On the Mend!

Hi Jeff;
These two photos were taken a few days after Tarikutu's discharge. I think Tefsa shaved his head to heal his scabies.

Dom wanted Tarikutu to stay in Addis for at least a month but Tefsa couldn't commit to that amount of care although she promised to drive him from the village for his weekly check ups @ Black Lion. She told me
later that she had instructed his mother to build a bed for him so he wouldn't have to sleep on the floor to keep his incisions clean. Tefsa agreed to keep him until the bed was done. What an angel!

O showed me the footage today inside the hut and it's very sobering so think it will convey the poverty of our patients. Look forward to reading the blog update.

Take care,
Sandra

scabies:
contagious skin disease occurring esp. in sheep and cattle and also in humans, caused by the itch mite, Sarcoptes scabiei, which burrows under the skin.

Down the Path to Recovery

Tarikthu is going home after four days in the hospital!!!! He was seen by Dr. Befikir five days later and is doing well. No colostomy and having BM's via the normal route.

The Final Act

It is impossible to know what he is thinking. His face is calm and expressionless, but his hands may tell a different tale as they cling tightly to a small cartoon drawn earlier by one of the WSF team members. Tariktu says he is hungry. He weighs in at 32 pounds, that is roughly 4.6 pounds for each of his seven years. The medical technician shows Tariktu a picture of his eleven-year-old daughter. The boy gently touches the photograph. He doesn't flinch when the IV needle is inserted into his arm.

The fourth floor is hushed, most of the team gone for the day. Tariktu would not be here now if the hospital staff had not forgotten to feed him. Patients must fast from twelve to twenty-four hours before receiving anesthesia. Luckily, the food cart didn't make it to this little patient's room.

The nurses and medical technicians glove up and arrange the surgical instruments. Tariktu lies motionless on the operating table. He is covered only in a sterile drape. He hasn't "gone under" yet. He is so passive, yielding to every procedure and gentle command from the medical team. He seems to flow in perfect cooperation with every directive, as if he is already downstream of his surgery, this terrible mystery now upon him. After a life of suffering, however short, he harbors a strength most of us cannot begin to understand. Dr. Alvear sits hunched in a chair at the edge of the room. A nurse vigorously massages his shoulders. He has been standing for hours. I don't remember seeing him in the lunch line today.

Each member of the team scrupulously suits up. Things must stay sterile. Infection is a very real concern. Accidentally, a glove touches something and the nurse quickly steps in with a new one. A plastic mask covers the little boy's nose and mouth. He doesn't protest, and he silently coasts off to sleep. The doctor applies a thick coat of betadine, painting his lower half a deep mahogany. This will keep the parts being operated on clean and sterile. An Ethiopian surgical resident stands on the opposite side of the operating table facing Dr. Alvear. He appears eager to learn how to perform this procedure. Put in layman's terms, the boy has a hole in the top and not in the bottom. They need to repair the colostomy (the hole in the top) and cut a small hole in the bottom. Then they will grab the colon (large intestine, which is the last few feet of the twenty-some total) and pull it through the hole. Sounds so simple that I could have thought of it.

Dr. Alvear reviews the medical charts once again before cutting. Apparently, his records, the ones that count and show where the colon is, are seven years old. There is not enough information to know just where the colon is in relation to where the hole is going to be. To get the full picture he will have to insert a catheter into the colon and push it all the way through to the bottom. If he sees it pushing through like a hand in a sock then he knows it is close to where it needs to be. If not, he will have to use the "old fashioned procedure" and go in through the front instead of the back. No worries. The doctor has performed both surgeries many times before. And just to add insult to injury, upon re-reading the boy's charts he notices that the boy has a non-descended testicle and a malformed penis. Two more possible surgeries. They say that bad things come in threes.

This oversimplified explanation of the surgery belies its complexity. This is one of those surgeries you just can't intuit on your own, too many moving parts. This isn't the U.S. space program where you would dare to put someone on the moon with a healthy dose of imagination, a dash of ingenuity, and a unwavering faith in Sir Isaac Newton. This is a little boy's body, a little boy's life. This is an operating room, not a lab. Not to diminish NASA's historic accomplishments, but they aren't taking any chances today in creating this historic moment in Tarkitu's life, a testament to the need for cutting edge training for surgeons all over the world. The doctor begins to expand the colostomy hole by making an incision. Soon enough, he is inside the tangled web of intestine and connective tissue. He effortlessly negotiates the route. He knows the way.

It has been 45 minutes since the first incision. The doctor has been meticulously scraping away the mucosa from the intestine, peeling and then patting it with gauze. Peel. Pat. Peel. Pat. Nothing can be rushed. Nothing can be missed. Whatever part of the world Dr. Alvear visits, he always brings the latest technology with him. Liz, the surgical nurse, turns to me and says, "He never goes anywhere without his harmonic scalpel." The scalpel looks like a thin pen connected to a cord that attaches to a generator and is controlled by a foot pump. The aforementioned piece of equipment is an ingenious little device that uses radio waves to create a vibration that allows it to cut through tissue and seal it by denaturizing the proteins and forming a coagulum that cordons off small blood vessels. Since this special scalpel uses vibrations instead of heat, it prevents burns and is therefore less traumatic for the doctor's tiny patients. His headlamp casts
a light on this tiny stage, which consists of a miniature hole and small handful of intestine. His extraordinary scalpel is central to the operation, the star of this procedure.

A thin white stream of smoke rises up from the wound. Just a bit more and the colostomy will be closed for the first time in seven years. "Eight-french," he says to his assistants, "and a syringe." He pushes the catheter into the colostomy hole. He feels the back where the anus should be to determine where the colon is. Looks like they'll be going in from the front "the old fashioned way."

It's been twenty minutes by my last count since he resumed the painstaking separation of the mucosa from the intestine. Peel with the scalpel and pat with the gauze. Peel. Pat. With each peel the harmonic scalpel seals the wound at the protein level. No burns and very little bleeding. This offspring of modern human ingenuity mimics Moses' great miracle when He parted the Red Sea, blazoning a path to freedom for the His people. Simply miraculous.

