Back in the CAR

I’m eating breakfast in New York. I was supposed to leave for the Central African Republic (CAR) three days ago but the most recent snow storm in Washington D.C. delayed my visa so instead I am leaving today on a two-legged flight from JFK to Bangui with a single 12 hour lay-over in North Africa. I used the extra days to work on my list of things that needed to be done before I left then came east 24 hours early to visit with my mom and sister for a day.

This will be my third trip with MSF and my second time in CAR. I was there in September 2012 working with MSF at a hospital in the western part of the country. Once you’ve visited another country, you can’t help but follow the international news there a bit differently. So since 2012 I have kept an eye on the news from CAR, following the conflict as it has grown, paying attention to the names of the different factions and how they and the conflict are described and characterized by the different international presses. I saw the recent uptick in reporting on CAR as the crisis has escalated and seen photos from there ranging from heart wrenching to horrific. So when I was asked to go to CAR again, I said yes to the opportunity to go back and see these changes first hand.

As much as you can have a routine for something you have only done three times, I seem to have followed mine for preparing for these trips (I’m reminded of Tony Danza’s description of Rocky III in the 80’s TV sitcom Taxi when he said “Alex, it’s the best Rocky movie since Rocky I”). So far there has been the initial excitement, the feelings of guilt about leaving the kids, the anxious dreams filled with obvious symbolism, the list of things that need to be done before I leave that really should be called the list of things that will mostly be done before I leave plus a few other things best left un-blogged. I’m anticipating the heat of the CAR, the novelty of being so close to the equator that your sunrise and sunset and daylight hours remain virtually unchanged week to week, the usual buyer’s remorse I have felt for the first few days of my previous MSF missions when I miss the family way too much and ask myself what am I doing here, the frustration and pleasure of being in a French speaking country and the excitement of being in Africa in the middle of a crisis.

This will be my last American style breakfast for a while so I’m going to have a little more scrambled egg from the buffet before I head out. Next stop, Bangui.

Read more from David on our Central African Republic blog.

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Goodbye DRC

It’s just after midnight in Rutshuru. Tomorrow morning Dr. F, the French anesthetist who arrived here with me, and I leave for Goma. Unfortunately the schedule worked out with me on-call at the hospital and I missed tonight’s farewell party.

This morning we had a fairly typical day in the OR, doing 12 procedures between 8am and 1pm including performing a skin graft, placing a traction pin in a patient with a fractured femur, draining a few abscesses, debriding a few wounds plus a handful of dressing changes including two children under the age of three with 2nd degree scald burns over roughly 30% of their bodies plus an eight-month-old who had her foot amputated for an infection two days earlier. I also admitted a 16 year old girl from the ER with chronic osteomyelitis [bone infection] who will need a fairly large operation in the next week or so to remove infected dead bone from her tibia. Chronic osteomyelitis in children is rare in the US but fairly common here in the DRC. Dr. M is fairly experienced with the problem. This girl has enough of her tibia involved that I think she may need an external fixature placed to prevent a fracture after the operation while the bone grows back in, either on its own or with the help of a graft.

Unless something exciting happens tonight or on the trip to Goma, this will be my last blog entry until my next MSF assignment. Thanks for reading my blog and a special thanks to the readers who left comments. I feel like I should wrap things up with some statement about the character of the people of the DRC but having only been here for four weeks in one area, it might be a bit presumptuous of me. Instead, I will pass on a joke that I was told the other morning by one of the Congolese national staff. We were on the way to the hospital in the Land Cruiser with 11 of us packed in pretty tight, three in the front seat and eight in the back on two bench seats that face one another. A French internist (who later translated the joke for me) and I were the only ex-pats in the vehicle, everyone else was Congolese. It was a sunny morning and the mood was bright with conversation and banter going back and forth, when a couple of the Congolese doctors started telling jokes. Here is the joke that got the biggest laugh, even though it was obvious that a few of the listeners had heard it before:

President George Bush (I didn’t ask which President Bush though it doesn’t really matter), President Francois Mitterand (a former French president) and President Mobutu (president of the DRC from 1965-1997) all die and meet each other as they are about to enter Hell. At the entrance, they ask the Devil if they can call home to speak with their families one last time. The Devil agrees, but only if they will be responsible for paying for the calls. They agree and Bush goes first. After a 10 minute phone call, the Devil hands him the bill. It’s $2,000,000 USD. Bush isn’t happy about how expensive it was, but pays the bill. Now it’s Mitterand’s turn and he makes a 5 minute phone call. The Devil hands him a bill for $1,000,000 USD and he pays, though he also isn’t happy about how expensive it was. Next it’s Mobutu’s turn. He calls home and talks for hours and hours, leisurely laughing and joking with everyone in his family. At the end of the call the Devil hands him a bill for only $1 USD.

Bush and Mitterand are furious. They complain bitterly to the Devil, accusing him of favoring Mobutu and taking advantage of the wealth of the western countries. The Devil just laughs and says “No, no, you have it all wrong. The US and France are very far away and your long distance calls were very, very expensive. But remember that we are at the Gates of Hell. The Congo is right next door. Mobutu only had to make a local call.”

I’ll be leaving the DRC with an appreciation and affection for the country and the people here. There is a lot to admire in the soaring mountains and expansive greenery, the laughter and music and hard work of the people I have met and seen on the street. I hope to come back someday, either with another round of work with MSF or maybe as a tourist to hike through some of the mountains and see some wildlife. For now I’ll just say thank you and good luck for the future.

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Language barriers?

