Perhaps the longest blog entry in the history of man

Somebody said something the other day that surprised me, though I suppose it shouldn't. It was only a snippet of a conversation that I wasn't privy to in the ward, but it made me pause to think this evening. She said, "that's not what the sponsors want to hear about."

I understand that the feel good stories are the ones of miraculous healings. Let's be honest, who isn't moved by the dramatic transformation of a malnourished or struggling child who is felt to be cursed because of a cleft lip or palate? Who doesn't look at those photos, regardless of his medical training (or lack thereof), and run his tongue along the smooth arch of his own mouth and along the backs of all his pearly whites? It doesn't take much to know how invasive, how complex, how deeply personal those surgeries are.

But we all know that some of the deepest wounds aren't visible. The patient who suffers from tertiary syphilis is battling much more than just a growth on the head- there's also the aortic aneurism and neurological changes. The patient whose body is riddled with keloids is tricky. We may remove the biggest ones that impede function, but they will still go home with so many keloids slowly taking over. Worse, the ones that were removed will likely grow back. Have we helped? Without a doubt. Is it a pretty picture? Perhaps not to everyone, especially to those who don't have front row seats. But here's the deal- as long as we're supported, I'm happy. I'm happy because all of my patients need to be given medical care, loved, and prayed for.

I've sent home a woman who had a tumor removed from her neck. I taught her how to make clean water, how to clean the wound, how to spot an infection, when to come in, and did some preliminary teaching on hypertension management. Why are we managing hypertension here? That's a good question. When her medication runs out, we've at least gotten her over the surgical hump. She made it through surgery and recovery without cardiovascular complications, and that's something that's somewhat in our control. What the local clinic instructs her to do, if she even goes, is out of our control. When she left, I got a hug and a blessing.

I've taken care of a man who opened and closed his mouth for the first time in nearly twenty years after an untreated ear infection left his jaw ankylosed- frozen shut. We sat there talking through a translator, reviewing how to do stretching exercises to prevent the jaw from scarring shut again. I removed a drain from the donor site for the reconstruction and then removed a large bore IV put in during surgery in case he needed blood or fluid resuscitation. Every time I looked over at him, he had those popsicle sticks in his mouth- we even had to discuss the importance of stopping for sleep. He is one motivated patient who couldn't stop watching himself open and close his mouth in the mirror!

I've taken care of a woman who also had a tumor and subsequent infection removed. I pulled a drain from her head and bandaged her back up. She walked out to join the others for an afternoon on deck seven, a ragtag group of patients of all ages in all manner of splints, casts, and bandages- literally, from their heads to their toes. They came back tired but seemed to appreciate the fresh air. Climbing five flights of stairs to arrive many stories up above the water in an African port is a novel experience for many people- our patients included!

I've admitted a newborn weighing in at well under two kilos- another cleft palate baby on the feeding program. When mama laughs at my broken French, I love her even more. And when she hands me the baby so she can use the bathroom or eat, I love watching her smile at everybody flocking over to cuddle and fawn over him. Seeing her eyes light up at the steady weight gain- attributed to her hard work- is priceless. Watching mom's restoration is as dramatic to me as the patient's.

I've taken care of a blind man, a man who looks well over his stated age of forty years. Sometimes it's hard to tell patients' real ages- hard lives, poor nutrition, and very little healthcare results in some mighty scrawny and prematurely aged patients- grit and determination notwithstanding. For the most part, though, I'm learning that age is just another one of those numbers I thought was so critical for taking care of my patients. Clinical relevance is a key concept here. Even in pediatrics, weight is more clinically relevant than age. Psychosocially, age is a helpful indicator for determining the approach and interaction with a patient, but of course patients across the lifespan vary in their developmental stages (regardless of age).

The manifestations of these developmental stages are sometimes difficult for me to spot here because of confusion with cultural differences. For example, all kids go through that stage where they freak out with strangers- except the babies here seem to get endlessly passed around, mama to mama, without too much fuss. But bring a Yovo into the picture and *bam* you have a hysterical child on your hands. Is this a developmental stage or merely culturally learned behavior? (no, the adults don't lose their wits and start screaming, but we're often regarded warily).

Anyway. My old man, he has a story to tell and his facial reconstruction is stunning. I could barely keep from jumping up and down as I unwrapped him for the first dressing change. I suppose there's always some disappointment when somebody finally sees (not just hears) that they won't look "normal" but will be functional and certainly look better than before. We all want to look "normal," if not perfect, don't we? I don't quite know where he stands on the whole thing yet. The wounds are still to fragile for him to touch yet- that will have to wait a while longer. For now he is relying on us and his sister for an honest appraisal.

And then there was the young boy whose jaw has been reconstructed. It's another life-altering surgery done by our resident max-fax surgeon who hails from non other than Seattle. For various reasons, these patients need reconstruction now, but will also need another one down the road for two very important reasons. First, the initial reconstruction is usually done with a metal plate. The problem with a metal plate in someplace like your jaw is that germs don't have very far to go at all until they hit the perfect site to live- your new jaw. Plates protruding through the skin are a problem as well because you are stretching skin over the hardware, not unlike a drumhead. There's precious little muscle and fat to ensure that it doesn't lose circulation under that stress. Regrafting bone to the site at a later date is the best course of action to both prevent infection and promote circulation.

Secondly, a followup surgery is needed because kids have an odd habit of growing. While your new jaw may look like a sixteen year old's on your twelve year old frame, by the time you are twenty-one, that jaw is now too small. It needs to be size appropriate for eating and pain reasons, let alone aesthetics. In the meantime, my young patient finally got his feeding tube out and is beginning to enjoy food again.

During supply runs down the hall, I've been ambushed by a young boy, maybe six years old, who climbed into my arms for a veritable smooch-fest. I gave him one kiss on his cheek, and then it was on- kisses on the neck, cheeks, and tummy! Embarrassingly, he landed one or two right on the kisser. Peleke? I can't promise that he didn't just steal a part of my heart.

Some of these patients have primary problems that are obvious. Some of them aren't so obvious to the untrained eye (an art perfected by the patients themselves). All of them have emotional and spiritual wounds directly related to the physical malformities. So while I celebrate victories with everyone, there's a special place in my heart for the ones that don't make the calendars, the videos, and the information packets. A picture paints a thousand words, but pictures can't capture it all. Neither can words- despite the absurd length of this entry.

Are your eyes burning yet?