Made to Serve: Lessons Learned in Kenya

It’s early June in Boston, and it’s one of those years in New England, where summer seems to be having a difficult time arriving.  It is cold and rainy today, more like an April day should be.  I sit in an apartment in Beacon Hill, one of the most affluent neighborhoods in Boston, and I look out of the window, where I see busy Bostonians hustling about on their way to work looking quite harried.  There seems to be no joy on anyone’s face even though they all live in this wonderful community of abundance.  It causes me to pause and wonder why we are in such a hurry, and so focused on our problems, when over all there is so much to be thankful and hopeful for.  I start to day dream about the wonderful community I have just left.  Kijabe was not free of problems…in fact there was an ever present climate of need and lack in this small town, especially during the drought when people were hungry.  But despite the problems, there was so much joy in the residents of Kijabe.  People were thankful for the smallest things, and most wore a countenance of hope across their faces, even when they were facing obstacles.  There was always a spirit of collaboration, and no one was allowed to suffer alone, even if the only help that could be given was an encouraging word or a willing ear.  A smile broke across my face as I began to think of my friends who I had just left in Kijabe.  My heart warmed as I thought of our moments of shared laughter and tears.  Then suddenly, my deep thoughts are interrupted by the sounds of the loud garbage truck coming down the street to remove the trash, and as I am startled back into reality, it hits me that I am not in Kenya anymore. 

***

Last September, I left Boston with great anxiety about what would happen to me in Africa.  In my spirit, I knew I was doing the right thing, but it is difficult to silence the doubtful voices in ones head, when one endeavors to walk by faith.  My mind was racing with a thousand “what-ifs”: “What if I get sick?”  What if I am not well trained enough to be a surgeon in Africa?”  “What if I run out of money?”   “What if I am lonely?”  I thought of all the things that could go wrong, and I just could not see how I was going to have a productive, safe, peaceful trip.  My mind would just accelerate with worries until finally, I would just take a deep breath and pray that everything would work out.  

Well…600 operations, 1500 clinic visits, and 300 inpatients later, I am happy to report that it was a wonderful trip.  I really had no major problems.  Financially, I did not have to go into debt to complete the trip.  I did not get seriously ill, and my PPD is even still negative.  I was able to thrive professionally, and most importantly teach many trainees and students which is probably the most crucial activity to helping change the quality of health care in Africa over the long term.  And I was never lonely…I made so many wonderful friends, and even though I was 10,000 miles away from home, I never felt like I was any further away from my family than when I am in Boston.   

And now as I look back on the entire experience, I can say that I learned some very valuable lessons about life:

 

We will never regret any decision to serve others.

We often regret decisions we make in life.  Sometimes those regrets are because we make decisions out of wrong motives.  For me, I still regret a decision I made over 15 years ago.  The decision eventually hurt several people, myself included.  And when I think back to what motivated me to make the decision, it was very selfish.  On the other hand, I cannot think of one time that I made a decision to do something for someone else, selflessly, that I regret.  I am not suggesting that nothing bad happens to us when we attempt to serve…actually, we can be used or taken advantage of when we try to help others, but even if our efforts to help are taken advantage of, we will not regret trying to help.  We may have to alter our approach or even abandon our work all together, but there is no shame or guilt in that.  Regrets only come when we do something and we should have known better.

 

What we do is not as important as how we do it.

When I moved to Africa, I was pre-occupied with the possibility of clinical scenarios that might overwhelm my skills and knowledge.  I thought that the most important thing for a doctor (especially a surgeon) is to know what to do…especially in an emergency.  But in actuality, knowing what to do is of less importance than knowing how to show respect for colleagues and care for patients.  A surgeon can be technically very skillful, but rude and condescending to co-workers or distant and unavailable to their patients, and that surgeon will be ineffective.  On the contrary, a good doctor leads by example first and foremost.  Other doctors can be consulted if one does not know what to do, but we cannot regain the opportunity to inspire our colleagues or make our patients feel important, and this is key to being an effective physician, or an effective anything for that matter.  Albert Schweitzer, the famous African missionary, once said “Example is not the most important thing in influencing others…it’s the only thing.”

 

Our financial problems are not as bad as we may think.

I used to believe that I had financial problems.  I used to believe that if I could just get a couple financial breaks, my life would be good.  I thought driving and old car, and not owning a home made me financially disadvantaged.  Living and working among the truly poor made me realize how wealthy I am.  Living in rural Africa has helped me to simplify my life and learn the value of a dollar (or a shilling at least).  Even now, as I re-enter life in Boston, I realize what I really need to be happy and healthy, and I have more than enough financial resources to meet those modest needs.  Plato said it well: “the greatest wealth is to live content with little.”

 

The collateral damage of love is more love.

Often times, my attempts to help patients while I was in Africa failed to achieve the desired outcome.  Even with my best efforts, some patients died.  And even with the patients I was able to help, there was always such a long list of people who I could not help.  People with incurable disease, or problems beyond my expertise to help.  Sometimes, I felt so impotent to make a difference, but what I learned was that even when my attempts to do good fell short of the immediate goal, the effort often had some unexpected benefit.  A co-worker might have been inspired by my dedication to a patient, even though the patient died.  Or a family member was able to renconcile with their loved ones, in the time we were able to delay the progress of their incurable disease.  There are so many unseen blessings that come when we serve.  So even when it seems that our service is in vain, it is not.  I believe that love is infectious this way, and can spread beyond the direct act of love we attempt to commit.  Love does not die…it multiplies.

 

The cure for a broken heart is to love.

