FEB-C-3

 

 GCMS VISITING PROFESSORSHIP:

WARD ROUNDS AND LECTURES,

SEEING THE QUALITY OF LEADERSHIP IN

SETTING STANDARDS

 

February 17, 2004

 

I am watching the sun come up over Gondar Valley from my mountain top Hotel Goha room as I prepare for the second full day as Visiting Professor in GCMS.  And it is taking me some effort to get up for it.  I am ill.  The kind of ill I am would be  more appropriate if I were in Derwood Maryland plowing myself out from a snowfall and worrying about the five tanks of fuel oil being consumed to keep the shell of the house reconstruction warm for the installation of appliances.   I had a “URI” with a cough, stuffed nose, and the kind of thing that does not fit in the pleasant, high altitude sunny warm-air cool-breeze setting of Gondar.  Add to that the final “catching up” of the GI distress that seemed inevitable in some of the sanitary conditions I had encountered along the way in Berbera and Hargeisa. 

 

I had met Leo Murray at breakfast at the Goha Hotel and we again compared notes on the adventures we have had and the attitude of a large number of the “wannabes” each of us might have whose comments generally include statements like “I only wish I could have done what you have done; what an exciting life you lead and how boring my simple existence is in comparison!”  I presume the same “three score and ten” has been allotted to each as the raw material, and each can choose to horde or squander it as each might like.  He will send me some of his digital pictures, and he will check my website for some of the reports and stories. 

 

MAKING ROUNDS AT GCMS

 

So, I have not been getting up early to work diligently on my recording the events of this trip, and when I get home after my mid-afternoon lectures, which coincide with my circadian nadir from my still-evident jet lag,  I simply crash and stare off into space.  I did that yesterday, and am likely to repeat that “non-performance” today, so that I may not give as richly illustrated and detailed account of what is transpiring around me as I did in Hargeisa.  And this is ironic, since this center in Gondar is organized in such a way that we can readily understand and accept the process, and therefore can focus on the contents of this process which is quite common to each of us in understanding the “acceptable standards” of what is happening.

 

WHAT A DIFFERENCE A CERTAIN LEVEL OF

ACCEPTABLE PERFORMANCE STANDARDS MAKES!

 

This matter of “standards” has been quite apparent here, and was even more striking by its absence in Somaliland.  The very matter of which I had spoken in the paragraph above, such as would you be willing to eat freely from what ever is served in a restaurant in a “lawless state” goes to the same characterization.  If no one cares, and there is no agreement upon some minimally acceptable standard of performance, the whole society is at risk—and not just for GI distress.  The distinctive impression I get in making rounds in GCMS is that there is a generally understood and accepted standard of performance and an attempt to improve upon it.  For example, in the formal rounds I made this morning, every intern in the rotating internship program was dressed in white coat and tie, with shoes rather than sandals and stood crisply before the Visiting Professor (who was the only one tieless, and casually dressed compared with them, sporting running shoes as his only footgear) and presented the patients’ stories succinctly---even if in a mumbling barely inaudible African English, deferentially and shyly looking away from eye contact and downcast gaze avoiding familiarity or little humor.  And, indeed, for most of the patients there was little to be humorous about.

 

The patients were all lined up in beds with matching covers, with their sheaf of X-Rays readily available at their bedside, with their wounds or physical findings ready for display, and each understanding that the professor would be by to consult and opine on there care, and that orders given would be carried out.   When I made rounds at Hargeisa Group Hospital, I was alone, without nursing support, and often finding patients by random coincidence, and never finding any data or chart on them and if an order were written, it would as likely as not never be carried out, since there was no assurance the any health care giver other than family members would be by to see it until the following morning, with no one in attendance after I had gone through.  Without a substantial difference in resources or personnel, what is it that makes the difference between these two patterns of practice?

 

I suggest it is leadership.  Pure and simply, there are certain acceptable patterns of behavior if one is to call her or himself a nurse, and if they are not carried out professionally, one is simply sacked.  Since both sides must understand and expect that, there is a starting point from which further improvements can be made, particularly as additional inputs are made in resources applied to patient problems.  Gondar may be poor but proud.  They know what is expected of them and have something to contribute to the professor visiting from far away, even as he is teaching them some things that they can benefit from as well, and it is a worthwhile exchange.  That pride may also be apparent in Somaliland, but it is the pride of simply showing up when everyone else seems to have "fled the field” in despair of what is going on.  That one is present at all is about as much as one could ask, and demanding further standards as to performance on top of showing up for the job is a bit excessive. 

