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.