FEB-B-4
A “THEATER DAY” IN
WITH A DOZEN CASES POSTED AND MOSTLY DONE,
AND EVEN MORE TURNED AWAY
AS THE TEAM REVOLTS FOR A QUICK TRIP
TO THE
THE VEHICLE STUCK IN THE
SAND,
AND RETURN TO THE CLINGING CONCLUSION
AS WE ATTEMPT TO GET ON THE
ROAD BACK TO HARGEISA, WHILE ATTENDING DELAYING DIPLOMATIC CEREMONIES AND
RECEPTIONS OF GRATITUDE BEFORE DEPARTURE FROM THE MAYOR
OF BERBERA ON DOWN
By cannibalizing the batteries from my Mag light to put into the Magellan GPS, I was able to get a fix on the Berbera site at our hotel as I waited for the others to gather for the new day. BERB = 10* 24.56 N, and 45* 00.04 E I had the leisure for this activity by dawn’s early light since I was not found to be wasting time doing such things as showering—after all there was no hot water in the “VIP Suite” two which “Hizzoner” had personally packed my bag. I had hoped to type in something, but the adapter did not fit the wall outlet, and there was no bulb in the lamp, but, I was still grateful for the honor of the VIP Suite for my four hours’ occupation of it.
We dropped the teams off at the front of the Berbera Hospital where the crowds had already gathered for the medical clinics, and I went around to the surgical hospital to start up the list of cases with the students assigned to each planning rotate out of the clinic and spell each other in theatre. I went in to theatre with the large duffel bag which I was planning to leave with all of its contents here, the most important ingredients of the bag being the suture materials and the selected instruments I had brought along.
To begin, I repaired a large hydrocele with Jay Maguire, a good anatomic operation which is easy to teach. We then did a recurrent inguinal hernia repair, and then Kevin spelled him and I did a scrotal hernia with him. A lymph node biopsy on the brother of the theatre staffer went back with Jay Maguire in his baggage for reading at GWU’s pathology department.
I then did an old
fashioned
We did not even pretend that I was instructing the local physician with the next case—the pretty woman whose life had been ruined and almost lost when she was shot at close range in an accidental triggering of an AK-47. She had a colostomy performed at the time for the penetration of the colon, which was by no means here most significant injury. The far more consequential problem she has and will continue to suffer until it is the indirect source of her shortened life’s end is the paralysis from her spinal cord concussion—a result of a nearby passage of the high velocity round as it exited, destroying the spinal cord as surely as if it had transected it. This was the time to be taking down here colostomy, and I helped Suleiman do it. He had seen similar operations before and had intended to simply put interrupted stitches in the colon to pull it together. Thus it was with some surprise that he learned the Connell suture for an absorbable inner layer suture that could be run for a watertight seal and an outer interrupted suture of silk for an expandable anastamosis. He was delighted that he had not only done this operation, but had learned a significant new technique in the course of doing it.
In between cases, I
would duck out as they set up the next one—far more efficiently than in the
I then saw a patient waiting for me to exit form the theatre who handed me a note “Dr. Glenn to see.” He turned around to show me a large patch of skin on his back with a very pronounced rash and cutaneous breakdown. I made my determination on what I thought he had and turned the paper around. On the back side of the note was written “Cutaneous Leishmaniasis?” Spot on! This was the first (and, quite possibly, the last such case the senior student from Washington DC had or would ever see, but it looked enough like the pictures I had shown in Hargeisa at the inaugural Faculty of Medicine lecture that it was recognizable, and by such an association of “pattern recognition” the fine art of tropical medicine had been passed along!
I shuttled over to
the medical clinic to congratulate the astute diagnostician who shrugged and
said “Well, what else could it be?”
Not bad for the “alpha case”. We worked
out the treatment of this condition and differentiated it form visceral
leishmaniasis, a lethal condition called “Kala Azar.” The expert on this
disease at present is a young woman from—of all places,
YEARNING AMBITIONS FOR A BETTER LIFE SOMEWHERE ELSE ON ONE SIDE OF THE CULTURAL EXCHANGE,
AND A REVOLT OF BEACHCOMBERS AFTER LUNCH
We had a full list
with another half dozen cases to go in theatre, and a still overflowing clinic
at the time we had designated to break for lunch. We all adjourned for the trip over to the Hab
seashore to enjoy a seafood lunch as the ebullient group of theatre and clinic
staffers were really excited about our presence, and over lunch came up with
the ever likely question—how about if we just go back with you and continue to
learn form you all about this fascinating world of medical care? The problem, of course, is that it is
impossible, even if they had heard of someone somewhere at some time who had
used the medical ladder to climb out of the environment in which they are
immersed, and there is no such “living laboratory” like this one in which they
would get the experience and exposure to the problems they would be trying,
allegedly, to equip themselves to fix. What that would mean is that they would
become obligatory immigrants to another very different medical environment in
which they would be trained to be misfits in their own system. As attractive as the idea is to even the
well-motivated, it inevitable resolves down to an escape form the oppressive
poverty and despair of one environment into the heady achievement and high
technology luxury of another. They know
Our own group was
going through a bit of a revolution of its own.