Mahatmas Ghandi said “the best way to find yourself, is to lose yourself in the service of others.”  I understand this now.  We often say to ourselves that we are going to get involved in some charitable activity or community service project as soon as we get our own lives straightened out.  Many of us are focused on our own pain and problems, and we don’t think we have anything else to give away.  But ironically, one of the best ways to deal with our own hurt, is to serve someone else.  We were created to love one another…it should be our primary occupation.  And when we “lose ourselves” in the occupation of serving others, our problems are able to come into proper perspective.  It turns out that we don’t have to be perfect to love other people, but loving other people will serve to perfect us.

 

I am thankful for the many lessons I learned in Africa.  My life was so enriched by this mission trip.  It’s a cliché to say that it was a “life-changing” experience, but that is exactly what happened to me.  I have been transformed.  I look the same on the outside, but my heart is alive in a way it never was before.  And now, as I look to the future, I know what I need to do to continue to enjoy this peace, joy, and fulfillment…even in America.  I have to continue to serve.  Perhaps I will not always be able to serve overseas, but I can have a servant’s heart no matter where I am and what I am doing.   

We were all made to serve.  The golden rule that is common to almost all religious faiths is “to do to others as you would want done to you”.  But it’s not simply something we should do, because it enhances the lives of those around us.  When we follow this simple rule, we are doing what we were designed to do…and when we do what we were designed to do, we experience fulfillment of our purpose…we feel complete…we know peace.  And what is most beautiful about this truth is that this wonderful way to live is accessible to anyone…not just doctors, or educated people, or the rich.  Each and every person has the capacity to love and serve someone in their life. 

I’m not suggesting that a life of service is always easy.  It can come with sacrifice, suffering, and in some cases even death.  But I can tell you from my own experience that those sacrifices that I had to make to work in Africa were well worth it.  I have no regrets, and I look forward to returning to Africa knowing that there are risks involved.  I would rather endure suffering on my own terms as a servant than to live a “safe” life, but not fulfill my purpose.  And I am not suggesting that we rush foolishly into dangerous situations in the name of doing good.  We have to exercise wisdom in our efforts to serve, but at some point we may have to put ourselves at some risk to meet the needs of others.  And of course, we cannot all move to a developing nation or a refugee camp…most of us have to serve at home.  But we can all find ways to serve effectively, whether it be raising money for good causes, mentoring someone in our community, or even paying a visit to a lonely elderly family member.  It is not really important how we serve, but just that when we see a need that we have the ability to meet, that instead of turning a blind eye to the problem, that we be willing to give of ourselves to meet that need.  That is where our own personal fulfillment lies…being willing to put ourselves someplace we don’t have to be…or give something away we could have happily kept…or fixing something that was not our responsibility to fix.  It’s what we were designed to do, and when we do it, the blessings are immeasurable.

***

As I have sat here in this Beacon Hill apartment thinking an writing, the sun has found a little crease in the clouds, and squeezed through for a moment of sunshine.  The weather in Kijabe was very similar.  Often, days that started off looking like they were going to be damp and dark would transform into gorgeous days with the sun streaming down over the beautiful valley below the town.  As my mind wanders back to those days in Kijabe, I realize why I was so happy there.  I was in a continuous state of service.  I have never been so eager to go to work in the morning, and even a late night consult was an excuse to breathe the clean crisp air and look at the multitude of stars in the beautiful African sky as I walked to the hospital.  It never felt like work…it just felt right.  My body was tired, and I got frustrated at times, but those were always fleeting moments.  The overwhelming feeling I had most of the time was serenity.  It’s ironic, because there was so much happening around me, and so many demands on my time, and so many problems that seemed insurmountable, but all the while I was content.  I felt at home in Africa…I knew I was right where I was suppose to be.  It’s a feeling I pray everyone get to experience in their lifetime.

Peacefully yours,

chad

 

“I don’t know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve.”

 ~Albert Schweitzer

Case Report #8: The Patient You Never Forget (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians.  For my non-clinical readers, use discretion before reading, and please excuse the medical jargon. 

Occasionally, a patient walks into your clinic, and right away you get a feeling that it is going to be more than the usual patient doctor relationship.   Even before taking a history and physical, there is something deeper that stirs within you, and tells you that you are going to have a profound impact on this patient or this patient is going to have a profound impact on you or both.  You just know that this is a patient you will never forget.  In the case of JW, I felt an immediate connection to her and her family, but the effect we had on one another was not what I expected.

***

JW is a 20 year old woman who came to see me in clinic with her parents.  The parents were very worried and concerned, and seemed desperate to find someone who could help their daughter.  She had been vomiting, losing weight, and battling multiple pneumonias over the last year.  Initially everyone assumed she had TB and likely HIV as that is the most common cause of weight loss and respiratory complaints in a young woman in East Africa.  However, after all her tests came back negative, and she was not responding to TB therapy, someone decided to investigate further. They had recently gone to a hospital where a barium swallow and upper GI endoscopy revealed that she had achalasia with mega-esophagus.  

Achalasia is a condition where the lower esophageal sphincter will not relax, and it causes the patient to store food in the esophagus until they vomit.  It usually has an onset during adolescence or young adulthood, and the esophageal sphincteric hypertension grows worse until the patient can develops severe esophageal dilation (mega-esophagus), malnutrition, and aspiration. The repeated respiratory infections that JW had were from aspiration pneumonia and not from TB. 

