Shisha (Shipshape) and Snacks Up Top

You just have to laugh (‘cuz otherwise you would have to cry). “Autocorrect” does some very silly things. For example, when I typed that we were having Shisha (spiced tobacco through an elaborate water-pipe), the computer figured I was just straightening up. And when texting to my Sweetie back home my strong desire to have internet access for email and IM, it decided I was a fuzzy hoofed quadruped – “I just Goat be Online!”? Whatever floats your boat.

© Mark Kostash

AD is the Team Shisha Maker. It takes a fair amount of time, so I volunteered to help (and to be an alternate so he would miss less socializing time). Proper hygiene is almost as important as careful “construction”; after all, dried out old bits of debris in the pipe or water aren’t likely to enhance the flavour.

© Mark Kostash

Now don’t get me wrong – I am rabidly anti-smoking. Most Anesthesiologists are, since it is the single patient habit which complicates our work the most (a close second being morbid obesity, and don’t get me started about really fat smokers). But as they say,”When in Rome…”

HN is back from her week-long visit to the project in Khamer. As I understand it, the project is high in the mountains, where the air is thinner and colder (she was warned to pack a sweater). I look forward to telling her about PC joking that she was shivering up there in the cold. Poor taste since he sent her there in the first place; actually, he’s been saying he rented her out). Funny, but still in poor taste! Might earn him a punch to the arm. At least she will get a warm welcome “home” to Aden.

Narrowing our “Scope of Practice” to “War Wounds” (or more accurately, victims of violence) certainly has had an effect on how busy we are. Prior to this decision in December, the program also accepted referrals of patients injured in RTAs (Road Traffic Accidents). We remain at about 50% capacity for inpatients and are averaging five cases a day in the Operating Theatre.

With “advertising” and referrals, as well as the occasional Mass Casualty event, it is expected that we will gradually become busier again. One possible plan for the future is to expand the project to become an advanced rehabilitation unit (similar to the program I worked at in Amman, Jordan).

There is a long waiting list for Amman and certainly a need for another reconstructive surgery program. We have all been asked to put in a “Wish List” and explanation of upgrades which might be needed if Aden Hospital were to open their doors for treatment of osteomyelitis, resistant infections, reconstruction (bone grafts, maxillofacial reconstruction, flaps and myocutaneous flaps). I have made a list of anesthesia equipment needed to expand the second OT to “full service”. It will be interesting to see what happens over the next one to two years.

OT classroom © Mark Kostash

I’ve been able to slip in a few teaching sessions between operations and naps. NA and AA have been keen to discuss anesthesia-related topics and HM has booked me in to give lectures at the weekly Physician Teaching sessions. I’ve covered Fluid Therapy and Management of Acute & Chronic Pain so far. I also spent an enthusiastic hour with the OT team today teaching how to do bedside ABO blood type testing.

Blood typing © Mark Kostash

Just about every team member poked themselves and confirmed their own blood type – it was very well received. As expected, almost everyone was “A” or “O” but they were excited when one of the female nurses turned out to be “AB”. We think she is very lucky since she could receive blood from anyone on the team in an emergency! This is all in addition to teaching NA to do some of the lower-risk nerve blocks for surgery and pain control. She has already had the opportunity to do five around the shoulder, wrist and foot and you never know what tomorrow may bring.

I have always said that “Chivalry is not dead”. This may well be the case, but on this mission, it’s really hurting. I stood by, helpless as our slight, attractive, Big Boss Lady from the regional office in Dubai carried a 20 kg replacement water bottle up the stairs and hefted it onto our water dispenser so I could have coffee one morning. This is after I have (not so grudgingly) surrendered the snow-shovelling of our driveway and patio to my wife at home. As if my back and leg pain was not bad enough, now my ego has been severely bruised. I may need a self-image transplant before too much longer. The only good thing about getting old… is that it beats our only alternative (getting cold and stiff).

I have been fortunate this trip that the vivid dreams often associated with malaria prophylaxis have not been a big problem (I refer you to my first mission where I awoke to witness the Log and Hospital Manager passing dead babies through my bedroom window and stuffing them into my pillowcase – while it makes interesting breakfast conversation, it does not make for restful nights of sleep).

I have taken a different anti-malaria drug on subsequent missions and not had problems. However the combination of jet-lag, back pain and gastro did lead to one particularly vivid dream involving the headless torso of my dead mother (sorry Mum, it was as disturbing to me as it probably is to you reading this).

I have discovered a down-side to living in a large, open building with lots of tile and high ceilings (not Celine’s <sigh>); it makes an incredible echo-chamber. When the wind catches an open door, the resulting “SLAM” is truly impressive. Especially when it happens at three in the morning, or when PC or ES get called to the Emergency Room and they close their door with a little too much enthusiasm. Enough to wake the dead (or the deaf).

Review of Abbreviations:
Expat Team
PC – Project Coordinator
LO – Log
PH – Physio
AD – Admin/HR
OS – Orthopedic Surgeon (Expat)
HM – Hospital Manager
HN – Head Nurse
MIA – Anesthesiologist (Yours Truly; Mark In Aden)
OT – operating theatre (what at home we refer to as the OR)
ER – Emergency Room (Resuscitation Room)
NA – National Anesthesia Doctor
AA – National Anesthesia Assistant

And to conclude; yes I went over the wall (with permission of course).

AD and I went with a driver to a nearby hotel (previously a Five-Star Sheraton but now slipped to Three officially… and a Seven-Star as far as this Expat is concerned). The drive across town was very interesting and I took copious notes between bouts of motion-sickness. No photos unfortunately at the specific command of the Powers That Be. No point irritating our hosts (and military installations, security checkpoints, police & vehicles and women would have to be excluded anyway). Still, I would have loved to take a photo of “Little Big Ben”, a clock tower built no doubt by a homesick English Expat. Right down the street was a miniature Eiffel Tower. I immediately thought of Las Vegas!

Crossing the causeway/bridge over extensive tidal pools and mudflats we saw thousands of flamingos wading, foraging, or just standing around on one leg. Lots of other shorebirds too among the wading or rafting fishermen & women. As we approached the coast, a number of roadside shops appeared displaying a variety of swimming attire and toys. I lost track of how many bright yellow ducks I saw hanging above the street, looking like a bunch of small yellow inner tubes with smiling heads. I even spotted a few giraffes (yah, yah – pun intended).

Pool at Gold Mohur © Mark Kostash

The hotel is situated on a quiet sandy beach. Far off in the distance, a number of freighters and tankers rested at anchor. We ordered a couple pizzas and a bucket-full of ice water and spent the afternoon chatting, swimming and suntanning. I was diligent with my sunscreen so no restless night of lobster-flesh would ensue. AD introduced me to a few Expats from ICRC who were also enjoying the fine sunny day. The water temperature felt about 23 or 24 C – a perfect, refreshing temperature. I gathered a handful of seashells at the waterline to send to a couple not-so-small girls I know out in Nova Scotia who used to enjoy collecting.

© Mark Kostash

I know, life just sucks! But it still beats the alternative!

MTIA :)

PS: As you might have guessed, the geological formation in the last photograph above is indeed called “Elephant Rock”. One of my kind colleagues told me the story… Many years ago a group of elephants made its way from Africa all the way to the Arabian Peninsula and then down here to its Southern tip. When they saw how beautiful it was, they decided to stay forever.

“The postings and views expressed here are mine alone, and do not necessarily represent the position of Medecins Sans Frontieres”.

