Plate of Misfit Cookies

Does anyone else end up with strange, deformed cut-out cookies when they make Christmas cookies? Somehow there's always a gingerbread man that looks more like an amoeba, or an angel that loses its head (I just frosted her head onto her skirt), or a "Birdman", or a snake or an-umbrella-shaped-who-know-what-it-actually-is cookie. They all get sent to the plate of misfit cookies, never destined for a platter for company or a giftbox. Despite their misshapen imperfections, they were still very, very tasty.

Floating down a River

Last Saturday I had a lovely break from the usual routine. Several of us took innertubes and went tubing down the river that runs by the hospital. Three and a half hours floating and swimming down a river, only rarely were there signs or sounds of civilization. The jungle crowded the banks of the river the whole way to the next bridge which was our landing zone. It was wonderful. It did rain the entire time we were on the river, actually it kind of poured, but it was a blast! :)

"No-See-Ums"

Overall, thanks to two cats in the house, I don't notice the bugs too much. The bugs mostly stay outside except for the occasional ant or little cockroach or this bug in the picture that keeps trying to get in the house. I've thrown him out twice so far. It's at night that you realize how much the cats help--the rain forest all around comes alive with sounds--chirps and whistles and buzzes and rustles. Or after a rain when you can watch the bugs pour out of the ground almost like turning on a spigot.

Then there are the bugs you don't ever see--the "No-See-Ums". The ones that leave a million bites on your arms without you ever knowing they'd been there. I've actually made it a month without any bites so I didn't really believe in the stories about the "No-See-Ums". Then I spent an hour at a church in a small village. At the end of the service, I looked down at my arms and it looked like I'd developed leprosy or a bad case of the measles. I never saw a single bug or felt a single bite.

Hand Trauma Week--Surgical Cases

Sorry to the nonmedical folk reading this, there's a little bit of blood--no guts though. So this week has been hand trauma week. One case was a machete wound to the wrist. The other was a close range shotgun wound to the hand. I'm still working to try to save the index finger and part of the thumb for the patient who accidentally shot his hand. I don't think he'll have any sensation left in his index finger, but he really wants to keep it. I'm going to have to do a tendon graft to reconnect the tendons in that finger. The patient with the machete wound severed both arteries, both nerves and all the tendons on the palm side of his wrist. The photo shows my repair of the arteries. Tomorrow he'll be back in the operating room for repair of the nerves and then tendons.

How you know you are a general surgeon in Africa
#10 Your first case of the day is a prostatectomy
#9 Your second case is a hysterectomy
#8 Your third case is an open reduction & pinning of a wrist fracture
#7 Your fourth case is a tonsillectomy
#6 Your fifth case is a VP shunt
#5 You do the difficult OB ultrasounds because you’re the best radiologist
#4 You scrub out to donate your own blood to your patient because he’s bleeding
#3 An intra-abdominal ectopic viable pregnancy isn’t that exciting--you get one every couple years
#2 You scrub with dish soap and river water
#1 You are your own scrub nurse, at times circulating nurse and at times anesthetist.

Arrived at Bongolo

I've arrived! I left on the 15th from Philadelphia, had a short layover in Frankfurt and then flew to Libreville, Gabon. Thankfully, the plane touched down and I got my luggage before the power went out in the entire city. :) The power came on in time for dinner and to turn on the air-conditioning to get some sleep. The next day I caught an hour flight down to Huimba and then it was a 2 hour drive to Bongolo Hospital.

The area around the hospital is beautiful. There's a waterfall just below the hospital compound and the house I'm living in has a great view of the river.

I'll start work on Monday.

Getting closer

Well, a ticket has been purchased and I have a visa...just not to Angola yet. I leave on September 15th to Gabon to work at Bongolo hospital while I wait for my visa to Angola. I'm excited! I'll be getting to Africa and I'll get to stay with an old friend from medical school, Wendy Hoffman and her husband. And it's about time, I learned a new language. But who invented French??? Why do they only say half of the letters that are actually written? I have increased my vocabulary...instead of just saying "Hercule Poirot", I can now say "I am a general surgeon" in French. :)

My first entry is simply a collection of my updates from my trip to Angola last month.

Angola

Monday, November 30, 2009 at 6:18am

Made it to Angola...so everything went smoothly, except the minor problem of miscommunication about my arrival date, so no one was there to pick me up at the airport and of course my phones got stolen from my suitcase so I couldn't call anyone. :) Thankfully, I speak Portuguese and could get a taxi, and the taxi driver talked to some other people at the airport who knew where Dr Foster's house was, because I didn't know the address, but I could recognize it. So i got there. No one was home, but I hopped the fence and only had to wait on the porch for a couple hours, before people came by. Fairly routine Angolan trip. :)

On my own

Tuesday, December 1, 2009 at 9:55am

So today was my first day as The Surgeon...as in...the only surgeon. :) Thankfully not yet the only doctor.

