FEB-B-3
ON ARRIVAL IN
AN UNCOUNTABLE CROWD OF
PATIENTS AWAITS,
WITH OVER A THOUSAND QUEUED UP FOR THE MEDICAL
CLINIC AND HUNDREDS MORE
FOR THE SURGICAL CLINIC,
WITH A RAPID TRIAGE OF THE LIST
OF THOSE WAITING,
SEEING CLASSIC ADVANCED
PATHOLOGY,
AND BOOKING A DOZEN CASES, INCLUDING THOSE WHO
FOLLOWED US DOWN FROM HARGEISA, TELEVISED SURGICAL WARD ROUNDS,
AND THEN A LATE NIGHT CLINIC CLOSING THE DOOR
AS PATIENTS ARE STILL COMING IN TO OUR EXHAUSTED TEAM
And, so, to
begin. We set up the medical clinic with
an adding room for the ‘women’s health” clinic, concentrating the nurse
midwives in the latter room and deploying the senior GWU medical students in
the large clinic dispensary room with our translators evenly divided between
those who came with us from Hargeisa, and those
The long queue of patients would be subdivided here into a stream of women who would be seeking the services of a Gyn or perinatal clinic (it remains odd for me to hear the term “Women’s Health Clinic” and to realize that this is applied despite the fact that they do not do Pap Smears or breast exams!—an oversight which would constitute malpractice in the developed world.) The remaining general medical and pediatric patients would be divided into two streams going to seek help at two stations manned by one of two senior students, beginning with ER doc-to-be Jay Maguire and Family Doc-to-be Kevin Bergman, while I took the third internal medicine/cardiology doc-to-be Juan Reyes with me to the next door Surgical Hospital where we would begin the screening of our won queue of self-selected surgical patients---those who were triaged to surgery because they had wounds, tumors, congenital abnormalities or quite obvious problems that would require surgical attention, like fractures or burns. And, so, to work.
A FASCINATING PANOPLY OF SURGICAL PATHOLOGY
TUMBLES THROUGH OUR SURGICAL CLINIC
IN A RAPID SEQUENCE OF PATIENT CONSULTATIONS
As I had advertised it to be in advance to the senior students who had started their week frustrated by their lesser activity in smaller numbers of patients with less significant illness, they had now dived into the “deep end of the pool.” In a nearly overwhelming whirl of rapid patient flow, I screened several hundred patients in our surgical clinic with the whole gamut of advanced tropical surgical diseases in a moving picture atlas that would have made a video of African illness in advanced stages. The treasure trove of learning experience was so intense that each medical student realized that exposure of this sort had to be shared, and the senior student assigned to me in the surgical station rotated around twice over for the duration of our clinic until all such patients had been seen on our side of the hospital. The only break the students had from the patient flow was in the run over from the surgical clinic to the medical stations to spell one of their colleagues there and send them over to see the “just wait until you see this!” quick patient presentation list breathlessly passed along to the incoming student. Some of the more fascinating patients were held over so that two of the students would have a chance to see them, the one student leaving the surgical clinic and the other one coming over on duty. It was almost like having a conveyor belt conducted by the surgical theatre staff as door keepers continually re-filling two chairs in front of me opposite a pair of translators.
We had met the surgical staff on
arrival and had made a brief stop at their Theatre facilities to drop off the
duffel bag of surgical instruments, sutures, sponges and dressing materials
with catheters and the like. The
reputation of Suleiman had preceded him, since he was the spark plug, the
“positive deviant” who was an OJT orderly, essentially, who had previously
worked in Hargeisa Group hospital, and now was the “Surgeon-in-Chief” at the
big Italian-designed and –built Berbera Hospital. There were several doctors; many of them had
gone to school in
With Suleiman, Hadid, and Ismail as
my “chief residents pro tem” we opened the clinic door, and triaged through the
mass of waiting patients that tumbled or staggered through the doors. We saw, in no particular order, a “surgical
list” of patients that included the following:
a pelvic gunshot wound had left a severed bladder neck and now a
consequent stricture of the urethra.
This patient would need the operation we had just carried out in
Hargeisa with the other two patients who had been recommended to accompany us
down here to Berbera, the “coals to
A “cold abscess” from a Tb psoas
abscess was pointing in the groin from a perirenal origin, and needed
drainage—like the large cold abscess we had drained in the woman in
Hargeisa. For the students who had not
seen her then, here was a duplicate patient giving the second chance, so that
no one could leave without seeing what a large retroperitoneal cold abscess
looked like—an opportunity vanishingly rare in the
A woman with a dermoid cyst of the ovary, which had twisted on several occasions causing pain, was confirmed on ultrasound—who will need an operation to remove it.