Monday, January 20th, 2014

 

Posted in Doctor, Surgeon, surgery, Yemen | Tagged , , , , | Leave a comment

Many Happy Returns

Remember what I said a few days back about “Happy Fire” and bullets following the laws of Physics? You guessed it. I could probably calculate the terminal velocity (where resistance from air counteracts the acceleration of gravity) and the altitude at which the bullet briefly hung motionless before it changed direction, based on muzzle velocity. But all that is irrelevant to the poor schmuck who really was, “Just minding my own business when someone shot me in the neck!”

 

"Cool X-ray though" © Mark Kostash

Luckily for him, the bullet found a nice soft spot to land (instead of his head) and missed everything important. Cool X-Ray though. We were planning to operate to remove it today after rounds, but a vascular emergency bumped his case. SSDD, Or more accurately, SSDT (Same Stuff, Different Time-zone).

 

© Mark Kostash

My last Installment took nearly two days to send out; the internet can be slow to non-existent and the file was a bit too big. I have been editing the photos to make them smaller but I’m still a Newbie with this app on my iPad. Sorry if the photos next time are a bit grainy! Anyway, I have had time to jot down lots of notes, so you get this one without having to wait as long. Yay, You!

The internet may be marginal, but there is nothing wrong with the power. Electricity is quite reliable in Aden, and the hospital has an advanced electrical backup generator system providing seamless transition if the power unexpectedly fails. No more operating by Braille!

As in our hospital tent in Gaza, the fuel supply for the generator is surrounded by sandbags to prevent sudden unexpected noise, wind and heat. Not to mention flying bits. There is a good supply of power outlets (four in my bedroom alone) so I have no excuse to let my cell-phone go dead.

The Expat kitchen includes a microwave and gas stove and the water cooler also has a hot-water option (warm enough for tea or coffee). There is even an electric kettle which I use constantly to reheat the hot water bottle PH loaned me.

We have been truly spoiled by our cook, who provides a large variety of hot and cold dishes. As I predicted, I have gained a bit of weight, but less than I might have due to my week-long gastritis. I didn’t even get back to unreasonable volumes of “coffee” until yesterday. Several other Expats did what my wife suggested to me – they packed a Bodum. I used the excuse of an overstuffed suitcase to demure; I’m not really regretting it since Nescafé with milk is beginning to grow on me. Like an invasive fungus.

 

The comforts of home © Mark Kostash

Today I had planned my traditional Expat dinner for the “Cook’s evening off”: Chicken On A Can. Last Friday’s barbecue was a bust for lack of supplies and ingredients, but it all came together today. I took two large chickens out of the freezer this morning, LO acquired a large (30 kg) bag of charcoal and I chopped all the veggies for the side dishes. Then PC told me about two more patients with gunshot wounds coming in by ambulance .

So AD & PC got volunteered to build the charcoal up and put the (dressed & spiced) chickens on at 5 pm. Our new Expat Orthopod (OS) is rebuilding a patient’s Achilles’ tendon and we have a young lad with bilateral femoral fractures to ExFix following. All I need now is someone to sauté the onions, braise the eggplant and zucchini, boil up the rice and I will have finished “cooking Friday’s dinner!”

Later the same day…

This is one of the things I love about our team; the way someone always steps up to help out. PC and AD made such a great charcoal fire that the chickens were perfect in exactly two hours.

 

Perfect chicken © Mark Kostash

AD lifted the lid on our makeshift oven and both chickens fell in two, their skins crispy and brown. I had just enough time to make the fried rice and ratatouille-cum-stew before racing back to the theatre for Part Three, but first LO and AD had to bring a new cylinder of cooking gas for the stove. I was in desperate need of a shower so everyone babysat my simmering pots while I cleaned up and dressed. Then they transferred the entire banquet to the patio. Dinner was quiet for the most part with all the chewing going on, but PC did enough talking for all of us ;p

Despite narrowing our intake criteria, it has been a little busier in the hospital the last few days. We have had two vascular cases (one axillary and one popliteal artery requiring vein-graft repair), two gunshot wounds to the legs and one to the chest. The latter surgery is amazingly simple, really; they either need just a chest tube and wound debridement and live, or the bullet hits something important and they are DOA (or like last night in ER, DOAA – Dead On Arrival of Anesthesia). Not a good finish to the day – a murder/suicide. Today was much better. So far. Though I did have to turn away a request to run to ER to intubate a patient a few minutes ago since the 15 year old boy with both knees shot out needs me a while longer.

I received a pleasant surprise last evening when PC invited me to join him on a walk around the yard outside the hospital. I hadn’t dared venture beyond the hospital doors (being a stickler for rules no matter how conservative). We had a pleasant walk discussing an unpleasant topic involving a difference of opinion between two Expat Physicians. Guess which one of the two dropped the “F-bomb” .

Trying to behave myself today because if I do, I will be allowed on a Field Trip tomorrow afternoon. Destination – a local hotel frequented by Expats with a pool to swim in and a patio to sit and suntan. I’ve been too busy lately to spend much time on our own patio before dark so I am looking forward to getting a little flushed. AD is planning to join me, and maybe PC and HM too, if they aren’t too busy. A little R&R is good for the productivity. And you can’t get Vitamin D poisoning from sunshine!

MTIA
(Mark Tanning In Aden)

“The postings and views expressed here are mine alone, and do not necessarily represent the position of Medecins Sans Frontieres”.

Friday, January 17th, 2014

Posted in Doctor, Reconstructive surgery, Surgeon, surgery, Yemen | Tagged , , , | Comments Off

On The Inside Looking Out

It’s a very nice prison, but a prison just the same. The guards are protecting the inmates from the public instead of vice versa, but none of us has any illusions about strolling outside (even in the compound surrounding the hospital). MSF has very strict rules to keep Expats safe and out of trouble. Ignoring these rules can get you sent home, for your own good and for that of the team (not to mention for our patients – the reason we are here in the first place).

At present, my back prevents me from walking more that 100 metres anyway, but it’s the spirit of the thing! Unfortunately, I arrived in Aden in the middle of the night, drove from the airport in the pitch dark and arrived at the hospital compound long before dawn. On my way home, I catch the same plane returning to Istanbul, leaving around 5 am, so I won’t be taking in the sights on that leg of my journey either.

We have a variety of activities to keep our minds occupied and to keep us from dwelling on restrictions. The best is a long, hard day of work, where you are so bagged as the sun goes down all you can think of is a meal, a drink and sleep. However when it is calm, like now, it takes a lot of imagination to keep busy and distracted.

We have only been working in the operating room until noon most days. I have prepared and delivered a number of “lectures” for National staff (including the physicians, nurses and Anesthesia team). These have been very well received, as usual (I have always performed well in front of an audience). I have half a dozen more talks organized (loaded onto my iPad before leaving Calgary).

Wifi in Aden © Mark Kostash

We have Wifi (most of the time) which is often slow and petulant, but occasionally surprises me (such as when I accidentally downloaded a large presentation off my home computer “DropBox” account and the 28 Megabyte file reached my iPad in about three minutes. All the Expats have a personal device of some sort; laptop, iPhone, iPad, iPod – but I think I’m the only one with one of each. I brought my old iPhone along to use as a notebook (jotting down ideas for my newsletter; work to do for the mission; things to pack next time), as well as to have constant access to my calendar. I really do need to keep track of my appointments, lectures and meetings, not to mention what night I volunteered to cook dinner. I was hoping I could also IM home from it, but although it will sync and update my apps, it doesn’t like the internet/wireless settings so texting home is out of the question. As a consolation, I also loaded my favourite music playlist which even some of my younger compatriots seem to enjoy.

As on my mission to Pakistan, we have a gym in the living compound. We share it with the National staff, some of whom have rooms adjacent to us for the nights they are on-call. A poster has been created for the female expats to hang on the door, preventing any uncomfortable situations resulting from male Nationals walking in on skimpy, sweaty Lycra (or whatever they wear – I haven’t caught the ladies in there either. Yet.)