My day...two EGDs--which are slightly more difficult here, since the patients aren't sedated and just gargle with local, so they are gagging throughout the entire procedure and you are using a colonoscope which doesn't help the gagging and won't retroflex, and it's not hooked up to any video screen with a lovely giant picture, nope, yoú've got your eye glued to the scope. Then to follow a L inguinal hernia repair--indirect with a good floor so did a Bassini with a relaxing incision, then anal dilation on a little baby with history of imperforate anus, bilateral hydroceles and one more bilateral hydroceles.

And it's all in Portuguese and wow, is my Portuguese rusty. Whoever is going to read my op notes in the future will be laughing because I'm pretty sure I'm making up words, half the time though I guess right simply by adding an -a, -o or -ia, -ao at the end of the English medical word but the other half is just nonsense. :) i.e. postoperativa, incisao, gastroscopia, herniorhaphia, urina. Or I just say the word with a Portuguese accent--so far that has worked with pancreas, hydrocele, Alees (Aliss clamp), hemostat. :)

Tomorrow a VVF, which means I'm reading alot tonight and if it is anything more than a small, simple fistula, the case will turn into an exam under anesthesia. Prayers would be appreciated! :)

Better (for me, but not for most of my patients)

Thursday, December 3, 2009 at 10:22am

You have to laugh when you realize how inadequate you are when it comes to third-world medicine. It's humbling. Yes, I have completed 4 years of medical school and yes, I have completed 5 years of general surgery and did well. But, I saw patients in clinic today and I kept realizing how little I know. A general surgeon is not the best person to evaluate urethral discharge, treat gonorrhea, diagnose and treat syphillis, counsel patients on infertility, make recommendations for menometrorrhagia, diagnose & treat tuberculosis, treat bladder pain, treat ovarian cystic disease. And I get to do this in stumbling, childish Portuguese. And despite five years of general surgery, I keep telling people to wait for their surgeries until a more experienced surgeon comes in 2 weeks--their hysterectomy, their prostatectomy, their vesicovaginal fistula repair, their uterine prolapse repair, their VP shunt placement, their orbital floor fracture repair, their acromioclavicular joint separation repair, their eyelid skin flap . Yup, inadequate. :)

I know that there are happy stories here. Stories where we cure or save a life or limb or provide relief. I'm waiting for those.

Today started with an abominal ultrasound on a gentleman with hematuria which showed a large bladder mass on the posterior wall, either bladder cancer invading through to prostate or the other way around, which was causing bilateral hydronephrosis and ascites. Not curable. Will go home to die.

Then the young man in the next bed who's been sick for 2 months, now with epigastric abd pain, emaciated and delirious who we diagnose with HIV and tuberculosis. And by ultrasound, likely chronic pancreatitis with pancreatic calcifications and ductal dilitation (I'm getting better with my ultrasound skills). HIV here gets treated with bactrim and multivitamin unless you're rich. His miliary TB will need to be treated at the sanitorium, but he's extremely cachectic and there's not much we can do to help.

The lady in the next bed comes in almost comatose. Took a root and boiled it to cure fevers and now has severe abd pain and a rip-roaring acute hepatitis, eyes are glowing yellow. Oh, and she has bilateral pulmonary infiltrates and typhoid and now her blood pressure is 70. And the family keeps asking me every time I explain that she's very sick "But she'll get better, she'll be fine right?"

And I scheduled a toe amputation for a little girl with chronic osteomyelitis while her father cried.

I'll try to find some happy stories for the next update.



Pus

Wednesday, December 9, 2009 at 7:03am

Pus...what would a surgeon's blog be like without a day devoted to the topic.

So, just to give you an idea of a day here at the Centro Evangelico de Medicina do Lubango.

The day starts in the banco da urgencia (the ER) and you see/admit the patients that are still there or came in overnight. I only had one patient left there--a pregnant lady with pneumonia and syphilis who is getting better, just waiting to be transferred to the ward. The other gentleman had urinary retention so had a foley placed and went home. My other lady with flash pulmonary edema suddenly died yesterday afternoon, even though her O2 sat was better, breathing was easier and heart rate was better--who knows, PE, MI, arrhythmia, hypokalemia, who knows.

Then ward rounds--there's only about 7 patients in the hospital at the moment. This is a surgical hospital for the most part and without all the scheduled big cases the wards empty out. My patients include the traction twins--two guys in the hallway with femurs in traction. They have another couple weeks to go in traction. Someone brought in a T.V. for them so they at least have something to do--elderly gentleman with hematuria, prostatectomy patient with multiple post op problems, baby with fevers, kid w/ dogbite who I drained his abscess yesterday--so no one had told him he should wash the bite out, but some helpful person told him to rinse it out with gasoline-- the lady post c-section and her baby.

