Time flies...when you're on call every third day :)

Sorry friends. But my time here has ended. I catch a bus in the morning (Tuesday morning) to Niamey. I fly out of Niamey Wednesday night. I reach Tulsa Thursday evening. I won't have internet access after I leave here. I'll blog some more if I get a chance. I still have several stories to tell that I've been thinking about. Since I've been on call every third day and in between hanging out with my friends here (and playing Settlers of Catan) its been a juggling act finding time to blog. But stay tune and I'll write more if I'm able. Good night! :)

The Galmi Church

Since the hospital has been around for 50+ years there is a Christian church in Galmi. The hospital staff is about 75% christian and 25% Muslim. There are several prayer groups that meet in the mornings. There's one for the missionaries. There's also one for the hospital workers (who are mostly all Nigeriens). Fridays they meet all together. Dr. Sanoussi meets with the surgery team in the morning and prays with them. The medicine physicians and nurses meet first thing in the morning to pray. In Galmi there are two Christian churches side-by-side. They started as one, but then split years ago about something or another. Now they have a good relationship with each other. I've gone to each so far. They're pretty much the same format and everything. One family even has the husband go to one church and the wife to the other. In both churches Men sit in one aisle, women sit in one aisle, and children sit in the middle aisle by age group. They start by singing all together. Then different "choir groups" each take turns singing songs. Kinda like a sing off :) All the songs are in Hausa. Basically the groups are the men, the women, the children and then a co-ed 20-30 yo group. Then they have the offering, and sometimes they all dance and sing their way up to the offering plate. Then they might have a couple different people speak. They'll often times translate the sermon into French (so it takes twice as long). Church usually starts on time at 9a on Sundays and often runs til 12p or later. The missionaries at the compound usually attend one of the village churches if they're not working and then they also have their own service Sunday evenings for about an hour. They also have bible class Wednesday evenings. The church is growing in Galmi, and the current effort is towards training up spiritual leaders. In the hospital there is a local man employed as an evangelist. He goes around and prays with the patients. Also sometimes the physicians will send patients especially to go talk with him. Especially, ones recently/newly diagnosed with terminal cancer.

Infectious Disease in Galmi

At Galmi a number of infectious diseases are pretty common, depending on the time of year. The rainy season is due to start in July through August/September, and with it bring malaria. Currently 30+% of the hospital patients probably have a malaria, but there will be more patients and they’ll be sicker then. Most of the year is typhoid season, except right now they’re not seeing very much of it. It’s a bacterial infection spread through contaminated water. The bacteria comes through the intestinal tract and then gets into the body through lymphatic tissue lining the gut a several locations called Peyer’s patches. Once in the Peyer’s patches it can spread throughout the body and cause inflammation everywhere. One common surgical issue that comes with it is perforated bowel (meaning a tear/hole in the intestine wall forms). What happens is all the infectious focuses in the Peyer’s patches iniatially and a large amount of the peyer’s patches are located kinda near the appendix at the junction between the colon and ileum. So that bowel gets inflamed/dies and ruptures. The can get multiple holes. Even after the surgeon repairs these holes, the infection is so wide spread that mortality rate is still upto 40%. Here is a picture of a girl who had typhoid two months ago. It’s a wasting disease and you loose a lot of weight. Because of the inflammation of the bowel, holes/passageways can form between the skin or other parts of the body, called fistulas. This girl has a fistula between her bowel and her abdominal skin which is now infected. So stool and pus comes out. She also has one starting to form between her bowel and vaginal, so stool comes out there to. She’s so miserable and her mom wept because there’s nothing to do. She needs improved nourishment and time for her body to heal. Her insides are still so inflamed that any attempted surgery would be disastrous and she would probably die. There’s also a lot of TB here. One of the American doctors said his annual PPD (TB skin test required to be taken by healthcare workers in the US) was positive after working here. I saw a lot TB in India and thought for sure mine would be positive. But I just had it done and its negative. Maybe next year it will be positive. There’s also a lot of HIV/AIDS here. We double glove on every surgery consequently. My hands are going to feel naked when I return to the US and only wear one pair during surgery. There’s also a lot of tetanus. There’s a room back at the end of a long hall way that is quiet for them, because they do better with low stimulation. And they just what it out. We have oxygen here but no ventilator.

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.

Mangos---a joke on America

Personally opinion, but I think mangoes (especially the grafted mangoes from Africa) are the best fruit on the entire planet. They're light years better here than central America. And comparatively, the ones imported to Washington that my mom buys taste like zucchini. I think mangoes are God's gift to the poor who tend to live around the world in areas where mango's grow. They're a funny fruit. They're in season about one month a year or less. There's also way to many when they come. And they don't export well. Which means, despite all the money in America, most Americans will probably never have the privilege of rich and flavorful mangoes. [currently my freezer is full of frozen mango chunks that I can suck on like Popsicles :)]

Xray of Chronic Osteomyelitis

Broken bones + Traditional Medicine = Disaster

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A tragedy commonly seen here relates to broken bones. After breaking bones, patients unfortunately go to traditional doctors first. The “treatment” from these traditional doctors often result in either the blood supply to be cut of to the surrounding tissue, misalignment, or severe infection from manura applied over open wounds where the broken bone sticks out through the skin. The patients then finally come to the hospital long after ideal. The people then unfortunately are crippled or loose limbs that they shouldn’t have had to if they’d come to the hospital immediately. One story is of a 38 year old man who had dislocated his right knee several weeks ago. It was “reduced” (put back into place) inappropriately by a traditional doctor resulting in compression on the blood vessels and nerves to his lower right leg. By the time he came to the hospital the tissue (bone, muscle, and skin) of his lower leg was dead and dieing and he needed an amputation. Dead tissue allows bacteria to come into the body and grow. The infection can get into the blood and cause the patient to be “septic” (meaning infection of the whole body which people even in the US have a 50% chance of dieing from. Here obviously the chances are even higher because of the limited resources in the hospital). The man refused amputation for 3 days. The day after the amputation he died of sepsis (whole body infection). A lot of what the doctors fight here is lack of education. They’re slowly making a change one patient at a time, educating as they’re able but the people are plentiful and the physicians are already so overworked. We saw one girl in the OPD (out patient department. Kind of like a clinic/ER. All the possible surgical patients are sent to the surgical part of the OPD to be seen by one of the surgeons). She’d broken her ankle a while ago. But the skin around the outside seemed to be breaking down and have fistulas (passageways in the tissue formed by the body so that pus from the bone can drain out to the skin). Sometimes because of the traditional treatment with inappropriate splitting or misalignment chronic osteomylitis (bone infection) often times would form. Or if part of the bone (sequestrant) completely broke of f from the rest and never grew back together, it wouldn’t have a blood supply, so would die and get infected. This infection: chronic osteomylitis would eventually have so much pus form that it would create fistulas that would drain the pus. (See posted picture of this girls xray). The treatment for chronic osteomylitis in this resource limited setting is antibiotics orally (by mouth). If there was a sequestrant then the surgeons would do surgery and remove the rotten chipped off piece of bone. This is so common here due to their cultural beliefs/ treatments. We probably saw 5+ new cases in a half day.