FEB-B-3

ON ARRIVAL IN BERBERA HOSPITAL,

AN UNCOUNTABLE CROWD OF PATIENTS AWAITS,

WITH OVER A THOUSAND QUEUED UP FOR THE MEDICAL CLINIC AND HUNDREDS MORE

FOR THE SURGICAL CLINIC,

WITH A RAPID TRIAGE OF THE LIST

OF THOSE WAITING,

SEEING CLASSIC ADVANCED PATHOLOGY,

AND BOOKING A DOZEN CASES, INCLUDING THOSE WHO FOLLOWED US DOWN FROM HARGEISA, TELEVISED SURGICAL WARD ROUNDS,

AND THEN A LATE NIGHT CLINIC CLOSING THE DOOR AS PATIENTS ARE STILL COMING IN TO OUR EXHAUSTED TEAM

February 13, 2004

And, so, to begin. We set up the medical clinic with an adding room for the ‘women’s health” clinic, concentrating the nurse midwives in the latter room and deploying the senior GWU medical students in the large clinic dispensary room with our translators evenly divided between those who came with us from Hargeisa, and those Berbera Hospital employees who would have local knowledge of what was available. Particularly helpful in this regard was the local Berbera Hospital pharmacist, who would tell us what it is that he had, and we would augment his stock by leaving everything we had brought with us after our clinics were completed. Our own medical duffel bags were placed as a back up to the clinical stations on tables, and they would be the dispensary of first resort, after which the patients would be sent to the local Berbera Hospital Pharmacy.

The long queue of patients would be subdivided here into a stream of women who would be seeking the services of a Gyn or perinatal clinic (it remains odd for me to hear the term “Women’s Health Clinic” and to realize that this is applied despite the fact that they do not do Pap Smears or breast exams!—an oversight which would constitute malpractice in the developed world.) The remaining general medical and pediatric patients would be divided into two streams going to seek help at two stations manned by one of two senior students, beginning with ER doc-to-be Jay Maguire and Family Doc-to-be Kevin Bergman, while I took the third internal medicine/cardiology doc-to-be Juan Reyes with me to the next door Surgical Hospital where we would begin the screening of our won queue of self-selected surgical patients---those who were triaged to surgery because they had wounds, tumors, congenital abnormalities or quite obvious problems that would require surgical attention, like fractures or burns. And, so, to work.

A FASCINATING PANOPLY OF SURGICAL PATHOLOGY

TUMBLES THROUGH OUR SURGICAL CLINIC

IN A RAPID SEQUENCE OF PATIENT CONSULTATIONS

As I had advertised it to be in advance to the senior students who had started their week frustrated by their lesser activity in smaller numbers of patients with less significant illness, they had now dived into the “deep end of the pool.” In a nearly overwhelming whirl of rapid patient flow, I screened several hundred patients in our surgical clinic with the whole gamut of advanced tropical surgical diseases in a moving picture atlas that would have made a video of African illness in advanced stages. The treasure trove of learning experience was so intense that each medical student realized that exposure of this sort had to be shared, and the senior student assigned to me in the surgical station rotated around twice over for the duration of our clinic until all such patients had been seen on our side of the hospital. The only break the students had from the patient flow was in the run over from the surgical clinic to the medical stations to spell one of their colleagues there and send them over to see the “just wait until you see this!” quick patient presentation list breathlessly passed along to the incoming student. Some of the more fascinating patients were held over so that two of the students would have a chance to see them, the one student leaving the surgical clinic and the other one coming over on duty. It was almost like having a conveyor belt conducted by the surgical theatre staff as door keepers continually re-filling two chairs in front of me opposite a pair of translators.

