Habari za leo!
Another photo essay: a potpourri of the last week.
The White Coat Ceremony for the new interns in the surgical program. I've been to only one White Coat Ceremony before, my own, where newly-minted doctors (or medical students, in my case) receive their brand new coat to signify the beginning of training. During the event I was privileged to serve as the photographer. For each of the residents the attendings said an aspect of their character that they admire, shared a verse or two, and then "coated" the resident.
One of the more enjoyable games to play at a training institution is to have the medical student interpret the grossly abnormal image. It is an important game and an important part of learning: often the grossly abnormal images have something that is grossly wrong meriting intervention. I took one stab at this one (combined hydropneumothorax) which was incorrect. After looking at it for another ten seconds the light went on my head and I thought "what is to the left of the heart is not usually in the chest...it is in the belly!" What had occurred was a traumatic diaphragmatic injury and the intestines (in this case, the transverse colon) wound up in the chest. The repair went well and the patient is currently still recovering from her multiple other injuries.
Big news from Kenya: I will be a general surgery resident! For the next five years the majority of my time will be spent at St. Joseph of Mercy Hospital in Ann Arbor, Michigan. I am beyond thrilled and blessed to start there in July.
The Match process is an odd one: every single medical student finds out on the same days whether or not they've matched and then where they matched. It is a nervous/exciting time and this stress was slightly compounded by being in Kenya. Last Friday I was sitting by the computer hitting the refresh button - you can see the Gmail loading screen on the larger monitor.
The day after Match Day a number of the volunteers and I went on a trip for the weekend to the Massai Mara. We were able to see a number of animals: elephants, lions, zebras, hippos, crocodiles, gazelles of many sorts, warthogs, and others. More beautiful than the animals, though, was the landscape. Mara actually means "spotted land" and one can see why: the plain is dotted with termite mounds and trees. It was good to get away from the hospital. While on the drive I thought of Psalm 19: "The heavens declare the glory of God; the skies proclaim the work of his hands. Day after day they pour forth speech".
Pathology:
(at times one does not write things for others; one writes for one's own self)
Yesterday I was working with Larissa, a talented general surgery resident at Brown who is also completing an away rotation at Tenwek. It was to be the last case of the morning and we were in a bit of a rush to get finished as if we completed things on time we could make it time to actually eat, rather than inhale, lunch. Cases are listed in the standard fashion: Patient name, Patient age, Patient sex, Patient ID number, Preoperative diagnosis, and Planned procedure. SC, 25, Female, ______, Grade III Decubitus Ulcer, and Debridement of wound.
After hurrying anesthesia to get the room assembled the patient was rolled back into the room. I was struck by how young, and yet how old the patient appeared. One could tell that she was young and yet did not appear young; she had the appearance of chronic illness. Her skin was sloughing. Sitting in her chair she could barely sit up straight due to weakness and deconditioning and was in obvious discomfort.
Wound debridements are not complicated procedures: if the tissue is dead and will not heal, it needs to go and is only a hinderance to further progress. It was a busy morning and I was just stepping in to help, so I was reading about the patient as she was being brought into the room.
In summary, SC contracted rheumatic heart disease as a child which lead to bacterial endocarditis causing salmonella sepis resulting in prolonged hospitalization which was what lead to her decubitus ulcers necessitating a debridement on the morning of March 23, 2015.
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Complex statements are best broken down into simple parts.
Strep throat is an exceptionally common condition which is exceptionally well-treated by penicillin. (Penicillin was discovered in the 1930's. This was more than 75 years ago.) If left untreated, strep throat can lead to rheumatic heart disease, which is an abnormality in one of the valves in the heart, the mitral valve. Any time that a heart valve has an abnormality there is the potential for bacteria to grow on the abnormal heart valve, forming a vegetation which cannot be treated except by surgical removal and replacement of the valve. Left untreated, these valves are prone to a condition called infective endocarditis, when bacteria grow on the abnormal valves,which causes someone to be chronically septic with bacteria living within the bloodstream. Sepsis is a severe illness requiring prolonged hospitalization and IV antibiotics. Prolonged hospitalization can lead to prolonged immobilization which puts prolonged pressure on certain points in the body, including the tailbone. Over time the tissue loses its blood supply and dies. Dead tissue falls away and leads to ulcers.
Woven into the story are so many places where proper care would have not lead us having to debride a 25 year old's grade III decubitus ulcer: timely treatment of strep throat, surgical management of her heart valve prior to developing endocarditis, simply turning the patient when she was septic and bedridden, tissue flaps for definitive coverage of her sacral wound, etc.
When we brought the patient up onto the operating table and exposed the wound I will never forget the waves of anger that washed over me. The mood in the room changed in an instant from a quick case that was standing in our way before lunch to a direct and ugly encounter with suffering.
Her decubitus ulcer was a circular wound that was 8 inches in diameter and 2 inches deeps with a large piece of tissue in the wound hanging on by a thin strand that had clearly been dead for at least a week. I could see the coccyx, or tailbone exposed, which meant that by definition it was infected. Whitish fibrinous material coated the base of the wound. The patient was put under sedation and remained comfortable while we removed the dead tissue to a point: one can only take so much before taking too much.
For definitive closure of this wound she would have to have her sepsis treated, be placed on parenteral nutrition as she was evidently malnourished, have her heart valve replaced, and then have a complicated tissue flap be placed so that her would would heal. I was aware of this while helping out with the debridement and it became clear that what we were doing was in actuality quite futile. In addition to her debridement she needed to clear her sepsis, she needed a new heart valve, she needed a plastic surgeon to close her wound.
In light of a grade III decubitus ulcer on a 25 year old patient whose long spiral downward was punctuated by multiple points at which her course could be reversed one begins to question. Why? Why is there no plastic surgeon here to give definitive closure? Why is it that a 25 year old has such a gaping wound? Why is it that she has not been able to get a new heart valve? Why was it that she was not treated appropriately for her strep throat while a child?
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Pathology.
The pathology here at Tenwek is so advanced, advanced beyond anything I have seen during medical school. This morning a 27 year old man died of a subclavian artery aneurysm. A 2 year-old child with burns died while I was on service because she aspirated. A 34 year old woman died because we couldn't close her abdominal wall long after her bowel perforated - this happened immediately after being pregnant she left behind many children; I helped to code the patient in the operating room. A 28 year old man died from complications in the ICU after completely severing his spinal cord after falling. A 68 year old woman is dying of her sigmoid colon cancer because she did not receive screening. At 25 year old woman is dying of her infected heart valves. I could go on and on. I have only been here at Tenwek for two weeks. Many of the missionaries here at Tenwek have been here for more than 15 years.
After a while the question ceases to be a "Why?", but a "How long, O Lord? How long?" And at times the questions progress to "How can God exist?" This line of questioning leads to the abyss.
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I will always question "Why?" and even at times travel a distance down the dark road of questions. But the rock of Christ's passion returns me to what, by faith, has been revealed to me to be true: God himself has come and suffered along with us.
He is despised and rejected of men; a man of
sorrows, and acquainted with grief: and we hid as it were our faces from him;
he was despised, and we esteemed him not.
Surely he hath borne our griefs, and carried our sorrows: yet we did
esteem him stricken, smitten of God, and afflicted. But he was wounded for our transgressions, he was bruised for our
iniquities: the chastisement of our peace was upon him; and with his stripes we
are healed. All we like
sheep have gone astray; we have turned every one to his own way; and the Lord hath
laid on him the iniquity of us all.
Isaiah 53:3-6, KJV
BWANA akubariki na kukulinda,
BWANA akuangazie nuru ya uso wake na kukufadhili,
-John