“I am not going back—at least not to clinic!” was one refrain,
particularly form the medical clinic stations and the “women’s health”
midwives. “I have come all this way to
be sitting at the die of the
The hospital looks
like a movie set. It has winds whipping
sand through the glassless windows and swirling drifts of desert debris—plastic
bags weighted down with their sandbagging.
This hospital was completely built by the Russians during the time when
they were cultivating
As we were cruising out along the deserted beach just above the water line through the soft sand, the pickup truck labeled “Berbera Hospital” groaned to a halt, getting mired in the soft sand. We were stuck. Scooping out handfuls of sand and trying to insert rocks under the wheels just allowed the vehicle to sink further into the sand to rest upon its frame. As the vehicle had stopped, in a place next to a few sand dunes, it was judged convenient enough by the erstwhile clinic workers, and the midwives went behind the dune to “change.” As the three GWU senior students went charging into the water in bathing trunks so that they cold later report that they had swum in the Red Sea. I watched as Surfer Dude could do his stuff in the body surfing of the minimal waves. I had stayed with the vehicle as they had tried to free it, perhaps out of a sense of duty and also so as not to allow our stay to be prolonged. It would not be much of an advance in my claim to have swum the Red Sea, a long time after the children of Israel had done so, having done magnificent diving trips into this superb aquarium of sea life, from this western shore at the Egyptian dive port of Hurgada, or the Sinai Ras Muhammad or the Eastern Saudi side from the port of Jeddah. But my musings on these subjects while watching the bathers did not help the ever more deeply spinning pickup truck.
Further, the
cultural hit of the sight of the next set of bathing beauties had me reeling
with the overlay of this particular beach as opposed to others I have combed,
as recently as my long run along the deserted beach of the Cumberland Island
wilderness only a month to the day before my strolling this one, trying to run
down the fiddler crabs that would dart back into the Red Sea. From behind the dunes emerged the midwives,
dressed to go swimming in the Red Sea—their “holiday” reward for their
prolonged hard work, and the reason they had been keen to accompany us to
Berbera. I had to do a double take. What?
They were going swimming?
They were dressed head to foot in log flowing robes with head covers. OK, they were different from the robes and head covers of their clinical working uniforms, but there was no difference in their complete veiling form the prying eyes of outside world (perhaps even a few males’) attention. The onshore breeze whipped their robes which flapped like sails, almost lifting them off the sand. They timidly walked out into the surf, getting their feet wet, then successively more and more submerged. Finally, with squeals of laughter and holding hands they plunged to be pulled around underwater by the excessive webs of cloth like trying to swim around in a nun’s habit. I thought, not for the first time, “How bizarre!” But, going swimming like this is a satisfying alternative to not ever going swimming at all, and even a little bit daring at that.
I walked back over to the vehicle as still more passersby came to consult and commiserate on the stuck pickup truck, while the midwives went behind their dune to change back into the dry robes they had brought. The Surfer Dudes returned also, and all but I were crusted with salt. As we stood there, Hizzoner the Mayor, always accommodating had driven up in his Toyota Land Cruiser and popped out with his first response to this crisis. Was it to get out a tow rope and affix it to the stuck pickup truck? No, he waved that aside. Of course that would be done later, but, first—he handed us a plastic bag which was filled with ice and bottles of Coke! He got us into his vehicle to get us back to the Berbera hospital for a later return to pull out the pickup truck. Off we went with Hizzoner himself at the wheel, reminding me that he was going to make a special copy of the video for me to take back.