A young fellow with a failed unilateral cleft lip repair had retuned with a low grade infection that if unchecked would proceed to cause the necrotizing affliction known as “gnoma” or “cancrum oris.” We started him on local and systemic therapy and took his picture, adding him to the pre-op Op Smile list of patients to be electively reconstructed.
A recurrent right inguinal hernia, that had been repaired, but had probably been simply repaired without attention to the underlying reason for it having developed in the first place—increased intrabdominal pressure from prostatism.
A VVF that had been twice repaired,
and was now, again, recurrent. This
patient will need a more sophisticated operation, not a simple re-do of an
attempt at primary closure which will fail again, but a vascularized
muscle-based flap of new tissue brought in, like a gracilis flap or labial flap
graft. She, like all but the unique
patient I had seen at Hargeisa, had been abandoned by her husband and cast out
by her family, and was, as seems almost by definition for most VVF’s a “poor person” who needed charitable support
while going through this series of procedures, a specialized repair not
available here. She cannot get to the
“Hospital by the River” in
A child of about five had a large involuting glabellar (the space between the eyes in the front of the brow) hemangioma. I took a picture of it and pointed out to all who had suggested that this patient could be operated on today that this would be a big mistake. First, a lesion in this position might represent an anterior encephalocele or myelomeningocele which a surgeon should not stumble into by accident, since this would have neurologic consequences to the patient. But it is not only a hemangioma, but it is clearly going through the involution and thrombosis that is the natural history at about this age of six to eight years, so that we should get out of the way of this natural process of self-resolution and not meddle in it causing a lot of unnecessary risk and scarring. The staff could see and appreciate that this was a disease well on its way of curing itself, and that no treatment would be necessary, for a result that would be far better then any intervention designed to make it go away faster.
I then saw three consecutive hydroceles, two in young boys, and one in an adult. This is such a nice anatomic operation, that I booked each of these to be done more as demonstrations so that this—like hernia repair—is an operation that Suleiman should be able to do himself, not only, but he might graduate to the “teach one” stage here, in training someone else to fix them. Before the fixing, the important distinction to recognize is the difference between a hernia and a hydrocele since the treatment is different. The difference is demonstrable in these patients since the hydroceles are not “communicating”, i.e., the fluid is not able to be expressed back into the peritoneal cavity.
Then I saw a series of clefts: three lips, one unilateral (the kind I can take on in repair) and two bilateral (the kind I would recommend that a “real plastic surgeon” approach, since it is an elective operation and the best chance at the optimum result is the first carefully planned and executed switching of flaps for best outcome.) I saw an additional pair of cleft palates, one with and associated unilateral cleft lip, in a child about ten years old, an age to which such a patient would never mature in an environment in which the resources were available to have had a go at this earlier repair. I saw later an adult bilateral cleft lip. This is significant twice over. First, I was seeing the patient, so it was not for reasons of reluctance to have the condition corrected that it had not been attempted before. And, second, it had never been attempted, even by an “amateur” would be plastic surgeon, meaning they simply are not available here, and no one had stopped by looking for such abnormalities to fix, or this patient who was more than willing to be forthcoming for repair would not have reached age thirty five unattended.
I saw one of the tragedies of a missed pediatric care in a nine year old who had a post-meningitis acquired cortical deafness. The child survived the acute infection, perhaps because it was partially treated, but there were other neurologic deficits as well consequent to the scarring of the post-meningitic state.
A young woman had a colostomy, secondary to an abdominal gunshot wound. This is significant, since she is the only patient I saw with a gunshot wound to the trunk—abdomen, chest or axial spine and head, whereas the wards are filled with extremity gunshot wounds. You know that no one here is selectively aiming at the extremities with the intent to maim, rather than kill. The implication is clear—anyone hit anywhere except in the periphery with the kind of weapons available here is going to die, and will not persist for later treatment This woman was the single exception, and it was because she was closely attended during her gunshot wound, made, as all of them seem to be here in the Horn of Africa, with the one kind of weapon readily available. All gunshot wounds I have seen here are inflicted with the high velocity AK-47, imported in lavish numbers from the mass production of the former Soviet Empire or its client states. This reliable, and nearly indestructible devilish instrument can faithfully spit out large volumes of very high velocity small rounds that tumble in their trajectory after striking anything that disrupts their rifled spin, like clothing, bone, or foreign bodies, causing a great deal of tissue damage in the tumbling deceleration of the unstable round. There would not be the same pattern of injury if the predominant weapon were a low velocity round such as a handgun, or the “nuisance weapons” like “Saturday night specials.” These gunshot wound victims can survive wounds to the trunk since the lower velocity allows simple penetration without the wide track devitalization that come s from a higher velocity deceleration. This whole society has become a military wound target, unlike the urban violence and antipersonnel devices available in the “developed world.”
