Last week was the annual general meeting of the Surgical Society of Ethiopia (SSE). It was a significant milestone for PAACS and God blessed us with encouraging evidence of how far He has brought us. Three years ago PAACS leadership put the Soddo program on probation because of significant educational problems. The residents weren’t operating enough. They were failing examinations. There were big problems. The PAACS team attended the SSE meeting in 2008 and the reception was anything but warm. It was before my arrival, so I only have second-hand testimony. But the PAACS residents at that time were openly told that they were fools for training with PAACS; that their training would be worthless. Reportedly one of the main topics of the meeting was the shortage of surgeons in Ethiopia and the need to address this issue. Despite this need, PAACS was viewed with derision.

Three years later, much has changed. The program is no longer on probation and, from an internal standpoint, is doing much better. The residents are performing an adequate number of operations. Last year, all Soddo PAACS residents passed their yearly PAACS exam. Externally, we have been granted accreditation by the Ministry of Education as a general surgery training institution. We have been accepted by the Ministry of Health and our graduates are being granted licenses as surgical specialists. New surgeons have joined the teaching staff and more are on the way. The College of Surgeons of East, Central, and Southern Africa (COSECSA) has granted us three years’ accreditation for general surgery training. We are establishing a partnership with Myungsung Christian Medical Center in Addis Ababa to double the size of the training program. God has done some wonderful things.

We have been openly invited by the SSE to contribute presentations to their scientific conference. This year, the PAACS program at Soddo contributed five of the twenty presentations at the conference. Duane Anderson, orthopedic surgery, gave a presentation on a method of treating chronic shoulder dislocations in the absence of available shoulder replacement prostheses. Segni Bekele, surgery resident, presented a case series on the treatment of complex pelvic fractures in the absence of portable x-ray in the operating room. Tewodros Tamiru, surgery resident, spoke about a case series describing a successful method of managing pediatric airway foreign body aspirations in the absence of available rigid bronchoscopy. (We are becoming adept at doing things without the standard equipment!) Tewodros’ presentation generated the liveliest discussion by far of the conference! He gave a smooth and polished talk and handled himself superbly during the question-answer time. Jonathan Pollock, general surgery, presented data about the hospital’s experience with the management of acute abdomens in the last three years. He tied this into the main theme of the conference, the training of health officers in emergency surgery. In particular, he commented not only on the need for increased access to surgical care but the complexity of cases that present with surgical emergencies. And Paul Gray, general surgery, presented data from a trauma registry that has been established at the hospital. Though I’m biased, I think PAACS made a strong showing at the meeting. For the first time at SSE meetings, an award was given for the best presentation. Jonathan’s presentation received the award.

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Perhaps a more profound testimony to PAACS’ improvements, though, was found in personal discussions held throughout the conference. Though there are still some sideways glances at the mention of PAACS (we are something completely new, after all), there seems to be a much increased acceptance. Many of the surgeons spoke positively to us. Additionally, in the midst of a lively debate about whether or not it is a good idea to train non-physician health officers to perform emergency surgery, we received several comments that our model of training in the rural community setting is a good option to meet the surgical needs of the country. Again, God has brought us a long way.

However the highlight of our time in Addis, by far and away, occurred after the conference was over. The two PAACS graduates who are practicing in Ethiopia were present for the conference. Solomon Endrias graduated in December, 2009, and Haileyesus Tesfaye graduated in December, 2010. We wanted to hold a “PAACS Alumni” dinner and the graduates and residents were asked to pick a venue. So one the evening after the last day of the conference, we gathered at the roof-top restaurant of the Webe Shebelle Hotel. It is a famous hotel in Ethiopia and the restaurant had the quiet and distinguished feel of a city icon. Present were Solomon and Haile, the current PAACS residents, Duane and his wife, Jackie, Jonathan and me. My greatest sorrow is that my wife could not be there. She is every bit as much a part of this as I am.

That night was beautiful. Life here has not been easy and it has often felt like a long, tough journey in the desert. But in that get-together, God gave us an unexpected and delightful evening at a cool, lush oasis. We listened as Solomon and Haile described their practices and related stories of their work since leaving PAACS. Both of them had a joyous and quiet confidence that was striking. I couldn’t help but marvel at the conversation. In many ways, they spoke mainly to the current PAACS residents, especially Tewodros, who will graduate next July. They encouraged the guys, reassuring them of the quality of their training. They spurred them on with stories and admonition of hard work. And they inspired them with stories of how God was working in their lives and practices. I marveled because I remember some the history. I remember sitting down with each of them at one point when they poured out their heart and discouragement and plans to quit PAACS. Each of them had decided that it was too much, that it wasn’t worth it, and that they would just get a job somewhere as a general practitioner. They could still offer surgical services with the training they had already received, but they were ready to move on. But God brought them both through to completion, and the difference now was so palpable! Both are strong, confident licensed surgeons who are making a profound impact in their respective places of practice. Both men are exhibiting a loving, dedicated care for their patients that is so striking because it is so rare. Both are highly valued at their hospitals and in their communities.

