FEB-A-18
OUR “THEATRE DAY” IN
OVERFLOWS WITH PATIENTS SPILLING OVER
OUR CAPACITY IN OUTPATIENT AND OR
WITH VERY INTERESTING “ONCE IN A
LIFETIME”
CLASSIC CASES, DRAWN DIRECTLY FROM
YESTERDAY’S
“TROPICAL SURGERY” LECTURE
THE DAY CONCLUDES IN A TELEVISED
RECEPTION AND DINNER WITH OUR HOSTS ON THE HOSPITAL AND HEALTH COMMITTEE OF
HARGEISA COMMUNITY LEADERS
February 10, 2004
Timing is everything. Be careful what you wish for—you might very well get it and a lot more than expected besides!
These two generalizable aphorisms
fit medical missions in particular in a very big way, and today, my senior GWU
medical students realized this in a rush of busy clinical discovery. Today was supposed to be our general surgery
operating day, and that we did, also.
But it was additionally a very big day full of patients overflowing in
two clinical sessions, caring for patients that ranged from neglected birth
defects of the desperately poor to the wife of the Director General of the
Ministry of Health. We are ending the
eventful day with a dinner for which we were the centerpiece hosted by our
Mansoor Hotel owner and family to include the
The busy clinical schedule seems to be matched by, and perhaps may be due to, a very much intensified “programme” being developed by influential collaborators among our hosts and the international and indigenous international community. This is best exhibited in the reception and dinner this evening that brought the “Health Committee” together by our Hotel Mansoor host.
OUR
OUTPATIENT AND OPERATING THEATRE
CLINICAL
EXPERIENCE ON AN OPERATING DAY IN HGH
They got the message! This time they were already here in force when we arrived before 7:45 AM at the OPD of Hargeisa Group Hospital. The patients were jammed up against the doors of the examining rooms elbowing to be the head of the queue before those doors were unlocked or before any of the nursing staff had come by for help in translation or crowd control. This time they knew we would be leaving the clinic to go to theater, and that at least half of us would be doing something else than granting them their wish to have medicine, free, for things that no medicine will fix. One woman had carried in her pocket a meaningless packet of papers with her name and registration upon them that was supposed to be information enough to compel us to operate on her that very day. The papers were folded over and had been unfolded so often that the ink of the copies was invisible at the creases, but there was one of the pages which showed an ultrasound scan of a very much enlarged uterus and an ovarian cyst. She had been advised in a refugee camp that she should take this to a surgeon and have an operation. How long ago was this set of papers generated and this advice recommended to her? Three years ago she left the camp, but here she was today at the first surgeon she could afford to see since the price was right. We sent her for a repeat scan to see if the fibroid uterus she no doubt had then is unchanged—as have been her symptoms over this interval.
Another man brought each of his family, and there were problems with each of them revealed one after another, and each were here to be fixed, apparently through some implied promise they had herd from the BBC TV or by word of mouth that had brought in the patients before the broadcast. A boy about eight had a hypospadias, second degree, and needed an operation, actually a series of staged operations, for reconstruction. He had come today, and it would all be done today, before the other procedures needed by the rest of the family were carried out, wouldn’t it? I explained that he could benefit from a series of staged procedures that would take over six months and we would be gone in a few days, so he should see Dr. Suleiman, and we would suggest the kind of repair procedures he might benefit from. “But, no, these other doctors are no good, since they will each require money, and we are here now since you will perform all these procedures free.” Sorry to disappoint, but perhaps that is an unreasonable expectation, from whatever source it had originated; now, here are the steps to be taken to get the child started on a plan for his eventual completion of repair.
