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. 

God’s judgment, the poor and oppressed, and a Gouda omelet

Hey folks,

As I sit here enjoying my gounda (thank you previous visitors) and onion omelet, I wanted to try and unpack a few things that have been on my mind over the past few days as I have been reading through Psalms, specifically chapters 9-12. I hope that I do not bore you with my theologizing, but who knows maybe this clanging gong with make some sense.

Many people in this modern world and probably a quite a few of those reading this blog think that Christianity is just for upper middle-class white suburban families who have a yippy dog, eat white bread, have 2.1 children and drive minivans. Many people also find the commandment “Love your neighbor as yourself” to be very easy to digest, but the idea of hellfire and the wrath of an angry, all-powerful God to bring on the GERD. In my reading (and some listening to Tim Keller) I have found these ideas to be completely false and rather narrow-minded. Of course keep in mind that like everyone else, I am a product of experiences and I type with my own worldview, but hopefully I will be somewhat close to the truth, even if it is by accident.

First of all, the God of the Bible is not a god for the rich and well-off, he is a God for the poor and oppressed. Ps. 9:9 says that “God is a stronghold for the oppressed, a stronghold in times of trouble.” In 18, “The needy shall not always be forgotten, and the hope of the poor shall not perish forever.” The psalmist (who has a great name) lays out this drama in 10:2: “In arrogance the wicked hotly pursue the poor; let them be caught in the schemes that they have devised.” And if that isn’t enough to convince you that God is for the poor, check this out in 12:5 “Because the poor are plundered, because the needy groan, “I will arise” says the Lord; I will place him in the safety for which he belongs.” Now, this is not to say that only poor people can be Christians, because Jesus said that rich people can “inherit the kingdom of heaven” but that they have to overcome the obstacle of their wealth (which I will get to soon). Nor am I trying to say that the organized church is always on the side for the poor and oppressed, but rather that God always is for those who are down-trodden. And this is not going unnoticed, Christianity is not primarily growing the in the western, non-majority, civilized, developed, whatever-you-want-to-call it, rich world, it is growing mainly in Africa, Latin America, and SE Asia ie some of the poorest places on earth.

Next, this whole idea of an angry Old Testament, bible-thumping God who is just ready to send people to hell. Everyone seems to like  Jesus  the good teacher who talking about loving everyone, or those nice stories about David and Goliath, Elijah, or Daniel, but who really wants to hear about an angry judging deity? Well let’s consider a classic example, those in the crowd who have children or work with them in some capacity have probably heard “that’s not fair!!” coming from one of your favorite angels. Now, does this phrase typically follow something good or something bad from the kids perspective? Does the child say that it’s “not fair” that they just got a giant chocolate chip cookie for no apparent reason? Of course not, they only demand fairness when something is taken from them, ie a toy, privileges, fun. In the same way, most of us (including myself) in the western, non-majority, civilized, developed, whatever-you-want-to-call it, rich world don’t really want fairness or judgment because life has been pretty good for us. But consider one of the residents that I work with who is originally from Rowanda and had to witness the genocide there. People who had to suffer as many losses as them completely understand it when chapter 11 says “His [God’s] soul hates the wicked and the one who loves violence. Let Him rain coals on the wicked, fire and sulfur and a scorching wind shall be the portion of their cup. For the Lord is righteous and he loves righteous deeds.” For those who have been subjected to true physical, emotional, sexual, or Paul Farmer’s “structural” violence, a God who “has established his throne for justice, and judges the world with righteousness” sounds like a pretty darn good option. At the same time, there is the age old desire for revenge and not that people shouldn’t be held accountable for their actions, but to go all King James on you all, “Vengeance is mine, I shall repay, sayth the Lord.” While this doesn’t make these other suffering people’s lives any easier at that moment, they can rest in the assurance that God will give them justice and let go of their hate.

 Well, it’s getting late, the omelet is long gone, and I am at the end of my theological rope so I should probably call it a night. Tomorrow morning I get to hike the mountain that overlooks the hospital so if it is not too foggy, I hope to have some sweet pics of the Rift Valley. Once again, I hope that you are all doing well and I look forward to seeing you again soon!!

In Him,

David

A little photo tour.

