Things are perhaps quieting down a bit with work. This was our last week of “class” – in fact on Thursday, all we did was a bit of review. Next Thursday will be the first written exam, and the following week two orals and another written – leaving us one last week for just working in OR, and being able to do it in a bit more relaxed atmosphere – we hope! My job now is to just let the students go! They are not perfect by any means, but they have to take responsibility themselves now, and learn from their own mistakes. I think they will do ok. Mark and Annemarie left last Saturday, along with a visiting ENT surgeon who had only been here for 3 days. She is someone however who has been coming to Cameroon for several years; I had met her last year too, and it was a pleasure to have a brief visit with her again. So that was several good friends gone, all at once. I am now the only expat living up at this end of the compound. The regular American surgeon has gone to Kenya for 2 weeks. We do have a visiting plastic surgeon here from South Africa, but his type of cases are quite limited. So that left us last week with our orthopedic surgeon, the eye people, and the surgical chief resident to get through the work load. I wouldn’t say it was very organized – but we did get quite a few patients looked after.
We had one very interesting girl come to be seen – a 13 year old who had had noma at age 2. Noma is a terrible affliction, related to malnutrition, in which infection gets started in the mouth and spreads very rapidly, over hours to a few days, destroying all the tissue around the area, and leaving a gaping hole in the face around the mouth and nose. We saw it quite often in Niger where malnutrition is so common, but I have never seen anything like this here. The child survived but has a large scar between mouth and nose, and could barely open her mouth – only enough to stuff food in at the corner and work it back between her teeth. We are so limited in our equipment, and our challenge was whether we could actually get a tube into her trachea in order to anaesthetize her. We tried what we could with her sedated but still semi-awake – and concluded that a tracheostomy would be the only choice that would work. In the end, the visiting surgeon consulted with a maxillo-facial surgeon who works on the Mercy ship where many of these patients are cared for – and they decided that this child could not be helped here. I felt quite sad that they had to be sent away. Our visitor surgeon spends quite a bit of each year on the Mercy ship. This is an ingenious idea: the ship is a fully equipped hospital, with lab, even a CT scanner, about 90 beds, and 6 theatres. It stays in port off the coast of West Africa (it has been off Benin most recently) for up to 10 months, while only elective cases are done. This allows time for follow-up and dealing with any complications. Emergency cases are referred to local hospitals – or sometimes the ship doctors (all volunteers) go to those hospitals to help with the surgery. Unfortunately Benin is a long way from here – so there was no way to get our little girl there for care.
Little Rikki, the small girl who had swallowed the caustic soda, is persevering, but still has a long way to go to be healthy and strong. She got very puffy last week, probably from her long period of lack of nutrition. She is the dearest little girl, but just sits or lies on her bed, rarely smiles, and looks exhausted, which I’m sure she is. She will wave to me when I come in the ward and wave at her – and sits and nods as I talk to her (she only understands French and I am talking English) – but she badly needs fattening up to give her some energy and joie de vivre again.
A tiny Fulani baby from far up north, Soudamatou, came a week ago, over 2months old, and weighing just over 2 kg. She had a mass on her neck (probably a cystic hygroma) at birth but was able to feed. After a month or so, her family took her to Yaounde where surgery was done, leaving her no longer able to feed - and so she was wasting away, with a tiny tube down her nose to her stomach for feeding of diluted powdered milk. Her chest was terrible, her airway looked difficult, and the surgery had left a draining sinus on her neck. We decided the only safe thing we could do was sedate her and put a tube through her abdominal wall to her stomach to allow better feeding, and to stop feeds going partially into her lungs. She is gaining a bit of weight now that she is being fed through the tube into her stomach. She has the biggest brown eyes, and a sort of chronically pained look on her little face. But what a little fighter she is, for such a tiny person (now a little over 3 kg) – one can only hope she makes it, just on attitude alone! Her mother and sister (about 9 or 10 years) speak a language that nobody here can understand, so all we can say to each other is “Sannu” (the Fulani / Hausa greeting) – but you can say a fair bit with smiles and charades!
Last Sunday was the graduation of the “Bible training course for pastors / church leaders” that is taught by the pastor of Mbingo 1 church. This is the 4th class to do the 16 month course – 400 hours of class time with another 250 hours of assignments – and the 17 graduates included many hospital administrative people and other staff. They all said how intense it has been, and I can only marvel that they managed to do it, and carry on their heavy duties at work as well. The service was very good, and I enjoyed it a lot since this year I know so many of the people involved. Afterward there were the compulsory photos out on the lawn, and greetings. My friend Clariss (the mother of little Philemon) had asked me to take photos for her, so I had responsibilities besides just greeting. Then there were celebrations at the homes of each of the graduates. I only got to 3 homes – the grads lived over a spread-out area, and of course almost all of us are traveling on our feet only – but it was lots of fun. Food at each place, music and dancing. It was a very happy day! And thankfully, it was the one day in a few weeks when we did not have rain until about 6pm – so we were able to be outside without getting soaked!
We did some interesting things in OR this week with our visiting surgeon who is not only trained for general but also for thoracic surgery. Because we have such limited monitoring for our anaesthesia, and no postop care except on the general ward, not much chest surgery gets done here. But this week was a bit different.
