A little peak at the hospital...

the hospital with a beautiful green field out front

Rounding...for some reason this old man has the whole ward laughing. I'm not quite sure why...but it was hilarious.

Morning round adventures: "Look what I found in my kid's poop."  A worm...just what I wanted to see on morning rounds. yuck.

The OR...

is this another planet?

After a semi-eventful trans-African journey (including an unexpected night in a very nice Ethiopian hotel), we have arrived in Burundi. And, well, we aren't in the desert anymore.

they messed up our flights...but at least this is a pretty sweet hotel 

free dinner...with fish

Burundi...definitely not the desert! It was green like this for the whole 2.5 hour drive 

and then we found this in our refrigerator!!! biggest avocado we've ever seen  (turns out there are huge avocado trees here...with avocados just laying around on the ground). All you can eat avocados, WHAT?!?!

and it wasn't even rotten inside

Guacamole and homemade tortillas (nope, didn't add meat or anything else)

Took a short hike to the top of the hill...its so GREEN!

In many ways, our experience here has been the opposite of the last two years. It rains every day. We are cold and wear our jackets and socks all the time, even inside, and sleep with four blankets on our bed. Our refrigerator is so full of fresh produce we don't know what to do with it all. Tab hasn't had that much work to do at the hospital- I guess the word got out that there was no surgeon here...so this might change soon.

Luke is still trying to fix everything broken.

Some other things are exactly the same, bad power, lack of resources, language struggles, and the ever present cultural misunderstandings. 

We are still looking forward to flying home soon. In two days we will have been gone for two years. It doesn't seem that long. Oh well, all things must come to an end.

skull and neck bones

Its been awhile since I've shared any medical stories...but, never fear, the steady stream of interesting, difficult, and heart-wrenching cases has not stopped (or even slowed down). Here are a few cases from the last month. Check this out:

normal neck x-ray

abnormal

I think almost anyone can see in this x-ray that something is horribly wrong. His upper neck bones are completely separated from the lower ones. When we saw the x-ray, we could not believe he was still alive- talking and breathing, but paralyzed. Unfortunately, we couldn't do much to help other than to make him comfortable.


In happier news, a couple of months ago we had a young man come in with a skull fracture. The story was told like this: he was in a tree and was frightened by seeing three demons, fell out of the tree, and hit his head on a rock.

his x-ray

depressed skull fracture

lateral view

putting the bone back in place after pulling it off the brain

His skull was smashed in on the right side, and he couldn’t move his left arm but everything else was normal. My partner, Dr S, took him to the OR to elevate the fracture and release the pressure on his brain so he could hopefully regain function in his arm. After the operation, the man still couldn’t move his left arm. I was pretty disappointed that the operation hadn’t helped him. We sent him to rehab therapy (another story about that on my our therapist's blog here). Last week when I saw him in clinic I could hardly believe my eyes. I asked him if he could move his left arm. He didn’t just move it, he waved it around- completely normal function!

Brace yourself (or stop reading here). This next story is one of the more disturbing things I have witnessed here. Last week a woman came in one-month after a C-section. We knew something was wrong when she walked into clinic and all the other patients covered their mouths and noses because of the foul smell. Our most experienced obstetrician saw the patient and found a hard object stuck in her birth canal…Then she called me over the see the patient since I was on call for the weekend and would be the one operating the next day. Even though we do several C-sections every day here, she was still able to recall the details of this particular C-section because it was so distubing. The midwife had called to tell her that the baby’s brain was coming out, but the rest of the baby wouldn’t deliver. So, a C-section was done to remove the already dead, mutilated baby. The woman was discharged a few days later doing well, but then started having foul-smelling discharge. Finally, one month later, she came back to be seen. When we took the woman to the OR, and this is what we found:

Yes, that is the top of the baby’s skull that was stuck in the birth canal. She had to cut out piece of it in order to remove it. One of the many examples of why we desperately need to educate and empower women here. 

