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.