 

“GOING THROUGH THE DRILL”

THE UNIT COHESIVENESS SOUGHT BY
”DEVIL DOCS” IN THE IRAQ WAR, AS A WAY OF SETTING

STANDARDS FOR EMERGENCY RESPONSE

 

While in Hargeisa, I had carried a few of the journals to be distributed from the Journal of the American College of Surgeons, the World Journal of Surgery and the Bulletin of the ACS, each of which are big gifts to a group of physicians who have apparently no access to journals of any kind.  I saw on the cover of one of the Bulletins of the ACS an article on the “Devil Docs” of the USMC as they are stationed on the front line battlefields of Iraq.  I read the article with a sense of gratitude that I had not wasted much of my life in the filthy, hot, and cramped conditions of the forward desert hospital camps, in which waste seems to be the rule of the day.  The purpose for being there is to support the mission with a well-drilled set of procedures in the event that casualties are taken,  The casualties are rarely coming in with the rapid advance and efficiency of the operation with the exception of some Iraqis who are treated, a number of them young victims of cross fire.  But, one statement caught my eye.  They mentioned endless repetition of drills of mock casualties to “foment group cohesiveness.”  This kind of statement would keep me out of any kind of uniform, quite apart from the tremendous waste, of materiel, equipment, expertise, but most of all productive life time.   The idea of make-work drills to sponsor a sense of a team ready to roll into action that does not often get applied for any practical good would be hard for me as an individualist who would rather seek out patterns that might be improved upon and follow his own drum.  But, the “drilling” did make for a “cohesive unit” in the deadly dull and boring synthetic circumstances of Iraqi forward fire support bases in the uncomfortable isolation of a  waterless desert environment.

 

“INSTITUTION BUILDING”

IN THE DEVELOPING WORLD

 

I am a witness of the process of “institution building” at minimum, and “nation building” in the larger context of the developing world.  Somaliland does not yet have a nation and is a long way from having any kind of reliable institutions within its “wannabe state.”  GCMS is not a “third world” developing nation context for health care.   In my estimation on a first visit, it measures up as a second world environment  with an institution soon to be declared a university after fifty years from its establishment, that can boast of a heritage already, with a standard approach to problems and a pattern of practice that is acceptable and subject now to improvement.   This mark of maturity and the advance that is possible, makes it truly a “developing nation” whereas that term applied to regions that are in entropic collapse is a cruel joke, a euphemism that implies someone is trying to do something to improve the circumstances rather than just having given up.

 

MAKING ROUNDS ON OUR SURGICAL TEAM’S

INPATIENT SERVICE AT GCMS

 

At the risk of coming later than I should have from the general to the specific on which I have based these somewhat more philosophic conclusions-in-progress, I relate the very effective formal Tuesday morning teaching rounds carried out with the interns—the first year postgraduates pf GMCS who are responsible for patient intake, evaluation, “clerking” them (as it would be described in Briticism) and getting them prepared for the Theater in the event that they might benefit from operation,  One of the first patients I encountered in the ward round was a young boy who had had appendicitis .  it was very late in its presentation, and the family had stopped first for a trial of traditional medicine’s practitioner’s incantations, but when he became remarkably sicker, he was taken to the GCMS and operated upon, being found to have sloughed his appendix off into a pelvic abscess.  This story is identical with the acute abdomen seen in the HGH, and for the same reasons.  I have usually pointed out that some diseases that fill many, if not most, of the hospital beds in the US are remarkable by their absence here in Africa, and I usually lead that list with appendicitis.  There are two such appendicitis patients in this experience of the Horn of Africa, and Dr. Mensur confirms my impression that this is getting to be a more common disease, especially in this young age group.  So, this is a mark of progress!  As economic development and urbanization and modernization continue, there will soon be the luxury of the development of colon cancer, atherosclerosis, varicose veins, hiatus hernia and the killing trio of “heart/cancer/stroke!”