It’s early evening and beginning to rain. It was warmer than usual with a clear sky all day until dusk. Today I was thinking about when my kids were younger and we used to talk about which super power was the best. Not ‘super power’ as in a nation but super power as in being able to fly, super strength, x-ray vision, invisibility, etc. It was always fun when we did this, coming up with new, unusual powers and exploring the possible ramifications or limitations that might accompany each possible choice.

I only have a few more days in Rutshuru. I’m scheduled to be on overnight call at the hospital on Wednesday, drive to Goma on Thursday, then catch a plane for home from Kigali, Rwanda on Friday. Just like my first mission, my time with MSF here has been very satisfying in a number of different ways. I have definitely had fun. I’ve enjoyed meeting people from different backgrounds, learning about the DRC, using surgical skills that I haven’t needed to use in years and learning some new ones, all in the context of helping people. At times it has been a bit exciting and at times a bit difficult.

Some of the surgical cases have been challenging, including a tiny two-month-old with a strangulated hernia, a pregnant woman with a ruptured uterus, a 40 year old woman with an unresectable tumor that was blocking her stomach (I did an operation called a gastrojejunostomy where you attach a loop of the small intestine to the stomach above the blockage so that she is able to eat and drink), and a gunshot wound to the leg where it was difficult to control the bleeding from some semi-large arteries and veins that had been divided. But I’ve been a surgeon long enough to know that you can come across challenging cases, whether in Africa or your home town. The surgery has actually been the easiest part of the assignment for me. The most difficult part for me has been the language barrier.

I should start by saying that I asked to come here knowing that the DRC is a Francophone country, that Rutshuru is a French speaking mission and expecting that the Congolese medical staff would speak French and Swahili but little English. I had French classes in junior high and high school but was a disinterested student who could easily have received an award for “Least Likely to Speak French in a Professional Context” if there had been one. I have worked to improve my French skills ever since applying to MSF and did a passable job on my first assignment in the Central African Republic, another Francophone country, with the help of a Canadian anesthetist, a French-English internist and an American logistics chief who were all bi-lingual and willing translators.

Currently my French is good enough to make basic conversation and have a discussion about a straightforward medical problem if we speak slowly and enunciate. But at the weekly Friday meeting when we gather to discuss bad outcomes and difficult cases, it’s impossible for me to fully follow the quick back and forth with the level of comprehension that I would like. I find it embarrassing to need to ask people to either repeat or simplify what they have just said, particularly if it seems to interrupt the flow of discussion. Expressing my medical opinion can require all my concentration to find the words (plus the occasional quick reference to the French-English dictionary app on my phone) and patience on the part of the listeners. At the residential compound, half of the residents are the Congolese staff and all of the other ex-pats are from France or Belgium. French is the spoken language at meetings, meals, evening gatherings and card games and any other recreation. I go to bed exhausted not from a hard day of surgery but from my day and evening of French language immersion studies.

I am not complaining. The European ex-pats speak English to varying degrees and are always willing to help me with explanations and translation. We sometimes have conversations one on one in a mixture of French and English, sharing idioms and expanding each other’s vocabulary. Everyone has been gracious with me regarding the language barrier. But there is no doubt that our language difference is a barrier that keeps me separate and can even isolate me at times despite the fact that we all like each other and are part of the same team, working and living together with a common goal. It makes me see just how difficult it must be to resolve an issue, whether it’s between individuals or countries, when there is a language barrier between two sides that have different agendas, values and goals. The language of Esperanto was created in 1887 to help break down these international language barriers between nations and foster world peace. So far, after 125 years, it doesn’t seem to have worked very well. I have heard people not so jokingly say that English is the next Esperanto or that the entire world will be speaking Chinese 50 years from now. Frankly I find it hard to imagine people ever willingly giving up their native tongue for any international language. I plan to keep studying French and hope to someday be near fluent but I can’t imagine ever giving up the familiar comfort of my American English no matter how well I speak another language. I don’t see why the non-English speaking world would feel differently about their native languages.

So what is the solution to the language barrier? I don’t know. I’m not even sure that the diversity of world languages is a problem that needs solving. Maybe language diversity is like biodiversity, a natural thing that is best preserved. But I do know that I have a new first choice for the best super power. The power of universal conversation, to understand any other language as it is spoken to me, without thinking about translating the words in my head, and then replying in my own English, idioms and all, and being understood by whomever I’m talking with, also without translating in his head. That would be cool.

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Complexities

My youngest daughter is a big fan of the Hunger Games novels. I am reading them on her recommendation and finished the second book in the trilogy this past week. If you aren’t familiar with the story, it’s set in a future post-war dystopian America where a totalitarian government cruelly exploits and suppresses the majority of the people. It is a good read. There are the two sides. One is good, the other evil. The characters and places are memorable and distinct. The characters have names that are easy to remember with one or two syllables, like Gale, Prim or Katniss. The cities are simply the Capitol or one of the numbered Districts where a single industry predominates. People’s motives, though not always clear in the middle of the book, are understood at the end of each book where all the twists are explained and the reader can make sense of what has happened plus what to expect in the next story. I am looking forward to the third book.

It’s not as easy to make sense of the storyline in the DRC. There are many more than two sides here. As well as the elected government, there are multiple groups that are labelled either rebel forces or freedom fighters or armies backed by foreign governments or bandits depending on your point of view, plus a variety of ethnicities and heritages to consider.

