FEB-A-16
THE FIRST ELECTIVE “THEATRE DAY”
IN
TOO MUCH OF A GOOD THING MAY BE ALMOST
ENOUGH!
MAKING CONNECTIONS:
AND LOBSTER DINNER IN THE DESERT WITH
EDNA ADAN AND HER MATERNITY HOSPITAL STAFF
FEBRUARY 8, 2004
“Be careful what you wish for; you may well get it!” It has been said before, and the “it” in this case what the students had wished for was a large number of patients with a high volume surgical experience with abundant tropical disease in this exotic African setting. It has arrived.
We got out early this morning as I had been thinking about the “Tar Baby” that always catches us as we loiter later in the afternoon before returning and usually find ourselves trapped by the odd patient coming in in crisis. We would try to work more efficiently today, and when we had completed our theatre and clinic gigs, we would split, thereby precluding our options for getting “Tar Babied.”
“MAKING CONNECTIONS”
MEETINGS WITH FRIENDS AND “COMRADES IN
DIS-ARMING”
AND EVEN PROGRESSING TO AN EMAIL SUCCESS
We met a
few folk at our Hotel Mansoor, where we are cared for as the resident
pets. The owner, who is Abdel Kader
Elmi, had come here from his other home in
One of
the members of this group is a rather prototypic Afrikaner, who points out to
us that he had "lived all his life in
One of the delegation in training a group of eighteen police who are being trained as a bomb squad is a Zimbabwean doctor named Chaitama (“Quite switched on, that black,” says the Afrikaner gratuitously about his colleague) who graduated from Paranyatwa Hospital in Harare of the University of Zimbabwe, the African nation in a free fall of de-development. This latter tragic fall is pointed out to the three students by the Afrikaner as a far more typical phenomenon, which, even if true, is annoying coming from him since he seems to delight in the inevitability reported by a self-fulfilling prophet. Dr. Chaitama reports remembering a visiting surgeon Senior Fulbright fellow in 1996 when he was a senior student in the Department of Surgery in Paranyatwa who lectured to the group on goiter. “I thought you looked familiar.”
We spoke of the activities they have in the EOD here, and all along the areas of the Ethiopian/Somaliland border, as well as other places in the region as in Eritrea. I told them of my familiarity with the landmine disposal activities along the Petite Lebombos on the border of Swaziland, South Africa and Mozambique, which I had witnessed in the Mozambican long and unfinished task of landmine disposal in the south and along the Malawi/Mozambican border in the Nyasa province near Lichinga, where the Brits of the landmine disposal crew served as my “walking blood bank” donors. Dr. Chaitama was unfamiliar with some of the medical reports of the devastating injuries to children particularly of the landmines that had brought the group I have been a member of to advocate a world-wide ban on landmine manufacture and deployment. I gave him the name of Jim Cobey, a Washington DC orthopedist, active in this effort, and will connect them by email. This group has won the THIRD of my Nobel Peace Prizes! First was my membership in the IPPNW, (International Physicians against Nuclear War), the first group to receive the Nobel Prize, and the second was MSF (Medzins Sans Frontieres.).
I had spoken with Abdel Kader Elmi and his influential group of the ‘shakers and doers” of the Somaliland indigenous elite who have been going it alone in their upscaling development efforts two nights ago. [“Switched on” indeed, that group!] I had spoken with him about the underdeveloped Red Sea port of Berbera, which we will be visiting for several days next week. I reported to them about Joe Gangi, my colleague back in Maryland, who has a process for high volume manufacture of cement using salt water. This would get around one of the principle inhibitions to large scale construction, particularly in a desert sea port—the severely limited fresh water. It is prohibitively expensive and energy-intensive to de-salinate sea water, and a salt water cement would be a “marriage made in heaven.” I left him with all the contact numbers, but also we immediately called Joe Gangi at 9:00 PM here which would be noon there. His cell phone has a “caller ID lock” which means I first had to identify myself for a call back, and I did so, with the call back ID of Glenn Geelhoed of Hargeisa Somaliland. Since I did not hear a return call, I fear that, once again, I must have a mis-copied phone number for Joe Gangi, since the email also bounced. We will try the office phone number as the next long distance attempt tonight.