 

ETHIOPIAN GOITERS

A CHACNE TO REVIEW AN ENDEMIC COMMONPLACE

 

I next saw a few patients right down the middle of my “strike zone:”  Two women were admitted with WHO Stage III goiters, and had the Amharic script tattoos stenciled across them.  I asked if the tattoo preceded or followed the goiter, and I was told that it is a cultural practice designed to prevent a goiter.  At least in these two patients, it did not work, and they are booked for theatre the next day   Each of these were cold multinodular goiter, but later I saw two more who were admitted with some degree of thyrotoxicity, one of them a rather readily apparent “Plummer’s Syndrome.’  The latter is getting Propanalol and Propylthiouracil, and I had suggested that each might benefit from Lugol’s iodine pre-operatively at least, to shrink the size and reduce the blood flow through them.  That will be the subject of much of the afternoon discussion after my lecture on Goiter and hypothyroidism in Central Africa. 

 

Here in the Horn of Africa, and particularly in Highland Ethiopia, goiter is very prevalent, with an incidence of 68% in school children—making it the norm and much more common than the absence of a visible goiter.  If the majority of the population has it, how then is it to be considered a disease? This is a starting point question for the afternoon lecture.

 

OTHER REMARKABLE PATIENTS

WITH QUITE ADVANCED DISEASE PRESENTATIONS

 

I encountered three patients with breast lesions---one each of the standard spectrum of inflammatory, benign and malignant neoplasms.  The first was a woman with a very large left breast multinodular lesion without nodes palpable in her axilla,  She had undergone fine needle aspiration (a very good clinical technique I saw subsequently applied to several more patients on this ward round!) which confirmed the clinical impression of Cystosarcoma Phylloides, a borderline lesion between benign and malignant breast cancer.  A second had mastitis, a common complication of nursing.  A third had a very large Stage IV breast cancer which already had pulmonary metastases at presentation.  It was fixed to the chest wall and had thickened the skin in the “peu d’orange” of dermal lymphatic invasion.  Early diagnosis is not the rule here in most diseases, but particularly not the ones that have such low public awareness as the breast cancer which had been relatively uncommon in Africa.  It is another unfortunate score cared of “development;” a disease correlated with economic advance and modernization and urbanization for reasons of factors as yet unknown.

 

I saw one skeletal patient who looked like the photographs of Dachau inmates.  He was so cachectic that he appeared to be a skeleton on display, a result of chronic Tb, but without any retroviral reason for his susceptibility to this very advanced tuberculosis.  One of those bones so easily displayed, was his ischium, and it had abscessed and was draining—an osteomyelitis of tuberculous origin.  All told, I saw four patients with complications of advanced Tb, including one that had a cold abscess of the kind treated in Hargeisa with the yield of such a large amount of pus, and the osteomyelitis of the long bones in one younger individual and of the spinous process (Pott’s Disease) in another.  I had saved up examples of Pott’s Disease from my original African experience in Nigeria which I had projected yesterday during my lecture on Surgery in Africa. I now find it is so common here that it would be recognized immediately by most Ethiopian practitioners even if very rarely seen or known by US trained physicians.  When I had met Rick Hodes, we talked about osseous TB, and he pointed out that two of his own adopted sons had Pott’s Disease and he had brought them to the US for advanced spinal surgery to straighten out the severe curvature of the spine brought on by the collapse of the infected vertebrae.

 

On making rounds later, I passed the medical ward where I had not made formal rounds, and saw a young girl standing in the door way with here robe wrapped over her head, furtively peering out at me.  Even the large billowing robe could not conceal the enormous protrusion of her belly, and I stopped to see her.  My first thought was that she had severe ascites no doubt due to schistosomiasis, but her eyes were not jaundiced.  The medical intern passing by was asked what the diagnosis was, and she fit into the category of this paragraph rather startlingly.  Almost exactly like the young man we treated at Embangweni last year, she has tuberculous peritonitis.  Her huge belly is distended to make more than twice the body weight of the rest of her.  This is under medical therapy, which will take a very long time.  In the instance of the young man at Embangweni, we had to tap off several liters per day just to allow him to breathe, a large volume loss he will need to make up over the course of this continuing treatment.