Once the diagnosis was made, she was referred to Kijabe hospital (where the family had been told there were surgeons who would take on her case).  She essentially had end-stage achalasia, and while sometimes medical therapy is used to treat the hypertensive sphincter, her condition warranted a more aggressive treatment.  I talked to the family and explained that I could operate to alleviate the obstructed distal esophagus and allow her to eat and hopefully gain weight.  They consented to the surgery and since my operating theater schedule was booked for the next two weeks, I asked the head theater nurse to arrange to have a team on Friday night of that week to operate.   As I talked to the family about what to expect, I noticed what good people they were.  JW was very polite, but also anxious about her deteriorating health and pending surgery.  I tried to encourage her, and told her how fat I was going to make her, and the skinny young woman smiled a smile that lit up the room.  Her parents were also very polite.  Her father in particular impressed me with his dedication and love for his daughter.  He had been traveling all over Kenya trying to get her help, and was willing to make any sacrifice for her.  He told me he had faith in me that I would help them, and I smiled a confident smile and said, I would do my best.

Friday came, and the operation went about as well as could be expected.  I knew I had to get the operation right the first time, because she did not have the capacity to afford any post-operative complications.  I went home that night after having operated from 8am until 9:30 pm (I started JW’s case after 7pm).  I was tired, but I still had this special feeling about JW and her family.  I just felt like our paths had been destined to connect.  The first couple of post-operative days were a bit bumpy.  Despite her rapid sequence induction in the operating room, she clearly had aspirated, and got a bit septic.  However, she responded well to antibiotics, and by that Monday, she looked much better.  Because of the pneumonia, I had waited to advance her diet, but I let her start sipping water on Monday, and then on Tuesday I let her drink liquids ad lib.  Unfortunately, she had some vomiting at that point.  The next few days, she was unable to drink very much, and her abdomen became distended.  Then over the next weekend, she began having fevers and peritonitis. 

I was devastated, I had such high hopes that she was going to do well.  I consulted a couple of thoracic surgeons by email back at home about what to do next.  And I took her back to the operating room where I found a leak from the distal esophagus and about 2 liters of fluid in her peritoneum.  I washed her out, fixed the hole, and buttressed the repair with serosa from what I made into a 360 degree fundoplication.  I left drains and a jejunostomy tube for nutrition.   She subsequently got very sick and had to be transferred to the “ICU”.  She had developed bed sores, anasarca, and sepsis.  Over the next 2 weeks, JW was nursed meticulously by the ICU staff (as I demanded when rounding on her 2-3 times every day.)   She slowly began to make progress, and started to look like she would soon be ready for the floor.  She had been through a lot, and was still far from being able to go home, but her bright disposition had returned.  When I would make my round she would flash that smile, and it would keep me encouraged for the rest of my day.  I thought to myself, this is why I had such a special feeling about her.  Because I was going to have to go through this extensive hospital course to get her better.  By this time her father and I had also become pretty close.  I talked to him everyday to give him an update either in person or by phone when he had to return home to work.  His dedication had been incredible.  He had spent every moment either at the hospital or at work.  We discussed everything that had happened, and believed that God had merely wanted to test our faith by allowing JW to get so sick. 

Then I came in one Sunday (about 2 weeks after the second operation) and JW did not look like herself.  She was a bit confused and had a fever.  I hoped it was just another mucus plug and lung collapse as she had had before, but the x-ray was okay, and over the next 48 hours, her fevers got worse and her abdominal pain worsened.  Then on Tuesday morning, I came in to find her feeding tube had fallen out.  She was as sick as ever, so I took her back to the operating room for the third time.  I found purulent fluid in the abdomen, but could not be certain if it was old tube feeds, or from an ongoing leak.  The repair appeared intact (or at least stuck down), and the fluid was in the lower right abdomen.  I washed her out, left more drains, and replaced the feeding tube.  We took her back to the ICU, and I prayed that she would get better.

Over the next 4 days, she walked a fine line of mild sepsis, but made good urine and maintained her blood pressure despite some low grade fever.  Friday, May 1, 2009 is a Kenyan Holiday (Labor Day), but it was also JW’s 21^st birthday, and she appeared to me as if she was starting to make progress again. I ran into her father as I finished rounds, we both believed that the “test” was finally ending and that JW was going to get well and be able to go home.  We remained optimistic as ever, and I still had that special feeling about JW.  It had been 28 days since I originally operated on her, and it had in deed been a trial of emotional ups and downs.  I had never had a patient come to mean so much to me.  She had become like my sister.  I would round on her sometimes in the evening and not even look at the flow sheets (unheard of for a surgeon).  I was just visiting my family.  As I left the hospital, I could see why I had that special feeling when I first met JW.  I had never invested so much of myself in a patient, and she had brought the best out of me as a doctor. 

***

At 2:05am early Saturday morning, just hours after JW’s birthday had ended, my pager went off.  I was on call, so I lazily dialed the number waiting to hear what trauma patient was awaiting me in the hospital.  But instead, it was the ICU doctor on call.  He was calling to tell me that JW had just died. He said she just became very unstable over 20 minutes, then her pupils became fixed and dilated followed by ventricular fibrillation and then asystole shortly thereafter.  I could not believe it…How? She was looking well.  How could she decompensate so fast.  While I lay stunned in the dark in my apartment, the ICU doc told me he was looking for the phone number to contact the family, but I told him I would call the father.   I did not want him to hear it from anybody but me.  I think this was the hardest number I have ever dialed.  He answered, and knew something was wrong from the hour of the phone call.  I confirmed his worst fear.  At first he said nothing, clearly shocked , and then I could hear the agony in his voice as he choked back sobs and said: “we did all we can do, we must accept God’s will” and then he hung up.   I lay there for most of the rest of the morning seeing JW’s lovely smile in my mind, and not being able to believe she was gone.  She was such a good person.  Her parade of dedicated friends and family confirmed that.  I kept thinking of the pain her father was going through (infinitely worse than what I was coping with).  And then the overwhelming guilt came over me.  JW would still be here if a better surgeon had been in clinic that day.  I felt so small and worthless.  I knew I had done my best, but my best is so inadequate.  I’m a 34 year old surgeon less than 1 year out from residency.  I let this woman down. I let this family down. 