HR/Admin dart board © Mark Kostash

We also have a dart board with a variety of high-quality darts courtesy of our HR/Admin who just arrived “home” from vacation leave this morning. Add to this the Olympic sized ping-pong table (currently doubling as a purse/backpack staging area for trips down to the hospital or meeting rooms). We have a smoking lounge and a smoking lounge [sic]. After all, this is MSF France we’re talking about. To give them credit, the smokers do make an effort at courtesy, smoking only by the open windows (although that could be just to catch a glimpse of blue sky and trees).

Whenever possible, we meet on the hospital roof, which is one big open-air patio. I have set up a chair to catch the late afternoon sun, and when I don’t have duties in the operating room, I have been known to read my Kindle or write in my journal and work on my Vitamin D levels.

Journaling © Mark Kostash

And yet, my under-taxed, over-imaginative mind still finds time to jump to some truly ridiculous conclusions. Take for example, the day I was cleaning up in anticipation of our usual 6 pm dinner gathering. I stepped out of the shower, dried off and dressed only to find the upstairs completely deserted. I checked out the offices – doors open, lights off, not a soul in site. Ditto the gym. And the rooftop patio. And the operating theatres. At ten past I decided there must be a meeting and I just missed the memo (or more likely, the memo missed me). But the Meeting Rooms on both floors were deserted. It was at this point that jet-lag, insomnia and chronic pain sneaked up on me and I was convinced it had happened. They were all kidnapped. I was alone with a new telephone that didn’t have any numbers programmed into its memory and now I there was no-one left to call, anyway. If I had been given more time to brood, I’m certain I would have started to be angry; “Hey! Why didn’t you take me?! What am I, chopped liver?!” Fortunately it was just about that time I received a text message inviting me to join the National team in the Inpat Mafrash Room (National staff lounge, TV room). Most of the Expats met me there. Mystery solved.

The actual operating room work has been very light. One theatre is fully equipped with an anesthesia ventilator, a laryngoscope with a variety of blades, a drug & equipment cart and most importantly, a small equipment table for us to use as a desk. The other theatre has only basic equipment and the monitor is missing half of its cables. Since the project opened, it has been used only for short (10 minute) dressing and debridement procedures; no spinal anesthetics or cases even remotely likely to need endotracheal intubation.

While there is no automated anesthesia ventilator, there is a simple manual device complete with a vaporizer capable of delivering isoflurane or halothane. No-one in the project, myself included, had the slightest clue how it works, so I asked and immediately received an instruction manual by email from my Anesthesia “Boss”, Xavier in Paris. I ran an impromptu workshop where the National Anesthesiologist, the National Anesthesia Assistant and I sat down and assembled the gadget piece by piece. Then we substituted it (briefly, for practice) in the operation of the next intubated patient. I was encouraging my team to learn the system to increase their knowledge and flexibility for the time in the future when and if the project became busier. I was pleasantly surprised to discover them using the machine for every intubated case over the next couple days, without further requests, coercion or whining on my part.

My work here is done!

PS: The PC has promised an Expat field-trip if security is acceptable. Not sure where or when and I really don’t care about the details – sign me up!

Manual Ventilator © Mark Kostash

“The postings and views expressed here are mine alone, and do not necessarily represent the position of Medecins Sans Frontieres”.

Tuesday, January 14th, 2014

Posted in Doctor, Surgeon, surgery, Yemen | Tagged , , , , | 1 Comment

Cries, damn flies and statistics

I thought this would be a catchy title when it came to me, but after a week, I must admit the bugs really aren’t bugging me much. Not the flying type anyway. Unfortunately, I can’t say the same about the microscopic variety; the day after my arrival three other expats came down with what looked like food poisoning. It made for a very quiet evening in the expat lounge. Not to be left out, I followed suit two days later, which explained my aversion to coffee. While not back to normal (whatever can be considered normal in a 49 year old white male physician who volunteers to go to Yemen), I am able to eat more adventurous foods than rice, bananas, bread and water. The Nescafé still left me queasy so I will likely stay on “the wagon” for another few days. Come on, I was just joking about being in rehab this month!

The good news is my luggage arrived, dry and intact as promised, the afternoon after my arrival. I was greatly relieved having imagined weeks of washing out my unmentionables and sprinkling cornstarch under my arms. This trip I was trying to minimize the weight of my backpack, but I will have to make an addendum to my packing list; make sure the cheese, sausage and chocolate are in the carry-on! Once everyone recovered, the Brie and saucisson were welcome additions.

Before leaving, I spent a little time Googling Yemen and Aden, since neither showed up in the curriculum when I went to school back in the Dark Ages (of Jimmy Carter and Ronald Reagan). I won’t bore you with all the details except to mention that the Wikipedia entries are quite interesting. Most people will remember that Yemen is one of the countries where a large number of Somali refugees have landed since 1990. Most will also recall the suicide boat attack on the USS Cole in Aden harbour in October of 2000.

Yemen is made up of two regions (North and South) which were unified in 1990 and form the “heel of the boot” of the Arabian Peninsula. Since then they have endured many difficulties including separatist movements, religious differences (especially between the Shiite Houthi and the Sunni in the North), economic woes (as oil production has been falling off and reserves drying up) as well as the usual anti-government, anti-corruption, anti-military, anti-establishment… Al-Qaida in the Arabian Peninsula (AQAP) is active here, which is part of the reason that US drones have been attacking.

Our hospital was built by the Aden Governate (administrative region) but was never opened. MSF negotiated an arrangement with the Ministry of Health and this project opened in 2011. The goal was to provide free medical care to victims of trauma, especially violent trauma (mainly gunshot and bomb wounds). While many patients with non-violent trauma have been treated, the focus has recently been narrowed to “war” victims in and around the Aden Governate.

We have space for 45 inpatients, including women, children and long-term care (often amputations). We have a 6-bed “ICU” – actually an “Intensive Monitoring Unit” since artificial ventilation is not possible with the equipment and training available.

At present we have twenty-five or so patients, many of whom are undergoing repeated surgical dressing changes in preparation for skin grafting. As you can imagine, when a modification of Newton’s Laws occur (an irresistible force meets a soft-and-squishy-human-object) a large exit wound often results and the resulting skin deficit begs to be replaced.

We have a good working relationship with other local NGOs and private hospitals and help arrange referrals for patients we are unable to treat and for post-op rehabilitation and prosthesis planning. We have two operating rooms and perform anywhere up to a dozen operations a day, ranging from dressing changes to laparotomy for abdominal gunshot.

Currently, the Expat team consists of medical; Nurse/Manager (NM), Physio (PH), & Anesth Physician and organizational; Project Coordinator (PC), Log (LO), Admin (AD) & Hospital Manager (HM). Most of my team members are on relatively short missions (six months or less) so the changeover has been high – our Operating Room Nurse/Manager just went home a couple days after I arrived and there is no plan to replace her in the near future.

The National Team is much larger and includes the majority of the “hands-on” workers (ward and operating room nurses, cleaners, surgeons and a Yemeni Anesthesiologist and Anesthesia Assistant as well as administrative, security, drivers… sorry if I missed anyone!) In the month before I arrived, there was no Expat Anesthesia provider so the local team has had lots of independent practice. I was informed by my “boss” hours after my arrival that it was now my turn – I was to be on-call every night until I left in four weeks. Have a nice day!

As I have found with most surgical missions, our accommodations are quite comfortable. The brand new facility adds a nice touch – all the lights, fans, appliances and plugs work. As an added bonus, we even have air conditioning (shhhh – don’t tell anyone). I haven’t made much use of the AC but it did come in handy when I was writhing in bed with cramps and it was too hot and loud outside to keep the window open. The housekeepers throughout the hospital and our living quarters are pretty diligent so the new tile floors and linoleum in the OR Suite are spotless. Our cook is inventive and thoughtful so I’m afraid I might gain a few pounds (assuming I don’t relapse with my tummy troubles).

