FEB-C-5
FIRST FULL OPERATING DAY AT EMBANGWENI
BEGINS
AT 2:30 AM “RENDERING UNTO CAESAR”
AND
CONTINUES THROUGH A VERY
GENERAL
SURGERY DAY
Feb. 22, 2002
My operating day started sooner than I had anticipated. An emergency Caesarian section was called for and George Poehlman was the back-up for anesthesia, and Dr. Alex Mac Lean, for ten years a GP in a quiet non-hospital practice in Scotland before coming here who has had zero to less contact with surgery which he will now have to be doing as he is rotating call with the others is up for the C-section. He had done a previous one on Monday night. When asking George Poehlman what to do, George had responded to do what it is that Mister Tembo suggests that he do. Now he has a professor of surgery to replace Mister Tembo, and perhaps the assistance is almost as good.
Mister Tembo is what the “Child Survival Program” calls, in its several points at which it has decided to spend money, a “Positive Deviant.” “Find people who make it all work, and try to assess the factors that went into what produced such a spontaneous resource and try to duplicate it.” Mister Tembo simply grew up in this station and makes it work. He is the jack-of-all-trades in theatre, and has the concession to sell candy and cokes at the gates—for which he pays the hospital some concession royalty. He changes dressings, drains abscesses, keeps the sterile supplies and makes the equipment work. He is humble about it, since the meritocracy of all he can do has made him nearly indispensable, but still has not propelled him to the rank of a chief in this society. He has seven children and three grandchildren (at least, thanks to twins, I have outscored him in one department!) He does all of the chores in a “utility outfielder” position, which is why the Child Survival (a nebulous term for a large amount of conscience-smitten donated funds is intended to make a difference in an area where the annual report from Embangweni Hospital says “Bluntly stated, one in four children born in this environment do not make it to their fifth birthday. So, finding the “Positive Deviants” (don’t you like the name? I rather envy the title for myself!) is a major cause for which the well-funded Child Survival folks here are searching. The other parts include the PHC (Primary health care) which includes the growth charting, Oral rehydration, Breast feeding, Immunization (the EPI –Expanded Program in Immunization.) Put together in the “GOBI” program (look back for the first letter of each of the four items above), the one thing they need is to find key local agents that can make it all work. Enter the “Positive Deviant.” Along with that for almost any other program here, the Child Survival programs would have to focus on malaria, and increasingly AIDS, so they are a piece of the MTCT program now well started here.
With Mister Tembo seeing that people got their gowns and gloves on, and the anesthesia administered we went forward to do the C-section with me assisting Alex. I told him that it is a very simple operation and could be considered nothing more than an “I and D” (Incision and Drainage”) with the exception that you do not throw away the products of the decompression. There is less to do with finesse than speed, since there is a certain obligate blood loss, and with speed and blood loss—in this community, above all—you have a care to see where the sharps and fling bloody objects are as you are moving rapidly along.
So, we did it. It was uneventful, with an Apgar five infant for starters.
C-section seems to be the most common operation done here, probably because the OB service is among the most active. The total number of sections allowable is three, at which pint a bilateral tubal ligation is required. A C-section is followed by another C-section rather than having the woman labor on a scar, so this woman is counseled about coming in early for the next pregnancy, which should not be too long in coming, judging from a female fertility rate of 7.5 in this region. This is a ticking time bomb awaiting detonation and AIDS seems to be the fuse.
There could be no running on a day that went from theatre to breakfast to chapel to theatre. I heard the antiphonal choir in the chapel, which includes my scrub nurse Grace from the night before. The chaplain of the hospital is a Mr. Mahoney, who sings a lilting sermon and prayers for inspiration, before the heads of the medical units go to report, citing the number of admissions, discharges, and “Rest in Peace” deaths overnight. In this hospital and its pavilion style wards, rounds are made every day except Sunday, whereas in the Malawian government hospitals the rounds are made twice a week. There is a difference in acuity of care, and the nurses (all male except for the midwives under Mama Chima and the overall Matron Kathy) take pride in the care they give, often affecting disinterest as a way of showing deferential respect.
