FEB-A-20
OUR HEAVIEST
WORKDAY OF THE ENTIRE EXPEDITION, WITH AN ALL-NIGHT WRITING OF THE EXPERIENCES
THUS FAR AND AN EMAILING OF A REPORT AT DAWN, FOLLOWED BY AN OVERFULL CLINIC AT
HGH WHERE GUARDS WERE WHIPPING BACK THE OVEREAGER CROWDS OF POTENTIAL PATIENTS
FROM THE DOOR, AND A SPECTACULAR SERIES OF OPERATING ROOM CASES INCLUDING A 5.5
MINUTE THYROIDECTOMY FOR GOITER UNDER CERVICAL BLOCK, THE LARGEST OVARIAN TUMOR
EXCISION IN HGH HISTORY, TWO HYDROCELES, TWO HERNIAS, AND ON TO THE EDNA ADAN
MATERNITY HOSPITAL WHERE WE SEE CLINIC PATIENTS FROM 4:00 TO 11:00 PM, AND
RETURN EXHAUSTED AND GIDDY TO REPEAT THE PROCESS ALL OVER AGAIN IN THE FINAL
SESSIONS IN EACH OF THE SAME VENUES IN THE MORNING
February 11, 2004
For a breathless few days, it will be impossible to both DO and REPORT the dense schedule of clinical activities including this concluding day at Hargeisa and the next two days of frenetic activity anticipated in Berbera. I will try to catch up with less detail but more action, since I am at the far end of our team's limited capacity.
I started this long day, by going around the clinic where a large and restless crowd was already gathered. I took a photo in the Operating Theatre (“OT” here as opposed to “OR” in non-British English) of the still-functioning steam autoclave—original equipment, installed by the British when the hospital opened in 1952 and considered obsolete almost anywhere else, but working, as we all must, in response to press of demands and needs.
An amazing sight greeted me on my next pass at the crowded clinic door. There were two camp-clad security troops on either side of the door, armed with switches made of the thorn scrub acacia. They were facing the surging crowd of mainly women in long flowing Somali robes, and as they pressed forward they were beaten back from the doorways by the guards vigorously swinging their scourges. These have sharp thorns and it is not a weapon that one charges against for a second time, so that the doorway was clear at the time I walked through it and saw many more patients crowded inside along the darkened corridor where the shrouded bodies are standing in a disorderly queue. IN the subdued light after coming in directly from the Equatorial African sun, I could not determine which way these robed hulks were pointing, since they had there eyes covered in the first several ones I had seen, and I did not realize that this faceless mass of people was actually facing toward me, expecting that since I had now arrived, they would be the first to be seen of the hundreds indoors and the many times more outside being lashed back from the doorway.
I had tried to announce to the teams inside, that I would alternate the cases so that they could send over one of the senior students when called for, and then he would have to scurry back to relive the other who would be next up for the procedure that followed in the OT. With Kevin on one side and Jay on the other side of the clinic rooms and each supplied with a translator, even if he did say about each patient that she has “abdominal aitch [sic] and nephritis” I started the day's list by taking Juan through his first ever hydrocele repair. While I was finishing this case, I got a patient sent over by Dr. Yasine, who needed evaluation and an operation, it was said, for an aneurysm of the neck and jaundice.” The “aneurysm was a large canon wave in the jugular from a wide open tricuspid valve and regurgitation and the patient was in high grade heart failure. The dilated vessels in the neck were not arterial but venous, and she did not have a surgical problem but a significant medical problem, and we started her on digitalis and diuretics—without an EKG or chest X-ray or electrolytes or the ability to replenish potassium after diuresis. The next thing we heard about her, however, is that the patient was remarkably improved. By pressing down on her liver, I could demonstrate the strong reflux of blood up the in nominate and jugular systems that were distended.