This is  the maternity record for one of the women I did a C-section for recently. Once again, I was shocked. In case you aren't familiar with the obstetric terminology, let me interpret:

Gravida (the number of times she has been pregnant): 15

Para (the number of times she has delivered): 14

Vivant (the number of children she has alive now): 4

D (number of her children who are deceased): 10

I did a C-section to remove her 15th child, a perfectly formed yet dead little baby boy. Most likely her uterus was too tired to push out another baby and she had started labor days before coming to the hospital. She told me that ten of her children died before they could walk. She didn't know why they died. They don't have a hospital near her village. Maternal and child mortality...not just a statistic but a personal tragedy for this woman and many more here in Niger.

first stop

Saturday morning rounds are rough. Its not just because it is Saturday and I don't want to be working. Or that I know I am on call for two more days. Its more than that. Its discouraging. It can be frustrating. Its sad. Its a lot of patients.

First stop, first ICU patient. He is a tiny baby with a tube down his nose. An oxygen monitor is hooked up to a sensor on his hand, but it is adult-sized and isn't picking up a signal.

The resident tells me that the patient is three week old baby transferred from another hospital with a tracheoesophageal fistula. As he continues, the story doesn't make sense. "Yes, he has been breast-feeding."  "No, he hasn't eaten anything since birth."  "He is having stools." "We could get an x-ray." "They transferred him here for pyloric stenosis."  "We did get an x-ray, it showed the esophagus is just a pouch."

Me: "Ok, so he has been in our hospital for three days with a tracheoesophageal fistula and is unable to eat. What is the plan?! Babies can't live very long without eating."

Resident:  "Well, we talked about it with [a different attending] yesterday, and he was going to read and think about it and decide what to do."

[I fiddle with the oxygen monitor, still can't get a reading. So, I walk down the hall to the surgical office and find a pediatric oxygen monitor. I hook it up to the machine. Still can't get it to work.]

Me: "What are we going to do about his nutrition?"

Resident: "If we put in a feeding tube in his stomach milk would reflux back into his lungs."

Me: "So, what is your plan?"

Residents:   [No real answer, I conclude that the residents don't have a plan.]

The story doesn't add up.The baby has been in the hospital for three days. I suspect that a plan may have been made, but perhaps hasn't been communicated or the residents didn't understand it.

It is a very difficult problem. But there are some very simple conclusions we can come to. Mainly, if you do nothing for a newborn baby that can't eat, he will eventually die of starvation. Yes, sometimes there is nothing we can do, but we have to consider all the options before doing nothing and allowing the baby to die.

We move on to the next bed because we have already spent 20 minutes on that discussion and its not going anywhere. I need to think about it. And we have 50 more patients to see.

After rounds and an urgent C-section, I took a look a the baby's x-ray.

Contrast filling the first part of his esophagus, which then stops. Lots of air in his stomach and intestines. Yep, looks like a tracheoesophageal fistula. 

Type C tracheoesophageal fistula. The first part of the  esophagus ends in a blind pouch. The second part of the esophagus attaches to the windpipe then goes to the stomach. 

I called the other attending and he was able to explain the story to me. He was planning to take the baby to the operating room yesterday and at least put a feeding tube into his stomach/small intestine. But, the baby became very sick yesterday afternoon and he didn't look like he would survive a procedure or even live through the night.

We decided that if the baby is looking better today, it would be reasonable for me to put in a feeding tube. After taking care of a few more emergencies, I went back to the ICU to check on the baby and decide if he was well enough for a procedure. His bed was empty.

I don't have a nice wrap-up for this one. The baby died, likely from fluid that went into his lungs from the connection to his esophagus. In America, a pediatric surgeon would have taken this baby to the operating room, likely within the first 24 hours of birth, to re-connect the esophagus. Most of the time, babies recover well and go on to live normal lives. This baby didn't make it to us right away. Perhaps we could have done the operation if the baby had come in earlier. There isn't a pediatric surgeon available in this country to send patients to for emergency operations. We are the pediatric surgeons. We do a lot of pediatric surgery but it is still daunting to do major operations on newborn babies here.

In happier news, we have two newborn babies with congenital anal malformations that are doing well after we gave them colostomies this week.

Also, did you know that healthy newborns can survive for a week without food or water? Apparently we know that out from the 1985 Mexico earthquake when several "miracle babies" were buried alive for a week and survived! (Miracle Babies Survive Quake- Chicago Tribune, 1985).

It's textbook...

Sometimes, I look at a patient in clinic and think, "This patient belongs in a textbook...in fact, I think I saw a picture like this in a textbook in medical school. If only I could remember what it is..."

This girl was one of those patients who looked like her picture belonged in a book. You can't tell as much from the picture, but she was short/stout.

