05-AUG-B-6

 

A STILL MORE SPECTACULARLY CLASSIC “GENERAL SURGERY” DAY OPERATING IN HAZHAZ HOSPITAL DEMONSTRATING CLASSIC OPERATIONS THAT NONE OF THE CURRENT MEDICAL STUDENTS OR RESIDENTS HAD EVER SEEN OR HEARD OF EXCEPT IN CLASSIC TEXTBOOKS: OPEN CHOLECYSTECTOMY, SUPRAPUBIC TRANSVESICAL PROSTATECTOMY AND HERNIA REPAIR, AND TRUNCAL VAGOTOMY AND RETROCOLIC GASTROJEJUNOSTOMY FOR A TOTAL GASTRIC OUTLET PEPTIC OBSTRUCTION, ALL DONE WELL AND SLICKLY IN A VERY UPBEAT OPERATIVE TEAM

 

August 10, 2005

 

            We began our OR list for the day with a cholecystectomy for stone.  Br Besrat from Howard’s Anesthesia Department said it takes about five hours to set up all the scopes and image intensifiers at Howard University Hospital in DC for the average lap chole these days so he planned something like three hours foe the general anesthesia for an open cholecystectomy.  Dr. Haregu is careful and swift, and not at all a “cowboy” charging into any area in which she is cautiously uncertain; yet, we have not taken an hour for any operation we have done so far!  The cholecystectomy was done safely and well through a minimal subcostal incision which the patient should tolerate well. 

 

            As at the Hargeisa Hospital in Somaliland, much of the fascinating world of surgical pathology came streaming by the OR door in between cases in which I was asked for a quick consultation on some rather advanced and obvious pathology which should never develop to such stages before repair in the US.  Large goiters, a recurrent hernia and another bad breast cancer appeared.

 

            One young man who is 22 years old coyly charming had won over the students as an age-mate of theirs who spoke English.  He had a big and nasty problem.  Wight months ago he was riding his bicycle and was slammed by a speeding car and knocked down.  The longer term injury he sustained was a complete rupture of his left hemidiaphragm and he now had most of his gut up in his chest.  This crowded out his lung and made him short of breath.  It also made it difficult to empty the GI tract, and he suffered the embarrassment of borborygmi coming out of his neck and chest.  He was most concerned about the fact that he had a scoliosis to accommodate the new resident in his chest in order to get emptying of it he had to bend his spine to the opposite side.  He was an engineering student and had looked up the treatment and was convinced he would need a separate operation to correct his spine.  I had assured him that he had one main problem just now and would need to have it fixed, and then the compensatory scoliosis would likely resolve.  I hade cautioned him that some of the bowel might be stuck in the chest and we might have to extend this into a thoracic approach to free it up.  He had a very scaphoid abdomen and I cautioned that the bowel had “lost domain” and returning it to the abdomen might push up his repaired diaphragmatic rent requiring some ventilation assistance.  I also thought from the size of the hole in his diaphragm that he would need a mesh graft tacked down to the edges of the rent diaphragm.  This meant that such mesh had to be brought over from Orotta Hospital in time for his operation scheduled quite soon—as in a few days, since we will not be here longer.  Both the patient and the staff were happy when we booked him in on our list with lots of people contributing for his well being.  He is one of two “pets” of the same age as our students and both relating well and speaking English.  One is Dinah, and she has the very extensive inflammatory breast cancer at her age of 23; the young man with the torn diaphragm is Johannes, and both of these are the stars of our wards—showing once again that identification is one of the strongest motivators for extraordinary effort in patient care.

 

            Dr Haregu is a graduate of the Gondar Medical College and did some of her training in the Addis Ababa area including the Black Lion Hospital—the two sites in Ethiopia where I had done most of my work.  So, I am familiar with her background and impressed with her cautious competence.  She has been eager to be operating with the help of “The Professor” since she can then take on several new procedures she had not done previously, and we will try to score as many of these “firsts” as possible for her.

