa blossoming out. How on earth had this guy survived for ten days?? How on earth was I going to fix this??
Duodenal injuries are something most surgeons have read about more than they have actually done. So I tried to remember how best to handle this, especially one so ugly and late. Since we’re so comfortable with textbooks here, I just scrubbed out and ran off to freshen my memory. After perusing the books, we got started. For the surgeons out there, we did a pyloric exclusion, gastrojejunostomy, placed a G-J tube down the afferent limb to internally drain the repair, and repaired the hole primarily. As we were finishing the repair, we saw the beginning of the second hole in the duodenum, a few centimeters downstream. It was very deflating, and I confess that I briefly wondered if God was punishing us for something. We fully mobilized everything and then repaired the second, similar-sized hole. Finally, we sewed some bowel onto the repairs to buttress them as a serosal patch, and placed a jejunal feeding tube. This kid needed a lot of prayer to pull through. Thankfully, he had already proven himself a hardy camper in surviving this long. So we had hope.
During the operation, someone called my mobile phone that was is in my scrub shirt pocket. So I listened to my little techno ditty while we operated until they hung up. After the case, as I was walking to the house after a long day of operating, I saw that it was my friend, Jon Pollock. I called him back and he said that he was just calling to see if I might be interested in having him come down and help a little. I couldn’t believe it. This was clearly from the Lord as I was nearing wits end. I thankfully accepted. He said he his wife was going to help with their kids and that he would be in Soddo the next day. An amazing blessing.
The rest of the week was busy, but it was so much better with Jon there. It was great to work together again. God has been so gracious with the patients. With the exception of the boy with the vena cava injury, everyone has been improving. The little baby with dead bowel recovered and looked like a champ at discharge. The woman with the jaw tumor has had persistent output through the drain we left in the wound, but she seems to be getting better (I’m seeking advice on this via another email). The young man with the duodenal injury is so far doing very well. Becca, my amazing dietitian wife, has been preparing tube feeds for him and helping him get feeds. So far the drains all look great and there is no sign yet of a leak. I am extremely paranoid about protecting the repair and I’m still not sure when I’m going to let him eat by mouth, despite his begging to do so. We have also been taking care of some burn patients and they seem to be doing better. We operated on a young woman with achalasia (abnormal condition of the esophagus where the muscle at the junction with the stomach is too tight) and she is doing well. Even the old patient with the typhoid perforation is doing better and will probably go home soon.
In the midst of all this, God has also answered prayer in several other areas of challenge, including issues with the residency’s accreditation, construction projects, and medical leadership at the hospital. I’m not sure why I’m sharing so much, but I wanted to better communicate how crazy this place is and how desperate we are for God’s provision. The deck is so frankly stacked against us that our only hope is that God pulls it off. He has to, or it all fails. Please keep praying for PAACS and for us. Please pray that we will take good care of the patients, that they would heal, and that we would not fail to share the gospel in the midst of all the chaos.
A few final updates: I’m writing this while I’m supposed to be paying attention at the COSECSA conference. I guess I’m busted! The guy with the duodenal injury is doing fantastic. He is now eating by mouth and there is no evidence of a leak thus far. We’re not out of the woods yet. But I praise God for the hopeful report.
I can also give a wonderful report on the woman with the encased lung from tuberculosis. It turns out that a gracious family in the US has adopted one of her children and they are willing to finance her care. Jon and I brainstormed about options and felt her best chance would be to get her to Nairobi. Then Jon had the idea of getting her to Tenwek Hospital in Kenya. Tenwek is another PAACS hospital whose program director is Russ White, a cardiothoracic trained surgeon. It would be great if he could operate on her. Then Jon had the even better idea of having Russ do the operation in Ethiopia. He was coming to Ethiopia for the COSECSA conference, so maybe he could do it at Myungsung Christian Medical Center? God quickly lined up several divergent needs and made it happen. Myungsung, including their CEO, Dr. Chul-Soo Kim, was incredibly helpful. Jon Pollock and Chi Chung did a great job of getting everything lined up. We were able to round up three units of blood in Soddo, including a unit donated by our obstetrician, Stephanie Hail, who knows the sponsoring family. I drove up to Addis two days ago with a full truck. One of our PAACS residents is presenting at the conference, so he and his wife were passengers. Additionally, we had the patient and her father packed in as well. She is a tough player and handled the trip swimmingly. Russ was willing to do the operation, and he and Jon did the operation this morning, along with our chief resident, Daniel Gidabo.
I’ll take a brief moment to brag shamefully on my colleague, Russ White. Russ is a fantastic surgeon. I think I drooled a little while watching him operate. The guy is a superstar, and was able to get all of the peal out beautifully. The lung inflated nicely and looked great. It was a great blessing to have the patient there, at that time, at that institution, with that surgeon. I thank God. Myungsung is the best place for her to be and we pray that her post-operative care will go smoothly.
Life here seems to go on and on and on. And, it seems, so does my writing. I’ll stop here. Thanks and God bless.