The salty group reluctantly re-entered the main hospital clinic area as I went around in the surgical hospital to get started on the cases that remained. We had made a plan to be departing to allegedly “get back before dark” to Hargeisa. Right! As I approached the theatre, a woman came running to me screaming out a series of pleas. It turned out that she was the wife of the fellow whose dry gangrene of both lower extremities we had seen on our ward rounds. When we had evaluated him, I said in a matter of fact tone that he would need bilateral amputations, and that quite soon. The staff agreed, but Suleiman added, "This is what we have been saying to her for two weeks, but she has refused this treatment offer. She says there is an American coming and she will listen to what he has to say before making up her mind as to what should be done for her husband.” Well, she had heard it. She had determined that my advice had fit with that which she had been offered by the local staff, and so she now had consented: therefore, it became an emergency after two weeks delay, and she could not understand why we had left for lunch when she had agreed that he should now be operated on—and right now!
Several other outpatients had pushed around to the head of the queue to demand that the American doctor see them and right now, since, after all, they had pre-paid for his opinion in consultation. What is all that about? I innocently wondered. This question was relayed from Suleiman to the others as we prepped for the next theatre case. It turns out that our presence here was an opportunity for some entrepreneurial advance. The outpatients had been charged 3,000 Somaliland Shillings---about a third of a dollar, but a considerable sacrifice in this impoverished country. Just how our free services and freely donated medicines were made into a money-making scheme by whom and for whose benefit was never made clear, and a subject of annoyance to Kevin and others among us who did not know about this charge the patients had been assessed, most of whom could never pay for such extravagance, and the less they were able to pay the more appropriate they were for our help. When Kevin pressed the pint on Mahmoud, he said that refunds would be arranged, but the organization of such an undertaking for refunding in contrast to the helter skelter organization of the patient registration to be seen means such a statement is fatuous.
I went on to theatre, where add-on patients were being tacked on the end of our theatre list to overwhelm our capacity to operate on them. We did one case without sterile gowns and another with the gowns still wet from the autoclave since we had run through all the sets form the morning which had been recycled while we were at lunch. The delay in the obtaining of surgical sterile supplies meant that we were getting on toward evening and the cases were still being added. “That is no problem; you can just keep operating tomorrow and stay an extra few days” was one response to this dilemma in an environment that does not seem to be as time-sensitive as the one from which most of us had come.
Then came the really tragic figure who appeared at the gate bending over his walking stick. I recognized the turban before I knew who it was. The young man form Hargeisa who had the Marjolin Ulcer had found the last of his brothers and each had now signed the permit agreeing to amputation for him. Somehow, he had got some form of transportation and had made it through the night down to Berbera and was found at the hospital gates, having come in for the amputation we had once offered, so he presented himself for the operation –now! Just like the woman who had earlier declined operation for two weeks until our opinion had been known, and once she had decided, the operation was a preemptory emergency, he, too, had come in urgently, a week late and 193 kilometers from home, but ready or not, we could do him now.
Stacy Norville, who was shepherding the midwives and who had gone swimming with them in like apparel, started another theme for worry among the staff. We have to be back to Hargeisa by nightfall, she warned, since we had no armed guards accompanying us, and the highwaymen and bandits that populated the desert by night under one or another of the warlord's purviews would have easy pickings if we tried the transit of the desert road after dark. So, we must be leaving and now.
I had one patient with a parotid tumor on one operating table and the woman with an ovarian cyst on the other. We had one set of wet sterile gowns for one of these operations. I suggested they proceed with the woman with the ovarian cyst since we might be able to do the parotid operation with gloves and no operating gowns. So, Ketamine was given to the woman and then there was a small dance as we tried to get a urinary bladder catheter into her. They had no such catheter, but the bag I had carried did have an abundant stock of such items which will be left here for endless recycling. So, one of these was produced and the second in command in the theatre was to do the honors. He could not find the urethra. There was a good deal of banter about the fact that he was not married, and that Suleiman, who had seven children, would be better qualified to find a female urethra if he had not already been scrubbed in to the only set of precious OR gowns that could not be contaminated in a preliminary procedure. I then went over to help, with my gloved hands and gown protected so that we could proceed with the operation when the catheter was placed.
It turned out to be not so easy—remember where you are! There was a reason he could not easily find the urethra. The anatomy was distorted in this young woman who had gone through the FGM that is the subject of a previous chapter in this description, and we were encountering one of the consequences of this cultural practice. I inspected and found that the clitoris and labia minora were absent and that “infibulation” had taken place—i. E., a suturing of the residua of the labia majora over the site of the prior excisions. The urethral meatus was hooded under the scarring, and only by gingerly feeling the muscular urethral sphincter in the anterior pubic arch (gingerly for reasons of not contaminating my protected gown and gloves more than for gently introducing the catheter tip) could the catheter be insinuated into the urethral outlet. I can add this somewhat exotic reason for delaying the start of operation to a much longer list of altogether too mundane a catalog of prior excuses.