Another patient sent over for gallstones and obstruction had hepatitis, with no obstructive e component to the jaundice, but a very sick liver that needed rest vitamins and certainly not an operative stress to compound the problem. The young man with the turban and foul-smelling leg had come back to the theatre door and had said that he had thought about the advice we had given him and he wanted to be treated by the amputation we had advised, and one of the brothers had been found and agreed also, but he was still searching for the other one, and would like to have it done by me and as soon as possible, as soon as he found his other brother. We told him that today was our OT day in Hargeisa, after which we would be moving on to Berbera. Dr. Suleiman had asked when we would be going to Berbera and had already identified several patients he had wanted operated on that could not be done in time here at HG H and so he had said he would be sending them to Berbera for us to operate on them there. This does not sound like a good idea to me, since it is a “Coals to Newcastle” situation in which we don to want to bring pre-operative patients with us to Berbera when they are anticipating our coming to operate on all these patients there that the Director has been gathering for us to be operating as soon as we arrive there in a very overcrowded schedule. Among those patients he had selected were a few he had naively put up front on the list: would I be so kind as to do the hip replacement first, and did we have hip prostheses in our duffel bag, as well as compression plates for difficult orthopedic fixation of complicated fractures? The young man with the Marjolin ulcer gave me a note that identified him as having been born in Kenya, and he asks, “How much I need to pay you?” I told him that my services came with a smile, and that there might be some supply items that the hospital might require, but that he should let us know as soon as he returned with his brother's signature. He had a mother and other female relatives who were eager also that he be treated, but none of them counted as legitimate permissions for his care.
A child with a hydrocele was presented with a very easy and short operative course predicted for him and I suggested that they add him to the early schedule for the day. As I suggested that they send for the next patient, Mousad said he had sent for the woman with the very large ovarian tumor, since we should try to do the “Big cases before the staff gets tired!” And, this, indeed, was a big case.
This woman had been “pregnant for five years.” She had been growing steadily bigger, and she had trouble both eating, and breathing, particularly if she lay down. If she lay on her back, she would get faint, from an interruption of her venous return to her heart. I had the benefit of a physical examination and an ultrasound and my prediction was that this would be a “big case” all right, but also a very swift and curative one, since I believe she has a very large benign ovarian tumor that will be ---as I had predicted for a couple in similar circumstances in Mindanao—“one clamp, one cut, one tie, producing one cure!” It was, indeed, a very big case. It was, indeed, over in a few minutes.
This case was my fourth for the day, and was a rush, as much fun as if I had been chewing Khat all night, rather than typing up the last day's report to get it into email transmission by dawn. I will describe the setting and the circumstances since it was a real crowd pleaser!
In the interval, I was called to see the Chief's mother who was sitting on the floor of the antechamber at the Theatre Door—my base of between-case clinical consultations. She had a “lesion of her foot.” I grabbed the nearest student and asked “What does this look like to you?” Once again, they could respond on the basis of the slide show I had given them now two days before at the Inaugural Lecture at the Hargeisa University Faculty of Medicine Here, in a remarkable mimic of the case I had shown in slides, was an African melanoma, originating in the depigmented part of the sole—exactly as I had show in the slide from Nigeria, and exactly as I had shown in the prior mission to John Sutter in Malawi, and to Kevin Bergman on the subsequent trip there—and now here. [Unknown to me at this time, would be a repeat of this precise lesion in Gondor College of Medical Sciences, and the students in each venue had recognized it precisely since they had seen this unfamiliar lesion first in the same slide show I had presented to them in each venue!] I recommended that she have a limited attempt at local control, with excision of the ulcer with a wide margin and a split thickness skin graft applied, since, as the students could readily confirm, she had large palpable lymph nodes in her groin, and would likely have the appearance of metastatic disease on her chest X-Ray, soon, if not already. She was one of several African patients to have melanoma, and each had them in the unusual distribution for the white-skinned people who are susceptible to melanoma in sun-exposed areas of white skin. More pigmented skin is a protection from the actinic radiation, and therefore, the “African melanoma “ is sited in de-pigmented areas such as soles, palms or nail beds.