The amenities include private rooms, often with private bathrooms, Wifi throughout the living quarters, two spacious (as in basketball-court-sized) lounges and cable TV. We even have an open-air patio on the roof, although I haven’t taken the time to suntan yet. Maybe this afternoon while cooking dinner on the barbecue (my specialty – Chicken-on-a-Can). Recent renovations have provided a pristine white wall which we plan to use as a projection screen for Movie Night tonight. The only downside is that the Wifi doesn’t reach my bedroom (but this ensures I don’t hibernate in my room instead of mixing and mingling with the rest of the team, so all is good).

Expat Mafrash Room © Mark Kostash

 

You have heard of, “Extremely Loud and Incredibly Close”? That about sums up what the team glibly refers to as “Happy Shooting”. It is believed that for the Yemeni population of approximately 30 million, there are also 30 million Kalashnikovs. Birthday parties, wedding parties, funerals, Wednesdays are but a few reasons for bursts of AK-47s into the air. Personally, the sound of machine-guns does NOT make me wanna get down and party… just Get Down (as in; Mark! Duck!!). I will keep my eyes open for souvenirs while on the patio, since another of Newton’s Laws deals with gravity (as in; what goes up must come down).

And finally, I have continued my habit of waking at 4 am. This was convenient at home since it was 6-hours after my last pain killer and it allowed me to take a pill and get back to sleep for a couple hours so I wasn’t in agony when I got up for work. The same doesn’t apply here – I could quite happily wake at 6 and still have a nice lie-in for a couple hours before the morning meeting and rounds. Tell that to my internal (infernal?) clock. The good news is, I finished this week’s statistics on the computer, had breakfast, washed last night’s dishes, showered and loosened up my back with a borrowed hot-water bottle (thanks PH – you saved my life) all before rounds! Woo Hoooo!

So life is great! But as I’ve said before – any day you walk away from is a good day! Stay tuned,

MIA

Friday, January 10th, 2014

“The postings and views expressed here are mine alone, and do not necessarily represent the position of Medecins Sans Frontieres”.

Posted in Doctor, surgery, Yemen | Tagged , , , , , , | Comments Off

The agony & the ecsta… well anyway, the agony

I made it safely to Aden. Unfortunately, my luggage made it safely to Frankfurt. Not really a surprise, mind you, seeing as A) I flew Air Canada, B) I had less than 90 minutes scheduled between flights in Frankfurt, and C) it is WINTER in Calgary and we pushed off an hour late with the winter storm and plane de-icing procedures. On the up-side, I would much rather have my luggage stranded en route than my person.

Calgary at departure © Mark Kostash

 

After final packing and cleaning up, I left my house in Calgary for the airport at 1:30 Friday afternoon. Traffic on the new ring road was light but the repeated episodes of -20 to +10C with scattered snow every few days had made the roads treacherous. I was very early at the airport so it only took a few minutes to sign in and drop off my suitcase.

The unexpectedly kind agent even waved the overage fee on my luggage (I usually bring over 10 kg of snacks, treats and toys for the Expats and paediatric patients and I can’t pack “light” to safe my life). All three airlines I was traveling on were affiliated so I was also able to pick my seat location and check my bag all the way to Aden (or, as autocorrect would have it, “all the way to Amanda”). In theory. Despite a slow trip through security (Calgary airport is renovating again and they were only running one line), I still had over three hours to relax and enjoy a meal. While the international flights are a bit better than the regional, I have learned the hard way that it is best to eat before any Air Canada flights – pretzels don’t stave off hunger very well on a ten-hour flight.

As some of you know, just after returning from our Rotary Club’s annual home-building (and Team Building) project last March, I managed to blow out a lumbar vertebral disk. Being an obsessive-compulsive doctor (is that redundant?), I always put in a 110% effort, so instead of a little sciatica I developed a foot-drop and bilateral back, hip and leg pain. Having a copy of the Y-chromosome, I am totally unprepared to deal with pain and suffering when it is my own. I had the pleasure to experience, first-hand, Canada’s exemplary Health Care System, including standby lists for scans, waiting lists for surgical consults and refusal of reimbursement for certain “nerve drugs”. Valium? No problem. Percocet or OxyContin? Here, take a bucketful. There is just the minor problem that I CAN’T TAKE THAT STUFF AND PRACTICE MEDICINE THE SAME WEEK.

At first, it looked like things were going to get better on their own, but alas, here is that 110% again. I’m managing on slightly sub-lethal (so far) doses of NSAIDs and the odd muscle relaxant; at least when I’m not working. Always wanting to stand out from the crowd, the usual pain with sitting and improvement with standing or walking is reversed for me. I can even bike, when the paths are free of snow and ice (but that’s another story). I debated for a long time whether I should go ahead with my annual MSF mission. In the end, I decided that I would feel no more miserable, suffering and neglected on mission than I would at home. Anyway, it’s only for a month.

As I mentioned at the beginning, we left the gate exactly an hour behind schedule. I inhaled another meal then washed down a sleeping pill. Not to put too fine a point on it, my back was killing me. Walking the three hundred metres through the airport followed an hour in the security line had made my hips feel like two motivated rats were burrowing in for the night. I popped another diclofenac and squirmed. Two hours later I was still wide awake and re-watching an old Batman film. I finally turned off the lights, put on a eye-shield and drifted off round about midnight. We made up a bit of time on the flight, but apparently still arrived in Frankfurt with less time than necessary to get my suitcase from Plane A to Plane B.

Suitcase © Mark Kostash

 

Istanbul airport was interesting. I was in an emergency row sans port-hole landing and it was too smokey on the ground to see much out the windows of the terminal. There were hundreds of flights but the departures board only displayed the last 50 or so (90 – 120 minutes in advance). Fortunately there were plenty of comfortable chairs and benches scattered throughout, so I spent two hours alternately reading and hobbling to the nearest display to determine which gate I needed. Making my way to Gate 311 was a trial, made no easier by the electric extended-cab golf carts whipping by with elderly and feeble passengers. One hand on the horn and the other on the steering wheel, moving far faster than on any golf course I have visited, I had visions of being hurled across the concourse for failing to move with due haste. Had I been able to figure out how to flag them down, I would have happily ridden along with the other old farts.

The remainder of my trip was uneventful, if rather long. I was met at the airport in Yemen by two of the National Staff, one of whom translated/cajoled/greased my way through Immigration. The guy working the baggage room at the airport had a paper with the tag number and location of my bag when I finally cleared Customs. I was promised my luggage the next day, without fail. Just under 30 hours after leaving my house, we pulled up to the security gate at the MSF-France Hospital, Aden. It was 5am local time and the sky was not beginning to lighten yet. The gate guards completed an inspection of the car’s undercarriage with a mirror on a stick before the gate was opened allowing us in.

I was met at the doors by our Logistician and she showed me the kitchen and a choice of bedrooms, instructing me to go to bed and not come out until I was rested (Read: speaking coherently). I complied, remerging at 11.

Bedroom in Yemen © Mark Kostash

So I’m here, I’m safe, and it’s sunny and 30C. What more could I ask?!

“The postings and views expressed here are mine alone, and do not necessarily represent the position of Medecins Sans Frontieres”.

