Dr. Geelhoed journal entry 14 Feb 2011 (part 2)

Series: 11-FEB-B-13

TURNING FROM THE DISTRACTIONS OF INTER-CLAN HOSTILITIES TO THE HEALTH CARE FOR WHICH OUR TEAM IS EQUIPPED TO TREAT, WE HAVE A FULL CLINIC AND THE OPERATING ROOM DELAYED FOR REACTION TO THE PRE-OP ANTIBIOTIC PROPHYLAXIS

AS WE ARE INSERTING THE SPINAL ANESTHESIA, WONDER OF WONDERS! THE CONTAINER TRUCK ROLLS UP TO MCH AND WE UNLOAD ITS CONTENTS IN THE MIDDLE OF A BUSY CLINIC AND OR SCHEDULE, CHANGING MANY PLANS AS WE STORE THE ABUNDANCE OF SUPPLIES FROM DERWOOD AND TOLEDO NOW SAFELY ARRIVED INTACT ON THE FAR SIDE OF THE GLOBE ON VALENTINE’S DAY!

February 14, (Ironically enough, Valentine’s Day) 2011

It has arrived! A Valentine’s Gift from around the world has just rolled on to the dusty rutted path in front of the MCH and the gate I had climbed over in the middle of the moonlit cool night, now in the baking sun of mid-day has just rolled open to have the Somali driver, his “road assistant” and Jacob Gai come tumbling out of it! We were just at the point of monitoring Juma doing the Lumbar Puncture to start the spinal anesthesia for the fourteen year old girl with the abdominal tender mass when Aaron came over and asked me “Were you expecting a container? Because there is a big one coming up the road through the gate!”

And there it was. A big Volvo tractor with two sleeping compartments in the cab had Jacob tumble out of one and the driver, a Somali looking down from the high up driver’s seat as he deftly made nearly right angle turns to haul the tractor trailer and its forty foot container up against the front of the hospital. The women who work in the compound came forward in the swaying dance and ululation of the happiness that comes to these people so seldom and bubbles over so easily when it does. They swung their arms over their heads and danced as the container came to a slow crawl and halt and the big engine was shut down. They danced around as I filmed it and the magnetic TR Logo was slapped on the side and tailgate. I took a video of it being opened up and the gleaming OR equipment from tables to new beds, which are capable of both electrical and hand cranking to change their positions. We saw the Hubbard tank for the treatment of the burn patients and the boxes of all the things I had put together into the Penske trucks in Derwood to get to the University of Toledo warehouse where it was repacked in the container that then—through Zach Smith’s efforts, made its way through Missionary Expediters to Mombasa, and then from there through Uganda and Juba –through Jacob Gai’s tireless efforts, got around the diplomatic, political and corruption obstructions to finally succumb on the last breakthrough to an overheated engine in the middle of the stark bush ten kilometers from Juba. Jacob got out and walked with the Somali driver through the blazing sun back to Juba to try to get a mechanic which finally materialized after the company that owns the truck flew one out from Mombasa, and some part of the compressor that allowed the cooling of the big diesel engine was replaced in the bush. Then, having used up all his cell phone battery in prior messages, Jacob could not tell us about the progress he had made and got into the big Volvo cab and came up to arrive at noon in MCH with their entire forty foot container still intact and sealed until we swung the big doors open and saw the unpilfered supplies inside!

It is a miracle, not to be taken for granted. It is a contingent event, with the contingencies involving the efforts of folk as generous and tireless in their patience as Jacob having made his fifth trip to Juba to get the Exemption letters delivered as they should have been accepted on the first pass. Then the vagaries of driving a big behemoth of a truck like that over the very same terrain I was stumbling over last night in my midnight run by moonlight in the deeply rutted roads all flooded out and torn up by the rainy season mud baths. It cannot be easy any way it is counted. The truck came right through the chaos of Juba where a thousand would be new government officials are eager to rip off the NGO’s and UN agencies for a handsome living by delaying and obstructionist tactics from which they profit in outright bribes. It came by the village where the Murle raid killed the sister of Ajak’s friend while it was still stuck in the nearby bush. It drove through the Bor Jonglei Headquarters where several officials have decreed that any such donation be given only to them to enrich their own fiefdoms and not given to distribute to other mission stations, above all NOT to those who have a history of hostilities to the same officials and their beholden constituencies.

But the “Mission to Heal” has made it thus far. We posed all the people who will take responsible ownership of the contents and recognize its value for the people they serve. As we opened it up, we off-loaded it by the old-fashioned African way, with head loads of stuff being portered to the ultrasound storage room where I had put Jacob in charge as the Chief Load Officer. I looked around and saw patients we had just seen, including the fellow with a goiter who was waiting for his ultrasound of the thyroid to see if he had a colloid nodule or a cellular neoplasm. There were women who were to have gynecologic evaluation who were dressed in colorful cloths abruptly leaving the front of the hospital waiting area and joining in the parade of porters with loads on tier heads. We had many sacks of flour and many more of rice of both American and Indian kinds and bidons of vegetable oil and whole cartons of egg noodles and powdered milk and can you believe it?—instant coffee!