 

There were three patients with gastric outlet obstruction from chronic peptic ulcer disease.  This is decreasing in incidence in the US due to the proliferation of now over-the-counter antacid regimens, but here it is more common than the other complications of peptic ulcer—bleeding and perforation.  There were two of these patients pre-op for subtotal gastric resections and one post-op. Gastric resections were a staple part of my surgical training as a resident, and almost none of the current group of US residents has any experience at all doing gastrectomy.

 

There were multiple patients with cholecystitis and gall stones in various places, several of them causing cholangitis from duct obstruction and requiring operation with T-Tube diversion.  This is an operation still done by open laparotomy here, although they do have the laparoscopes.  Almost none of the US residents has seen an open cholecystectomy in many years, and fewer still any biliary tract operations not done endoscopically.

 

There were two rather young patients with inoperable gastrointestinal cancers.  One was a young man with jaundice who was explored and the tumor was found to be up higher than the gall bladder in the junction of the right and left hepatic ducts—the so-called Klatskin Tumor.  The position of this tumor ruined my chance to tell them about the physical examination of Courvoisier’s Sign!  But, it ruined considerably more for this young man: he was told without any ceremony that there was nothing that could be done for him and he could go home now.   He rather expected as much, and shrugged, accepting this news as much of African reality has always been.

 

Just after yesterday’s lecture I had given in which I displayed the “African melanoma” a melanoma that arises in the only skin in which Africans do not have a good deal of protective pigment, we came upon a patient in the ward who had had a “melanotic whitlow,” a melanoma arising in the subungual nailbed.  He had an amputation of his toe, and was advised to have his palpable groin nodes also resected but he declined.  This is exactly the set of circumstances that brought about the death of Andre (the Dentiste’s) father in the Congo, as described in “Out of Assa:  Heart of the Congo.”  This man has now returned with a large fungating mass growing out of his groin that is draining and foul smelling, a mass that will need some cleaning up but will not be able to be more than palliated, since it is already outside surgical control.

 

There were three or four patients who had had trauma that had “degloved” skin that was now ready for re-surfacing with a skin graft since the wounds were well granulated.  I saw two patients who had gunshot wounds. One young man had a very high velocity rifle wound of the humerus which was completely shattered with a wide gap between fragments and no function of his severed radial nerve.  It is remarkable that he still has any arm at all, since somehow the vessels were not severed in this explosive injury, and an external fixator was applied to hold the pieces of the arm together.  If it is salvaged, there will not be much use to this ruined extremity.

 

For a few of the patients with an interesting physical finding, such as the tattooed goiter patients, I asked if I could take their photograph and they assented.  I would like to go back without the entire entourage in train and take a few photos of a number of patients who would fit very well into an “Atlas of Tropical Pathology” that I continue to accumulate.

 

I will be the one who does the formal teaching rounds on Thursday morning for the interns and the students who will go with me.  I had moved the lecture from Wednesday to Thursday in the hope that I might be able to become a bit of a tourist on Wednesday, but that time has filled up as well with other patients and their care and a formal repeat meeting with the Dean to formulate an affiliation with GWU.  The lecture that I had though I might give on goiter on Thursday was postponed until Rick Hodes arrives here on Wednesday afternoon and then we would go back together on the first flight Friday morning.  But, the lecture advertised for Thursday is Surgical infection: Management and Prevention” for which I used up my limited awake time after return to the Goha Hotel last night unscrambling from the thorough mix experienced when the ring of the carrousel popped off and all the slides were found scattered throughout the bag.  This was the most carefully organized series of slides and it had taken several sets of tries to re-organize it from its total disruption.  It is now on the schedule for Thursday and the goiter presentation is prepared for Tuesday afternoon after we had completed our rounds and a visit to the OPD and minor surgical suite where Dr. Mensour carried out an endoscopic study of a patient with reflux, and then we adjourned for lunch down in the town

 

A QUICK TRIP “DOWNTOWN”

PASSING KING FISALIDE’S CASTLE AND 44 CHURCHES

 

We had made a quick round of the laboratory where they have remarkably new equipment, including the autoanalyzers, and they can do most all the blood chemistries and special tests on advanced notice.  They are particularly good, of course, at identification of Ova and Parasites, a standard item in my LSHTM Laboratory experience.  It is of interest that the pathologist here, who comes from a southern region of Ethiopia, was himself admitted with the diagnosis of “Kala Azar.”  This is the nasty visceral form of Leishmaniasis.  It is treated with pentamidine, a substance I got very familiar with when I was about the only one with any information about pneumocystis carinii pneumonia before AIDS made it a commonplace.  On one review of my CV, someone once asked me how I was always ahead of every curve, having written extensively about pneumocystis ten years before everyone had to be aware of it and its treatment!

