BRAVERY

We have it easy in the USA. Education is highly accessible. Travel abroad is easy. Not so in Nigeria. Eseose (God's Gift) is a very interesting woman I met in Nigeria. She is 27 years-old; newly wed to Dr. Kelechi Eguzo, administrator of the Nigerian Christian Hospital. Since her marriage, she has become pregnant for the first time and is due in September 2012. 

She attained a Bachelor of Science in microbiology at the Ambrose Alli University,  Ekpoma. She applied for training in Food Science and Technology in Belgium to begin September 2011 and was accepted-a prestigious but expensive school. She applied for her visa in May but the visa did not come through until this week.  Now she leaves for Belgium today, to start the course of study almost 2 months late.   

Think of the obstacles this young woman faces! She has never left Nigeria, She has little money. She is traveling to a foreign country to start school 2 months late. She is pregnant for the first time and will have her baby in a foreign country with no husband or relatives with her. She is as brave as they come! She is a hero!

This story is unusual but not unique. All over Nigeria, people are battling against all odds to inprove their situation. While we in the USA are living, Nigerians, and billions in the third world, are just struggling to survive. Kudos to these brave people who accept these challenges.

Addendum: Eseose made it to Belgium. She is struggling to catch up on studies and having some money problems but surviving!

HOME

I arrived home today. I'll rest tonight then start making plans for the next trip tomorrow !

SURGERY DAY 22-FINISHING UP

Liver mets

Yesterday was the mother of all surgery days. We started with 2 pediatric hernias. Next we operated on a lady with a right lower quadrant mass and an enlarged liver. We suspected a cecal cancer with liver mets and, unfortunately, we were exactly correct. We did a right hemicolectomy as the tumor was near obstructing. 

The next patient was an older lady with a large flank bulge. She had a previous surgery and most of her intestines were in a hernia that tracked posteriorly. We repaired this with mesh. Next a submandibular mass which I am sure will be an adenoid cystic carcinoma. The mass was hard as a rock. Then, a woman came in with a fibroid which was prolapsing through the cervix and bleeding. We resected it without a problem.

Next,  a 13 year-old with a large jaw mass. On palpation, the jaw was crackly from the bone being thinned out in areas to less than 1 mm. In other areas, there was no bone! This is probably an ameloblastoma. We had to perform a total right hemimandibulectomy. 

We then placed a chest tube in a man with a pleural effusion. Next we operated on a 21 year-old female who previously had a resection of an ovarian endodermal sinus tumor. She failed to get her followup chemo and now has a recurrence. We found a tumor mass above the bladder. We were able to remove all visible tumor and she will get chemo. 

Finally, we operated on a 25 year-old female with a scalp mass that has been growing for 24 years! We suspected a dermoid cyst. We were correct, as we found, when we accidentally entered the cyst and yellow mush squirted all over the field. There were three of us working on the case and I'm sure each was praying it would be the others that entered the cyst first-LOL!

This is it. I am leaving for Lagos today and then to the USA. We completed 133 cases in 22 days.  Most patients are heading home. There are a few who will be in the hospital for awhile. There is already a list of patients growing for ths next trip. 

Addendum (10/27/11) : Our lady with the dermoid cyst is doing well and discharged. I can't wait for her hair to grow out!

HAPPY 55TH BIRTHDAY

Many doctors, nurses, employees and patients came out to wish me a happy 55th. It was.

After surgery, we had a birthday party with cake!

SURGERY DAY 21-LATE NIGHT

Surgery was busy today. The word is out that the trip is almost over so many people are coming at the last minute, hoping to get their surgery done.  For tomorrow we have a mandibular tumor, a giant ventral hernia, a submandibular mass, a cecal cancer,  2 pediatric hernias and a recurrent ovarian tumor in a 21 year-old female. More will becoming,  as well. Tomorrow is the last day of operating so we plan to finish all comers, even if we stay up all night. We have done 122 surgeries.

Sister Mary Joseph Nodule

The clinic was also busy. One old man came with an umbilical tumor, a Sister Mary Joseph Nodule. The tumor was fungating and bleeding so we resected it-not expecting a cure but a slight improvement in the quality of life for the patients final days. He has carcinomatosis from an unknown source.