I had attempted to email and “attach” the most recent several chapters of my report on the Somaliland mission last night. I had a complete loss on my first effort, since the “attachment” process took so long that the email connection had ‘timed out” and the typing of a cover letter on line similarly overwhelmed the slow server, so all of my one hour’s efforts on-line were an irretrievable non-message. In the spirit of the working through the “infinite threshold of frustration,” I went back to my previously balky laptop, which at least is not time-limited with a reliable source of electricity to keep the battery charged, and repeated my cover letter (see Feb-A-14) and go the advice from another of Abdel Kader Elmi’s relatives in the Hotel Mansoor who knows the computers of the Business Center and their satellite connections. “It is always very sloe at 6:00 PM, so you should try again after 8:00 PM” he advised. Sure enough, after cutting pasting and attaching, I believe I have succeeded in sending the first messages through my server from my internet access. The previous chapters that had been sent through Kevin Bergman’s’ yahoo account had apparently arrived, since Somaliland’s US Ambassador de facto Saad Noor reported in response to the earlier connection that he felt like he was standing side by side with us as we were moving on through the mission, and that the account should be a book (Isn’t it always?) or film!
THE START OF OUR “THEATRE DAY”
After a brief look around the wards to check on only the sickest patients, one of whom we had propped up yesterday in congestive heart failure with digoxin and furosemide, who looked like he was agonal today and about to die, we headed to clinic and began with a cute six year old girl who had diarrhea. She had just entered the age in which she was sexually differentiated, i.e. she now went from a colorful toddler to a young girl who would now be buried under a burka and head coverings from this point forward in her life. She received treatment with rehydration salts and metronidazole for amebic cysts identified on O & P (Ova & Parasite identification on microscopy), and we also gave her the stick on tattoos as a small gift. We then took her photo with Kevin’s digital camera, which we could immediately show to the young girl, for me to get the more amusing shot of her peering forward in wide-eyed wonder as she looked into a small box and saw her digital image looking back at her through the slit for her face and eyes. This might have been the last leisurely patent visit we had, since among the next few patients was a tall 22-year-old Somali youth whose father and brothers helped him to stagger in. At once glance, and even before the one hand cursory examination of his belly I identified a surgical abdomen and devitalized bowel with peritonitis. He is going to Theatre and bump the first prostatectomy on the schedule.
How does one buy a ticket into the theatre in Hargeisa Group Hospital? The surgeon sits down with the family and prepares a shopping list. Itemized requests are written as a prescription for everything from gauze sponges, to sutures, to suction catheters, to the Ketamine for anesthesia, to the dressings and drains expected for use in this case, It pays to estimate for more than is needed in a “worst case scenario” since the under estimate will come out of someone else’s previous over estimate. The family is then given this list and they go shopping over to the pharmacy or anywhere else they can get it, and then come back as quickly as possible with the box containing the expendable supplies. While this was happening, I saw several patients, literally at the Theatre Door.
One was a mane with a large mass at the angle of the left mandible, which was firm, nodular and fixed to the tissues around it. It may be a mixed parotid tumor with malignant degeneration (present three years with rapid growth and symptomatic problems the last seven months, including now voice change and inability to swallow) or it could be a glomus jugulare as we had undertaken in Mindanao two years ago as the biggest operation we had done there requiring many of the staff to donate blood. The differential requires a biopsy. Since there are no such services inside Somaliland, the very expensive and late transfer of the tissue to Addis or more expensively but faster Dubai is a more formidable barrier than the treatment. But, we can biopsy the tumor and carry it back to GWU and email the result twice as fast and at a zero cost, so we will do that next Theatre Day.
I saw a woman with a breast abscess during nursing, drained, leaking both pus and milk from the infected breast. Before leaving clinic I saw a man with a very large inguinal hernia, with the complaint of a cough—the latter to be resolved before the hernia repair on the next day, A woman with a large goiter was referred in since they knew that this was something I could possibly “read up on” overnight, Kevin said. We also had seen some pelvic masses to differentiate ovarian or uterine masses on ultrasound the following day when we will try to get the key to open the room where the scanner is stored.
Back at theatre, a relatively young woman was transferred over to us from the TB Hospital. She had local practitioner’s scarification marks nicked on to her belly denoting that we were not the first practitioners to opine on her care, but the branding irons did not go deep enough for her purposes. She had an enormous “pointing: of a fluctuant mass in her left iliac fossa, and a somewhat smaller swelling on her right. She had dissected all this pus down from her retroperitoneum, and she was surprisingly comfortable in her belly itself, with no peritoneal signs. She was not febrile. She was cachectic probably from her underlying TB illness, but this was a very interesting complication. She had an enormous ‘cold abscess” a tuberculous psoas abscess tracking down the fascial muscle planes to present in her groin, and would have gone down into her upper thigh. I called each of the students over in turn, and then set up Jay Maguire to do the honors. An aspiration was done to prove the cold greenish pus, and then an I & D (“Incision & Drainage”) was done feeding a catheter drain all the way up and into the retroperitoneum. More than the predicted eight liters of pus came out filling emesis basins and the trash can. The right side may be draining through the retroperitoneal pelvis to be completely drained through this incision, and if not, we will vent it on the opposite side the same as the first.