While in the neighborhood, the doctor removes an abdominal testis. It never descended into the scrotum and stands the risk of developing into cancer later in the boy's life. One more problem to add to the long list of untreated misfit parts in this innocent.

They expect that the surgery will take at least two hours "skin to skin," an insider medical phrase that means from the first incision to the close. We began at 6:58 pm. Now it is just after eight. It appears that the separation is complete. A bouquet of clamps sprouts from the opening in his belly. Something new is happening. He swiftly maneuvers through the twists and turns of Tariktu's insides. A pair of scissors in the doctor's hands quickly snips while the resident adeptly comes in to clean up with a miniature vacuum tube. The light attached to his head shines into the surgical field. We are beginning the final act in Tariktu's epic play. The doctor dabs with the gauze and checks for bleeding. Dabs and checks.

At last, Dr. Alvear calls for the "marking pen." The surgical technician carefully unwraps the marker and hands it to the doctor. It looks like a Sharpie you would buy at Staples except that it comes in sterile packaging. The moment is truly dramatic. The diminutive audience, clad in scrubs and gloves and masks, moves a little closer, not wanting to miss the long-anticipated event. A tiny triangle is drawn on Tariktu's bottom where a hole should be. For a moment the doctor becomes like the children's book character, Simon. "Well you know my name is Simon and the things I draw come true!" He fires up the harmonic scalpel and begins to make an incision, skillfully following the lines he drew with the marker. The plan is to make a hole and pull the colon through, like David Copperfield pulling a scarf out of a hat. A feat of modern medical magic.

8:34 pm and he cuts a piece of something off. We sense a turn of events, the next step, a new act in this surgical drama. He calls for "silk ties." Don, the surgical technician, hands him a neatly bundled wad of black fibers. He gently threads a couple of the sutures before passing the needle to his resident.

Expectancy is building, and we sense the energy in the room change like the last two kilometers in a "10 k." Are we nearing the finish line? Something is about to happen. Not yet. The doctor irrigates the opening with a small hose, watering the little garden of clamps and surgical twine. Bundles of fingers go down into the hole. One set goes in and out with a needle and thread, the others move things around for a closer look, keeping a look out for possible complications – a tear, a bleed. There are a lot of blood vessels in the mesentery, the matrix of intestines and connective tissue where their hands and surgical instruments have been living for the last two hours. Blood vessels play a large role in the digestive process in absorbing essential nutrients from the stuff that we consume. "All the better to eat you with, my dear!" The rest of us watch and wait.

Back to the hole in the top one more time to line things up. Make sure all of the "i"s are dotted and his "t"s are crossed. From beginning to end the team has been on high alert for detail. The surgical nurse, Liz, accounts for sponge number forty. Each sponge is lined up and attendance is taken, absenteeism is not tolerated in this classroom. At long last, the time has come to sew up the rabbit hole on top. From now on, he will escape through a new hole in the bottom. For the first time in seven years the colostomy opening will be closed, keeping his insides on the inside.

Suddenly, Dr. Alvear stops and leans over the table. "Are you alright?" Liz asks. "I'm alright. My back just hurts a little." he responds stoically. It's after nine o'clock. He's been standing for nearly twelve hours. Even so, Liz is worried about him. She sends a nurse to get some water.

Moments later, Dr. Alvear is in good spirits. He chuckles from under his mask. He knows it's almost over. Somehow he has managed to get his second wind or third wind or whichever one he is on. Perhaps he has caught the wave of excitement that now surges through the room, carrying the promise of another successful surgery for a small child in need. It is all worth the effort if he can help make a life better, fuller, richer, and more complete.

"He looks good. I think he's going to be alright." So far, the room has been enveloped by a deeply serious tone, the focus grueling. Now, he begins to joke around, possibly to keep himself awake. Maybe it is because he's energized by his role in this boy's life, now filled with promise as a result of his work, a product of decades of training, experience and dedication.

The surgical resident threads the final suture. The colostomy is closed, protecting his precious insides from the dust and disease of his little mud hut in Mojo, and bringing down the curtain for a production almost an entire lifetime in the making. A wave of relief washes over the team. Splashes of laughter bounce around the room. The anesthesiologist, also Dr. Alvear (a husband and wife team), circulates with a makeshift hors d'oeuvre's tray of citrus lozenges. "These are good!" the team giggles like school children. It has been a long haul since the examination five days ago, from his diagnosis to mother's consent, from the trip out to his mud hut in Mojo to the seventh floor. Now we are here waiting for the grand finale, the final trick up the good doctor's sleeve.

They revisit the hole they made earlier. The doctor calls for the "nerve stimulator," a hand held device that delivers a small current of electricity, which stimulates the nerves in the area it touches. He places the stimulator at the edge of the hole and gives it a little shock. "See the wink?" Miraculously, the hole contracts on its own. The hole works like anyone else's, opening and closing when necessary. Now, for the first time he has one of his own!

As a final gesture of trust extended from the master to the pupil, Dr. Alvear allows the surgical resident to "do the honors." The magician's apprentice will perform the final trick. The young doctor-in-training carefully ties the colon and gently pulls it through the hole. Voila! Someone starts singing the old folk song, "My bucket's got a hole in it! My bucket's got a hole in it!" No disrespect is meant by this, it is just that this little band of volunteers can finally laugh about it all. The sad story is over. Ironically, this whimsical children's song is a perfect fit. A child has just gotten his childhood back, and this drama has been transformed from a tragedy into a comedy. It's 9:30 pm on Friday night. He can now go to school and learn to read and divide. He can develop relationships with his peers and his community. He can have a normal life. Tariktu will contend with enough suffering here in what the United Nations deems the
seventh poorest country in the world. Now he can wrestle with all that Ethiopia has to dish out from a level playing field. These volunteers just gave him that hand he needed to pull him out of the hole that he has been in for so long.