My heart was warm as I listened to the graduates and residents chat. And I worshipped God for what He has done. At one time, this whole project seemed quite tenuous and insubstantial. But at that dinner it was evident that something real had developed. Men were in training and men were finished, with stories to tell. There was a sense of belonging to something, a spirit of PAACS and a pride for being there. But at a more foundational level, there was sense of brotherhood and fellowship in the service of our Lord Jesus. The stories weren’t about personal conquest or achievement. They were about the amazing things God had done. The reality is we were gathered at the table of fellowship sharing stories and boasts of our God’s greatness. Though the night definitely felt like an oasis, I think the more accurate picture is that it was a preview of the Day we will gather at the banquet table of our Lord, when He will once again break bread and share wine with us. I can’t wait to hear the stories on that day! How wondrous our God is and how great are His achievements!

But we are not there yet and there is more work to do. So we’re back in Soddo and back at it. I wanted to share this with you in the hopes that it will be an encouragement. Thank you all for your love, prayers and support. God is very, very good.

On the night of the dinner, I jotted down some notes so as to not forget what Solomon and Haile told us. I’ve added them below.

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Solomon

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Solomon was previously the lone surgeon at the Otona Hospital in Soddo, a government hospital. He worked there for about a year and a half after his graduation from PAACS. He was recently offered a position in Hawassa, the head of this region, and he moved there with his family in August of this year, despite the pleas of his hospital and community in Soddo. He is the lone surgeon at a small government hospital in Hawassa. The hospital is new and was recently upgraded from a health station with the intent of serving the local population of Hawassa. The Hawassa Regional Referral Hospital exists on the outskirts of town to serve as a regional tertiary hospital. Solomon’s new hospital has two operating rooms and forty beds, of which twelve are allocated to surgery. When he arrived, there were no supplies for performing operations and he spent his first month building a functional operating room, after which he started performing emergency operations. In the intervening months, he has become progressively busier and the people are starting to come to him preferentially as the hospital is gaining a reputation where there are good patient-doctor relationships. His OR is now reasonably well stocked, but he had several elective cholecystectomies on hold because he didn’t have an adequate retractor. SCH donated some Diever retractors and he has now completed those operations and is actively using the retractors.

As of right now, he is operating at his hospital three days a week and is spending two days a week at the Hawassa Regional Referral Hospital. He reports that the hospital is in bad shape and that surgical patients are not receiving good care. There is a large backlog of general surgery cases (which he is now whittling down). Additionally the orthopedic care is significantly lacking. There is no orthopedic surgeon and these patients are being managed by the medical service. However appropriate care is not being given. Fractures are being inappropriately casted by internists. Inappropriate wound care is being done, including simple external dressings for osteomyelitis and open fractures. Apparently there used to be an orthopedic surgeon there, but he was also working at a private hospital in town. He was noted by the hospital to be deficient in his duties; inappropriately canceling cases, not showing up for clinics, not rounding on patients, etc. It seems he was offering the patients more timely and efficient care if they would transfer to the private hospital (and pay the private hospital rates). He and another surgeon carrying out similar practices were fired from the government hospital. Solomon is now tackling these cases. Solomon reports that another example of such forced shunting of patients into the private sector includes operations for neural tube defects (including myelomeningoceles). Solomon offered to operate on these patients at the Hawassa Referral Hospital and faced opposition for doing so from the surgeons who were financially benefitting from their activities. However he did it anyway and has successfully treated several patients despite the opposition. He is actively involved in teaching at the Hawassa medical school; to medical students and house officers.

He particularly commented on the sad situation where patients are being transferred to this referral hospital from far away, but they are not receiving appropriate care. In particular, he noted patients being transferred from two areas: Shashemane and Bale. This is interesting because our next PAACS resident scheduled to graduate (Tewodros) is planning to go to a hospital in Bale, in a city called Goba. The next PAACS resident scheduled to graduate after Tewodros is Daniel, and he plans to work in Shashamene! Solomon encouraged both of them as to the very definite need in their respective areas and fruitful possibilities for meeting those needs.