As in any real war, all sides have committed acts that make it difficult to award the moral high ground of “the good side” label to anyone. It is difficult to keep the players straight when names of people and places can be five or six syllables long and sound unusual to the western ear. The various armies have confusingly similar names with acronyms like AFDL, FDLR, FRF, FRPI, LRA, MLC, MPA or RCD that are as easily confused. In a world where much of the news is delivered in 30 second increments, it’s much easier to find a story that is more easily explained and easier to focus on. If a conflict has only two sides and can be framed as a genocide based on ethnic tensions or a war between oppressor and oppressed, it’s more easily covered by the press and understood by the public. This may partly explain why the western press and public focused relatively little attention on the two Congo wars that happened between 1996 and 2003, compared to the coverage and understanding of the events in Rwanda in 1994 and South Sudan in 2010.

I would like to share three books that have helped me make a bit more sense of the past and current situation in the eastern DRC.

“In the Footsteps of Mr. Kurtz” by Michela Wrong tells the story of the Congo during the time when Mobutu Sese Seko was president. It gives an overview of the history of the Congo dating back to when it was the personal property of the King of Belgium and then a Belgium colony before independence in 1960. The book was based on the author’s experience living in what was then Zaire and firsthand interviews with African politicians, ex-CIA officials, Mobutu relatives and associates and a wide spectrum of Congolese citizenry. It ends soon after the fall of the Mobutu government and his death from prostate cancer in 1997.

“Dancing in the Glory of Monsters” by Jason K. Stearns covers the period from 1993 to 2010, telling the story of a conflict that cost the lives of five million people by some estimates but is little known to most westerners (maybe I should just say that I didn’t know much about it until recently). The first part of the book discusses the Rwandan civil war and genocide and its role as precursor to the two Congo wars. The next two parts cover the first Congo war (1996-1998) and the second Congo war (1998-2003). A shorter fourth part tells the story of the ongoing conflict in the Kivu districts (where Rutshuru is located) of eastern DRC.  Like Wrong, Stearns has a great deal of experience in the region but most of his book relates interviews and first hand experiences reported by people involved in and/or affected by the wars.

In his preface to the paperback edition, Stearns expresses concern that his book had only told a story of war and tragedy but failed to extol the many virtues of the DRC that he had come to know. “Radio Congo” by Ben Rawlence tells the story of those virtues. While preparing for a trip to eastern Congo in 2007, the author came across a Belgian mining company promotional pamphlet for the city of Manono in the Kataganga province of the DRC circa late 1950s. He set out on a quixotic voyage to see what has become of the city, armed pretty much with only his ability to speak Swahili and counting on the kindness and warmth of the Congolese people. He was not disappointed as he meets friendly, helpful people along his entire journey, dispelling the image of the DRC as a dark place, too dangerous for the individual traveler. Like the other two books, the strength in the writing here lies in the telling of the stories coming from a wide spectrum of Congolese who suffered and still suffer from direct and indirect effect of the wars.

I came away from these books with a better understanding of the situation in the DRC and an appreciation for its complexity.  One of Stearns’ stated goals in writing his book was to tackle what he called “Congo reductionism”, the desire to reduce the conflict into an easily understood framework. The same likely holds true for many of the world’s problems and issues; most are too complicated to be explained in a 60 second sound bite or a brief magazine article or a paragraph in Wikipedia. After reading these books, I feel pushed to look for the complexity in political and social situations not just in the DRC but everywhere in the world.

After all, I am a US citizen who votes for presidents and senators and congressional representatives, the people who make and direct US foreign policy which for better or worse affects many throughout the world. I am resolved to leave the DRC with a renewed feeling of responsibility to stay informed about the world and understand that there may be few uncomplicated questions and fewer easy solutions.

But tonight while I’m still here in the DRC, scheduled to take overnight on-call in Rutshuru tomorrow night, I think I’ll just relax, start the third Hunger Games book and root for Katniss and the good guys. I can’t wait to see what happens.

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The burns unit

In one of my early blogs here, I mentioned two children with burns, a 21-month-old with burns over 20% of her body surface and a 10-year-old with a 40% total body surface area burn. The hospital is a local referral center for burn treatment with a 13-bed dedicated burn unit plus the occasional patient in the intensive care unit. We treat a fair number of burns here and do a large number of the dressing changes in the operating room (OR) for two reasons; pain control and sterility. I saw both of these girls for dressing changes this past week. I’m happy to pass on that both have healed their burns almost completely and will be going home within a few days.

Contact burns are categorized as 1st, 2nd or 3rd degree depending on how far through the skin it goes. Sunburns are 1st degree burns. Any burn that develops a fluid filled blister within a few hours is a 2nd degree burn. A 3rd degree burn goes all the way through the skin and often has a leathery appearance. Because the burn is so deep, the underlying nerves are also injured and you can’t feel anything in the burn, even pain. If a 2nd degree burn isn’t too deep, it will heal itself (with proper care that is) within three weeks; a burn like this is called a superficial 2nd degree burn. After a week or three, the raw surface of a superficial 2nd degree burn starts showing small islands of new regenerated skin that in my training were called skin buds and are always a happy sign. But if a 2nd degree burn is so deep through the skin that it will only heal by scarring rather than growing new skin buds, it’s appropriately called a deep 2nd degree burn.

Most of the burns we see here are 2nd degree burns, largely from hot water accidents. The trick with a 2nd degree burn is to figure out if it is superficial or deep, then keep it from getting infected while it heals (if a superficial 2nd degree burn gets infected, it can turn into a deep burn that won’t heal with new skin), give your patient enough nutrition to grow new skin and control their pain. Like all burn units I’ve worked in or visited, Rutshuru has a number of protocols for nutrition, pain control and dressing changes.