This is only one drama highlighted out of a series of productions that played out successfully under the skillful direction of the World Surgical Foundation over the last two weeks here in Addis Ababa, Ethiopia. The World Surgical Foundation performed hundreds of life-changing surgeries in multiple hospitals, provided invaluable one-on-one trainings with medical students and surgical residents, gave several workshops which showed how to use state of the art equipment and conduct important cutting edge procedures such as laproscopic surgery, donated essential medical materials and equipment, hosted visiting pediatric surgeons from Cincinnati Children's Hospital, introduced members of the International College of Surgeons to key medical personnel at local hospitals, and hopefully developed profound and lasting supportive professional relationships with the surgeons of Ethiopia. The disparity between those who have and those who do not are stark in places
like Ethiopia. The members of the World Surgical Foundation are supremely qualified, highly trained individuals who are willing and eager to travel to the most needy places of the world for the simple privilege of helping others and, perhaps, to even things out a bit.

The Seventh Floor

I lay a hand gently on Tesfa's shoulder. "He may have surgery today. If not, I'm afraid he will have to wait until Monday." She abruptly turns toward me but doesn't look at me directly. Her face becomes ashen, her body shudders, and I fear she will fall if I don't hold her up. "We will know in about an hour or so." For once, she does not say a word. Tariktu, silent and stoic, lies in his bed with his half-brother, Josef, standing by his side. They both perk up when they sense her reaction to the news I have given her. Anticipation hangs in the hair like a thick cloud of smoke. It has been a tense couple of days. When they first arrived two days ago, there were some misunderstandings about admitting Tariktu to the hospital. Tesfa was purported to have given the nurse an earful before finally getting him signed in to a room on the seventh floor – the children's ward.

Earlier in the week, I had seen the multi-colored bed sheets hanging over open windows in order to keep the sun out, but this was the first time I had been on the other side of those sheets. Unsupervised children dart back and forth across the hall from one room to another. Patients and their families are stuffed into undersized rooms. I am having trouble discerning a system of organization. If there is one, it seems to be provided by the patients' families rather than imposed by a hospital and its staff. There is a small office in the middle to the hall. I knock on the door and find three young adults in white lab coats. They seem to have been swallowed up by the swells of humanity. Maybe they are just hiding, grossly outnumbered. They are friendly and helpful. They quickly direct me to Tariktu's room.

The families of the patients bring their own bedding and are responsible for staying with their children overnight if necessary. It is a common site to see laundry drying in the courtyards and clearings just outside the hospital walls. The Black Lion Hospital seems more like a campground than a hospital. You select a campsite, haul in your gear, and set up camp. Maybe there are a few rules such as not playing music after ten, but otherwise everyone happily fends for themselves. Siblings? Cousins? They're all running the halls, letting off steam. They have been there for hours or days, huddled around the campfire waiting for the doctor to call.

Tesfa is noticeably fatigued. She's been on a vigil most of the week. She has a daughter in the hospital who is very ill. She brings me to see the child. I immediately notice that the girl has an adema (swelling) on the right side of her body. She makes a feeble attempt to lift up her right arm and communicate her pain and discomfort. She is limp and drawn. She moans and manages a half smile with the side of her face that isn't swelled up like a party balloon. I can tell that my friend needs a break. Tesfa needs to go home and regroup, get some tea and a quick nap. But she has hours to go before her work is done here.

I leave Tesfa to go check in with the surgical team. I promise to keep her in the loop. I begin my long walk down the hallway through the children's ward. Unexpectedly, I see Tariktu lying still in the middle of the hallway in his rusty metal bed escorted by a woman in white hospital clothes. Could it be? Did word come up from the OR? It's 6:15 in the evening. The doctor has been operating all day. Tariktu's surgery will take at least two hours in the best of conditions. Tesfa follows quickly behind me. She is already talking to the nurse. A smile comes across her face. She appears nervous yet relieved. The surgery will be tonight. The long wait is almost over.

We stand in the hall for a few moments. Waiting for something, someone to call us down. Possibly hand signals or flashing lights because I don't see a phone nearby or a walkie talkie, and I haven't heard an intercom since I got here five days ago. All of a sudden, she begins pushing the bed down the hall. We follow, each grabbing a bar on his little metal cage as if holding on to the side of a moving boat in fear of being left behind in a drifting sea.

We get to the end of the hall and stop at a set of dilapidated green elevators. Up until now, I thought these elevators were out of order. They don't even close properly. I'm somewhat horrified by the idea of packing in to one of these things. A couple of women stop when they see Tariktu and Tesfa. They seem to know them. They appear to be congratulating them. I can feel a positive energy coming from the group, a sense of hope. He's about to set sail. The elevator doors part and an invisible current pulls Tariktu's little boat into the small space. Everyone flows in behind him. To my relief, there isn't quite enough room for me. "I'll meet you on the fourth floor!" I cast them off and race down the stairwell through drifting masses of people. There are people everywhere.

It Takes a Village

As we enter the house made of mud and sticks, a member of our crew turns to me and says, "This is one of the nicer ones. Look at the metal roof. Often it's just a tarp." Sandra and Osian, two very talented filmmakers who are documenting the World Surgical Foundation's mission to Ethiopia, set up in the kitchen.

When we arrive at Tariktu's little village on the outskirts of Mojo, we don't hear the word "ferengi" which means "foreigner," a phrase some of us have become quite accustomed to hearing within the city limits of Addis. But we know they must have been thinking it. A busload of white faces speaking English with camera gear dangling from every arm, we might as well have dropped in from outer space. A scene right out of Stephen Spielberg's Close Encounters of the Third Kind, a gaggle of intergalactic diplomats exiting a spacecraft onto the tarmac of Devil's Tower.

Our senses are overwhelmed. The dust. The heat. The flies. Children gather around with feverish excitement. They all want their pictures taken. They all want to see themselves instantaneously immortalized in the tiny screen on the back of my digital camera. "One more, please! One more!" I am surrounded. I feel a kiss on the back of my neck. I am from outer space.

The mud house sits on roughly an eighth of an acre of dry soil. Chickens cluck out back and a small brown calf wanders out of the brush into a clearing. Someone feverishly sweeps the inside of the house with a straw broom. Guests have arrived.