Monday, January 6th 2014

 

 

Posted in Doctor, surgery, Yemen | Tagged , , | 1 Comment

It’s Only Money

Aqaba TanningI think it’s funny that I am returning from a surgical mission overseas and my biggest problem is that I might run out of money before I get home!  Never before have I had the opportunity to SPEND money on mission – nothing to buy, nowhere to go and not allowed to go even if there was.  Amman was different.  Between shopping excursions for food and drink to entertain my room-mates and neighbors; last minute expenses for taxis, Visa extensions and dinner in Paris; and a whirlwind tour of Aqaba…but I’m getting ahead of myself.

I’m writing this, the last Blog Installment of my MSF-France Mission for Iraq in Amman in the boarding lounge at Charles de Gaulle Airport.  It’s just before 6 a.m. and my day is already three hours old.  I had a bit of a “Senior Moment” when I set my alarm clock and failed to take into account the change in time-zones between Amman and Paris.  So, I had an extra hour on-line waiting for my taxi to arrive at 04:30 <sigh>.  It probably wouldn’t have mattered – I woke up an hour before my alarm was set anyway, but this explains why I never got the 4 a.m. wakeup call from the hotel desk…

I cheated a bit on my arrival time at the airport.  I know the printout says, “…three hours in advance…” but I was certain there would be few flights this early in the day.  Even the subway doesn’t start running until after 5:30 (thus one of the taxi charges – luckily he accepted VISA, otherwise I was going to have to pay him with a combination of US dollars, Euros and coins).  Traffic was light (as expected) and we got to the airport at precisely 5 a.m.  I did the electronic check-in and bag drop-off and was on my way to the gate at 05:10.  I do love European airports.  The long walk to the gate and security screening still took under 15 minutes.  Charmed life, I keep saying!

My final week of work was fairly calm.  The first Iraqi Anesthesiologist came back from vacation and the second left for his week off.  Work was light again – MSF was putting on an Exhibition at the Cultural Centre, and the Queen came for a photo shoot with our surgeons (so all surgery was put on hold for the day).

Lecture to OT team

Since, understandably, I wasn’t on the invitation list to meet the Queen, I filled my day giving lectures to various groups of nursing staff on acute and chronic pain management.  No surprise that a large percentage of the patients in our program have persistent or chronic pain after being blown up.  I stopped by the Exhibition the next day – it was a smaller version of the Refugee Camp in the City program which has been so successful touring Europe, the US and last summer, Western Canada.  I found a photo in the display showing my Anesthesia Technician from Gaza last January, wearing the scrub hat I gave him on my departure – like I said before, it’s a small world!  They are bringing the RCIC to Eastern Canada this spring, so if you happen to be in Waterloo or Montreal…

AT in my old hat - Gaza

Aqaba tall flagpole 2There are several Expats with experience in diving (or interest in traveling around Jordan on their weekends off).  Unfortunately, due to a combination of weekend commitments and upcoming flights, no-one was able to join me on my last weekend traveling around Jordan.  Grabbing the bull by the horns, I booked a bus ticket, hotel room and series of dives in Aqaba, and headed south out of Amman on Thursday evening.  Thanks to my remaining travel companions (red wine and Gravol) I had a lovely sleep on the 5 hour trip and woke up refreshed and ready to party.  The feeling wore off quickly, but I did have a chance to stroll the streets and experience some of the nightlife in Aqaba late Thursday.  I found a great store selling fresh roasted & seasoned cashews, pistachios and a variety of other munchies so I loaded up for the weekend.  As usual, I woke up before my alarm the next morning and after a huge “Jordanian Continental Breakfast” at the hotel, I wandered around the neighborhood again.  By chance, I stumbled upon the dive shop I had booked with and arranged for two dives with all the equipment and trimmings – 25 JD per dive (ludicrously affordable after $100+US dives in the Caribbean and Mexico).

One bonus of diving in the Gulf of Aqaba is that transport to and from the dive site is by road instead of open skiff.  I never have problems with motion sickness WHILE diving, but trips to and from in high chop make me regret (and on occasion, relive) breakfast.  This time both dives were off the shore at the same public beach so I could spend my surface interval basking in the sun.  Dive #1 was on the planned wreck (for reef development) of the “Cedar Pride” now covered in a variety of corals and filled with fish.  We saw at least a dozen frilly Lion fish and half a dozen eels (two of which were in the open – a very uncommon experience on my previous dives).  I was a bit disappointed…well actually, JEALOUS when we came up and heard another group hadAqaba hotelAqaba marinaseen a large Whale Shark swimming near the wreck.  We must have missed it by just a few minutes!  We made up for it on the second dive coming across a large sea-turtle which hovered nearby peacefully ignoring us.

Aqaba Red Sea BeachAqaba skyline

It is common for surgeons and anesthesiologists to complete shorter missions than other MSF volunteers.  Nevertheless, goodbyes were a bit sad for me.  It’s always bitter-sweet leaving for home…I know I’ll miss the friends I met in the field, but I do look forward to my friends and (especially) family back home!  Getting away from the noise is a benefit too – I probably won’t hear another car horn until the rodeo comes to town for the next Calgary Stampede.  Unlike Gaza and Somalia, loud noises here have had innocent causes (mostly fireworks celebrating weddings and birthdays).  I DID get a bit of a flashback walking home on my last day – the contrail might still have been made by an F-16, but at least it wasn’t going to strafe me as I lay soaking up the sun on the roof!

No HornsGaza Flashback

I certainly won’t miss the electrical connections, intermittent baseboard heating or maimed children – humans WILL continue being nasty to each other, I’m afraid…

power outlet

Best wishes to my team members, especially the “Self-Professed Serial Monogomist”, the “Vegetarian Hiking Yoga Instructor” and the “Oklahoma Cheerleader”!

Posted in Jordan, Reconstructive surgery, Surgeon | Comments Off

Alice in Horrorland

Valentine's 2010This week started out badly – we lost a patient (I’ll call her “Leila”), our first death since the project opened.  All the staff, patients and families have been dealing with their grief ever since.  Leila was very ill when she arrived from Iraq – in and out of ICU and suffering from severe leg infections.  I looked after her a few times, providing sedation so the surgeons and nurses performed dressing changes.  I was impressed by the compassion and skill of all the staff, taking care to minimize Leila’s pain.  Frail and cachectic, she eventually succumbed to overwhelming infections resistant to the newest (and most expensive) antibiotics modern medicine has to offer.  Her death has affected us all and provoked feelings of guilt and anger directed toward the government and armed forces responsible.

 

 

Some of the surgical procedures being performed here are truly amazing.  Facial trauma is common in our patients and requires prolonged, multi-step reconstruction (especially when the jaw is damaged by bomb blasts or gunshots).  The process begins with a complex assessment of bone and dental loss.  “Three dimensional” C.T. scans are


Face CTFace x-ray

 

forwarded to a company in Europe which creates models of the skull and mandible the surgeons can use to plan the steps required.  An early step involves attaching a multihole plate to the remaining mandibular bone to act as a “skeleton” or framework for future bone

 

 

Model - Face 2Model - Face 3

 

 

attachment.  The maxillofacial and plastic surgeons performed an 11+ hour free fibular flap to rebuild the mandible of a teenage boy last week.  You can see from the radiology studies, he has lost about 9 cm of his right mandible with the accompanying teeth.  Once the bone graft has healed, the plate will be removed and a dental prosthesis can be created for him.

 

Preop jawmandible postop


There are several children in the program in addition to the boy, above.  Burns to the face and hands are a common indication for plastic reconstruction.  Contractures develop and if not treated immediately, loss of function and cosmetic distortion are dramatic.  Facial burns and trauma make my job much more complicated (a fiberoptic bronchoscope is available and frequently necessary).  Hand contractures involve both skin grafting AND digital manipulation and wiring, followed my months of physiotherapy to improve range of motion and practical function.

