Posts Tagged With: global orthopedics

Difficult Discussions: Flunking Sainthood Day 24

Busy day in surgery today, as well as seeing consults between cases.  The surgeries went fine, but what was really hanging over the orthopaedic resident and I today was a discussion we needed to have with a patient and his family.  Last week, we worked hard to save the life of the man who had a terrible injury to his pelvis and leg.  You might remember a photograph of a mangled leg accompanied by warnings not to look if you would find it disturbing.

Thankfully, he has stabilized.  He has gone from the intensive care unit, to the intermediate care unit, and today was able to transfer to the regular men’s ward.  His blood pressure has stabilized, and we have been taking him to surgery every two or three days to clean out his wounds, and remove damaged tissue.

The leg is teetering on the edge of being salvageable.  The bones and muscles are so damaged that he has little hope of a well-functioning limb.  Though his hip, knee, and ankle are fine, the areas in between are mostly devoid of functioning muscle, and severely fractured.  We have had discussions with him over the last days, but wanted to have a family care conference today so everyone was on the same page.

His social situation is far more complex than I could have imagined.  He is an orphan.  Both his mother and father have died, but we did not discuss how they died.  His father had three wives, two of whom are still living, so we had the discussion with a dizzying array of uncles, in addition to his brother and older sister.  Decision making authority rests with the patient, as he is lucid and capable of making his own choices.  Kenya has a strongly family-oriented culture, however, so group discussions and consensus building are vital.

The relatives strongly recognize that they may be held accountable by other family members for medical decisions, so they made it clear that they would abide by “whatever the doctors decide.”  This puts a little too much authority in our hands, however, as the final decision needs to be up to the patient.

Thankfully, the family had outstanding English skills, and communication skills in general, and the Kenyan resident I’m working with filled in my language and cultural blind spots.  We had a long and intricate discussion, and each person voiced his perspective and concerns.  I’ve been in discussions like this a number of times, and I’m often struck by the patience, careful listening, and gentle pace of the dialogue.  It is vital for the health care providers to understand the depth and breadth of implications of decisions like this.  In the end, we met privately with the patient, who was markedly comforted by the group consensus.  We discussed his options again, prayed with him, and he expressed his decision.

The plan is to do everything we can to save his leg, regardless of cost, number of surgeries, or length of treatment.  If at any point we feel like the endeavor is hopeless, or is putting his life at risk, we will communicate this with the patient and with the family.

For this man, I think this is the best decision.  If things go well, his leg will work a little better than a prosthesis would.  Moreover, his psychological and social situation would make amputation an unusually devastating blow.  He and his extended family realize that this is a real possibility, but they would all rest easier with this decision knowing that every effort had been made.  Remarkably, one of the uncles present is on a disability awareness council, and repeated the mantra that “disability doesn’t mean no ability.”  He is encouraging his nephew that, regardless if he winds up with an amputation or not, he can continue with a productive life.

I feel privileged, if also saddened, to be part of discussions like this.  Kenya is a country with a high incidence of motor vehicle violence, and few doctors to treat the suffering.  We may or may not succeed in saving this man’s leg, but I am pleased that he knows he is cared for by his family and by the staff here at Kijabe.

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The Big Fig

Saturday, a break in the rain, blue skies with serrated clouds, brilliant sunshine.  Time for a hike!  The Big Fig is a famous tree near Kijabe, with huge roots winding through boulders, perched on the edge of a 200 foot drop into a small canyon.  The tree is about an hour’s hike through the bush from Kijabe.  We gather our friends the Heins and Higgins families, load back packs with snacks and water bottles, and head out.  Our first stop is at our friends the Davis’ house, where Rich bluetooths the path from his gps to mine.  Once you’re in the bush, it’s difficult to follow the correct twists and turns to the Big Fig, so now we have satellite navigation!  The Davis’ dog Radar decides to abandon his family and join us on the hike.

The hike down is a little muddy, but the footing is good.  Monkeys stalk us in the trees, giant centipedes wiggle across the trail, black ibis, hawks, and colorful song birds punctuate the walk.  An animal skin on the trail is animated with a lacy white fungus.  The gps takes us straight to the big fig, where we take a welcome break in its  cool shade.