 

            We followed with a large Right Inguinal Hernia recurrence, and showed the students the anatomy of this standard operation.  We then did a suprapubic transvesical prostatectomy, with a big relief for the patient who could not stop smiling upon his waking up after sedation coupled with spinal anesthesia.  As I was teaching surgical lore, a similar teaching session was going on at the head of the table as Dr. Besrat taught the anesthetists techniques they had not done before.  He was a superb collaborative anesthesiologist and our care in OR was second to none.

 

CLASSIC OPERATIONS

FOR “TEXTBOOK” ADVANCED PATHOLOGY,

NOW WITH PROFESSINAL INSTRUCTION

IN PLACE OF “DO IT YOURSELF” TRIAL AND ERROR

 

            Dr. Haregu came to thank me effusively saying that she really appreciated the fundamental principles detailed in the instruction since she had to look up on her own everything she had known and practiced so far, and envies those who get the kind of careful prospective teaching I have been doing.  She said if only I had had the kind of professional instruction you have given, I might have advanced far beyond my status now, and I would gladly trade places with your students and residents and do it all over again.  She said she had confronted a group of men with prostatism when she had first arrive ed at Hazhaz Hospital and had applied to the Minister of Health to transfer saying she would like to learn thoracic surgery.  But two applications for transfer were turned down, so she turned to do what she could learning on her own and did a series of the prostatectomies, trying them out herself for the first time without instruction.  The first was difficult, but she got better, and then before long she was known for this operation and others came for it here at Hazhaz (the name means “holding” or “Hugging” whereas the name Orotta is the name of a battle site in the war of independence.)  So, now she can have a chance to learn operations she will not have to go through by trial and error, such as the first hysterectomy she will ever do with my help.

 

            Now we have encountered the most classic of untreated patients with a classic problem almost vanished from the US or developed world Operating Rooms.  A 28-year old woman has had an untreated chronic peptic ulcer in the duodenum and simply suffered through this pain without treatment.  Over time the duodenum scarred down to become a gastric outlet obstruction.  She had duodenal stenosis secondary to a chronic untreated peptic duodenal ulcer.  In the US she would have been treated intensively with diet, then antacids, then H-2 receptor blockade (cimetidine, ranitidine, or Pepcid famotidine) and on to PPI (Proton Pump Inhibitors).  Here she had nothing so she presented not with an ulcer as her chief problem, but a complication of an ulcer –the obstruction.  So, this case afforded the teaching point that you do not operate any longer on ulcer disease, but only on the complications of ulcer disease, treating the ulcer diathesis medically.  The four complications of peptic ulcer disease that may require operation are 1) obstruction (case in point), 2) hemorrhage not controlled, 3) perforation, and 4) intractability –A-of the patient (noncompliant with medical therapy ) or B—the Ulcer (Inpatient care under maximal medical therapy and nasogastric drainage and an unhealing ulcer.)  So, here we have “Exhibit #1 in an ulcer complication for which we will fix the complication and incidentally reduce the acid secretion while in there.

 

            We did a classic beautiful operation no one here had ever seen before—they are all products of the post-cimetidine world.  We did a truncal vagotomy and a gastrojejunostomy in the antecolic position.  I asked the anesthesiologist Dr. Besrat from Howard when he had last seen a peptic ulcer operation.  “Never, but that also goes for an open cholecystectomy or open prostatectomy or most of the other cases I have seen you do here, and all of them are done more swiftly with better patient outcome than the time- and labor- saving techniques used in our allegedly advanced OR at home!”

 

            It is true that we work well as a team.  At many times it is unclear whose hands are dong what in a coordinated team as the stream of teaching information is absorbed by not just the enthusiastic students but also by the OR team.  I learned that they are having meetings after the cases to review what they have learned to take maximum advantage of the team’s presence here.  One fellow is intent on learning the “hand signals” I use to call for certain instruments.  Ordinarily I simply do the signals to avoid interrupting the line of teaching I am otherwise using, so no words interrupt the principles being discussed.  But, there is a tremendous advantage across a language barrier and the ambient sounds of the OR muffling the voices strained through masks.  So, he is practicing and will give me signals he is uncertain of and I reply with illustrations by touching the correct instrument the hand signal calls for. He is delighted, since he is learning fast at his level while all others are choosing the level of their won enhancement.  He has a relative somewhere in the Virginia suburbs of Washington DC, as do many of the staff here including Dr. Haregu, and I will try to contact them upon my return.  I may be able to get the text books I had promised Dr. Haregu to her niece in Virginia who will be coming out for a visit in two months’ time, and use that package to forward pictures and this description since I doubt the email capacity here for reception since it has not worked for me.

