FEB-C-8
AN
OPERATING MONDAY, WITH DAILY CHAPEL,
AN
ORTHOPEDIC SEQUESTRECTOMY,
A
THORACIC RIB RESECTION EMPYEMA DRAINAGE,
AND AN AFTERNOON SORTIE TO SEE BRICK MAKING IN PROGRESS FOR THE NEW SCHOOL AMPHITHEATRE
Feb.
25, 2002
I had wanted to run this morning, but it was explained to me that I would not have time. Since the sun rises around 5:00 AM and the breakfast would be about 6:00 AM for a 7:00 AM chapel service that would precede the staff meeting and I could not work in a run an ablutions in between. I listened to this advice for today, but will try to run anyway tomorrow, probably by trying to start in the dark. Fresh from a big celebration weekend with multiple services of worship, it seemed that we were gathering the same folks to say the same things and sing the same songs at 7:00 AM, but it is, after all, a mission station.
A Belgian Flamand couple came through and stayed in the guesthouse last night. They were a lean and tough pair, tanned and cheerful. They were delighted to hear my name, and said that no one would be able to pronounce theirs, but, of course, they were easy Dutch names. They were on bicycles for two months and had come all the way around southern Malawi, stopping whenever they ran the backroad bikes into evening—so, our accommodations were luxurious including hot water showers. They had gone around the Tete Province side adjacent to Mozambique on the Eastern side of Lake Malawi, and had gone up to Fort Maguire and taken the Steamer across to Mkata Bay. They were having a great time, since the people were friendly and the Malawians themselves were big bikers and full of helpful directions. It seemed to be a really neat way to see the “real Africa.”
STANLEY—EMPYEMA OF
THE LEFT THORAX
BOTH, OF COURSE,
HIV POSITIVE
The menu
for the patients of today is, as most often, “AIDS +.”
The first is Victor. He has had a draining sinus from his left thigh with occasional spicules of bone extruded. He has also had a not very mysterious lack of energy and a wasting away, and after “VCT” the voluntary counseling and testing which takes six weeks of training to be qualified to do, he tested—no surprise—HIV positive. The nurses and one clinical officer (only Ishmael) have had two weeks of classroom teaching in what the information of a positive HIV test means and how it can affect the patient and the society around him or her, then two weeks of role playing in breaking this news after counseling the patient on whether they should or should not have the test done, and then two weeks under supervision in actually doing it before they get a certificate saying they are qualified to deliver this highly standardized message. After all, 78% of all tests done will be positive since they are done for cause. And following a positive test there is a lot of information on how to behave, and in what way relationships can continue, and what it means to decrease the viral load to someone already positive. The negative are also given a large dose of prevention, and told how to stay that way.
Victor has osteomyelitis. We have an X-Ray unit here, and an X-Ray technician. But, of course, this is Africa, so the unit has not worked for many months, and the technician has been used for ultrasound and other tests he can do in the interval until the machine is fixed, which is not on any timeline on the immediate horizon. I think it is just as well, since we are treating most things quite clinically without a lot of help from an X-Ray—the nearest one that works is in Mzuza three bumpy road miles away. The rainy season roads involve a lot of sliding at best, but real horrors of getting stuck or swallowed by a pothole are also a possibility, so the ride to another facility for someone sick is not a good idea. I will give you only one such road sign caution: “Bumpy Road Ahead: Remove Dentures!” This is a sign on the M-1 (Main Malawian Highway) let alone the secondary roads, which I have been trying to run.
We had one young man in the active TB ward off the Male Ward, where three sputum positive young men were staying while starting the TB MDT (Multiple Drug Treatment (Rifampicyn, Ethambutol, PZA, INH) 14 days in hospital, until sputum negative, then 8 months on M/W/F schedule of DOTS –Directly Observed Treatment Schedule—where the patient swallows the pills in the health workers presence, and if they do not show up for treatment, the health worker tracks them down. This is a model TB program in Malawi, which is in need of it because there is a high prevalence of the very nasty kinds of TB given the AIDS that makes people susceptible.
This young man casually mentioned that he had been coughing up blood. Right. Then he showed us the emesis basin overflowing with the amount of blood he had coughed up, and that was just since the previous one had been emptied. This means that he had a large cavity eroding into a vessel, and one of the rare indications for operating on someone with TB is when they reach the stage of exsanguinating hemorrhage for m a localized source. If it could be proven that he had a localized rather than generalized TB process in his lungs, I might consider a thoracotomy and lobectomy to stop this hemorrhage as well as to resect his major locus of TB, which would make his general MDT more effective. Such an operation has not been done here before, and the Medical Director said that “Well, you might consider such therapy, since we cannot.” So, we needed an X-Ray on him. He coughed up blood for two days, and then got on our ambulance when it was scheduled to go to Mzuzu, and came back with the film. For two reasons he will not be operated on. For one, he stopped bleeding so much and now coughs up very little—apparently the cavity is drained internally into his bronchus and the eroded vessel has clotted off. But, second, he has “Pneumonia Alba”—i. e., his chest X-Ray is whited out with a disseminated TB that was coughed up from a localized source and flooded all parts of his bronchial tree, so the TB process is no longer localized. He does not have then any surgical indication for TB treatment, which the staff here was a bit disappointed in since they were curious about the limits to which the visiting professor could go in showing them more extensive treatments of some disease management efforts. Don’t worry; we will be back doing another thoracic surgical procedure later today!