A patient came in with a burn with contracting scars on hand and face. There was hope that I would do a “Z-plasty” as I had described in the lecture at Hargeisa University—but I had suggested that was to restore mobility to a fixed upper extremity. In this case, the fingers and wrist were mobile and there was no inhibition to movement in a “position of function” and there would be no relief from Z-plasty (since I am in a former British colony I must call it a “Zed-Plasty” here!) since there would be no gain in mobility. I emphasized that in palliation, you cannot make an asymptomatic patient better, and there was no functional relief in this case but for cosmesis, and that procedure for relief of scarring might interfere with a later release if the scarring continued to form an inhibition of function.
An elderly diabetic man was presented in great dignity by one of the local MDs whose father he was. I went through a rather lengthy “internal medicine –like” review of his status, and found that he was both well cared for and also had a local physician who was on top of his care in all the items for which I would have alerted them. “So, why are you here, and what aspect of your care do you find unsatisfactory?” I asked. “Oh, I have no problem, and I am content with the care I am getting, but I had heard on the radio that there was an expert here from Washington DC who was coming to give free care, and I insisted my son bring me here to see him!” the good-natured elder said to me. We shook hands all around and I pronounced him well cared for, which inflated the prestige of both caregiver and recipient.
A hapless patient had stumbled into clinic for some other reason and had been found to have an innocent lipoma—and the student seized the patient and shuttled her over to OT for “immediate operation.” “I want a chance to cut!” was the real reason she was sent over in a state of some bewilderment. I asked if she was having problems from it, since it was not at a bra- or beltline and did not interfere with any joint surface. “No, but he said I should have it removed.” Here I have desperate people pursuing me to chop off their legs to save their lives, and Surfer Dude is trying to seize an African to cut! Sorry! I said to him; and “Congratulations!” I said to the patient who would need no operation.
There was a waiting period before we could get to the patient with the large ovarian cyst. Why? They want to transfuse her since this is a very big operation. I suggested that it would be a very big but a very brief operation and we could proceed without the transfusion. They did get a unit of blood from some one of the relatives however, and it would not hurt her—if the HIV screen is OK. We drained a very large retroperitoneal “cold abscess” of Tb that was pointing in each groin. I also did a very rapid thyroidectomy under cervical block anesthesia since we had neither endotracheal tube nor satisfactory general anesthesia.
THE “BIG OPERATION” WHICH CURED THE WOMAN
FIVE YEARS PREGANT WITH ONE CUT AND ONE STITCH
AND RELIEVED HER OF A BENIGN 22 KG PASSENGER
The woman with the bulging belly was given Ketamine, and her impressive belly was prepped and draped. Even Dr. Suleiman came around to admire the case, and had brought from home his new toy, which surpassed mine. He had a new digital camera that seemed to be ideal for OT work. He took a few still photos and then even a short video clip. I made an incision in the abdomen as the startled Jay Maguire looked on, and then tried to mobilize and deliver the very large ovarian cyst with a tough white outer coat and a heavy pedical on the right tube. I reached under the heavy load and camped the right tube and snipped it off staggering over to the side table with the intact large ovarian mass. The operation was over a moment after it had begun. While Mousad helped him close the abdomen, I opened the large multiloculated ovarian cyst to show that it was in fact a very large cyst and did not contain the mucinous cystadenocarcinoma that I had also shown them in the slide show lecture. She is fixed. She can breathe easily, and could even lie down on her back and not faint or suffocate—all of those improvements apparent within the hour of the operation—and she still did not have the unit of blood so carefully procured for her! The video clip on the CD that Dr. Sulemain had presented me with later after I had inscribed my “Study of Surgery” text which I gave him shows the operation and the bisection of the huge tumor in a video clip on the disc, and the much diminished patient on her way.