We had met the surgical staff on arrival and had made a brief stop at their Theatre facilities to drop off the duffel bag of surgical instruments, sutures, sponges and dressing materials with catheters and the like. The reputation of Suleiman had preceded him, since he was the spark plug, the “positive deviant” who was an OJT orderly, essentially, who had previously worked in Hargeisa Group hospital, and now was the “Surgeon-in-Chief” at the big Italian-designed and –built Berbera Hospital. There were several doctors; many of them had gone to school in Mogadishu in the “other Somalia” which had been a part of the “Greater Somalia “union until the civil war had torn them further apart after secession. But, it was that Civil War that had determined the experience and the course of the Berbera hospital. The Italians left, and the staff that remained could either give up, after cowering under the huge influx of casualties and the steady flow of other surgical staples (like the leading cause of bowel obstruction in this part of the world, sigmoid volvulus) or they could rise to the occasion by “making do with what they had.” What they had was a self-starter named Suleiman, orderly-cum-self-trained surgeon, one of those who did not “give up.” Around him are a group of assistants who are either like him, or help in ways to keep the system going, despite obvious deficits in supplies and gaps in expertise and training. And they were doing a creditable job.

With Suleiman, Hadid, and Ismail as my “chief residents pro tem” we opened the clinic door, and triaged through the mass of waiting patients that tumbled or staggered through the doors. We saw, in no particular order, a “surgical list” of patients that included the following: a pelvic gunshot wound had left a severed bladder neck and now a consequent stricture of the urethra. This patient would need the operation we had just carried out in Hargeisa with the other two patients who had been recommended to accompany us down here to Berbera, the “coals to Newcastle” idea I had recommended against. A suprapubic catheter was in place, and sounding the urethra from below came to a dead end at the membranous urethra at the site of the disruption, and a “filiform and follower” procedure would be required to “connect the dots.”

A “cold abscess” from a Tb psoas abscess was pointing in the groin from a perirenal origin, and needed drainage—like the large cold abscess we had drained in the woman in Hargeisa. For the students who had not seen her then, here was a duplicate patient giving the second chance, so that no one could leave without seeing what a large retroperitoneal cold abscess looked like—an opportunity vanishingly rare in the US.

A woman with a dermoid cyst of the ovary, which had twisted on several occasions causing pain, was confirmed on ultrasound—who will need an operation to remove it.

A young fellow with a failed unilateral cleft lip repair had retuned with a low grade infection that if unchecked would proceed to cause the necrotizing affliction known as “gnoma” or “cancrum oris.” We started him on local and systemic therapy and took his picture, adding him to the pre-op Op Smile list of patients to be electively reconstructed.

A recurrent right inguinal hernia, that had been repaired, but had probably been simply repaired without attention to the underlying reason for it having developed in the first place—increased intrabdominal pressure from prostatism.

A VVF that had been twice repaired, and was now, again, recurrent. This patient will need a more sophisticated operation, not a simple re-do of an attempt at primary closure which will fail again, but a vascularized muscle-based flap of new tissue brought in, like a gracilis flap or labial flap graft. She, like all but the unique patient I had seen at Hargeisa, had been abandoned by her husband and cast out by her family, and was, as seems almost by definition for most VVF’s a “poor person” who needed charitable support while going through this series of procedures, a specialized repair not available here. She cannot get to the “Hospital by the River” in Addis Ababa, so she will have to wait for a return visit by a team wiling to undertake this repair. It will not be a pleasant waiting interval for her or those around her.

A child of about five had a large involuting glabellar (the space between the eyes in the front of the brow) hemangioma. I took a picture of it and pointed out to all who had suggested that this patient could be operated on today that this would be a big mistake. First, a lesion in this position might represent an anterior encephalocele or myelomeningocele which a surgeon should not stumble into by accident, since this would have neurologic consequences to the patient. But it is not only a hemangioma, but it is clearly going through the involution and thrombosis that is the natural history at about this age of six to eight years, so that we should get out of the way of this natural process of self-resolution and not meddle in it causing a lot of unnecessary risk and scarring. The staff could see and appreciate that this was a disease well on its way of curing itself, and that no treatment would be necessary, for a result that would be far better then any intervention designed to make it go away faster.