By this time, I was due in theater, and would have to shut down one of our examining rooms and take with me one of the students at least, in a rotation that would allow each of them to be involved in reconstructive procedures. The first was a patient with a very large left inguinal hernia. He was not yet ready by the 9:00 AM time suggested to me when I had gone to theatre to check on the timing of our operations to mesh the schedule with the clinic, and I could not escape the crush at the door, as more outpatients surged in to catch the doctors before they were distracted elsewhere. The reason the fellow with the hernia was not ready was that, as you had heard in a prior day’s operative list, the “ticket to theatre” is that the patient’s family is given a list like a prescription. The list includes all the items that are expected to be used in the operation proposed, including the sutures, gauzes, anesthesia, dressings, drains and post-op medicines, and this list of about twenty items for a typical hernia operation is then brought to pharmacy where the items are purchased and brought back in a box to the theatre. The daughter who had brought him to theatre had received this prescriptive list, and come back to clinic and stood in the queue until she was let in to be seen, and she produced the list for us, so that I might run around town to gather up such supplies as had been prescribed for the operation I was then expected to do! Well, do you not have sutures and gauze and surgical supplies you have brought with you? And aren’t many of the items on this list included within those packs back at your hotel or wherever else they may be procured? Perhaps there may be an excess of charitable zeal anticipated by this group of people, however they came about it!
RECONSTRUCTIVE
REFERRAL CLINCLA PROBLEMS
AND THE
MEDIA USED TO PULL OUT SUCH PATIENTS
FOR
REPAIR—HERE IN AFRICA AND ASIA
We saw other patients who might
benefit from operations, and a number of more tragic conditions that needed
specialty care on an ongoing basis. A
number of these were pediatric surgical needs that would have to be referred
out of the country, when the families could not go even so far as out of
town—and this is the largest resource and capital city of the new nation. One of the children was an eight year old
with a roaring heart murmur from a large ventricular septal defect. For some reason, in our many trips to the
Himalayas, of the patients picked up in the screening clinics, this is the kind
of problem that seems to be the one that
is always picked out for appeal for donor funds to carry the patient out of the
environment they are in to some urban center to have “surgery”—the operation
proposed seems always to be a cardiac one, since that big ticket item is the
one that makes the most heart-tugging appeal, and several such have been
selected out of the rural poor people to have been transferred to Delhi to the
AIMS (“All India Institute of Medical Sciences” where I had once lectured, the
“NIH referral center” of India) at a cost of about five thousand US dollars if
the purchase of a heart value is included in that “box of pre-op supplies to be
purchased” is added in. At such a cost
for this single patient with only one kind of “high end” abnormality, this
entire mission can be funded for the relief of scores of patients surgically,
hundreds medically, and thousands in public health measures. But, the photo op is so much easier to
understand at a “quick read” or for a TV sound bite in the drama of a heart
operation. We opened up our own drama
department very shortly and then added our own media and PR campaign later in
the same day.
“Operation Smile” functions to effect repair of children’s congenital deformities through the appeal to the donor and volunteer communities of an innocent child with a problem that can be reconstructed through a telegenic before and after problem. We had several that do not make for a quick and easy understanding such as clefts, but whose needs were greater since the condition required prolonged follow up and special services for such children who would not be cured by a one stop intervention. One interesting familial problem included a young girl with cerebellar ataxia and an ocular abnormality that included congenital cataracts. She was able to stand but unable to walk without assistance at about age seven since she had an unstable gait, despite lack of any spasticity. What made her particularly interesting is that she had two siblings with the same problems, and one had undergone eye surgery repeatedly. This meant that they had achieved some kind of contact somewhere with specialty services and they should try to return. I suggested AMREF (The “African Medical Research and Education Foundation” centered in Nairobi, founded by Michael Wood and supported by the British as a charity, with a large New York office for support—this was formerly called the “Flying Doctors” service.) We tried to hook up several other patients with referral services, with a few of them very urgent and requiring immediate repair of major congenital lesions that would otherwise be life-threatening. The problems of some were compounded by the desperate poverty of the patients’ families, such that they could not manage to eat here, and could hardly be expected to do so as well as travel and continue support in s bewildering foreign environment. I saw the next one immediately.