The tree is remarkably large, and precariously set.  Roots more than a foot in diameter snake their way through 10 foot boulders, leaving the trunk hanging out over a precipitous drop.  We herd the kids, all kindergarten to fourth grade, away from the edge so the adults can relax.  Michael and his friend Noah impress each other by getting ever closer to the edge, pretending to slip.  Somehow we don’t find it as funny as they do.

The tree’s rocky home provides comfortable seating as we take our break.

Mara family, On the Edge!

Mara family, On the Edge!

The canyon opens up to farmers fields planted with maize and kale, and lazy cows drift from one field to the next in the valley below.  Red-garbed Masai herders dramatically decorate the lush green vegetation.  Rock hyrax duck in and out, resenting our invasion, and Jane finds an 8 inch lizard.

Heading back up, the heat kicks in, but we make good time and relax in the cool of the house.  Jane heads up to a friend’s house, I make grilled cheese sandwiches for Michael and Noah, and Ann takes Bosco out for a walk.  He’s getting a bit old, and we don’t take him on big steep hikes anymore, but he hates to be left behind.

Tonight, we’re looking forward to having the Higgins family over for dinner.  Meghan is cooking, which is a sure sign of Ann’s friendship with her.  Normally, it takes years before an Irish “mammy” will allow another woman to lift a finger in her kitchen, so they must be tight.  Either that, or Ann is just really sick of cooking dinner every night.

I had the pleasure of running into my good friend, Dan Galat, today.  Dan is my doppelganger at Tenwek hospital, about three hours west of here in Bomet, Kenya.  Dan is an orthopaedic surgeon from the US, who came to Kenya straight out of his residency at the Mayo clinic.  We are twin brothers, both sharing a passion for providing orthopaedic care and teaching Kenyan surgeons.  Dan recently started an orthopaedic surgery residency at Tenwek, and we are finding ways to collaborate for better care and training.

It’s nothing short of miraculous that I can sit here in a muddy little village in Kenya, and be working alongside talented Kenyan surgeons such as Dr.’s Muchiri and Wamae, as well as surgeons from the US.  If defies logic, but you have to get used to that once you quit living on your own power and trust that God will provide what you need, and when you need it.  You might not know what tomorrow will bring, but you can have confidence that God has it covered.  And He never fails!

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Day 6: Dawn to Dusk

Today was a hard, but great day.  I like working, though at 51 years old, the energy doesn’t hold up quite as late into the day.  The day started with a 7:30 meeting called by our gifted medical director, Dr. Mardi Steere.  The medical director is an important job here, as the liaison between the medical staff and the Kenyan leadership and hospital board.  The medical staff itself is remarkable, with about 30 doctors, half Kenyan, half expat, all dedicated to providing health care to the most vulnerable.  This morning’s meeting dealt with the big picture, strategic planning, and was really encouraging.

Following the meeting, straight to surgery.  We are extremely fortunate to to have Dr. Thomas Higgins working with us.  Thomas came out with his wife Meghan, and two children Owen and Corine.  Amazingly, they have taken a leave from their comfy life in Salt Lake City to work with us here in Kijabe.  They have settled in like pros, the kids jumping right into kindergarten and second grade at RVA, Thomas being the work horse at the hospital, and Meghan going for runs in the hills around Kijabe and shopping “madukani” (at the shops) like she’s lived here for years.

Thomas took the first case in Room 8, pinning a badly fractured elbow in a 7 year old child.  Meanwhile down the hall in Room 6, I cleaned out a man’s broken leg which had suffered a bad infection.  He’s almost ready for a SIGN nail and bone grafting, maybe in a month or so.

As I was finishing the first case, a friend from Bend showed up in the operating room.  David Utley, a professional photographer, and his wife Cindy used to live in Bend, but now work for Samaritan’s purse, based in North Carolina.  David was passing through Kijabe on his way back from a photo shoot of Samaritan’s Purse’s work in the Congo.  He snapped a few photos in the operating room, and then I walked him  to a friend’s house in the pounding rain.

Following this, Shelminth, a talented general surgery resident in her second year, removed some pins from a child who had previously had his elbow pinned.  Later in Room 6, we had to amputate the leg of the poor man with the overwhelming infection.  Amputation is heart breaking for everyone, and is a last resort when all hope is lost for the limb, or when continued efforts to save the limb would gravely endanger the patients life.  Sadly, Kamau fit both these criteria.  Though tragic, he can now get on with healing, his chances of survival are much higher, and he will eventually walk with a prosthesis.