For patients with large burns like the two I mentioned earlier, we do all their dressing changes in the OR. There they receive a strong anesthetic, often something called ketamine, and then the staff begins the routine. The old dressings are removed wearing clean non-sterile gloves. Then one or two of the team dons sterile gloves and places a sterile drape under the part of the body where the burn is. In the case of large burns, our patient is often lifted up entirely to place a sterile drape underneath them. Next the burns are cleaned with 4% Betadine solution, rinsed with sterile normal saline and them dried carefully. A new pair of sterile gloves is used to place sulfadiazine ointment on the burns, then a Vaseline impregnated gauze followed by sterile gauze pads and held in place with a sterile bandage wrapped circumferentially around a leg or arm or head or the trunk. It’s an efficient process by an experienced team. And just like I remember from my residency days on the burn rotations, if you waver from the protocol in Rutshuru, even with good reason, you’ll get a look that says “What the heck are you doing…don’t you know how to treat a burn?”.

My first week here, one of the Congolese nurses was explaining that they have more burns in the DRC than the US because everyone boils hot water and cooks on an open fire here. I’m not so sure. In my experience, kids in the US have the same tendency to pull pots of hot water off the stove, ending up with the same burn pattern on their dominant arm and half their trunk. I imagine that kids chase each other through the cooking area just before mealtime all over the world, be it an outdoor fire pit or an indoor kitchen. DRC has their open flames for their kids to fall into but the US has our propane grills that tip over, not to mention ubiquitous electric clothes irons, curling irons and hair straighteners to be grabbed by curious hands. When it comes to burns and kids, I think there are some universal factors at work that cross cultural differences.

There are some differences in the way we do dressing changes here compared to home. In Rutshuru, we do the burn dressings every two days which is a longer interval than most US units for sulfadiazine dressings. Some burn units in the US have moved away from using sulfadiazine for their dressing changes and use more so-called biosynthetic dressings, which better mimic the function of natural skin but can be expensive. We do more dressing changes in the OR here because we don’t have the monitoring equipment or staff to have nurses on the burn unit give the heavy sedation needed for adequate pain control and still be safe. But the basic idea is the same; treat the burn patient with a dressing that works, control their pain and maintain their nutrition, don’t let the burns get infected, skin graft patients who need it, don’t skin graft patients who will heal sufficiently on their own, and do all this within the framework of your budget and the hospital resources so that you can keep your burn unit open for business because as long as there are kids and boiling water or hot grease, there will be patients with burns that need to be treated. It’s as simple (or complicated) as that.

Having just summarized the basics of running a burn unit in one long, run-on sentence, I wish I could do the same for the DRC. Next time I’ll talk about why that seems to be an impossible task.

 

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On the road

So far I haven’t posted anything about my living conditions in the DRC. They are not that different than what I blogged about on my last MSF mission. The team here is bigger so we have a few more outdoor showers and latrines plus the luxuries of running water, round the clock electricity and one almost western style toilet. The biggest difference for me is that my movements outside the compound are much more restricted on this assignment. The political and military situation here is in an ongoing state of flux.

For security reasons, other than daily Landcruiser rides to and from the hospital, ex-pats can only leave the compound on foot during daylight plus have to travel in pairs, carry a walkie-talkie and stay on the main street within half a mile of the compound. That’s a pretty short leash to be on so it was a huge treat when I got to go on a road trip to Rwanguba last week. On the morning of my post-call day off, I heard that our project chief, medical chief and an internist doing hospital QA work (gathering data, looking at outcomes, trends, etc) for MSF were going to visit a smaller hospital for the day so I asked if I could tag along. Fifteen minutes later I was heading out south on the same road I came in on two weeks earlier, accompanied by three French women and a Congolese driver.

msf drc

The road between Rutshuru and Goma ©Aurelie Baumel

 

The first five km of the trip was on the road I travel every day. As the road rises from the village center toward the hospital, you can see Rutshuru and its surrounding villages spread out across a wide flat valley surrounded by mountain ranges generated by a combination of volcanic activity and plate tectonics. The entire valley is green, much of it cultivated. The road passes along an eclectic collection of buildings including mud huts, brick and stone buildings with metal and tile roofs, a few decaying structures either left half built or half destroyed, a large compound with a UNHRC (United Nations Human Refugee Committee) sign, the largest compound along the road locally. Despite the limited number of motor vehicles on the road, we passed two vehicles where the drivers are talking on their cell phones. Distracted driving isn’t an American invention. I’ve seen Congolese on motorcycles, steering with one hand to avoid the bigger pot-holes while holding a phone up to an ear with the other.

South of the hospital we passed more of the same, a couple of large schools, some municipal government buildings, a banana grove where on my previous trip from Goma I had seen locals using the five-foot-long leaves as makeshift umbrellas. We eventually reached a turn-off with a few local stands selling bananas, cigarettes and various sundries near a small concrete obelisk with painted arrows, names and corresponding distances including one announcing “Rwanguba Hospital 14km”.

We took a left turn onto what was disappointingly an even bumpier road. Like the main road, it had been paved at some point though it was hard to know when. For the next 14 km we ascended through a river valley filled with activity including a fish farm and a wide variety of agriculture. There were no other cars on this road but we passed a few motorbikes, a dozen tchukudus (a local mechanical phenomena which has been described as a wooden bicycle which is like describing a computer as an electronic calculator…I may make a blog posting about them sometime but meanwhile you should google them) loaded with produce (sugar cane, bananas, bamboo, potatoes), about a half dozen beat up bicycles all which appeared to have only one gear and a large number of people walking, most of them carrying fairly impressive loads, many of them children and adolescents (I made a note to myself that I should have my kids do a few more chores when I get home). Midway we passed a clearing with some type of community center and an open air market where vendors and buyers were beginning to gather. As we traveled further up the valley, the scenery became even more verdant and lush. On either side of us rose mountain peaks covered with a variety of exotic greenery, as unbelievably beautiful as a Hollywood background for “Jurassic Park” or “King Kong” but with the appearance of authenticity and natural disorder that just can’t be duplicated using CGI.

