Community.

Bon jour!

Life continues here in Togo.  Rhythms are established - waking, devotionals, rounding, operating, clinic, lunch, clinic, dinner, tucking patients in for the night, reading, and sleeping.  Of course, there are the occasional emergent cases and wrenches thrown in the schedule, but there is a beautiful simplicity to it all.  Yes, life is busy, but I am happier that way:  I go to sleep feeling that I've earned a night's rest.  And less than a week until I leave.  One of the difficult parts of life as a medical student is that once you learn to function in a given setting are whisked away.

A brief photo essay: Snippets from Togo.

Doughnuts.  Every Saturday we play basketball in Mango with the Togolese and it is followed by fresh-from-the-oil doughnuts made by the Wegner sisters.  Sumptuous.

I gave a small piano concert for the folks who work here.  First half: Debussy and Chopin.  Second half: Rachmaninoff and Beethoven. 

Dr. Nathan Huber and myself.  It was a big, big blessing to work with Nate for the past 4 weeks.  He is a great surgeon and even better person.  If I turn out to be like him when I am done with training I will consider myself a success.


Community:

One thing that has struck me, both in Kenya and Togo, has been the warmth with which I have been received.   The depth of relationship between people who work here at the hospital is astounding: they have truly been through it all.  

After spending any length of time in Africa one finds that things simply run at a different pace.  Accomplishing a task is much different in Mango than it is in the States.  Everything that has been a part of the hospital was shipped 10 hours north from Lome on a dirt road on massive containers filled to the brim by volunteers in Michigan.  Then, teams of construction workers have come out to construct the hospital.  Finally, there are volunteers from the US ranging from laboratory to pharmacy to nurses to physicians to landscapers to administrators.  This common purpose, building a hospital in Mango and all of its associated frustrations, has forged a truly unique bond.  I cannot begin to imagine how painstaking it must have been to build the hospital; it truly has been a dream over a decade in realization.

Despite being such a tight-knit group I have been welcomed with open arms.  The surgery department is headed up by Todd DeKryger, who does everything from Orthopedics to Gynecology to General Surgery to Family Practice.  Dr. Nate Huber (from the picture above) has stepped in to help out Todd during the opening of the hospital with coverage of the surgical service.  Every other night for two months they have been on call.  And then there is me, the fourth year medical student.  Over my month here I've found a role - making rounds more efficient, seeing patients in clinic, lending an extra set of hands in the OR, sewing up lacerations in reanimation.  At work I have been very much included as a part of the team.

And I have been welcomed outside of work as well.  From doughnuts to the Weighers to basketball on Saturday to board games with the DeKryger children to movie nights on Saturdays to church on Sunday nights I have become a part of the life here at HOH.  Yes, I am very excited to go home, but at the same time, a part of me will remain here.

----

What is it that forms connections between people?  What is the basis upon which humans relate?  

There is utility: people benefit each other.  There is pleasure: people enjoy each other's company.  There is virtue: shared value.  The first two fall short - utility and pleasure soon fade.  Even virtue falls short: people are not virtuous at all times and all places and often fades.

And finally, there is a person that forms connections: Christ as Mediator.   That Christ does not just pave the way for us to be in right relationship with God, but also paves the way for right relationship with others, means that there is something eternal at the root; an unchanging Person forming the foundation of Christian fellowship.  Christ means that we can forgive each other and be able to love the other person as ourself, something that is so essential when working closely together with the sick and dying in the 105 degree heat.   It also means that a complete stranger can arrive knowing nobody and yet, somehow, feel entirely at home.

L'Éternel te bénisse et te garde! 

L'Éternel fasse luire sa face sur toi et te fasse grâce! 

L'Éternel tourne sa face vers toi et te donne la paix!

-John

12PM- 3PM of 15/4/2015.

Bonjour!

I am now on my second week here in Mango.  During my brief stay I’ve been reminded very acutely of why I decided to go into medicine (and surgery) in the first place: to help people who are suffering and in need of medical attention, serving them where nobody else is giving care. 

Nonmedical highlights of the past week:

•  a going away party for Kyle heading back to the States, complete with homemade doughnuts
• watercolor night
• working on a puzzle at the guesthouse
• sharing many meals with Sarah, an ED attending from Atlanta, and Heidi, a midwife from Washington
• dessert at the DeKruyger household followed by a victory in Settlers!
• Fellowship meeting on Sunday night
• Finding a place to live in Ypsilanti!  My Mom and Dad and Aunt Lynne and Uncle Kevin were instrumental in helping me find a condominium on Ford Lake!  What a blessing!