I then saw three consecutive hydroceles, two in young boys, and one in an adult. This is such a nice anatomic operation, that I booked each of these to be done more as demonstrations so that this—like hernia repair—is an operation that Suleiman should be able to do himself, not only, but he might graduate to the “teach one” stage here, in training someone else to fix them. Before the fixing, the important distinction to recognize is the difference between a hernia and a hydrocele since the treatment is different. The difference is demonstrable in these patients since the hydroceles are not “communicating”, i.e., the fluid is not able to be expressed back into the peritoneal cavity.

Then I saw a series of clefts: three lips, one unilateral (the kind I can take on in repair) and two bilateral (the kind I would recommend that a “real plastic surgeon” approach, since it is an elective operation and the best chance at the optimum result is the first carefully planned and executed switching of flaps for best outcome.) I saw an additional pair of cleft palates, one with and associated unilateral cleft lip, in a child about ten years old, an age to which such a patient would never mature in an environment in which the resources were available to have had a go at this earlier repair. I saw later an adult bilateral cleft lip. This is significant twice over. First, I was seeing the patient, so it was not for reasons of reluctance to have the condition corrected that it had not been attempted before. And, second, it had never been attempted, even by an “amateur” would be plastic surgeon, meaning they simply are not available here, and no one had stopped by looking for such abnormalities to fix, or this patient who was more than willing to be forthcoming for repair would not have reached age thirty five unattended.

I saw one of the tragedies of a missed pediatric care in a nine year old who had a post-meningitis acquired cortical deafness. The child survived the acute infection, perhaps because it was partially treated, but there were other neurologic deficits as well consequent to the scarring of the post-meningitic state.

A young woman had a colostomy, secondary to an abdominal gunshot wound. This is significant, since she is the only patient I saw with a gunshot wound to the trunk—abdomen, chest or axial spine and head, whereas the wards are filled with extremity gunshot wounds. You know that no one here is selectively aiming at the extremities with the intent to maim, rather than kill. The implication is clear—anyone hit anywhere except in the periphery with the kind of weapons available here is going to die, and will not persist for later treatment This woman was the single exception, and it was because she was closely attended during her gunshot wound, made, as all of them seem to be here in the Horn of Africa, with the one kind of weapon readily available. All gunshot wounds I have seen here are inflicted with the high velocity AK-47, imported in lavish numbers from the mass production of the former Soviet Empire or its client states. This reliable, and nearly indestructible devilish instrument can faithfully spit out large volumes of very high velocity small rounds that tumble in their trajectory after striking anything that disrupts their rifled spin, like clothing, bone, or foreign bodies, causing a great deal of tissue damage in the tumbling deceleration of the unstable round. There would not be the same pattern of injury if the predominant weapon were a low velocity round such as a handgun, or the “nuisance weapons” like “Saturday night specials.” These gunshot wound victims can survive wounds to the trunk since the lower velocity allows simple penetration without the wide track devitalization that come s from a higher velocity deceleration. This whole society has become a military wound target, unlike the urban violence and antipersonnel devices available in the “developed world.”

This woman survived a close range high velocity gunshot wound with an AK-47 round, but she, too, experienced the devastation of this bullet’s deceleration force. She was shot at close range by an acquaintance pointing an “unloaded” AK-47 (“Automatisch Kalashnikov, 1947 vintage”) which penetrated her colon, which had been exteriorized by Suleiman in a colostomy now ready to be taken done and reconnected, but not without the collateral damage of a disrupted spinal cord which left her paralyzed. The bullet does not have to transect the cord to damage it, since the nearby passage of the high velocity round causes a “wound channel” that is “sonicated” in the shock wave around it, so that a near miss of twenty centimeters away will exceed the elastic limit of the tissues stretched out in the shock wave passing through the tissue to disrupt blood supply and function of the spinal cord. We booked her for an elective colostomy closure tomorrow. This is a pretty young woman, whose life is wrecked by the passage of this random bullet through an unintended target. There are no rehabilitation services here for her, and she has gone from a vital young pretty woman to an instantly aged invalid. This is one of an endless litany of tragic stories that in sum, but not exclusively, characterize Africa—or, except for unusually insulated shelters from life’s violent storms, life, in this real world.

