Saying Ciao to Soddo

Packing up and saying Ciao (you might want to grab a cup of coffee)

This will likely be my last post from Soddo. We are packing up the bags for the 5h drive to Addis tomorrow morning (hopefully free of any mango-vomit this time). We just had a wonderful evening of fellowship (including food) on Harry's lapa (grass-thatch patio that is essentially public property), even though Harry is already in Addis awaiting us. Most the foreigners (ferengi) in Soddo who have any sort of affiliation with the hospital were there. This included long-term servants like the Grays, the Karnes (OB-Gyn from Muskegon, MI), Stephanie (Hail, another OB from MI), Sophie & Angela (do-everything nurses from Idaho & Illinois) as well as short termers like ourselves, John, Will (a urologist who just arrived yesterday from Muskegon, here for 2 weeks), Luke & Christina (IM-Peds resident and ICU nurse from Rochester, NY who have been here for a couple of months), and others whose roles I still haven't quite pinned down (not everyone is working within the confines of the hospital compound). As you can imagine, the conversation is incredible and wanders all over the place. We had a Mexican buffet (including multiple renditions of home-made guacamole and salsa), then coffee and smores for dessert. We could have stayed for hours longer if we didn't need to pack. Though we miss our friends and loved ones (not that we don't love our friends) at home, we have not struggled with loneliness on this trip.

Earlier in the day (Thursday), John and I enjoyed our last operative day on site. What at first appeared to be a slow day, actually became quite busy. I started out in the burn room changing dressings and getting one last look at how the wounds and skin grafts are healing. It is a mixed picture for sure – some things getting better, some sites stalling or getting worse, even on the same patient. We struggle with infection due to a lack of adequate topical antibiotics (thanks to Greg and Jerel in the HFM pharmacy, this will soon be remedied – thanks guys). The infection causes skin grafts to fail and stalls more shallow burns from healing as quickly as they otherwise would. Burns also require good nutrition to heal, and we are in a country who's name is synonymous with malnutrition. In spite of these barriers, things seem to be progressing overall in the right direction. I am left with the faces of some of these patients seared into my memory... there is the young epileptic girl, unable to afford her seizure meds, who convulsed while boiling water on the stove – she burnt ~14% of her body surface area, including parts of her face, both arms, and both legs. Her hair was shaved when we found her to have headlice. Most notable are her eyes – they constantly give a look of sobering resignation made only worse by the haze of mild sedatives (required for her wound care) and anticonvulsants. I pray she has brighter days ahead (her wounds will ultimately heal qutie well with the care she is receiving), though the reality is that she will at some point find herself unable to afford her medicines once again.

There is also the resolute face of the father who rescued his children from his burning home. Though they escaped unscathed, he suffered extensive (though shallow) burns to his head and face. At first, it did not appear to be all that severe, but as we first washed his head, most the skin came off even with gentle wiping. His eyes were spared, giving him the look of a pink racoon. Thankfully, we could see the hair follicles still intact all over his scalp – this meas the burn is superficial (akin to an open blister) – if we can hold off infection, it should heal without the need for skin grafting and without marked disfigurement (though his complexion will be permanently changed).

After burn care, I proceeded to do a hernia repair (Segni, the intern, really did the whole thing quite well and I just assisted. I think he will be a bright spot here in the training program in future years). I also did a startling case on a 10 year old boy who had a bleeding rectal polyp. Those in medicine will know that 10 year olds have no business having rectal polyps or even hemorrhoids for that matter (shoot, with all the lentils, beans, hot peppers, parasites, and whole grains they eat, no one in Ethiopia has any business having hemorrhoids). Once under anesthesia, a more thorough exam revealed that he had innumerable polyps – a condition known as Familial Adenomatous Polyposis (FAP for short). He will need to have his entire colon, rectum, and anus removed (this will require a permanent ostomy here in Ethiopia) or he is guaranteed to develop colon cancer at a young age (he would likely get it before age 20 given the extent of his disease). Though his survivial with surgery should be excellent, the need for a permanent ileostomy is a bitter pill to swallow in rural Ethiopia. Most people with ostomies must manage them with a combination of rubber bands and plastic grocery sacks – it can lead to social ostricism merely because of the leakage and odor.

After this, I staffed clinic with the residents. We saw everything from urinary retention (a lot of big prostates here in Soddo), thyroid nodules and goiters, hernias, to elderly people (here that means 50's or 60's) with difficulty swallowing. I did an upper endoscopy on one lady and found a nearly obstructing stomach cancer. She is already emaciated and anemic. The tumor can be felt when I press on her abdomen and it is quite unlikely to be resectable. She will have an operation to bypass the blockage, but will likely not survive the year.

