Peltier moments

Hello all,

This will be a brief entry for the fairly good reason that little has happened, and the less satisfactory reason that I've been sitting and typing at a computer pretty steadily for the last few days and I'm afraid it has lost its considerable power to charm. This is especially so as I am, alas, a wretched two fingered typist. Doubtless that's why I selected medicine as a career instead of, say, law. Lots of typing in law I reckon. Yuck.

What have I been typing? I'm trying to knock together a plan for managing the flu (you know, the flu) should it have the temerity to show its infectious little head here in Djibouti. You'd think any self-respecting microbe would find a more congenial climate, and abandon this dusty corner of the world to the vipers and sand flies. We'll see, I guess. The fact that my last formal infectious disease training was a bit more than 20 years ago has compounded the problem for my less than dexterous digits. Ah well.

I did have a chance to visit with our colleagues at Peltier, the Djiboutian hospital, this past week. Herman, Bill and I assisted with a prostatectomy, a hydrocele and a neck mass removal. It wasn't exactly the most challenging anesthesia in the world but it was a pleasure to spend a little time in the OR. The prostatectomy was illustrative (I should mention that the next bit may be a bit, um, medical. If you can make it through "Nip and Tuck" you should be okay. Although there's no sex). As there is really no such thing as a recovery room in the sense we use it - an area staffed by highly trained nurses, carefully monitoring each patient to be sure that they emerge unscathed from the arms of Morpheus - general anesthesia is generally avoided where possible. This means that we do a lot of spinal anesthetics, and because there are very few sedative medications available this means that we do a lot of spinals, and operations, on wide awake people. They are comfortable, of course, being unable to feel pain, but sleep they do not.

Now, this might be an awkward thing in the best of circumstances - say where you and your patient shared a common language. As most of our patients speak either Afar or Issa (seldom both) it is trebly so. Although much can be conveyed, one hopes, by means of gesture and glance, we are of course in masks, hair covers and scrubs and this type of communication is limited at best. For all that though, the patients are incredibly stoic. We start IV's, we sit them up and place spinals - an uncomfortable procedure that is made worse by knowing that there is someone behind you with a needle and he's going to stick it in your back. But our patients are almost unflinching, uncomplaining, mute. They do not protest, they don't pull away and they don't seem to be anxious as a rule in that most alien of environments - the OR.

Sometimes I think that perhaps the lives of the people here are so hard, and pain and discomfort such a commonplace fact that the transient discomfort of the anesthetic procedures is meaningless. As to their forced immobility (for with a spinal one loses not just feeling but movement below the level of our block), this seems to be accepted unquestioningly. Is this the embracing of Imshallah - the unquestioning acceptance of God's infinite power and wisdom? Is this a cultural stoicism? Or having commended oneself into the mysterious realm of the medical men, does one just resign oneself to their unintelligible jabberings, their annoying piercings and the odd effects of their medicines, serene in the knowledge that what can be done for you is being done? Something of all three I expect.

Anyway, there we were at the end of a prostatectomy. Bill and Dr. Elias had skillfully worked together to remove this organ whose overgrowth had caused almost complete obstruction of urinary outflow for our patient, a dignified older Djiboutian man whose beard was dyed red with henna in keeping with the local custom. The operation over, the gentleman lifted his head up and asked Elias a question. Replying in his language, Elias reaches over to the stand at the foot of the table, picks up a set of forceps, and grabs the now ex-vivo prostate with them, producing the offending organ for the patient's intent examination. The patient studied it silently for a moment and then asked another question in the Issa dialect. Elias responded thoughtfully and at length - all the time with the excised prostate on the end of the forceps waving about in his gloved hand, occasionally being gestured with to make a point. It was a singular sight. After a bit the patient nodded, laid his head back down and we wheeled him to the recovery area.

Later Elias explained that is was important to almost all of his patients to see the thing that had been taken out of them. In fact he showed us a small collection of gall stones he keeps in jars in his spartan surgical supply office. In many cases of gall bladder surgery for stones, the stone will not be extracted intact but will be found as sludge or sand in the gall bladder once it's out. The inability to see the stones is such a source of concern for patients and their families post-operatively that Djiboutian surgeons have found it best to keep some stones around to show as evidence of a successful surgery. The patient is cured, the family is happy and much worry is thereby avoided.

So that was one thing. The other was this. As the day wore on, I sat, paced the room, stretched, peeked over the drapes, fiddled with the stuff on the back table - stuff that anesthesiologists do while surgeons struggle on. Herman was watching the patient as well, so I felt no compunction about walking over to the far corner of the room and squatting down on my haunches - much as a cowboy might do out on the range by a campfire (providing he was careful about his spurs). It is a way I have of working the kinks out of my back. It seems to stretch out some nameless bits of ligament and muscle that start to protest after a morning plying my trade. As I sunk down, eyes half-closed, waiting to feel the tension in my lower back ease, I felt a hand in mine.

I looked up, and Ali (whose name as far as I can tell is Ali Hajji), the surgical "tech" whose job it is to assist with setups and breakdowns, to bring the surgeons anything needed during the operation and in general to function as dogsbody for the OR suite, Ali had taken my hand. You must understand that all day the halls of the OR's at Peltier reverberate with the call "Ali!" or "Hajji!" as this slender, quiet man runs from room to room fetching and doing for the surgeons and anesthetists. Ali had been slumped on a stool in a corner of the operating room, but when he saw me squat at my end of the room, he figured that it was because I had no seat. Squatting is a common posture of - especially poorer - Djiboutians relaxing in shade or around a fire. The rocky ground is unkind I'm sure to those who would sit or lay down. Anyway, Ali smiled, took me by the hand - Djiboutian men will often walk hand in hand - and led me to his stool. It was done with such gentleness and such thoughtless generosity despite my protests that the moment has stuck with me all week. There is a solemn courtesy that many Djiboutians carry with them through their hot dusty days, a generosity with the little that they have which may serve to ease a bit the harshness of their lot.

And that's it for the week. Nothing terribly profound, I guess, but I hope you get some of the flavor of the people we live among and sometimes work beside.

I have great hopes for next week's entry, as a trip to Lac Assal, an ascent of the cliff trail near Khor Ambado, and even a possible trip to Garmisch, Germany may all have taken place ere I put digits to keyboard again. Not sure if all or any of these will come to pass - but they'd be good blog fodder if they do. Check back next week then, gentle reader and we'll see.

Picture today is of the surgical ward at Peltier in the noonday sun.