Meanwhile in Room 8, we are preparing for a big case, fixation of an acetabular (hip socket) fracture.  Dr. Higgins is a trauma specialist from a large trauma center, and acetabular fracture is one of the signature surgeries for a trauma surgeon.  I took the opportunity to scrub in with Dr. Higgins to learn from the master.  I have done these fractures here, but he makes it look easy and taught me a number of “pearls”.  The surgery went extremely well, and both the resident, Dr. Kingori, and I learned a lot.

Back in Room 6, a big upper extremity case.  This poor woman had been shot through the arm during a church bombing a couple of years ago.  Remarkably, she has essentially the same condition as the young lady, Caroline, we saw yesterday.  The problem is that the gunshot wound had removed most of the ulna (forearm bone), one of the bones was dislocated from her elbow,  and her hand and wrist were no longer linked to her arm.  The injury had been about two years previously, the arm was badly scarred, and the surgery proceeded slowly.  In the end, however, she had a nice stable arm, so much so that we didn’t even need to put her in a cast.  She’ll be painful for several weeks, but can start using her arm immediately.

Meanwhile back in Room 8, Dr. Higgins repairs a badly broken wrist.

The day went much longer than expected, and as I walked up our driveway in the dark at 7:30 pm, it seemed much steeper than usual.  We had had 17 people over for dinner from our team, and they were just leaving as I walked in.  Ann had graciously hosted them and had a beautiful dinner of salad grown in our own shamba (garden), and creamy tomato chorizo pasta with fresh home-grown basil and toasted pine nuts.  Amazing!  I warmed mine up in the microwave, and plopped down in front of the fire with Michael and Jane.

Tomorrow is a national holiday, and I’m not on call, so I plan on sleeping in, going for a bike ride, and preparing for a talk I’m giving tomorrow night.  Thanks for walking with us here in Kijabe.

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Day 4….Some days are better than others

As I sat down to write this, my phone rang.  It was the excellent resident I’m currently working with, calling with bad news.  He had brought our patient from Sunday, the one with the terrible leg infection, back to theatre to wash out the infection again.  Instead of finding the leg improving, he found toes turning black, and the muscles dying.  We got to Kamau too late.  The infection had gone too far.  This young man is going to need an amputation.

I can feel the resentment build:  why did this have to happen?  It wasn’t a complex problem: with some basic surgical care from the outset, he could be planning his recovery, this episode soon relegated to a painful memory and tales to tell his children and grandchildren.  Instead, he will be an amputee, in a country which doesn’t look kindly on disability.  Here we have no “Kenyans with Disabilities Act” to put in sidewalk ramps, require accessible public transport, or prevent employment discrimination.  Disability is sometimes viewed as a curse, creating fear, suspicion.  He will have some difficulty finding and affording a good prosthesis.  This is a huge setback for his life.

If this were an isolated instance, it would be simply frustrating.  But it is a regular occurrence, even here in Kenya, one of the more developed countries in sub-Saharan Africa.  I’ve been to countries where things are much worse, where there is simply no hope for patients with significant injuries.  The suffering across this continent is unimaginable.

There’s a lot of people working on this problem.  My Notre Dame classmate and roommate from medical school, John Meara, has risen to the highest echelons of the academic world, and is spearheading the Lancet Commission.  The Lancet, one of the oldest and most prestigious medical journals in the world, has decided to undertake a major project, looking at the effect of this severe lack of surgical capacity in the developing world.  The governing body of the World Health Organization meets in May and will pass a resolution declaring basic surgical care a right, much like access to clean water, food, security, and vaccines.  This is a watershed moment for the billions of people suffering worldwide from lack of access to adequate surgical care.

In our lifetimes, this problem will be reversed, and severe lack of surgical capacity will go the way of smallpox and polio.  But that doesn’t help Kamau today.

Our first patient for the day, a young man in a car wreck, was due to have his hip socket reconstructed after a fracture-dislocation of his hip.  Unfortunately, due to a scheduling error, we had to re-schedule his surgery for Thursday.

