05-AUG-B-12

 

THE PENULTIMATE DAY IN ASMARA BEGINS WITH A PAIR OF GOITERS FOR THYROIDECTOMY AND A YOUNG HERNIA REPAIR DEMONSTRATION FOR GWU DELEGATION

AND GOES ON TO MEDICAL DIPLOMACY WITH THE

ERITREAN MINISTER OF HEALTH

 

August 16, 2005

 

            We are getting “short.”   Amy had already left last night in time to get to her first day orientation to medical school as a GWU freshmen with stories that would be hard to believe for anyone not here to confirm her experiences. It is now Sherry and me, along with Dr. Haregu for the remaining patients as well as the many who still pop up at the OR door for consultation in the hope of being added in to the schedule already booked fully.  She had told me she wanted to keep a part of the afternoon open tomorrow to have a small celebration of our volunteer service here and to receive from the patients and staff some tokens of their esteem and gratitude for what we have done for them in a traditional coffee ceremony.  I would also have the official meeting with the Minister of Health which may find some formal way to recognize an affiliation between GWU and Eritrea to support their plans as we will learn them from him in an afternoon session set up to coincide with my being here and the arrival of Bryan McGrath and Huda Ayas from the International Medicine Programs of the kind of “Photo Op hand shaking and MOU signing types.”  We worker bees could hardly make it into the schedule since we were each working overtime on the patient add ons.

 

            We started off in the OR with a very large goiter suffered by a woman who had an elaborate series of tattooed scripts around her neck.  I tried to learn what the script had said but was told that it was decorative, and also an apparently failed method of preventing the very problem we were setting out to treat.  Her trachea was much deviated from the presence of a large mass, and she had the large goiter pressing on her airways as well as her food passages so she could not breathe and swallow at the same time.  I estimated the pre-op size of this gland at five hundred grams, certainly not up in my record class, but a sizable one to be done here.

 

            Despite the size, we actually scooped it out smoothly and swiftly and she went to the recovery room in good condition.  She got very anxious however when we made rounds later and she had a hard time coughing out secretions.  She may have a little longer recovery than the others who were already eating and smiling when we woke them up an hour after the operation—but one of the neighboring patients explained, “She is coming form a long way off in the country, and she is very anxious and scared to be here with a professor form America.”  That should have resolved with the operation as it had with so many before here, but I noticed she had breathed a lot easier when we were not making rounds on her and focusing a lot of attention on her.  She did not have a positive Chvostek as the one prior patient had nor did she get any evidence of carpopedal spasm, so I believe she will be fine.  We were going to do a second goiter which was a re-do recurrent goiter when we had encountered two patients at the “OR Door Consults,” one a three-year old boy with a large scrotal hernia who might have been first into the list if his mother and he had showed up early. He came later and his mother was very eager to have this fixed.  Another was a fifteen year old boy with an undescended testis, a question of what one does at that age.  He is not being operated for fertility, since the undescended testis would not contribute much to the redundancy of the  sperm produced by any male, but he could have a salvage of some of the endocrine function if the gonad were brought down.  A much more important reason is to bring it down to get it within examination range, since the malignant potential of an undescended gonad is higher, and if he were any older, or if hew were not going to be seen and examined annually, I would recommend orchiectomy of the undescended testis to reduce that risk to zero.  But, if we can impress upon him the need to be seen and followed, at age fifteen it is late but still possible to pull down and fix the undescended testis.  So, we keep adding cases.

 

            The GWU administrative contingent with whom we had dinner last night had been intrigued when they had heard us describe our set up here at the Hazhaz Hospital and had wanted to see an operation. Remember that Huda had been over twice before and although we could not convince her to come in to see an operation the first time—as she was highly anxious about her own reactions to being in an operating room when she had made only one prior trip in and that was at Cleveland Clinic to have her mitral valve prolapse repaired—she did come in the second visit, when she witnessed thee spectacular case of the repair of the extensive diaphragmatic rupture in Johannes, the 22 year old engineering student who had become a favored patient because of his very personable interaction with the students and staff.  So, she had witnessed a very major operation and was surprised on how well she had weathered that witnessing she had never anticipated, so was going to come over with Bryan McGrath who is an anesthesiologist curious about how we were doing over here.

 

            They witnessed a simple, small, but very instructive operation—we had them come in for the three year old boy who had the large scrotal hernia which I repaired with Sherry.  So, here was a GWU freshman medical student who had seen prior hernias with me only this week earlier and now was being grilled as to her understanding of the anatomy and embryology of the layers we were going through in the repair. She gave a good account of her self, and the use of an epidural anesthesia technique worked well also in instructing the anesthetists.  So, we all got maximum educational benefit out of the case, as well as an opportunity in our Tea Room to have the other administrative parts of the GWU team meet the people we had been teaching and working with for the ten days.  They, of course, were quite impressed with the size and complexity of the patients we had repaired already, and how well they were doing as we made rounds in the post-op wards.  They may have witnessed the smallest operation I did while here (If you discount the excision of the wart of the bridge of the nose of the Judge!) and the effusive thanks from the patients as we introduced them all around.  They took a few photos in the post-op rounds and I also showed them the pediatric wards where I had caused such a stir by distributing a bag full of small toys for the kids on the last day last week.

