Alimamy Conteh (not his real name) is 9 years old. He is the size of a six year old. He has not felt good a single day of his life. Every time he eats, his belly swells and he has cramps. It is easier not to eat. He was born with a rare malformation of his anus – there was only a very narrow opening, smaller in diameter than a pencil, in front of the usual place for the anal sphincter. His devoted mother has searched but not found anyone able to help her precious boy here in Sierra Leone.
A short time ago, she found her way to the dock of the Mercy Ship. She was wearily hoping that we could do something. I was called and I examined the little boy. Her eyes never stopped searching my face and then she smiled gently. There was something that we could do for him. The mother left the ship that day with two precious things: a chit of paper bearing the date of his admission and a blazing hope in her heart that her little boy would someday be normal. Alimamy was admitted Monday of this week. On examining his swollen abdomen, we found a huge mass – confirmed by x-ray to be a massively distended colon, full of feces. A contrast study was done and confirmed that the anatomy was favorable. Fortunately, there was no abnormal communication with the urinary tract, a much more common finding in this kind of disease in boys. He underwent three days of a liquid diet, laxatives of various types and irrigations of his colon (enemas) twice a day through the small opening in front of his anus. He was amazingly stoic about the torment and told his mother, as his belly regained normal size, that he was feeling better.
In the late summer of 2008, I had the pleasure of watching Dr. Alberto Pena, the world’s expert in this condition, perform several cases of similar type in his home base at Cincinnati Children’s Hospital. My fellow chief resident, Dr. Fred Ryckman, is a transplant surgeon there and arranged the opportunity for me, for which I remain grateful. Dr. Pena gave me several DVD’s that showed the variants and how he repaired them. When packing for this trip, I threw them in the suitcase. They would come in very handy this week. Both I and Dr. Agneta Odera, a Kenyan fourth year general surgery resident at Tenwek who wants to be a pediatric surgeon, reviewed them before his surgery on Thursday.
Fortunately, at surgery, he had very normal appearing muscles in his sphincter (sometimes they are undeveloped), so in a painstaking three hour operation, we were able to reconstruct the entire area, repositioning the opening within the anal sphincter. We then flipped him over to give him a temporary colostomy (to protect it from infection and to allow healing because of his malnutrition). In about 10 days, we will begin to teach the mother to gently dilate the new opening until it is of normal size and elasticity. We plan that a general surgeon on the ship at that time will take down the colostomy in about six weeks. We are praying that he will regain absolutely normal function over the next several months.
More from the Shrime blog:
[Last week, two stories from the blog of Dr. Mark Shrime (http://mercyinafrica.blogspot.com)were featured. Shrime is an ENT surgeon from Boston who was on the Africa Mercy for a few weeks, working with the PAACS residents. Here is the last story, reproduced with permission, which tells a great deal about why I am involved with PAACS and why he wants to be in the future].
Last week, Agneta took out a man's jaw.
But, before I tell you about that, some background. There is a tension in global health between relief and development. I've written about this before, but to summarize: Where infrastructure doesn't exist (or does so at a level that barely meets the needs of the population it undergirds), aid comes in two, often mutually exclusive, flavors. At the risk of oversimplification: if attention is focused on the redevelopment of infrastructure, the vast masses of patients who become sick while this infrastructure is being redeveloped are left undertreated. On the other hand, if attention is focused on these patients, the infrastructure is itself undertreated, perpetuating the steady stream of those who need more help than it can provide.
Bridging these two basic paradigms of aid is thorny. Although each is important, each has its stentorian prophets, and development's prophets have, of late, carried the day.
To a (very) large degree, the sort of work that's done on this ship leans toward the less popular of the two, with occasional nods toward development. Sustainability and capacity-building are discussed nearly constantly, local surgeons have been a fixture in the operating room, and agricultural education, mental health education, and primary health education programs form a part of the ship's mandate. (At one point in the last four years there was also a well-digging program; I'm not sure when or why it saw its demise). But, as a whole, we provide relief to the medical infrastructure in the countries we go to.
So, when Agneta took out a jaw last week, it was more than just an operation.
Dr. Agneta Odera is a fourth-year surgical resident at Tenwek Hospital in Kenya. She and two of her Pan-African Academy of Christian Surgeons residency colleagues are on-board for three months, doing month-long rotations in general surgery, anesthesia, and head and neck surgery. Yesterday, she finished her month with me on the head and neck service.
Agneta is one of the finest residents I've ever gotten the opportunity to train so far in my short surgical career; she has the makings of a great surgeon: she is compassionate, detail-oriented, knowledgeable, and handles tissue like an expert. So, training her wasn't difficult, and last week, she flew solo on a segmental mandibulectomy and reconstruction for a large midline ameloblastoma.
Watching a resident flawlessly perform an operation is always a thrill. Watching her flawlessly perform an operation she had never seen three weeks prior, and knowing that her commitment is to Africa, to surgical development on this continent, and to bucking the brain drain—knowing that she leaves this rotation with at least one measurable, sustainable skill which she can take back with her is more than just a thrill. It is immensely, deeply satisfying.
Praise and Prayers:
- Pray for the strength and enthusiasm to finish strongly on the Mercy Ship. We are weary and discouraged about many things right now. We leave August 8.
- The COSECSA trip finished safely and we need your prayers as now they decide at their meeting in August about the level of accreditation they shall grant to us.
Rocking on the waves,
Bruce for Micky and Sean