When we reached the hospital, our first stop was at the head administrator’s office. The hospital is actually a collection of about 8 to 10 buildings on a ridge. From this ridge, foot paths lead off in all directions to other nearby hillsides where there are residences all along the valley, many of them farms. We walked up three steps to a one story concrete building and met the hospital administrator, a slender, soft spoken man with glasses. He was dressed casually with a simple gold wedding band on long slender fingers that made me think of a pianist.

He invited us into his office in a room about 20 ft by 15ft with the door painted the same green as the window frames, the walls blue on the lower half like a chair rail transition, white on the upper half, peeling all over. I liked his desk a lot, simple but well constructed out of beautiful African mahogany wood that is only seen in high end custom pieces in the US, much like a lot of the furniture I have seen here. The laptop on his desk was plugged in and powered up. In the far corner of his office was a good sized battery bank tied to an inverter with a regulator on the wall and a thick conduit exiting the ceiling to a solar panel or a generator or both. There was a top loading freezer next to the battery banks that I assumed was for routine storage and never plugged in as it had a number of things stacked on top including some books, a globe and a 24″ non-flat screen TV still in the box. The walls had a variety of graphs, schedules and charts with statistics about immunization, hospital numbers, etc. taped up plus a hand written sign talking about the signs and symptoms of ‘fievre ebola’ and isolation precautions. I noted the corners of the Ebola sign were browned and the tape edges curled. I hoped that this sign was older than the other papers and did not reflect an active problem.

We met with him for the next half hour, then met with the medical director for another half hour in a different office that was slightly bigger than the administrator’s. I listened attentively but I’m not 100% certain of what all was said. My French improves daily but on average I still only understand about 50% of what I hear (with the range being from sometimes understanding 90% if someone is speaking slowly and directly to me to sometimes missing the point all together and getting the message exactly backwards). As best I could make out, the hospital in Rwanguba is a small one with about 60 beds and refers a number of patients to the MSF hospital in Rutshuru. The medical staff is made up of three local general MDs. They have an OR that can do up to three cases per day and they perform about 20 c-sections each month. Like many small rural hospitals, including those in the US, they have difficulties with issues of volume and attracting experienced staff as well as feeling an obligation to serve the local community.

Next we had a tour of the hospital grounds. The buildings in the hospital compound were a combination of brick or stucco with metal frame windows. The maternity ward is in the nicest and best kept-up of the buildings. When we passed through it, the central room was being used for a well attended pre-natal instruction class. The medical ward beds were in an older building with mosquito nets overhanging even older metal hospital beds. The pharmacy shared a large room with general storage but seemed well stocked, with medications ranging from pre-natal vitamins to ceftriaxone, a commonly used intravenous antibiotic. The two operating rooms had a mechanical device that is common here for delivering concentrate oxygen at a mildly increased positive pressure but no real anesthesia machine. I felt grateful and a bit spoiled for having the MSF operating rooms at my disposal, with equipment for sterilization, standardized instrument trays, anesthesia machines and anesthetists. I was more than a little impressed that the local doctors here who have limited surgical training and less technical support are doing 20 c-sections a month.

Before we leave the hospital, there is a patient referral. A premature baby who is quite small, even by local standards, hasn’t taken to breast feeding and there is concern he won’t survive. In Rutshuru, we can feed babies who won’t eat through a tiny naso-gastric tube but for some reason that is not an option here. After a conversation between our medical chief who is also a nurse and the baby’s mom and dad, they agree to ride back with us to Rutshuru.

The ride back seemed even bumpier as I worried about the baby being shaken and saw how tired the mom looked, just a few days after giving birth. It would be better for them if the road was paved, I thought. We passed the open air market at the community center that had now filled up. The stalls were packed and there were more people and bikes and tchukudus on the road now coming and going in all directions. I thought more about the road. We had only seen two other cars on the road that day, one from another NGO and a pick-up filled with soldiers. Would it be better for  this community, where very few own a car but everyone uses the road for walking, where so many goods are moved using non-motorized carriers, where children routinely walk and play along it, if it suddenly were paved tomorrow and the NGO Landcruisers and the soldiers’ pick-ups could drive faster? I have little doubt that someday the people of the DRC will be more prosperous and the road to Rwanguba will eventually be paved again. It will be interesting to see how the area changes when that happens, what is gained and what is lost. But for right now, the road seems to be working for the community as it is.

Next time I’ll talk about the burn unit here.

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Saturday evening

It’s late in the evening and I’m on call overnight again. After a busy day in the operating room (OR) there hasn’t been much activity since 9pm. I ate a late dinner (late for me that is; the French and the Congolese here both like to take dinner at 8pm) with R, one of the Congolese nurse anesthetists here. She has worked for MSF for several years, spending a month at a time in Rutshuru between time at home in Goma with her husband and two daughters.

Among the cases toward the end of the afternoon were two men in their early 20’s with gunshot wounds, one in the arm, the other in the leg. They had been seen at another smaller hospital where their wounds were bandaged and splinted, then transferred to Rutshuru for definitive care. Ideally we would have x-rayed the injured extremities immediately but the x-ray machine was down for the day so they came to the OR for debridement [the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue] and wash-out of their wounds without x-rays.

