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 (3rd
year resident), Victor (intern), John (4th year resident), Dr. Many
(consultant/attending), Patricia (1st year resident), and Lando (2nd
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,
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