FEB-C-10
A MORNING RUN, AND
A DAY IN WARD WORK,
WITH A “SWAN SONG”
C-SECTION BY A PEDIATRICIAN,
RETURNING FROM THE
HEADY WORLD OF SURGICAL CHIEF
TO THE STUDENT
STATUS OF A CONTINUING PEDS RESIDENT
I ran. It was suggested that if I went behind the manse—the unique two story building that Loudon built here as the “Big House”, and probably the only two story building within two hundred miles—I might find a long straight road that should accommodate a good long run. I did. Within a few hundred meters of the compound I recognized that I was on the Tusa Road, which I have run three times previously, except that I had accessed it from the other, north, rather than south sides of the compound. I may try it again tomorrow, again at dawn under the spectacular thunderheads at the time the sun rises, but this time trying to go west toward Zambia. I may be running across international boundaries if I am not sure—as the population here also may be unsure—where one artificial “nation-state” ends and another starts up.
As I ran this morning, I thought about what I am doing here, and the question that always arises after a period of third world work—“Toward what end?” Maybe this is why each of the books I had read in Mindanao, one about a missionary surgeon in Mindanao and one by a South East Asian MK who expected to be going to the field where he knows the languages and winds up being set to West African Gabon, each of them wind up less doctors than preachers, since there is only so little they can accomplish of real significance in doing what seems to be futile. What is the end point of medical care there, or here?
JUST WHAT IS IT
THAT WE ARE DOING HERE?
THE STORY OF
HUMPHREY
AND THE LIMITED
OBJECTIVES OF OUR MISSION
WITH THE
SURPRISING OUTCOME OF HOPE
Let me introduce you to Humphrey, who will be on the schedule tomorrow. Humphrey is lying in the corner of the male ward, curled up, with several problems, all of them based in his fundamental status, as are all the others I seem to have been describing. Humphrey is HIV + in late stages of AIDS. He is lying in bed, with a deep infection in his right lower leg, that is a unique tropical problem called pyomyositis, but in his case really got going with his depressed immune status. Some time ago, he was admitted, and a large incision and drainage of liters of pus was done from each side of his left lower leg, with the whole of his deep compartments dissected free of their adherence by lots of pus. So, as I said to the students, coming to terms with pus in the tropics is something they should do early and often, since, as they, and you, can see from the Theatre Lists, “Piss and Pus Must Pass.”
Humphrey had through and through drains placed in his lower leg, and the swollen skin wounds had eventually granulated to be ready now for grafting to close up these large superficial burn-equivalents. But, during the prolonged confinement, both his knees were drawn up in contracture so he cannot straighten his legs beyond about 100*. Since, as we outlined in a previous dissertation of mine in these chapters, “The function of the lower extremity is stability”, the bent limb is unstable and cannot bear weight. So, he is going to be confined to bed as an invalid for the rest of his limited life. His open wounds and his contracted limbs are keeping him invalided, so that his last days are spent in a very confined and unrewarding environment, which is also pauperizing his family, which has to bring him food to which he cannot contribute as well as pay the minimal fees associated with his hospitalization (there are 2 million Kwachas, about $30,000, of uncompensated care delivered in this mission station hospital where no questions are asked at the gate as to your ability to pay when you need help, and with regular care without cost, no one is too eager to get up and out if they start out in a destitute situation for which the hospital accommodation is a definite step up. Of course, there is no state or third party payments since there is no state—a failed flag flies over an area where the government cannot support or protect its overpopulated citizenry, and almost all of the GNP is donated foreign aid. That comes to this hospital as a subsidy from the good people of Presbyterian churches in the US who may not even know where Malawi is. And here lies Humphrey.
What can we do for Humphrey? We are not going to cure, or even slow down his underlying disease. While he was here it made a substantial advance upon him. In fact, when I was checking his thigh for a potential skin donor site, I found a rough surface of superficial nodules—a hallmark end-stage malignant degeneration seen in late stage AIDS called Kaposi’s Sarcoma. I had talked about trying to straighten out his limbs using a bone pin called a Steinman Pin put in the Tibia and anther in the femur to get a fixation in some kind of external device, since we cannot apply skin traction, which would not be effective anyway. He has large patches of open wounds where the skin traction would need to be applied, and he has pus where the pins would have to go. And, now, he has the superficial malignancy of Kaposi’s Sarcoma. Things are not going kindly for Humphrey.
His family needs to support him, so we gave Lillian, his aunt, a job. She is the new guesthouse manager, and comes to talk to me about how hard things are throughout her very large and extended family. “I cannot even think of what the cost of my nephew Humphrey’s hospital bills might be,” she says, although it is unlikely she has to do more than just add that item to her worry list, since there is not money enough for the whole rest of the family and Humphrey would cost ten times that. So, that brings us back to Humphrey—what to do about and for him?