This woman survived a close range
high velocity gunshot wound with an AK-47 round, but she, too, experienced the
devastation of this bullet’s deceleration force. She was shot at close range by an acquaintance
pointing an “unloaded” AK-47 (“Automatisch Kalashnikov, 1947 vintage”) which
penetrated her colon, which had been exteriorized by Suleiman in a colostomy
now ready to be taken done and reconnected, but not without the collateral
damage of a disrupted spinal cord which left her paralyzed. The bullet does not have to transect the cord
to damage it, since the nearby passage of the high velocity round causes a
“wound channel” that is “sonicated” in the shock wave around it, so that a near
miss of twenty centimeters away will exceed the elastic limit of the tissues
stretched out in the shock wave passing through the tissue to disrupt blood
supply and function of the spinal cord.
We booked her for an elective colostomy closure tomorrow. This is a pretty young woman, whose life is
wrecked by the passage of this random bullet through an unintended target. There are no rehabilitation services here for
her, and she has gone from a vital young pretty woman to an instantly aged
invalid. This is one of an endless
litany of tragic stories that in sum, but not exclusively, characterize
An elderly (by local African
standards—a sixty-year-old) woman was brought in with a clinically obvious
breast cancer. There was a hard mass
fixed to the skin and free of the chest wall that was a T-3 tumor size but
without palpable axillary nodes. This is
an unusual lesion in an African woman, but is likely to be the slow indolent
tumor of the kind that the patient would die with, rather than of. WE booked her for Total (simple)
mastectomy tomorrow. This is more like
American pathology than African since carcinoma is rare in comparison to the
A woman was seen with a huge
ventral hernia. She had a large
diastasis rectus
with a large hernia which went in and out without any signs of
obstruction. She could be treated simply
without danger by a Scultetus binder, an ancient dressing of alternating web
strips that in her case is a better substitute for an operation that would
require the implantation of some kind of foreign body graft materials.
I saw two bilateral web contractures of the upper extremities from flame burns. One was still mobile with ability to use the upper extremities well and need no surgical therapy now. The other needed a Z-plasty release of the web contracture in order to restore upper extremity mobility.
One young man had had a shattered femur and now had a healed fracture but with trophic ulcers, since there was neurologic impairment of the leg at the time of the fractures. This needs to be treated since he will otherwise lose the insensate leg. When it was pointed out that we should treat this ulcer aggressively, as if it were a foot ulcer in a leprosy victim, I pointed out that the leg might not have sensation, but it was useful in weight bearing as he could walk, and that it was much more functional than a wooden peg, which is the best he could resort to in the otherwise inevitable outcome if untreated, since there were no prosthetists nearby nor PT training programs.
I saw two foreign body injuries with broken off thorns from running through the desert bush. This would be a constant source of infection until the foreign body is extruded or removed. I had pointed out earlier that the desert thornscrub is definitely a user-unfriendly environment that is well defended even before it was seeded with landmines.
I saw two complications of FGM. One woman had a dermoid inclusion cyst from the infibulation she had undergone as a young girl that had tuned in some epithelium in the suturing of the labial remnants. Another patient was a relatively young woman with symptoms of urinary tract obstruction and infection. On examination she had what would have been called a Bartholin Cyst if she still had labia, but it was a mucocele from a turned in vaginal mucosa buried in the suturing she had had of the remnant labia. It is not bad enough that the people here have abundant natural illnesses befalling them, but that there are additional contrived burdens from inflicted suffering.