Back to Victor. H e has osteomyelitis, and has had it for a year. Probably throughout that time he has been HIV positive, so that his resistance is low, and he could have been infected with any number of organisms that were spread in his blood stream (TB included) and set up a nasty non-healing infection in the biggest bone in his body, his left femur. The dead bone is a “foreign body” and like all foreign bodies in a puddle of pus, it must be removed before the infection can clear. If that bone is in the middle of the femur, it cause a healing callus to from around it called an “involucrum.” If it has been there long enough, the involucrum becomes very solid and is probably stronger, at least heavier, then the normal bone it replaced around the dead bone, which is “sequestered.” This “sequestrum” is the dead bone, which must be removed. To do so, one has to make a “window” in the callused hard involucrum (“fenestration”), and do this in such a way as not to break the solid involucrum. I f that should happen, the patient would have the worst of all worlds, an infected bone, and a flail extremity, since the “non-union” of such a “pseudo-arthrosis” would not allow weight-bearing, and the purpose of the lower extremity is STABILITY. The purpose of the upper extremity is MOBILITY, so that we would encourage any amount of pseudoarthrosis, but if that were in the lower limbs, no weight bearing could be achieved and Victor must get back on his feet and walking about to prevent the contractures and wasting that are easily seen on a fellow named Humphrey tow beds over from him in the Male Ward.
So, under spinal anesthesia, I chopped a window in his left femur. (I know, it sounds like “chopping” is crude, but that is what it is, even though we use a “mallet” –read “hammer”—and “osteotome”---read “chisel” in doing it.) This is not rocket science, and not even finesseful operation, but a way to “dig out” the dead bone “sequestrectomy” without injuring the live and callused bone, the involucrum.
This was done, let it be added, without benefit of X-Rays, since Victor could not tolerate4, let alone afford, the trip. We got a good result anyway, and chief among these results is that his family and guardians figured for the first time someone was showing him some attention and that was most encouraging, so he will try to get up and about, now that he has had the operation that has been diagrammed and shown to him and to them. He has been the beneficiary of both professional and professorial care.
Now, Stanley. Stanley seems further along in his HIV + course. He is not only suffering from a chest full of pus (empyema) but also is a little foggy on even his good days, so he has not been getting out of bed. This may be AIDS cerebritis or it could be that with very high fevers from all the pus still in his chest, he is wasting away on that basis as well as the viral problem. He has had multiple chest tubes placed and he has had an open chest wound draining liters of what George Poehlman called “millet seed soup.” There is no point in culturing it—if we could—since it must be drained, no matter what it is. If he were in good shape, he would need a resection of the thick “peel” over his lung (a “decortication”). But if I add that Stanley has 4 grams of Hemoglobin (compared to your sixteen), you can see he is not in “good shape” for an extensive operation. So, we asked Stanley if he could find a few blood donors to help get him ready for operation. He has two –both older women (“ngongos.”) It was in Stanley’s case I asked if it would not be possible to get blood donors from the thousands of people who are HIV + and use this blood for those who are HIV+ and in need of it, covering them with the same drug as is given to women who are HIV+ giving birth, to decrease to half the chance of spreading HIV from mother to child MTCT prophylaxis. No one, of course, in the developed world could even conceive of approving such a use of HIV+ blood, but, then, no one in the developed world is working in a 78% HIV+ environment.
As it happens, Stanley’s donors are HIV-, so he got one unit before the operation, and was getting one unit at the time he came to theatre. I did a very limited decortication and resected a devitalized rib to achieve dependent drainage, stuffed a set of gauze packings in his thickened pleural space to be torn out along with some of the pussy lining each time the “wet to dry” dressing is changed, and made an inferior hole in his chest with a drain inserted in the place that would be most dependent—if we could only get Stanley to sit up.
Because of the attention invested in him, probably even more important than the operation, Stanley is not only sitting up, but with the help of his extra Hbg he is even trying to move around, and with the dependent drainage, Elizabeth Yellen, who participated directly in Stanley’s thoracic operation, and to her great amazement, did not require the prophylactic chair Tembo thoughtfully provided behind her in the event that she felt dizzy and faint –as she had the day before when I had her excise a pyogenic granuloma from an index finger—Stanley is now afebrile for the first time since he was admitted to the hospital months ago..
