Thursday, August 15, 2013

Lap Choley

Should a laparoscopic cholecystectomy be attempted in eastern Congo?  That is a question that I am still asking myself.  It can be done.  We did one yesterday, but it nearly killed me.  There are a lot of machines to coordinate.  The patient has to be under general anesthesia, a challenge in itself.  There are video monitors on either side of the table.  You need an insufflator, a light source, a camera module, suction, cautery, trocars, specialized instruments, a gas source, clip appliers, endo-loops, etc.    In short, there are lots of moving parts, and whatever can go wrong, will go wrong.  I couldn't find the special cautery cord and I had to make one with a wire.  Burned/shocked myself in the process.  Most of the equipment runs off of 110V and our transformer can't quite handle the load.  What usually happens is that the ladies in the sterilization room turn on the washing machine and then the whole system shuts off.  It is unsettling to have instruments inside the patient and have no idea where they might be.  In the US we use carbon dioxide to blow the abdomen up with air.  No CO2 available around here, so I use a medical air compressor, which seems to work...except when it doesn't.  

I am the only one around who actually knows how to manipulate laparoscopic instruments, and I'm not all that good at it.  It's kind of like operating with chopsticks and doing it in a mirror, as all the directions are reversed.  I selected the person who I thought would make the best assistant.  It didn't work out so well.  I asked him to grab the top of the gallbladder.  He could see it, know what he wanted to do, but simply could not make it happen.  Every time I needed him to do something, I had to reach across the table, put the instruments where I needed them, and then return to my instruments.  I also had to hold the camera, as no one else could manage to show me what I needed to see.  

Anyway, we struggled and sweated through it, and finally managed to get the gallbladder out.  We lost power a couple of times.  I poked a hole in the gallbladder and spilled some bile.  Not such a big deal.  The clip applier did not function well and I had to get a tie around the cystic duct.  I finished the case with a splitting headache.  It left me wondering if it was worth all the effort.  On one level it was.  The patient left the hospital the following day.  I know we'll get better at it.  I'll teach someone to assist me.  We'll work through the technical challenges.  This is not a new operation, and I believe with all my heart that I should do the very best I can for the people I treat.  The young doctors working here deserve to learn about laparoscopic surgery.  In the meantime, however, it is so, so, so hard!

Most of what we do is really, really hard.  It demands a lot from me and I leave the hospital feeling spent.  We are pushing the envelope here.  Nearly every day I end up doing something and wondering if I should.  I am also finding that it becomes a vicious circle.  The more you do, the more you have to do.  Yesterday we did a laparoscopic cholecystectomy, and today another one showed up to be scheduled.  We have started doing more ortho cases.  The more we do, the more patients are referred to us.  We have started doing procedures such as cystoscopy and endoscopic banding of esophageal varices here.  No one else around here is doing this stuff, so we get more and more referrals.  The more you do, the more you do.  Eventually you arrive at a balance, I suppose.  We have yet to do so.  At some point I will need help.  Maybe even (dare I say it?) another surgeon!  I'm doing what I can to train the folks here, but it is a process and they simply aren't there yet.  Last I checked there wasn't a backlog of trained surgeons wanting to go to Congo...  Who knows.  God might have someone in mind.  It would be wonderful to share the burden.  

In the meantime, we do what we can.

Warren Cooper

Saturday, August 10, 2013

New Apple product available in Congo!

Yes folks, the new iPhqne is here!

August - some pictures

A few pictures of life in Nyankunde.

Dynamic Hip Screw

The OR Crew

Adventures in plumbing.  Some pipes just don't go anywhere.

A SIGN nail satisfied customer.  We fixed his broken femur.


Bullets and bones...

Sein and the big spleen!

In the OR

Sammy - another sad case...

Gloria.  Had to trach her for papillomas on the cords.

Gloria, Dad and Lindsey

Peterson plays rough

The three of us.

The Tenpenny's

Friday, August 9, 2013

July - Projects

So, Lindsey's been on my case to write a blog update.  I don't know why it's been so hard to do this.  I've made a couple of uninspiring starts, but I end up deleting them the next day.  On one level, my life here is monotonous.  Not boring, by any means, but many days look the same.  I get up, I operate, I see patients, I go home.  I could write about the interesting cases, but for non-medical people, this gets old fast.  There was the man with the rectal cancer, the woman with a horseshoe kidney (true disease - google it!), the kid who lost his scalp, the child with hydrocephalus, the child who burned all the skin off of his right arm, the woman on whom I operated for a femur fracture who then went on to develop a perforated ulcer of the duodenum.  Exciting stuff?  I thought not.  I mean, it's exciting for the person who has to figure out what to do with these poor people, but for everyone else it just sounds weird.

Instead I'll tell you about a few of the little projects I've been working on.  The big one has been plumbing!  Yes, you got that right, plumbing.  We have a new family staying here at Nyankunde and  we have worked very hard to fix up a house where they can stay.  It has been a lot of work.  The house has some very old plumbing.  Every time I think I've got it sorted out, something else springs a leak.  I can't even count the number of times that I've had to smash out walls to fix the leak in a rusted pipe.  The tragic part of this job is that nothing that everything that can be purchased in Bunia is Chinese-made stuff of the very lowest possible quality.  I actually prefer to use the 30 or 40 year old rusted pipes and fix the holes as they occur.  There is a water heating system that requires lighting a fire under a metal tank.  It is not exactly high tech, but it works.  Anyway, I cannot begin to count the hours I have spent trying to patch this system back together.  There is a plumber around, but I find that I usually have to redo whatever he does.  These are the non-glamorous aspects of missionary life that no one ever writes about.