It’s been awhile since I’ve treated someone with a gunshot wound though I saw my share during residency on the trauma service. There’s a significant difference between wounds from a handgun and a military rifle. The speed of a bullet as it leaves the barrel of a typical 9mm handgun is 300 meters/sec compared to 900 meters/sec for a military rifle. The force behind the bullet is in direct proportion to the speed of the bullet squared. This means that if a bullet from a Kalashnikov rifle is traveling 3 times faster than a bullet from a Glock 9mm handgun, it carries 9 times the impact. Compared to gunshot wounds at home, the ones in Rutshuru come with bigger holes and more tissue destruction. The protocol here for treating gunshot wounds is based on the recommendations of the International Committee of the Red Cross. It involves two operations, the first being debridement of all infected and dead material with leaving the skin edges of the wounds open, thus avoiding secondary infections that threaten life and limb.

The man with the leg wound had two holes in his upper leg. His smaller hole was the size of a US quarter, coming in the back of the leg at the mid hamstring and his larger hole was the size of my fist, coming out in the front just above his knee a bit to the outside. After induction of anesthesia, we removed his splint, pulled the compresses that had been packed into the wounds and surveyed the damage. There was a large cavity with torn muscle and bone fragments between the two holes. Almost all the bleeding had stopped. I could feel an abnormally rough texture to his femur bone but his leg felt structurally stable. I was comfortable that the main artery in his leg, the superficial femoral artery, was intact because it travels around the other side of the femur away from the damaged area, plus I had felt a good pulse in his foot before we started.

Using a scalpel I cut the bruised, dead skin from around both wounds so that I could better see into the cavity. I removed fragments of cloth and bone and cut away fat and torn, bruised muscle until I was satisfied that anything that would act as a source for bacteria to grow in had been removed. I rinsed out the cavity with saline and Betadine, put a loose dressing on both sides so that any infection could wick out and wrapped the wound. With the help of the nurses in the OR, we put his leg in a plaster splint to immobilize it until he can get an x-ray tomorrow.

The next patient clearly had an open fracture of the upper arm because even with the arm immobilized in a splint, it didn’t look quite anatomically correct. I felt a strong pulse at his wrist, indicating no major arterial damage. It was harder to be certain about the three major nerves (the median, ulnar and radial nerves) that travel through the upper arm. There is a quick examination to see if they are working but it can be difficult to rely on when your patient is in pain, has received narcotics and you don’t share a common language. After induction of anesthesia and the removal of his splint and dressing I could see he had a 2 inch diameter hole through his mid upper arm. By pulling on his arm I could see straight through to the other side. Needless to say, the exposure of his cavity was good. His humerus was broken with the two ends staring at each other 180 degrees apart and a visible gap. Without an x-ray it was impossible to tell how much of the bone, if any, was missing. I debrided skin and fat, cut away pieces of bruised and non-viable muscle with attached bone fragments and washed out the wound. There weren’t that many bone fragments so either he hadn’t lost much bone (good) or a big chunk had already been blown out (bad) or I had done an inadequate debridement and left dead bone fragments (worse). I looked in the cavity to see if I could identify the ends of a transected major nerve but didn’t see any. If I had seen one, I would tag it with a blue suture to help find it at the next operation when it would be repaired. Having completed the debridement, I washed out the wound with saline and Betadine, checked to be sure there wasn’t any more bleeding, placed a dressing followed by a plaster splint and we were finished.

Like all our patients with gunshot wounds, these two will come back to the OR in four or five days for re-evaluation. For smaller wounds without bone injuries or secondary infections, we close the skin at the time of the second operation (called delayed primary closure or DPC if you want to talk like a trauma surgeon). For larger wounds, we wait until they are ready for a skin graft. For patients with open fractures who need an external fixature (our second patient will definitely need one to salvage his arm), it is placed at the time of the second surgery. Some readers may be interested in looking at the ICRC publication “War Surgery” (just google search “war surgery ICRC” and you will find a downloadable pdf) which talks authoritatively about the treatment of high velocity gunshot wounds (some photos are not for the squeamish). As well, it provides a readable (at least I thought it was readable, but then I’m a surgeon) overview of the tremendous variety of injuries that occur during war and natural disaster and the complexities of treating these injuries.

When I left home to come to Rutshuru, there was a renewed and vigorous debate in the US about the restriction of military style rifles for personal ownership that began after the recent tragedy in Newtown, CT. The subject is a political hot potato involving powerful lobbies, heartbreaking tragedies and passionate arguments on both sides. Regardless of where one stands on those issues, there is one indisputable fact; bigger guns make bigger holes. If you ever get shot, hope it’s with a handgun and not an assault rifle.

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Primary objective

One of the things I like about being a surgeon is that the primary objective of my job is to help people. Most people I know like to help others and try to do it through their work but it’s often not the purpose of their work. I go to work every day with the purpose of helping people, not hitting a home run or making a movie or managing a project or picking a winning stock or winning a legal argument or writing a report or making a sales quota. I’ve done this job every day for so long that I have come to take it for granted that I will help the patients I see. So it is all the more difficult for me when I come across a patient that I can’t help at all.

Last week I was consulted in the Emergency Room about a 22-year-old man who came in for help with progressive swelling and pain near his right knee. Standing at his bedside I could see his knee was swollen to at least twice its normal size. In French, I asked him how long this had been going on for. The Congolese doctor on ER duty, Dr. C, translated the question into Swahili as well as the reply back into French. One month. I examined his knee which was firm and warm but not tender to the touch. With Dr. C as a translator, I asked whether there had been an injury or infection. The answer was no. Then I looked at the X-ray that Dr. C had ordered which showed irregular and uncontrolled bone growth in his distal femur, the part of the thigh bone just above the knee joint. It was clearly cancer. I went back to the bedside and examined him again, this time feeling for and finding enlarged, rock-hard lymph nodes in his groin area, a sure sign of metastatic disease. Again through Dr. C, I asked whether this had really only been going on for a month or had been there longer. It had been longer.