A young woman came in with a
flowing robe and silently stood waiting until I had finished with the prior
patient. Then, wordlessly, she raised
her robe to reveal her legs. One was
normal. The other was the classic
tropical disease—
I saw two more urethral strictures, one from Gonococcal urethritis and the second one from a pelvic fracture that had impinged on the urethra
I saw goiters galore. Two of the goiters had very interesting patterns of depigmented spots over them having been treated by a local native practitioner which left a polka dotted pattern of burn marks. This emphasized the sincerity of the woman’s wish to be rid of this mass. I gave iodine to see if it would shrink it down, which would put the depigmented polka dots closer together in a grid mark pattern if the treatment were successful. I treated at least ten other goiters that were symptomatic only in causing some difficulty swallowing, but none impinged on the airway or I would have selected such goiters for thyroidectomy while we are visiting here.
I saw two patients with polio who had the deformities of denervation at an early age. One could benefit from an arthrodesis to make the weight bearing on a stable leg possible. “Orthopedics” means “straight child” and I thought of this as I imaged “straightening out” several congenital abnormalities, including two talipes equino vera (club feet).
Two young children came in with trachoma, one unilateral. We treated them with the antibiotic eye ointment, but hoped to prevent blindness in one of them and the other one would be a candidate for corneal grafting if such were available in this environment, which is unlikely for the next decades at least.
Three patients had prostatic obstruction, tow on the basis of benign prostatic hypertrophy and one with a smaller but firmer hard nodule suspicious for prostatic malignancy. That latter we booked for operation.
I saw three salivary gland tumors, two in the parotid, and one in the submandibular gland. We booked one of the parotid tumors for operation.
I saw two cases of osteomyelitis, one with an early involucrum that would require many more weeks of callus formation in order to insure a stable weight bearing lower extremity without the risk of a non-union pseudo arthrosis. The second was a primary osteomyelitis from hematogenous spread in a patient that we would study by checking of sickle cell disease to consider the possibility that the infecting organism might have been salmonella. A simple way to check for sickling in an environment in which there is no hemoglobin electrophoresis is to wrap a rubber band around the fingertip to allow a period of tourniquet time desaturation. In the hypoxia that results in the finger tip environment of the tourniquet rubber band, the red cells assume the sickle shape—a cheap substitute for a fancy test which is as definitive.
COMPLETION OF SURGICAL OUTPATIENT CLINIC,
AS THE MEDICAL OUTPATIENT WAITNG QUEUE BECOMES LONGER AND MORE RESTLESS
In screening over a hundred surgical patients and demonstrating the pertinent positive findings to the rotating team of senior medical students, I booked over a dozen patients for operation and had to throttle back a bit to consider our operating Theatre capacity, but we did manage to treat or defer the majority of the patients to get some therapy started. It was a fast-paced clinic, unlike the medical clinic to which I moved after clearing all the patients from my previously crowded waiting room area. The pace was slower over in the medical side, and at the rate the patents were being seen, there was no obvious diminishing of the waiting queue outside the medical clinic stations. In fact, it appeared that the patient accrual was gaining on them by the time we had suggested that it might be a good idea to break for a late lunch. The waiting queue of medical patients represented the Biblical “cruise of oil that never ran dry.”
LUNCH BREAK AT
“THE HAB”,
A RESTAURANT
THAT MEANS “THE SHORE”,
OVERLOOKING
THE
We had to
walk away from a lot of anxious patients who had crowded the doors of the
medial clinic and were eager to be the last patients seen at the morning as we
were inching into mid-afternoon. We had
to break it off, however, and those patients assumed the strategic positions at
the door way so that we could not get back in after lunch without them spilling
into the clinic which was still running after I had shut down our surgical
clinic. We went over to the ‘HAB” a
restaurant whose name tells you where it is on the shore of the
The mayor of Berbera had come by to
see that we were going to be accommodated well, and he supplied a TV crew to
follow us around on rounds as we returned from lunch. The midwives in their traditional head covers
and
As we went along from one to another of these pulverized bones and protruding sequestra, a cameraman followed me as I examined wounds and reviewed X-Rays, and continued the coverage for whomever he was filming. It turned out that this was the mayor of Berbera’s idea and he wanted to show the film on TV as well as make sure I had a copy to bring back to America with me—a gift he was going out of his way to make sure was ready for us before our departure.