 

Hand Burns


My presentation on Pain Management was well received at “Journal Club” on Thursday – so well received that I have been requested to give another lecture NEXT week.  I was also signed up for no less than three lectures for the operating room and ward nursing staff.  I never pass up the opportunity to get up in front of an audience!  Since this is my last week (and we already have 15 operations scheduled), I will have to be very efficient with my time – I can always sleep when I get home…

 

I talked most of the team into joining me for dinner and a drink at the “Irish Pub” at a nearby hotel, which I can see from our apartment.  None of us has been there before, so we weren’t even sure what they served as far as food (but hey, it’s a PUB, right??)  Imagine my embarrassment when we walk in to find all they serve is alcohol!  Even worse, as my two supervisors enter in front, the bartender looks at me and says in English, “Hi, welcome back!”  No, seriously, I’ve NEVER been in there before!  Trust me!  <sigh>  We pulled a U-turn and fortunately found a nearby Sushi restaurant a couple of the team had heard about and wanted to try.

 

A few of us took advantage of the good weather last weekend to make a day-trip to the Dead Sea.  Because it is landlocked, technically the Dead “Sea” is a salt-water lake.  The only significant water entering it comes from the trickle of the Jordan River, but during the rainy season a lot of water rushes down the wadis into the Dead Sea too.  Because of the ongoing drought, the Dead Sea is gradually drying up – the water level has dropped substantially over the years.  Because the water continues to evaporate and the salt has nowhere to go, the concentration of sodium chloride (and many other elements and compounds) is over 30% (compared with the more usual 3% in ocean water.  This is why the lake is really DEAD – nothing grows in it or near the shores.  This is also why it is much more buoyant than fresh-water

 

 

Dead Sea shore

 

 

(or even usual sea-water).  Swimming is really impossible – you don’t dare get water in your eyes or mouth (I dipped a finger in and touched it to my tongue as an experiment, and the area burned until I generated enough spit to dilute it).  You cannot submerge enough body parts to really swim – anything but paddling around on your back causes your legs to flop about uselessly in the air.  Quite amusing, really!

 

Dead Sea SaltDead Sea Floating

 

It was sunny and warm so there were lots of families at the beach resort we chose (which had the added advantage of fresh-water showers and two swimming pools).  The “Lake” water was warm (probably 21 degrees or so) but the pools felt icy and refreshing after lounging about in the sun, eating ice cream.  On a clear day, you can see the West Bank of Palestine on the other side, but it was hazy (either from smoke or sand & dust in the air).

 

Dead Sea WadiDead Sea Wadi 2


We concluded the afternoon with a short walk up one of the nearly-dry wadis, where several large plumbing pipes were laid to collect a few drops of the remaining run-off.  It wasn’t as challenging a hike as the ones at Petra and happily, I have been keeping up with my exercises and long walks in Amman (mainly home from the hospital when the weather is good).  My skipping rope has been ignored until recently, but with the deluge of rain we’ve seen the last few days I’ve been making more use of it.

 

exercise equipment


Just as long as the rapid heart-rate only occurs OUTSIDE the hospital!

Posted in Jordan, Reconstructive surgery, Surgeon | Comments Off

It’s A Small World, After All

Mark Trimmed 1It really is like a small club of friends in MSF – everybody seems to know everybody!  This week I discovered that our Psychiatrist worked with Elena (one of our psychologists in Gaza who also Blogs for MSF), Anne knows Michelle (Post-op Clinic Manager from Gaza), Debra was providing Anesthetics in the Sri Lanka project which I was originally hoping to join last summer, and Anne was working in the Yemen project (my alternate plan) which was suddenly closed, leaving me with the sad duty of golfing and fishing at the lake all of August.

I have agreed to extend my mission a bit to allow both Anesthesiologists here to take some vacation time.  Those who know me will agree that I believe strongly in rest and relaxation.  The interesting thing is that in order to extend my Jordanian Visa past one month, the government requires that I take an HIV test!  If the result comes back positive my Jordanian Visa will be the LEAST of my problems.

KaMainSutraAs I mentioned last week, I was given a tour of the Hotel where patients remain during their convalescence.  In the well-equipped Physiotherapy department, the staff has put up a poster demonstrating hand and finger movements (which I think is an ingenious maneuver to avoid confusing translations).  I took a photo, partly for interest in the rehabilitation positions, but even more so for the title.  You gotta love the French!

Our Plastic Surgeon is back from vacation so our relatively quiet operating room is now hopping – seven cases today in two operating rooms.  I got here nice and early so that we had two small operations finished in the first 30 minutes.  Unfortunately, our best efforts to move along failed miserably.  The combination of a late surgeon and missed critical blood-work left one operating team cooling their heels for over an hour and the other two and a half hours behind <sigh>.  As they say in the armed forces, “Hurry up and wait.”  Happily, the test results were eventually obtained and we went ahead in our room – this poor guy was injured in a bombing in Iraq over 3 years ago.  He had his humerus and tibia repaired but fell in 2009, refracturing the tibia.  He has been on crutches ever since.  He cruises around the ward with a big smile on his face practicing his English and is just happy that he’ll be able to walk again.  If only I had been able to talk him into a spinal anesthetic!  I still remember how to DO a general anesthetic, he woke up with a big smile, thanked me and gave me a kiss (a sign of great affection and friendship in Jordan – and please, no comments about disinhibition and erotic dreams from the propofol).

Our Pharmacist is into the full mind & spiritual health idea.  She is a vegetarian, practices advanced Yoga, enjoys regular Chinese massage, avoids pharmaceuticals (showing true restraint, being a pharmacologist) and even dabbles in acupuncture.  So when I heard the sound of birdsong coming from her room a few mornings ago, I naturally assumed she was playing a meditation soundtrack.  It sounded just like the Ashley & Franks albums I acquired from a friend back home.  You know what I mean – the sound of a dozen tropical birds twittering in the trees, making you imagine you are high in the Cloud Forest of Costa Rica.  Turns out it was REAL birds in the eves outside her window.  They must be celebrating the warm weather as much as I am!

The high point of the week (and of the Mission, so far) was our trip to al-Petra last weekend.  Truly one of the most impressive sights of my long(ish) life!  We made our way south from Amman by tour bus along the desert highway.  I was a little worried about the bus-ride since I’ve been known to get a wee bit of motion sickness (read:   Mallory-Weiss tear of the esophagus in the Caribbean) but I needn’t have worried.  Once you leave Amman the highway heads due south for two hours,

Speed Bumpthen makes a hard right toward the Israeli border with only the occasional speed bump to slow traffic down at rest-stops along the way.  We arrived at the bus station which stands right between our hotel and the main gates and had checked in, unloaded our bags and made it through the gates before 11 a.m.

Petra is a marvel of ancient settlement culminating in an advanced, wealthy trading civilization called the Nabateans, who eventually partnered with and

succumbed to Roman influence.  The main city centre, consisting of several

temples and other buildings, is now reduced to rubble by earthquakes and the elements.  The amazing feature of Petra is the Tombs carved directly into the mountain face (instead of the more traditional free-standing assembly).  The entire valley is teeming with elaborate facades, sometimes with tiny crypts where bodies were laid to rest, occasionally with large multi-room chambers large enough to hold feasts or religious ceremonies.  The

tombs appear to have been commissioned by the wealthy, powerful or famous to be built after their deaths as a tribute (or perhaps to provide a more comfortable afterlife).  Because of their proximity to the surrounding rock many have been protected from the weather and resisted 2000 years of erosion.  The most notable Petra - Treasury First Glimpse

(and the most well-known, in part due to the filming of “Indiana Jones and the Last Crusade) is the “Treasury”.  This glowing work of art is the first thing a visitor sees when emerging from the 800 m long Siq (or gorge) entrance to the valley.  Breathtakingly beautiful, the sandstone glows in the morning light like a beacon to travelers.