In a man this young, the most likely diagnosis is Ewing’s sarcoma and the second most likely is osteosarcoma. Once either of those tumors has spread beyond the original site, a patient is unlikely to be cured with any treatment. Patients with metastatic Ewing’s sarcoma in the USA are treated with a combination of chemotherapy, radiation therapy and surgery but still have only about a 15% chance of living another five years. Chemotherapy and radiation therapy aren’t available in the DRC and surgery has nothing to offer this man because of the spread of his tumor. If I amputate his leg and remove as much tumor as I can from his groin, he will have the difficulty of recovery and still die from this illness just as quickly, if not sooner.

In the US, I am sometimes involved with a patient where I am the one who has to deliver devastating news of a bad prognosis or even that there is no medical treatment that will help their situation. But in cases like this at home, I can offer up glimmers of hope, the possibility that a biopsy might show that I’m wrong about it being cancer or that an oncology consultant might know of a new treatment. I always say “We might not be able to cure this problem, but we can help you” and when I am on my home turf, it is the truth. There are disease and age specific support groups, multiple social services workers in each hospital unit, pain specialists and hospice and palliative care services into which I can plug my patients.

In eastern DRC, there are no oncologists to send him to with the hope of a different diagnosis or a new cutting edge treatment. The hospital here has only one psychologist for the entire facility and palliative care services for the control of pain. There are no other specific social services or medical programs here for him. I feel like I have nothing to offer him; I don’t even possess the language skills in French, let alone in Swahili, or have a good enough understanding of his culture to have a respectful nuanced discussion about quality of life and end of life issues with him. The best I can do is to pass on my knowledge of the diagnosis and prognosis to Dr. C and tell him there is nothing I can do…Rien de faire.

If he were in the US, his chances for cure would be small but finite. Most likely he would have sought care earlier, maybe before the tumor had spread beyond the femur when the chance for cure was even higher. It is certainly unfair though I can understand and accept the situation on an intellectual level as being part of the general unfairness of life. In some ways it is no different than the disparity between educational or economic opportunities for people living in different countries, even not that different than the unfairness of the increased risk of dying from gun violence in the US if you are a teenager living in urban Chicago versus one living in an affluent western suburb. The part of his situation that I have a hard time accepting is that it is my job to help people and this time, I didn’t do my job.

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Orthopedics

It’s a sunny Saturday afternoon here. It’s been a week since arriving here and I have more or less fit into the rhythm of the project and the hospital. Work begins at 7:30am with a team meeting at the compound before heading to the hospital for what have so far been full and busy days. Much of the work here is taking care of people with burn injuries, an area in which I received a lot of experience during my residency training and which falls well within my comfort zone. Another large part of the practice here is taking care of people with orthopedic injuries. Unfortunately my training and experience in orthopedics is limited to ER rotations in medical school and the early years of residency, research done after tearing my own ACL in 2004, on the job training from the CAR on my last MSF assignment and some self directed study in anticipation of coming to Rutshuru. Still, this week I’ve been able to get by as an adequate orthopedic surgeon and still keep at least one foot in the comfort zone thanks to three things here in Rutshuru.

One of those things is the experienced and knowledgeable local Congolese staff in the OR and orthopedic ward. The second is the MSF protocols. Doctors and surgeons have different levels of experience with the problems they treat in the field and experienced surgeons often have their own individual and often idiosyncratic ways of treating the same problem. Rather than have the local staff try to learn to do things a new way with each new surgeon, MSF has treatment protocols for common problems to provide standardized care that has been proven effective locally. The third and most important thing has been the other surgeons. The chief of surgery Dr. M is always available for a second opinion (yes, that closed forearm fracture just needs a reduction under anesthesia and a plaster splint) or an encouraging word (don’t worry, placing a supracondylar femoral traction pin in the femur is straightforward and you can do it, no problem). Dr. J, the other surgeon here, also helped me immensely this week. He is a Belgian surgeon currently working as an MSF “flying surgeon”. He has a nine month contract with MSF to go wherever they need him whenever. This was his last week in Rutshuru and he spent part of it teaching me how to do external fixation for open fractures.

A fracture is a broken bone. If the skin, muscle and soft tissue overlying the break are intact, it is a closed fracture. But if the broken bone is exposed by injury to the overlying soft tissue, it is an open fracture. A fracture heals optimally when you can get the pieces of the broken bone to line up in an “anatomic position”, meaning the way they look naturally and keep them there without moving. This is called “reducing” and stabilizing the fracture. Ongoing movement or infection of the bone leads to problems with healing. With open fractures, the risk of osteomyelitis (infection of the bone) and non-union (failure of the fracture to heal) or both is increased compared to closed fractures. In the US, both open and closed fractures are often treated using a technique called open reduction and internal fixation (ORIF for short) where the surgeon makes an incision in the skin exposing the bone and uses a combinations of metal rods, plates, screws and nails to secure the pieces of bone in the “anatomic position”, then sews the skin closed. In Rutshuru, we don’t perform ORIF, primarily due to the risk of infection. The infection risk after ORIF for the treatment of an open fracture increases with the time it takes to reach the hospital and the OR. The difference in pre-hospital transportation times and the causes of open fractures between the DRC and USA make external fixation (Ex-Fix for short) the treatment of choice here. Here it’s not unusual for a patient to be seen days after their initial injury due to transportation issues in a country where the roads are unpaved and unlit, most people don’t have a car and driving after dark for anyone, even an ambulance, carries significant risks of banditry or being mistaken for a military vehicle. Gunshot and blast wounds from military grade weapons resulting in bones being broken in multiple places with injury to the skin and muscle that can’t be sewn closed are a major cause of the open fractures here.