For the first time I’ve decided not to include a photo essay.  Currently my phone is dead and loading pictures takes a considerable amount of time.  I will be good about taking photos of my various adventures and promise to include an extended montage next week.

12PM- 3PM of 15/4/2015.

Following a mildly chaotic morning that included an amputation for a bleeding leg status post washout in a cirrhotic man in hemorrhagic shock and a chest tube for a girl with a parapneumonic effusion, a man came into the reanimation (the ER) with a complaint of sudden onset chest pain (what was really bothering him) and abdominal pain that started this morning when eating his porridge.  His history was difficult to gather as we had to go through two translators and he was in quite a bit of pain – it was a bit unclear as to what was going on.

                                                

We (Dr. Nathan Huber - a general surgeon from Indiana who has been phenomenal to work with over the past two weeks and myself) sent off labs (CBC, HIV, Malaria) and brought him down to radiology where we performed an upright Chest X-Ray.  Right off the bat we saw air under his right diaphragm: he needed an operation.

Our incision extended from his xiphoid process down to just above his belly button.   We entered into the belly safely and shortly thereafter found pus. After clearing out the pus with suction we looked around until we found a small hole in the first part of the intestine, the duodenum.  Three sutures later and a patch of abdominal fat, the omentum (a Graham patch) the man’s abdominal problems were solved.

This is the kind of case that makes me love general surgery:  a bit of uncertainty in the beginning, an efficient diagnosis, definitive one-step (we pray) surgical therapy, a young person without other serious comorbidities, and an excellent prognosis.

Following this operation we saw in clinic a woman from the Ivory Coast (quite a distance from Mango) who had some sort of intraabdominal catastrophe resulting in an ostomy and two places where her stool was draining through the skin complaining of nausea, sweating, and vomiting.  She is evidently not succeeding with outpatient therapy.  She needs an operation to close her EC fistulas, but prior to that time she needs to become nutritionally replete:  she appears like a living skeleton. An X-ray did not show blockage of her intestines and her electrolytes were within normal limits.   We thought that she is likely dehydrated and we are giving her fluids and seeing how she does; we will check on her in the morning.  She has a very bad problem.

After this clinic visit we had to go back to the operating room to help a woman pass the remainder of her placenta – this happened uneventfully.  While we were finishing up alarms for the medical gases started going off.  What was happening was that the oxygen compressor (a very expensive machine) had overheated and there were only two bottles of oxygen left for the entire hospital.  In short, a disaster.

Todd (an immensely talented and experienced surgical PA who functions as a general and orthopaedic surgeon here at Mango) and Sarah (my ED Attending friend who I share meals with) went around the hospital seeing if people really, really, really needed the oxygen.  If prognosis was poor, the oxygen was discontinued.  I sat while the walked around and just prayed – there was nothing else I could do. 

                                                      

We had another case going back to the OR – a septic hip in a baby – and Todd expressed his frustration to me: he had spent over one year raising support for L’Hopital d’Esperance and this hospital has been a calling for the past fifteen years.  For something as critical as the oxygen machine to go down during the first two months of operation of the hospital was disastrous and maddening and discouraging.

In the OR we found pus in the baby’s hip and were finishing the case following leaving in two drains to let the pus evacuate from the joint.  I walked out into the recovery room and didn’t hear the sound of the alarms indicating that the oxygen was low.  I went to Todd to let him know that the numbers looked better – we didn’t get our hopes up.  While walking back to the nurse’s station I saw one of the maintenance men, Allain, who reported that they were able to fix the oxygen compressor (the dust of the Sahara clogged the air filters more rapidly than the U.S. manuals would predicted – the filters were changed and everything started working), meaning that we wouldn’t have to deliver the hard news that we just did not have oxygen with which to support people with limited pulmonary function, from newborns with bad lungs to people who are recovering from their operation.  I started shouting (literally) and still have a big smile plastered on my face.

                                  

This is just a slice of what happens every day at L’Hopital d’Esperance, just at the surgical department.   Countless other happenings occur in pediatrics and in medicine.

What happens is a mixture of good and bad; disheartening and nearly indescribably joyous.  More than anything, there are answers to prayer.  

The heart of the people who work here is truly awe-inspiring.  Everyone has left friends and family to serve in the heat here in Mango.  And one finds that every single person has such a critical role to keeping a major part of the Mission’s work here at Mango, from the maintenance men to the nurses to the financial gurus to the physicians.  More than anything this reminds me of the body of Christ, which is the church: many parts doing their role to serve collectively as the hands and feet of Christ to a very needy, hurting, and broken world.

