A Year in Review: Excellent Care

Chronic Osteomyelitis

From a clinical standpoint, this first year as a missionary surgeon has felt, in many ways, like being an intern all over again. In those first few months especially, I constantly felt in over my head as I tried to learn general medicine, tropical medicine, and the vast breadth of the surgical subspecialties that made up only a brief part of my residency training. The “normal” day-to-day work on surgical ward and in the operating room (“operating theatre” as it is known here) has been busy and full of many learning opportunities. In the past year, I have performed nearly 1000 operations. Only 2/3 of these cases are what would be considered within the scope of a general surgeon in the United States, hence, only 2/3 of the cases I have done have been procedures I was trained to do in my residency. The rest fall into the categories of OB-GYN, orthopedics, and urology. In fact, the most common operation I do is bilateral tubal ligation (“tying the tubes”) for women who have decided that they’re done having babies (usually after they’ve already had an average of 8-10 children), which is traditionally done by an obstetrician. The vast majority of operations I do emergently in the middle of the night are C-sections with the occasional laparotomy for sigmoid volvulus (twisting of the colon, which causes a blockage and cuts off the blood supply to the colon). I have learned procedures such as prostatectomy, hysterectomy, and how to set a variety of fractures. In addition to learning the surgical subspecialties, I am learning a great deal about HIV, tuberculosis, sickle cell disease, malaria, and typhoid and how they relate to surgical pathology.

It has been a challenge to learn to care for patients in a setting of significantly limited resources compared to what I have known in the States. Just a few examples:

*Patients come from great distances, and most do not have a car or access to reliable transportation. Many have to make a hard decision to leave fields and crops unattended or large families at home uncared for in order to come to the hospital. As a result, by the time most patients come to us, they have been living with their condition for weeks, months, and often years! 

*We often experience inadequate supply of medications and blood. When we have more patients who need blood than we do units of blood to give, we have to make difficult decisions about who will receive the precious blood available. 

*We do not have any oral narcotic pain medicines, meaning that patients going home after major surgery, with broken bones, or with inoperable cancers are given only Tylenol and/or ibuprofen for pain. 

*We lack advanced medical technology in the way of CT scanners, ventilators, intensive care monitoring, advanced lab tests (i.e. electrolytes, bacterial cultures), laparoscopy, endoscopy, on-site pathology, and the ability to provide advanced cancer care through chemotherapy and radiation.  Our ability to make diagnosis is dependent on a good history, physical exam, and occasionally an x-ray, ultrasound, a basic lab test, or even exploratory surgery.

Melanoma of the foot

*With the exception of Burkitt’s lymphoma, Kaposi’s sarcoma, and Wilms tumor, we do not have the ability to administer cancer chemotherapy here.  Many of our patients do not have the means to go to the capital city for advanced cancer care. Most with a diagnosis or suspected diagnosis of cancer will not be able to receive the appropriate medical treatment that will provide a cure or prolong their survival. Cancers often are not diagnosed until they are very advanced and after they have spread throughout the body, meaning that surgical resection is not a reasonable option. Our main focus in advanced cancer care is helping our patients be reconciled to God through Jesus Christ and in making them as comfortable as possible for however long they have left to live.

*Patients who need long-term nursing care in the way of home health or inpatient nursing facilities do not have access to such services. This means that those with significant disability (spinal cord injury, stroke, debilitation from chronic illness, major trauma) do not have the option of rehabilitation. They must rely on their families to care for them in places where there are no wheelchairs, ramps, or handicap accessibility.

Despite our many limitations, it really is incredible how much we are able to do here.  It’s amazing to see God at work when we feel like we have little to offer.  Just last week, I operated on a woman who developed multiple large enterocutaneous fistulas (small intestine forms a connection with the skin and drains its contents onto the abdominal wall) after complications from previous operations. Operating on her right away would have been dangerous because of the inflammation and scar tissue inside her abdomen, so we were forced to wait. The injuries to the small intestine were high enough in the GI tract that whole pills would come out of her wound rather than being absorbed by her intestines. Her condition put her at significant risk of dehydration, malnutrition, and skin breakdown as well as a good chance she would not survive. She has been admitted here for the last 4 months as we have worked hard to keep her alive, healthy and strong, allowing time for her skin to heal and the scar tissue inside her abdomen to become less dense to prepare her for an operation. In the States, this woman would have had multiple CT scans and a vast diagnostic work-up. She would have had home health nursing care to help her manage her fistula output. She may have even received IV nutrition (TPN) or tube feedings to maintain her nutrition and electrolyte balance. We have none of that here. Instead, she was given a bed with a hole cut into the foam mattress to allow stool to drain from her abdomen into a pan on the floor. We kept her in a steady supply of Vaseline and cotton wool to help protect her skin from the caustic intestinal contents that spilled onto her skin. Each week, we bought her a tray of eggs and a jar of peanut butter to provide her with enough protein to help her body heal and to keep her from losing weight (in 4 months, she actually gained 1 kilogram!) We spent much time in prayer, asking God to heal this young lady and to help us make the right decisions regarding her care. Her operation this week to remove the injured intestine and reconnect the healthy ends went so smoothly, and she is recovering well on the ward. Hallelujah! 

Every day, people come to our hospital with a variety of illnesses and injuries, and every day, people go home healed or on the mend, having received treatment, medication, surgery, physical therapy, and spiritual counseling.  Like most mission hospitals, we operate under the knowledge that “We Treat, but Jesus Heals.” We believe this wholeheartedly here, and we see it every day as patients are healed despite lack of resources or limitations in our knowledge and ability.

Mukinge is not on the main road. It’s not on the way to anywhere, really. It’s at the end of the paved road, about a 2 ½ hour drive from the nearest city. And yet, patients come from far outside our district, making the long journey here because they have heard that if they come to Mukinge, they will be cared for. They have heard that there’s something different about Mukinge Hospital. They come all this way because they have heard that God is at work here, and they come believing that they will get better.

Over the course of medical school and residency, as I would talk with people about medical missions and about becoming a surgeon in the developing world, a number of medical professionals made comments to me about how they didn’t think they could practice medicine overseas because they couldn’t stand the thought of not being able to provide “excellent care.” I’ve thought about this a lot over the years.  What does it mean to provide excellent care in the developing world?  In Africa?  In Zambia?  At Mukinge Hospital or elsewhere?  Can a commitment to excellent practice be made in a place where the conditions seem less than ideal?

I appeal to you that it is possible to deliver quality medical and surgical care in the developing world, that it is possible to provide excellent care even when the conditions are less-than-excellent. I think we do this every day at Mukinge Hospital. I don’t think that Excellent Care means that we have the ability to provide stereotactic radiation, robotic surgery, or state of the art diagnostic imaging.  I believe that Excellent Care is providing the best care possible with the resources available in a compassionate and caring manner. It means treating patients and their families with love and integrity.  Sometimes it means knowing helping a patient to die well without inflicting unnecessary suffering through prolonged hospitalization or surgery that will not improve their quality or length of life. Here at Mukinge, we strive to provide excellent care for each of our patients. As we work under the guidance of the Great Physician, we trust that God will provide for our needs and those of our patients. He does excellent work, and it is a privilege to work in a place like Mukinge Hospital where “We Treat, and Jesus Heals.”