The OT staff figured they had done a full day's work after this brief and definitive case, and were actively shunting the other patients back to clinic or the wards. The young man with the Marjolin Ulcer could not be found, and Jay Maguire had gone trolling around looking for the lipoma patient, saying he was really bummed that the patient was not going to be done. To substitute for his frustration, I had a cute young boy whom we gave Ketamine and then we excised his supernumerary extra digits on the lateral side of each little finger. We did another case of a young boy who had multiple pelvic fractures that had transected his urethra. He had a suprapubic cystostomy, and we were going to try to open a new urethra in the disrupted part of his transected membranous urethra. We managed to pass a sound up from the penis and then tie a suture to it and pull down the suture to which a catheter was pulled back into the bladder. All told it was as smooth as it could be expected, and Dr. Suleiman was delighted, suggesting we send the other patient with a traumatic section of his urethra to Berbera so that he could be done and that the staff there could see how to do it. I thought we would have enough down in Berbera without a BYO patient OT list, and encouraged him to undertake the man's treatment similarly to what we had carried out on the boy.
THE MARATHON CLINIC AT EDNA ADEN HOSPITAL
FOR A “BRIEF AFTERNOON SESSION”
We went over to the Edna Aden Hospital where we had lunch late and spoke with Edna before we entered into her clean and well-painted outpatient department (a recent gift of USAID) to “see a few patients." We also talked about the site and the history behind the Edna Aden Hospital, which was formerly the killing fields of the Siyad Barre regime, that doubled as a cemetery. The executions would take place here and the burials were immediate. The builders that were asked to build a hospital and put up the structure were quite suspicious at first, but Edna solved that by moving into the unfinished building, and stayed here alone, despite its haunted reputation.
We swapped stories about the unusual things we had seen in the remote places we had worked. I told them the story of the “lithopedion” delivered by abdominal operation in Nigeria. Edna told the story of a woman who had delivered at home with traditional birth attendants, but the placenta did not follow. Sol the patient was transferred over to the Edna Aden hospital and when they rummaged under the sheets, they found an old shoe tied to the cord. A shoe is a contact with the lowest form of stuff you encounter on the streets, and it would be an offense to be presented with an old shoe. The traditional birth attendants to offend the evil spirit that was holding onto it as a retained placenta had tied the shoe on the cord. They first excised the shoe and then delivered the placenta, for which the traditional birth attendants rejoiced in the efficacy of their treatment at offending the evil spirits that had tire dot foil their efforts.
One woman had had a long trial of labor and could not be delivered in the village and had been transferred when the traditional birth attendants looked up between her legs and declared that the woman “was delivering a devil.” It was unlike anything they had seen before and was quite puzzling to the team here as well. Only later was it recognized that what they were looking at was an enormous edematous and swollen scrotum, since the woman had a podalic presentation of a male infant and over the prolonged labor, the edematous scrotum had swollen so large that it was the presenting feature at the time of delivery.
Of the unusual obstetric complications, they claim they have a very high number of face presentations. They are not sure why. When I briefly mentioned that one of my least favorite operations is the destructive delivery, they said that they too had gone through that, but perhaps because women are now coming a bit earlier since they know the hospital is here, they have stopped seeing these extreme cases of “Accouchement force'”
I was shown a chest X-Ray of a large calcified hydatid cyst of the lung. We made brief rounds before we went back to the outpatient department where patients were already queuing up for the “small clinic”. As I waited to start, I went over the photo albums of Edna's amazing career, as an independent woman who had been educated in Djibouti, and then in UN positions and then the First Lady of Somaliland, with diplomatic receptions and White House dinners in the LBJ era and with the German Chancellor Kissinger, then a cadet under arms and in uniform by a vindictive Siyad Barre who wanted to see the former first lady transformed into a desert rat combatant, carrying out the capricious orders of the warlords that followed the period of early promise of Somaliland into an anarchic Dark Ages. She had also been attached to the diplomatic corps, for six years as the wife of the Somaliland ambassador to Oman. Before the harder times that descended on Somaliland, she is shown with her pet cheetah. When Siyad Barre came to power as a dictator, he had the cheetah killed as it represented a “capitalist pet.” Edna has gone through a real roller coaster career, and emerged more successfully than the cheetah.