After an Ex-Fix, the patient looks a bit like he is wearing a bionic erector set. The broken bones are stabilized using a series of rigid bars of varying length attached to each other with adjustable clamps on the outside of your body. These bars are attached to your healthy bones above and below the area of the break using metal pins with threaded tips that are screwed into your healthy bone, then clamped to the bars. In Rutshuru, the pins are screwed into the bones with an old-school brace and bit style hand drill. The surgeon screws at least two pins into the bone above the break and clamps a bar between them, another two pins into healthy bone below the break and clamps a bar between those, and then connects the two bars with a third bar using more clamps. Extra pins, bars and clamps are used as needed to make sure the bone fragments are stable and in an “anatomic position”.

My first patient was a 27-year-old woman caught in some type of blast with shrapnel injuries to her left thigh and calf and a piece of the top of her foot missing. She had come to the hospital in the middle of the night, had the bleeding controlled, dressings applied and an x-ray now showed she was missing most of one of the bones in the mid-foot, the navicular bone. The plan was to place an Ex-Fix in the hopes that her foot bones will fuse and she can avoid an amputation. We removed her dressings and saw that the wounds were all clean without any infection nor dead tissue that needed to be debrided. We started with two pins in her shin bone (the tibia) and connected one bar between the two pins. Next we placed three pins in the 1st, 3rd and 5th long bones of her foot (the phalanges), with a bar between the 1st and 3rd and another bar between the 3rd and 5th, essentially constructing a rigid bar bending over the top of her foot. Then using the bars and clamps, we placed one long bar from the shin bar to the left side of the foot and another bar from the shin bar to the right side. J explained the logic behind deciding where to place the pins, how and where he makes his incisions and why, the pitfalls to be avoided, and then he had me place the pins. Like any good surgical instructor, he was impossible to please 100% (the first pin was 1° too far this way, the next 1° too far the other) but when things were done, we had a good result with the Ex-Fix stabilizing the injured foot and ankle in the “anatomic position” but with room to access the soft tissue and bone defect for daily dressing changes.

msf orthopedics

External fixation © David Lauter

 

 

There is a saying in surgery that “you see one, do one, then teach one” but I’m a slow learner so J stayed to help me with my second patient, a 25-year-old man who had been shot in the left leg a few inches above the ankle. Both of the bones in his lower leg, the tibia and the fibula, had been broken. He was missing a chunk of skin and soft tissue as well as a piece of the fibula but luckily the appearance of the ankle joint on his x-ray, called the mortise, looked normal and intact as was the pulse and sensation in his foot. The far end of the fibula where it makes the ankle joint is important but you can largely do without the rest; the larger tibia accounts for the vast majority of the weight bearing strength in your lower leg. With normal blood flow and no nerve or ankle injury, he should have a relatively normal functioning leg if we can get this to heal. Like the first time, I placed two pins in the tibia above the fracture. In addition to  placing pins in three of the phalanges, J had me place another pin in the tibia below the fracture but above the ankle joint. This set-up allowed us to get the two pieces of the tibia lined up in an “anatomic position” with greater stability. At the completion of the operation, we were happy with the result, the fracture stabilized with good access to the open wound for daily dressing changes.

There is nothing like learning about problems and procedures in another surgeon’s area of expertise to give you an appreciation for their knowledge and abilities. In Rutshuru, I’m getting an immersion course in the part of orthopedics that most orthopedic surgeons master before completing their training. In medicine, like in many fields, different specialties often are given stereotypical characteristics. Surgeons in general aren’t considered exceptionally cerebral by our internal medicine colleagues and orthopedic surgeons often are considered to be at the far end of the spectrum. There is a joke that I first heard in medical school that goes “What are the best two years of an orthopedic surgeon’s life?” with the answer being “6th grade”.  After experiencing first-hand how difficult and nuanced their work can be, this might be the last time that I repeat that joke making fun of orthopedic surgeons. Especially now that I’m sort of one myself.

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Burns

It’s Sunday, early evening in Rutshuru, and I am on overnight call at the hospital. It’s cooling down outside, my guess to about 67°F, and the sky is turning a reddish hue in the west.

This morning I worked in the Bloc from 8am until 1pm. We did seven cases including two dressing changes under anesthesia for burned children, debridement of a hip abscess in a one-month-old, drainage of a breast abscess for a breast-feeding mother, irrigation and closure of lacerations for two different trauma patients and repair of a strangulated hernia in a six-year-old boy.

As it has been during my entire career, it was emotionally moving and disturbing to see the children with burns. I suspect that most surgeons feel the same way. Both of our patients were girls with second degree burns from boiling water. One is a 21-month-old with burns over 20% of her body and the other a 10-year-old with 40% of her body surface area burned. The younger one’s burns all looked like they will heal without grafting, with some buds of skin already appearing in the burned areas but the older girl’s burns look deeper in some areas. She may need skin grafts. We will just need to wait and see and in the meantime treat the wounds to keep them clean and avoid a secondary infection.

In the afternoon, I had lunch, rested a bit and am now back at the hospital on-call. Watching the sunset, thinking about the patients from this morning, I’m grateful that my own children are safe and well. I think I’ll text them later this evening to say hi.

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