Petra - Treasury 1Petra - Panorama

On our second day, we got up at 5:30 and passed through the gate even before the security personnel arrived.  This enabled us to take an alternate route into the ancient city, following the Wadi Muthlim stream bed (impassable during the rainy season due to flash floods).  We picked up two companions at the gate – dogs presumably belonging to the local Bedouin clan.  While dogs are unpopular with (and even shunned by) most Arab communities, the Bedouin frequently keep them.  The dogs who joined us had some of the distinctive markings of border collies (which explained why they nipped at our heels and bounced around like delighted children when they realized we were going for a walk).  The hike in was somewhat challenging what with the walls closing in to less than one metre in places and boulders blocking the way.  Petra - Mark clambering At low points, residual water from last week’s snow and rain formed pools which had to be leaped, skirted or (once) waded through.  “Lonely Planet – Jordan” was quite positive about the route, but my “Rough Guide” advised against wading due to the water snakes… I guess I should have read that BEFORE the trip!  Our companions left us at an obstruction made up of two boulders and a 3 m expanse of water – we reluctantly left them behind, realizing they would have to find an alternate route home at the end of the hike (as would we).

We came out into the valley above the Royal Tombs, found a quiet place to sit and ate our Bedouin breakfast overlooking the glory of Petra.  Not a soul was about – it was just after dawn and not even the local traders in jewelry, postcards and tea had come down from the town.  The rest of the tourists hadn’t made it as far as we had yet, so we had Petra to ourselves (at least for a little while).  Eventually the earliest Bedouin  Petra - Bedouin lady riding overtook us and we were invited by a lovely lady on donkey-back for après breakfast tea at her “shop”.  I had to laugh when two young men in traditional Jordanian attire passed us while listening to Bob Marley on their portable Boom Box.  The music matched their dreadlocks (and strangely enough, their long black shirts and baggy trousers) perfectly!

Petra - from High Place of Sacrifice

Next we made our way up to the “High Place of Sacrifice” (al-Madhbah), 170 m above the valley floor.  The Royal Tombs are even more breathtaking from above, and from this vantage point cliff tombs & carvings spread out in all directions as far as the eye can see.  To put things in perspective, the dark opening you see in the bottom of the tomb farthest to the right, is about 2 m tall (and in the following photo, the small white speck in the doorway is a tourist!)

The Negev of Israel lies to the west but due to the heat haze (or dust and sand) we were unable to see it.  On the bus-ride back to Amman I Petra - MonastaryPetra - Colourful doorway realized this was the first real hike I have been on while on any mission with MSF and I was especially grateful I brought good hiking boots.  Up until now, I have been satisfied with my Birkenstocks, which fill the role of hiking boots, shower flip-flops, house slippers, and occasionally operating room clogs.  I even hiked to the top of Red Mountain once or twice to pick Saskatoons, not to mention wading through the flooded O.T. Tent in Gaza last February…

BirksBirks frozen

It’s nice to be busy again – lots of plastic surgery and combined maxillofacial-plastics free flaps booked the next few weeks.  I managed to have a senior moment and completely miss didactic rounds last week, so I was “volunteered” to give the next one.  Between lecture Petra - Desert at duskpreparations, 10-hour operations, shopping and cooking I now have full days.  I even helped move a few cases of I.V. fluids around in the Pharmacy (now that I have pretty-much recovered from my New Year’s Eve hernia repair – I have been waiting for an opportunity to comment on the “comb-over” and self-imposed “Hemi-Brazilian”).  Over-share alert!

Speaking of over-share – if you ever find yourself in a country with slightly tighter restrictions on personal attire than that in the West, try not to pull one of these…

Petra - Uncovered

The End.  So Far.

Posted in Jordan, Reconstructive surgery, Surgeon | Comments Off

Running Hot & Cold

Cute but psychoFirst the Bad News – the heat went off in our apartment last week, so it remained 12 degrees in our bedrooms as well as in the common area.  The Good News – it was corrected before the snow came on Thursday.  It was brutally windy and cold for awhile, rattling the shutters in the middle of the night – it felt just like home!  It snowed on & off for a couple days, but despite warnings and staff fears it never accumulated and it vanished rapidly when the sun came up.

Lucky thing because I missed the instructions to turn the hot water heater back on in the evening, resulting in a “refreshing” morning shower.  On a positive note, the freezer compartment of our refrigerator is cold enough that I’ve had ice cubes to go with the lemon twist in my drinks.  I keep saying I lead a charmed life!

snowy carsIce in glass

My sleep cycle is finally back to normal…I get up around 5:00 and have a nice leisurely coffee and breakfast with time left over to “work” online before we are picked up at 7:30.  Jet-lag had been getting ridiculous – I began waking up earlier every day (at 02:30 the night after posting Installment-I).  I was feeling pretty exhausted – I figured it was at least in part because there is no inhalational gas scavenging system in the operating theatres.  Exhaled nitrous oxide and volatile anesthetic is vented into the room.  Then I realized we had performed spinal anesthesia on all the patients that day, so no gases were present <sigh>.  Trying to “catch up” by going to bed early seemed only to make it worse.  The combination of exhaustion, winding roads and heavy smoking in the operating room lounge was causing serious nausea for awhile, but all is good now.  Fortunately, I don’t have to take malaria prophylaxis, so I don’t have to deal with the bizarre dreams and insomnia I experienced in Somalia.

no smoking

Much to my chagrin, I have developed a taste for the instant coffee packages provided to us in the operating room – a sickly-sweet combination of Nescafe, Coffee Mate and sugar.  I still prefer the Arabic coffee cooked on the stove (with cardamom) but I have to admit the instant stuff is simple and portable and it’s easy to find hot water.

Anesthesia Machinefiberoptic

It has been fairly quiet in the operating room – one of the surgeons is away on vacation.  He is scheduled to return on Sunday, so we might find things picking up.  We have only been running one theatre so far, which has allowed me to get used to the procedures, meet the staff and give a few lectures ( I do love a “captive audience”).  MSF has outdone themselves with the anesthesia and surgical equipment.  The surgical and patient complexity requires live X-ray (fluoroscopy) and advanced airway equipment (flexible fiberoptic bronchoscopy).  Multi-tissue flaps and complex maxillofacial reconstruction are common and we have access to monitored postoperative care beds and even ICU ventilation.

humerus fracture 1humerus fracture 2 - xray

humerus fracture 3humerus fracture 4

Many patients have injuries which are several years old.  Osteomyelitis is common and multi-resistant bacteria are the routine instead of the exception, so isolation protocols are rigidly enforced.  It was explained to me than one gentleman in a private isolation room had both Pseudomonas and MRSA (a resistant staphylococcal strain) cultured from his wound on arrival in the program.  Infections must be eradicated (or at least controlled) before considering implantation of tissue expanders, bone grafts or internal fixation devices.  Some patients present with serious systemic illness from their wound infections (why it is advantageous to have a good working relationship with a facility with an intensive care unit).

Most patients expect to be in the program for several weeks to months.  A hotel nearby the hospital has been leased and patients and their caregivers live there while recovering and awaiting their next surgical procedure.  The building houses an advanced physiotherapy program, a psychology department (and even several kiosks in the Atrium).  Patients are transported to and from the hospital for some treatments and for follow-up appointments with surgeons in the attached Outpatient Department.  Recently, the project was featured in a television news program (www…….) – putting MSF in a very positive light.

little one mask induction

The quiet days have allowed me to explore the city quite a bit.  After Grand Ward Rounds on Saturday, Jorg and I went for another “Long Walk”, a combination of shopping and rubbernecking.  We descended the hill the hospital is perched on, weaved through much of the downtown markets and into the Coliseum.  It has been partially restored and contains two museums with artifacts and displays of traditional apparel and weaving equipment.  From the Coliseum we climbed up toward Al-Rainbow Street, managing to climb the wrong hill and having to backtrack several hundred meters (in distance and altitude).  We made it eventually, also discovering a great restaurant for a greatly appreciated sandwich (shawerma) and bottle of water.  Deciding discretion was the better part of valour, we hailed a cab for the remaining trip back to our apartments.

