05-AUG-B-5

 

A BUSY, VERY GENERAL SURGICAL DAY IN HAZHAZ HOSPITAL: A RECURRENT HERNIA REPAIR, CHOLECYSTECTOMY, PLASTIC SURGICAL WART REMOVAL, TOTAL HYSTERECTOMY FOR FIBROID UTERUS, AND A BOWEL RESECTION FOR SMALL BOWEL OBSTRUCTION, WITH THE PROMISE OF MANY MORE CASES TO COME—ALL MADE TO ORDER AS TEACHING CASES, FINISHING THE EVENING AT THE “BLUE NILE”

 

August 9, 2005

 

            It has been a full, old-fashioned general surgery day complete with a variety of specialty areas in which I am operating and with unexpected emergencies popping into the schedule, with a gratifying response from both the patients we have fixed and the students taught.  If I had gone out to order up from Central Casting an array of patients to be assembled in order to have the best teaching material possible, it would not have happened as dramatically or thoroughly as with the general surgery principles here re-enforcing the tropical medicine and public health goals I had discussed in the intensive tutorials earlier.  Now it was time for them to see each of these principles in action.

 

            Our first case was a recurrent hernia repair in an older man.  He had a very impressive looking sac when it had been dissected out and ligated by overseeing, but he had also had a mid-line operation before.  What was the operation?   One that should be familiar to us tomorrow, since we have a fellow coming in with a hernia and with BPH (Benign Prostatic Hypertrophy) a combination which is one of three that can give rise to increased intra-abdominal pressure as previously discussed when I had told them about acquired hernias.    So, today we fix the consequences of an earlier operation in which they had fixed the prostate but had missed the sac in an incidental hernia repair.  Tomorrow we will be in a position to make the same mistake, since we will be doing a supra-pubic prostatectomy and will incidentally fix the hernia to which the prostatism had given rise.

 

            Next came a woman who had had the cooling down of acute cholecystitis, and who had stones but minimally recent adhesions to her formerly inflamed gall bladder.  It was an easy cholecystectomy.  I then did the pretty woman we had seen over at the Halibet Hospital who had a recurrent wart on the bridge of her nose, which I made an elliptical excision of it and a 5-0 prolene repair.  I realize now that since I had last done fine plastic surgery I was better able to see the 6-0 Prolene back then, which I now cloud identify only by feel.  She will come back on Friday for the students to see her and have her sutures removed, and we will get the pre-op pictures they had taken promising to send them to her before and after.

 

            We had lunch, this time brought in from the Italian Restaurant we had been in the night before.  We could also appreciate that we were given bottles of water taken from the stock supplied to the other bigger hospital at the halibut Hospital, where the majority of the team are.  We have a unique opportunity to be heroes, since the Hazhaz Hospital is a 22-bed smaller hospital on the hill overlooking the town, and has had a broken autoclave for the past two years.  So, there has been no operating being done here for those two years.  Since we are getting our surgical kits shipped over from the bigger newer (and emptier) Orrotto teaching hospital, we are carrying out the first operations that have happened here in two years or more, and while we are at it we are doing it up big!  There is a good and cautious woman doctor here, Dr. Haregu Mehari (we all are first-named “Doctor Glenn,” or Doctor Haile,  or Doctor Bisrat, so she is Doctor Haregu)  who is the surgeon of record, and I am helping here do the cases in which she is getting to be more confident.  She is being observed by a Chinese doctor from somewhere in the provinces of the PRC.  There is a director of the hospital at Hazhaz and he allegedly was once a surgeon but is now primarily and administrator.  They are each very excited about what they see getting done.

 

            Our next patient was the one I had seen at Halibet Hospital on our first day here on Sunday and had advised here that the large abdominal mass she had presenting from the pelvis as big as a six months’ pregnancy that she should prepare herself for the loss of her uterus in hysterectomy, since it was likely that the infertility she had form the large mass and the anemia she had from heavy menstrual loss was due not to an ovarian mass but a large fibroid uterus, symptomatic from pressing on her bladder, and that t he likely treatment she would need would be a hysterectomy.  She understood and agreed to that.

 

            That operation, carried out expertly and swiftly and smoothly, is exactly what we did as Dr. Hegiru handed me the scissors for my side and I handed it back for her side, in a ballet of hands that carried out the operation with slick efficiency removing the large mass of her uterus. The students even took video clips of the procedure including a short clip on my camera.  As we were finishing the operation, Dr. Hegiru said in quiet expression of triumphant satisfaction: “This has been my first hysterectomy!  I had always sent them away to a gynecologist before, but I had also always wanted to do one if there were an expert nearby to guide me through it!”  If she only knew that at GWUMC—no matter what my experience with the so-called “TAHBSO” in Africa or Mindanao has been, I would be considered unqualified to see, assist or do such an operation in Washington DC, let alone lead and guide another through it!          

 

The patients were cautious at first, and could hardly believe that they had American physicians and surgeons wiling to come here and to consult them, so they wanted to be sure.  As happens each time, most notably as I had predicted at Hargeisa in Somaliland, that there would be a slow and stumbling stagger-start, then a bum’s rush, and by the time we were reedy to leave, we would be overwhelmed, leaving large backlog of patients we had not been able to get to almost guaranteeing a future second run at the list of those wafting if they could l for elective operations, and wiggling the emergencies into the schedule along the way.  This pattern is repeating exactly, and we are about up to full expectation now with cases already saturating our future operating times. 