The simple traction apparatus was made of a boxed wooden contraption with old IV tubing used as rope and a sandbag for traction around a pulley scavenged from the sailing dhows and maritime supplies. All the patients were encouraged by our presence and I made cheerful comments to each of them, saying to one who had an external fixators applied to his leg with a large missing segment of bone in between the pins that held it externally in place “Your leg would have been a lot shorter if you had come under my care at the time months ago when this injury occurred, so you certainly came to the right place where they did such a good job of it!” No matter that the eventual outcome will be the same, the patients and staff were encouraged by this assessment, much more so than they would have been by the realistic appraisal of the likely therapeutic failure of such a flail extremity.
Another patient had a large mycetoma of “Madura foot.” It is a very slow growing fungal infection that everyone has time to suggest some new kind of treatment for it, including lysosomal incorporation of the antibiotics used to treat it, which are not very effective to begin with, and the long term future for these patients is a lot of misery attending this stumpy foot until it is finally replaced by a stump of a different sort.
One patient who had been injured very recently and was acutely ill was a high ranking justice of the courts here and had a closed head injury and was in a coma. A very large and attentive family was holding him down as he seemed to have periodic seizure activity. That seemed to be the only therapy he was getting at the time, and he had the very bad sign of blood coming from both ears signifying a skull base fracture. But, the good news is that he as still here, and he had not got worse. With a little prompting, the family seemed to note a miniscule amount of improvement, and they were encouraged to think that the patient would be coming around to full consciousness. AT this stage such watchful optimism is perhaps the best kind of treatment he could get, whereas he would have had a “full court press” with steroids, mannitol and hyperventilation in the first hour after his injury if he were in some from of trauma center. But, however high ranking he is or was in this Berbera society, he has got the best and worst of the hospital care available, and so must be encouraged toward the best outcome the circumstances can afford right here.
We made the rounds of the very extensive number of orthopedic patients who seemed to be “bed-fillers” and who were sitting through the long and slow process of knitting bones or watching them get extruded in pus. Once again, I noted that it seemed that there were only extremity gunshot wounds that were alive to make rounds on, and with the single exception of the pretty woman with the colostomy scheduled for closure tomorrow, no other wounds of any hits in the thoracoabdominal or head anatomic regions were around to be discussed no rounds.
We swooped through two other wards
as a “fly by” with less advice to make and recommendations for change in care
plans—one woman who was an habitual aborter but who had a competent cervix I
had recommended be tested for brucellosis, a simple test that if they cannot
do, we might carry a sample back for the laboratory at Edna Aden Hospital. One of the staff members had a brother, also
a hospital employee, with a rock hard mass in the posterior cervical triangle
that appeared to be a very fixed malignant lesion, which we will biopsy, and carry
that tissue with us back to
I GET THE BELLHOP SERVICES OF NO LESS THAN
“HIZZONER HIMSLEF”
AS WE ARE ASSIGNED ROOMS IN A BARE BONES FUNCTIONAL HOTEL
Before we headed back to clinic, we
were brought to the hotel that would be our base here—although we were fated to
be resident in it for only a few hours that night. As I looked around for my simple carryon bag,
I could not find it, and in going down the hallway, I was surprised to see the
Mayor of Berbera carrying it to be sure that he had the honor of installing me
in my own room for the night. He is a
friend of Saad Noor in
We went back to medical clinic,
where we fought our way through a crowd that did not appear to be at all
diminished from the one we had encountered in the first appearance at the
I stationed myself behind the pharmacy stock of our drugs: two large duffel bags packed with most of the medicines that we had remaining. I could see three stations of translators and nurses with each of the students and the smaller room where the midwives were rapidly at work with a large number of women who were coming in with complaints related to what in my youth was demurely referred to as “female trouble.” One of the nurses who was male would occasionally bring me a patient as I nodded off in the chair at the back of the room in my backup position there, and point out that this patient was special since he or she was related to someone in the employee group. One rather large woman had complained of hemorrhoids and had undergone a traditional therapy of some unknown sort that had left her with a complication that is called a “wet anus.” This is due to the progression of mucosa outside the anal sphincter and its advance onto the skin of the perineum, the so-called “Whitehead deformity.” I do not know what treatment the native practitioner had used, but he had achieved a result usually only seen with radically heroic attempts at extended hemorrhoidectomy.
I was ready for this clinic to end,
considerably longer than any of the patients who were still counting on being
seen and were still lined up outside the door.
As it got to be
It is hard to get away from Tar
Baby once you have struck out and made contact.
The whole continent is connected to the one patient you are engaged in
seeing at that moment, and they are unaware of time zones and other factors
that may make the health care provider less than eager to take on yet another
single case, and if that one, why not just one more? It was