Jorg’s enthusiasm for walking (and his reassurance that the walk home from the hospital was only about 90 minutes) encouraged me to walk home after work on Sunday.  As promised, I entered the Shmesani district and approached the apartment after an hour and a half.  Maneuvering around the two tunnels along my route was “interesting”…mainly trying to avoid being run down in the traffic circles at ground-level.  Jordanians drive quite aggressively, treating lane markings more as guidelines and using the car horns to mean anything from, “yes, please go ahead,” to, “hey Ahmed, nice to see you again,” or the more common, “What in the name of Allah are you doing?”  Despite this, they ALWAYS stop before running into each other or into pedestrians.  I’m certain their reflexes are better developed than ours in Canada.  Cellular phones, while everywhere, seem to be used less commonly while driving.

Sunrise

Tomorrow, Jorg travels back to Europe – a going-away party is planned and will be well attended (he seems to make friends everywhere he goes)!

Live Large…

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On The Road Again

My Shirt Now! – the day before departure I participated in the Calgary Flames Charity Poker Tournament, knocking out Brent Sutter and thereby “won the shirt right off his back” – he was a good sport and even signed the front for me.
My Shirt Now! – the day before departure I participated in the Calgary Flames Charity Poker Tournament, knocking out Brent Sutter and thereby “won the shirt right off his back” – he was a good sport and even signed the front for me.

It is Saturday morning and I’m sitting up in bed in a comfortable apartment in Amman, Jordan.  As usual, my current mission was not confirmed until days before my departure.  The disaster in Haiti threw another wrench in the works – but the combination of my embarrassing French and more extensive clinical experience and diplomatic skills (?) convinced Paris to send me to Amman and their Iraq Surgical Project.  MSF was forced to pull Expats out of most of Iraq in 2004 due to security risks despite injured civilians suffering from the weakened healthcare system and fleeing of many physicians out of Iraq.  Thus was born the idea of transporting patients who required complex surgical reconstruction and rehabilitation to the capital city of Jordan, where MSF has contracted

operating room, ward and clinic space from the Jordan Red Crescent Hospital.

And so on Monday, I left at about 10:30 a.m. for the Calgary International Airport, arriving well before the lines formed.  My only request to the T.O. office when booking my flights was to avoid Air Canada, if at all possible (I’m bored with their poor service, depressed & grumpy staff and inflexibility).  Unfortunately, Lufthansa’s airplane coming to Calgary was delayed due to snow and bitter cold in Europe, so I started my adventure with a five hour wait.  With the delay, my connection time in Frankfurt was too short, so they moved me onto a later flight to Paris, thus providing me with another three “free” hours in Frankfurt <sigh>.  I dragged my butt into the MSF office in Paris Tuesday afternoon, 21 hours after leaving my house.  I did manage a few hours sleep on each flight (hamdu lillah – thank God – for Zopiclone and red wine) so I only felt HALF done in.

An advantage of the late arrival was a VERY efficient briefing schedule.  No-one wanted to hang around after 18:00, so I didn’t have any long waits.  I was out and on my way to the hotel in short order – I even had time to help the communications department with an English voice-over on a couple video clips from the emergency project in Haiti.  Wednesday morning I went straight back to Charles de Gaulle Airport for my noon flight to Amman on Royal Jordanian Airlines.  I planned lots of time to buy duty free (cheese, chocolate, magazines, etc.) for the team in Jordan.  Most everything is actually available in Amman, but the Paris office suggested real French cheese might go over well.

On arrival in Amman, it took me a little while to get through Passport control (since I had no clue the address or phone number of where I was staying – not to mention I still have TWO Yemeni visas in my passport), but once I thought to show the copy of my MSF Mission Order, all problems went away.  I was a little stunned with jet-lag and managed to tip the guy who insisted on helping me with my suitcase 5 Jordanian Dinar (nearly $10 Can) – I figure I made his day.  JD have Arabic writing on one side and English on the other – I’ll have to look a little closer from now on.  Since I’m still healing from my hernia repair on New Year’s Eve, I didn’t really mind him schlepping my 30kg suitcase up onto the X-ray belt leaving the airport.  It was dark by the time we left with our driver, so I didn’t get to see much of the city on the ride to our apartment.

hospital outside

Each MSF surgical mission can be radically different from the last.  In the short time I’ve worked with them, I’ve looked after acutely war wounded, obstetrical emergencies, delayed obstetrical complications and (most recently) delayed reconstructions from violence or burns.  As in Gaza, the patients I will look after here in Amman will be having (semi-) elective reconstruction of injuries – many of which were sustained years ago.  Their caseload includes complex maxillofacial reconstruction, orthopedics and plastic surgery.  They run two operating rooms with two Iraqi Anesthesiologists – my arrival provides them the opportunity for well-deserved vacations.  There are also two anesthesia assistants, so we have lots of hands available for procedures and monitoring.  Since many of the maxillofacial patients require awake fiberoptic intubation, the extra help will be welcomed.

living room

My accommodations are, again, similar to those in Gaza.  We have an apartment in a residential area close to a large grocery store (Safeway!) and produce market.  There are no security risks so we are free to walk throughout the city and to travel around Jordan in our free time.

books@cafe

The Expat team is small and I only have two room-mates, our Psychiatrist and Pharmacist.  The apartment is some distance from the Hospital, so we commonly car-pool with Arielle (Field Coordinator) and Jorg (Medical Director).  Yesterday, the five of us spent the day starting

Al-Rainbow street signCitadel & cityscape

with a huge breakfast at the landmark Books@Cafe on Al-Rainbow Street, followed by a

Temple of Hercules
Temple of Hercules

walking tour of Citadel Hill (Jebel al-Qal’a) and surrounding shops.

Street names and addresses are a relatively new invention in Amman, and most people completely ignore them.  Instead, you have to ask the taxi to take you, “across from the Royal Jordanian Hotel,” or,

Umayyad Palace

Umayyad Palace

“up the street from the King Abdullah Mosque.”  Taxis and food are relatively cheap:  the 20-minute ride from the hospital to the apartment runs ~ 1.5 JD and I stocked the fridge with milk, eggs, cheese, bread, cooking oil, spices and a litre of pop for 10 JD.

Hiking up and down the narrow streets and stairways helped with the guilt (and calories)

stairs downplaystation

associated with our 5-course breakfast – and allowed us to justify dessert and coffee at the end of the day across the street from the beautifully maintained/ restored Coliseum.

Coliseum - farColiseum - closeup

All in all, a fascinating collection of old and new – Amman will be a lot of fun to explore.

Metal-plating replicas of the Dead Sea Scrolls

Metal-plating replicas of the Dead Sea Scrolls

Arriving home near dusk I had just enough energy for a few quick Emails before falling unconscious into bed at 9.

I finally had a drug-free sleep, waking a few minutes before the 04:30 call to prayers.  The voice, acoustics and speakers nearby are excellent, so it isn’t a bad way to wake up.  We have internet access (although I have been unable to get WiFi to work and have to sit out in the cold living-room…don’t cry too hard for me), so I will finish editing photos and start the Blog-posting clearance process ASAP.  Tomorrow we start the new week, but today I can be lazy and hedonistic (a new experience for me –LMAO) .

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