A little patient follow up

I just got an email from Dr. Anderson about one of the patients that came to Soddo while I was there. Here he is sitting with Dr. Anderson.

This guy is 17 years old and fell out of a tree a day or two before he made it to Soddo. When he came to us, he could not move anything below his neck, but still had sensation throughout his body. This is good because it means that the spinal cord is not completely severed and it is likely that on the front part of the cord is damaged. 

We got some xrays that you can see below. It's a little tricky to see, but the vertebrae right at the level of the shoulders were squished down from their original squares into triangles. I did my best to outline what I'm talking about with a little Microsoft paint. The red triangle on the bottom should be virtually square and the left edge should be in the same line as the left border of the square above it. For the top vertebrae, the red outline shows about where the bone actually is and the yellow on the top shows where it probably should be.

At the time we were unsure if we should take care of him at Soddo or he would be better off going to a neurosurgeon who works a few towns over at Bethlehem. However, this would mean several hours of travel, likely in the back of a bumpy pickup truck, and would very likely worsen his injury. 

Instead, Dr. Anderson elected to operate at Soddo. Below you can see the pictures from after the operation. For the first part of the surgery, Dr Anderson made a cut on the back side of the neck and very carefully placed wires around bony arch where the spinal lives. Obviously, this is quite dangerous as any slight movement could damage the spinal cord itself. These wires are pointed out by the arrow and were wrapped together to fuse the spine. For the next part of the surgery, Dr. Anderson brought in Dr Gray and I (I was on general surgery at the time) so that he could get at the spine from the front of the neck. There are many important structures here like your jugular, carotid arteries, esophageus (food tube), trachea (breathing tube) that could be injured during this approach to the spine. Fortunately, everything went well and Dr. Anderson was able to move some bone from his hip to his neck and over time it would fuse the three separate vertebrae into one solid chunk that is outlined in the yellow box.  

Shortly after this surgery I had to return to the US and did not hear how this patient did. However, just yesterday, Dr. Anderson sent me these pictures and told me that he has regained movement of almost his entire body!! His hands are still not 100% but he can almost run and jump!! 

Also amazingly, he comes from an extremely poor family and they could not pay for any of his medical care. Fortunately, Soddo has a benevolent fund, donated from Westerners for patients like him. Not only was he able to walk again, but it was given to him for free!!

I can't help but think of how this story parallels our story with Christ. Without Christ, we are paralyzed in our sin and have absolutely no means to pay to get it fixed. Yet while we were still in this sad state, God completely healed us and whats more, He did it without any cost to us.

 I would also like to put out a shameless plug for my buddy's blog http://jeremiahjohnsonblog.wordpress.com/2014/01/21/welcome/ In just a few weeks, Jeremiah gets to go on a similar trip to Kenya and I know that I cannot wait to hear about his experiences. Godspeed man!!

Until next time, I hope that you all stay warm and can enjoy some of the snow!!

In Him, 

David

Back home (finally) and Patients

It is hard to believe, but it's been 5 months since I left for Ethiopia. After getting back to the States, I had to quote Robert Frost "miles to go before I sleep." Since getting back, I have taken my board exam (Step 2 CK), vacationed with family up north and friends in the Grand Tetons, done rotations at Burlington VT and Greenville SC, and now started up a pediatric rotation at St Paul Children's. These adventures have given me the opportunity to see many old friends and meet several new ones, but the change took some getting used to.

Transitioning back to the US was not too difficult as I had a number of things on my plate to keep me busy. The biggest differences were the changes in food, ie not eating injera for every meal, being able to blend into a crowd once again, and actually understanding the conversations that were occurring around me. Also, the ease of doing day to day work and travel continue to amaze me. Rather than having to visit 3-5 different shops to fill my grocery list and eventually realizing that there are several items that I will simply have to do without, I can simply visit "Price Chopper" (South Burlington's main grocery store). The bigger transition has been getting used to healthcare in the US. The multiple moving parts and copious documentation that is involved in patient care here has taken some time to get used to. Also, the very different patient population and mechanism of injuries has been a change. For example, rather than typically seeing hip fractures in young people who have been hit by cars while walking down the street, now I am seeing hip fractures in elderly osteoporotic patients who fell down at home. Or rather than seeing kids with draining sinus tracts, I see asthma attacks or the stomach flu.