She is an adolescent with a goiter that had been growing since she was a child. Her parents said that she used to speak as a child but for the past eight years she hasn't made much sense. Although, she understood when I asked her to come and could say her name. But she didn't say much else, she just looked at me with a somewhat vacant, sad stare.

huge goiter

We checked her thyroid function and her TSH was 26. (very high, which means her thyroid isn't working). All of her symptoms (mental deficiency, goiter, stunted physical growth) seem to be from congenital hypothyroidism, which causes cretinism. 

Cretinism. Thats the textbook diagnosis I was looking for. Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones. Its a condition that has been all but eliminated in developed countries due to the introduction of iodised salt and other iodine supplementation. It was so effectively eliminated that I had only seen it in the black-and-white pictures of my medical school textbooks...until now.

typical textbook cretinism photo

I did a little reading and found some quite interesting information:

• According to the World Health Organization, "Iodine deficiency is the single greatest preventable cause of mental retardation."  The Lancet, Iodine deficiency- way to go yet. 
• When iodized salt was introduced and became widely used in the USA in 1924, there was a gradual increase in average intelligence of one standard deviation. IQ increased up to 15 points in iodine deficient areas!  (fascinating article here)
• Millet (one of the staple foods here) decreases iodine absorption (cabbage, corn, and radishes can also).
• We are on the UNICEF list of sixteen "Make-or-Break" countries with high numbers of unprotected newborns, low levels of salt iodization, and a need for a high level of support in attaining universal salt iodization. (UNICEF report here).

The same report shows that from 1995 to 2005 iodine intake has increased from 7% to 46% of households here. Perhaps that is partly due to the ubiquitous, iodine-containing Maggi chicken bullion cube used in cooking here.

Don't forget the iodised salt and MSG!  

on a good day...

Not gonna lie. Its been a bit rough around here lately. There hasn't been just one major tragedy, but multiple tragedies (big and small) and the every day struggle has been wearing me down. Patients dying, difficult operations, barriers to good patient care...the list could go on. I could write a blog post every day about the continual frustrations of trying to provide good medical care in a resource-limited setting. But then, no one wants to hear about that every day any more than I want to write about it every day. :)

Instead I will write about today. It was a good day. A really good day. Nothing earth-shattering happened...but it was just one of those days that things went well. Here is how it went...

I woke up before my alarm and actually felt rested. While making some tea, I checked online and learned that the Seahawks won the Superbowl. I don't get too excited about football...but I did grow up in Seahawk territory and I'm happy they won. :)  AND...it was cold enough this morning that on my walk to work that I wore my sweatshirt (it got all the way down to 75F last night)!

During morning report, I got a few words of encouragement (its nice to have some positive reinforcement sometimes).

Then, I rushed off to the OR for an emergency C-section for fetal distress. When I opened the abdomen, I saw an amniotic sac with a baby in it...but it wasn't in the uterus. My heart sank. Another dead baby. I took the limp, blue baby out and then... he moved!!! He was alive and started crying! What a happy surprise! A live baby is very rare after uterine rupture.

Between cases, one of the residents asked for help exchanging a gastrostomy (stomach) tube. The patient was a little six year old that had accidentally swallowed some of her mom's cleaning chemicals a couple months ago. The chemical caused her esophagus to scar shut so she can't swallow anything (even her own spit). She was very thin and dehydrated when she was referred to me for placement of a stomach tube.

Little F....she looked like she had gained about 10 pounds! She wouldn't smile or look at me because she was still upset that I had exchanged her tube. 

She will need esophageal replacement surgery, which we cannot do safely here. Hopefully we can find a way to get her to another country to have the operation performed.


Next, I did a washout and closure in a patient who had had a perforated stomach ulcer. Then, my next operation was for a girl in her late teens with a huge abdominal mass (she looked like she was 7 months pregnant). When I saw her in clinic, I couldn't quite tell where the mass was coming from on ultrasound. It definitely wasn't her uterus. Probably not her liver. At the start of the case, I told the team that the case would take one hour or six hours...turned out it took less than thirty minutes! It was a huge ovarian mass that almost literally popped right out. All I had to do was divide the vessels and tubes that attached it to the uterus.

the mass

checking it out

trying to explain where the mass came from in Hausa. its quite difficult since there is no word for "ovary" in Hausa!

When I cut it open I found clumps of hair, chunks of bone, lots of fluid and creamy white sebaceous material. This is good news because it means it was a benign dermoid cyst.