L'Éternel te bénisse et te garde!

L'Éternel fasse luire sa face sur toi et te fasse grâce!

L'Éternel tourne sa face vers toi et te donne la paix!

(Numbers 6:24-26, in French)

John Donkersloot

Give us this day, our daily bread.

Bonjour!

I’ve been in Togo for a week and am just getting around to posting.  Take note of the map that I made below with annotations for each leg of the journey:

(I could not find out how to make the map of airplane travel; I did not drive to Togo from Kenya, although it would have been quite the adventure.)

1: Bomet, Kenya -> Nairobi, Kenya: 5 hours

(Stayed in airport overnight due to runway construction.)

2. Nairobi, Kenya -> Addis Ababa, Ethiopia: 3 hours + 3 hour layover

3. Addis Ababa, Ethiopia -> Lome, Togo: 6 hours

(Slept in a gueshouse in Lome.)

4. Lome, Togo ->  Mango, Togo: 10 hours

Needless to say that I was (and am still) tired from the journey.  Wait until you hear about the journey back.

And now, my first photo essay from West Africa:  Bon voyage!  (Abbreviated from my initial conception as it takes ~7 minutes to upload one photo.)

The lunch stop en route to Mango from Lome, on the 10 hour van ride.  (Note the tree protruding from the restaurant.)  I enjoyed a hearty plate of spicy spaghetti while watching soccer from the English Premiere League.  And this may be too much information, but I do not yet have diarrhea.

From the drive.  On the 10 hour trek north the towns thinned out, we went through a stretch of mountainous land covered by forest, and then we hit desert.  Not the sand-dune desert you think of when you think of the desert, but just a  dry and barren land with scattered trees.

L'hopital d'Esperance, or the Hospital of Hope.  It was built by American Baptist World Evangelism at the request of the Togolese government and has been in the works for more than 7 years.  I have the upmost admiration for all of the people who worked so hard to build the hospital to serve the people here.  Coming in for just a month almost feels like taking advantage of their hard work.

Give us this day, our daily bread.

It is a rare opportunity these days to hear a true lecturer.  Not someone who just prattles from a powerpoint reading projected slides word-for-word – a lecturer: someone whose knowledge of a material is so deep and broad that brilliant thoughts skip off of their mind like stones skipping off a still lake.  The lecturer and thinker who comes immediately to my mind is Dr. John Patrick, the speaker at the Michigan CMDA retreat in February. One topic that he mentioned was the Lord’s Prayer.  He’s been praying it once in the morning through, and then once again, stopping on a particular word or phrase to try to delve into the depths of its inner meaning. Over the past two months I have been trying this practice to begin the day.

           

A phrase from the last week: “Give us this day, our daily bread.”

           

Here at the hospital there has been a water shortage.  It has to do with something to do with the pumps that put water up in the hospital’s water tower.  The regular faucets were shut off and people are having to use hand sanitizer (expensive) to wash hands in between seeing patients instead of regular soap and water. 

Another shortage is antivenom.  In the area there are a species of viper that is quite poisonous.  At this point there have been a number of mortalities from the bites  - the antivenom isn’t effective – and we the hospital has given most of its supply to people who have come in.  Currently there are 2 units left in the entire hospital, the amount that is given to a person upon admission.  Supplies just arrived Saturday, right when our stocks were completely depleted.

Earlier this week we performed a biopsy on a young boy who had a parotid mass, enlarged submandibular lympy nodes, and a soft-ball sized abdominal mass.  All of these findings point towards cancer.

Burkett’s lymphoma is very common in West Africa and he was started on chemotherapy.  The therapy worked – the tumors started shrinking instantaneously – but it worked almost too well:  he currently has a massive GI bleed from tumor surrounding some vessel in his abdomen shrinking at an incredible rate which caused it to bleed into his intestines.  Blood is coming out of his mouth as vomit and out of his rectum.  We do not have the normal tools (tagged red blood cell scans, therapeutic options with upper endoscopy, angiography+interventional radiology to localize and possibly stop the bleeding) like we would in the States.  

He received 3 units of whole blood and was in hemorrhagic shock.  The surgery team had been following closely along with the pediatrics team but we did not feel that there was a role for operative intervention in a malnourished boy who is on chemotherapy.  The decision was difficult, but the potential for operative mortality was exceedingly high. Underlying surgery is the premise of success, even when there is potential harm, and in the judgment of the staff the chances of successfully identifying an obscure source of intraluminal GI bleeding is low.  To compound matters there are not ventilators at the hospital, making postoperative care for the patient difficult, if not impossible.  As I walked home from the hospital one thought was going through my head: “Not every patient needs an operation before they die.”  The next morning when I went in his bed was empty.

