As the bowel churns

It's been a packed couple of days here in Soddo.  

On Thursday, I (Matt) had a full morning at the hospital with a variety of operations.  With three surgeons (Paul, John, and I) we were able to knock cases out pretty efficiently - I took out a huge goiter and drained a weird pelvic/ proximal thigh abscess while John did a mastectomy and then helped with an exploratory laparoscopy on a young girl (25) to confirm inoperable gastric cancer.  I am surprised by the young ages of some of our cancer patients here - a 25yo female has no business with bulky gastric cancer, nor does a 26yo female usually get recurrent breast cancer (already at least at stage IIIb).  With a scarcity of chemotherapy and/ or radiation in the country, their prognosis is quite grim.  We literally had the "come to Jesus" talk with a 30-some year old Muslim Somali man with a large thoracic esophageal cancer - his prognosis would have been poor even with all treatment options available to us.  Alas, it was best for us to do nothing but inform him of his situation and earnestly pray for him.  His friends expressed to us that they still consider Christians to be polytheists.  We attempted to explain otherwise and to present the gospel to him, but since his friends were serving as his interpreters (he speaks a different dialect, not Amharic or Wolaitinya), we are not sure how accurately the message was conveyed.  

Wendy and the girls went to a women's bible study with many of the missionary/ expat wives in the area.  The home where it is held is the one with the pet Dik-diks (Tazzle and Izzy) that the girls like so much.  

When I got back from the hospital, Emma and I took a walk with John up to the café on the roof of the local bank builing.  It was a long, hot walk and I ended up carrying Emma for about half of it - we got a number of strange looks from the local kids (who are obviously accustomed to walking much farther distances without parental assistance).  Though I have fond memories of getting 20 cent lattes at this place last time I was here, this time their machine was broken - they, of course, were too embarrassed to admit this and instead attempted to piece together some sort of replacement out of instant coffee, cocoa, and water.  It actually wasn't half bad, but it was nothing compared to the Macchiatos we have had elsewhere in the city.  

Friday was the most interesting day so far from a surgical standpoint.  The three of us and the residents banged out a good number of cases all before 1:00.  This included a prostatectomy for BPH, a appendectomy, another mastectomy, repair of a depressed skull fracture, an endoscopy for suspected esophageal cancer (thankfully negative), an ex-lap on a two year old suspicious for intussusception (negative), a scrotal debridement (lovely), debridement of a tropical ankle ulcer, and what we thought would be a repair of an inguinal hernia (it wound up being a resection of a hair-filled mass called a teratoma instead).  We did our daily wound care on the burn patients as well before heading up to the library for Friday afternoon educational conferences.  We had M&M and then Segni, one of the interns, presented a power point presentation on transplant surgery (they take turns each week teaching through the standard surgical textbook chapters).  Even though they will likely never see nor do a transplant, they still take it upon themselves to learn what they can about all the surgical disciplines - it is quite an extensive curriculum.  Paul gave them each oral examinations afterwards.  

Friday evening brought the weekly Pizza night at the Bowers.  Harry has a gigantic concrete wood-fired pizza oven built into the corner of his patio (called the lapa).  Everyone on the whole compound assembles their own pizza and brings it over for baking, then we all (about 20 of us) eat out on the patio and shoot the breeze.  It is an experience as rich in Christian community as it is in calories.  We had people from Madison and Manitowoc, Ohio, Texas, Norway, Spokane WA, Idaho, Michigan, and South Africa - a mix of short-term and long-term servants.  The conversations, as you could imagine, were also all over the map.  

After dinner, Paul asked if I wanted to cover an emergency case on a three year old with a severe intussusception.  This is when the intestine starts to telescope upon itself, causing both a complete bowel obstruction and also threatening to kill the segment of intestine involved.  Ideally, this can be undone without any intestine dying or bursting in the process.  If either of those events (intestinal death or rupture) occur, however, the operation becomes much more extensive (with long-term repercussions) or the patient can go into septic shock and die.  The patient was a three year old boy, though this is always hard for me to tell.  His arm and legs would suggest that he is two, but the look on his face was almost that of an adult (as if he has already suffered much).  His abdomen was bloated, enlarged way out of proportion to his pencil-thin extremities.  It was tight as a drum and one could feel the loop of bowel to blame quite firm and distended on his left side.  He had not had any bowel movements or even passed any gas for five days due to the obstruction.  This had been preceded by some bloody diarrhea, an ominous finding in a three-year old.  Now, one could feel the involuted portion of his GI tract, possibly even his small intestine, on rectal examination.  This indicates that it is quite a long segment of intestine involved.  If this much bowel dies, the results could be catastrophic at worst, debilitating a best.  