A poor woman was carrying a baby under a headdress she had draped over it. The wide-eyed baby when popped out of the folds of this cloth looked as fetching as any anywhere on earth as it tracked with big eyes the adult world around it and particularly this one fellow who by now was wearing this funny-looking hat and a scrub suit. But, as startling as I might have looked to an infant, the infant was especially interesting to me and about monstrous to my students. I called them one at a time to come to see her, even though it meant they had to brave passage through the Maginot Line outside the clinic doors and run the gauntlet of the corridor through a thickening crowd of increasingly anxious aspirants for their services. When the baby’s wet cloth is removed, a cherry pink exteriorized mucosa is the most obvious defect seen in the lower mid-abdomen. She has “Extrophy of the Bladder.” I had encountered this problem early in my career on several occasions by being in a highly specialized referral center—Boston Children’s hospital Medical Center, where such problems were forwarded as a very rare occurrence in the general population funneled to such a center. One complaint frequently raised by each of the specialty referral centers in which I have worked is that the number of such extreme cases had decreased in each leading center because of the proliferation of trainees going out and setting up their own centers and diluting down these rare congenital abnormities that no longer concentrate in single centers of referral. Where is the peak of this pyramid now? I could surely use it!
This child needs to be in a “Children’s Hospital” right now, and the closest one I can imagine would have any services that could address the long-term and staged repair of this abnormality (as I once was involved in at Boston Children’s Hospital) would be an urban center such as Addis Ababa. So, I have taken the child’s particulars and said that I would go to Addis and check into the possibilities of referral there and send back email to Dr. Suleiman what I learn in Ethiopia. Meanwhile, there is nothing we can do here for the child. Surgeons do not fix such a problem, a complex social system in a city geared to rescue its “outliers” centralized in institutions does, and such an infrastructure is a long way from one of those highly trained specialty surgeons standing right here right now, with a poor woman with her deformed baby in need of specialized service to survive with any hope at all.
By now, I had a list of a half dozen “special needs children’ from this limited screening run through he Hargeisa population that has come to us in hope, expecting that a mobile group of junior health care workers is in a position to fix pretty much any problem that can befall the human condition—after all, didn’t you go to school for this? So, this woman, and her doomed baby stand at the theater door, as I get the inguinal hernia patient to the theater after an underhand pass of US currency had helped the daughter make her trip over to the pharmacy to purchase the kit for her father’s operation
DR. BERGMAN
DOES THE FIRST HERNIA REPAIR
HE HAS EVER
SEEN, AS WE BECOME THE PATHOLOGY
CONSULTANTS
AND ADVISORS FOR A VARIETY OF PATIENTS SEEN AT THE “THEATRE DOOR” BETWEEN CASES
Dr. Suleiman had seen a patient in his private clinic whom he had sent over to the HGH for operation, and he was awaiting the arrival of the patient who needed an operation. The patient had an acute abdomen, which he said might most likely be due to acute appendicitis. But, it had been several hours and the patient had not arrived. This s very common, Dr. Suleiman shrugged, since they had obviously consulted with the elder men and had been advise to undergo some form of traditional healing instead of operation. So, the patient is probably in some quiet agony somewhere getting herbs, poultices and incantations with a lot of moxabustion and branding in scarification. Won’t this be a very dangerous delay? “Yes, but we will see the patient in the next night, when the appendix ahs ruptured and a peritoneal abscess makes them moribund. We do not get a chance to see too many early problems in patients when they are easier to fix, and this one will require resuscitation before the operation originally recommended can even be attempted at his stage.”