We spent one whole day on table 1 operating on a 3 year old girl, Rikki, who had swallowed caustic soda 10 weeks ago, and completely scarred shut her esophagus. She had wasted away badly, and desperately needed something done. So Mark took out her esophagus, and pulled her stomach up into her chest as a replacement. This involved both an abdominal incision and a chest incision – and hours of careful dissection of all the terrible scarring caused by the lye in both her abdomen and her chest. It was one of those cases where it is real nice to be able to trust your surgeon, as there were a multitude of potential disasters – none of which happened. It is amazing that we can do this with our very basic anaesthetic setup – I have done these surgeries at home, and we use EVERYTHING to care for the patient intraop! Rikki is now 4 days postop and drinking a little, and although she is still having a lot of pain, she is looking not too bad.
We have also had 2 patients in the last couple of weeks with tumours of the chest wall and ribs – and Mark has removed those. And Friday afternoon he operated for several hours on a 12 year old girl who probably had acute appendicitis at age 7, not treated, and developed an abscess in her abdomen. Subsequently she has had 3 surgeries on her abdomen – and came to us with a fistula between her bowel and her abdominal wall. She had absolutely terrible scarring inside her abdomen – too much to ever take down – and even once the fistula areas were taken out, it was almost impossible to close her abdominal wall. Today I went in to see how she was. Mark had ordered morphine every 4 hours for her – but obviously the nurse who looked at the orders did not understand how he had written it – and that child had had NO pain relief postop, for 2 days. And what was her complaint?? That she was not allowed to drink. Oh my goodness – these people are tough as nails. And the fact that she was not getting pain relief did not register with any nurse, so a doctor would be asked about it?? Who knows. Maybe the nurses DID give morphine, even if they did not see an order they understood. Often they give it and don’t chart it. It is the sort of thing that makes western doctors tear their hair. But as I say, the little girl was only thinking about her longing to take water and food – I’m sure she was dreaming about fufu.
We recently had a visiting urologist from US – a man who has been here several times over the last few years. This time he brought a scope setup worth – hang on here – a million dollars US. This is not the first fancy equipment brought to Mbingo by any means. Someone brought out echocardiography equipment since I have been here – and we have a high quality endoscopy setup. But on the other hand, the OR does not have a glucometer, something every diabetic in North America has as his own (and I am not sure there is a functioning one on any ward here), we are about to run out of spinal bupivacaine which we use on a daily basis for spinals for longer procedures – we would do a minimum of 3 or 4 of these every day; and we can only give oxygen to 9 patients at a time (in a 200+ bed hospital) because we do not have more oxygen concentrators (and compressed oxygen is too hard to transport and too costly to buy). The one million dollar gift was announced one morning in chapel, and here is the saddest little commentary on it that I heard: a man who has almost no fingers left, because of leprosy when he was a child, runs the hospital library. He commented to me that with “the container” coming with this enormous gift, he was sure there would be included some new books for his library. He has not seen the million dollar gift – but it sits in 2 large cardboard boxes, the size of very small refrigerators, in the OR. All one can say is that sometimes the west and Africa just don’t get it together real well!
There was a family from near home here for 2 weeks, with 3 children. What a nice treat to have people of my own tribe around! The parents had both lived in Cameroon with missionary parents in their early childhood, the mom here at Mbingo – so it was so much fun to watch her introduce her own youngsters to life in Africa. I’m sorry they were not here longterm.
It just rains and rains. Any sign of the sun is a source of excitement. Yesterday we had 4 cm rain in less than 2 hours. Today has just been cloudy and cool and foggy – we are often right in the clouds here at Mbingo. Only 4 more months of rainy season!! At least it is very green – today it made me think of the Swiss Alps, looking at the green steep hills with houses and fields, under the low-lying cloud.
This was the week of the project defense – and it’s finally OVER! We are all very, very relieved. Those things have been a huge amount of work. Final exams seem small stuff by comparison. Just 6 weeks and my students will be finished and going on holiday before beginning their internship.
Thursday there was one student after another into my house to practice another time or two through their presentations with the power point on my computer. The defense is very formal, although we tried to tone it down compared to what the school normally does. The jury consisted of the director of the school who traveled down from Banso, John as head of anaesthesia, me as the trainer, and Mark who is our visiting surgeon and acted as external examiner. The students came in one at a time, and had 12 minutes to present their project and results, and then were asked questions. Another official from the school also came, and the spouses and one friend of the students made up the rest of the audience. Every student did a very good job, so I think it was a successful finale to the projects.
Once OR finished Friday afternoon, everyone came to my house for fufu (we bought it in the market for 15 people for under $20 which is my idea of good entertaining).
On July 1, I made some posters for OR and tried to decorate a bit – and ordered puffpuffs which are about the closest thing here to Tim Horton’s donuts. I put up some little memo sheets with “I love (as a maple leaf) Canada” at the top – and most of the OR guys signed them for me – what a sweet bunch. For the defense day, my students were all spiffed up in their “uniforms” (white lab coats) with their Canadian flag pins on their collars! It is appropriate, as the financing to get them through this year came from Canadians – so the Canada-Cameroon bond has been strengthened.
It is raining and raining and raining. We will apparently normally get 30 inches in July alone – and August is no better. The clouds come in and hang right down over the hills, and we often have fog. Humidity is over 80% and mold is growing on everything – I took my leather sandals out of the closet (which I always leave open for air) and they were covered with white fuzzy mold. When the sun does come out though (as it did for the whole of yesterday morning), it is absolutely beautiful – green like Ireland, or like the Scottish highlands. For a prairie person though, this is really a bit of an endurance test!
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