An elderly (by local African standards—a sixty-year-old) woman was brought in with a clinically obvious breast cancer. There was a hard mass fixed to the skin and free of the chest wall that was a T-3 tumor size but without palpable axillary nodes. This is an unusual lesion in an African woman, but is likely to be the slow indolent tumor of the kind that the patient would die with, rather than of. WE booked her for Total (simple) mastectomy tomorrow. This is more like American pathology than African since carcinoma is rare in comparison to the US.

A woman was seen with a huge ventral hernia. She had a large diastasis rectus
with a large hernia which went in and out without any signs of obstruction. She could be treated simply without danger by a Scultetus binder, an ancient dressing of alternating web strips that in her case is a better substitute for an operation that would require the implantation of some kind of foreign body graft materials.

I saw two bilateral web contractures of the upper extremities from flame burns. One was still mobile with ability to use the upper extremities well and need no surgical therapy now. The other needed a Z-plasty release of the web contracture in order to restore upper extremity mobility.

One young man had had a shattered femur and now had a healed fracture but with trophic ulcers, since there was neurologic impairment of the leg at the time of the fractures. This needs to be treated since he will otherwise lose the insensate leg. When it was pointed out that we should treat this ulcer aggressively, as if it were a foot ulcer in a leprosy victim, I pointed out that the leg might not have sensation, but it was useful in weight bearing as he could walk, and that it was much more functional than a wooden peg, which is the best he could resort to in the otherwise inevitable outcome if untreated, since there were no prosthetists nearby nor PT training programs.

I saw two foreign body injuries with broken off thorns from running through the desert bush. This would be a constant source of infection until the foreign body is extruded or removed. I had pointed out earlier that the desert thornscrub is definitely a user-unfriendly environment that is well defended even before it was seeded with landmines.

I saw two complications of FGM. One woman had a dermoid inclusion cyst from the infibulation she had undergone as a young girl that had tuned in some epithelium in the suturing of the labial remnants. Another patient was a relatively young woman with symptoms of urinary tract obstruction and infection. On examination she had what would have been called a Bartholin Cyst if she still had labia, but it was a mucocele from a turned in vaginal mucosa buried in the suturing she had had of the remnant labia. It is not bad enough that the people here have abundant natural illnesses befalling them, but that there are additional contrived burdens from inflicted suffering.

A young woman came in with a flowing robe and silently stood waiting until I had finished with the prior patient. Then, wordlessly, she raised her robe to reveal her legs. One was normal. The other was the classic tropical disease—Africa unveiled---elephantiasis of the lower extremity. She had redundant folds of skin rolled over each other and edematous brawny skin changes in the lower ankle. The whole leg weighed about what the rest of her did. She simply looked at me, as if to say, “and just what did you expect to find and do in taking care of me?” I had just now learned about the commensal organism Wolbachia, a microbe that lives within the filiaria that may actually be a major cause of the scarring of the lymphatics that give this heavy lymphedema, not necessarily caused alone by the mechanical plugging of the lymphatics by Wucheria bancrofti, one of the several kinds of filarial worms. So, the inflammation and scarring from the microbe released from the killing of the filarial worm may be as important in the control of this disabling disease as that of the filarial organisms themselves. So a treatment course of doxycycline is given along with the Diethyl Carbamazine twice daily for two months. Telling her to apply heat, rest elevation and compression stockings is a foreign language that need not be translated, since she will have none of the leisure required for resting and elevating that leg. So, we will have to see if medicine can substitute for some part of the advice that I would ordinarily give in its management.