In the middle of rounds, I was called up to see a consult on a 15 y/o girl who had initially been sent to the opthalmologist with swelling of her eyelid. Anyways, a week ago she had some swelling above her right eye, she was seen at a clinic and given aspirin, the swelling got worse and she went back to the clinic and they told her to come here to see the opthalmologist. The nurses here redirected her towards me--the poor girl's eye is swollen shut, her R upper eyelid, her entire R forehead up onto her scalp are bulging 2-3 cm higher than her surrounding face--it's filled with foul smelling pus, a giant abscess. That got drained.

In between the pus, I did my first ganglion cyst excision, dorsal wrist, under local anesthesia. I felt rather proud of myself since the lady still had intact motor and sensory function at the end of the case. :)

The next case was an 18 y/o girl who had had an infection at the tip of her thumb opened and drained 3 weeks ago. She'd been coming to the hospital for dressing changes. They brought her to see me and the wound at the tip of her thumb was necrotic with pus squeezing out of it. Her whole thumb was swollen down onto her hand. I thought I could debride under a local finger block, but when I injected lidocaine at the base of her thumb it came out the tip, so I opened her whole thumb. Not alot of pus but necrotic granulation tissue along the entire tendon sheath. The tendon was avulsed from it's bony attachment and the ragged proximal portion was in the palm. I couldn't recognize normal soft tissue. I washed it out and am bringer her back to see if I can figure out what to do.

The next patient is a young woman with a giant 20-30 cm long thigh mass for the last month or so. Soft, fluctuant, nontender. No evidence of infection or trauma. The outside clinic had told her to go to the capitol, Luanda to get it removed. On ultrasound it was a well-encapsulated fluid filled structure with debris--old hematoma, old abscess? Who knows, I'll find out today--I've got her on the schedule.

Then the last patient in clinic is a a 3 year old girl who 4 months ago had some pustules on her left arm that were drained and treated at another hospital. Then 3 months ago she started having pain and swelling of her right shoulder and couldn't move it. She got some antibiotics, but it hasn't gotten better. Now she's having fevers. I included the picture down below. I took a needle and syringe and aspirated 40ml of pus from the little girl's shoulder. Three months with septic arthritis--her humeral head looks ragged and abnormal so she probably has chronic osteomyelitis and has destroyed the joint cartilage.

Then just to finish off the day, two ladies came to the Banco de Urgencia. One lady has felt weak for the last week after she gave birth, also has a cough, nausea, vomiting, diarrhea and right upper quadrant abdominal pain. She took some traditional medication 2 days ago and then her eyes turned yellow. The traditional medications around her involve boiling certain roots to make a tea to treat fevers, etc. Only problem is that they are hepatotoxic. So she now has acute hepatitis. She's also HepB surface antigen positive, but I have no way of knowing if it's an acute or chronic infection. So far everybody I've tested for hepatitis B is positive.

The other elderly lady is just lethargic with normal vital signs and otherwise normal exam. Supposedly she had 2 weeks of throat pain or difficulty swallowing, but after the outside clinic cleansed her mouth with lemon juice it all got better???? Then her legs started hurting and then she got weak and now she's here. ????? Labs are basically normal. I've got no idea. I'm planning to see how she does in the morning.

Then I get to go home.

I'm learning Umbundu & I just ate some fuzzy meat

Thursday, December 10, 2009 at 9:37am

In between tapping ascites, diagnosing abdominal tuberculosis and figuring out how to do an IVP, I'm learning Umbundu. It's a great way to make people smile and laugh as I try to say "Hello, how are you?". That and "Thank you" are my current limits in the language. Umbundu is the most common, widespread tribal language in this area of Angola. There's a whole long list of others, but I had to start somewhere.

Yeah, fuzzy meat and very chewy. At first I thought it might be tongue, but I think it was too fuzzy for tongue. The other chunk that I first though might be blackened potato or eggplant or rock was a hunk of liver--rather hard. I got down a couple bites. The fuzzy meat was about impossible to chew so eventually I just swallowed. I still have organ meat breath and I'm wishing I had some mouthwash...I'd settle for some mint gum.


Crying with happiness

Monday, December 14, 2009 at 4:07am

Most of the weeping here is not with happiness, but there are some amazing moments. I was rounding with Dr Collins,the ophthalmologist on his postop patients--all patients who had had cataract surgery. These are people who had been completely blind from cataracts before their surgery. When he took the patch off the woman's eye and she saw her husband, the woman cried, laughed and clapped her hands with joy. With each patient, it was a celebration when the patch came off and they could see their family members. The whole ward was laughing and clapping their hands. It was wonderful.