A patient from two years back also came today. She is 40 years old. In 2009, she came in with a rectal cancer. I performed an abdominoperineal resection which involves removal of the anus and formation of a colostomy. She was wealthy enough to get chemo and radiation after surgery and is doing quite well now. She was wearing a standard appearing colostomy appliance, which surprised me. She was able to purchase it in the market for 350 Naira, about $2.33. She uses a bag about every 5 days so she will spend about $150 /year on ostomy appliances-not much unless your monthly salary is $100!

It is 845 PM. We just got called for an obstructed hernia so we are returning to the hospital. Don't wait up.

CHIEF ENGINEER

Jerry Nwosu used to be the assistant cook. Then the hospital electrician was electrocuted and he became the Chief Engineer. He is fantastic! He is trained as an electrician but he can fix anything. He is the one that set up the emergency light system for the operating room. He even fixed my hair trimmer.  We are lucky to have him.

SURGERY DAY 20-GAS-GANGENE

Today I was called for an emergency-a woman with an injection abscess of the buttock. The patient had the abscess for several weeks after an injection for malaria. She looked terrible-wasted, pale, diaphoretic and tachycardic-a true emergency. Her buttock was grossly swollen, red and full of pus. 

Wound 1 day after I&D

When the patient was asleep I could examine the wound better. I could feel crepitus (air) in the tissues. When I cut the wound open, pus and air bubbled out-gas gangrene-a clostridial infection. This patient is critically ill and the situation is complicated by her being HIV positive. Even in the USA, this would be a challenging case.

We will see if she can survive.

SURGERY DAY 19-GALLSTONES

262 stones

Gallstone disease seems to be less common in Nigeria than the USA but we do see some cases. The incidence seems to be increasing. This may be because the obesity epidemic is coming to Nigeria.









On this trip, I have performed 3 cholecystectomies. On my last trip we performed several as well, including one woman who had 262 stones! I have been quite surprised how beautiful the stones are from Nigerian patients. 

Beautiful stones

A new team member has arrived, Charles Nwajei, MD,  a Urologist. Charles went to medical school at the University of Calabar and did urology training at University of Benin. I first met Charles when he came to NCH in 2006. Uche brought him for extra training. He has just finished all his training and is looking to get some additional general surgery training. He is a kind, quiet man. He is a good surgeon and an asset to to the team.






We have discussed cassava previously. It is a dietary staple in Nigeria. Today on the way to work we learned some more. The young man in the picture has a mobile millstone for grinding cassava. The mash is then made into gari. His machine runs on gasoline. He charges 200 Naira ($1.33) to grind 2 large bags.

Cassava in....











                                                                 Gari out!

NIGERIAN SCAMMERS

Nigerians have a bad rep in the world which may have begun  with the four-one-nine scams. The 419 is an advance -fee fraud (see example below).  This type of internet fraud appears to have originated in Nigeria but is now omnipresent. The Nigerians who make lots of money from internet scams are sometimes called Yahoo Millionaires or Yahoo Boys.

Of course, the 419 is not Nigeria's only public relation problem. It is common for Nigerians to be portrayed poorly. For example, Nigerians are portrayed as scammers  in Sony's PS3 commercial.

In the movie District 9, they are portrayed as an evil, gun-wielding gang, cheating and killing the downtrodden Aliens-who only want to eat cat food and return to their planet. This is a great movie about man's inhumanity to man (or alien). Of course, it is banned in Nigeria!

Most of these stereotypes are quite funny if people can just 'get over it". And remember what W. C. Fields said. "Never give a sucker an even break".

Please My Dear I Need Your Help.
   

I know you will be surprise to receive this email, but Before I go further I will like you to understand that, I am writing this mail to you With due respect trust and humanity, I appeal to you to exercise a little patience and read through my letter I feel quite safe dealing with you in this important business, honestly i am writing this email to you with pains, tears and sorrow from my heart, i will really like to have a good relationship with you and i have a special reason why i decided to contact you, i decided to contact you due to the urgency of my present situation here in the refugee camp. My name is Miss. Mary Kipkalya Kones, 25yrs old female and I from Kenya here in Africa; my father was the former Kenyan road Minister. He and Assistant Minister of Home Affairs Lorna Laboso had been on board the Cessna 210, which was headed to Kericho and crashed in a remote area called Kajong'a, in western Kenya. The plane crashed on Tuesday 10th, June, 2008.
     