Because the first patients had not appeared, the next ones were seen including the fifty year-old man with the solid mass at the angle of the right side of the mandible. This is likely to be a mixed parotid tumor (a kind first described by the ten-chairman of the University of Michigan’s Pathology Department, so it is called a “Warthin Tumor.”) To treat it by parotidectomy, a diagnosis should be made, rather than trying to operate and find out it is a glomus jugulare vascular tumor, as we had undertaken a rather heroic resection of one such tumor in Mindanao and removed one of the latter. So, an incisional biopsy is done, and the tissue is put in formalin (the wait for this case was the wait for the finding of formalin for this biopsy, a bulk item available by the carboy in any pathology laboratory elsewhere.) But, WE are the pathology laboratory here, and we will carry this tissue back to GWU along with my photos and description of the tumor, and email Dr. Suleiman the result. The fastest solution to this problem comes from a half world away, since there is not pathologist in the Horn of Africa, and the nearest one is in Dubai which would make the diagnosis be more expensive than the entire treatment program including operation and hospitalization. The tumor was very solid but with a mucinous center—no doubt a mucinous cystadenocarcinoma, the malignant degeneration stage of the pleomorphic Warthin’s Tumor.
And, now came Kevin Bergman’s move to center stage, on the operating surgeon’s side of the table with this “largest hernia ever seen” by Jay Maguire, and the firs hernia operation that Kevin Bergman would ever see. This pushes to fast forward the contracted experience of “See one, do one, teach one” since Kevin is going to do the firs one he has seen and I will teach the first combined “Schuldheis” (Toronto-based surgical approach) and Bassini (the classic Italian anatomist’s approach) to the hernia repair, a hybrid technique that we will call the “Schuldini.” A liter of fluid was infused and a spinal anesthetic administered, along with some bupivicane injected for longer term analgesia. With a fair amount of “assistant direction” Kevin carried out the dissection of the large hernia sac that was fixed by high ligation. The medical student who had accompanied us back from Hargeisa University after the lecture yesterday, the six foot three black-burka-clad Zoura, came to theatre for her first ever appearance in such a clinical or anatomic display, and she watched as we described the operation to her. It was pointed out that the patient had reasonable “dermatome anesthesia” from the spinal anesthetic, but expressed some visceral pain when we excised the sac, since the peritoneum has a very different innervation than that which is distributed to the skin. The former is called “visceral afferent sensation” which results in a feeling of nausea and vague malaise, where as the latter is called “two-point tactile discrimination” because of the higher specificity of the pain sensations. The solution to the visceral afferent pain under spinal anesthesia in this—or any other --environment? Cut it fast! Like puling a tooth, there is a time for expeditious movement in general surgery, not completely made obsolete by anesthesia, and especially not by the pressures of time/economy!
I left Kevin after the “Schuldini” repair of the inguinal canal and the cinching down of the internal inguinal ring had been completed, and let his assistant Mousad now play the role of professor in helping him close the skin. Now, every member of the operating team had gained and contributed, and passed along the chance to impart to others what it is that they know, since Zoura is as early a “medical student” as would e considered anywhere, but, she, like everyone else in this society, must be on the fast track forward, since there is a lot of catching up to do.
MY OWN
PRIVATE PRACTICE OF
HIGHLEY
SPECIALILZED SURGICAL ENDOCRINOLOGY
FOR HIGLY
PLACED PATIENTS,
PREVIOUSLY
TREATED BY THE “TOP SPECIALIST” HERE
I had been summoned to se a special private patient of my own. The General Director of the Ministry of Health and Labor had taken me up on my promise and I came to the theater door to review the sheaf of chart papers from the Islamabad physicians who had last treated his wife for hyperthyroidism. She has had a long history which had followed a classic pattern of “Hashi Tox”---Hashiomoto’s toxic thyroiditis. She had first developed a tender mass in her neck and then lost wait, had palpitations of the heart, developed an increased swelling of the neck for which they sought consultation here. They went to the local traditional healer. He applied searing branding irons in the classic moxabustion approach, and then applied poultices to “draw out” the demonic inflammation inside. It may have drawn out inflammation all right, but most of that was the inflammatory response to the treatment and not the underlying disease from which the therapy certainly did distract her. An abscess developed and spontaneously opened discharging pus from the center of the neck where the scarification had been applied. Over the subsequent months, the local inflammation had subsided somewhat as they got further out beyond the “treatment”, but her hyperthyroidism increased to alarming levels Because of his medical background and status as one of the elite in Somaliland, Dr. Ahmed Alah Jama was able to carry his wife to Islamabad Pakistan to seek consultation. I reviewed the chart, and she received entirely appropriate care there, with a T-3 and T-4 that were approximately twice elevated, and she was started on “Carbamazle” (=methimazole) and “Atenolol (= propanolol, a beta blocker). She improved.