 

            I had the recurrent goiter to do as they were going to go back to be on time or early for the meeting with the Minister of Health at the MOH office, so I proceeded with my case with the instructions given to the driver to pick me up in plenty of time—this going through several interpreters.  I finished the re-do thyroidectomy, and then waited out in front—and, of course, no one showed up.  So, by the time of the MOH office meeting, I was still sitting in the courtyard writing postcards as a way of wasting the time altogether, and finally commandeered the ambulance and driver.  She did not quite understand the mission either, so she stopped to pick up and drop off several people and a propane gas tank, so the MOH would just have to wait for the “Eritrean time.”

 

MEETING WITH ERITREAN MINISTER OF HEALTH

AND RECEIVING OF HIS THANKS AND PRSIE AS WELL AS HIS HOPES OF FUTURE AFFILAITON AND CONTINUING CONTIRBUTION TO POSTGRADUATGE TRAING OF SPECIALISTS IN THE ERITREAN HEALTH SYSTEM

 

            The Minister was eager to meet me and effusive in his praise, since he had spoken at length with Dr. Haregu about heir experience and how she had learned so much amounting to a full general surgery residency in the two weeks time.  He had suggested only slightly facetiously, “Can we keep him and clone him to support our plans here?”  In fact, Haile Mezghebe is committed to come to help establish the surgical residency in January 2007 and stay.  In 2008 he will be joined by his former chief resident in surgery at Howard Fatima, who is going to New Mexico for an Indian Health Service position for two years, then coming here essentially paid in room and board.  The medical school is brand new and was simply (like the Nike philosophy-- That is= “Just Do It!”) They had simply started the medical school two years ago without any thought about how they would get the clinical years started, farming out the basic science teaching to Cubans, and it will not be until 20090 that the first class of medical school graduates would come along to be ready for any kind of residency, but the interval the MOH wants to have filled up with applicants to residency by GP’s currently in practice in Eritrea.  He wants to bull his way forward with or without support, but would be grateful if some help were forthcoming.  He even pointed out that he did not care about funding—which is either disarming or naïve.  But, he was determined to push ahead, and hoped that GWU and others would give support to his plan to have the residency program established and quite soon, whether the medical students come along later or not..

 

            I was one of the group at the table to caution against over promising what can be delivered, since Huda mentioned sending students and residents, and certainly no residents can come with any accreditation except for short term vacations. And I do not believe the students would have had anything quite like the experience they had with me, if there were no similar person involved in seeing to their care and overseeing their education at every step, particularly at the junior level the current two students are who are having such a wonderful experience.  But this is a labor intensive process, and also requires someone who is wiling to pay not only all the expenses of the visit, but also support the students with their expenses as well.  There are no large numbers of such folk around—as Huda pointed out, limited to the one present right now.  But, the MOH is going to try to do it, whether or not GWU is involved, and he had recruited Haile who had intended to be coming home anyway, so it will happen by a lurch forward, with perhaps less planning and careful control than anticipated by the administrative types.  The integrations of the medical school and the postgraduate programs is something that is not pre-planned but they simply hope it will eventually come—that the chief of surgery would probably also be the chairman to a faculty program, for example.  But they have many other specialties to consider, like pediatrics, and I suggested that one of their first priorities might be a good public health officers training program as part of every medical students’ experience.  It is unlikely that all these tall orders can be pulled off simply on the basis of good will and hard work without a bit more intelligent planning than I had witnessed in our meeting, but the MOH seems determined, and I would think that GWU would be involved simply because we are already here.  But, I also have a number of other nations and regions with even lesser development requiring the kinds of educational services I can provide, so we will see what comes of this one of many contending competing African programs for upgrading indigenous skills and a laboratory for first world students who have little expertise to offer, but a whole lot to be learned in such an affiliation.

 

            I went on with the GWU contingent to make a couple of stops as we anticipated a rainstorm.  WE were going to do a post MOH debriefing session but the essence of the impression has just been described (above) so the choice was to go the luxurious Intercontinental Hotel for a drink.  It is across for a large high rise building with a large parking lot filled with White SUV’s each with the big “UN” stenciled on them.  The license plates say UNMEE—UN Mission to Ethiopia and Eritrea” and this has to be the single biggest industry here in the country—Most of the traffic in town could be what I had once described in Mozambique—UN vehicles colliding with each other in the country they are allegedly here to straighten out in redundant overlapping programs.  I say there are more people living OFF this international aid than WITH it!  Such people need accommodations of course, and they have to come up to a certain standard of what we might become used to so the Intercontinental Hotel is filled with UN consultants. On the per diem they draw, it must be a lot more than my Central Hotel room!

 

            We took a taxi back with the promise we would get together later that evening after Sherry had done her Shopping if she has managed to get more Nakfa.  When we did get tighter, we walked to the pizza place that Bryan and I had discovered the two nights ago when he arrived, and we had planned to go t to the Casa del Italia, but found that it did no t serve food on Sunday night.  So, we just walked into this restaurant, and did so again tonight with the five of us along with Steve whom I asked to accompany us.  We waited while they found a table big enough for the five of us.  When we went back to the room, there at a very long table was the rest of our group who had been working late at Halibet Hospital so over two thirds of the restaurant were the PFP group working in the four different hospitals—we had taken over the town and its economy every bit as much as the UN had which we had just witnessed at the Intercontinental Hotel a few hours earlier!