 

            The patients are very delighted and eager to be examined by an American Doctor, particularly a renowned professor of surgery.  We have a very good staff, including a fellow who is form Eritrea by his parents’ birth, so that he has the language, but has never visited here; he is a very competent attending anesthesiologist at Howard, Dr. Bisrat, and is eager to see what it is like in the ancestral homeland.  He has been teaching the anesthetists at the same time and rate that I have been teaching the GWU medical students with me who are so lucky as to be getting three years clinical experience in three weeks.  Although they are entering the experience at a very junior level in medical school (Amy has not yet started here freshman year, although she took time off to get  Georgetown Masters in Microbiology after hearing my “tropical surgery lecture” in the MTM department eighteen months ago and decided then to apply to medical school and also to accompany me on such an experience) and Sherri has just finished her freshman year at GWU so she is not yet up to the levels of pathology and pharmacology in the pre-clinical years.  Both of them may realize later just how lucky they are to get this full-time tutorial at an age and stage when they can use this incentive to really learn what it is that they would otherwise have to simply cram in rote memorization.  Sherri had also got a masters degree in addition to her MPH while applying to medical school, and is the daughter of two Egyptian born Coptic physicians, her mother a pathologist and her father a practicing internist.  They are at the perfect point in their lives to absorb the huge load of information in principles and practice that we have decided to fast forward for them. 

 

            This older man looked very ill and I guessed he would need about six liters of fluid.  He had a blood sugar drawn which confused people since it was well over six hundred, the highest they  could measure—until it was repeated at 147 and found that it was drawn originally from the arm vein that had the dextrose and water infusion!  Here is an example in which we are benefited from not having that many laboratory examinations available to us.  He looked like he had tympanitic abdomen with absent bowel sounds and I could feel dilated loops of bowel on exam.  His flat plate abdomen X-Ray showed the “step ladder pattern” of bowel obstruction, so it was a good teaching case to show that the “sun should never set on a bowel obstruction.”  We took him to the table and opened to show that large dilated small bowel, then the flat ribbon like bowel with the black spot in between where the adhesion was.  We resected the bowel and did an end-to-end anastamosis, all with the complete understanding and appreciation of the students and others since this was all out in the open before them without anything on virtual guess.  No staplers were used, just a two layer hand sewn bowel anastamosis as it should be for anyone to understand.  Dr. Meghiru and I were the only ones who had ever seen an open bowel anastamosis done before! He did well in the operation for someone who cam into it as a person who could not survive the day.

 

After the full day of the clinical activity, we went back in the somewhat rainy afternoon and had a crash tutorial based largely in the Toledo Ohio MMHOF presentation and others like it to give an introduction to tropical surgery, in addition to what Amy remembered from my lecture to them and intensive discussion at the MTM session at which many of the students lingered after class to ask for more, and—unusual, I am told,  by those who have tried to teach in similar settings,--I received independent letters and emails form four of the twenty students saying that they were both informed but above all inspired by the presentation in the class they had attended and never had dreamed that they might be interested in the subject, but would it be all right if they could correspond further with me and meet with me to discuss the possibility of joining me later?  And, here, one of them has, Amy.  The other, Sherri, is a friend of Siyavash who had been with me in the Dominican Republic and Haiti and had wished very much to be with us on this trip, but for the conflict of his schedule and is planning on going with me on the next trip—perhaps to Kabul Afghanistan.

 

So, when we had completed the crash course in the tutorial based on my laptop presentations, we knocked off for a brief rest period at the Central Hotel, and then prepared to go for a long walk through the spitting rain to a famous restaurant here called the Blue Nile.  They told us we would have to wait for a table big enough, so we went to a bar next door, where we would have a beer, and a round of flaming Sambuco aperitifs sucked through a straw.  One hardly got a chance to taste the licorice flavor of the liqueur before the flame and all vanished up the straw.   The combination of the drinks before dinner and the long day had three of the participants taking a nap in the lounge before we were called for the Blue Nile table an hour and a half later. 

 

The dinner was a large mixed meat platter on a highly spiced tray of Engira bread with a special chick pea puree called Shiras.  We got to eat and drink before making the long haul home, as I had heard from Steven Katz the Norfolk professional photographer who is contracted to cover us in the work we are doing for the PFP (“Physicians for Peace”) and hopes to be with us for the next couple of days at Hazhaz Hospital.  We are taking a fair amount of pictures ourselves, and will add to that the professional with both digital still photos and the videos of our activities here, but we are certainly doing the most general of surgery cutting across all specialty bounds, since tomorrow it looks like I will be seeing a patient who needs a prostatectomy (Urology) and a repair of the diaphragm (event ration of the diaphragm from an accident two years ago (thoracic surgery) and will do a few endocrine surgical operations and GI surgery cases as well as breast operations and gall bladders.  It is a good thing that I am the most “Major General” of operating surgeons and that Dr. Hegiru is eager to learn it all, since we are on a ride!