The garden.  One one level the whole thing seems too easy.  You make a hole in the ground and drop in a seed.  Then you wait.  Out comes a plant which you can actually eat!  It still amazes me.  We've done pretty well with some things.  The eggplant was a big item.  Unfortunately, eggplant just isn't good!  The greens have been great, as has the okra.  The tomatoes did well.  Other things flopped.  The cabbage was a big disappointment, as were the melons, the corn and squash.  The watermelon looked promising, but seems to be dying.  So many things can go wrong.  It doesn't rain enough, there are insect attacks, there is some sort of fungus which grows on the leaves.  Even our gardener Soborabo can pose a threat.  Sometimes he doesn't weed at all, other times he does it too aggressively.  Anyway, we are learning a lot.  I've learned that food tastes better if you grow it yourself.  All of this takes some effort, and I don't exactly have the time to do it myself, but I'm trying.  The more food we can grow ourselves the better.  We have also been providing food for some of the needy patients in the hospital.

Meat can be a challenge.  It is hard to get a piece of meat that can actually be chewed by human teeth.  Armed with a diagram of a cow and a pig, Elliott (the new doc) and I went to the market to select some choice cuts.  The picture looked pretty clear.  Sirloin here, chuck there, ribeye there, etc.  When you have a bloody half of a cow hanging up under a tree, and some guy hacking at it with a machete, things looks quite different.  The nice thing is that there are only two prices for meat.  One is for "fillet" (what we would call meat) and "melange" which is a mixture of bones, gristle, blood vessels and the like.  I generally stick with the "fillet".  To the Congolese, meat is meat.  We approached it like an anatomy lesson and directed the butcher to cut off the choice parts.  I think we did fairly well.  Most of it we ground into hamburger.  The really nice parts are destined for the grill.  It drew a crowd and lots of commentary.  The butcher, in particular, seemed quite impressed by the notion that some parts of the cow are better than others.  From there it was on to the pig butcher, where we bought about a quarter of a hog.  This we made into sausages.  Lindsey hasn't yet allowed me to buy any pig intestines, so I can't make proper sausages, but I mix up the spices and roll them into little cigars.  Lindsey gets a little frustrated with the magnitude of these little projects, not to mention the unsettling mess created by grinding up a lot of meat, but it is great to have chewable meat.

We have an African Gray parrot named Bubu.  It has been a long process, but I've finally gotten her to perch on my hand.  This is kind of sore point with Lindsey as I can tend to harass the bird a bit.  Tonight she made a miscalculated leap and hit the ground pretty hard.  She seems to have avoided any severe internal injuries, but I have been forbidden from messing with her for a while.  Still no talking!  We talk with her at every opportunity, but she refuses to say anything.

We also have a remote-controlled dog.  Peterson, our Bullmastiff is growing at an alarming rate.  At six months of age, she can actually put both of her paws on my shoulders.  She is incredibly powerful and she has a stubborn streak in her.  I made the investment in a remote-controlled shock collar, or "E-collar" for the animal lovers who prefer euphemism.  Best thing ever!  There is one button which causes the unit on the collar to vibrate.  This communicates that it is time to pay attention.  There are two other buttons which give either a nick or a continuous stimulation.  I love this device!  It allows the dog a bit of freedom, but she knows that she has to behave.  If she starts tearing after a goat or a small child, I can communicate to her that this is not acceptable behavior.  I can adjust the level of stimulation.  She responds to levels between 20 and 30.  One time I had to go up to 40 to get her attention.  The maximum shock is level 127.  We've really enjoyed having a dog.  She is a great watchdog and just fun to have around.  She also takes care of the problem of leftover food in the fridge.  I've found that I tend to carry on nonsensical conversations with pets.

Another little project of mine has been the construction of an outdoor clay oven.  It is quite expensive for us to buy propane, so I designed and built an oven which works with charcoal.  Instead of wasting money on propane, I have decided to support and encourage an industry which is resulting in the deforestation of Congo.  It's hard to win on these things.  Anyway, it has taken me a couple of weeks to finish this thing, but I'm pretty happy with it.

This is just a taste of the projects that I'm working on.  There are more.  There is the challenge of trying to learn Swahili.  There is the electrical system of our home.  I've done a fair amount of tree-climbing to get the wires in place.  There is the motorcycle.  I have a Honda XR 650L which brings me great joy, but also inspires terror in me.  It is a very powerful and heavy motorcycle.  Today I rode up the the mountain where the cell phone towers are located.  It was kind of hairy, but also a lot of fun.

The hospital also carries its share of projects.  There is always something breaking which needs to be fixed.  There is organization that needs to be done.  There is the small matter of surgical education on a variety of different levels.  There are mountains of boxes that we need to go through.  There are always cases requiring creative solutions.  How will I get this lady's leg in the proper sort of traction?  What will I use to drill holes into the skull?  How can I get the monitor mounted on a wall in the proper place?  The other big project has been trying to be a surgical role model for Elliott Tenpenny, the other post-residency doc. He has struggled to begin using his conversational French. He is also trying to adjust to many cultural and professional challenges. At times I feel like I may not be the best of role models, but I feel like we're making some progress.

I complain about all of these challenges and responsibilities, but the fact of the matter is that I love it!  It keeps me active and it allows me to learn about lots of new things.  I actually know where the filet mignon is located on a carcass of a cow!

The great challenge is too keep these projects in perspective and not drive Lindsey crazy with them.  I haven't quite learned how to do that.  My other challenge is to not neglect other more important relationships.  I can tend to get really annoyed when someone shows up needing something when I want to finish a project.

Well, that's a little taste of life in Nyankunde.  On a side note, anyone looking at the news is probably aware of the renewed fighting in North Kivu.  We are very far from this conflict and it does not affect our work in the least.  Nevertheless, please pray for this messed-up country and the thousands of unfortunate people whose lives are torn apart by this fighting.