Well, our objectives are not rationally to cure him. I know it is a laudable objective to make the lame walk and the blind to see, each of which are occasionally possible, especially if there is some future for these rehabilitated lame and blind. But, Humphrey will not be self supporting let alone a family contributor, so let’s see what can be done short of that. If I could only get him out of bed, and then out of the hospital, at least he would be back with the family he left, before becoming invalided here in an unaffordable bed that may be needed for some one rehabilitatable.
Three things keep him bedridden: 1) His open granulating skin wounds; 2) His flexion contractures of both knees; 3) His despair and isolation.
We can fix a few of these. If we work around the area of his Kaposi’s Sarcoma, and try to take the donor skin from the same thigh as his open wounds lower down on the same side, we may be able to split graft him, and even use the mesher to expand the coverage of a limited amount of donor skin. Second, while under spinal anesthesia, we may be able to vigorously stretch his contracted hamstring tendons. No incisions, no Z-plasties, just aggressive physical therapy, stretching under anesthesia, which should give us the best result we can hope for, maybe 140* of extension so that he might be able to get up and walk with a shuffling crouch. Third, the encouragement Humphrey has already derived for the attention he has received for the visitors who have not only been looking at his exotic wounds, but even know his name and his family members.
I found this out while sitting next to Lillian his aunt, who seemed to have something to do with my room, which has minimal needs of any cleaning or rearranging since I do not have much to rearrange, not even so much as a mirror to shave by. But, as I sat outside with the laptop to get as much daylight as possible (the electricity is intermittent and the light in the room keeps flashing off) she was talking with me while I continued to type. I asked how many siblings she had and how many were in the immediate family of her nephew Humphrey. I lost count after she gave me the names and relationships, and, there we go again, the pressures of a very large population of people on very constrained resources, but viewing the only one they can depend upon is the relationship they have with the others. She was telling me how much Humphrey was recently encouraged simply because we were paying attention to him. He was looking forward to the treatments since he thought they would give him real progress. With the usual cautions that we were not going to be able to change his underlying disease, and our limited objectives were going to be to try to get him up and out so that he could control his own limited destiny outside the hospital where he had been simply vegetating away whatever limited time he—or I, or anyone, --may be allotted, I learned how much just seeming to care meant to Humphrey that broke the despair that he could reasonably sink into given the bleak circumstances of his being here.
So, here I have been going on about my task while Lillian, Humphrey’s aunt, is sitting there near me, and I am paying her scant attention while going on about my own agenda here on the keys. About twenty minutes later, she stood up and said, “Thanks for encouraging me, as well as Humphrey!” Here, I had been largely ignoring her, asking a few questions she could respond to about herself and her family without listening very well to the answers since they involved a lot of people and complex interrelationships, but she considered that this was very encouraging since I seemed to share a period of sit-down commiseration without, at least, sending her away. And the perfunctory conversation each day with Humphrey in the corner of the Male Ward constituted the high points of his day, which, of course, are the peak experiences in the last days of his life
So, tomorrow, I will try to straighten out and resurface Humphrey, but that does not really matter that I succeed, since simply directing attention toward him and trying has been therapeutic enough for him and for his family around him. I have generally said that there are three things any clinician should do on rounds: 1) Listen first, rather than only giving the patient a list of marching orders, (if you sit down, only for a few seconds, it makes it appear that you are not in a hurry, even if you are); 2) always ask some non-medical personal question, often about family or personal hobbies or skills they have that interest you, so they don to think that you are making rounds on their interesting colon instead of the person who bears it; 3 ) Touch them. Only a healer is authorized to do this—not the person who comes to clean the room or the one who is trying to sell them a newspaper or TV rental, or anyone else from whom such a touch is considered “battery.” But, I am authorized to touch; after all, I do that rather liberally on the inside, so it should also be on the outside when the patient is awake. This is especially important across wide gulfs of difference, in language, skin color, geography, to let them k now I am a fellow mortal in the same human condition as they even though I may be, temporarily, the one standing up.
So, I am going to operate on Humphrey tomorrow, and see what more can be done for him, but most of what can be done has been already, and that is that we are here, and paying attention to him for his pathetic end-stage condition for which a long and bright future is out of the question, but a better day today is within reason.
I had told
Elizabeth and John, my GW students, that objectives of therapy change
dramatically when working in a place like Africa. You may not be setting the world right and making of their very
sorry circumstances a better place. In
fact, a real and significant measure of success is: to retard by one more
day the entropic collapse of their world around them.
PRE-OP PATIENTS,
AND THEIR HOPES,
DREAMS AND PLANS
Another older man came to us today with a very foul catheter that had been put in a month ago in some other clinic which had written a note sending him out into the great beyond somewhere saying that he had very large BPH and that he would need a resection of this somewhere somehow in a facility not their own since they could in on way carry out such a procedure, having neither the expertise nor resources. Lucky him. He comes by just as we have the time and inclination to try—even if the American Board of Urology would cringe to consider me an expert by their standards, I certainly fulfill his bill, and the price is right!