Our next patient was due for wrist reconstruction after a mangling injury a year ago when his van rolled over as his arm was out the window.  As we were preparing him for surgery, I pressed gently on a little opening in his arm.   To my surprise, a 3/4 inch seed pod popped out, followed by pus.  Apparently, despite multiple surgeries at two excellent hospitals in Tanzania and Nairobi, this remnant from his roadside injury had hidden inside his arm for a year.  It decided to work its way out on the day this patient was finally scheduled for his reconstructive surgery.  We cleaned out the infection and took him to the ward for intravenous antibiotics.

The third patient today was a middle aged lady who had fallen down some stairs, shattering her wrist.  She was scheduled for a combination of plating and external fixation today.  Though she has a history of hypertension (high blood pressure), she has been well controlled by medications.  Until she got onto the operating table.  Her blood pressure shot up to a dangerous 200/100, and persisted despite intravenous anxiety and blood pressure medications.  Surgery cancelled.

Next up, a two year old boy who fell down some stairs, hyper-extending his elbow to the point where the elbow broke just above the joint.  Jane had this same injury just last November.  The treatment is a surgery where the bones are manipulated back into position, and then held there with two pins introduced through the skin into the bone using video xray.  This went flawlessly, all the equipment worked perfectly, and he should be fine.  Finally, we accomplished something for the day.

Our last patient was the disastrous Kamau, wrapping up an all-too-typical day in the battle against trauma in Africa.  When he wakes up, we’ll need to give him the bad news and obtain consent for amputation.

In the big picture, I know progress is being made, systems are being formed, surgeons are being trained, the John Meara’s of the world are pushing global organizations to wake up to this unseen epidemic.  But day to day, my picture isn’t that big.  My picture is the men, women, and children in my clinics and theatres who suffer agony and disability from lack of safe roads, safe drivers, and access to safe surgical care.  Though we’re too late for Kamau, my prayer is that his children will live in a world with less suffering.

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Flunking Sainthood: Day 1….make that Day 2

I just finished reading “Flunking Sainthood”, by Jana Riess.  It’s a pretty light read, documenting this spiritual tourist’s attempt to reproduce one ancient “spiritual discipline” per month, for a year.  Things don’t go as planned, as she tries to emulate a strict Jewish sabbath, practice Benedictine hospitality, tithe, and sit in contemplative prayer. flunkingsainthood But the sum is greater than its parts, as she finishes the year with some wisdom, and humility at how difficult even simple disciplines can be.  I give it two thumbs up, but I’m into this sort of thing.

Her book got me thinking about a practice I used to embrace.  In grade school, we were taught a simple prayer, traced back to the fourth century mystic “desert fathers” of Egypt.  This prayer is still practiced in Eastern Orthodox Christianity, and has recently regained a toe hold in contemplative Christian practice in the west.  How and why a Redemptorist Catholic priest in Midland, Michigan was teaching this powerful practice to 11 year olds in 1975, I can’t imagine.  But it’s stuck with me:  Breathing in: “Lord Jesus Christ;” Breathing Out: “Son of God;” in again: “Have Mercy On;”, final exhalation: “Me a sinner.”  Lather, Rinse, Repeat.  The desert fathers prayed this ceaselessly throughout the day, and some even prayed it in their sleep.  It was felt that this powerful mantra invoked the name of Jesus in his relationship as King and Son, and then placed the servant humbly in his place in the universe, in need of grace, mercy, and forgiveness.  I dare you to try it:  it’s remarkably powerful, and also a great sleep aid.

The has me considering spiritual disciplines, setting a challenge that will center me on what’s important and making time for something just because it is worth doing.

Here’s my plan: my spiritual discipline will be to write a brief blog, every day, for four weeks. At the end of four weeks, I’m going to be traveling to a country with little internet access, and zero tolerance for Christian bloggers, so that will be that.  And I wrote a blog yesterday, so this counts as day 2.  My spiritual discipline, my rules.

The concept seems a little self-indulgent, like posting on Facebook a picture of what you’ve eaten for lunch that day.  But Jana Riess wrote a whole book about her pursuit of spiritual disciplines, so I feel enabled to write a blog.  I love writing blogs, and kind of feel like it’s a chance to give a glimpse into our life for all of the people who support us emotionally, in prayer, and financially.  But too often, I’m exhausted at the end of the day, and a bowl of popcorn and episode of “Prison Break” take the place of sharing my day.  I can’t promise any profound insights, but I’ll try to just give a fair representation of the day to day here at Kijabe.