The inside of the house is dark and dusty. It takes a moment for our eyes to adjust to the light. There is a small mattress on the floor in the corner of the main room. A dresser at the far wall holds a small radio. I still can't see where it plugs in. Children with toothy smiles rush in to sneak a peek and race out again. Tariktu's mother stands quietly holding a toddler. The small child clings possessively to her mother and nurses, always with one suspicious eye on her mother's visitors. We all move into the kitchen. That's where the interview will occur. We're all along for the big story, from examination room to recovery room. The drama is tangible. Act II is unfolding before our eyes. The experience is surreal. Small boys peer in through the kitchen window as Don explains to us what each utensil is for. A sign on the front door tells passers-by that bread is made and sold here. All the necessary equipment is present. The traditional coffee
pots and clay stove are neatly set up on the floor in the corner. The house is sturdy. The walls, a matrix of straw and manure, are firmly packed and dry, ready to withstand years of weather and toil.

The dust. The flies. Disease? I can't help but think about the opening in Taritku's belly. How do they keep things out? The village school certainly keeps Taritku out. Children with Taritku's condition are often excluded from participating in the basic communal activities such as attending school. As one would imagine, anal atresia is often messy and the smell can easily offend others. Whether these children are not welcome at school or parents keep them home to avoid offending others, the child inevitably suffers from ever-increasing isolation and missed opportunities.

An old woman holds a small child. She has smile from ear to ear. She willingly poses for a picture. She is wearing her best; a dress with a blue and white flower pattern, a necklace adorned with large wooden beads, and a hat. There's a nervous energy in the kitchen. They're checking the lighting and getting ready for "mom's" interview. The natural light coming in through the kitchen window is perfect. Three boys poke their heads in through the open window to get a glimpse of the excitement. Aliens are in their house.

This is where Tariktu lives. This is where so many of the people of Ethiopia live. I dare not judge their standard of living. After all, they appear to be very happy. They have family and neighbors and houses and land. But what about Tariktu? Is he missing out on some of the basic components of happiness? He can't go to school. He can't learn to read or add triple digits. He can't develop relationships with his schoolmates. What does his life look like further down the road? A wife? Children? Work? Perhaps one operation could change the course of his life and provide some of the materials he needs to build the shelter of his happiness.

Children are everywhere. One child holds a puppy and brings it over to show me how it wriggles around when he rubs its belly. I ask where the bathroom is. I'm on the moon. Where does one go to the bathroom on the moon? "Out back" of course. "Go anywhere you want." Don gently encourages me. "When in Rome!" Out of practicality I have to quickly overcome my refinements. Finally, I get up the courage go "out back" and investigate. I am accompanied by a small band of curious children. I walk faster. I take a few more pictures and show them the tiny screen on the back of the camera. I turn around again and walk rapidly toward the fence at the rear boundary of the farm. They seem to get the picture.

I stand by a row of bushes and attempt to relax. I imagine that I am alone in the private restroom of my hotel back in Addis. Suddenly, the vegetation to my right shakes violently and a large half growl, half whinny comes from behind the bushes. A donkey? I have little previous experience with the species. Then I notice two individuals walking toward me. The village is a hive of activity. We are the main event. It was foolish to think that I would go unnoticed back here by my personal patch of sage scrub. I'll have to wait for the "rest stop." "Selam!" I say. I ask myself whether it was "selam" or "salem?" I can't remember. Seems like don't know much about anything today.

I wander back to the hut. People are congregating in the front of the house. The filmmakers are setting up the final interview. Lighting is checked. Don holds a piece of equipment that reflects the sunlight toward the subject being filmed. I am asked to take stills of the interview, "production photos." Sandra and Osian go over the interview questions one last time. Everyone is watching. Tesfa stands waiting. A quick sound check and the first question is asked. Like a miracle, the fire wells up and words emanate from her effortlessly and fly out to the world. Tesfa's story is Yeab Sera's story is Tariktu's story, the story of her people. Suddenly, Osian backs up and accidently knocks over a bottle of water belonging to Tariktu's mother. He apologizes profusely. I begin to say that I have water. "It's a large bottle and it's back in the…in the…?" At once, I realize that the few words that I need for the moment are gone, lost in
the dust.

Correction!

I made a typo! Addis Ababa is close to 10,000 ft. above sea level, not 1.000 ft.

The Journey Home

The boy is named Tariktu. His name means "history."

We finally pull out of the parking lot of the Black Lion on "abesha." Abesha or "Ethiopian time" has its peculiarities. For instance, "zero" is sunrise and "one" is one hour after sunrise. It makes perfect sense in a world that moves as slowly and whimsically as Ethiopia. Our first stop on the way out of town is Tesfa's house to pick up three young children: Josef , Yeab Sera, and Taritku. We pull into a small alley and stop in front of a gate at the entrance of her modest home. Tesfa gets out of the bus. There is a small reunion with her son and her two adopted children. Smiles and affection are exchanged. Her nineteen–year-old son appears relieved when given the small box of medicine. Tesfa says goodbye to her son and the two younger children get on the bus with her. Instantly, it is clear to all of us that both of these children are special. Yeab Sera, whose name means "God's work," reveals that the struggles of her short
life thus far are easily defeated by a smile that is mesmerizing. We are sure that we will never forget her. Her brother Josef's gentle face and warm smile immediately put us all at ease. Everyone settles in for the trip. The children have not seen their mother in a week.

Tariktu is small for his age. He looks more like a five-year-old than a full seven. A small ponytail hangs from the back of his head as he stares out his window. He is stone-faced and silent. I wish I could say that his silence belied his fear and uncertainty – but his thoughts and emotions remain a mystery, concealed by a stoic countenance.

The drive out to the village of Mojo is about an hour and a half. The smell of diesel and exhaust pours in through an open window sometimes overwhelming us. The children are in a playful mood. They skillfully demonstrate variations of the iskista, a popular rhythmic dance in Ethiopia. Their agile bodies adeptly perform the complex movements of each dance. We pass a famous prison on the left. Just as I snap a picture, Tesfa tells us to put our cameras away. This is a country where soldiers are painfully camera shy and all government buildings appear to be "off-limits" to photography. Perhaps invisibility lends to longevity.