Dejene, the intern, had done a good job taking the history, doing the exam, and making the correct diagnosis.  He gave the proper IV fluids and antibiotics, prayed with the child's grandmother, and we took him to the operating room.  Towodros (the chief resident) and I did the operation with Dejene providing exposure.  We were thankful immediately upon making the incision because the fluid in his abdomen was not bloody - if so, that would indicate that the bowel had likely died.  For those who care, the intussusception wound up being in an odd location (splenic flexure) caused by a congenital band adhesion of the transverse mesocolon.  Though odd, this was good news as these can be caused by tumors and his thankfully was not.  

Reducing (undoing) an intussusception is a slow and gentle maneuver.  The bowel is quite swollen and fragile.  If one tears a hole in it, it is difficult and often unwise to repair - this would likely obligate us to remove the entire segment involved.  Towodros and I, however, took our time as we gently massaged and milked the bowel back into its normal configuration.  Thankfully, it all appeared to be viable and there were no perforations.  Towodros said a prayer of thanksgiving and then we closed.  This morning, to add to the miracle, the kid was already sitting up, sipping orange Fanta and eating his boogers - back to normal sooner than any of us expected (I know where he got the boogers, but I'm not sure who gave him the soda, though).  

Today (Saturday), we made rounds, then had resident Bible study before Paul and Becca took off for a weekend getaway.  Wendy and I (okay, mostly Wendy) will be watching their kids (3yo Nathan and 1yo Lydia) while John and I cover the hospital.  Even though Paul is a little under the weather, it will be nice for him to get away… hopefully he doesn't have too many nightmares about me doing a prostatectomy by myself.  

Congratulations to anyone with the stamina to still be reading at this point (I eschew brevity).  I will now put you out of your misery and wrap this up.  We'll have to let you know how our weekend of zone-defense childcare went.  

Venturing out

Venturing out.

It's been a busy couple of days here in Soddo. Where to start...

Tuesday and Wednesday started to get busier in surgery – of course it always seems that half the cases cancel for one reason or another – financial problems, a change in condition, or maybe the patient just decided to eat lunch (because they had only been told not to eat breakfast). At the beginning of they day, it seems like we'll never get everything done, but we always manage to finish at a decent hour. At some point, the cancelled/ postponed cases will likely all come out of the woodwork on the same day. For Paul's sake, it would be nice if that happened while we are still here.

I'm finally getting a little more used to the flow of things and am feeling a little more emboldened to teach and correct the residents. It's just another element of awkwardness which I'm getting used to. Add that to doing unfamiliar operations, familiar operations with different equipment, or operating on more advanced diseases (had to operate on a very advanced breast cancer in a 26yo female today) – there is plenty of opportunity to trust in God to come through in my weakness. I think I'm beginning to embrace awkward, but Wendy (and many others) would probably tell you that it's been my style for a while now.

Had a chance yesterday afternoon to go out for coffee with John (Foor) and Harry (Bowers) – there are more options in Soddo than the last time I was here. In short, we went to a place called "Fanta Vision" which is a combination hotel, quicky-mart, coffee shop, bar, and construction zone. They served us espresso machiatto for about 3.5 Birr apiece (that's around 22 cents). The espresso was literally so thick that John's spoon stood up in it (this may also have had something to do with the shape of the cup, I'm told). I had two and vowed to come back, often. I'll post pictures to facebook at some point since I can't post them directly to the blog.

Today, Wendy and the girls had the chance to go to a large food distribution event today near the future site of Dr. Bowers "Wolaitta Village." (I'll try and link to his blog if you'd like to learn more – you really should). It was the girls most adventuresome cultural experience yet. The local church here hands out grain to those most in need once a month. They feed them spiritually, too, before the distribution. The girls were fascinated by the process and met several new friends. At first they were very shy at all of the stares, but they soon warmed up to them and let them touch their arms and hair. Tessa was the first to "be brave" as she told Wendy. They played a few games (Duck Duck Goose, etc) but did reach a point where they were tired and hot enough to need some space. They experienced their first taxi ride (it's an enclosed 3 wheeled motorcycle) called a bijaj (not sure on the spelling). Prior to the food distribution they visited another missionary in town who has two pet dik dik's (small antelopes), Tazel and Izzy. Emma was able to feed Tazel some milk from a bottle. She liked that very much.

