FEB-C-5

FINAL CLINICAL DAY IN GONDAR,

MAKING TEACHING ROUNDS WITH THE

INTERNS AND RESIDENTS, THEN SENIOR STUDENTS,

THEN FINAL LECTURE, A QUICK GONDAR TOUR,

AND A RECEPTION DINNER WITH THE DEAN

February 19, 2004

The day began early, as I got up for the first time ready to type up a chapter or two entries in the Gondar series, and joined Rick Hodes at breakfast. The car had come for me, actually the Mercedes diesel van, had arrived, and so I left early for my rounds with the staff and later teaching rounds with the students. I arrived early, and a good thing I did. I waited as streams of patients came flowing around me and their family members queued up in front of the respective wards. I watched and waited. I know that I am wanted somewhere else than here, and I am a scarce resource for their teaching, a freebie professor who is leaving tomorrow, which is why it make s it doubly annoying that I am awaiting in one palace and they in another each probably calculating that the other is just proving the point about being on African time.

I waited over a precious hour of the day. Then I saw a small knot of the students and interns coming along the walkway previously crowded only by patients who do their best to appear not to notice me, as they clearly had from under their blankets wrapped around and over their heads. I had no explanation of where they were, and I had waited here having told everyone who came through that I was here, but getting no response. This is the hang up about starting in to work anywhere new and getting lost in the place and time in which you are such a high profile participant. I got very active in their “Intake Conference” where the patients were discussed from the week’s admissions and emergency operations. In the stilted phrases and a whispering quiet voice the interns presented each case. “This 61 years old male had stick injury to the side of head and ran away. He was struck upon the side of the leg by a road traffic accident and then when he attempted to walk he fell down in pain upon his left side.” First I have to strain to hear, then I have to translate, then I have t figure what the nature of this injury might mean to me. I parsed out each of the patient problems—a penetrating stab wound of the abdomen that was a blunt injury to the right upper quadrant; a sucking chest wound that was closed and then developed into a tension pneumothorax; an AK 47 GSW to the abdomen eight road hours away who survived to arrive at the hospital, so it must be self-selected case that he had not died enroute to be able to hold together long enough to be operated here for what turned out to be multiple small bowel perforations. He had those patched and he joined two others on the ward.

I had critical comments to make on each case, largely since the problems represented were staples of the kinds that any professor in the trenches for a long time would enjoy. The fun parts are in the decision making process, and grunt work is common in any busy clinical service; we could smile at the experiences in common with the frustrations of the system on either side of a world away.

TEACHING ROUNDS AT BEDSIDE WITH THE SENIOR

MEDICAL STUDENTS OF GCMS

Now came the time the students had been nervously prepping for—their chance to make rounds with and present to an American professor of surgery. In their dreams they might hope to be refugees in the US and there to make application to the kind of school that would have the kind of American professor, who, by some good fortune, had come all the way over here, so they might hope if they performed satisfactorily here they might be able to hope to do it there—and maybe even attract his attention so that he might want to recruit them and take them back with him. Each of them carried a spiral notepad which they filled with regularly spaced notes. They had each worked up (“clarked” a patient in the fine old Briticism) and would now be able to present their patient to the professor.

The first one was a 34 year old woman with a breast mass. As happens altogether too often, she was treated with antibiotics, since it is, after all, one thing we can do, and who knows if it might not help? How can it hurt? This continued for nine months as the rock hard mass filled the breast and involved two lymph nodes in the axilla. The patient presents, therefore, as a late stage breast cancer, with a disease just on the outside margin of surgical treatment, with a poor prognosis even if all the treatment options are pulled out and employed right up front. The patient did not understand my English language as the students, who speak a clipped English with clinical colloquialisms, did, so we had an extensive discussion and bedside examination. By the time we moved on, the students had filled four or five sheets in their note pads.

Next was a woman with a goiter, and, of course, I might have something to say about this condition. The remarkable thing is that this woman also had been treated with antibiotics—after all, it could help and certainly can’t hurt. I said that the ward was full of patients that made the need for the afternoon lecture most imperative! The subject will be the management of surgical infections with special emphasis on the use and abuse of antibiotics.

We then examined a 62 year old farmer who had acquired a direct inguinal hernia, and, yes, you guessed it, had been treated with antibiotics for four months, which did not seem to make the hernia go away, but certainly did give him diarrhea. “It certainly cannot hurt, can it?” is a phrase I wanted them to remember. Each of the patients had remarkable physical findings and the patients were quite cooperative in the teaching rounds allowing multiple student examinations---looking not a lot different on the big ward as “Old Main” of the UMMC when I was a student wearing my starched white coat and trying to impress Gardner C. Child III, chief of surgery on our walking rounds.

The commonest cause of intestinal obstruction in this hospital is sigmoid volvulus, a particular problem of northern Ethiopia. They average two or three such patients per day, and the lifetime experience of the average American surgeon might be that same number. It is not just the diet of the Ethiopians, since the diet would be much the same Ngera in the south where it is not as frequent, and here in the north (= “Simeian”) which includes Tigre and Gondor of the Ethiopian Highlands along the Sudan border. The explanation is said to be a genetic one in which the people here have a along sigmoid colon mesentery and a floppy redundant colon. The treatment offered is the resection of the sigmoid colon electively after reduction by sigmoidoscopy, but most of the patients refuse, and come back in with recurrence, and have to be done emergently, sometimes with gangrenous bowel. This is one disease entity that anyone from the US would quadruple his or her experience within a very short exposure here.

