Tesfaishope. Hope of salvation, hope of health.
Jesus came so that we can have life, life to the fullest (John 10:10). Health is an intrinsic part of that. Some people have asked what is our role here in Kibogora? Its something that i am finding out on a daily basis. It’s about going in faith and trusting God to show you how you can be useful. I have found the local surgeons and residents to be very knowledgeable and skilled at operating. I was personally embarrassed when a first year surgical resident showed me his operating list. He had performed over 400 open procedures in little over one year. This dwarfs the surgical experience of a first year surgical resident in Norway! However, as I resonated, operating volume is not everything. I don't like comparing my hospital at home and Kibogora because they are so vastly different in structure and resources. Regardless of where I or my fellow Rwandan surgical residents work, we would in each scenario, work to the better of the patients with the resources you have and the system you are placed in.
In the gap between these two medical worlds there is the opportunity for us to learn from each other.
Bjarte can teach all aspects of general surgery and especially colorectal cancer surgery. He has performed some “firsts” here in Kibogora, including a total colectomy with APR (abdominal perineal resection) , a total gastrectomy to name a couple examples. Here the whole surgical team comes to watch and learn invaluable lessons as knowledge is being shared.
Everyday I'm learning and am thriving in this environment. The other residents Francois and Venuste are happy to teach me the principles in plastics, ENT and pediatric surgery. But what do I have to contribute? I have only a couple years of surgical experience and most of that on vascular (operating on blood vessels). However every now and again an opportunity arises. During our first week we operated on a man with a large sarcoma (soft tissue cancer that is very aggressive) in the groin. Here I demonstrated how to dissect the tumour away from the femoral artery and vein, something the residents haven't seen before.
Bjarte is teaching 3 at a time!
A week later we operated on a young girl with a disfiguring facial mass. She has a gorgeous smile, one that lights up a room. The operation turned out to be a particularly difficult neck dissection of a residual branchial cleft cyst involving some important nerves in the neck. There I had a chance to show how to control unexpected bleeding which are really the ABC’s of vascular surgery and I'm proud of my colleagues and friends at Haukeland for teaching me these skills which can now be passed on. I was anxious to see how Zara would be after the operation as we had to sacrifice some nerves to remove the tumour.. is her swallowing okey? Is her voice the same? Has she lost that beaming smile? You can see in the picture as we discharged her she came bounding up to me, smiles and all, wanting a picture of herself and her younger brother. This is also part of being in the Tesfa team. Not just operating but contributing as ourselves by showing compassion, sharing a meal with colleagues or by sneaking chocolate to the kids on the intensive care ward!
Preop and post op picture. Zara has still got that amazong smile!
Here is a story of a rather typical day in Kibogora:
We finished the elective program of hernias, hydroceles and soft tissue infections. Then came the emergencies. I was honestly tired, thirsty and wanted to put my feet up. Standing all day in a hot operating theater with poor ventilation makes the fatigue set in quicker. One patient came with a suspected incarcereated hernia had increasing peritonitis. Bjarte started on that patient with an intern. A senior resident, Venuste and I waited for the anaesthsia team to induce the second emergency case. She’s a young woman, who got married less than a month ago. In the same time period she has had abdominal pain and collapsed earlier today.
As she came into the surgical intensive care unit I performed an ultrasound of her abdomen. Her liver looked strange. Like small webs were floating around it, almost like septa (a small membrane within an abscess). Why would she have septa around her liver? The case got stranger as more bits of information were translated from Kinyarwandan by different people. She was referred by a gynecologist despite the patient not being pregnant. Weird. She did however have a large mass in her pelvis going up to beyond her belly button. Weird. The ultrasound looked like small flecks of bone inside the uterus. Is this intrauterine foetal death? She had vaginal bleeding as well. She was diffusely peritonitic, septic and we planned on an exploratory laparotomy. I beckoned Bernard our consultant to join us for the case and he waved his hands towards Veniste and myself. We are not getting help just yet.
I opened the abdomen and I thought I'd pass out as the foul stench of pus hit my nostrils combined with the heat of the operating room. Last week after a perforated peptic ulcer operation i declared “i have never seen an abdomen that bad”, well now that got trumped. There is no peritonitis like African peritonitis i thought. The mass in her abdomen was indeed her uterus but it looked grossly misformed, covered in yellow and green pus (you are all spared a photo). The abdomen was floating in pus covering the loops of bowel. The suction machine had trouble keeping up as pus seeped over the edge of the abdominal wall and down the drapes to the floor. Damn i should have brought my wellies i thought. I'm pretty sure my socks got wet not too soon afterwards (surgery by the way is not as glamorous as shown on TV).
The misformed uterus was due to myomas (many muscular tumours of the uterus), one of these balls of muscle was infected, formed an abscess and perforated allowing the infection to spread to her abdominal cavity. We swept through the abdomen breaking the abscess membranes with our hands and the torrent of pus continued . I came up to the liver with my hand and continued breaking abscess walls, sure enough the ultrasound was correct. There is actually a fancy medical term for this young woman's condition. One all poor medical students will memorise and then subsequently forget immediately after their infectious disease exam. Fitz-Hugh-Curtis syndrome describes an ascending infection from the uterus causing a liver abscess most commonly due to gonorrhea.
The smell leaking outside our operating theater door had interested Bernard enough to join us. We began removing the infected myomas from the uterus and once we were finished it was unfortunately in tatters. No way would she be able to have children I thought, perhaps its best to do a hysterectomy (surgical removal of the uterus). Then we will have removed the source of infection and even if she does become pregnant in the future the risk of uterine rupture is very high. Bernard chirped in “Matteu, hysterectomy in honeymoon is contraindicated! You cant remove uterus in honeymoon you know.” I’m the resident here, I have to respect the surgical hierarchy. Perhaps the knowledge of being made infertile now is worse for her than not being able to conceive in the following years. Here infertility is grounds for divorce I have heard. We washed the abdomen with 10 liters of saline and closed. 5 days later she is in good shape, much better than expected, hallelujah!
We are not machines that operate on other machines but humans; body, mind and spirit. In being with our Rwandan friends, we share the burden of the long hard days and also the highs of humbled relief when a child pulls through against all odds. Then we give thanks to our Father in heaven who does His healing work through this small family at Kibogora and we teach each other something about humanity, hope and how to live a life worthy of our calling (Ephesians 4).
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*Mr’s Fitz, Hugh & Curtis never elaborated if hysterectomy was indeed contraindicated whilst on honeymoon.
**Zara is still smiling
All photos are taken with written consent from the patients.
Where applicable details have been changed to protect patient confidentiality.
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