Went to play soccer with the locals this evening. They no longer have a field on the hospital grounds (okay, they do, but it's not flat and there are too many sheep grazing in it), so we go to the local "Stadium." An OR nurse I worked with the last time we were here invited me to come play. Sophie (an adventuresome rural nurse from Idaho who friended us on Facebook) was nice enough to give me a ride on the back of her motorcycle (the "donor-cycle" as Paul calls it). When I got to the field, I could not find anyone I knew. This did not stop me from being found by many people whom I did not know. I had an instant entourage of young and old people. They were interested to see the "Ferengi" (isn't that some sort of wrinkly alien from Star Trek?) play soccer. They were intrigued that I would take off my flip flops and put on soccer shoes as for many of them, flip flops ARE soccer shoes. I had a couple of willing volunteers to guard my sandals and water bottle while I played.

I didn't last long on the field. Between my atrocious physical condition (haven't had much time for exercise leading up to the trip), the altitude (around 7600 feet, I think), the cloud of dust called a soccer field (I think I need a lung transplant for acute silicosis), and my age relative to my competitors, I had soon confirmed most of the peoples' impression of America's soccer prowess. My apologies to those at home who are actually good at this game. I had fun, though, and had a nice walk back to the hospital with Hasabu – I even made it in time for a late dinner.

Well, the kids are in bed and the laptop battery is dangerously low. Lest I lose the whole post, I'll sign off for now. Until next time. Ciao.

Jetlag recovery program - 2/21/2011

Jetlag recovery program - 2/21/2011

The first stage of jetlag is denial.  I thought I would have an easy run of things as I stayed up a bit late (~11pm local time), slept well, and started to stir around 0430 - not much different than my normal sleep pattern at home.   I dutifully laid there for another hour but was unable to doze back off.  A shower and a cup of strong coffee were good for, at least temporarily, another 3 hours of sleep or so.  So energized, I snuck out of bed (Wendy and the girls were still comatose) and walked up to the hospital for rounds with Paul - about 7:00am.  I'll separate out the medical details below so that those of you who don't care can spare yourselves the shop-talk.  

The workload was uncharacteristically light.  I got to meet the four residents:  Towodros (the chief), Daniel (3rd year), Segni and Dejene (the interns).  They did most the presenting of the patients while Paul mostly asked questions to draw out the necessary information and lead the residents to the proper conclusions.  He is a very calm but direct teacher - well suited for his role here.  Makes me miss at least that aspect of residency training.  Rounds are different, of course, than in the states.  It is thin, but not entirely devoid of paperwork.  Also, malaria figures into the differential diagnosis of pretty much everything… fever, anemia, malnutrition, tachycardia - where a patient is from winds up being important as those from areas with endemic malaria may have this additional malady to contend with.  Hemoglobin values are suspect, so an exam of one's palpebral conjunctiva is  a critical gaugue of whether or not a patient has ample red cells to tolerate an operation.  We also pray regularly on rounds, especially if someone is having a difficult source or appears to be struggling emotionally.  It is neat to see the residents do this with genuine caring and without a hint of awkwardness.   

After a few cases, we returned to the house for lunch - Injerra and Wat (that's Amharic for culinary heaven, if you didn't know).  After that we headed back up to the hospital.  That's when I hit the wall.  There was a period of relative inactivity (something that was quite rare the last time I was here).  The residents handle much of the pre and postop work.  Our role in the clinic, much like on rounds, is more supervisory.  This relaxed pace, though nice in some ways, served to unmask how truly tired I was.  I went back to the house for a fifteen minute nap and wound up taking 10 of them in unbroken succession.  Hopefully it will translate into a resurgent work ethic in the coming days as the workload is expected to increase.  

Rounds were much shorter (and more organized) than I remember them being the last time I was here.  The surgical load was to be light for a Monday - just a few scheduled cases.  We started in the ICU (no one was bagging themselves this time through) and saw a trauma admission from the night before - a man hit by and then run over by a car - he had stable pelvic fractures, a proximal tib-fib fracture (he had already been put in traction), hematuria, and generalized abdominal pain.  We performed a bedside ultrasound and it seemed that the foley catheter balloon wasn't necessarily in the bladder, though the catheter itself clearly was.  There was no free fluid in the belly, but we were rightfully suspicious for a traumatic bladder rupture.  Short on other diagnostic means (no CT scanner, only barium available for cystography), we decided on laparotomy - suspicions would be confirmed and Daniel, the 3rd year resident, completed a nice two layer repair.  In the afternoon, it was mostly dressing changes on skin graft patients.

The girls were a bit crabby today, but on the whole did quite well.  They took a walk around town with Wendy and Becca Gray - Tessa said that was her favorite part of the day.  As expected, Tessa dove right into the Ethiopian food while Emma picked at it.  Dinner was a bit more western and Emma managed to make up for her lean lunch.  The girls are in bed now (again, not necessarily sleeping, but at least pretending that it is possible).  I'll be heading to mine soon enough.   We expect tomorrow to be a but busier for today - hopefully we'll all be through the jetlag by then.