These changes have served to strengthen my resolve to continue with long term missions and hopefully I can remember them 7-10 years down the road when I can actually return to the international mission field long term. I figure that the best way to remember this passion is to try to remember the patients, so I would like to introduce you to a few of our patients. BTW, there will be some blood and guts type of pictures, but in a lesson I learned from Dr. Gray, Goldy will give you a warning so if you have a weak stomach, you can dip out.

This guy I only met briefly in clinic, but he is a great example of the kind of work that Dr. Anderson is doing and I hope to do one day.

 Several months ago this guy was hit by a car and basically mangled his foot causing about 3-4 inches of bone to die. Fortunately, his foot still had blood flow and the nerves were intact and although they tried to talk him out of it, he wanted to try and save his leg. This would mean the placement of an external fixator frame on the outside of his leg and slowly pulling the bone from the top of his leg to his foot.

 This is after the initial placement of the external fixator. Notice the lack of shin bone that Dr. Anderson is pointing out.

This is his X ray when I saw him. Although it looks like the bone is missing at the top, there is very subtle calcifications that show up as white puffy clouds on the xray. He will need another surgery to bring the bottom ends together and had a long road to recovery, but his leg is functional and he avoided an amputation

This dude traveled all the way from Somalia (likely several days) to get treatment. 

Sorry for the blurry picture, but this is as much as he can straighten his knee (about 80 degrees).

The solution was to place a pin at the base of his shin and put him on traction to literally pull it straight. As you can see, it worked and this was literally overnight. He will still have a fair amount of physical therapy to do, but should be able to walk again. 

This guy came into clinic and clearly shows why polio is such a devastating disease. He had polio as a child and now his legs are basically stuck in this position. 

In order to "walk," he uses these blocks and crawls on his knee

Although Dr. Anderson was able to offer him some surgeries to release his tight muscles so that he could hopefully at least straighten his legs and walk (albeit awkwardly), we were able to get him a hand-powered tricycle so he would at least be able to stop crawling in the dirt. 

Yup, here's Dr. Goldy encouraging the squeamish to advance with care. For those weak of stomach, I hope that these patients helps give a flavor for the kind of injuries that are seen in these world situations and will give you a passion or a curiosity for missions. 

I honestly can't remember how this guy broke his leg, but he did a few years ago and it managed to heal, although not exactly straight as you can see below. 

A few months before he came into see us, his leg began bothering him so he went to the local "healer" who recommended a regimen of treatments that included branding the skin with a hot piece of metal. Leaving the characteristic scars that you can see here. However, this did not solve the underlying osteomyelitis that ultimately needed surgery. 

Since he had such a robust immune response, we were able to simply cut out a small window of bone (a cortical window) and wash out the dead debris. 

Sorry but I don't have a picture of this guy, but basically one of the bones in his forearm (his radius) had a long term infection. 

We opened up his forearm and removed the dead bone that you can see below. Fortunately, he also had a very strong reaction to the infection and we did not have to help him regrow the bone. 

I'm going to warn even the bravest, these next few pictures are rather graphic. 

This man came in after breaking his leg a month ago when he was rebuilding his barn after an arsonist burned it down. Since he literally didn't have a dime to his name, he went to a local "healer" who wrapped it up really tight and sent him out.  

When he took off the bandages, his leg looked like this. ^^^^ It was very fluctuant suggesting fluid underneath. Initially we were afraid to do any sort of surgery since his hemoglobin was 6.0 (normal is 12-15), but when Dr. Anderson saw him on rounds, he made the below intervention. 

With a small nick of a scapel, we were greeted by roughly a gallon of surprisingly nonodorous puss. He needed multiple additional surgeries to remove all of the infection and several blood transfusion including some from the hospital staff, but when I left he was looking like he would make a full recovery. 

I do have many other patients that I could talk about, but blogger.com is starting to get mad at me saying that my post is too big. I hope that this gives some insight into healthcare in the developing world and will give you a passion to help the people there in anyway that you can. 

Have a happy Monday!!

In Him, 

David

Reflections

Sorry that it has been so long since my last post, we have been having some internet problems and it is rather tough to get things together. It’s hard to believe that I’ve been here more than a month and that things are already beginning to wind down. I’ll be heading back to the States on next Friday. It feels both like I just got here and that I’ve been here forever. The patients and their problems have been absolutely amazing to see and it is the kind of thing I would love to do in my future practice

One of the things that has struck me is just how much luxury we are accustomed to. Here I am, out in the middle of Africa where most of the people have never lived with have electricity or even used an indoor toilet, and I have the nerve to get annoyed when the water doesn’t work for a day, or the power shuts off for a few minutes (ironically like it just did), or the internet isn’t working. Being a student, I often have to live frugally and sometimes it is frustrating knowing how many loans I have to eventually pay off. But in comparison, going on a date (even a modest one) will often be more than what most of the staff pay for 2 weeks of rent.