I flipped the patient’s chart over and saw a letter for m a consultant tin the same institution at which I had once been a visiting professor in Islamabad, on my first of several visits there. I recognized the name of the institution, but never expect5ed to see a name I would recognize. I tried to remember what had been the subject I presented there. I knew that one had been on the subject of Shock, and Sepsis and Steroids, since it was during my James IVth Fellowship as traveling surgical scholar, and I was met by a medical Science Liaison of the then-Upjohn Company (before multiple mergers within Pharmacia dissolved the name and connections) What was the subject on the second visit? I remember that it had to do with endocrinology, and I now remember that it was on Management of Hyperthyroidism. I turned the consultant’s letter over, and there is the name I now remember as the chairman of the conference at which I had presented this lecture. Maybe my dropping what I at that time, at least, thought were pearls (the name of the hotel in which I had stayed at Islamabad) a whole wide world away two decades ago could be coming back to pay a late but compounded dividend!
She is now brought before me and in the presence of her husband I am privileged to examine her and remove her head covering burka and its neck scarf. The residual scaring and evidence of the “prior consultant’s treatment” is abundantly present, but her gland is now receding and is about three times enlarged at fifty grams of goiter. It is firm and rubbery and not tender. So, she is in the fortunate stage of toxic thyroiditis in that the end stage results in a “burn out” of the overactive thyroid gland which will go on to fibrous atrophy and scarring. This means she would not need any additional ablation from surgery or radioiodine—the former dangerous in her scarred condition and the latter not available anywhere short of Europe for here. Further she would need follow-up, since the end stage of this condition would be HYPO-thyroidism, and she could have mxedema, for which I had cautioned him to be on the lookout. I continued her medication on Carbamzole and Atenolol at the same doses, since I could demonstrate that she was still moderately hyperthyroid—she had a fine tremor that was demonstrable on her outstretched hands. But her weight is stable, she sleeps through the night, and her GI tract not over active—the socially acceptable way to say that her rapid transit time diarrhea had subsided as her thyroid cooled down. She is lucky, in that she is curing herself, despite the help of previous practitioners, but she must be watched to se that when she begins gaining weight and getting lethargic and congested she be re-checked and started on thyroid hormone replacement.
Fortunately for her and for them, the capability for the measurement of T-4, T-3 and TSH has just now arrived in Hargeisa, and she will go to get one of the earliest uses of this laboratory test in the new private clinic in town, and return to me with the results to predict how soon she might need thyroid hormone or to decrease her other meds. She also has knee pain and the general body “all-overs” which every older woman in the Somali culture seems to have, and I promised to supply some of the free Ibuprofen for her to take when I review her tomorrow with her thyroid hormone measurements. After all, she is a highly placed person in the Somaliland society, and as such she has eaten rather well—and her hyperthyroidism was the only thing that prevented her weighing even more than the estimated 280 pounds I gave her as the “stable baseline” now.
Remember, this woman is a Cabinet
Minister’s wife, and recall her treatment history. George Washington was bled to death by his
practitioners, the best of their era and the local experts in the Alexandria
Mount Vernon Community. It was all they
knew and all they could do, even if it was mainly incantation and ceremony to
no therapeutic purpose and actually injurious to their patient. I shudder to think of what percentage of
current practice will be looked upon with similar horror only a decade or more
hence, but that is not the philosophic point to be raised here now. The pint is that this woman got the best that
Somaliland can offer NOW, and that was a lot of, shall we say charitably,
“counter-productive” intervention mainly for the appearance of doing something.