    After the burial of my beloved father, my stepmother and uncle conspired and sold all my father's properties to an Italian Expertrate which they shared the money they sold from the properties among themselves and live nothing for me. Unfortunately to me I fined my father's briefcase and when I opened it I found a document which my Father used to deposited amount of money in one bank here in Burkina Faso, with my name as the next of kin. I travelled to Burkina Faso here I am, to withdraw the money for a better life so that I can take care of myself and start up a new life and also further my education, when I arrival to the bank, the Bank foreign Operation Department Director whom I meet in person told me that my father instruction to their bank is that the fund would only be release to me when I am married or present a trustee/partner who will help me and invest the fund overseas after the transfer, and the bank ask me to go and look for a foreign partner, that was why  am contacting you, which I believe that you are going to be honest and reliable person that will help me and stand as my trustee/partner, so that I can present you to the Bank for the release and transfer of the inherited fund into your bank account in your country.
     
    I have chosen to contact you after my prayers and I believe that you will not betray my trust. But rather take me as your own sister. Though you may wonder why I am so soon revealing myself to you without knowing you, well I will say that my mind convinced me that you will be the true person to help me. Moreover, I will like to disclose much to you if you can help me to relocate to your country because my stepmothers have threatened to assinate me. The fund my Father deposited into the bank, is ($8.5 USD) Million United State Dollars, and I have confirmed from the bank here in Burkina Faso, on my arrival, You will also help me to place the fund in a good profitable business venture in your Country, However you will also help by recommending a nice University in your country so that I can further my education. It is my intention to compensate you with 40% of the total money for your services and the balance shall be my capital in your establishment. Now my dear as soon as I receive your positive response showing your interest and wiliness to help me, I will put things into action immediately. In the light of the above, I shall appreciate an urgent message indicating your ability and willingness to help me and also handle this transaction sincerely. Awaiting your urgent and positive response. Please my dear I want you to keep this as a top secret only to your self for now until the bank will release and transfer my inherited fund to you as my appointed trustee/partner. I beg you once again not to disclose this to any body until i come over your country because I am afraid of my wreaked stepmother who has threatened to kill me and have my inherited fund alone. I thank you very much and am expecting to hear from you soonest.




     
 Yours Sincerely
  Mary  Kipkalya Kones. 

District 9 Alien

SURGERY DAY 18-MORE KELOIDS

"If I were two-faced, would I be wearing this one?"  Abraham Lincoln

You have seen this sweet little girl before. She is 11 years-old, the same age as my son.  She came to the operating room yesterday with a smile. There was no crying when Eric placed the IV and she walked into the OR with a grin. There are no complaints today-even when I cleaned the wound for pictures! After excision of the keloid we injected depo-medrol and will continue this monthly to try to prevent a recurrence. The result isn't perfect but the patient and mother are very happy.

SURGERY DAY 17-DEATH

It was the time of the preacher
In the year of '01
Now the lesson is over
And the killing's begun

It is a drag, but sometimes patients die after surgery. When this happens, I question every aspect of our care to try to understand why the death occurred. We can't undo the past but we can improve the future.

On this trip we had a few deaths including two preoperative deaths- two babies came to the hospital  many days after disasters had occurred in their abdomens'. We had planned to operate on both but they died before getting to surgery. Both cases were long shots, but I have seen these occasionally have a happy ending. The irony is that if these two patients had come one hour earlier, they almost certainly would have been postoperative deaths. In the USA, this would result in several inches of quality control/peer review paper. In Nigeria, we can just accept that we tried our best under very difficult circumstances and the patients died.

We have completed 109 surgeries. 

SURGERY DAY 16-WHEN THE LIGHTS GO OUT

Uninterrupyible power supply

Despite being a major oil producer, Nigerians are often without power. The power generating company NEPA (National Electric power Authority), and the associated delivery infrastructure are terrible. Power outages are the norm-lasting from minutes to days. Yesterday, for example, we had no power and this trip has been one of the worst in recent years. Most facilities have a back up generator which, in reality, often becomes the main source of power. NCH has a large generator but it is decades old and expensive to run. There is also a smaller generator but it cannot run air-conditioners. Recently, Dr. Kelechi installed an uninterruptible power supply (inverter). This is a system of batteries that are charged when there is power and take over when there is an outage. It is designed to run the OR for 4 hours but, after installation, it was found that the batteries were bad so the system can only supply power for about 1 hour-and the system cannot run the air-conditioners. Well, at least we have light!

