Pretending he's beside me

It was yet another day in the hospital, operating like a mad woman. When I got to theatre in the morning, there were 18 cases scheduled! Luckily for my Friday evening (and perhaps not so lucky for the patients), the interns had failed to prepare a number of them for theatre. Labs hadn’t been done, blood hadn’t been prepared, and so a reasonable amount of them ending up getting cancelled. In the overall scheme of things, not the preferred choice, but at least I am home at 8pm and not still at the hospital. ;-)

Me and Dr. Raburu, head of surgery at New Nyanza PGH

Learned first-hand of some more differences between Kenyan healthcare and American healthcare:

If you think there is a blood shortage in the United States (and there is, that’s why there are so many pleas for blood drives!), you can’t even begin to imagine the blood shortage here. For elective cases, the patients undergo preparation for auto transfusion. They will be bled once a week for three weeks (banked whole blood is only good that long), and if the operation is delayed, they are transfused one of the expiring units and then bled again the next day! Two cases today got cancelled because the interns hadn’t bled the patient pre-operatively.

Ok, ladies. Let’s spend a minute or so to discuss breast cancer. We all have the pink logos everywhere, we all do our self breast-exams (we do, don’t we?), we give to Susan G. Komen or the AVON walk or whatever charity is out there, because it’s breast cancer. It hits close to home. 1 in every 7 American women will have breast cancer at some point in their lives. The good news is that between early screenings, early excision and improved chemotherapy regimens, it’s not always a death sentence.

I was prepared for the fact that there is no early screening. Mammograms are expensive, and women are much more worried about feeding their children. I knew that cancer here tended to present at much later stages because of this. Today, I did a mastectomy on one such woman. She had a large mass that had broken through the skin and obviously hard lymph nodes in her armpit (T4N3Mx, for those medical among you). We did a palliative mastectomy and selective lymph node excision. Why? There is no chemotherapy in Kisumu, no occupational therapy to help reduced chances of arm swelling after a complete lymph node dissection, no radiation therapy. These were all facts I was willing and able to understand knowing what I do about the area.

What I wasn’t prepared for, despite thinking that I was a culturally sensitive doctor, was listening to the senior surgeon tell me why these women don’t see the inside of a theatre until this point. The first is understandable. There are superstitions and traditions that many of the Kenyan tribes have about the female breast. The removal of such is traumatic and spiritually offensive. Even if a woman is seen with a small palpable mass and excision is recommended, she will likely disappear until it grows through the skin and then she will come to the surgeon “because she is smelly”. Even that, knowing that it is the patient herself that is making those decisions, within her cultural context, is acceptable to me. Painful, but acceptable.

Less acceptable is the fact that sometimes these women will be diagnosed and the husband and/or father will not allow the woman to undergo the recommended treatment, even if her life is on the line. The senior surgeon today told me of at least one case where the woman came with a small “curable” lesion two years ago and is now dying. If he has at least one story like that to share, imagine how many are out there. That situation, despite it being within the male/female cultural context, is not acceptable to me.

::steps down off soap box::

On a different note, I learned that there is an immeasurable difference between watching/assisting on a case dozens of times and being alone in the room to do it on your own with an intern that has no clue what you’re doing or anything about the patient (because he hasn’t read the chart AT ALL). We get a fair amount of surgical autonomy at Columbia, but there’s always someone in the room that can help, and the resident assisting you has some knowledge of the procedure at hand.

Maybe you’re thinking… but, Steph, you’ve been telling us about all these solo procedures. And the answer is, yes, I have. But those have been things I am confident that I can perform. This? This was a colostomy in a 3 week old baby girl. Conjuring up all the confidence I could, I just thought, “What would Abbey do?” ;-)

This weekend will be some non-medical things, so hopefully some cool pictures and thoughts to write about. A break from all this daktari stuff…

Two weeks of operating completed! Only 6 theatre days left! A short operating week next week as Friday was declared a National holiday for the president and ministers take new oaths of office under the referendum that was passed the day I arrive. Then only a partial week before I head to Nairobi, London and ultimately NYC!

Going by too fast…