I saw two more urethral strictures, one from Gonococcal urethritis and the second one from a pelvic fracture that had impinged on the urethra

I saw goiters galore. Two of the goiters had very interesting patterns of depigmented spots over them having been treated by a local native practitioner which left a polka dotted pattern of burn marks. This emphasized the sincerity of the woman’s wish to be rid of this mass. I gave iodine to see if it would shrink it down, which would put the depigmented polka dots closer together in a grid mark pattern if the treatment were successful. I treated at least ten other goiters that were symptomatic only in causing some difficulty swallowing, but none impinged on the airway or I would have selected such goiters for thyroidectomy while we are visiting here.

I saw two patients with polio who had the deformities of denervation at an early age. One could benefit from an arthrodesis to make the weight bearing on a stable leg possible. “Orthopedics” means “straight child” and I thought of this as I imaged “straightening out” several congenital abnormalities, including two talipes equino vera (club feet).

Two young children came in with trachoma, one unilateral. We treated them with the antibiotic eye ointment, but hoped to prevent blindness in one of them and the other one would be a candidate for corneal grafting if such were available in this environment, which is unlikely for the next decades at least.

Three patients had prostatic obstruction, tow on the basis of benign prostatic hypertrophy and one with a smaller but firmer hard nodule suspicious for prostatic malignancy. That latter we booked for operation.

I saw three salivary gland tumors, two in the parotid, and one in the submandibular gland. We booked one of the parotid tumors for operation.

I saw two cases of osteomyelitis, one with an early involucrum that would require many more weeks of callus formation in order to insure a stable weight bearing lower extremity without the risk of a non-union pseudo arthrosis. The second was a primary osteomyelitis from hematogenous spread in a patient that we would study by checking of sickle cell disease to consider the possibility that the infecting organism might have been salmonella. A simple way to check for sickling in an environment in which there is no hemoglobin electrophoresis is to wrap a rubber band around the fingertip to allow a period of tourniquet time desaturation. In the hypoxia that results in the finger tip environment of the tourniquet rubber band, the red cells assume the sickle shape—a cheap substitute for a fancy test which is as definitive.

COMPLETION OF SURGICAL OUTPATIENT CLINIC,

AS THE MEDICAL OUTPATIENT WAITNG QUEUE BECOMES LONGER AND MORE RESTLESS

In screening over a hundred surgical patients and demonstrating the pertinent positive findings to the rotating team of senior medical students, I booked over a dozen patients for operation and had to throttle back a bit to consider our operating Theatre capacity, but we did manage to treat or defer the majority of the patients to get some therapy started. It was a fast-paced clinic, unlike the medical clinic to which I moved after clearing all the patients from my previously crowded waiting room area. The pace was slower over in the medical side, and at the rate the patents were being seen, there was no obvious diminishing of the waiting queue outside the medical clinic stations. In fact, it appeared that the patient accrual was gaining on them by the time we had suggested that it might be a good idea to break for a late lunch. The waiting queue of medical patients represented the Biblical “cruise of oil that never ran dry.”

LUNCH BREAK AT “THE HAB”,

A RESTAURANT THAT MEANS “THE SHORE”,

OVERLOOKING THE RED SEA

We had to walk away from a lot of anxious patients who had crowded the doors of the medial clinic and were eager to be the last patients seen at the morning as we were inching into mid-afternoon. We had to break it off, however, and those patients assumed the strategic positions at the door way so that we could not get back in after lunch without them spilling into the clinic which was still running after I had shut down our surgical clinic. We went over to the ‘HAB” a restaurant whose name tells you where it is on the shore of the Red Sea. A number of our clinic fellow attendees, like Suleiman and Dr. Abdullah and the nurses and helpers joined us and tried to listen in as we talked of the wealth of patients we had seen, with many more to come later in the day. We had the standard menu of grilled kingfish from the fresh “fish of the day” brought out of the Red Sea lapping at our feet, with tidal mud flats being poked into by the sacred ibis that were working the flats.