Tariktu is still looking out the window. What is he thinking about? He hasn't seen his mother in a week. Does he miss his home? Does he miss living with his brother and sister who now live so far away in Addis Ababa? Tesfa tells us Tariktu's mother has seven children with three husbands. We respond with bulging eyes and gasps. She quells our shock and naïve appraisals by saying, "If you don't have a husband, you don't eat." It takes a village to raise these children. After all, space is limited in a two-room mud hut.

Tesfa-Hawat Means “Hope” and “Light”

She says it's a talent from God. "If my son needs medicine and the government refuses to give it, I will say something. If someone needs something and I know they are refusing to give it, I will say something. I don't care! God is always with me." Tesfa tells us that her name means "hope" and "light." She is always prepared to speak, equipped with a relevant anecdote or a poignant sound bite. In the face of opposition, she effortlessly conjures up passion and fury. Perhaps she is accustomed to advocating for her nineteen-year-old son who is a type-one diabetic. My son, if he dies then goodbye." She stops momentarily to choke back tears and then a fire wells up from within her and erupts in exclamation. "No one can take anything from me, only God!" Tesfa is a born advocate.

Our story begins two days earlier at the pediatric clinic in the Black Lion Hospital. A little boy who is escorted by a brother and an older cousin sits in the examination room. He is quickly diagnosed with an imperforate anus or anal atresia. This means that he was born "without a hole in the bottom." Since his bottom doesn't work like other people's, he moves his bowels through a small tube emerging from his belly called a colostomy. This rubber passageway directly to his colon was surgically implanted when he was an infant. There is nothing between the tube and the outside world, creating an open door that permanently exposes his insides to the outside. That was seven years ago. Since then nothing has changed. He has not received any further surgeries. Isolation, lack of information, misunderstandings? They don't know why his mother hasn't brought him in to the hospital for further treatment, but now he has a chance to live a normal life.
His cousin acts as his interpreter. He says he will talk to the boy's mother today. Surely she will not deny consent to close the door on a life of suffering.

Tesfa climbs onto the bus, a small fourteen–seater that picks us up in front of the Black Lion Hospital. We just got word yesterday that the mother gave consent for the surgery. Several of us are being transported from the hospital to meet Tariktu's mother in their small village 75 kilometers outside of Addis Ababa.

As Tesfa gets on the bus she is already casting aspersions on the government. She holds up a small box of medicine. "800 burr a month!" she exclaims. Tesfa claims that this medicine, which is essential to her son's health, is rendered unaffordable by a corrupt "government tax." She has a lot on her mind and frustration vents from her, brimming over and erupting into a steady stream of words denouncing the indignities that are all to commonly imposed upon her people. Her daughter is in the public hospital and very sick. Her son has diabetes. She is the adoptive mother for two other children and is currently advocating for their little brother, Tariktu.

Tesfa's husband died four years ago. When asked politely why he passed, she says she is not sure. This is typical in a country as poor as Ethiopia where too many medical conditions are the equivalent of a death sentence. It's difficult to say if he saw the doctors he needed to see. The likelihood he saw the necessary specialist is low. "He was very kind." She says. She explains that she asked him before he died if they could adopt and raise a little girl named Yeab Sera, now eleven years old. The little girl was severely hearing-impaired. "He said it was OK. Now he is gone. But I have her. Thanks God! Thanks God!" This is a mantra she uses frequently. It seems to vocalize her trust in the invisible hands that guide her through a sea of uncertainty.

An Impossible Task

Wails of anguish come from operating room number two. Don Leiber, a surgical technician, rushes in and gloves up in order to be of assistance. Moments earlier the patient was lying unconscious with a leg flayed from hip to ankle like a trout. The black necrotic skin was removed in order to prepare his leg for a skin graft. In the absence of necessary antibiotics, the nurses are pouring gobs of honey into the open wound.

The Black Lion staff face tremendous need with very little resources, and it is woefully hard to find good help around here.

Meskee is the head surgical nurse. Dedicated, responsible and dependable. She is always prepared to help. Supremely qualified, she never leaves a room without the familiar refrain, "Is there anything else I can do?" But that's just not enough. She desperately needs to motivate her staff. Culturally, it's not their way to push one's colleagues. She has a kind face and a warm smile. She is always polite. What could compel a person to stay still in the face of such dedication? At present, her job proves to be an impossible task.

A patient is left in PACU. He was in an auto accident one week ago, an all to familiar occurrence in Addis. He has multiple chest injuries, a lacerated liver, and broken bones. His chest tube is not functioning properly. Helen, a WSF PACU nurse, is exasperated. "There isn't even any suction!" There's nothing to protect them from HIV and TB. It seems impossible to do their jobs. The situation is dire. "I could lose him," says Helen. In the midst of such chaos it is difficult to get cooperation, to get help.

Suddenly, a small Ethiopian woman, gentle and polite, dashes into the room. Moving quickly, she responds to every request made by the WSF team. In her subtle manner, she anticipates their needs and acts instantaneously, quickly taking control of the situation. Bethlehem is a nurse anesthetist at the Black Lion Hospital.

"She stayed!" said Helen. "She spoke to the patient, and when I said that the patient needed blood, she left and came back with the blood." Every step in this difficult situation demanded the help of someone who "knew the ropes." Committed to excellence, dedicated to helping others, and proficient in English, Bethlehem was the person for the job.

"The blood needed to be warm. There was no warmer!" Exclaimed Helen. Bethlehem did the only thing available to her. She brought in a pan of warm water. "It was probably from the kettle in the break room. I couldn't believe it!" Simplicity is the mother of necessity.

Earlier today, an anesthesiologist from the WSF team was leaving operating room number four when I overheard him say to another anesthesiologist from the team, "Don't worry. Bethlehem has it taken care of."

Government Hospital:Things are Up and Walking

Dr. Stephen Chmil has been waiting for two hours to operate on a bypass patient. There is an undercurrent of frustration in the operating room. WSF medical staff is eager to be of service and is disoriented by the slow pace. Doctors who are accustomed to well-oiled machines back home are not used to delaying surgery because there aren't enough gowns and sterile drapes to go around. The "deficiencies" of the Black Lion Hospital that were foreshadowed by the Dean of the Medical School are now materializing.