There is a child here who had been dropped in a cooking fire—epilepsy again—with the full thickness loss of the entire scalp on the whole side of the head. One thing than might be done is to simply wait and to put a spit graft on that so the kid would have a “hemihead” and there certainly are no wig-makers in the area that I am aware of. So, with a little imagination, I might be able to make a big relaxing incision on the opposite side of the head and slide the whole scalp over to leave a denuded area over each ear, but cover the majority of the head with hair-bearing scalp, particularly if I make further relaxing incisions in the scalp to granulate or get grafted later. I will literally be “lowering his ears” as my father used to describe a haircut, but it should be better using the forehead and occiput as a bipedical graft that, at least in the first of a couple of stages might make this child look almost normal among his peers. Check with me tomorrow to see if this faith becomes sight.
A CAESARIAN SWAN
SONG:
NEIL KENNEDY’S
LAST OPERATION
IN HIS NATIVE
ELEMENT
Neil Kennedy is getting “short.” His wife, Sarah, said she had never seen a C-section nor seen him operate, so I stepped aside from the planned assistance for clinical officer Ishmael, and we all cheered on the usual intact team of midnight operators, Neil Kennedy, returning pediatrician doing the operation, with Tembo, very experienced Theatre Tech assisting, while I mainly operated as cameraman. So, Sarah now has a memory as well as a few pictures to remember this interval of four years in their lives in which her husband had to be an all-‘round doctor, before returning to the flea-status of a non-operating pediatric resident.
The patient on the ward who had had an ill-advised circumcision instead of a dorsal slit in the foreskin for his balanitis/phimosis in another clinic had come in with half his glans necrosed. When he could not pee, he was catheterized, and not for the reason that he had this messy necrotic penis tip, since the catheter passed rather easily, but because he is found to have a large prostate—so post another in the series so that this part of my aphorism is balanced out, having passed a good deal of pus, I am granting equal time to the passing of urine as well.
I also “unbooked” a couple of operations. One was a 12-year-old boy who was sent over to get a bilateral mastectomy for gynecomastia. For several reasons, the first of which being that it would resolve, and the worst of which is that he would have an “outy” replaced by a very much more unsightly “inny” I canceled him after discussing with his guardian what would be his resolution. A couple other patients we had seen were addressed not according to their principle problem (Like urinary tract obstruction rather than remote fear of cancer of the prostate, at the age it occurs, probably of no consequence to the patient) and other misdirected treatments, possibly by focusing on one of many problems and going forward on the generally positive “Syndromic management guidelines.”
FOR AFRICAN
PROSPECTS
So, problems in Africa are both very easy, late presenting, obvious and fixable, and at the same time complex, subtle and very involved in both the culture and the almost insurmountable economic drag. I remain as optimistic a person as can be found walking God’s green earth, but every day in every way, it seems Africa gets worse and worse. And I do not even believe it is because of the AIDS that is everywhere around me, which is not even close to being its biggest problem. After all AIDS occurs in people and there are certainly a lot of them, and ever more despite this plague. So, I see things getting worse rather than better, since whatever short term resolution of some problems can be brought to bear, the population pressures compounded by these often medical fixes of epi-phenomena magnify the oppressive fate bearing down on the whole continent.
Does this mean it is time to pack up and go home, and to forget Africa until it dies down to a more manageable human mass? Certainly not.
These people here and now have the hopes and dreams that any of us
anywhere might share, even if they are often a very long reach for them and
with a lot of counterweights dragging any aspect of progress. A number of Africans are empowered by their
own cleverness or mendacity to try to get out, which is hardly a noble
objective on their part—even as it would be a cowardly withdrawal on the part
of a first worlder who has seriously engaged the African condition. The quick reaction of one fellow traveler,
who came to look at the birds and was very depressed at that fact that there
were many desperate people interfering in his unobstructed view of the wildlife,
was said in my presence to be a summary disposition of all Africa. Throw
them all condoms, and run for your lives!
Africa is more than birds and beasts in the bush, and may be attractive to some (and to me) for this aspect, but I am not here bird watching or even what I might rather be doing for a brief holiday excursion: big-game hunting. I am here sharing in this other corner of the global laboratory of the human condition, where we all share the fate of this “part of the main” from which no man is an island apart. I watched Neil Kennedy’s last operation today, delivering a third baby by repeat C-section and tying tubes on a patient at a young age, his valedictory procedure. Another Kennedy had another valedictory. If John F. Kennedy could use “Ich bin ein Berliner” as a parting line, I have had and continue to have a perspective of this problematic part of the still-hopeful world: I am an Africanist.