Sunday, June 7, 2009


Bonjour, Tout le monde!

Your faithful Djibouti correspondent here, with tales of adventure from the shores of the Gulf of Aden.  Well, today was unexpectedly interesting.  Last night, as I was getting ready to retire with Colleen McCullough's The First Man in Rome - an interesting combination of bodice-ripper and extremely well researched historical fiction - the phone rang.  Now, my phone never rings, so the tendency is to assume it's either a wrong number, or a catastrophe.  If you guessed one of those, you'd be right 50% of the time, historically.  This time though, it was our surgeon Bill, asking if I wanted to go to Peltier - the Djiboutian hospital - to assist him in assisting Dr. Elias with a common bile duct exploration.  I would be the first to admit that back in San Diego I might have turned up my nose, waiting for an open heart case to come along, but that was then.  " What time do you want to meet?" I asked.

Thus at o8ooish (after colors and the Rogers and Hammerstein anthem of Djibouti), Bill and I set off on our excursion.  A couple of firsts were gotten out of the way, actually.  Neither Bill nor I had driven on the Djiboutian roads to this point, and neither of us had actually done anything at Peltier.  As to the roads and driving in Djibouti, well I can only say that I hereby apologize for any criticisms made or implied by me about the terrifyingly random driving habits of Sicilians and Neopolitans.  

Friends, any object on any road or roadside in Djibouti - trucks, really big trucks, goats, dogs, camels, pedestrians, donkey carts, scooters, taxis, children to name just the more obvious actors - can at any time be in any lane going any direction at any speed from 0 to 60 miles per hour.  This has been explained to me as the imshallah philosophy as applied to traffic patterns: If Allah the merciful, who has ordered even the fall of the grains of sand from the top of the loneliest dune in the most remote desert, wishes one to die in traffic then it would be impious even to attempt to avoid one's fate.  I can't comment on the accuracy of this imputation, nor on its theological merits, but it does make driving here resemble Mr. Toad's Wild Ride.  Luckily Bill was driving (surgeons always want to drive), so I could watch the whole thing between the fingers of the hands I was holding over my eyes. 

Anyway, we made it.   On arrival, after changing into scrubs in Dr. Elias' office, we made our way to the OR suite.  As it turned out, Dr. Elias was delayed, so we cooled our heels in the Bureau Anesthesie  (pictured) while we waited.  A bit different from my cherry wood desk and panoramic view of San Diego bay!  The 5 OR's are quite, um, spare.  The fixtures are old, and many are broken - held together by a range of ingenious adaptations of materials donated,  left over, or supplied by the Health Ministry.  Tile is missing in patches from floors and walls, and the ORs are curtained off from the central hallway.  The staff consists of the several surgeons - the orthopod and "visceral" surgeon were operating today - two Djiboutian anesthesiologists, augmented by a Chinese colleague, and 4 anesthesia assistants.  These latter are nowhere near the capability of an American CRNA, nor I suspect of our AA',s but they are often left to themselves to manage patients as the anesthesiologists move from room to room.  The drugs and supplies are pretty familiar stuff, especially if you trained about 15 years ago, although they do have Paracetamol - IV tylenol - that I don't think we'll ever get to use in the States.  The Anesthesia machine is a simple Italian model, with oxygen as the only available gas.  Local anesthetics and spinals are preferred where possible as they are easier for the physicians to leave in the care of their assistants, and use fewer resources.  The recovery room is spartan so prolonged recoveries are not a good option either.

In any event, as always the people were friendly, or as friendly as was possible given language barriers (the American english speaking anesthesiologist speaking to the Chinese manadarin speaking anesthesiologist in French, assisted by the Cuban trained Djiboutian).  The two local Docs - Dr. Meseret, a diminutive Djiboutian lady, and Dr. Assam, a darkly handsome Egyptian man - were happy to have us there.  We've been invited back to give some lectures to the Anesthesia Assistants, and shall look forward to doing so.  As it turned out, by the way, the bile duct case was postponed (her serum potassium was worrisomely low), so I observed mostly "lumps and bumps" sorts of fairly minor surgery.  

This was interrupted when a Djiboutian man who had been struck by a car was brought into the OR suite - for evaluation as far as I could tell.  He had obvious significant head trauma, a fractured lower leg and multiple other injuries.  They finally got his leg splinted, and pulled the gurney out of the room - I thought - to the CT scanner to evaluate his head trauma (his neck must have been stable anyway, as his head was yanked this way and that as a bandage was wrapped around a major scalp laceration, and yet all four extremities were moving).  I was surprised therefore about 15 minutes later to find that they were in the next OR sewing up the scalp wound.  Somebody asked me if I thought he should have some morphine, and instinctively I said "No".  His mental status was obviously impaired, and he needed to have his neurological status carefully followed (he needed a CT scan).   I was brought up short though when Bill murmured that, as there was no neurosurgeon in the country, and no prospect that he could be treated for any neurologic injury, maybe fixing his superficial wounds and a little comfort care was all that could be done.  Ouch.  Kind of an adjustment coming from our model of rapidly escalating care for the seriously injured.  I left the team to make their own decisions...

No other news (and I've been typing this for 3 days!).  Off today - in my role as the Captain & Colonel lounge liquor distributor - to see Mr. Moda - the wine and beer negociant in the city.  I'll be restocking the White House fridge and wine storage area.  I think I might pick up a couple of nice French roses (I can't find a way to get the accent on the compose screen),  in additon to whatever else the gang wants.

And with that I'll sign off and get this posted.  26 more taco tuesdays to go... :-)

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