Public hospitals in Ethiopia are in desperate need of more support, more training, and more missions. Although there are some very competent physicians at these hospitals, there appears to be a very real disconnect between the needs of patients and the administration of available services. Even if there are services available they are not being provided in an efficient and timely manner. Tanya, an engineer from the United States, has had the job of being in charge of biotech equipment for the Black Lion for the last six months. "There are no systems in place for maintenance of equipment. Equipment that breaks down just sits in a closet with no hope of being used again." Looking around one can quickly see that systems for patient follow-up, organization of meds and supplies, and many other necessary components to the daily operations of a hospital are not in place here. The challenges posed by an under-sourced public health system are a reality
here in the largest city in one of the poorest countries in the world.

An X-ray film hangs in the light. From looking at the luminescent photograph one can easily see that something is off from center. A hip joint hangs a little too low, dangling just beneath the pelvis. The film next to it shows a clavicle in two pieces. Could this be the same patient? This man was in a car accident eleven days ago. On the day of the accident he was rushed into emergency surgery to repair a lacerated liver and ruptured bowel. He has waited a week to get his bones back in place.

Dr. Maxime Coles discusses a plan of attack with a visiting orthopedic surgeon from Scotland. "Let's get him in a lateral position." They discuss the possibility of completing a closed reduction of the right hip. Why cut if you don't need to?

A couple of rooms down, Dr. Bucs preps a patient who exhibits multiple symptoms that indicate tuberculosis of the spine. HIV and tuberculosis are reaching epidemic proportion in Addis Ababa. A doctor sitting in the lounge spouts off some statistics he has heard. "A person who gets pricked with a hollow needle from an HIV infected patient stands a three in a thousand chance of contracting the disease." Contracting HIV seems unlikely, but no one appears eager to test their odds.

Dr. George Faries gently slides the scope down through the esophagus and into the stomach. Eager Ethiopian surgical residents wait for their chance to try it out. Rules are that the "attending physician goes first" and they will have to wait their turn. Dr. Faries narrates the scope's journey into the stomach and through the opening into the duodenum. Suddenly, the end of the scope opens up like a tiny crocodile's mouth and little metal teeth plunge into the wall of the stomach, swallowing a tiny biopsy. "Got it!" exclaims Dr. Faries. It may not be the biggest catch of the day but it's a keeper.

Meanwhile, Dr. Coles has decided against a closed reduction of the hip. There may be some stray bone fragments in the leg. It looks like they'll have to cut after all.

In the storeroom, an anesthesiologist holds an essential component to an anesthesia machine. "These are disposable? You need to be able to take this out," he says while pointing at a small blue cap on the device. "I suppose we could drill a hole and tape it up later. I can't see any other way of doing it." In the meantime, we've learned that our crate full of equipment and supplies is finally in Addis Ababa. Now it just needs to clear customs. The hope is that it can be cracked open and sorted this weekend. Perhaps by Monday Taritku won't have his surgery delayed for a few gowns and drapes.

The Nurses: Anticipating the Need

The patient, a hard looking man with arms covered in tattoos who arrived in the operating room a couple of hours earlier accompanied by two well-armed guards, moans and rolls slowly toward the edge of the gurney. "Careful. We don't want you on the floor. You're too big to pick up." says Helen, a WSF recovery nurse. She attaches the pulse oximeter to her patient's left arm (it's a small but indispensable piece of equipment which reads the patient's oxygen saturation and pulse). Languid and weak from the anesthetic, he looks up at her and asks for something. It's difficult to hear what he is saying. "Kleenex? Do you need a Kleenex? A hanky?" asks Helen. "Paper," he says. She turns abruptly around and darts over to the supply basket. In no time she is back by his side gently placing the tissue in her patient's hand. Anticipating her patient's every need, calm and always prepared with a joke or a soothing word, Helen defines
"bedside manner."

A veteran of nine WSF missions Helen knows the drill. "I was only going to go on one mission. I love 'em! I love 'em! I'm hooked." It's a good thing too. On one of the India missions, Helen worked six recovery rooms by herself armed with nothing but a pulse oximeter and her charming wit. There is no doubt that she is in her element. It's as if she was plugged into some limitless energy source. And yet, regardless of the level of stress in the room she remains calm, sociable and jovial.

The WSF nurses are more than just the glue that holds everything together. They bear the mantle of responsibility for so many of the needed services on this mission. Whether in tending to the patients in PACU (Post Anesthesia Care Unit) or making sure everything is in place and running smoothly in the operating room they are dedicated and unflagging in their efforts to, as one nurse put it, "do some good and help these people!"

Helen puts an arm around her patient and props him up. Still too weak to crack a smile he gazes into her eyes with tacit trust. This image would be incongruous with any other setting, but Helen, with her sincere smile and easy manner, makes it look like business as usual.

Young Heroes: A Volunteer Extraordinaire

A Somali woman supports a boy's tiny frame in her arms. His heavy eyelids and listless body imply a story of pain and suffering. She has traveled 800 km and waited four months in an unfamiliar city seeking a cure. Her words come to us clearly through the adept translation of Kristen Straw.

This small blond haired white woman in her jeans and ponytail might fool the casual onlooker, but not for long. She's a formidable personality. She interacts with these parents and their children with an ease that suggests a much-earned familiarity. She jokes with a young boy and pats him on the head. He giggles and revels in her attention.

Kristen's facility with Amharic comes from living in Ethiopia for the last one and a half years as a peace corps volunteer. The niece of one of the WSF surgical nurses she was recruited for her talents as a translator and her intimate knowledge of the country and its people.

It is always remarkable how a noble cause inspires the spirit of volunteerism. The WSF missions call for all types of service. Even though physicians and other medical professionals provide the majority of the services needed, lay people are indispensable. Some volunteers are trained to assist with the sterilization of equipment while others liaison with local aids to get lunch to the mission volunteers.

Momentarily, relief washes over the Somali woman's face. Someone has listened. Someone has understood.

In Chaos, Attention to Detail

Off to a rocky start on "day one." Not unusual for missions conducted for the first time in a new country. Getting equipment prepared, coordinating, communicating, etc. Doctors wait for patients to be prepped and equipment to be set up. A patient lies on the table ready for surgery, meanwhile the surgeon wanders from room to room looking for a missing transformer. Without it he'd be practicing medieval medicine.