The mayor of Berbera had come by to see that we were going to be accommodated well, and he supplied a TV crew to follow us around on rounds as we returned from lunch. The midwives in their traditional head covers and Somaliland robes were tailing along as our group came into the large orthopedic ward, filled with cradles for limbs that were obviously home made in jury rigs of which they were quite proud. The patients had all been primed to know we were going to be making rounds and that a US medical team was coming to appraise them and to make comments on their care. In fact, each patient had his or her own X-Ray under a pillow or nearby, and if someone faltered in the story of a present illness, the patient or attendant family m ember would prompt them and produce the precious X-Ray to show the lesion. These folks are used to self-care and are a lot of the time reliant upon the family nursing skills. They had been well socialized in the large Nightingale Wards, and took interest in each others’ stories and outcomes. There were a lot of infected bones in the ward from open fractures, a very large number of which were open fractures because they were high velocity gunshot wounds. I saw very large sequestra of rotting bones with an extruding sequestrum almost ready for sequestrectomy. Only a couple of these were the young people in whom primary osteomyelitis was suspected of being the cause, and of those one seemed like he might be a sickle cell disease candidate for the rubber band around the finger tip trick.

As we went along from one to another of these pulverized bones and protruding sequestra, a cameraman followed me as I examined wounds and reviewed X-Rays, and continued the coverage for whomever he was filming. It turned out that this was the mayor of Berbera’s idea and he wanted to show the film on TV as well as make sure I had a copy to bring back to America with me—a gift he was going out of his way to make sure was ready for us before our departure.

The simple traction apparatus was made of a boxed wooden contraption with old IV tubing used as rope and a sandbag for traction around a pulley scavenged from the sailing dhows and maritime supplies. All the patients were encouraged by our presence and I made cheerful comments to each of them, saying to one who had an external fixators applied to his leg with a large missing segment of bone in between the pins that held it externally in place “Your leg would have been a lot shorter if you had come under my care at the time months ago when this injury occurred, so you certainly came to the right place where they did such a good job of it!” No matter that the eventual outcome will be the same, the patients and staff were encouraged by this assessment, much more so than they would have been by the realistic appraisal of the likely therapeutic failure of such a flail extremity.

Another patient had a large mycetoma of “Madura foot.” It is a very slow growing fungal infection that everyone has time to suggest some new kind of treatment for it, including lysosomal incorporation of the antibiotics used to treat it, which are not very effective to begin with, and the long term future for these patients is a lot of misery attending this stumpy foot until it is finally replaced by a stump of a different sort.

One patient who had been injured very recently and was acutely ill was a high ranking justice of the courts here and had a closed head injury and was in a coma. A very large and attentive family was holding him down as he seemed to have periodic seizure activity. That seemed to be the only therapy he was getting at the time, and he had the very bad sign of blood coming from both ears signifying a skull base fracture. But, the good news is that he as still here, and he had not got worse. With a little prompting, the family seemed to note a miniscule amount of improvement, and they were encouraged to think that the patient would be coming around to full consciousness. AT this stage such watchful optimism is perhaps the best kind of treatment he could get, whereas he would have had a “full court press” with steroids, mannitol and hyperventilation in the first hour after his injury if he were in some from of trauma center. But, however high ranking he is or was in this Berbera society, he has got the best and worst of the hospital care available, and so must be encouraged toward the best outcome the circumstances can afford right here.

We made the rounds of the very extensive number of orthopedic patients who seemed to be “bed-fillers” and who were sitting through the long and slow process of knitting bones or watching them get extruded in pus. Once again, I noted that it seemed that there were only extremity gunshot wounds that were alive to make rounds on, and with the single exception of the pretty woman with the colostomy scheduled for closure tomorrow, no other wounds of any hits in the thoracoabdominal or head anatomic regions were around to be discussed no rounds.

We swooped through two other wards as a “fly by” with less advice to make and recommendations for change in care plans—one woman who was an habitual aborter but who had a competent cervix I had recommended be tested for brucellosis, a simple test that if they cannot do, we might carry a sample back for the laboratory at Edna Aden Hospital. One of the staff members had a brother, also a hospital employee, with a rock hard mass in the posterior cervical triangle that appeared to be a very fixed malignant lesion, which we will biopsy, and carry that tissue with us back to Washington to give the results by email. We saw two children of school age with untreated clefts, one bilateral and another admitted for aspiration from the palatal defect.