And, the traditional healer even got the anatomic target organ
correct. He focused on the neck, largely because that was where her thyroiditis
fortunately manifested her problem to be in her thyroid—if she had had Grave’s
Disease, I am unsure (and so would he have been) on what target to hit with his
“counter-irritation.” What this means
is that it was 200 years ago that George Washington was on the Potomac River
bank being treated the “best they knew how” by the experts respected in his
day. Now two centuries later another
expert from the university named after him is half a world away giving a
learned opinion on the management of a highly placed cabinet minister’s wife,
who has had the equivalent of George Washington’s treatment---within the past few years.
Two centuries of progress—whatever its current status on the Potomac River—has had to be made up within the past decade here. And fortunately it has been in part at least, and for at least this one highly placed member of this Somaliland society. She will return to me tomorrow with her radioimmunoassyed T-4, T-3, and TSH, tests that my students here have ordered a dozen times in the past month as “throwaway clinical screening” yet are only this week available here—but, we will see, here and now. So, we may not be doing the open heart repair of the young man with the murmur that I can hear without a stethoscope. We may not have done the total correction of the bladder extrophy. And the minister’s wife’s treatment is not available to everyone in Hargeisa—let alone food in the quantity she can dispose. But, things ARE moving, and at least some of them, now, in the right direction, judged by one visiting professor’s standards—even if they have been warped by the narrow perspective of treating a few glands!
A
SPECTACULAR PATIENT PROBLEM,
DIAGNOSED BY
THE ALERT MEDICAL STUDENT SLIDE PROJECTIONIST FROM YESTERDAY’S HARGEISA
UNIVERISTY LECTURE---
HAVEN’T I
SEEN SOMETHING LIKE THIS BEFORE?—
LEADIGN TO A
DRAMATIC DECISION OFFERED FOR CHOOSING DIFFERENT LIFE OPTIONS
I was getting the next patient prepped after the prostatectomy combined with hernia repair. This one was the patient with an epigastric hernia that can be well demonstrated for students by having the man put his hands behind his head and try to do and abdominal muscle pulling sit up, which pops out the pre-peritoneal herniated fat through the epigastric fascial defect. This demonstration was going on for Jay Maguire, the student who had won the toss in being “up” for this one, when an excited Juan Reyes came on the run, hauling a patient behind him. “Doctor Geelhoed, just before you get in the OR, I want you to see this, since it looks just like one of the patients you showed us yesterday, and I think he may have the same!”
Precisely!
The man had hobbled behind Juan trying to catch up, his right leg was flexed at the knee and his toes were pointing up, a result of a burn contracture on the dorsum of his foot and a quarter century of hobbling along as he was now to compensate for the burn contracture at his fight knee. He wore a turban headdress and a white gown and hobbled with the aid of a knobbed stick. He looked concerned and looked from Juan to me for encouragement. I had the Hargeisa student Zouar towering over each one of us in her burka behind me, as the patient exposed his right knee and a foul-smelling expophytic mass that covered the whol medial side of his leg. What do you think this is? Juan said “I think it could be one of those—what did you call it—a Marjolin Ulcer? It could be a malignancy in an old burn scar just like the one you showed us.” Each of the students, including Zouar, agreed it looked like the slide I had showed of a similar patient in Nigeria almost even longer ago than this patient had burned himself, twenty seven years ago. Only last year I had brought a man with a similar story over to see Kevin Bergman outside the Operating Theatre at Embangweni, to show him a Marjolin ulcer which we subsequently excised. Kevin cannot be accused of having cribbed this information to the other students since he never saw this patient, being, as he was, tied up in completing the care of his hernia repair patient. So, here, through another generation of passed along information in teaching, was the same human problem coming to the attention of another group of health car workers.