In room two, Dr. Roger Bucs kindly speaks to nurses, respectfully giving them the benefit of the doubt in their judgment, thoughtfully steering them in the right direction only when they need it. The attentive doctor gently maneuvers the patient, a frail Ethiopian women in her 70's. The job of the anesthesiologist could possibly be more art than science.

Many physicians get to show how well they operate under fire on the WSF missions. The conditions of the hospitals on these missions vary. Although some are better equipped than others, each mission presents significant challenges to upholding the extraordinarily high standards to which these medical professionals are accustomed. In fact, Dr. Bucs could be nicknamed "Dr. McGuiver." On a previous mission, Bucs was short one anesthesia machine, and so he constructed one out of old anesthesia parts and duct tape. A work of art sculpted from the mortar and clay of a broken down operating room.

Back in room two, Dr. Bucs mixes a carefully balanced cocktail of anesthetics into an "IV" bag. He asks me to hold the bag up high while he explains how one drug blocks something and the other increases something else…"one makes you big and one makes you small." Too much of either and you've got problems. Art or science? It's hard to tell. Nevertheless, he continues to fine-tune every detail, a fragile life in his hands. He checks and then checks again. Finally, he looks at the Ethiopian nurse and says, "She's ready." Painstaking attention to details harmonizes into a delicate balance in a master's hands.

Pay it Forward

Tiny and scared, tears flow and pain seethes up through a hole in his tummy. A man makes a slight gesture with his hand, distracting the tiny boy from the nuisance in his belly and suddenly a smile appears and tears vanish into thin air.

We often call something someone can do that can't be fully explained a "gift." I find myself in this situation while in the presence of this doctor at work.

Dr. Alvear is a pediatric surgeon. As the founder of WSF, for the past 11 years he has led surgical missions to countries such as the Philippines, Thailand, Honduras, and India inspiring other physicians, nurses, and medical staff to exercise their calling in the service of humanity.

A sea of parents waits outside. One after another they arrive. Each one brings his or her child to a small chair in front of the doctor. Looking out the door of our small examination room, the line seems as if it will never end. And still, he treats each little patient as if he or she was his first patient of the day, his only patient.

At the inaugural meeting of the Mission to Ethiopia, Dr. Alvear spoke about the main principles of the World Surgical Foundation as being threefold:

1) Provide much needed surgical services to underserved patients.
2) Donate important medical supplies and equipment to host hospitals,
3) And most importantly, to give invaluable training to surgeons and residents of the host hospital.

A young medical student from Israel, Sarah Tannenbaum, watches the good doctor at work and eagerly awaits answers to her questions. Suddenly, he turns to the young medical student and says, "see where the urethra connects to the bladder?" he proceeds to explain the x-ray and give a prognosis with an energy and enthusiasm one could only hope to achieve on his best of days. His love for what he is doing is palpable.

Meanwhile, surgeons from the Black Lion Hospital pepper him with questions, hoping to tap his vast knowledge and experience with these complicated procedures in hopes that they can one day safely and successfully treat these maladies in their own patients.

Dr. Befikir Elefachew watches intently as Dr. Alvear's nimble fingers resect a small piece of colon from the tiny figure on the operating table. He then gently hands Dr. Elefachew the instruments and guides him through the rest of the surgery. "How else will he learn the necessary procedures and techniques to operate on his own patients safely and successfully in the future?"

Dr. Alvear firmly believes that training and education is the most important goal of these missions. He encourages surgeons to develop relationships with members of ICS (International College of Surgeons) in order that top surgeons will visit them more often bringing their expertise. Members of the ICS, like orthopedic surgeon Maxime Coles (presently on the Ethiopia mission), are invited to join the missions and frequently attend. Workshops on the latest techniques, such as the laproscopic surgery trainings given by Dr. Rolando Mendiola are provided to the surgical staff of the host hospitals.

In fact, if you were to wander the fourth floor of the Black Lion Hospital and peak your head into any of its six operating rooms you would see and hear the WSF volunteers eagerly engaging the Ethiopian medical staff in instruction. By all appearances you could say that a small teaching hospital has been erected in this place of need - fertile soil to sew the seeds of much needed medical training.

Later on in the locker room, Dr. Befikir Elefachew can hardly contain his surprise and excitement when sharing his feelings about the day with a doctor from the WSF mission. "Three procedures in one day, and we started late! We usually only do one case per day! We've had other groups come and work with us, but it was never like this!"

Two weeks of surgery to individual patients potentially touches hundreds of lives. Teaching invaluable skills to able surgeons will surely touch thousands.

1 Rule When I Return: NO COMPLAINING FOR ONE WEEK…ABOUT ANYTHING!

What I will show you in the upcoming weeks will give you a window into how many of the world's people live. Their desperation and vulnerability is beyond most of our experience. I find it virtually impossible to imagine myself in their position, so accustomed to my life of comfort and safety.

So I ask you to take a moment to absorb what you are seeing and hearing. Imagine your brother, sister or best friend is so sick that he or she could die. Then imagine that he or she could be cured through medicine or a simple procedure. You see other people around you going to the doctor and getting well but you don't know if you will ever get to see the doctor to help your loved one. No one can help you. You wait. No money, no guarantees, helpless. Don't feel bad if you can't imagine it. I can't. I can only feel deeply for these people. The privilege of a person living in a developed nation, a privilege I think I will never take for granted again.

Are There Words?

Dignity. Humility. Determination. Patience. Kindness. Self-sacrifice…

…virtues fully embodied by these parents in their desperation to obtain for their children the healing they need.

How could I have known before today that seeing these frightened parents sitting on dusty benches, cradling their fragile, broken children, and silently championing their cause would be the greatest act of heroism I have ever witnessed. Patient and determined, unsung and unseen, magnificent.

Many have traveled long distances at great expense after long waits and unsuccessful surgeries. And again they wait.

When a piece of sand or foreign material gets trapped in an oyster, it has an interesting response – it grows a pearl. Maybe that's what I saw today. Love personified, manifested and defined.