It was quite a contrast to be sitting in Edna Aden's new and A/C climate-controlled clinic with the colorfully robed women of the maternity hospital gathered in the clinic waiting room, as opposed to seeing earlier in the day the camo-clad soldiers whipping back the crowds of would-be supplicants at the HGH Clinic doors. But, the effect was the same. We were mobbed.
Among the patients seen were three small children with Ano Rectal Malformations, who would require the care of a specialized pediatric surgical service. We had been gathering a list of specialty kinds of patients such as bilateral cleft lips, and the extrophy of the bladder and other high-grade surgical candidates, and I began thinking of the possibilities of an Operation Smile mission to do definitive care for such a group of patients.
We were so busy that we got a little giddy over the time we were still supposed to be wrapping up as new patients kept on coming. Reluctantly, we agreed to come one more day to attend this clinic as well as wrap up the clinics here on the grounds of the HGH in Hargeisa before departing early the following morning for Berbera,
FEMALE GENITAL MUTILATION
The practice throughout the Horn of Africa called “FGM” is a cultural practice imbedded in beliefs that a woman has an unbridled nature that needs to be controlled, and that can be helped by what has been euphemistically called “female circumcision.” That can take four or more forms, and Edna had got videotape coverage of midwives doing the operations to enhance a woman's value in a marital transaction in the only hope she would have for any quality of life, in making a good match with a well-placed spouse. This requires some sacrifices.
I had discussed the practice of FGM with many people in East Africa over time, but at not point would I be in such a clinical epicenter as I am here. I had discussed this practice with Edna and with members of here staff since I knew that they would be seeing a lot of Somali women, and that officially the practice was frowned upon as putting a distance between the culture of the Somali people and their Islamic faith that would condone or even require such a practice, with all the implications it had for the anti-liberation of women. But, even being an employed woman with a job or income has been hard for most of the population to understand or tolerate. Edna told me that it was the impossible part of three marriages for three husbands to understand that she was going to carry on with a career and a professional life of her own. So, the underlying practice of the FGM is not a very well understood even if widely decried cultural conundrum that makes a favorite “worst case” example for post modern analysis of the Horn of Africa—as in, “these people are not even human” type.
I had seen only a few instances of this practice and they were the ones that were complicated, often resulting in urinary tract outlet obstruction. I knew that the obstetric services here would have greater exposure to the results, and they agreed to discuss them with me. I talked about the varieties of practice, often done by the traditional healers who were women and traditional birth attendants in the villages, but more recently it had been done by midwives and even by some doctors who had volunteered to carry it out in as sterile and “correct clinical technique” as possible, under the assumption that if it were going to occur anyway, they would try to do it in a way that minimized complications. This was the argument about criminal abortions earlier in US history--about the time I was a surgical house officer at Harvard, and a staple of my middle of the night operations were septic, soapsuds, or coat-hanger abortions. Those abortions should be legalized in order to make them cleaner and more clinically efficient to minimize the morbidity and mortality of the back alley variety. I will tell more when I review the brief video tape that Edna has of a midwife carrying out the more extreme type of the FGM operations, a tape meant to illustrate the practice “as good as it can be.” Even under such circumstances, it is a horrible thing that requires a good deal of cultural explanation that falls short of justification. The theory is that a good woman should be docile and domesticated and not subject to wild urges or desires of her own. As a consequence, a symbolic and even an anatomic castration would be appropriate to make a young woman into a good marriage candidate since she would be prepared for a life of domestic bliss, freed of any desires to go philandering. The genital mutilation is done to release her from this anatomic burden, the way that animal castration might be done to tame livestock, but without the dreaded consequences of infertility. In the extreme form the vaginal opening is sutured shut with only a small pore left to relieve the urinary and vaginal secretions that might otherwise be trapped.