By the time the sun came up, I was able to let go of the guilt.  Even though I am young, I know I am a good surgeon, and I know complications will happen to everyone.  I know I had given everything within me to help JW, and there is no shame in that…even with the adverse outcome. 

As I walked through the hospital gate, I saw JW’s family gathered in the courtyard in the morning hours.  As is typical for Kenyans, the father was totally composed by this time.  He thanked me for my efforts, and would not let me express any apologies or sorrow.  His faith is strong, because in just a few hours after learning that his precious daughter was gone, he could say that it was God’s will.  He was thankful for the time he had with her, and he had no anger toward me.  While the father was strong, JW’s mother was still shaken.  She is a quiet dignified woman who had never said anything to me other than “habari” (how are you), and nzuri (I’m fine), but now she sobbed and cried with emotion she had never showed before.  I guess, I had not really grieved myself, because as I tried to say some words of encouragement to the family, tears begin to fill my eyes and my voice broke down.  JW’s father told me, “I have lost a daughter, but you have lost a sister.”  He was right, and I needed to grieve too. I pulled myself together to make rounds, putting forth my usual smile and laughter for rounds, but after I came back home…I finally let go and cried.  I miss her.  She came to mean so much to me in such a short time.  Making her better mattered more to me than anything.  And now, I sit here broken-hearted, with tears still rolling down my face trying to write this blog entry.  My heart hurts, and I wonder why God would allow the one patient who I have cared for more than any other before to die?  What is the meaning in that?  I thought this bond that developed between me and this family was going to end in joy and celebration.  I would always remember the patient who I saved, and they never forget the doctor who helped them, but instead we are etched into each others memories through loss and pain.

It is almost midnight in Kenya as I write this, and it is certainly the darkest moment I have ever had as a doctor.  And while weeping may endure for a night, I know that joy will come in the morning. And in the midst of the darkness, I am thankful.  Even though, I hurt right now, I know that I am blessed.  I am blessed to have a job that matters to me and other people.  I am blessed to be working in a setting where I am needed.  I am blessed to have come to Africa and learned to care for patients more than I ever did before.  I am blessed to have gotten to know JW and her family.  I am blessed for being able to care for her in her last days in this world.  I am blessed, because in those last days I saw her smile.  And I am blessed not only for having a special patient that I cared for, but for having a sister that I loved.

Rest in Peace Jacinta.

I will never forget you.

chad

"I have found the paradox, that if you love until it hurts, there can be no more hurt, only more love."

~Mother Teresa

Case Report #7: A surgeon cuts, but a doctor listens (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians.  For my non-clinical readers, use discretion before reading, and please excuse the medical jargon. 

 

Here in Kijabe Hospital,  there is a large variety of patients and problems that show up in my clinic.  Many of the cases are routine, like old men with urinary retention and BPH, young women with goiters, and hernias, hernias, hernias.  Sometimes it gets a bit boring, and there is a temptation to emotionally disengage and just work on autopilot.  But just about every week, someone comes into my clinic with a very unusual problem.  A problem that I would never think a general surgeon should be assessing, but there aren’t that many doctors around here so sometimes, people are just seeking your opinion even when the problem does not appear surgical, but is “unsual”.    

Often, the diagnosis is not that difficult to make, it just requires that someone actually listen to the patient.  In Kenya (like America), clinicians often focus on the easily obtainable data: labs, reports, and previous notes, and don’t talk to patients, because of time constraints.  I always do my best to not fall into this trap, and I think I have made a few diagnoses that had been missed by others simply because I took the time to hear what the patient was saying.  GS is an example of a patient with a problem that had been undiagnosed for years despite his complaints, because no one had really listened to him.

*** 

GS is a 16 year old boy who presented to Kijabe hospital complaining of abdominal pain for FOUR years.  According to the chart, he had been seeing doctors most of his life for various vague  complaints.  His past medical history was notable for having bilateral undescended testicles.  The chart also noted that he had a low transverse incision on his abdomen that was thought to have been from an exploratory surgery to find the testes.  The chart said the patient was non-tender, with no nausea, vomiting, or unusual bowel habits, but that he just had low abdominal pain.  He had labs including a complete blood count and liver functions that were normal and an ultrasound showing a normal gall bladder and no hydronephrosis/hydroureter.  After this work-up, someone sent him to me, thinking that I might want to explore him.  But most general surgeons hearing this case would be uninterested.  No signs of obstruction, inflammation, or even focal tenderness rarely adds up to a problem that is correctable with surgery.

Part of me wanted to toss the chart aside, and tell him to follow up with the internists or family medicine doctors, but I decided to be faithful to my training, and take a history myself and examine the patient. 

I asked the patient about his symptoms and he confirmed most of what was in the chart.  He had a normal appetite, no weight loss, no vomiting, no diarrhea, no fevers, no dysuria, or any other complaints besides four years of abdominal pain.  I thought maybe the previous operation had been the source of the trouble, but he had no documentation about the surgery, and could only tell me that it preceded his pain by some years.  Then, I asked him to describe the characteristics of the pain, and suddenly the clinical picture changed.  He said that he had been having pain in his lower abdomen every month for 4 days since he was 12 years old.  He said the pain came and went like clockwork every month.  Should sound familiar, especially to my female readers.