There was a formal introduction of us as visitors for a few weeks, with me as spokesman to give a response to the introduction. I responded “Monere musa”—“Greetings to all of you.”—and they all murmured a response—I have subsequently noted is an obligation to respond to anything cheerful said to them.
After report b y the heads of services, we made rounds, staring in the Men’s Ward. The charts include a front sheet with a concise History and Physical and the problems and program for each patient’s treatment. The charts of the patients in and out, weight, height, BP and temperature curves are on sheets of paper that follow these terse front sheets, and are given to the patient later to be taken to the “cho”—the “loo” where the paper is recycled in a somewhat more immediately useful from of hygiene.
The specimens are not usually sent all the way to Lilongwe for pathology exam, where they are examined in the order of the payments received for this service. If a specimen is actually needed for diagnosis, it is sent, and the diagnosis on a standard payment may return in a few weeks—so, there are very few requiring this “service.” All the rest go into the “Placenta Pit.” This is a covered cement receptacle that is anaerobic like a septic tank, and the large pile of biologic material accumulates in there without flies or mush odor, as it is kept sealed.
I started the theatre schedule with the right superficial parotidectomy for a mixed parotid salivary tumor. Things went well and the tough, almost cartilaginous tumor was removed intact. I was told that there had never been a parotidectomy performed here before, and I had seen another obvious parotid tumor in a patient walking along the road, so perhaps this is true. But this also reflects good sense, since almost all the operations here are emergencies, reluctantly performed, since the people doing them are not surgeons. Neil Kennedy, medical director is a pediatrician, and his successor is a public health administrator. The other who will be operating are not even doctors, with Ishmael, the clinical officer, and Tembo the Theatre Tech, probably being the most skilled and experienced. The parotidectomy patient immediately post-op had a normal smile, but later had some swelling and acquired what will be a transient facial palsy. She is doing well.
We excised the African melanoma from the plantar surface of the dignified elderly woman—John Sutter’s first-ever operation I guided him through—and now he has ambitions as a primary care doc to do a C-section! The next case was the young woman who was sent back as a one-month bride for having seizures, and she then seized over afire and burned both legs. WE did a split thickness skin graft to cover her granulating wounds. She is doing well.
One of the obligations of a mission station is inviting the guests for dinner—the biggest meal of the day, which is at noon. This was for John Sutter, and me since Elizabeth had gone out on a pediatric well-baby outreach clinic ride to a distant site over the rainy season roads. Neil Kennedy, his wife Sarah, and their two children Been and Grace are in their last weeks before returning to Ireland and will coincidentally be on the same flight as Elizabeth, at least as far as Heathrow. Both Neil and I know and respect the London pediatrician David Morley with whom I have done programs. As we were at the Kennedys, any number of calls were made to the door, as in the Congo, with multiple “Hodi-Hodi” at the door with an eloquent request for school fees, for support of someone who has no job but needs a steady income to keep them and a residual income from a reliable source—you Wazungas, for example—would quite nicely fill the bill. I have to get used to the continuing imploring requests of African mendicants at the door, who have an overwhelming claim upon me since I am white, and I am a Have, whereas they are black and are Have Nots. There are both “Positive Deviants” and a thousand fold more obligate Dependents.
We are all preparing for a grand celebration that is about to happen this weekend with the Kennedys’ farewell ceremonies, attended by all the locals, but including the paramount chief, the Nkosa. So, I will have a front row center seat on entry to the culture and community as the retiring medical director is in “Hand Over Notes Phase” after four years on station and the pivotal part of every health related and mission station welfare issue. It is strategically a very key point to be here for me and my students as well as the centerpoint for the Poehlmans stay here as their son and daughter-in-law are gearing up for their year-long stay and social science research in the role of theatre dramatizations in role playing AIDS awareness and prevention practices—now twenty years in to the modern recent plague that has dwarfed most other health problems for which this station was set up from the time of David Livingston, friend of the founder.