Give us this day, our daily bread

Here at Hospital of Hope there are so many luxuries:  working OR lights, a working X-ray machine, general anesthesia delivered by trained anesthetists, suture selection, sharp scissors in the OR, excellent nursing care, and brand-new facilities.  Many places in the world do not even have these things that are the bare minimum in the US. The care that is being delivered here in this setting is nothing short of exceptional.  I am blessed to be able to work the people who are serving here.

Give.

On days that I halt on this line, often the word that I stop at winds up being Give. Plumbing to the depths of give alters perspective and brings back up gratitude. There are so many things to be thankful for in life aside from what I listed above: food, water, shelter from the sun, the ability to communicate with friends and family and loved ones, health, the ability to serve. Give causes one to realize that what one has is not his own, but provided from someone Else.  Not only this, it implies reliance on someone Else to provide.

So, here at the Hospital of Hope, we do what we can for people with the skills and tools we have been provided to the very best of our limited ability, pray, and let God do the rest.  And, oddly enough, there is a comfort to practicing medicine (and living) in this.

Au revoir,

John

Hope.

Habari za leo!

A theme I return to often is the swiftness with which time passes; my time at Tenwek has come to a close. The past month has been one of the most formational during all of medical school – I’ve been able to do more, make more decisions, worked closely with residents and attendings.  During my time here I’ve scrubbed on cases ranging from obstetrics to general surgery to neurosurgery to orthopaedics to urology to gynecology.  All of this has taken place under the guidance of the incredibly talented and compassionate residents and consultants (attendings) who are serving here in Bomet.  My goodbye is not a farewell.

A final photo essay from my time here at Tenwek:

              

(Warning: there is an intraoperative photo in the photo essay.)

A lot of the visiting crew sitting on the porch.  Closest to the windows is a small bench that is able to rock back and forth.  In the evenings, after work is done but before dinner, we will sit and just enjoy conversation.  

 

One thing that is quite abundant is Coca Cola.  Their marketing campaign of “Share a Coke with…” extends all the way into Kenya.  It is not clear on the photo, but this one said “Share a Coke with Auntie”.  To all of my dear aunts, this photo is for you.

One thing I love about Bomet is the abundant natural beauty.  The area is exceptionally verdant and flowers thrive: good soil, 12 hours of sunlight 365 days per year, temperatures in the 70’s.   Here at Tenwek there have been a number of the long-termers who have planted rose bushes – this example is immediately across from the guest house.  This past weekend with the watercolors I brought along I attempted to paint how I saw the rosebush, with varying degrees of success.

A uterine fiberoid taking up the entirety of the abdomen.  More on this later.

My last day on rounds.  From left to right: Damaris (chief resident), myself, Valentine (3^rd year resident), Victor (intern), John (4^th year resident), Dr. Many (consultant/attending), Patricia (1^st year resident), and Lando (2^nd year resident). 

Hope

The intraoperative photo was from a case my second-to-last day at Tenwek.  The woman had presented 5 years with a lower pelvic mass and did not want to undergo surgery – she was scared and wanted medical management. She returned to care with on a Sunday night complaining of abdominal fullness and difficulty breathing. A CT scan was performed which showed the mass filling the entirety of the abdomen all the way up to the diaphragm compressing the liver to the right, the entirety of the small bowel to the left, and the kidneys to the back of the belly.  Concerningly, we thought that there was blood supply to the mass coming from the retroperitoneum and as such had blood on hand when we went to theatre.  Dr. Hernandez, the Ob/Gyn who I became friends with and invited me to join in on the case, said “I hope we can get it out”. 

Fortunately the blood supply was not coming from the retroperitoneum (from behind – very hard to get to) but from the top, from the omentum.  First, we performed an omentectomy, taking out the parasitic blood supply. The neck of the tumor did not have any neovascularization and the rest of the case was similar in nature to a standard hysterectomy.  Dr. Hernandez and the other consultants were able to get the entirety of the mass out successfully with acceptably low blood loss.  In all likelihood the mass was uterine fibroids that had been allowed to grow for far too long a time.  Currently the patient is on her first day after her operation and is doing well – she has hope for a full recovery.

On my last day at Tenwek I rounded on the male surgical ward.  There were only three patients and I was expecting it to be much like any other day: look up vitals, read through the history and operation, check for ins/outs, examine the patients, and then present them to the team.