 

Today alone, the GWU medical students have seen three classic operations in which they participated directly and got to touch the tissues involved in advanced “textbook” pathology: 1) Open cholecystectomy, 2) Open transvesical prostatectomy, 3) Peptic Ulcer Operation for duodenal obstruction—a truncal vagotomy and antecolic gastrojejunostomy.  Chances are much better than even that they will never see these diseases so clearly and will never witness such operations again in a more developed world where such operations have become obsolete supplanted by medical treatment or converted to “closed” minimally invasive procedures.

 

A WALK AROUND ASMARA IN THE

HIGH ALTITUDE “WINTER RAINY SEASON”.

SEEING SIGNS AND PHOTOS WHILE TAKING SOME

BEFORE HEADING OFF TO DINNER FOR THE EVENING

 

After returning to our hotel following an exhilarating OR day, we took a walk in the sprinkling rain of the high altitude “rainy season” called “winter” here.  That is because the highlands has what is classically called a “Mediterranean climate” which means, in essence, “winter rains.”  There had been many years of drought and this is the first time that there has been a year of good rains.  But the capital is sited such that the rains run off the rocky slopes and they need to capture it with impoundments.  There is one now outside town called Maisirwa, which is precious, and they need others.  There is a five year plan for the country in which the dams proposed might make Eritrea self-sufficient in water and the food that comes along behind the conservation of that most precious resource.

 

We walked a few streets we had not strolled before passing some government buildings with public exhortation s to the public spirited and patriotic—some of which are comical.  One blustering sign advises no one to take on Eritreans lightly since they will always fight to the last man and woman (equal opportunity has never been put to such a test as here in their wars for independence) and adds “Woo [sic] be to him who underestimates the strength of our resolve!”  A lot of non-“wooing” attention has been lavished upon Eritrea by its friends, neighbors and foes alike, as evidenced by the scattered frequent memorials and markers, and even more lavishly distributed wreckage of war.  We walked toward the market square near the mosque, seeing a large block of bicycles parked as if a crowded parking lot at Tyson’s Corner were filled with their more typical conveyance here.  It seems that at all hours of the day and night there are hundreds of pedestrians strolling the streets where they are there to see and be seen.  It must be one of the safest cities to walk around in—at least in all Africa.  Single white women can stroll at night.  I am walking about with a camera among people varying from shabby beggars to strutting highly stylish young women in latest fashions, most wearing some form of “winter wear.”

 

There are scores of “photo shops” which must be big business here, as well as “computer training courses.”  One of the shops had displayed in front of the window a series of portraits in frames.  One of the pictures showed an attractive woman with a cap and gown at a graduation.  Sherry exclaimed “Oh, Look!  Don’t you know her?”  Sure enough, it was the attractive young woman we had seen on our first day at Halibet Hospital with a large wart on the bridge of her nose, who had come to ask if I might remove it.  We said we would get to her as an add on case, and she appeared on the first day at Hazhaz Hospital when we were busy so she had waited much of the day and went home, only to come back the following day.  Because of her persistence, I did her as a separate case as I was between cases, hoping to take one of the students through the excision of the wart in the very prominent place on her pretty face where it had been attacked twice before.  But she had come because she heard there were American experts here, and she had a very engaging warmth and a facility with English, and I had promised so I fulfilled that promise by removing it myself with very fine 5-0 Prolene sutures—which I discovered I can hardly see in the dim light of the Recovery Room.  I had told her to come back for suture removal in three days, and she did.  This was the second day, with her arrival planned for the following day—and here she was in portrait form displayed in the shop “pre-wart.”