There are also seven beds with electric mobility as well as hand cranked back up mechanics. The Hubbard tank for the treatment of burns such as I had seen here at Werkok two visits ago and had seen last weekend in Bor hospital. We had OR tables and gurneys and the surgical equipment I had loaded at Derwood including OR anesthesia monitors and the surgical sutures and disposable gowns which will never be disposed and the gloves by the gross and sutures by the caseload. When the question had been asked frequently as we had during each clinic and tutorial “Do we have any….?” The answer has changed to “We do now!”

How this cornucopia is apportioned is going to be a delicate issue and I am glad I am not that final arbiter of that, but had delegated that specifically to Dr. Ajak and to Jacob Gai, the Medical Director and the administrator who made it all possible and our “point men” to the Murle on our last visit to PiBor. They know the purpose envisioned for this Mission to Heal Peace Initiative and the principle piece of the overall puzzle—to achieve a continuing education ongoing symposium among the representatives of EACH mission in and among the various factions of tribal loyalties, with an equitable distribution of the largesse of both the education and the equipment to facilitate it spread out with no one taking exclusive ownership except to serve their rivals with heath care and its delivery and health care education.

We have made a good start with a full week of the tutorials with fewer of them being given by me each evening and more by all other participants with half or less now being given by the TR team and increasingly the assignment of the topics going to the Sudanese to prepare as their “dress Rehearsal” for coming Missions Network Symposium.

CLINIC AND OR WERE ALSO AT THEIR BUSIEST DURING THIS EXCITING INTERVAL OF THE CONTAINER’S ARRIVAL

While this was happening, our biggest clinic to date was in progress as the waiting patients were entertained by the sight of the staff scurrying back and forth in scrub suits carrying loads of stuff into storage. Forty two outpatients were seen by John Mchol alone, as I was involved with Dan Fong and John Sutter as the anesthesiologists in chief after Juma instilled the Spinal Anesthetic and they supplemented the adequate coverage with IV analgesia. Kannan and Juma were going to be scrubbed with me assisting and Ajak looking on as we opened the abdomen and found a distended uterus which was the tender mass in this virginal fourteen year old. She was squeamish about a vaginal examination and we agreed to do that while she was under spinal anesthesia. She had a negative Gravindex and had never had a period at age fourteen. She had already developed other secondary sexual characteristics and would be considered past due for menarche so we had an idea in the differential diagnosis—she may have had an ovarian teratoma that twisted in November and gave her the tenderness then which had untwisted and re-twisted in the last few days which gave her such pain that she walked the eight hours each way to get her with her brother. He speaks adequate English, but medical terms and body fluids are not his strong suit so we would explain what is going to happen as he would translate to her.

Her operation had been delayed since she developed a rash to the pre-op dose of cefazolin and we had given her Benadryl to counteract that. We had no suggestions that this was an inflammatory disease but had focused on a congenital and developmental disorder figuring her to be past menarche by several months and two other possibilities were likely—“hematocolpos” a collection of pent up menstrual blood in the upper vagina held back by an imperforate hymen, or “hematometria” a collection of unshed menstrual blood retained because of an undilated plugged cervix. We found out that the second was the correct diagnosis. We closed up the abdominal laparotomy and while she still had intact spinal anesthesia put her heels together in frog leg position and had Kannan insert a hemostat to gently dilate the imperforate hymen which had fibrosed to a thick peel. With the entry into the upper vagina, a gush of “tomato soup” appearing uninfected unclotted old blood gushed out in over a liter quantity. The uterus was massaged to expel another half-liter and she has a permanent correction and entry into the new life a young menstruating Dinka woman.

Her brother had an explanation of this situation which I though was rather thorough but then Dr. Ajak also asked him to step through the OR door. He seemed to me to take it all in and start wavering on unsteady feet when he saw the now released pent-up menstrual blood and I figured this was a discussion that could probably take place more adequately in the ward from which he had come in his waiting. We also busied him in being part of the porter parade as items continued to come out of the container.

I also evaluated a large goiter in the clinic in a woman of bout age fifty which was not impairing her airway but she was genuinely interested in having it resolved. It is not one that is symptomatic and I would be willing to relive her of it but she should be done with an endotracheal tube for airway protection and a general anesthesia. A woman who had had an earlier inguinal hernia repair here has now got a femoral recurrence which will be our next day’s case. We saw many miscellaneous patients and admitted a young girl with severe malaria and started her on IV quinine therapy while she was vomiting from the illness.

All in all, I believe we took rather good care of a full clinic and OR schedule during the excitement of offloading a forty foot container with all the things that may keep this center and a half dozen satellites functioning at a higher level of care competence in the course of the next year.

“MISSION TO HEAL” ACCOMPLISHED!