Ann and I have really settled into our lives here. We’ve both gotten so involved in our work here that we’re having to make decisions about “balance.” The volume of work is limitless. You’ve probably heard the starfish parable. If not, it’s a good thing to google. Both of us are trying to help each starfish, but also address the systemic reasons that the starfish are all washed up on the beach. So if there’s no end to the work, when do you go home? When is the need of the hospital, or a patient, or a colleague, less urgent than the need to have dinner with the family, celebrate a birthday, or get a good night’s sleep? Everybody faces these issues, but the decisions just seem a little more stark here.
As a physician in the US, I had the luxury of a cadre of super-specialists around me. Rarely did I have to make the difficult decision alone. And almost never did I have to stray outside my comfort zone of orthopaedic and hand surgery. If I started to tip toe towards the edge of my comfort zone, there was always an endocrinologist, an internist, an oncologist, a neurosurgeon, or some other genius available to share the burden. Almost daily here, I have to grab my phone and access an app called “Up to Date”, a huge library of medical information available online. Then I sit down with the patient’s chart and write orders for medications I’ve never heard of before. It’s very humbling, and would be terrifying, except there’s no one else to do it. So my best effort is what the patient will get. I’m sure I’ll get used to it, but right now it makes for some pretty interesting thoughts as I drift off to sleep.
One of the problems I see regularly here, which is rare in the US, is chronic osteomyelitis. This ten dollar medical name refers to a “chronic” (longstanding” infection of bone “osteo-bone, myelitis-inflamation, or in this case, infection.) Rarely seen in the US, it’s common enough in Africa to have its own abbreviation, “COM”. COM is a disease of poverty. Healthy, well fed individuals almost never suffer from COM. Our immune systems are so strong, we fight off these types of infection before we even know we have them. Occasionally, a healthy child in the US comes in with acute (short lived) osteomyelits, but the condition is treated with surgery and antibiotics as an emergency, and this almost always leads to a permanent cure.
Where children are malnourished, weak, have other disease like HIV or TB, and have limited access to health care, COM is rampant. Everyday in clinic, we see children and adults come in with foul-smelling sinuses in their leg, arm or spine, draining pus for years on end. The chronic drainage and infection saps their immune system even further, putting them at risk for further complications. The chronic infection leads to loss of employment, dropping out of school, multiple surgeries and hospitalizations, amputations, great expense, and in general, a deteriorating quality of life.
It’s difficult or sometimes impossible to cure COM. The bacteria settle deep inside the bone, the weakened immune system puts up an inadequate fight, and the patient is committed to a long course of disease and treatment. Properly treated, however, many patients with COM can return to a productive, near normal life, and some are cured.
This past week has been tough. I’ve had to tell two patients, and their families, that the back pain they came in with was due to a malignancy called multiple myeloma. In the west, good treatments are available for this condition. These patients, however, don’t have access to adequate treatment. Chemotherapy is available in Nairobi, but it’s extremely expensive. Patients may have to choose whether to extend their lives with expensive treatment, or to forego treatment to avoid leaving their surviving spouse and children penniless. Thankfully, an oncologist is currently visiting Kijabe and has helped greatly with these patients.
After the multiple myeloma patients, we began treating a two year old child with hip pain. The pain has been going on for a couple of months, and the child can no longer walk. Xrays show that the hip is being eaten up, either by tumor or infection. It turns out the little man is HIV positive, most likely since birth, which means the destructive process in his hip could be any one of a long list of infections or even lymphoma. I operated on his hip yesterday, and it looks like it was probably tuberculosis in his hip. We’ll find out in a few days. Believe it or not, TB might be the best news he and his mother could have gotten. TB in the joint tends to be less destructive than other infections, and usually responds to medications. The hope is his hip may be functional, allowing him to walk again.
As we were getting ready to start our next surgery, we got word that there was an emergency in “casualty” (Emergency Room in the US). An angry ex-husband had tried to kill his 25 year old ex-wife with a machete. Some good Samaritans eventually pulled the man away, but not until he had cut through her scalp, her ear, the bones and nerves of her forearm, and her elbow joint. It’s hard to imagine the horror this young lady has been through: there’s a significant difference between the random violence of a car wreck and the intentionally inflicted violence of a machete wielded by someone you once loved.
By this point in the day, I was kind of wondering what I was doing here. I was tired, dejected, and feeling a little overwhelmed. I went in to orthopaedic surgery because I love fixing people when they’re broken. Most frequently, patients are much better, near normal, once they heal up from their surgeries. But on this day, all I could see was cancer, AIDS, TB, and violence. And, ever so gradually, it became about me. I was tired, I was dejected, I, I, I….
Who would have thought that strength and encouragement would come from a patient with chronic osteomyelitis? Akbar is a young man from the Oromo tribe, one of the most ancient cultures in Africa. Oromo means “The Powerful”, and Akbar fits the description. He’s 17 years old, but not much bigger than my 8 year old son. The Oromo live in a remote, desolate, difficult land, and have survived drought and famine for over a thousand years. Akbar is tough. I first met him strolling around outside the hospital, with his brother and another clansman who was raised in Nairobi. Akbar speaks the Oromo tongue, his brother speaks Oromo and Kiswahili, and their clansmen speaks English and Swahili. So to talk with Akbar, I would talk to the clansman in English, he would speak to the brother in Kiswahili, and the brother would speak to Akbar in Oromo. Reverse the process for Akbar to answer me.
You would think all this translation made for poor communication, but Akbar and I seemed to be able to get the point across. The point was this: he had a huge hole in his leg. He had suffered from chronic osteomyelits for over two years, and had had to suspend his education due to the chronic, foul drainage from his leg. He’d had surgery at a hospital in his area to clean out the infected bone. This surgery was extremely well done, leaving Akbar with very little remaining infection, but a hole the size of a baseball in his leg. As he removed the bandage from his leg in the hospital courtyard, we were looking at the exposed surface of his tibia. Akbar is tough. He’d just travelled for days to get here, without so much as a tylenol for pain, but he was cheerful, and excited to move forward with his treatment. We found ourselves laughing and hi-fiving as we translated back and forth through our linguistic maze.
The surgery to cover the hole in Akbar’s leg is a pretty straightforward application of orthopaedic and plastic surgery techniques, and should give him a stable, pain free and non-draining leg. His goal is to go back to school next year, and I believe with his positive attitude, he’ll do it. His resilience and joyfulness shone a light on my fatigue and discouragement, and even made me a little ashamed of my lurking self-pity. At the end of this draining week, I thank Akbar the Powerful for the gift of hope and enthusiasm.