As I talk with more Ethiopians and see more of the country, I come to realize that we are accustomed to things that they couldn’t even dream of and they deal with things daily that we would find completely unacceptable. I was talking with the nurses about the expense of medical school and the loans that I have to take out and they were rightly flabbergasted as my student loans are 200 years salary. And these are nurses who are “middle class,” I can only imagine the people who I cross paths with when I am running who likely fall into the $1 a day crowd. Most of us consider a car to be a basic necessity (aside from those dedicated bikers and the passionate city dwellers) but a rundown Chinese import cost $15,000 here and will have a 280% tax, that’s 40 years worth of pay!!! Some of the nurses live in house with dirt floors and have to walk over a mile to work each day, even in the rain and like I mentioned, there’s no way that they have a car. They eat the same type of food every day (injera), often for breakfast. lunch, and supper. Some of their meals are even injera with injera!!

On one hand it makes me feel sorry for the people here and want to provide for them in any way that I can, I mean really, even a student can afford to donate $1 a day so someone can eat. However, I know that this has been the approach toward impoverished countries for many years and it has done nothing for them. If anything, it has crippled them by removing the initiative to improve things for themselves.

Rather than more money or used clothing or free bottles of hand sanitizer, I am convinced that first and foremost thing they need is to hear the truth of the Gospel. Many people may discount the role that it played in the development of the US, and say that we are basically a secular country. But keep in mind that we are born out of an extremely concentrated wave of extremely passionate Christians who saw religious freedoms to be more important than the safety and comfort of home. The founding fathers continually noted their faith in God as an inspiration for making a more perfect nation. These Christian values held by rulers and the population at large allowed for basic morality and made life much simpler. Until basic morality and as one speaker at Dordt put it, “the rule of law” is established, developing countries will remain undeveloped. Once the population at large is moral, a host of changes can start to come forth. Governments will no longer be blatantly corrupt and will allow people and businesses to grow without ridiculous regulations that only serve to give them power. Besides having not having to worry about government, people will be able to start businesses without worrying about having their inventory stolen at every possible opportunity.  Banks would be able to offer loans (unheard of here) being relatively confident that their investment didn’t just disappear. Basically, development would occur.

By now, all of dem good luterans out der are asking that famous question: “What does this mean?” Do we in the western world just turn our backs, live our lives, and wait for the missionaries to convert the heathens? Should we all invade with our Bibles and holy water ready to baptize anyone who will sit still long enough for us to do so? (See Nacho Libre for an example.) You might have guessed it, but I don’t think so. Spreading the gospel requires more than just showing up and talking, it often requires an open door into a culture and must do so without damaging the society further. Oftentimes this is medicine and it is a great medium. Another great way is through teaching practical skills, especially in agriculture, but also carpentry, electrical, civil engineering, plumbing, or anything that seems basic and straightforward in the US. Elementary levels of education are also very important. But handouts and infrastructure building projects are doomed to failure because once the money runs out the society is at a worse place than when the frinjes showed up in the first place even if people are brought to Christ.

Well, I suppose that is enough reflection for now. Look forward to some pictures from Arbaminch, a local wildlife park with hippos, crocs that look like dinosaurs, zebras and all that good stuff as well as some pictures of a few of our patients. Hopefully I survive the former without being eaten to pull on your heart strings a little with the latter J

In Him,

David

Running the list

Those of you not in the medical field might think that this title refers to some crazy track workout or some ancient Spanish tradition. Actually, it refers to a treatment team sitting down at the end of the day to quickly go over each patient on the service and hitting the main points of their treatment. I would like do this with you so that you all can get a flavor of the kind of patients that we are seeing here. For the medical people, please note that I will be skipping a fair number of details that you would probably like to know on the patients. For the non-medical people, I will try to explain the jargon and any abbreviations that I use, but I can’t do all of them or it will get too long. Let’s get started

1.       Male, 6 years old. Acute osteomyelitis (bone infection) of distal femur and proximal tibia with septic knee s/p (status post, it means that he had the listed procedures) sequestrectomy (taking out dead, infected bone), I&D (irrigation and debridement, washed out the infected wound) x 10, and ex-fix placement (external fixator, screws and pins that are used to fix the fracture outside the body). I&D every 48 hours until infection is controlled

2.       M57 Bimalleolar ankle fracture with ipsilateral tibial plateau fracture type V vs VI (very bad upper shin fracture) s/p knee immobilizer. Surgery tomorrow.