I quickly had him lie on the exam table.  His abdomen was in deed non tender, and soft…totally normal, but when I examined his genitals, I noticed his penis was bit small for a 16 year-old.  I confirmed that he had no testicles as the chart had said, but I took a close look at his scrotum. He really had no scrotum.  Instead at the base of his penis, he had what appeared to be large labia.  He also had a slight hypospadias (a urethral opening on the ventral penile shaft instead of the tip of the glans).  I stepped back to assess the patient again.  He had a soft voice, was short in stature (shorter than his mother), and he had some mild gynecomastia. 

After actually listening to his complaints, his physical findings made perfect sense.  He had been having pain for 4 days every month since he was 12 because he has a UTERUS.   His pain was worsened by the fact that he was not able to pass blood, because his “vagina” has no real entroitus…kind of like having a really thick hymen.  Now the group of disorders that can cause these types of presentations are beyond my general medical knowledge (ambiguous genitalia, pseudohemaphroditism, true hermaphroditism, mosaicism, etc), but fortunately me making the general diagnosis was all that was required.  Kijabe hospital has a group of pediatric surgeons who are much better equipped to counsel this patient on what should be done.  Now if his condition had been diagnosed as a baby, there would have been an option to try to make him into a girl (he essentially has a vagina with a hypertrophic clitoris), but he had been raised as a boy for 16 years, so psychologically, debulking his “penis” may not be a good idea, and I was happy that Dr. Heuric was willing to take this case on for me.  However, I did need to explain the diagnosis to the “boy” before I could refer him, and that was a delicate conversation to say the least.  As I explained to him and his mother, I told the him that he was not “cursed” and that God did not make a mistake…to not let anyone make him feel like he was less than human.  I told him that outside of Kijabe, he would be ridiculed, but the doctors here understand that it is a medical condition that can be treated.  I told him that we were happy to care for him, and excited that we could do something about his pain.  I shook his hand, and made sure he knew that we cared for him, and did not judge him for his condition.

Two weeks later, I popped my head in the operating room to observe his hysterectomy (as that was the plan that the pediatric surgeons and the patient decided was best).   Knowing what to do with the gonads is a little tricky.  Without frozen sections, we cannot be sure if they are testicles or ovaries, so they pediatric surgeons biopsied them and left them in, in case they are testicles.  (One gonad appeared to have an epididymis  associated with it.)   He may need yet more surgery, but I was happy to see that his problem had been taken seriously, and he was being treated to the best of our ability. 

Intra-op photo I took of uterus and gonads

In hindsight, I am very grateful that I was able to participate in his care.  I felt ashamed that I was initially upset about the referral, and reminded that patients are sent to me because they have a problem, and it’s not their fault if the problem does not fit neatly into one of our little specialty boxes.  Each patient encounter is an opportunity to make an impact in someone’s life…sometimes a major impact, and I should never become detached from interviewing and examining patients.  I am not just a surgeon who cuts whatever patient that is brought before me.  I am a doctor, and doctoring requires that I listen to patients, and treat each one as a valuable individual, not another chart in the pile that is keeping me from escaping clinic.  So I thank GS for restoring my perspective.  I did not even do his operation, so I can’t say I was his surgeon…but I listened to him, and I cared for him so I was something much more important…I was his doctor.

 

Yours in relearning compassion,

chad

 

“Difficult as it is really to listen to someone in affliction, it is just as difficult for him to know that compassion is listening to him.”

~Simone Weil

Look into the Eyes of a Somali Refugee

Currently, Somalia is in the thoughts and minds of many Americans.  Of course, most Americans are thinking about the rescue of a ship captain and the thwarted plans of the Somali pirates who tried to take the Maersk Alabama hostage.  But long before Somali piracy brought this East African nation to the forefront of the American consciousness, Somalia has been a troubled land.  

Somalia has basically been in a state of civil war for over a generation. Many Americans remember that in 1992 and 1993, American forces (as part of a UN team) came to the aid of Somalis who were suffering from this civil war as famine had become widespread from the ongoing conflict.  Initially these operations were successful, but eventually these peace-keeping/humanitarian forces came to be seen as a threat and the conflict between the Somali warlords and the UN forces became bloody, most famously in a raid in Mogadishu in October 1993 that led to 18 American casualties. (This part of the conflict was the basis for the 2001 movie, Black Hawk Down.)  By 1995, the UN had largely abandoned peacekeeping efforts in Somalia, but not because order had been restored.  In fact, the last 15 years have essentially been lawless with clan loyalties and regional authorities exercising most control while weak externally recognized central governments have been ineffective at maintaining any consistent national order.

*** 

In the setting of this civil war, a refugee camp opened up in the desert region of Kenya near the Somali border in a place known as Dadaab.  The last 15 years have seen steady growth of the camps in Dadaab, and today Dadaab is probably the largest refugee camp site in the world in terms of population.   At the beginning of 2008, approximately 160,000 refugees were in the camps, but new arrivals continue to pour in and just one year later, the number of refugees is above a quarter million.   I recently had the opportunity to visit Dadaab on a brief 3 day medical mission trip. It was very eye opening to learn more about the suffering of the Somali people, and even more helpful to understand some of the situations that are currently facing Somalia such as Islamic fundamentalism and offshore piracy.