The multiloculated ovarian cyst was removed as the medical students looked on—rather that being scrubbed in, for lack of linens. This ovarian cyst was large, but not so spectacular as the one I had removed in Hargeisa, so it was not as much a crowd-pleaser. We completed this operation and then heard the reverse situation as the previous evening—the midwives were standing around the vehicles waiting to leave as we were still in taking care of patients. In this position they were subject to the harangue of the still-coming patients who were insistent on being seen, now joined by the wife of the patient who had decided that the bilateral amputation she had agreed upon for her husband was being delayed unconscionably by willful neglect of the medical staff. We came out to the vehicles and unloaded all the materia medica that I had saved up for them, and donated the instruments and high quality suture material. It was getting dark. Were we ready to leave now?
COMPOUND THE MEDICAL DELAY,
AS WE FINALLY DEPART BERBERA IN THE DARK
Not yet. Suleiman asks me to come on over to his quarters to have a private word with him. There in his on-call quarters, he has a remarkable gift—a video collection of most of the operations he has learned by watching the tape, particularly orthopedic operations that he can literally “See one and Do one.” He has a request to make. I know how important he is to the running of the Berbera Hospital in general and the surgical service in particular; isn’t it time he got some formal education? And, would I make it possible for him to go to medial school in the US? Recognize that there are certain barriers to this happening. Despite his native intelligence, there are certain standards of admission that require a high school and college equivalent. And beyond that, the astronomic expense of transportation to any area that might be conceivably open to him if all the other waivers had been granted, and then the not minor complicating factors such as supporting not just him, but a wife and seven children as well. But, even beyond all that, what would be doe at Berbera in his absence, even temporarily? And what would be the likelihood that his absence would be temporarily? These are things to think about, not just for me, and for him, but also for any right-spirited donor who might try to help. He ended by asking us to remember him in the event that any such “scholarship” became available.
What next? Hizzoner the Mayor insists we come over to join him in a leisurely dinner and stay the evening at his place. The urgency of our departure is conveyed to him, and he still insists that we come over to have a snack and coffee with him at the seaside restaurant we have become familiar with in a leisurely farewell where he and several other representatives can express their gratitude for our services. We expressed regret that we could not remain for dinner, but Stacie was getting even more concerned about road safety and the effort to be on our way. We had tea with Hizzoner, and he wrote his name and address for our further contact and a future mission : Abdi Jama Duale, Mayor, City Council, Berbera, Somaliland. He could not have been a more accommodating host. He then remembered that we had not yet received the videotape that he wished to have us take along with us as a videotape record of our visit. We followed him through the city of Berbera at night—a flickering black and white “pre-talky” movie illumined by kerosene lamp. We stopped at one alley and a runner retrieved a video tape that he presented with a flourish. With many more showers of thanks and promises to return, we launched our midnight run up the 193 kms of the desert road from Berbera to Hargeisa, a navigation that had seemed tricky by daylight.
ALONG THE DESERT ROUTE FROM BERBERA TO HARGEISA
All this talk about desert banditry by highwaymen seemed to have infected Mahmoud, who put the hammer down in the rapid transit from Berbera in the dark. We had to be careful, less for highwaymen of the evil-doing kind, than for the more pedestrian concerns about running down road walkers. The police check points had the speed bumps I remember in the Gambia being labeled as “Sleeping Policemen.” In this case the sleeping policemen were real, and the unmarked speed bumps were there as traffic hazards that we would have hit at highway speed had Mahmoud not traveled this way before often and knew when to slow down, so that we might wake up the sleeping policemen who could recognize the Berbera hospital’s truck’s government plate and wave us on after a curious glance inside to see white faces in what appeared to be drugged slumber.
I had kept one eye open for what I assumed might be an occasional nocturnal antelope, a dik-dik perhaps, darting across the road, or a camel lumbering away down the unpainted median strip. But we managed the slalom course without hitting anything more substantial than one nightjar which fluttered up at the last moment and got knocked considerably more airborne. We threaded our way around the kerosene flickers of Hargeisa by night, and crawled up to our still-waiting rooms and still-cheerful staff at the Maansoor hotel—you guessed it, in our fourth consecutive after midnight return from full clinic days. But, why not? Our leisurely holiday today included a little beach time lolling about in the Red Sea—so who is to complain?