The man hoped for help, but there were only two options we could present. I felt his right inguinal area and did not palpate any nodes. I saw that his knee still had about ten degrees of movement, flexed in a 60* contracture, but he was still “plantigrade” meaning that he could bear weight on this extremity. We explained that he had a malignancy that could not be cured in his leg, and that it would no doubt spread over time, although slowly. But it would likely give him masses in his groin and over a longer time, nodules in his ling and it would shorten his life considerably, perhaps to a matter of the next few years. We could not make the decision for him, but we could advise that he might have a longer life without his leg than a shorter one in which he would at least be able to shuffle as he was now using two legs, even if one was bent and very foul-smelling from a big squamous cell carcinoma that had ulcerated and was breaking down in multiple places. He had to consider this factor and his social repulsiveness in his own quality versus quantity of life decision. Because of the extent and position of the tumor, the amputation that was our only operation would have to be an “A-K” (“above the knee”) and no useful prosthesis or training would be available for him here, so he would be crutch walking only in the future, which, for all practical purposes, he was now.
I told him that in my opinion, I would not make his choice for him, but I would want to have it removed to improve my chances for a longer life without the anchor of this smelly mass continually being the focus of my concern. I am willing and able to do that operation soon, but there is no emergency for him to decide, except that it would be someone else who would do the operation if it were not in the next few days. These options and the concerns we had for him, were expressed in English, which he partly understood, and again in Somali through the translation of our medical student Zoaur. At first he was eager to be treated but did not like the extent of the treatment; he was inclined toward amputation when this option was expressed, but would need to talk it over with his brothers. I said I understood, and would encourage him to think about it even longer if he needed to, but that I would advise the group her on how I would treat him, since our team would be gone in a few days. There was a heavy drama in the air as the man looked over the faces of the medical students, who—also for them—were in a direct an immediate decision process for a life-altering change that had grave consequences to either choice to be made. It was not easy. And it was the first patient to be treated by a very junior Somali woman just entering medicine. Juan had made an independent diagnosis that was “spot-on” in his screening patients in the clinic from a very recent learning experience in the same classroom where this young woman has had her own “medical epiphany.” Each of them could make a difference in this man’s life, directly, right now, and already had, which ever way the decision would go. This is the health care triumph and tragedy at the Theatre door: one a newborn with extrophy of the bladder needing sophisticated specialist care somewhere else far away. And, now, a man whose life is dependent on a choice we offer him and are willing to help him make—right here, and right now, with what is available on the spot carried in our duffle bags and heads—and slide carrousels, alertly observed during teaching sessions in how to pursue this art under any and all conditions.
RETURN TO
CLINICS, TO FURTHER PATIENT TREATMENT DECISIONS,
AND THEN
CHANGE GEARS TO PERFORM IN A HIGH PROFLIE PUBLIC RELATIONS AND DIPLOMATIC
EXCHANGE
AT A FORMAL
DINNER HOSTED AT THE HOTEL MANSOOR AND TELEVISED ON HARGEISA TV
Further patient decisions were carried out at “Theatre door” and back in clinic. Two involved patients with minimal non-toxic goiter who had been eager for removal for cosmetic indications only. The students were eager to participate in thryoidectomies with me having heard rumors that this is a “slick operating experience.” Except in these patients, I pointed out. The one woman had even had a complete evaluation at some clinic and was shown to have a minimally enlarged 28 gram gland with what she described as difficulty swallowing. If she indeed did, it was not on the basis of this minimally enlarged soft gland without any sub-manubrial extension. The other patient had hardly any enlargement palpable, let alone either visible or symptomatic, but thought she would like to take advantage of a free surgeon awhile he was here—not my best indication for operation.
We went without lunch and back to clinic with a swelling group of patients, as there was a diminishing number of staff. We were finally seeing patients with only our medical student Zouar as translator and helper. We reluctantly “pulled the plug” and awaited Essa to carry us back to the Mansoor since we have an important dinner meeting tonight. .
Our host, Abdel, owner of the Hotel Mansoor, is a very community spirited leader who had done whatever he could to make our stay pleasant and productive and has had each of his staff go out of their way for us. I thanked him in the presence of his employee team, and Abdhi particularly, for his people skills and accommodation in our mission. The Mansoor group beamed with this recognition. Now Abdel had assembled the entire Health and Hospital Committee of Hargeisa to a dinner meeting and the chance for them to express their gratitude for our help as well as to hope to institutionalize the association in working for improvement of the hospital environment, saying “as you can see, we have a very long way to go.” But, they are started on that very long way, and even any little improvement they make gives immediate and noticeable benefits.