Me and my two colleagues from Kijabe Hospital took a small plane from the cool comfortable Nairobi airport, and landed on a lonely air strip in the sweltering desert of Eastern Kenya. Dadaab is not actually a refugee camp.  It is a small town that serves as a base for the organizations that operate the camps.  Outside Dadaab there are three camps  (Ifo, Dagahaley, and Hagadera) with a fourth camp being planned in the near future.  UNHCR (United Nations High Commission for Refugees) is primarily in charged of the camps, but they have several implementing partners (NGOs) that work with them, most notably CARE which implements food distribution, education, social services, water and sanitation programs. 

 The UN airplane on the desert airstrip in Dadaab

Another implementing partner that specializes in medical services in Dadaab is GTZ (Deutsche Gesellschaft fur Technische Zusammenarbeit or German Technical Corporation).  GTZ was our host organization.  GTZ provides medical staff for the camps. The three camps each have a doctor and medical facilities, but 3 doctors for more than 250,000 refugees (who have more health problems than most, because of what they have been through) is not nearly enough.  GTZ also staffs a small health center in Dadaab that serves to care for refugees and also the local Kenyan community. Kijabe hospital has a relationship with GTZ, and they send us many patients who need inpatient care that is too complex for the camp's simple facilities. In addition, we routinely plan trips every 2 months to the camps to do screening for certain diseases that need specialized care.  Usually a surgeon comes along on these trips and does surgery in the in the single operating room in the Dadaab town health center. 

On this trip, I was this surgeon.  They basically have a long back-log of patients that need surgery (that is doable in this setting) like hernias and lipoma excisions, and my job is to operate continuously from arrival to departure and try to do as many cases on the list as possible.   While, I do not like being a technician who merely operates on patients who are brought in front of me, the circumstances dictate that more people can be helped in limited time this way.  To be honest, it was a privilege to be able to participate in the surgical “assembly line” and while Dadaab is the dustiest, hottest, poorest place I have ever been, the operating room was an oasis of air conditioning and cleanliness in the midst of this austere outpost.  There were still some unusual challenges to adjust to like flies landing all over the sterile field while I was operating and working with very little limited supplies and technology, but we managed to do quite a few substantial cases.  

OR list for the day in Dadaab

While mostly, there were hernias, hydroceles, and lipomas, the cases were all quite challenging, because they were all big.  (I was very happy I had brought some hernia mesh with me, because I operated on some giant scrotal hernias that would have been near impossible to fix without prosthetic materials.)   One case was a 32 year-old man who supposedly had a groin hernia, but when I examined the patient, he only had one testicle.  Upon exploring the groin lump that was suppose to be a hernia, I found his undescended testicle (which we removed because the vessels were too short to relocate it to the scrotum, and cryptorchidism is associated with increased risk of malignanacy). 

Hernia repair in the beautiful Dadaab Health Center Operating Room

During the time when I was between operations while the room was being cleaned, they brought an endless parade of patients for me to see for surgical consultations.  There was an array of ailments, many of which were problems from violence suffered in Somalia like complications from gunshot wounds or burns.  It overwhelmed me to see what burden of untreated disease exist in the camps.  The most memorable was a 12 year boy with soft hypervascular tumors growing from multiple parts of his skeleton including his skull.  I had never seen anything like that in my life, and despite his condition clearly warranting medical attention, he had essentially received no care up to this point.

Boy with soft tumors on skull, right shoulder, and knees

Despite working continuously from breakfast until supper every day, there were always more patients to be seen when we had to return to the GTZ camp, and it left me wondering how many sick people remained in the camps that were simply being ignored due to the massive numbers of refugees.

The most relaxing part of the trip though was the evenings.  We had dinner with our host who told us many of the overwhelming problems in the camps.  To hear the stories of the numbers of people fleeing Somalia, and the amount of resources it would take to continue to support them in the camp is very discouraging.  Somalia’s population is estimated at just under 10 million, and the largest city (Mogadishu) has about 3 million of  those people, but if things continue to grow at the rate they have been for another 10 years, Dadaab will be the most populous “Somali” city on the map. 

Also, another interesting thing about the evenings was visiting the NGO camps.  Our trip happened to occur around March 17th, and we left the GTZ camp to go visit the UN camp that night for a little St. Patrick’s Day celebration.  We drove by half a dozen NGO camps to the sprawling UN camp.  Seeing how much money, personnel, and infrastructure  are required just to “support the supporters” was overwhelming.  The financial costs of supporting a refugee camp in the middle of the desert is mind boggling.  To see how many resources are needed just to provide the most basic of services for this humanitarian crisis makes you realize the scope of the problem. 

But for the entire trip, the most meaningful part for me was the time I got to interact with the refugees, in particular the patients I operated on who were kept in the health center over night, so I could check on them in the morning.  I operated on several children and I got to see them with their parents.  These were the most encouraging moments, because I had been able to fix the child’s problem surgically, and the parents were so grateful…  While it was nice to see some patients get help, most of the Somalis I met had problems I could not fix.   I was deeply troubled to see patient after patient (in particular the children) with terrible problems that desperately needed attention, but was beyond my scope to help.  I would write on the small bit of paper they were using for a chart to refer the patient to some hospital or clinic, but in my heart I knew there were no resources or money to pay for such a referral. 

All the while, the Somali refugees were very accepting of my inability to help them.  It seemed they were accustomed to suffering.  They had become used to people not being able to help them.  They had no expectations or demands that their problems be fixed.   When I would look into the faces of these patients, their expressions were so blank.  It’s difficult to describe what you see when you look into someone’s eyes, but there was something subtle missing in their eyes, and I sensed it over and over again.  There were no smiles, or frowns for that matter.  Many Africans are stoic, but this was different.  When I looked into their eyes, I could not see any hope…they were merely trying to survive, and to some degree I think many had even loss the desire to survive; they merely wanted to suffer less. 