I would like to start this picture collage with a few bulls that were fighting just over the hill. I think that it is a nice symbol of our daily struggle against sin, with Christ being the mountain in the background overshadowing all of us. (A bit of a reach?)

 This is the dirt pile just outside my house, which the kids of the compound have turned into a castle. Dr. Hardin is supervising their work and occasionally will call them to stand at attention if they play a little too rough.

This is the Anderson's house and as you can see in the coming pictures, their gardens are amazing. 

 This is the house that I am staying in. Pretty darn nice, even by Western standards.

This is the living room.  

 This is the washing machine. It returns clothes folded.

 This is another washing machine. It does not fold clothes.

 The kitchen

 My bedroom.

 A nice little gazebo, perfect for church, birthday parties, or bible studies.

Our porch, from whence I currently type.

 Now to the hospital. This is the surgeon's room, and as per usual Teddy, one of the residents from the Black Hospital in Addis, is hard at work. The table to the left magically has injera appear on it every day at noon and the bookshelf in the back has more medical knowledge in it than I could ever hope to fit into my head.

 This is the Pan-Africa Academy of Christian Surgeon's (PAACS) resident's house. It will eventually expand from 7 apartments to 21.

 A nice little pavilion just outside of the hospital, if you squint you can see the common occurence of a family member of a patient sleeping on it.

 This is the new CT building. We spent most of this morning unloading a shipping container into this building. The pictures at the end document this cheerful event.

The driveway into the hospital

 This is just overlooking the hospital compound. The mountain in the background is about 9500 ft high and will be conquered before the end of this trip.

 This is a shot of the wards, they generally keep it pretty clean.

This is our arch nemesis, the food cart. We try to beat it on rounds so that we can see our patients while they are still fasting and have the possibility of taking them to the OR. 

 Dr. Warren Terry, my former roommate, with one his favorite patients Maria.

 One of our patients. I hope that my PT friends will note the continual passive motion machine, rehab is key.

 This poor kid had a bad open fracture of his femur and has a 8 inch wound that goes down to bone on his thigh. If you recall my previous post about pain, he is a prime example, but he is a really nice guy whenever his bandage isn't being changed. Each room typically has 3-6 patients in it, although there a few private rooms.

 Another patient, still kinda in a daze this morning.

 Same deal.

This is known as OR 3. Notice the C-arm that can be used for intraoperative X-rays. 

This is OR 4 and these two beds are often going simultaneously. Generally we put our smaller cases in this room. 

This is a classic example of the kind of problems that you see in Ethiopia. This is a 18ish year old guy who broke his leg several years ago. It obviously wasn't casted very well and his leg is about 3 inches shorter than his other leg. We took him to surgery, rebroke his leg, made it the right length and fixed it with a metal rod down the middle of the bone (aka IM nail). 

 This is the ICU/PACU/Pre-Op and where we start rounds every morning.

 The sutures, trying to find the correct type of stitch on the correct needle in the correct size is a constant battle.

 This is one of our patients and her mother. This sweet little girl is 2 years old and has had shin pain and swelling for the past 3 weeks. After being seen by another hospital, she was brought her and found to have acute osteomyelitis (bone infection). If you can catch it in the early stage, you can do a minimally invasive surgery where you drill a hole at the top and bottom of the shin bone and flush out the infection. She just came here on Saturday and she will likely need to go back to the OR several times before she leaves.

Another picture of her. She was not happy to see me. 

The long awaited container with the equipment for the CT scanner has finally arrived!!! This crod of Ethiopians pretty much self-assembled to unload the truck. By the end, I think there were 30-40. 

 Those darn lazy Americans, just watching things...

 Since we couldn't get the truck into the compound, we had to load everything into Dr. Grey's truck or Dr Ayre's SUV and ferry it about 500 yrds to the CT building.

Since we couldn't shut the door to the SUV, my job was to ride on the back and make sure that it didn't open and spill our precious cargo. This was one of our many violations of OSHA during the day.  

We started the process at about 9 and finished around 3. It was basically a controlled disaster, but we were rewarded the entertainment of watching the shipping container being pulled off the truck. The tied it to another container and just pulled forward. Although this sounds simple, it still took about an hour. This whole experience made me appreciate the infastructure of the US and how easy it is ship and move stuff.