Her case brings up the sad reality that we are unable to "save" many of the patients that come to us. In a country this vast with such poor infrastructure, low per-capita health spending, and lack of screening initiatives, most cancers present when they are quite advanced and, barring a miracle, incurable. We do what we can (or must) surgically to alleviate symptoms and to allow patients to return home and die in peace with their families. Even today on rounds we talked and prayed extensively with three people with terminal malignancies, helping them make arrangements to go home. This point is reached much sooner here, as the patients are quite reluctant to consume their meager remaining financial resources on end of life care when their families could instead use it to feed those who will keep on living. I was impressed by the bravery with which these patients receive their news and direct their concern towards their families, barely shedding a tear for themselves. In each scenario, Paul and the residents have gentle but direct conversations with them and their families concerning the spiritual realities of their situation. The gospel is laid out in plain terms and time is taken to make sure that people understand what they are being told. No one is forced to make decisions they are not interested in, but nothing brings one's standing with God to the forefront like being confronted with a terminal diagnosis in rural Southern Ethiopia.

After work, John and I were able to pull Paul away and take him to the FantaVision for one last round (or three) of machiatos. We talked about many things, including our potential future here in Soddo. There are to be two new full-time general surgeons starting over the course of the next year, which will leave much less of a need for us to fill. Though I'm sure there will still be opportunities, they will be less often and will come about less predictably. I do hope I can return, though, as I'm really getting to like this place and its people (both native and expat) for so many reasons. It will be hard to leave tomorrow.

Before the party, John and I managed to walk our loop around upper Soddo one more time, pausing to take in the beautiful scene over the valley as the sun was setting – mountains beyond mountains as far as the haze would let one see. My camera lens had malfunctioned earlier in the day, so I am left only with the pictures in my mind. I guess I'll have to come back anyways.

Tuesdays cases had been somewhat similar in nature, but I did manage to do a laparoscopic gallbladder case with the hodge-podge of equipment that Paul has been able to assemble. It was one of the more difficult ones I've done, both because equipment failures/ limitations and also because the gallbladder was quite diseased. I was teaching Segni to run a camera for the first time also, but he did quite well with it. When I had gotten back to the house, Wendy was still away on her rural clinic adventure, so I picked the kids up from Becca and we played around in the yard and kicked a soccer ball with Nathan.

Wednesday was a national holiday, so we didn't do much medically. We rounded, and did some burn care, but then I went and joined Wendy and the girls for a field trip to see the work of the Mossy Foot program. Mossy Foot, also known as podoconiosis, is a common condition in Ethiopia caused by walking around barefoot for too long. The feet absorb the fine silica particles, which eventually clog up the lymphatic system and cause a sort of elephantiasis of the lower legs and feet. The feet swell terribly and develop thickened skin and painful nodules. They then develop infections in the crevices between the nodules. Many of the patients become bedridden because of it (usually the women). The men who continue to work the fields in spite of it often develop infections so severe they are fatal. It is sad that this disease can be entirely prevented simply with footwear (even flip flops will do). Once it has developed, it is a chronic condition that requires much in the way of hygiene and specialized footwear to manage.

The Mossy Foot program, however, was a true joy to behold. This is public health work at its finest. They had 15 rural clinics each with two staff. There, they wash feet all day and teach the patients to do the same. They wrap those with swelling with tight wraps to reduce the edema. They care for open wounds and treat the infections. They have a staff of cobblers who make specialized shoes for the swollen and fragile feet. The people are ministered to emotionally and spiritually as well. We then got to visit a group of women who have all had marked improvement in their condition – the swelling is minimal, their wounds are healed, and they are able to venture out again. These women are being awarded "micro-loans" of ~$25-50 USD with which they will start small businesses in their village – either baking and selling injerra or running a fruit stand. Most are able to pay the interest free loans back in less than a year and thereafter they are much more self sufficient.

After this, we went to an even more remote site where the program is teaming with local village church members to build mud hut housing units for the older women who have been widowed by the disease. The program provides a tin roof, nails, a door, and a window while the local villagers provide the labor. They were having so much fun as they hauled in the water, straw, and dirt and made the mud wall-paste with their feet. The old women were there watching and expressing their gratitude repeatedly.

Emma and Tessa came along on this trip. It was such a blessing for them to witness service at such a basic level. Foot washing, clothing of the naked, housing of the widowed, – it doesn't get much more biblical than that, really. Tessa really seemed to take it all in.

Well, it is now Friday morning (almost 7:00) and the girls are getting up. Our van leaves the grounds in about 2 hours, so I'd better get packing. I thank those who have persisted in reading this blog, even though every post gets longer and longer. As I reflect more and more on the trip, I could keep going I assure you, but out of mercy I won't.

Ciao.

-Matt