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!

Work at Tenwek

Here's the long awaited update! I can't believe that we've been at Tenwek for 39 days now. In just a short time we will have eclipsed the time we spent here in 2005. Wow!

Work at Tenwek

Dr. White and I met the day after we arrived at Tenwek (on a Saturday) and had a great meeting about plans. He left just a few days later for the States and just recently returned after his three-week trip. But, in the meantime I have a much clearer picture about duties, responsibilities, and expectations.

Clinical Duties

During usual circumstances my duty is to report to the endoscopy suite each weekday and perform all of the routine endoscopies. This includes many cases of esophageal cancer a day and the dilation/stenting that goes along with it (see this link and this link about stenting). In 18 days of doing endoscopy (pretty much unsupervised), I have seen 18 cases of esophageal cancer. That's over four times as many as our entire hospital in Lubbock averages in a year. The average age: 54. I've listed the ages just so that you can see how this disease spans an entire lifetime:

16, 24, 35, 36, 38, 43, 45, 51, 55, 60, 60, 61, 64, 69, 76, 77, 78, 80

On Monday I sat with a 24-year-old. I was angry. I shouldn't have to tell a 24-year-old he's going to die soon of cancer.

So far I have done more upper endoscopies than I did all of last year. The guys there are great to work with. Robert is the head nurse, David and Ruben are the other two nurses. Stanley Tonui ("ST") also pops his head in from time to time (more about him later). Robert and David have worked for Dr. White for almost a decade, so they know more than I do in some ways!

I'm also covering surgical cases when I have time or a specific interest. Call is approximately every third or every fourth night. It's home call, and I usually have at least three hours in bed (maybe answering questions from the intern though). I have operated most call nights though at least once. Weekends are interesting because you take both Saturday and Sunday! But, since you are able to go home (in theory) and things are not quite as busy, it's tolerable. Not possible at home, that's for sure!

The other part of my clinical duties is covering when a resident goes on leave or has a day off. Then I help by rounding on the patients, coordinating the wards, etc. I'm basically the chief resident on the service.

Other Schedule Stuff

Like at home we have an educational conference and M&M (though it's quite different). Our educational conference is every Tuesday at 7 a.m., and we take a test and review a chapter in Schwartz, one of the two authoritative surgical texts.

Research

Well, this is primary academic reason I'm here. So, there are some exciting projects that I'll be working on here:

• Case Control Study: In a nutshell, a case control study takes people with a disease and compares them with people without the disease and looks for risk factors. To improve its accuracy, the two groups are often matched for age, gender, tribe, et cetera. We are going to look at a host of factors including diet, living conditions, herbal medication use, disease exposure, and genetics. We aren't expecting a breakthrough as much as a tiny foothold to start climbing our way up! If we can at least know to screen all those over thirty with specific risk factors, that's a great start.

• Follow-up: We have a huge registry of those who have been stented, have been previously screened, and those under the age of 25. So, we have Stanley, our Community Cancer Coordinator (who I mentioned above) out on his piki-piki (motorcycle) going to the different villages and finding these folk and doing follow-up. Stanley ("S.T.") has been a longtime worker in Community Health, so he really knows all the little villages well and how to find people. Already Dr. White's preparing to publish his series of 1,000 stents. That's more than most institutions in the world, let alone one individual.

• Database: Yup, this is where my strengths in computers come in. We have year's worth of patient records that we've kept on every patient that's come through endoscopy. Bob, my predecessor, got it caught up to January 2008. The problem is that it's in Excel, not a very user-friendly way to enter data. In particular it doesn't do much to prevent data entry folk (who typically don't know what data are supposed to go where and why) from entering mistakes and misspellings. By creating a database using Microsoft Access I can create parameters and warnings so that our data are already screened and standardized before I go through it. (Example, in one database the same province was entered as Rift Valley, riftvalley, RiftValley, rift valley, RV, etc. Computers like consistency).

• New Endoscopy Equipment: We're getting new endoscopy equipment soon that has ben donated by Fujion. And, we should also be able to set up a computer to do the standardized reports like you may have seen with a colonoscopy (pictures and all). Right now we just have hand written reports. The thought of having a searchable PDF database with all of our reports is exciting.

• Cryotherapy: For the (unfortunately rare) patient with just dysplasia (very early cancer), we can remove just the lining of the esophagus. One way is by freezing it off! A company in Baltimore that is owned and run by Christians has donated a machine for us to use in a clinical trial (See link). So far we only have one of the thirty-seven patients needed, but we're working on that. We have several people recently identified with dysplasia that should be candidates if they're willing to participate. It should be an interesting trial.

That's only the tip of the iceberg, which is exciting for me. I feel like there are many projects that I will be involved in this year. Dr. White is an inspiring, visionary individual. In many ways he reminds me of when I worked for Dr. O'Keefe.

So, my job is essentially to coordinate and carry out the sundry projects that Dr. White has going on. Though I knew esophageal cancer was prevalent here, I have had many days I have quite literally sat down, sighed, and just wondered if I was really witnessing all of this disease. It's stunning. And thus esophageal cancer has been transformed in my mind from something that I think needs to be investigated to something I feel really passionate about. It only takes looking one 24-year-old (or 30-something year old) in the eyes and telling them they're going to die of cancer to be motivated!

Knowing Christ

I'm glad to finally get my introductory post onto the medical blog.  These last few weeks I've been primarily involved in clinical work.  That time has yielded a few opportunities to share the Gospel.  Many have been those with terminal illnesses (HIV, end stage Esophageal Cancer).  One man touched my heart in particular--he was only three years older than I--diagnosed HIV/AIDS on admission.  He said that he didn't know Christ.  After I shared his new diagnosis I explained that I also had a life full of sin, but that Christ had taken them away.  The man said he'd never been to church, but that he was interested in "this Christ."  The new diagnosis weighed heavily on his heart, and he gave me permission to contact a chaplain to come by later.  I wrote an order that I could never write at home:

"Please consult chaplain to share the Gospel of Jesus Christ with this patient.  He is interested in the Gospel."

Later that night I returned, picked up his chart, and read in the chaplain's handwriting that this patient "accepted Jesus Christ as his savior."  As I sat there with the nurses on the unit I was overjoyed to learn the best news about a patient I could have ever heard.  Though he faced eventual death from HIV, he now had eternal life because of Jesus Christ.  The next day I told him he was now my brother in Christ.  Day after day when I talked with him, it was obvious that he had a new hope and a hungry heart.  Please pray for this new brother and share in rejoicing in his decision!