Our dinner was a tour de force for the kitchen and serving staff and they gave their extra best. We got a chance to meet and talk with each of the shakers and movers of the Hargeisa community, from business and social institutions. I spoke at length with one man who was the former hospital director, and he had been followed by Dr. Yasine the current director, the real hero who has tried to continue conscientiously in a group that gets paid less than the total cost of my dinner alone in their monthly salaries. They have to have some other means to make a living and pursue the private sector opportunities in the afternoon and evening, after working for the morning essentially for a public charity.
I asked about Islamic charities that could take up the slack for some of the needs that our patients, particularly single mothers had come to us complaining to be taken care of by us as their dependents. “Are there no Islamic Zakat charities operational to care for these poor people? “ I asked. I had not figure in a major disruption of the entire system of private Islamic foundations for the international relief and what had happened to them after 9/11/01. Many of these were Saudi and a number of them funneled fundamentalist and terrorist funds around with more largesse than that experienced by the poor as their reputed beneficiaries. Any good they might have done, on the side or as their main business, was eliminated as well as the intended outlawing of most of them for any al Qaeda connections.
One of the other reasons that the employees leave early from the hospital besides the very low esteem that the minimal payment for their services makes them feel they are entitled to minimum effort, is that a number of them are eager to get home, not just to make a living, but to enjoy their daily hit of the stimulant “Kaht” which is a plague throughout Somaliland. They enjoy this amphetamine like high from this barley legal drug, which allows them to stay awake longer and is alleged to enhance various of life’s experiences. The high grade stuff that is the principle product out of Wilson Field in Nairobi is all controlled by a wealthy Somali family, and it is called Mera. It is pure and potent. The more affordable stuff from Ethiopia is often sprayed with insecticides and is soaked in some kind of chemical preservative to help it travel further for a bigger market. The chemical contaminants give s rise to liver failure, seen in chronic heavy users. They have their own social “drug problem” but in a “lawless state” there are few controls on a product that is outlawed in many countries. One could draw parallels with the spectrum of alcohol, marihuana cocaine and crack in the US which has not accommodated various mind-altering substances in its culture either.
The dinner was concluded “under the klieg lights” with a brief speech by the chairman of the hospital committee and brief remarks of gratitude by our host who choked back tears after my impromptu speech, since he is a community spirited leader who felt anyone who came across the world from the land of milk and honey to participate in the big problems and attempt solutions not as a donor but as a partner must be the kind of friend they would like to continue in a lasting relationship with. They have had only two partnerships so far, one with TEAM of King’s College in London and another in a New York based NGO called IHAN—International Health Awareness Network. The kind of association they would like is the leadership and encouragement of a George Washington University, within a brief walk of the new would-be Somaliland embassy. If we could begin a formalization of such a relationship, that could begin as soon as the next meeting of the board. That is Sunday at ten o’clock and he offered the Business Center of the Mansoor with free of charge fax, phone and computers for our coming to an agreement on a continuing plan of association.
So, I may be a TV star in Hargeisa---and I hope you didn’t miss it! It was a very moving experience to speak with all of them concerned about the current status and trying so hard with so few people and only their own internally generated resilience to rely upon. Their confidence in having been encouraged by our presence is a moving experience for our team and I did respond in kind for our forthcoming meeting with the board on Sunday after our return from Berbera.
So, it had been a day full of surprising experiences and critical choices—many for individual patients and some, potentially, for the whole society, if we can associate in such a way to bring benefit upon their long and heroic task of “building the whole system from scratch” as a number of them had said. We are not big donors, but we can be encouraging partners, and for a first approximation, this medial mission has already achieved most of those goals. So, let’s not just get started—let’s carry on and keep on, with that same “infinite threshold for frustration!” It is a very rewarding experience—ask the team members from both sides of the exchange. Or just watch the tube!