1) One form is essentially ritualistic and is a razor cut in the clitoris to allow the loss of one drop of blood. This is the most frequently performed type today.
2) Clitoridectomy and excision of the labia minorae
3) Infibulation
4) “Azura” excision and dilatation, only for vaginal secretions and urine to escape
5) “Tira” insertion of the bark of a tree giving a caustic lye burn and cicatrisation and stricture; this is also modifiable with certain herbal tree bark treatments which are said to be astringent and give a tighter and drier vaginal introitus
During my stay in Somaliland (as I had seen in some patients seen in Kenya before and as a number of them I would see in Ethiopia later) I would see about a dozen women who had had some form of FGM that had not only accepted it but had eagerly requested it for the only way they could get an elevation in their social status and escape the burden of unwed bliss. They had to go through this rite of passage as an entry into the good life and they were even willing to accept certain consequences that often involved urethral stricture and Urinary Tract Infections Most of them I saw, had, by definition, one of the more severe forms of excision in order to come to medical attention for the complications that might ensue. It is said to be a practice now that is much less frequently carried out since it has been declared illegal; but there seem to be the same percentages in each age group that presented to us in these clinics that might be an interesting blend of the medical and cultural implications of this practice in the Horn of Africa.
RETURNING TO THE MAANSOOR HOTEL
AFTER MIDNIGHT, GIDDY WITH FATIGUE
I do not believe I will hear too much more about the boredom and uselessness of the medical team being here, and how with nothing to do that we should get out and advertise our services to attract more patients. As we were given a ride in the Edna Aden Hospital van after midnight to a late supper of a sandwich that the Maansoor cook had stayed overtime to prepare for us, the team was giddy. In fact, some members had “lost it” the way I remember after consecutive all-nighters in the Peter Bent Brigham during my surgical internship. Laughter came at the description of impossible clinical situations, and “inappropriate” behavior (a favorite description of long-term patients in an ICU by the nurses who label such obstreperous patients that they have been stimulating at all hours of the day or night in a completely non-circadian pattern in their own swing shifts.) I used to ask the nurses “Just what would be “appropriate behavior” on the part of a patient in an ICU setting when the practices you have been perpetrating upon them would not seem appropriate at any time or any place of their previous experience from which you have isolated them? But, as we were riding home, there were exchanges such as “So, you people have a country here? You have a national anthem? What would that be—the Macarena?” We spoke Spanish to give the impression that we had come from a different world and were communicating in gibberish, at least because they could not understand us when we spoke to each other, much as were the roles earlier when we were not part of the conversations in Somali. We had spoken with Rhoda, who is closest to us, but she too is in a burka and has her native language, Arabic, from her strict upbringing in Doha Qatar, and she is isolated from the family and birthplace since her father died leaving no male relative to take care of them, so she had to leave to a more liberal environment—which Somaliland represents. This is the point at which the cultural differences, which are interesting when they can be examined in their own right, wear down to bizarre annoyances, when the old assumptions do not hold, and the differences become magnified in ridicule. We are tired, hungry and overwrought by a very busy work week, with an even bigger day coming up tomorrow (or, more accurately, later today) and then a smersh of hectic clinical burden in the Berbera setting as we will adjourn to the Red Sea Coast for two full final days. So, singing the Macarena and muttering in Spanish, we are off loaded at the Maansoor to get our late night sandwich to go to bed for early rising for more of the same. Welcome to a “pre-internship” experience team!
We will see the full impact of such publicity as they had suggested as a way of getting additional patients to be seen in a later series of our final day in Hargeisa and the next two days in Berbera in which the volume is overwhelming. Be careful what you wish for; you may get it and more beyond.