 

Sherry and I took the pictures of her portrait and showed them to her eventually and she was amazed.  When her sutures were out and we got to talking with her later, it turns out that she has an unusual position here in Eritrea—she is a law school graduate and, even though she said she reluctantly took the position—she is a Judge!

 

So, for a “Bush Surgeon “ who comes to care for the poor, down and out, I have come a long way upmarket, doing a cosmetic operation on a pretty woman who is a post graduate citizen and a judge in robes and white wig in her day job!  OK, it did happen to be the smallest case that I did, but it is probably good that I did not give her over to a freshman medical student as there first operation they would ever do on the mid-face of a pretty Eritrean sitting judge!

 

We made the very short walk from the Mosque where the faithful were coming for the “Adan” in response to the evening prayer call by the muezzin, to the Cathedral where services are held in Italian.  Under the eves of the cathedral are scores of mud swallow nests.  On the pavement beneath was a small unfledged bay swallow that had fallen form the mud oven nest far above.  I could not hoist the small bird back up to safety, so I could only take a photo of the tiny life on the pavement, as a single acknowledgment of an aborted start on a fledgling life that might never soar.  I felt that way often in Africa, with starving kids in Sudan and destitute folk in the Horn of Africa most recently.

 

The population of vigorous strollers around me looked at me askance, especially when they saw me with two women and a professional photographer and his large telephoto lenses—they were curious but not intrusive.  Only a few beggars accosted us, and most of them were small boys trying to sell a stick of gum or a pack of cigarettes.  I told them that I do not smoke and that they should not either, but knew no other way for them to subsist in an urban cash economy.

 

On the subject of sings, and cigarettes, there is a favorite of mine here near the Central hotel.  It says “Avoid Alcohol; It May Lead to Unwanted Sex” beneath the text in English and Tigrinya is an AIDS sign and cigarettes being crushed.  Another sign shows cigarettes being stomped by four feet, one with stylish high heel, one with a running shoe, one with a sandal and one barefoot--  message clear and crossing all spectra of the society.  Each sing touches all three vices.  Booze, Butts, and Bodies.  There is an even more frequent sign that shows a romantic silhouette of a man and woman at a beach with palm trees overhead in the sunset, and a leaping dolphin nearby—the symbol of sex here (as it coincidentally was in the “Bota” of the Amazon delta.)  The warning is clear, even if the AIDS ribbon nearby were not as prominent as it is.  Life is precious here—do not risk it in vices or casual sex.  In the corner there will be a crushed cigarette and bottle—once again, economically covering all bases and vices.

 

I pulled up to take a picture in front of the cathedral—then, uncharacteristically, backed off, not even shooting from the hip.  There were two groups of young women, four in on e group heading north and six in the other group heading south, all side by side holding hands.  The four were wearing headcovers and long flowing robes, not quite abayas, but modestly covered Islamic women.  Two of the others showed off in tight revealing “boulevard strutting attire” were  in the lead of the collision course with the four behind them holding hands and looking like normally dressed school girls each with Coptic crosses on her neck.  As they came closer to each other, these groups which might be assumed to have fallen form different worlds at least, and perhaps different planets at the extremes, did not collide or force the others to step aside, but gave a cheerful wave and unlinked to mingle through each other to reassemble on the other side.  I do not know if they knew each other, but the symbolic imagery was a very hopeful sign for me.

 

Despite having been there the night before, there was a ground swell of enthusiasm for a return to the Blue Nile Restaurant, where we returned for the spicy Shiras (chick peas puree) and the large Engira flat bread, shish kebabed lamb and Asmara beer.  Since we had waited for a couple of hours for formal seating the night before—which had occasioned the snorting of flaming Sambuco and other time filling sports during the long wait in the adjacent bar, we took random seating in the bar at Blue Nile to reduce our waiting time down to a mere hour.  One of the more time-consuming events on this excursion has been getting fed and watered at regular intervals—a social more than nutritional event.  But, in the course of the long walk to Blue Nile and back to our Hotel Central, most of the calories picked up in the excursion are well used up by the time of our return—and enough to make me drowsy to record these events for you before rallying for a new operating day tomorrow!