Medical Post #1—Returning "Home"

Any surgeon who has traveled halfway across the world (should) anticipate that he will be challenged in many ways.  Whether he finds himself in Europe, Asia, or Africa, the obsessive, detail-oriented surgeon will suddenly find that all the familiarity of his home operating room is gone.  That favorite suture, the scrub techs who have the procedure memorized, or the specially ordered equipment.  This is nothing specific to working in a LMIC (Low and Middle Income Country) setting—it’s just part of working in a new environment.

More so then when I was here as a resident (2008-2009), now that I am an attending (consultant), I find accommodating to those details to be my greatest challenge.  Yet, it is also a lot of fun at times to find creative solutions.

The biggest help during this whole process has without doubt been the PAACS residents that I work with (Pan-African Academy of Christian Surgeons).  When we were last here this was a fledgling general surgery residency with only two residents.  One of these is now faculty here, Dr. Agneta Odera, a future pediatric surgeon awaiting further training.  Now the program is at full capacity with fourteen high-quality surgical residents.

The PAACS residents are impressive because not only are they capable technically in the operating room, they are also quite knowledgeable on the wards.  But this is not just in the narrow scope of general surgery that we know in the United States, but also in the fields of urology, neurosurgery, orthopedic surgery, and plastic surgery.  When you’re training to be the only surgeon in a remote, underserved area, you can’t rely on a specialist to be of any assistance!

Most of all, I have been impressed by their commitment to serving the Lord with their gifts.  They are training to be servants in tremendously underserved regions of Africa.  And they do so with the desire to share the love of Christ with others.

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Personally, it has been returning to my training as an adult general surgeon that has been both refreshing and challenging all at once.  I have done my first trauma splenectomy in years, honed my skills with thyroidectomies, rounded on a few ruptured AAA’s who were status post repair, burns and wounds of all ages, and refreshed my knowledge of acute limb ischemia and open revascularization techniques.  I have really enjoyed this time of re-expanding my care to patients of all ages.

From a pediatric surgical standpoint, this week has been about undescended testicles (4, 7, and 14 years old).  And to any pediatrician or pediatric surgeon, those ages would seem quite old for an orchidopexy for an undescended testicle.  This is reflective of what I perceive to be one of the greatest surgical public health issues in this region—delayed presentation.  Not limited to the pediatric population, diseases usually present end-stage, well along their course, or after many years of suffering.

My other cases have included a neonate and a pre-schooler with probable Hirschsprung’s Disease.  This led to my performing my first contrast enema—something I normally write an order for (or tell my resident to write for!) and then follow up with our pediatric radiologist.

It is exciting to see a pediatric surgical practice here that is both active and alive thanks to the devotion of the full-time general surgeons here, but also growing and with tremendous potential to rapidly expand.

Kenya Hospice and Palliative Care Association Conference

I am attending the 1st KEHPCA (Kenya Hospice and Palliative Care Association Conference) Conference in Nairobi today and tomorrow. It has been really remarkable to see how far Kenya has progressed with regard to palliative care in just two decades. Considering how often I diagnose patients with terminal cancer, this is particularly important to me. Not only does Tenwek have a very successful hospice program, other tools are readily available for clinicians. I can easily dispense liquid morphine, refer patients to our own hospice, or get the assistance of our cancer chaplain, Elijah Bii. But though there is much to rejoice in, I also have daily seen the lack of end of life care available to those in Kenya. This conference has highlighted those needs. I am grateful that our hospice and endoscopy teams have the opportunity to be a part of this conference that we might be able to encourage and support our own people who have terminal illnesses.

I think that I'm learning more from them!

Well, it's been a long time since I've blogged. The last few months have been fairly steady at the hospital, so sometimes it's easy to get complacent and think that there's nothing to share! Well, here are some highlights since I last blogged in July.


Who's Going through the Trial?

Last month I quickly flipped through the chart of a 60-year-old lady with stomach cancer. She had a referral letter from an oncologist in Nairobi asking us to examine her for any residual cancer after completing chemotherapy. A quick endoscopic examination showed her stomach to be full of residual tumor. I didn't know what to tell her. Here was the rare patient who had gone all the way to Nairobi for aggressive care, and I was going to have to share that it had failed.

As usual, I asked "unaelewa kingereza?" (do you speak English?). Surprisingly, she did. She had a smile on her face as I began to share what I had found, and before I had talked long she interrupted me. "I do not want any more treatment for this cancer. God knows the plans he has for me, and I have no fear." She was completely confident that the Lord would walk down this path with her and be her strength.

This last week I saw her again to share with her the biopsy results. The results showed ongoing stomach cancer. With the same strength she reminded me of her unwavering faith. And then she added: "I lead a group of ladies in my church, and the Lord is using this to encourage and strengthen them. I do not fear this cancer."

She witnessed to me that day. The Lord provides all the strength that we need for the trials that we will face.


Cancer Chaplain

One of the challenges of working in the Tenwek Endoscopy suite is the tremendous volume of patients with cancer. Dealing with a high volume is difficult enough, but when the next patient is being brought in the room as you're trying to explain to the last one that "yes, you're 30, but you have end stage esophageal cancer"-that's tough! And it really doesn't allow for much opportunity to encourage, counsel, or witness.

That's where Elijah Bii, our head chaplain, has been a blessing. When I arrived in May, Dr. White and I talked about this great need, and over the last few months we've been able to move Pastor Bii so that his primary duty is now ministering to patients throughout the hospital with cancer (the majority of whom are diagnosed in the endoscopy suite). He is well qualified not only because is nearly completed with a degree in professional counseling, but he is also a gentle, patient, and kind man who has a soothing spirit about him. There have been many times lately where I will share the tragic news of cancer, and I find that Pastor Bii will often spend an hour counseling and encouraging the patient and his family.



MPH / Research

This week I started phase two of my time here at Tenwek. The first few months I've been heavily invested in the clinical work in the endoscopy suite. While permitting me to amass very large numbers of cases and quite a bit of experience I won't see in the States, it has not allowed me as much time for research.

Fortunately, we did some schedule rearranging, and I'm now able to spend several days a week entirely devoted to esophageal cancer research. In addition, Sonja Dawsey, a recent college graduate, arrived from the States and is going to spend eight months working with us here. Her arrival will provide a nice injection of energy, enthusiasm, and just an extra pair of hands to get things done!