Surgery in Galmi

My time in Galmi has been such a blessing but so challenging. My daily prayer is that when the people see me they only see Christ and that God is glorified by me being here. What I do know is that by being here God's begun the training I need on how to work in a resource limited hospital. There are two surgeons here that I'm working with: Dr. Starke and Dr. Sanoussi. there's a third but she went home to Switzerland on a year furlough. Dr. Starke went to ORU Medical school with several of my attendings (the word we use for supervising board certified physicians with in a residency program who help train the residents, who are techniquely doctors, but not yet board certified): Dr. Duininck, Dr. Powell, Dr. Rylander, and Dr. Boyles. He providentially has completed a fellowship in oncology surgery. One of the big things about working in a resource limited hospital as a surgeon is that most of your days are spent doing emergency surgeries. there's rarely or limited time for "elective" surgeries (ie ones that would be helpful or cosmetic, but wouldn't neccessarily make you live longer or keep you from dieing). Alot of the outpt clinic the surgeons do here involves choosing not to do surgery on patients with end stage cancers, and just giving them pain medicines instead. There's chemotherapy available here but no radiation, which limits their ability to put cancer into remission here. Since being here I've see so much cancer. Dr. Starke thinks alot has to do with malnourishment. Part also has to do with neglect, or they go to traditional doctors first and then come after its pretty far along. I've seen so many huge fungating breast cancer mass. Parotid cancer, jaw cancer,coloncancer. Burkettes tumors. We ressected (ie cut out) a huge kidney tumor about the size of a soccer ball out of a tinny 8 year old boy (was full of cysts, so Dr. Starke didn't think it was Wilms tumor but wasn't sure). I also so a huge osteosarcoma on a 26 year old man. Do to the resource limited state of the hospital, first he'll try to figure out what type of cancer it is. He'll biopsy if he needs to. Then if its not a type that tends to be malignant and spread to the whole body then hell just cut it out. Burkettes tumor responds well to chemo, so they'll be started on chemotherapy. If it is a type that can spread (such as breast or colon or the osteosarcoma) then we'll stage it (crudely). "To stage" in cancer words means that depending on the type of cancer you can figure out if you can treat it just by cutting it out, or if chemo and/or radiation are needed or if its too late and its already spread through out the body and like a thoroughly rotten fruit there's nothing you can do (ie. if you cut off all the "bad spots" there'd be nothing left). Usually a cancer will spread within the tissue/organ it starts. Then some will go to the blood vessel and then to the whole body. others to the lymph nodes and then to the whole body. the cancer gets to other organs via either the lymphatic vessels or the blood vessels. Different organs travel to different organs characteristically based on where the blood vessels/ lymphatic vessels go next. Usually once you find it spread to another organ than the fight is pretty much futile if you're trying to extend that persons life time substantially or if you want to "cure' them. In the states staging is done with CT scans or MRI's of brain, liver, chest to see if its spread to other organs (depending on the type of cancer and where it usually spreads). Sometimes they use PET scans which basically makes the parts of the body consuming lots of glucose (ie energy) light up. These are usually the heart, some other organs, and the cancer (especially if its a rapidly growing cancer). Here we use ultrasound for looking at the liver for obvious metastases [ie cancer in other organs] (ultra sound is the one diagnostic test that is free and readily available. there's an ultrasound in the out patient clinic and several in the hospital. as long as the physician knows how to and is able to use it, then there are endless possibilities for the diagnostic use of the ultrasound.) This is sometimes difficult because sometimes its difficult to distiguish cancer tissue from normal tissue. Ultrasound creates a picture of reflected sound waves. Different colors are based on the density of the tissue. Water is black because the sound waves travel very easily through water. Thats why when you're at a lake you can hear the people on the opposite shore or out on a boat talking as if they were standing right next to you. Bone is white because it stops the sound wave. We then do a chest xray looking for cancer spread to the lungs. If we find evidence of cancer spread anywhere, then we send them home with pain medicine. Its hard, especially with the huge masses, but a surgery to make the mass less big would take many many hours, wouldn't change how long the patient lived for, and would take some of the surgeons precious time that could be doing one of the numerous life saving operations they perform. The second surgeon I'm working with is Dr. Sanoussi. He's from the Galmi area originally. He went abroad for medical school and surgerical training. None exists within NIger. He also completed additional training in urology, which again has ended up being a huge blessing. Another huge surgical issue we see here is urology, primarily male patients. We see a lot of bladder stones in little boys, so probably do one to two bladder stone removal surgeries a day. There's also a lot of "urinary retention" (meaning, in ability to urinate). The most common causes are urinary strictures (scarring of the urethra [i.e. the tube that takes the urine from the bladder, down the penis and out the body] which tighten and block off the passage way so urine can't leave the body) and enlarged prostate (BPH). The strictures are do to old inflammation from either STD's or schitzosomiasis (a parasite that affects the bladder and urinary track. It lives in lakes/ponds/stagnent water. its spread oral-fecally; its super common here because many people around here don't purify/filter their drinking water). The treatment for the strictures is placement of a suprapubic catheter (a urinary catheter through the lower abdomen into the bladder) and sometimes a bougie (metal rods of various thicknesses. you start with skinny ones and use fatter and fatter ones to dilate the urethra). The treatment here for BPH is prostatectomy, which we usually do one a day. In the states that's not true, because we have really good medicines available. In Galmi if you're not a surgical candidate (since BPH tends to be more common in old men who would die if you took them to surgery) they we given them some of the weaker BPH medicines used in the states which are available here. My schedule (roughly) currently on weekdays has been surgical rounds in the morning. Then OR for the rest of the morning. Then out patient surgical clinic from 3:00 til 6 or 7:00 or when ever it finishes. I'm on medicine and surgical call every third day. Medicine i'm now one by my self (Saturday was my first day mostly on my one. It's hard because diagnostic tools are limited as are medicines. Follow up is bad. So we end up keeping a lot of people to keep an eye on them.). Surgical call I'm on with one of the surgeons. The days I'm not one surgical or medicine call, who ever is on OB call has been calling me in to do c-sections with them. Today Dr. Phlaum was on and she called me in for a Ruptured uterus [Sometimes the women labor so long in the villages, and a lot of them try to have home deliveries, so their uterus tear open a lot more easily than in the states. We learn about ruptured uteruses in the us but I've never seen it there. Dr. Phlaum also thinks Ruptured uteruses are so common her because the women are so malnourished and also have so many pregnancies. this lady looked young 20's. this was her 7th pregnancy. She had 3 living children, which is about average as far as statistics go here. During a ruptured uterus the baby is expelled out of the uterus into the abdominal cavity and dies there. This baby was already dead by the time she came.] Sundays we go to church in the village in the morning and then the missionaries have church in the evening in English as well. The local languages spoken here are Hausa (which is the second most commonly spoken African language in Africa. Second to Swahelee) and French.