I don’t mean to depress you by writing these things, but I have to be honest.  Life in a refugee camp is harsh and the hopelessness is pervasive, but there are moments when humanity can be restored…when you see a smile break across a child’s face or see a need met and the individual feels cared for.  This happens too infrequently though.  What is needed is so much more.  More education, more health care, more services, and most importantly, an opportunity to escape the refugee camp for a better life. 

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I was not able to take many photos of the camps due to the operating schedule but these are some photos of Dadaab that I borrowed from others: 

While no one will argue that refugee camps are a tragic reality of the modern world that demonstrate man’s inhumanity to man, what many don’t understand is how closely the circumstances of life in a refugee camp are related to life in the developed world.  Somalia’s long lasting civil war is not merely the result of a nation not being able to get along.  It is also the residual effect of colonialism, and the result of present external forces that maintain conditions that foster conflict, because they can be profitable.  Where do all those weapons in Somalia come from?  They are not made in Somalia.  If large oil reserves are found in Somalia (as many believe there are), suddenly there will be a financial interest in stabilizing the nation (at least enough stability for Western industry to invest in Somalia), but until Somalia’s lawlessness led to the unforeseeable consequence of piracy costing hundreds of millions in international commercial trade revenue, the West had lost interest in stabilizing Somalia.  Now millions are being spent in ineffective policing of the waters off the coast of Somalia, but if the international community had been more interested in the suffering of the Somali people since 1995, then perhaps this situation might have been avoided and Dadaab might have been closed by now.  (Similarly, troubles in Afghanistan were largely ignored for years when the Taliban were running amok, but when that ignored suffering created an environment to train anti-Western terrorists, and the World Trade Center attacks occurred in 2001, the international community became suddenly interested in the suffering of Afghanistan.)  Incidentally, Somalia is also struggling with an Islamic fundamentalist insurgency, and is considered one of the potential new training grounds for terrorists (the weapons are clearly there).  Just this week, the Somali Parliament signed Sharia law into effect for the nation to appease the Islamic radicals.  (Strict interpretation of Sharia law forbids schooling for girls, television, and music, among other things.)  Somalia has slid into an anti-Western posture, while the international community was ignoring it.  The international community cannot continue to ignore large populations of people who are suffering and not expect repercussions.  Can you blame a young Somali from developing anti-Western feelings when he watches rich Western countries ignore his suffering, and even support it by profiting from Somali conflict?  

 

So the reason I am posting this today is not just to write about my trip to a Somali refugee camp, but more to write about what is going on in Somalia today.  Somalia is not a nation of thieves, pirates, and war-mongerers.  Most Somalis want peace, and they want to support themselves through honest means, but after a generation of chaos, one might see how the sentiment toward piracy and anti-Western values might proliferate.  What is required to prevent further sequelae of suffering is that Somalia be helped.  And not helped out of selfish reasons.  (Afghanistan was “helped”, but the primary motivation was hunting down terrorists and revenge, and now the situation in Afghanistan is dreadful.)  People are not stupid, they know when they are being used.  If the international community sends forces into to Somalia simply to secure the international waters outside Somalia, and then just build a couple of token schools, then nothing will change.  The West needs to undo what years of colonialism and external political tampering have created.  The West needs to truly serve Somalia.  That means more money for education, schools, health care, infrastructure, and more Westerners to help implement the programs.  Will this work?  I am not sure, but I believe in the principle of sewing and reaping.  If the international community sews seeds of good will into Somalia, I believe it will reap not only less suffering for Somalis, but good will back to the international community.  There will be no need to police international waters outside Somalia if Somalis determine they are not going to tolerate their countrymen being a menace to the world at large.  There will be no need to continue to support hundreds of thousands of Somalis in refugee camps.  And there will be no need to hunt down anti-western terrorists from within the country.

Maybe I am naïve to believe that complex problems can be solved so easily by merely taking care of the most poor and oppressed people of the world.  Maybe it’s foolish to believe that the hostility against Americans and Christians can be extinguished by acts of kindness, but I can tell you this for sure:     I took care of the child of a Somali man in the Dadaab camp.   Before I operated, the father looked cold and hopeless, but two days later, when I removed the bandage, and the child chuckled from the ticklish tape coming off, the father laughed too and looked into my eyes and said thank-you.  In that moment, I saw a glimmer of hope in his eye that everything was going to be okay.  So I know that an act of kindness has changed one heart, and that is there is at least one Somali who appreciates a Christian American doctor...because I could see it in his eyes.   

 

Yours in hope,

chad

 

“To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds. And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to suffering outside our borders; nor can we consume the world's resources without regard to effect. For the world has changed, and we must change with it.”

~Barack Obama, Presidential Inaugural Address

 

Case Report #6: Driving at Night Without Headlights (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

One of the most difficult aspects of being a surgeon is taking care of trauma patients with closed head injuries. These are often healthy patients who have been in a severe accident of some sort or maybe they have been assaulted. Despite being previously well, the consequences of severe traumatic brain injury can be death or permanent disability, devastating outcomes for otherwise healthy individuals. One of the things that makes managing traumatic brain injury exceptionally frustrating is the difficulty in predicting who will do poorly. Prognosis is notoriously difficult and inaccurate at times…so much so that we usually tell family members “we will just have to see how he does”. Some unconscious patients will wake up and be totally normal, but some others that initially seem only mildly injured may decline suddenly and rapidly to brain death.
For acute trauma patients who present with an altered mental status (anything from mild confusion to profound coma) and evidence of head injury, the brain must be imaged promptly to determine the extent and type of injury after the patient’s airway, breathing, and circulation have been assessed and appropriately managed. In the developed world, this means a CT scan of the head which will tell the surgeon (neurosurgeon usually) whether there is extra-axial blood that needs to be drained (i.e. subdural and epidural hematomas). If there is no drainable hematoma, and the patient has a severely altered mental status, then he will be admitted to the ICU and have a pressure monitor place in his skull to help the ICU staff keep the intra-cranial pressures (ICP) appropriately under control.