THE
NEW MEDICAL DIRECTOR,
MALAWIAN
DR. NGERE,
RETURNS
FROM THE KENYAN CMDS CONFERENCE,
WHERE
I HAVE LECTURED PREVIOUSLY IN TIGONI, KENYA
A big event is happening, in that Neil Kennedy is departing, and the new Medical Director is replacing him, Dr. Ngere, who is the first Malawian in this post. He has been away at the Brackenhurst Conference Center, for what was this year’s 23rd biennial conference, with over 250 participants. I had participated in that conference several times and recognized the names of half the faculty who were in this year’s conference, several of whom were my co-panelists at the American College of Surgeons Plenary Panel in New Orleans last October. Since Dr. Ngere has been an administrator in public health for the past six years, he will need help in the coming weeks to get him back into a comfort zone, in doing some of the necessary operations when he will be alone here in the next years. He said that he had arrived in June, and was frightened by his first few C-sections, the only operations he has really done, and I have tried to save a few of the ones he will have to do next months when no one more experienced will be here to help. Both a prostatectomy and a thyroidectomy are booked from my clinic visits today, and I presumably will not need to look into any book to see how to do the latter, but I referred him to Maurice King’s book on Primary Surgery to follow the steps of a Retropubic Trans-vesicle Prostatectomy for the former. These operations will be the first of either he has done, and possible even seen. Remember that his previous surgical consultant, who had helped him through C-sections, was Neil Kennedy—a pediatrician!
So, if being an orthopedist and thoracic surgeon this morning is not bad enough, wait until tomorrow, when I will morph over into not only a urologist, and obstetrician, but also an instructor in each of these surgical fields!
Under the spectacular cumulonimbus clouds of African rainy season twilight, we walked a dusty very eroded road washout with Mr. Jeri (remember the political context of that hereditary entitlement to chieftainship that comes along with that name.) He was gong to show us the project he was sponsoring with his schoolboys to get the amphitheatre built over on the compound. We walked along many fields o f maize and cassava, and learned of the hereditary ”TA’s” (Traditional Authority’s) distribution of land rights and the use thereof from Mister Jeri. We came to a large anthill, with an open well for water and nearby trees for firewood. The boys had made bricks and fired them so that there were at least half of the fifty thousand made already that will be useful in the construction they have planned. This has been made easier by the fact that the land is his father-in-law’s. In theory, he is not allowed to talk to his father-in-law (bad from and a political disgrace), but since he is also his uncle, this allows the second title to be used in his addressing him.
On the way back we stopped at Mister Karunga’s “village”—his cluster of huts has grown so big since he has a dozen offspring—as any good Catholic would wish to have. One son is Andrew, our cook. One son is Peter, our night watchman. Another is Martha’s cook, (she is the GP at another station formerly here who was returning after caring for her father in Michigan but got sick and was sent instead to the UK). And one son is in secondary school funded by the Poehlmans. So, the Poehlmans are heavily invested in this Karunga family—one daughter of which was the nun who officiated at the Catholic service they attended yesterday. With thirteen kids running around in the next generation around the huts of senior Karunga, all of them were given a new shirt to replace the brown rages they were wearing when we first came upon them, so there were many smiles and lots of cheers as we left. A Kodak Moment occurred, which you will see later.
The other family here with at least that many kids is the “Mahoney’s” the name of the hospital chaplain with the stentorian voice and the vitiligo hands. One of the dozen kids is Timothy, allegedly a grandchild of his, but looks a lot like him. Timothy is a small African boy who has figured his niche and is secure in it. Before I knew his name, he looked for me and came up to me and put his hand in mine, and walked along proudly hand in hand with the Wazunga. I am not alone, since he has implicit faith and trust in the charitablity of any white face, and has played those odds well, being far better fed and clothed than any of the two dozen playmates his age, half of whom are directly related to him. For this he gets chased, teased, and beaten by some of the other kids, but he still comes out ahead in the gross cargo that he has sequestered from his foreign friends, which replace the tattered singlet brown with dirt and a perfect mendicant uniform. Timothy is a pet around the Wazunga compound, and will be in a sorry way once we pull out.
I am getting into a rhythm of my own here, which will last only another full week. Elizabeth is going out on Saturday, flying with the Kennedy’s who are currently in Lilongwe making farewell rounds there. I will be leaving to Lilongwe myself (an 85 pound ride, since the ambulance rental is expenses plus 45 Kwacha per kilometer—which keeps the local joyriding down to a bare minimum. There was talk of a game park visit since John Sutter has bee keen on seeing hippos and crocs, and cannot return from Africa without a few photos of some big and scaries. I could guide him if I were still here, but I suspect I will be employed up to the last minute, and then Wednesday go to Lilongwe, for the flight out through NBO and AMS on Thursday, overnighting in the mission guest house there run by the Rodehavers whom John and Elizabeth stayed with for their first few days while awaiting my arrival last week.
So, this is the half way point coming up in the Malawi Mission for at least Elizabeth, and nearing that for me and John who will be here a few days beyond my leaving, which will extend another week before the Poehlmans leave. I believe that Victor had it right—our chief product here is not just the treatments we administer to patients or teach to staff, but the encouragement that our presence gives them all.