Can we fully comprehend the extent of the desperation of their situation? When most of us reading this blog arrive at our doctor's waiting room, we come with feelings of expectation. We see health care as a right.

To these people, health care is a miracle.

What’s Wrong With This Picture?

Use your knowledge of the skeletal system to find the problem!

High Altitude

I am at almost 1,000 feet above sea level. At such a high altitude my body has to compensate for certain deficiencies. More specifically, the oxygen level at this elevation is much lower than at sea level. The people who live in this city have more red blood cells (hemoglobin) and larger lung capacity. Why do they have more blood cells? See if you can figure it out before you get to the end of this post!

Red blood cells pick up oxygen as they pass through the lungs. The device in the picture above measured my heart beats per minute and my oxygen saturation level (how much oxygen is in my blood). Since I've arrived in Addis Ababa, my heart rate has increased to almost 100 beats per minute, up from my normal 60 - 70 beats per minute. My oxygen saturation has been low as well. I'm breathing more frequently and I get winded climbing one flight of stairs. I've got to work extra hard to get the oxygen I need and circulate it throughout my body (Thus, the heart and blood vessels are called the _____________ system). Wouldn't it be great to have a few more blood cells?

Learning to Be Polite and Ask

Taking pictures of people is a touchy subject. Not everyone wants to be "famous." I have to be careful to ask directly or look for a nod of the head to confirm that it is OK to take a picture of someone. I didn't ask this woman if I could take her picture. As I look at her photograph, I can see how much she is able to say with her eyes. What do you think she's saying to me?

Traditional Ethiopian Dancers

These dancers bring a powerful and youthful energy to tradition.

Culture, Food, and Fun

I have had a great time learning about the culture of Ethiopia. The little I have experienced thus far is very interesting, inspiring, and entertaining.

The basic unit of currency (money) is called the "burr." A U.S. dollar is worth 11 "burr."
The food consists of meat and vegetables served in a stew of spices (such as curry) and oil. The food is placed on a soft and spongey bread called "injera." Once the food is served, you eat the food with the bread it's served on. Money, food, music, culture

Many restaurants present a show of traditional Ethiopian music and dance. I've already been to three shows and it's only Tuesday. The young dancers move rhythmically to traditional "azmari" music played on traditional instruments. The dancing is hard to describe. The dancers move in jerky motions shaking their heads and shoulders in perfect time to exotic rhythms. It's like a cross between break dancing and I don't know what! You'll just have to see the video.

Our hosts: Rare and Precious Gems Serving a Country in Dire Need

Surgeons in Ethiopia are all too rare and undeniably priceless. Ethiopia is a country twice the size of Texas and 80,000,000 strong. Out of those 80,000,000 souls, only 500,000 are physicians. An even more alarming and downright staggering figure is this: out of those 500, 000 physicians, only 200 are surgeons! That's one surgeon for every 400,000 people - a rarity the Ethiopian people can scarcely afford. One can only ask, who out of those 400,000 will be lucky enough to receive the priceless healing touch from one of these surgeon's skillful hands?

Another concept that is overwhelming to consider: during the two weeks that we will be in Ethiopia, our twenty-four WSF surgeons will make up roughly 10% of the country's surgeons. You do the math!

On the first day of the mission, all of the volunteers from the WSF and the Black Lion Surgical staff met to conduct introductions and discuss the days ahead. Our hosts graciously welcomed us to the Black Lion Hospital and to their beautiful country. The Dean of the Addis Ababa University Medical School, Dr. Miliard Derbew, introduced his staff. Dr. Alvear gave an overview of the mission and prompted the team to introduce themselves individually. A spirit of cooperation and fellowship emerged from today's meeting.

The challenges posed by a third world country are already presenting themselves A giant crate of much needed medical supplies and equipment that the WSF sent to Ethiopia a month ago is still sitting on a dusty warehouse floor in a remote town about a day's travel from Addis, taken hostage by a band of shady opportunists who hope to put a few more "burr" in their wallets ("burr" is the Ethiopian currency). Not to fear! According to our hosts, these part-time pirates will soon find their plans foiled by the Secretary of Health, Secretary of Education, and the Head of Customs. The cavalry has been sent!

Friday the 13th and Luck is on Our Side

Ethiopian Airlines Flight #503 was the only flight out of the United States on Friday with "Destination: Ethiopia." In fact, Dulles International Airport in Virginia is the only airport in the U.S. used by Ethiopian Airlines. With an average of three flights per week, it's neither convenient nor popular for U.S. citizens to pursue this exotic port of call. But the WSF was out in numbers, fearlessly blazoning the "airline less traveled."

In short order, all bags were successfully checked, and every member of our little band of volunteers sailed through security almost unnoticed, like a quiet yet forceful wind. Long flight story short…sixteen hours later our feet were pounding against the tarmac in Addis and we were populating the tram to the customs terminal. After a few minor hold-ups at customs and several WSF group photos, we were off to the Ghion Hotel in two wobbly busses packed to the gills with people and stuff. Luck and grace prevailed on this most auspicious of days – the first day of our philanthropic adventure: Mission to Ethiopia.

A Dream Come True

I've been here for two days and I feel I could write a book! My words don't come fast enough to express everything I've experienced so far (also, I revise my work – let Mrs. Nathan know when you get a chance).

There have been these incredible moments here when I cannot believe I am actually here doing these things. It's like I'm in a movie or a book. I have wanted to go to this part of Africa all of my adult life. Now, it's nothing short of a dream come true. I can scarcely believe I am here meeting and helping these remarkable people!

I know we joke around a lot in class – but please know that I am serious when I say I am thinking about you and that I long for you to have the same thing – that you can realize your dreams. I'm not just saying this - if I can do it, you can!

Visiting other countries and experiencing their people and culture is so invigorating. What's more, there is nothing that feels quite like helping others who are less fortunate.

Be forewarned! At times this blog will take on a rather serious tone. I would not be doing my experience justice if I did not convey to you the dire situations so many of these people contend with daily and the feelings that witnessing their plight invokes in me.

This is a test from Addis Ababa

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