So, here we go…

Today is Sunday, and we’re deep into the rainy season.  Our cement-block house has a sheet metal roof, and the only heat is from a log-burning fireplace in the living room.  African rain can feel primordial:  it comes down so hard, so suddenly, so loudly, that it saturates the senses.  We cocoon in front of the fire, secure that our little house has stood for half a century against such tropical torrents.

Duty calls, and I’m up at 8 am to get coffee, french toast, and sausages ready for the troops.  Kenya produces dark, rich coffee beans, the sausages come from Nairobi, and the eggs are laid here in Kijabe. The kids have been on school break for a month, but go back to school tomorrow.  Ann and the kids get ready to go to the chapel up at Rift Valley Academy, but I am on call and have to go in to the hospital.

The northern parts of Kenya, bordering South Sudan, Ethiopia, and Somalia, are very remote and largely outside the rule of law.  Sadly, a wedding party was ambushed by bandits in Marsabit yesterday, on their way to the ceremony.  Multiple members of the wedding party, in traditional garments and face paint, were gunned down.  The survivors were swept up by a missionary pilot in a bush plane, and deposited at our gravel airstrip.  The victims have been undergoing surgery, one after the other, since yesterday afternoon.  Only one of the patients had a fracture, so that waits until this morning.

The surgery goes well, the bone is shattered, but the nerves and blood vessels are okay.

Gunshot wound to the humerus.

Gunshot wound to the humerus.

I just clean out the wounds, apply a splint, and we’ll come back later in the week to put a SIGN nail down the humerus to let it heal.  He should be fine.

Next up, a disaster.  Kenya has one of the deadliest road systems in the world.  14-passenger vans, often dilapidated wrecks, serve as share taxis:  Uber taxis on drugs.  The drivers are often lawless, pulling out into oncoming traffic to pass, forcing drivers to the shoulder of the road or be hit head on.  Eventually, the Pauli exclusion principle prevails, and people are horribly injured.

Kamau was a passenger in such a vehicle, and survived with a relatively simple tibia (leg) fracture, which had protruded through the skin.  He was taken to a rural hospital, where antibiotics were started, and surgery performed to clean out his wounds.  Perfect care, up until this point.  Unfortunately, at the end of the surgery, they tightly sutured his wounds, trapping any residual infection inside.  Over the next week, huge amounts of pus built up, eventually stretching the surrounding skin to the point where it died.

Kamau came to us with fevers, a horrible smell, and whitish green pus dripping through his bandages.  After his spinal anesthetic was placed, we peeled back his splint and dressings.  Seasoned operating room tech’s fought the urge to gag from the stench.  The skin of the leg was dead from knee to ankle.  Pus dripped from his leg, onto the operating room table, and pooled on the floor. We spent the next two hours excising dead skin and muscle, finding yet another pocket of pus, cleaning the infected bones, and applying an external fixator to stabilize the fractures and allow access for wound care.  At the end of the surgery, the wounds looked much cleaner, but he will need several more surgeries to eradicate the infection.

Leg cleaned out, external fixation applied.

Leg cleaned out, external fixation applied.

Once the infection is under control, we can swing muscle flaps to cover the exposed bone, and then skin graft over the muscle flaps.  He’ll probably be in the hospital for a month or so.

As I finished the surgery, the heavens open again.  I walk home grateful for the cool, cleansing shower, the scent of wet grass and mud replacing the terrible stench of infection.  Surgical scrubs go into a bucket filled with bleach and water, and I climb straight into the shower, fearful that I could bring these aggressive drug resistant bacteria into the house. Ann has been hanging out with our new friends the Higgins family, who are here for three months from Utah.  The kids are off playing somewhere, and we start organizing for dinner.  The night gets chilly, we light the fire, and get ready for another week at Kijabe.

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The New Normal

A little less than three years ago, the Mara family drove away from our house in Bend, Oregon, with a mixture of excitement, fear, sadness, and anticipation.  Ann and I had lived there our entire married lives, brought our newborn babies in through the front door, and we shared a little fear that we would never feel quite as “at home” again.  As I walked to work this morning, however, I realized we now have a new normal.  Things which would have seemed bizarre, exotic, or even frightening three years ago now simply add to the richness of life here.  Over the last three years, we have experienced close encounters of the best kind:

Murit, Jane's adopted baby elephant.