I GET THE BELLHOP SERVICES OF NO LESS THAN

“HIZZONER HIMSLEF”

AS WE ARE ASSIGNED ROOMS IN A BARE BONES FUNCTIONAL HOTEL

Before we headed back to clinic, we were brought to the hotel that would be our base here—although we were fated to be resident in it for only a few hours that night. As I looked around for my simple carryon bag, I could not find it, and in going down the hallway, I was surprised to see the Mayor of Berbera carrying it to be sure that he had the honor of installing me in my own room for the night. He is a friend of Saad Noor in Washington and had been the one to arrange the videotaping of our clinic activities and insisting on my carrying a copy back with me.

We went back to medical clinic, where we fought our way through a crowd that did not appear to be at all diminished from the one we had encountered in the first appearance at the Berbera Hospital. The crowd was not just a passive waiting room group however, since as the night fell and the queue was lengthening rather than diminishing, there was insistent hammering on the door as the impatient ones who could see that it was not likely they would be seen tonight wanted to be sure they go t into the room, and would dash in past the employee stationed there as crowd control.

I stationed myself behind the pharmacy stock of our drugs: two large duffel bags packed with most of the medicines that we had remaining. I could see three stations of translators and nurses with each of the students and the smaller room where the midwives were rapidly at work with a large number of women who were coming in with complaints related to what in my youth was demurely referred to as “female trouble.” One of the nurses who was male would occasionally bring me a patient as I nodded off in the chair at the back of the room in my backup position there, and point out that this patient was special since he or she was related to someone in the employee group. One rather large woman had complained of hemorrhoids and had undergone a traditional therapy of some unknown sort that had left her with a complication that is called a “wet anus.” This is due to the progression of mucosa outside the anal sphincter and its advance onto the skin of the perineum, the so-called “Whitehead deformity.” I do not know what treatment the native practitioner had used, but he had achieved a result usually only seen with radically heroic attempts at extended hemorrhoidectomy.

I was ready for this clinic to end, considerably longer than any of the patients who were still counting on being seen and were still lined up outside the door. As it got to be 10:00 PM I had said that we were closed and that no more could be admitted through the door. At that point the door burst open, and people literally fell all over each other. They had accomplished their goal; they were inside the door, so now they could wait as they stood hovering over the stations still seeing patients figuring they had made it through the door and would be among the last twenty patients or so that would be seen in this very long day. I said to Kevin: “We are closed.” He said “What about all these—don’t they exist?” I said, “We can tell them they will be the first to be seen in the morning or they can get a lick and promise tonight but we will not be here past midnight yet another night, and we have got to get the team back since there is an early start in the morning.” We ran through the last of the patients inside, then went out to the vehicles and waited for the midwives who were still doing pelvic exams. I said “We cannot wait here with the scores of annoyed patients who had not been seen milling around and getting more hostile all the time we waited right in their line of sight. If the midwives did not come out immediately, we would leave since there is no purpose in being present where the patients can continue to come for us, regardless of the track record we have all had that has extended through a long day and an official announcement that we are closed, they will still continue to work their way in to be the putative last patient, each with a special reason to be seen despite the rules set up. We had to go back in and literally haul the midwives out since they were getting the same bum’s rush that we had had by those still outside, with dozens of women crowding around the women who were being examined in a room so filled that the staff could not move. “OK, see you in the morning!”

It is hard to get away from Tar Baby once you have struck out and made contact. The whole continent is connected to the one patient you are engaged in seeing at that moment, and they are unaware of time zones and other factors that may make the health care provider less than eager to take on yet another single case, and if that one, why not just one more? It was midnight when we pulled out. I made it into the room that the mayor his honor had carried my small backpack to in mid-afternoon, and I just lay down on the simple bed and woke up a few hours later thinking “Well, let’s all get back at it again!”

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