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.