We asked him if there are any other particular areas of difficulties that we might be able to help with. He mentioned that he doesn’t have any legitimate chest tubes, so we will get a handful of chest tubes up to him. He also expressed a desire to work on some research for presentation at the Ethiopian meetings and requested assistance with this. We also agreed to work with him on this, as he directs.

Haileyesus

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Haile is working at a new government hospital at Gimbi in west Ethiopia. Similar to Solomon, the OR facilities needed building after his arrival. But he has a supportive administrator and has been able to set up a functional OR. His initial routine included operating five days a week with daily surgical clinics. However he fairly quickly recognized this as unsustainable and has now shifted to operating on Mondays, Wednesdays, and Fridays. He holds surgery clinics on Tuesdays and Thursdays. When asked about emergencies, he says he has them most nights. However his clinical duties have not eliminated his efforts to serve Christ in his career. He describes how he was faced with the question of prayer before surgery with his first operation at the new hospital. He was called by the gynecologist working at his hospital about a pregnant patient with appendicitis. Haile was the only professing Christian in the operating room and he debated internally about praying before the operation. Finally he announced to the room that the routine in his training was to pray for each patient before operating. Therefore he was going to pray. He said a loud and firm prayer and, as he put it, the room was silent well after the prayer ended! But in his heart, he felt his fear and intimidation at his first operation fade into Christ’s peace. The operation went well. The entire hospital is now well acquainted with his practice of praying before surgery and it has become accepted and expected. His anesthesia team keeps the patients awake until prayer is finished. Haile told one story where he was about to operate on an emergency patient and asked for the knife. His assisting nurse, not a Christian, reminded him that he had not prayed yet! Indeed patients are coming in from the community with the expectation that Haile will pray over them before surgery.

But his service to the Lord does not end with prayer in the operating room. He says he is busy enough that there is little time for “preaching” on rounds (sharing the gospel). But he continues to pray on rounds. He is using his clinic time to specifically share the gospel. He related one story where he treated an older man with a stab injury to the chest. The man was an alcoholic and was in the habit of beating his wife. The wife has a grown son from a previous marriage and, on one incident, stabbed the man in the chest for attacking his mother. Haile treated him with a chest tube (he also doesn’t have chest tubes – something we intend to remedy immediately). Haile shared the gospel with him during his hospitalization. In follow up clinic, the man accepted Christ as his savior and repented of his sin. The wife was present and began speaking badly about the man, skeptical that he would change. Haile encouraged her that his heart was changed and that Jesus could change his behavior. He also encouraged her to believe in Christ for her own salvation. However she was reluctant and preferred time to think it over. Haile and a Christian general practitioner who has been working with him (and, incidentally, has applied to join PAACS next year…) traveled out to their home one weekend to follow up. Haile says it was a very poor home and they were surprised to see them visit. They encouraged her of her need to follow Christ and encouraged the man in his new faith. The wife was convicted and accepted Christ in her house. The son was no longer living in the home, for fear of the step-father he had stabbed. Haile and Surafel encouraged the man to drop any legal action against the step-son and seek reconciliation. He had been forgiven by Christ and he should forgive as well. Over the course of a three to four hour visit, the son was returned to the home and reconciliation had taken place. Furthermore, the entire family had placed their faith in Christ for salvation and life!

Haile has been working in coordination with the local church. He is referring people who become believers to the church for discipleship and fellowship.

One challenge Haile faced early on in his surgical practice was the need for a productive partnership with anesthesia. Thankfully most of the nursing staff was young and new, as it was a new hospital. Therefore they were pliable and eager as Haile set a high standard of care, especially relative to the usual setting in government hospitals. He feels the quality of care in the wards is now quite good. However he initially faced strong opposition from his anesthetist. The man was an experienced anesthetist and used to working at his own pace of life… and resistant to Haile’s desire to get work done. The man was also an alcoholic. Haile relates there were several heated discussions, including the ultimatum that one of them would have to leave. He eventually received the support of the administration to be named the head of surgery and this improved the situation. But the final solution ultimately came when, through Haile’s witness, the man accepted Christ as his savior and gave up alcohol! Additionally another anesthetist was hired, also a Christian, and they have a good team at this point.

Haile repeatedly expressed his thankfulness for his training with PAACS. He feels well trained and is confident about his surgical work. He is also thankful for the spiritual lessons he learned in PAACS and for the ministry he now owns because of his training. He felt a burden to make sure that the other residents knew this and that the PAACS faculty knew it as well.

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