Wilson-nurse anesthetist

It is a sad day-Wilson is leaving. They need his anesthesia abilities back in Enugu. He has been a great help. Chineke gozie gi (Go with God).

Smart-surgical technician and author

Today we crossed the century mark-100 surgeries. We are still plugging ahead. I am doing my surgeries with Smart Uruakpa-an excellent surgical technician who can close a wound much better than I can.

I LOVE WHAT I DO

"Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do"  Steve Jobs

Some have asked why I do what I do-Travel overseas, leave my family, risk my health, reduce my salary etc.

The answer is simple-I love what I do.


"In the end, it's not going to matter how many breaths you took, but how many moments took your breath away"  Shing Xiong

SURGERY DAY 15-URETERS

Yesterday was a busy day. We started with a bilateral inguinal hernia. Next, we reexplored a woman on whom we did a radical hysterectomy for cervical cancer. She had preoperative chemotherapy. The left ureter was involved and very small, so we ligated it. On reexploration, we reimplanted the ureter ito the bladder. After this, we reexplored the woman with an intraabdominal pregnancy-her bleeding had stopped so we closed her abdomen. Next we did 2 goiters. We then debrided the wound of the woman with sarcoma of the chest and shoulder.

Massive ascites

We proceeded to what we thought would be our last case of the day-a young girl with an abdominal mass and massive ascites. We explored her and drained 8 liters, then removed an ovarian tumor. We are hoping it is not malignant.









We packed up to go but on night rounds found a woman with a near strangulated bowel in a Pfannensteil Incison. We repaired her hernia with mesh-the bowel was bruised but seemed viable.

Today we operated on a baby with syndactally. We had done the left hand in June and today we did the right hand. Then we worked on a baby boy with a severe burn contracture of the leg. We did a series of Z-plasties to release the contracture.  Dr. Umezerike and I then worked on a lady who had a uretero-vaginal fistula post C-section. We divided the ureter distally and reimplanted it in into the bladder and the problem was solved. Next, we moved on to a lady with an ectopic pregnancy. We removed the tube and pregnancy which was hemorrhaging into the abdomen. We then did the mandatory daily goiter and finished with a submandibular tumor!

Jaw Tumor

An interesting patient came to clinic today. He has a recurrent lower jaw mass-probably an ameloblastoma. He has had this problem for 5 years. It is a very difficult situation because resection would require removal of almost the entire lower jaw. He needs reconstruction. I will see him next trip and perform the resection. 

Gynecomastia

After SQ mastectomies

The man on the left came to clinic with bilateral gynecomastia. This is not life threatening but very embarassing for him. We performed bilateral SQ mastectomies and he was very happy. 

























The boy on the right also came to clinic today. we removed a large left maxillary tumor in February. He has a beautiful result.

SURGERY DAY 14-EXHAUSTION

Yesterday's blog was cancelled due to exhaustion. Eight major cases yesterday and 93 total.

SURGERY DAY 13-MALARIA

Today, Dr. Samuel Oje, resident in OBGYN, called me for an emergency. A young woman, HIV positive, came with a fetal demise. Despite induction elsewhere, the fetus would not pass. Samuel did a c-section and found a intraabdominal pregnancy with a long dead fetus. All the bowels were adhesed together secondary to the placenta which was in the Pouch of Douglas. The posterior wall of the uterus was perforated by the placenta. We slugged our way through the superglue and got things sorted out. She is doing well.

Delux Suite

I came back from surgery tired and crashed in the "Delux Suite". As you can see, I sleep under mosquito netting. Malaria is a major problem in the world, especially in Sub-sahara Africa. There are 250 million cases of malaria per year and about 1 million deaths, mostly in young children. I have had malaria and it is no fun! Fortunately, I have some resistance now so, if I do get malaria, it is mild.

We have done 85 cases. Tomorrow is Monday so more patients will be pouring into the hospital. 

SURGERY DAY 12-HOW ABOUT SOME MODESTY?

"Be who you are and say what you feel because those who mind don't matter and those who matter don't mind"- Dr. Suess

A few people have stated "How about some modesty for these patients" or "You can identify them". I have thought about these issues. Quite simply, I won't dehumanize these patients by "cutting out their privates" and "blackening their faces. The patients I see are real patients, with smiles and frowns, breasts and  genitals. If we crop out their humanity, we also crop out their problems. Let's look at some examples. 