Murit, Jane’s adopted baby elephant.

Michael and Jane with two new friends

Michael and Jane with two new friends

Simba and her litter

Simba and her litter

We have become patients ourselves:

Prayers for Jane with her surgeon and anesthesiologist

Prayers for Jane with her surgeon/dad  and anesthesiologist Dr. Newton

Ann, very stoic as she gets an IV in casualty.

Ann, very stoic as she gets an IV in casualty.

Mike going in for the first of his two surgeries at Kijabe.

Mike going in for the first of his two surgeries at Kijabe.

My friends and I have had multiple bike wrecks:

My friend Andy:

My friend Andy: “I feel cold. Tell my wife I love her” (He had sprained his shoulder)

Adam attracts a crowd after his bike disintegrated beneath him.

Adam attracts a crowd after his bike disintegrated beneath him.

We’ve gotten used to driving three hours round trip for groceries, not being able to understand most conversations around us, and sometimes feeling like a novelty or curiosity.  Happily, we also feel embraced by a culture which values time spent face to face, gentle suggestions over confrontation, and family life over consumerism.  I’m slowly learning that relationship is more important than achievement, love more important than efficiency, and compassion more important than titles or degrees.

Sadly, the most constant rhythm of life at Kijabe is the incessant flow of very sick and badly injured patients.  Some of these patients are too injured, or come to the hospital too late, for us to be able to give them a good outcome.  But the thing that amazes me the most about Kijabe Hospital, is how miracles happen on a weekly basis.  I’d like to tell you about two recent patients that demonstrate this.

Ahmed broke his leg when he was struck by a passing “piki piki” (motorcycle) in a remote and lawless area of Kenya.  With no access to health care, Ahmed’s family did the best they could, taking him to a local bonesetter.  He was quite malnourished at the time of injury, and the forced bedrest in his hut led to huge ulcers, bedsores, which covered his back side and injured leg.

When Ahmed was finally brought to Kijabe, he was semi-conscious, with foul smelling pus and bodily fluids contaminating his wounds.  He was in marked pain, with his unstable fracture allowing his damaged leg to flop around during the long car ride over bumpy roads.

I must admit, when I first saw Ahmed, I wasn’t sure he would survive, and I even wondered briefly if the most merciful thing would be if he passed away quickly.  But of course, that’s not why we’re here.  A team of compassionate nurses, pediatricians, pediatric surgeons, plastic surgeon, and orthopaedics took him under their wing.  Intensive nursing care helped heal his wounds and improve his nutrition.  Hospital chaplains came and poured love and prayers over Ahmed and his family.  The paediatric surgeons performed a colostomy to avoid his wounds being soiled by bodily fluids.  And our talented plastic surgeon managed finally to close the gaping wounds in his leg and buttocks.

Due to the gross contamination of Ahmed’s wounds, we could not risk operating to fix his fracture.  But due to his huge wounds, treating him in traction would worsen his life-threatening bed sores.  The solution was unusual, but we placed him in traction after rolling him onto his stomach.  For four weeks, he had to lie on his stomach while his femur and wounds slowly improved.

And then, remarkably, he was healed.  And several weeks later, he walked into clinic!

Ahmed, gravely ill, and now walking under his own power!

Ahmed, gravely ill, and now walking under his own power!

I didn’t recognize him.  He wasn’t even limping.  Instead of the poor, dying, semiconscious, badly infected patient, he was a happy, energetic, funny young man.

Some things can never be the “new normal.”  Joyce’s story is one of those situations.  Last week, in the midst of our busy orthopaedic clinic, with 90 patients waiting to be seen, one of the clinical officers came over from “casualty” (the emergency department).  “Dr. Mara, could I show you an MRI scan”  This is a common request, usually patients with back pain who have gotten a scan done in Nairobi and want someone to look at it.  I always ask the clinical officer to describe the patients history and physical exam before we go over the scan, to emphasize that careful history taking and examination are really more important than expensive tests.