Last case of the day: an inguinal hernia. I am becoming much more proficient at performing inguinal hernia repairs without mesh (not something we do often in America). Now, the tissue based inguinal hernia repair is among my favorite operations here. It was a good way to end the day.


.

rough

Today was kind of a rough day. This weekend I'm on call which means I work from Friday evening to Monday morning. At 7:30am today, I walked into the surgical ICU to start teaching rounds with the residents. Immediately, I saw the charge nurse doing chest compressions (CPR) on a little boy. It was the little boy I had admitted from clinic yesterday afternoon. He was severely malnourished. We had operated several weeks ago and fixed his typhoid perforation. He was discharged from the hospital last week and had been staying close by in the ambulatory care unit behind the hospital. When he came into clinic he could barely open his eyes. His surgical incision had come apart. I wish I had a picture of the boy to show you. But perhaps you would rather not see it. Just picture one of the starving children you see on the news.

His dad said that he hadn't eaten since he left the hospital (one week ago). His father had been faithfully dissolving the pills in water so he could given them through a syringe and had been giving the child water as well. They had been told to come back in a week after discharge. He did. It was too late. I guess he didn't know to bring the child back as soon as he stopped eating. He obviously cared and was trying to help his son.

But now the boy was too weak to breathe.  We helped him breathe for a while...but we don't have any ventilators here so we were unable to keep breathing for him. There was nothing more we could do.

After taking a few slow, agonal breaths he stopped breathing. Then, his heart stopped beating. I said, "I'm sorry, he is dead." The charge nurse translated for the father who was standing by his bedside. The father let out soft, heart-wrenching, sorrowful cries as he covered his son and wrapped him in a mat to be buried.

It is only the second time I've seen a man cry here. Not a good start to the day. But, unfortunately, it was not the end of the sadness.

why now?

It may not always be an appropriate question. But sometimes I just can't help myself. I am curious. I don't understand. ..and sometimes the answer is important.

What causes someone to finally come to the doctor after waiting months or even years? Every day in clinic I see more advanced pathology then I ever did in training. Its "the worst" of this and "the biggest" of that.

Why do patients wait until their condition is so bad it often can't be fixed? What finally pushes them to decide to come? How many people never come? Likely it is a combination of lack of education, lack of money, and a fatalistic worldview...but I'm still asking questions... looking for clues. So I'll ask. "Why now? Why today?" Then, I try to figure out if we can help.

some people may find the following medical images disturbing

Here are some examples from the past few weeks.

An all-too-common story. Little boy whose dad brought him in 2 weeks after an elbow dislocation/fracture. His arm below the fracture was so tightly wrapped in the traditional manner that all the skin was dead and had to be removed.

Young boy complaining of trouble walking after a motorcycle accident two years ago. He came in because he has been having more and more knee pain. Check out his x-ray:

Yep, its broken!! It healed..just not straight and he's putting stress on the knee joint causing permanent damage.

Several years after an elbow dislocation...chronic nerve injury. Not much we can do.

there's  been something wrong with my foot for the past year...now we have to amputate

Advanced male breast cancer (there for a year). Breast cancer is more rare in men, but we have about 1-2 women a week come in with an advanced breast cancer similar to  this.

A woman my age...huge mass involving the lower abdomen and hip. I had to tell her that there is nothing we can do.

Two years with an infected, exposed tibia bone.  He sat on the floor in front of me because he can't walk (he can't straighten his knee). I asked him why he waited so long (Imagine two years as a kid...not being able to walk without help from his mom). He showed me his elbow fracture that had healed on its own (with a small residual deformity) and said he had hoped his leg would heal too. Now the only thing we can do is amputate...but at least then he'll be able to walk with crutches.

I bumped my elbow...

A year...probably longer than that for a tumor this size. Now she needs an amputation.

"Doc, I've had it 50 years...can you please take it off?" At least it looks benign. :)

Seeing all these people reminds me of how broken, physically and spiritually, we are. Sometimes its not as obvious...but we all need healing.

Psalm 103

 Bless the Lord, O my soul,
    and all that is within me,
    bless his holy name!
² Bless the Lord, O my soul,
    and forget not all his benefits,
³ who forgives all your iniquity,
    who heals all your diseases,
⁴ who redeems your life from the pit,
    who crowns you with steadfast love and mercy,
⁵ who satisfies you with good
    so that your youth is renewed like the eagle's.

sometimes it gets better...