The poor little girl below is a real patient a with a terrible cosmetic problem- a giant keloid secondary to an ear piercing. Despite this, she can come before the camera and smile, knowing there is some hope with surgery. I think we lose a lot be covering her eyes. She is no longer the smiling little girl but just an ear with an ugly blob.  The eyes are a window to the soul.

Let's look at another example-this woman has a term pregnancy but also has an ovarian cyst that is twice as large as the term uterus. Her belly is so full she can barely breath and her feet are swollen from venous obstruction. Despite these problems, and the fact that she is about to have major surgery, she is smiling and her bravery comes through. Can we really get the story from the cropped picture. Nope! 

I explain  to patients that the photos are for communicating about the work we are doing. I ask their permission. They are almost always happy to have their picture taken.

Today is a busy day-a  radical neck/total thyroidectomy, a cholecystectomy, a cholecystectomy/TAH, a bilateral hernia repair and bilateral subcutaneous mastectomies. Fortunately, Dr. Uche is back and we are ready to work. We have done 83 surgeries. I am starting to get tired.

SURGERY DAY 11-HALSTEAD

"Surgery would be delightful if you didn't have to operate" - W.S. Halstead

Most surgeons are happy to be in the operating room. We can do dramatic surgeries, effect changes and are in control. But that doesn't mean we always want to do surgeries. The best surgeons know when to say no.  At the NCH, I am always encountering the most difficult cases-patients who have had surgery multiple times before or who have been elsewhere and told that surgery is too difficult or 'impossible'. We are often the hospital of last resort. Many times we tackle these cases and we get  good outcomes-sometimes not so good. But, it is hard to tell a patient that you have nothing to offer them-except a prayer.

Theo

A new team member has arrived-Theo Ezeonwumelo. Theo did medical school training at the University of Port harcourt and is doing surgery training at the Federal Medical Center Umuahia. He is a fourth year resident now. He came to work with me in June, 2011 and is back. Theo is a very pleasant and humble chap, like his attending Dr. Mike Enyinnah. We are glad to have him.








To date, we have done 71 surgeries-many are still waiting. We started today with an incarcerated hernia. Next, we did an unusual case, a term pregnancy with a giant ovarian cyst. The cyst was twice the size of the term uterus. We attacked the cyst first and it exploded all over the operative field. Gallons of fluid poured out. We removed the cyst,  then we did the CS. We followed this case with a giant goiter, 400 grams. Several more surgeries were done but they are all starting to blend together. Dr. Uche is returning in the morning and we have some big surgeries scheduled.

Term preganancy with giant ovarian cyst

Drained ovarian cyst

SURGERY DAY 10-KELOIDS

The dangers of piercing

Yikes

Imagine if, every time you shave, get a cut, or pierce your ears, you develop a tumor! That is the plight of of the keloid former. Keloids only occur in humans and are most common in blacks, least common in whites. The tumors can be very dramatic and very resistant to treatment. If the keloids are excised,  they often grow back larger. Overall, patient satisfaction with treatment is low.  I have found the best treatment is to send these patients to another surgeon-LOL.

This poor man developed keloids after shaving-a common presentation. The smallest nick-even one that doesn't bleed, can be the start of a lifetime of torment. In bearded areas, men will develop keloids that include hair follicles. The hairs can grow inside the dense scars and get infected with resulting draining sinuses.

We will try to help these patients.

SURGERY DAY 9-HUBRIS

Today we dealt with two complcations-postop bleeds after hemimandibulectomy and splenectomy. These incidents show us we are fallible-even when we want to believe we are not. Both patients are doing well now-Imela Chineke (Thank God). 

The big surgery of the day was excision of a right maxillary tumor in a 15 year-old boy. The tumor had growing for 5 years and distorted his face. I suspected it was fibrous dysplasia or ossifying fibroma. The tumor was so large it had completely eroded the anterior maxillary bone and part of the orbital floor.

Fortunately, enough of the orbital floor is intact that I do not think the eye will not sink into maxillary space as has happened to a patient named Mary Sunday. In the USA, a prosthesis would be used to solve these problems but they are not available in Nigeria. In most cases, we get a very good cosmetic result (such as Esther) if the zygomatic arch and the orbital floor are intact since these support the skin flap.

Esther

Mary Sunday