A Honky on the Horn of Africa - in Soddo at last

A Honky on the Horn of Africa - in Soddo at last.

We've finally arrived.  The girls are finally nodding off  (even though it's only about 1:00pm Wisconsin time) after nearly 48hours of constant travel.  I will take advantage of the jetlag and stay up a bit to post this and update all who are following along.  I'll link to it on face book.  Disclaimers are that blogspot is technically blocked in Ethiopia - I'll have to post via e-mail, so I don't think pictures can be uploaded.  I'll try to post some pics to Facebook, but it looks like internet speed may be a limiting factor there (it is much faster than two years ago, however).  

The big blessing so far is that the girls did extremely well with the travel.  Thanks to all who offered prayers to this end, but their travel stamina was something to behold.  They got enough rest on the first flight (Chicago to London) to stay fresh - Tessa slept about 5h, Emma about 4.  The London layover (5hours) went faster than we expected, and they ended up sleeping for about 8 hours straight on the 11h flight from London to Addis Ababa via Amman, Jordan.  They didn't even know we were in Jordan.  

We landed in Addis around 2:30am local time, but it took us about 2 hours to clear customs due to haggling over duties on laboratory equipment we were bringing back into the country after some repairs.  The Ethiopian Customs people are quite meticulous, playing everything by the book.  This makes for slow going, but it all worked out well.  The amazing thing was that the girls just played with each other without making much of a peep for the entire two hours.  They just kept putting each other through the x-ray machine while I would give the other one anatomy lessons… just kidding.  They really did do well, though, and we finally made it to the van at around 4:45am.  It was about 20 minutes to the SIM guest house where we sipped some orange Fanta, then laid down for about 5 hours of sleep.  We were to pack up and leave the guest house by about 11:00am so we could do some grocery shopping in Addis before the drive to Soddo.

All that went as planned.  We pulled out of Addis a little after noon and made it to Soddo at 7:00 just after sunset.  This included a scheduled lunch/ potty break in Butajira - the culinary scene along the Addis/ Butajira road have improved substantially since I was last here (so have the toilets).  The girls did get a bit car sick, but only Tessa puked.  She had just sipped some Sprite and eaten a mango, so it really didn't smell that bad.  They slept for about half the drive and really only got whiny towards the very end.  

Had a nice evening settling in and finally meeting our hosts, the Grays.  We've been friends on Facebook, we've talked on the phone, I filled in for Paul on the job two years ago and even lived in their house before it was their house, so it was nice to finally meet them.  I think we're going to enjoy getting to know them a lot more closely over the next two weeks - more on that to come I'm sure.  

Well, I'm going to go and attempt sleep.  If I can manage to nod off, rounds start around 7:00am here (10pm CST).  That is when I will meet the residents, the patients, and find out what surgical adventures await.  Wendy and the girls will likely sleep in, though that gets hard to do here once the sun rises.  Thanks again for all the prayers and well wishes.  Remember, comments on the blog may not get to us since I can't access the site in country.  Best to communicate with us via Facebook.  We might not do much personal emailing as we want to be on the computer constantly when we need to be builing relationships here.  We'll likely stick mostly to group mails and blog posts.   Night all.

On our way

Well, I guess I'll resurrect the blog since we are on our way to Ethiopia again. Not sure if anyone will actually read this, but at least I can look it up later myself.

We left Manitowoc around noon on Friday the 18th and we're already enjoying our layover in London. The girls did remarkably well on the 8 hour flight (Chicago to London). Though we intended for them to sleep the entire flight, benadryl was no match for their excitement, nearly constant beverage service, and Secretariat as the in-flight movie. They did eventually doze off, however, and the girls probably got about 5 hours of sleep - not too bad - I only managed about two, but I'll take anything I can get on a plane. Before we knew it, the lights were back on the flight attendant was handing us a cup of yogurt and a spork for breakfast... still trying to get my mind around that one.

We are now in the airport lounge at Heathrow awaiting a 12:50 departure (I think that's around 7:00am in Wisconsin) for Addis Ababa via Amman. We land at 2:20am Ethiopian time (another three hours ahead of London) - that's when the girls real culture shock will set in. They will be disappointed with the lack of moving sidewalks at the Bole International Airport.

Thanks again to all the well-wishers. Your prayers have made for a smooth journey so far (either that or it is the calm before the storm). We'll keep this posted as often as possible, but I'm not sure when I'll next have internet access.