3.       M30 left sided  femoral neck and midshaft shaft factures, T-type condylar fracture (his thigh bone is in 5 pieces). Right sided degloving injury to heel and foot pad, loss of 6 cm by 15 cm, presented after 4 days with simple closure leaving in gravel and dirt and foul smelling from outside hospital. S/p I&D x2, and internal fixation of femur fractures

4.       50M, transverse acetabular fracture , S/P traction pinning and plating. Nonweight bearing for 2 weeks.

5.       F35 Left open (type IIIb) distal segemental tib/fib fracture with ipsilateral patellar fracture and ACL tear. S/P I&D and posterior gutter splint. Repeat I&D tomorrow

6.       M13 Distal open type IIIa tib/fib fracture. S/P I&D and splint. Ex-fix under C-arm (x-ray in the OR) today

7.       M32 Surgical neck and medial epicondyle closed  fracture of humerus with 10 cm wound. S/P I&D

8.       F16 Proximal 1/3 femoral shaft fracture, closed. S/P traction pinning, Intramedullary nail (a metal rod that goes down the middle of the bone and is held in place by screws at either end) tomorrow.

9.       M45 Left distal and right midshaft femur fractures s/p bilateral traction pins, Colles wrist fracture  s/p casting. Bilateral IM nail today

10.   M49 Closed bimalleolar ankle fracture, s/p casting. Open reduction internal fixation later this week.

11.   F18 Distal 1/3 open tib/fib fracture. S/p  multiple I&D’s, Ex Fix and skin grafting

12.   F30 Med malleolus facture s/p casting, 3x10 cm skin loss s/p skin grafting.

13.   F50 degloving injury (skin is ripped off) to ankle and heel 20x30 cm, open tib/fib type IIIB. S/p ex fix and I&D x4, possible amputation vs contralateral leg skin flap.

14.   F70 severe bilateral hip osteoarthritis with less than 20 degrees of movement in any direction. S/p bilateral girdlestones (removal of head of the femur)

15.   F45 remote history of AK47 wound to subtrochanteric femur with segemental bone loss. Was treated with IM nail and cement spacer placement at Soddo, lost to follow up due to funds. Presents with draining wound and proximal screw from IM nail (yes, it came through the skin). S/p bead placement, plan to remove next week and exchange IM nail

16.   F25 6 weeks out from flexion-distraction injury to C5/6 s/p closed reduction with continued unilateral slipped facets. S/p spinous process wires, iliac bone grafting and facet wires for fusion of C5/6

17.   M35 Night stick fracture of ulna with severely comminuted distal tib/fib fracture. Ex-fix tomorrow.

18.   M8 chronic osteomyelitis of tibial s/p I&D and sequestectomy x5 with segmental bone loss. Will bone transport once infection is cleared

19.   M30 Tibial plateau fracture schattzer type IV. S/p posterior gutter splint. Ex fix today

20.   M13 chronic osteomyelitis of tibial s/p I&D and sequestectomy x2 with segmental bone loss. Traction pin in place. Will bone transport once infection is cleared.

21.   M24 Chronic osteomyelitis of radius. S/p I&D x 3 and sequestrectomy Progressive wound closure.

22.   M10 Chronic osteomyelitis of tibia. S/p multiple I&D ‘s sequestrectomy, epiphysiodesis (removal of growth plate to prevent limb length discrepancy) and casting.

23.    M15 Chronic osteomyelitis of tibia. S/p multiple I&D and sequestrectomy and ex fix.  Will bone transport

24.   M30 Open tib/fib type IIIb, s/p lateral rotational flap, ex fix and 3x8 cm skin graft. Middle humerus fracture, s/p casting.