“This is a 7 year old girl.  She was healthy until 10 months ago, when her legs became clumsy.  Then she became paralyzed.  She hasn’t been able to walk for five months.  Now she can’t move her arms or legs.  And since this morning, she’s having trouble breathing.”  A quick glance at the MRI scan in the CO’s hand showed an extremely rare condition which is fatal if not treated.  Due to a birth defect in her upper spine, her head was not properly attached to her neck.

Joyce's MRI, showing severe compression of the spinal cord

Joyce’s MRI, showing severe compression of the spinal cord

This creates instability which had progressed to the point where her spinal cord was severely compressed at the base of her skull, at the junction between her spinal cord and her brain stem.  We ran over to casualty.

Over the last months, the spinal cord damage had progressed to paralyze her legs, then her arms, and finally, that morning, was beginning to paralyze the muscles which allowed her to breathe.  She was within hours of dying from respiratory arrest.  We put her on oxygen, and I ran back to clinic to get Dr. Muchiri, our spine specialist.

We left 90 patients waiting in clinic, to quickly put Joyce in traction.

Joyce lying comfortably with the life-saving traction applied to her head.

Joyce lying comfortably with the life-saving traction applied to her head.

Michael and Jane on their way to visit Joyce.

Michael and Jane on their way to visit Joyce.

This is a medieval-looking but painless procedure, done under local anesthetic, which pulls the skull away from the damaged spinal cord and allows healing to begin.  Within minutes, her breathing improved, and she required less oxygen.  Dr. Muchiri and I were breathing a little easier too.

I came home from work that night and shared Joyce’s story with Michael and Jane.  Without hesitation, they adopted her, and decided they needed me to take them to the hospital that night.  Michael went and got a favorite blanket he’s had since he was an infant, and Jane collected a stuffed bunny, an embroidered pillow, a story book, and another blanket.  We went to the children’s ward, prayed for Joyce and her mother, and delivered the gifts.

Joyce, a little scared, but comfortable, and awaiting her life-changing surgery.

Joyce, a little scared, but comfortable, and awaiting her life-changing surgery.

This past Monday, Dr. Muchiri and our neurosurgeon combined their considerable skills to decompress and stabilize Joyce’s spine.  This involved removing some of the bone from the upper spine, and base of the skull, and then using metal plates and screws to fix her skull solidly to her neck.

Joyce is now able to move her arms and legs!  She has a long way to go, but there is every chance she will be able to walk and use her arms normally again.  Children have such amazing powers of healing, and the care she got at Kijabe Hospital has given her the best chance possible for a full life.

Our new normal involves some challenges, but also allows us to witness miracles like Ahmed and Joyce on a regular basis.  As a family, we feel incredibly fortunate to be part of showing God’s love to the thousands of people who come to Kijabe.


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Managing Surgical Emergencies

One of the greatest blessings of living and working in Kenya is getting to be a teacher of surgery.  My work at Kijabe Hospital involves working daily with trainees.  Some are senior level orthopaedic surgery trainees, honing their skills before embarking on their new career.  Some are clinical officers, like a physician’s assistant, who don’t do major surgeries but will be on the front lines of diagnosing and providing crucial early treatment to the injured.  Almost every patient we see, and every surgery we do, involves teaching young Kenyan professionals.  In a country and a continent with a heart- breaking shortage of trained medical personnel, it is incredibly exciting to watch young trainees grow into confident, and competent, professionals.

Much of the teaching we do here falls under the auspices of the College of Surgeons of Eastern, Central, and Southern Africa (COSECSA).  Through COSECSA, I have the privilege of working with and training young surgeons from Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe.  South Sudan and Somalia have also applied for membership in the college.  This is a college without walls, a huge group of surgeons from Africa, Europe, the UK, US, and Australia, who come together to teach the next generation of African surgeons.  Thought leaders in surgical education from around the globe strive to provide advanced training and assessment.  The testing and assessment process is in some ways more thorough than the board examinations I went through in the US.

Amazingly, much of the funding and intellectual firepower behind COSECSA has come from the Royal College of Surgeons in Ireland (RCSI).  Visiting faculty from both Ireland and the UK come regularly to conduct courses and administer examinations.  In accordance with ideal development practices, the European influence lessens each year while the African surgeons take authority over this African college.

