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.