RETURN TO THE HOTEL GOHA

FOR A BRIEF LUNCH FOLLOWED BY THE LAST

LECTURE OF THE VISITING PROFESSORSHIP

I was brought back to the Goha Hotel perched high on its hilltop for a lunch stop. I had done this once before when I had not eaten lunch, but came back to try to type up some notes before falling asleep. This time, I ate lunch and prepared for the lecture by again sorting out the slides, which someone curious had looked into as they had been stored in the surgery office, thereby scrambling them in order and upside down and backwards in re-installing them in the magazine for their different slide projector. In the future, a CD or Power Point presentation should present this last minute scrambling to put slides in order. I passed thorough the large “parade grounds” that Gondar has as a part of its Mengistu heritage, in which the large cities like Addis have their big plazas for review of the troops and mass demonstrations to “foment a feeling of unit cohesiveness.” The three tableaux at the backdrop that had featured Marx, Lenin and Stalin, now have a local booster’s logo, and the extensive rows of bleachers are now the ranks for the tandem fuel trucks driven down from the Sudanese refineries. It is a nice irony that this power plaza for the people of the communist’s era under Mengistu is now a rallying point for capitalist distribution!

Many of the professors here now got their start during that era—the Dean was sent to Leipzig in East Germany to study Physiology for six years as a cooperative project from the fellow communist state, as had Muhammad who studied surgery there, and another fellow I met tonight who was a health economist—an ideal field to study in a communist state. With the collapse of the Soviet Empire and the reunification of Germany, there is less exchange with the East, and the Leipzig connection continues only in the form of the two medical students I had met on a three month elective. The University of Leicester in UK has a link in which someone comes down to Gondar every three months and two such doctors arrive today. Mensur has been there twice, once for the learning of endoscopic surgery in a laparoscopic two month course, and the second time to learn the organization of s surgery residency. Gatchen has been there to learn Urology, and Muhammad Orthopedics for a period of a couple of months. This seems to be their best live “link” now.

Then came my final lecture—the much anticipated one on surgical infections, with heavy emphasis on the random use of antibiotics and the nearly promiscuous application of a number of useful drugs rendered useless by their unprincipled application. I pulled no punches and gave the full lecture as it might have been done in the US teaching programs, since the earlier two lectures were geared very specifically to African problems and their solutions. The audience included Rick Hodes and a student applicant of his named Adam. A number of physicians also attended including the woman I had met when I went to examine the young girl with TB peritonitis. There was a protracted discussion and question/answer period following, which was unusual for Ethiopians and was in response to my repeated encouragement.

CURTAILED TOURIST VISIT

I had been promised a tour of Gondar as my last item on the agenda, and the Mercedes van and its driver—hardly an informed tour guide—were commissioned to take me to the Fasilides Castle and a classic church. WE arrived after five o’clock PM when the two structures were closed and the tour guides who are furnished at each site were already gone. I wandered around the mostly locked up fortress and walled church—which looks a lot like medieval Europe transplanted to an African setting, with the ubiquitous African doves perched in the thatched eaves of a very pretty stylized church from the era four centuries back. I would have liked to have heard the full explanation of much of what I had seen only in a cursory glance. I would even more have liked to go up to the Blue Nile Cataracts and climbed Mont Dashen, highest peak in Ethiopia and the top of the Simeian Range. Even more, I need to get out and hunt the forested mountains for Nyala and Wailua Ibex. All will be coming to me—next time.

THE DEAN’S FAREWELL DINNER AND RECEPTION

FOR ME AND THE US EMBASSY PERSONEL AND OTHERS

Dr. Mensur picked me up, wearing coat and tie, and we went off to the Restaurant Misrak (which I learned means “East”—so, now with Simeian meaning north, I have two of the four cardinal directions in Amharic.) I was the guest of honor with the US Embassy represented by John Dunham, cultural affairs officer from Addis. He has been here in Ethiopia a year and a half, then goes to DC for a few months and comes back to Cairo as a Consular Officer. But, now for the big surprise: where is he from, and what is his background?

He was born of missionary parents in Kodicanal India, the same place that Bill Rambo and Tim Harrison were born. He said that this area is very much like that part of southern India since the altitude and latitude are the same. His parents were in Oman as missionaries of the RCA Reformed Church of America. His father came from New Jersey, and his mother from—would you believe?—Pella Iowa, and he attended Hope College! I told him as a Calvin graduate I would not be allowed to sit with him at the head table any further!

The group included many of the leaders of Gondar –soon to be University—presently for the next two months still Gondor College of Medical Sciences. They toasted a potential link with GWU and with the American counterparts to the two University of Leicester physicians just arrived and present. We had a discussion with a fellow named Johannes, an orthodox Ethiopian church member, who gave a bit of the church history.

WE discussed some of the historic movements back and forth through this area of the world to learn more about the various popes and schisms. Apparently this orthodox church split from the Coptic church of Alexandria over the succession issue that I remember vaguely for the Church History as a controversy entitled “Filioque”—the Holy Spirit was derived from “The Father and from the Son” that was crystallized in the Athanasian Creed. We spoke about the Felasha—the term now used for the Ethiopian Jews, literally the term means “outcasts”. There were several present who claimed to be Felasha, and it was pointed out that Amharic is a Semitic language. This, of course, is a reason that Rick Hodes is here, since the Jewish community is concerned about brethren in an environment in which they might continue to be outcasts. I learned a bit, but was also referred to a large tome on the history of the flow of peoples and ideas through this area of the world. That. Along with tourism and adventure travel, may have to be reserved, as most things were in the Congo at my last visit, for “la prochain fois.”

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