By now, the acute abdomen 22-year-old tall Somali youth was ready for his single shot of Ketamine, and an opening of the abdomen, immediately confirming the abundant pus that came oozing out. The cecum was infracted and the site where the appendix was no longer had anything attached to it—an autoamputation of the appendix. The stump was oversewn and a big drain was put into the pelvis, and this patient was much better immediately despite this significant presenting crisis. The Somali sheepherders that were his family tried to follow me after I made a brief reassuring explanation that was not understood in words but in body language, then they eagerly cleared a path for me through the waiting crowd, touching my hand and raising my arm like a prize fighter coming out of the ring victorious. They understood that he was “bad sick” and that he was now going to be better, God willing in my terms, or “Inshallah” in their terms.
HOLDING COURT IN HOTEL MONSOOR,
RECEPTION AND LOBSTER DINNER,
WITH FOREIGN MINISTER EDNA ADAN AND HER
STAFF
After completing all the patients reviews at the outpatient clinic---for which our MAP pack drug stock has saved more than the day---we returned to the hotel Mansoor, characteristically late for lunch. We are now able to appreciate a few of the more subtle relationship problems in dealing here in Somaliland and are looking for a way to surmount what might be considered social services deficits among the patients. In the last group of patients we had several desperately poor women who had small children clinging to them, and who had zero social resources with which to cope. One came with a small baby and a five year old girl clinging to her emaciated frame. She had, of course, to produce a physical complaint to be seen, and her “all overs” were gone through quickly (from my first African trip, at the same age and stage as the students with me now I recall the most common presenting complaint: “My whole body pains me.”) But, her malaise came from a social problem that had resulted in her literally starving to death in front of us. She was emaciated and could no longer nurse the baby. We gave her vitamins, and we gave the kids chewable vitamins which we found upon scrambling through the pack—ironically cheerful colorful animal-shaped pills in the desperate circumstances in which they are dispensed. But, she had one insistent demand---that she become our full-time dependant and be taken care of by us. She returned repeatedly, since she was sure we had not understood, since we had not satisfied her request: she needed to attach herself to us, not just to better her lot in life, but to survive. Faisal, our nurse/translator had adequately transmitted her insistent solution to her problems to us, which I would have considered unrealistic, but she had no there way to make it, and would not leave until she had joined us. Faisal explained that her husband had left her, and that in an Islamic Somali society was the sole social security she had, and now she was bereft, and probably would die if nothing could be done about her primary problem which seemed that her marital union that was her lifeline had been dissolved with the three times repeated “I divorce thee.” There was no family and therefore no social safety net in this “non-state.” She could not appeal to Oprah. She could not go to the mosque. She had run out of options, and the only hopeful “Manna from Heaven” was right in front of her eyes, and she was not going to let go of it. IU tried to explain that I had not been shopping for another dependent, and that my mobility would be considerably interfered with by acquiring this instant “family” not of my making nor wishes. When I suggested other sources of support to be tried, the answer was brutally simple; they do not exist.
I went over to review Kevin’s patients on the other side of the hall, and he was in a similar situation, where he was trying to deal with a woman and her small children who had no money and had been separated from a husband and paternal family. When I heard that they had been in Saudi Arabia, I suggested that they return there since there would be good support systems through the state social services from the Saudis and their largesse. It was patiently explained to me that this was the primary problem: these women have been exiled from Saudi Arabia, and they had no claim on them or any other state or social system, since they were now resident in a “non-state.” Kevin was asking Faisal if it were appropriate that he give some money to the woman, but, this short term handout would not be a solution except to protract it. It is not just this “nation” that is legally invisible. These are "non-people" and the linkage of the women is particularly precarious if they are ignored by a husband who is free to abandon them.
When we returned to Hotel Monsoor, we met a number of the agencies working as volunteers in Somaliland and I asked about what could be done, and there was a bit of a shrug. There are targeted programs dealing with landmines, or other well-defined problems for which the kinds of grant proposals can be put together, but the social service problems I had described were nonexistent.
We were scheduled to meet with one woman who has made changes in the Somaliland society by sharply targeting her own beneficiaries and working hard on services that are brought up to standards that are uncompromising.
WE ASSEMBLE FOR DINNER WITH EDNA ADAN,
WITH HER STAFF FROM THE MATERNITY
HOSPITAL,
AND LEARN ABOUT THE HARGEISA DEVELOPMENT
IN AN UPSWING OF FORTUNES FOR THE
SOMALILAND
PEOPLE DESPITE THEIR START AT THE BOTTOM
OF THE
POVERTY AND DISEASE INDEX