While my clinical interest in trauma patients is higher than most general surgeons, I must admit that I have not enjoyed taking care of acute brain injuries here in Africa. In addition to the problems mentioned above, these patients are particular challenging because we don’t have a CT scanner at Kijabe Hospital. That means I have to make decisions about who to operate on without any imaging (except maybe a plain film of the skull, which is largely unhelpful). This is a little like driving a car at night without any headlights, because imaging is so central to managing closed head injury.
The usual approach is that anyone who presents with lateralizing signs (a unilateral blown pupil, hemiplegia, etc) goes to the operating room for decompression. Also anyone who has a documented drop in their Glascow Coma Scale (GCS) of more than 2 points (from their baseline score on arrival) goes to the OR for urgent burr holes as well, but this is a relative indication, and takes some judgement. If they don’t meet these criteria for surgery, we focus on preventing secondary brain injury (hypoxia, hypotension, elevated ICP), and they are managed accordingly. If they are stable, and make it through the night, (and have family members with money) we sometimes send them to Nairobi by ambulance for a head CT the following day, but by that time, imaging is rarely helpful.
My experience with managing acute severe closed head injury so far has been disappointing. To illustrate my frustrations, I present the following case.

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TS was a 58 year old male passenger in a motor vehicle collision. The patient was found to be unconscious at the scene, and was brought to Kijabe hospital at night by some good Samaritans. On arrival, he was hemodynamically stable and breathing spontaneously, but his GCS was 8 and on close examination he was found to have unequal pupils, with a “blown” pupil on the right. The patient was quickly moved to the operating theater where he was intubated.  I confirmed the examination and prepared to drill burr holes.
After prepping and draping, I drilled holes on the ipsilateral side of the blown pupil first. I found no extradural blood, but on incising the dura, CSF spurted from the durotomy across the room at high pressure. This confirmed elevated ICP, but no hematoma was found on this side. I then turned my attention to the contralateral side, drilling more burr holes there. Again, no epidural or subdural blood was found, but only CSF (under slightly less pressure, since I had decompressed him a little on the other side). At this point, I was not sure what to do, I had found no blood, but there had clearly been elevated ICP’s. I talked to my colleagues who counseled against a craniectomy, but said perhaps a ventricular drain might prove to be helpful for ICP monitoring and even drainage. I tunneled a catheter under the scalp and through the burr hole into the anterior horn of the left ventricle. I then attached the drain to this low-tech cylindrical column/drainage system before closing the wounds and taking the patient to the ICU.
Over the next 12 hours, his ICP remained controllable without having to drain anymore CSF, but his mental status did not improve. He remained with a GCS of 6T, so after securing funding from the family, we packaged him up to go to Nairobi by ambulance for a head CT scan (a somewhat risky adventure for many reasons, the most obvious being traveling on Kenya’s dangerous roads with an intubated patient). The patient returned that afternoon with the CT scan, but it showed little to help us…some small contusions and evidence of edema was all that was seen. Surprisingly, we often get amazing radiographic studies from Nairobi including the 3-D reconstruction you see below, but we were still left with an unconscious patient with no real plan of how to help him.

Fancy 3-D rendering of head CT after burr holes and drain were placed

Over the next 7 days, we attempted to support TS hoping he would wake-up from his head injury. We fed him via an NGT, and even extubated him at one point when it appeared he could protect his airway, but without recovering consciousness, he slowly began to decline eventually developing complications including an aspiration pneumonia which he eventually succumbed to.

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TS was just one example of the many patients with acute closed head injury that I have cared for since arriving in Kijabe. It’s very difficult to have patients come in alive, sometimes only mildly confused and only hours later be looking at fixed and dilated pupils. To be honest, my interventions and care seem to have little effect on the outcome.

Despite the discouraged tone of this post, I am very pleased that I have been allowed to participate in caring for these patients. It’s invaluable experience to get to do craniotomies, and that has helped me immensely in managing the sub-acute subdural/epidural hematomas (those patients have uniformly done quite well after having their brains decompressed). Also, I hope that one day, I am able to actually “save” an acute closed head injury patient with a correctable problem. And with all the practice I have had, I feel that I am well-prepared to do so, should such a patient present while I am on call.

And finally, while medicine is humbling at times, and we can often feel helpless in treating our patients with life threatening problems, the one thing I am learning at Kijabe Hospital, is that the care we attempt to give is often of great comfort to the family (to believe that “everything was done”).
The brothers and cousins of TS came to me after he had expired. They all shook my hand individually. They expressed their deepest gratitude to me for caring for him. And though their loved one had been taken from them suddenly, they were accepting. 

In my mind, I was more hesitant to accept that death was the inevitable outcome, but I had done everything I knew how, and lost the patient despite my best efforts. In the minds of his family members however, TS had received world-class care from a stellar ICU team of health care providers… led by a first-rate “neuro”surgeon named Dr. Wilson. Humbling indeed.

Yours in reluctant acceptance,
chad

“Acceptance of what has happened is the first step to overcoming the consequences of any misfortune.”
~William James