Beginning last year,  I’ve been privileged to participate in a course called “Managing Surgical Emergencies” (MSE).   This is a week long course, aimed at teaching a core set of surgeries that can save life and limb using low technology and limited resources.  The course is intricate, and extremely fast paced.  The orthopaedic surgery module was designed by my great friend Dr. Yogesh Nathdwaralawa, an orthopaedic surgeon from Wales.  The longest lecture is 12 minutes, followed immediately by hands on application of the surgeries taught.  A very large pig is euthanized so junior surgeons can learn how to drain blood from a bleeding brain, save the life of a baby and a mother with a rapid C-section, stop bleeding in an abdomen traumatized by a car wreck, recognize life threatening infections and fractures, and other vital procedures.

The course is set in a remarkable surgical skills laboratory located on the University of Nairobi campus.  Professors from England, Wales, Scotland, the US, and Kenya teach the different modules.  To date, most of the funding and teachers have been from the UK, but with the class we held last week, this ends, and the African staff take over completely.  This is an historic and exciting moment in African surgical training.

One of the most remarkable things about this course is its practicality.  The students return to their hospitals and immediately start performing these life and limb saving procedures on a daily basis.  I feel if only one surgical course could be taught to medical students and interns in Africa, it should be this one.

In the few days since we finished the last course, I have had two patients who demonstrate the vital nature of the MSE course.  The first is tragic, the second encouraging.

Victor is 10 years old, the same age as my son Michael.  He has been an orphan since a very young age.  About four years ago, he developed swelling and then pus coming from his ankles.  One of the things we teach in the MSE course is how to recognize and treat osteomyelitis, a common, dangerous, and crippling bone infection.  Osteomyelitis strikes the most vulnerable:  the very young and old, the malnourished, those with AIDS.  Likely because of malnutrition and sickle cell disease, Victor had osteomyelitis in both feet and ankles.  The bones of his foot were destroyed by infection, to the point where his tibia, or leg bone, was protruding through the skin.  He is a social outcast, unable to go to school, due to the smelly pus and disturbing appearance of his ankles.  Xrays showed complete destruction of the bones of the foot.  Despite multiple consultations looking for a better answer, the only way for him to survive, go to school, and one day work and have a family, is to amputate both legs below the knee.  With prosthetic legs, paid for by our vulnerable patient fund, he will be able to walk, run, go to school, and rejoin society.  We met with him, prayed with him, and performed the surgeries this past Monday.  Within several weeks, we’ll begin the process of getting him new prosthetic legs.  The silver lining of this awful tale, is that he has discovered his faith while in Kijabe Hospital.  He is reading a Bible, and wants to commit his life to following God’s will for his life.  This has given him a purpose and hope as he faces life with prosthetic legs.  Amazing how God can work through even the most miserable of circumstances.

This could have all been prevented with some simple training in recognition and treatment of osteomyelitis in children.

Our second patient yesterday could be diagnosed from the hallway.  A 45 year old man had been hit by a motorcycle on Sunday, suffering a moderately severe wrist fracture.  A local hospital had put on a full tight cast, something we teach never to do in the MSE course.  Overnight, the swelling had progressed to the point of cutting off the circulation to the arm, a condition called compartment syndrome.  The excruciating pain and numbness brought him to our casualty department (ER).  The astute clinical officers rapidly removed the offending cast, but the cascade of events had progressed too far.  As the arm lost circulation, the pain became intractable, and we could hear the poor man screaming from the hallways by the operating room.

Thankfully, the well trained clinical officers recognized the urgency of the situation, contacted the orthopaedic team, and we rushed to casualty.  Cases were cancelled, we pushed the trolley rapidly through the halls to Operating Theatre 1.  One of our recent junior trainees from the MSE course was by my side, and I asked him to do the surgery he had just learned.  He completed the job beautifully with little guidance, saving the man’s arm.  Though he will have some scarring, he can plan on having normal function once he heals.  I was so proud of our junior clinical officers and doctors, rapidly recognizing and treating this surgical emergency.

These types of disasters and near disasters are a daily occurrence in most of Africa.  So much more work needs to be done, but we can already start to see the benefit of basic surgical training.  If we could take the MSE course to every corner of this continent, many many thousands of lives would be saved, and even more people saved from a life of crippling pain or disability.   It is a great privilege to be part of this process, and we thank God every day for bringing us here.

 

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