                                                              

Esophageal cancer is endemic in Kenya.  Dr. White, the chief of surgery and UMMS grad (Go Blue!  He proudly wears a Michigan Wolverienes scrub cap) trained at Brown then did a thoracic fellowship and has likely personally placed more esophageal stents than any other person alive.  The disease is insidious and presents late, with patients arriving for their initial clinic appointment malnourished usually with a tumor that is unresectable.  Ideally there is neoadjuvant (prior to surgery) chemotherapy; this is not available unless one is wealthy in Kenya.  Normally the cancer is present in older individuals but in Kenya the cancer shows up in the very young.  To this day nobody really understands the reason why.

                                              

The second patient I examined on rounds was an 18 year old male who presented to clinic with symptoms of not being able to swallow.  He had a scope put down his throat which showed a large mass – cancer – at the junction between his esophagus and stomach.  He was brought to surgery the day before to see if it could be taken out. Tragically the tumor had spread to surrounding structures and there were enlarged lymph nodes next to the aorta – it was unresectable.  Dr. White placed a stent and closed the midline incision. 

Being 18 years old and the fact that he was opened and then closed there was nothing acutely wrong with the young man – he was the definition of a stable POD (postoperative day) 1.  As I turned to go, I was asked by his father who was with him:

“Doctor, do you have any advice?”

Dr. White has published extensively on stenting in Esophageal cancer; posters and papers of his research decorate the upper floor of the theatre building.   The average length of survival after stenting is less than 1 year.  I was lost for words.  The last thing I wanted to do was offer false hope for a cure – it is one of the largest disservices one can do to another.

Knowing not what else to say I turned back and said after a long pause:

“Today is Good Friday.  Sunday is Easter.  Cling to Jesus.” 

I had to stop in the hallway to compose myself prior to seeing the next patient.

I would argue that Tenwek is the flagship program for the Pan-African Academy of Christian Surgeons.  Currently there are more than 10 residents per year and they have had two stellar graduating classes.  If I turn out to be a quarter of the surgeon as Dr. Agneta, who came from Tenwek’s first class, I will consider myself a success – by the end of her residency program she logged 5,000 cases, more than four times the average amount for an American General Surgery graduate. She is going to be leaving for South Africa, where she will complete a pediatric surgery fellowship.

The rest of the residents are cut from the same cloth.  A number of them have completed a 2 year fellowship in endoscopy.  During one week of my stay the upper level residents were in Mombasa at the Surgical Society of Kenya presenting research they had conducted.  One of the residents (residents!) is the assistant editor of one of Kenya’s major surgical journals.  Another is from South Sudan, training in orthopedics, and is going to go back to his homeland to be the sole surgeon in the area – he will be a busy man.

What is the function of a program like PAACS?  There are surgical residency programs in Kenya that are run by the government.  In all of the major cities there are places that train surgeons – what makes Tenwek different? 

Medicine is primarily a moral activity.  Yes, significant amounts of technical skill and scientific knowledge are required and are acquired throughout a lifetime of a practicing physician, but technical skill and scientific knowledge are not the ends of medicine. Instead, they are means to a moral end: the alleviation of the suffering of another human being by either prolonging life or by making its end more tranquil.

                                                     

Yet it is a grave mistake to think that suffering is consigned to the physical.  Anyone who has seen the long, slow decline of a loved one knows this to be true. 

The questions of “Why” are  sometimes answerable in a physical sense.  “Tumors grow for known as well as unknown reasons when control of the cell cycle spins out of control.  The tumor at the distal end of an esophagus is causing a narrowing of the lumen leaving normal contents unable to pass through distally.  Eventually, the tumor will invade through the wall into adjacent structures and seed surrounding structures.  Death will result from malnutrition leading to infection, invasion of the tumor into a critical structure, or some combination thereof.”   

But in the metaphysical, spiritual sense, the questions are much more difficult.  “Why me? Why the 18 year old boy?” 

                                 

These types of questions are not answered; these types of questions are journeyed through. It is this journeying process that the PAACS residents are being discipled through every single week through the example of the consultants, regular blue book meetings, and regular Bible studies.  They are being trained to treat the whole patient and walk alongside them during their journey, not just resect their tumors.   This type of training is what sets Tenwek and the other PAACS residency programs apart from any other I have visited.

It is because of the PAACS residents that the future of surgery in Kenya and beyond is bright, bright with hope.

Onward to Togo – it will be different, but good.

BWANA akubariki na kukulinda,

BWANA akuangazie nuru ya uso wake na kukufadhili, 

BWANA akugeuzie uso wake na kukupa amani.

-John