Its not always depressing around here. We do have moments of victory. Remember this kid?

I saw 47 patients in clinic that day, but one of the highlights was hearing about this boy that I saw a couple of weeks ago. We weren't sure what this mass was, but we decided to treat him with chemotherapy for Burkitt's lymphoma since that was the most likely treatable diagnosis. Guess what?! He came back to clinic this week, happy and smiling because after just a couple rounds of treatment the tumor has shrunk to about half its original size and he can eat again! Yay! Thankfully, Burkitt's is very treatable and he has a good chance at complete cure.

That's the biggest...

There are a few key phrases that are uttered repeatedly throughout the day by doctors here:

"That is the biggest ... I've ever seen"

"I've never seen anything like that before"

"That is the worst case of... I've ever seen"

"What is that?"

Here are a few personal examples from the past two weeks:

 

First clinic case of the day. "What is that?" And "Biggest jaw mass I've seen...so far"

Biggest leg mass in a teenage girl

 Its not always the biggest...sometimes it is the lowest or highest...or both.

Hypertension and severe anemia?!

This is one of our outpatient clinic cards. If you look closely, you will see that the patient's hematocrit (blood level) is 12%. Normal is about 40%. Often we transfuse if the hematocrit is less than 21%, sometimes if it is less than 30%.  Where I trained, a hematocrit of 12% was pretty rare and would cause a flurry of frantic activity. Admission to the ICU, extensive work-up for bleeding, immediate transfusion. Here, its almost routine. I think this was the third or fourth patient I saw in clinic this week with a hematocrit of less than 15%. The amazing thing about this woman was her blood pressure. It was high. 160/90. With a hematocrit of 12%. It makes you wonder if the blood pressure was accurate...but I wouldn't be too surprised if it was. I've seen stranger things around here. She was walking and talking.  She also had one of the biggest abdominal masses I have ever seen. It was pushing her whole liver up into her chest. We aren't sure what it is, but we are planning to operate next week.

Her CXR with the liver up in the chest pushing her heart over the the left side (arrow)

the ocean

"For the needy shall not always be forgotten,

and the hope of the poor shall not perish forever." 

Psalm 9:18

Perspective.

Yesterday morning I did teaching rounds with the residents. We saw every surgical patient in the hospital. There were 46. It took almost three hours to see them all. Seven patients with typhoid perforations. Two with peritonitis scheduled for exploratory laparotomy after rounds. Seven patients with neglected infections that will lose or have lost an arm or leg.The little boy who lost his arm because he came to the hospital several weeks too late. The girl with epilepsy who burned both of her hands and needs multiple finger amputations, but refuses as her fingers become more black and shriveled every day.

Healthy, straightforward patients seem few and far between- there is the man who can pee now because we took out his prostate, the child with the hernia repair, the thyroid removal. Despite all of the suffering, almost every patient responds with a huge smile when I greet them. Even the kids smile with just a little coaxing and a piece of candy. They are amazing, resilient people. I'm not so strong. By the end of rounds I just want to go home and forget about the suffering somehow.

I find myself thinking...Why does being a doctor here seem so hard? Why does it feel like there is a never-ending ocean of patients needing help?  

Because there is . 

It feels hard because it is hard. 

Turns out, its a big adjustment to move from practicing medicine in a country ranked number three on the UN Human Development Index to the country on the bottom of the list.  Last week, I read an article that was recently published in the Lancet, Malaria and Malnutrition: Niger's Twin Crises. Somehow, it helps me mentally to have a bigger perspective of the health care situation here.

"According to the UN Human Development Index, there is no country worse off than Niger. The landlocked West African nation, which is mostly desert, lingers at the bottom of the index: 186th of 186. Its government, heavily dependent on foreign donations, spends a paltry US$10 per person on health care every year. Vast swathes of the country are effectively wild: without schools, roads, or security. There are fewer than two health-care workers per 10 000 population (23 is considered the minimum number for provision of essential care) and more than 2 million people live in chronic food insecurity, of a population of 16 million." 

Life is hard. But there is hope. So I didn't go home after rounds and hide in my house. I did what little I could. I stayed and repaired a typhoid perforation and a stomach ulcer. Yes, its only a drop in the ocean, but I think I'm ok with that. I'm not here to save the world.

Friday night sunset