 

We drove out for a fleeting view of the business district of Gondar, a bustle of activity in a colorful swirl all around us. Donkeys are prancing around women with large sacks on their heads as horse drawn carts are pulled through the pedestrian traffic amid impromptu stalls of fruits and vegetables set out on the curbs.  The “old market” of corrugated sheets is being replaced by stalls that are in two levels, and we went up around a bank—banking has become a big business here in the last few years—and into a restaurant.  We ordered fish and I drank Fanta—I always seem to need three times the fluid volume of anyone around me and Dr. Mensur had already picked up on that and had ordered the second one for me before I had noticed it.  We talked about the era in 1630 when King Fasilide was emperor, ruling from Gondar and its castle as the capital.  The Greater Abyssinian Empire spread over Yemen and many other parts, at the “High Water Mark” of this region’s influence.  Now, they add ruefully, it is at its lowest ebb, with the secession of Eritrea, and they have become landlocked, from having been a shipping and sea power. The Eritrean War was a big thing here and the bitterness is still hanging over the relations with the outside world.

 

Sudan has a Christina and pagan south and a Moslem north, and has been blowing apart as long as it has been a “nation” declared in the fine old British tradition of drawing lines on maps. The southern part is now cooperating with the US in its anti-terrorism drive, and as a reward, has had several major developments—including a big industry here in Gondar.  The heavy tandem tanker trucks are hauling refined fuel from Sudan through Gondar where a depot occupies much of the “reviewing stand” as there is here a copy of the large plaza for May Day type reviews seen in Moscow and Addis Ababa.

 

“Addis” means “new” and the capital’s name means “New Flower”.  Addis is only 115 years old and is recent in the longer history of Ethiopian power.  Because of the earlier power of this region as the capital, the local Amharic group imposed its language as the national language, even though the group probably numbers only about 16 of the 70 million Ethiopians.

 

MY VISITING PROFESOR KEYNOTE LECTURE

 

We returned and the group gathered for the lecture.  Included in the group were a young man and woman who turn out to be German students from Leipzig University Medical School on a three month elective rotation—exactly the kind that I would be setting up for future GWU medical students.  I gave a long and detailed lecture, sparing them none of the philosophic nuances about the implications of intervention in an adaptive process.  There was a longer discussion this time, since they had figured out that I was not averse to opinions. 

 

U crawled back after another full day, and essentially crashed early.  I managed to select some post cards during the brief flurry that the gift shop was open in the Goha hotel as a horde of tourists descended, including a bus load of Italians, another of Germans, and a group, already here. of Japanese. I was the only primary English speaker in the dining hall when I came in, and the attentive staff had whisked me to a special table reserved for the “Professor.”  They are very impressed with my presence here, since they picked up on the fact that the Surgery Professor Dr. Mensur, whom everyone in a town of 200,000 knows, had brought me here and had shown deference in carrying my bag for me, so they are all trying to outdo this gesture toward me. I had taken a large bottle of Highland Water back to my room, declingin the Desha Beer, the local brand named after the highest peak in the Simeian Mountains the target of many people who come to climb in the Roof of Africa, as they designate the Simeian Mountains,  It was an hour after I had gone to bed, that I had heard a knock on my door, as the clerk from the gift shop who had tallied the postcard purchase on my room number had come by with some one who could speak English to inform me that she needed to have cash instead.  So, my early evening was punctuated with my sole purchase completion in Gondar.

 

The tourists who are making the rounds of ancient churches and seeing the sights such as the cataracts of the Blue Nile Falls about 100 km from my Goha Hotel are seeing what I would like to see in the orientation to this area.  For me, that will have to wait until the “next time” a perpetual signal about any of my opening round visits anywhere.