25.   M60 Open tib/fib type IIIb, s/p lateral rotational flap, ex fix and 3x8 cm skin graft.

26.   M25 Proximal segemental tib/fib, s/p IM nail. Discharge today

27.   F22 extreme valgus deformity of tibia. S/p corrective osteotomy

28.   M32 Pathologic femoral neck fracture ( PMHx polio). s/p girdlestone, complicated by post op wound infection, I&D x2

29.   M25 patellar fracture s/p wiring and extension casting for 3 months (this basically fused his knee straight). Hardware removal and lysis of adhesions today

30.   M35 chronic elbow dislocation, waiting for surgery

31.   M6 Acute osteomyelitis of tibia and septic knee. Multiple I&D with gradual wound closure.

32.   M15 Chronic osteomyelitis s/p ex fix, sequestrectomy and multiple I&Ds. Currently transporting bone.

33.   M30 Chronic hip dislocation s/p open reduction with corrective osteotomy and IM nail

34.   M55 chronic shoulder dislocation, waiting for surgery this week

35.   M10 Pubic rami fracture, s/p traction pinning. Degloving injury to pelvis 8x12 cm, s/p full thickness skin grafting

36.   M35 acute posterior hip dislocation s/p reduction. Open type IIIa middle 1/3 tib/fib fracture s/p ex fix with IM nail soon. Tibial plateau fracture type V.

37.   M30 Previous proximal tib/fib fracture with IM nailing and middle 1/3 femoral shaft fracture with IM nail. Presents with femoral neck fracture. Girdlestone tomorrow.

38.   M45 Open IIIa distal tib/fib fracture s/p ex fix with wound vacuum, will discharge today.

39.   F75 Distal femur and femoral neck fracture. S/p gamma nail (basically an IM nail with a big screw that attaches to the end and holds the head of the femur in place)

40.   F25 Open humerus IIIb fracture15 cm of segmental bone loss. 3x20 cm of skin loss. Complicated by cellulitis and abscess formation. S/p multiple I&Ds

41.   M6 acute osteomyelitis of proximal tibia with septic arthritis. S/p multiple I/D

42.   M10 chornic osteomyelitis of tibia. S/p multiple I&D’s, rotational skin flap and skin graft replacement.

43.   M10 L open type IIIb tib/fib fracture. S/p ex fix, medial rotational flap and skin graft

44.   M30 Acute traumatic big toe amputation with 10 x10 cm degloving injury to dorsum of foot. S/p I&D x 3 and skin grafting

45.   M30 chronic mid shaft humeral fracture with nonunion (He broke his arm a long time ago and the bone never healed so he basically had two elbow joints) s/p plating

46.   M 25 open type IIIa middle 1/3 tib/fib fracture s/p ex fix and I&D

47.   M22 open type IIIc (femoral artery injury) distal femur fracture. S/p I&D x6, antibiotic bead placement, IM nailing

48.   M70 Closed comminuted intertrochanteric hip fracture. S/p dynamic hip screw

49.   M35 Open type IIIa tib/fib s/p IM nailing. Complicated by poor alignment after fixation requiring return trip to OR to fix external rotation.

50.   M16 open type IIIa distal tib/fib and Achilles tendon rupture. S/p Im nail and rush rod of fibula

51.   F50 closed middle 1/3 spiral femoral shaft fracture (fracture site ~15 cm) s/p tibial traction pin. Will IM nail soon. Diagnosed with type II diabetes on presentation with sugars in the 400s

52.   F26 closed bimalleolar ankle fracture. S/p posterior gutter. Waiting for decreased swelling before surgery.

53.   M7 closed distal tib/fib fracture s/p lower leg casting. Degloving injury 3x4 cm s/p grafting

54.   M 25 closed midshaft femur fracture. S/p IM nail.

To those of you who stuck out to the end, I salute you and I hope that you found this mildly interesting.

In Him,

David

The land of Cush

Some of you true scholars out there will remember this Biblical term, but may not know that it actually refers to modern day Ethiopia.

I wanted to show you a few pictures from two hikes that I took. The first is up Mount Damako just outside of the hospital and the second is to Ajora Falls.

The Crew: Our guide Abe, Me, Matt, and John

The road from the hospital

Just off pavement

It was very misty this particular day, so some of the pictures with more distance may not have turned out, but  it really made for some sweet effects. 

It is just so lush and green, I was amazed

Potato field!!

Many of the local people will make this hike everyday to sell their wares in the market at Soddo, here are few donkeys. 

We had some local kids follow us for a while, I think that they were looking for tips. 

This is a church that is at the top. 

 

 The flooring was awesome

These poles are 12-15 feet long and yes, he is barefoot

For the bulk of this hike, we were in those clouds

This is looking into the Rift Valley and the outskirts of Soddo

Now onto the falls

This is where we are heading

"Don't let me fall!!"

"Oh, dude, David is taking a pic."

We had some kids chase the van from time to time. Evidently this girl was very happy to see us. 

Pants make for great head cushions. These kids would make this hike every day to gather fire wood for their family.