Bamako, Mali 10/02/2010

Saturday in Bamako. I am only getting html language for photos, so cannot see to arrange. Sorry for the miss-match with the text; I'll fix that after I get a better connection.



We saw Pam briefly downstairs and got a photo of her with the Taureg man who sells his wares in the lobby. He put his head scarf around his face and got in his best nomadic Taureg pose with Pam. He is very sweet: says hello each morning and gives a report on his children. I showed him a photo of my sons, and he gave me a frame that his son made to put it in. His only request was, "Just come back and buy something, I give you good price."



Went with Chuck to discuss the banquet to be held at the American Club, which is part of and near the Embassy. Chuck is quite the horse trader! We arranged for a meal to be had with those who have hosted us here as a way to say thank you. Moussef waited for us outside the gate. When we came out, there were two beautiful young girls on their way to the Niger River. They posed for me, then ran off laughing and holding hands.



On the way back to town, I got a photo of a poster at the convention center. Gaddafi had been here for the celebration of the 50th year of independence, and the poster refers to him as the "guide de la revolution". The taxi driver started waving his arms and called Gaddafi a crook.
http://en.wikipedia.org/wiki/Muammar_al-Gaddafi



A view of one of the streets out my window. Not paved, no sewers or infrastructure. So poor. I can't imagine life without safe, running water, but here it is a fact of life for most of the people. Things slowly change, but it takes money, organization, and control of corruption. Apparently someone at the hospital is under scrutiny for charging the government for things that were not done.



Women as well as some men carry most loads on their head. They often use a flat pad that helps give a level place for the item, as well as offering a bit of padding for the head. Sometimes they do not even hold it, and may stack items one or two high - even cans of petrol. Some people may be seen with carts, but these are probably too expensive for the average person, and the rutted and pot-holed roads are not very forgiving.



Chuck and I went to the N'golo Nina market. This is the largest market in town for wares, and many of the artists can be seen making items. This first store we saw is a hardware store, with boxes of nails on display on a table and other items hanging from the walls. No electrical tools, and no lumber yard.



I feel bad bartering with anyone, but it seems to be an expected part of the transaction. Nothing is labeled with a price, and they often start at three or more times the price they are willing to give. This young man had to call his "brother" to check on a price, which added to some of the pressure and tension. But whenever you walk out the door, the phone comes out again and a new price is approved. For the earrings, which this same man made himself, I could bargain with him directly. Makes each purchase take a long time, but when both parties are satisfied, the deal is done.

The "streets" are narrow, crowded, and busy. Around each doorway is a dirt floor with someone working, wares displayed around the walls and small shelves, and a brother or two to make the pitch.



This man was carving wood items, and holding them with his feet. He had all his fingers and toes, so he either knows what he is doing or is very lucky.



This young man is a delightful Taureg who had never seen himself in a photo. His name is Moustafah and he was making metal ware "for his family". He said money is just paper in the desert, and he wants to buy tea and chocolate to take back to Timbuktu for his family to use to trade for things. He showed us his head scarf and robe that he had folded up in his stall (see first photo above for example). He seemed very proud of his heritage.



Chickens. In crates, carried by hand alive, boxes of them. They are all pretty scrawny; I'm sure they are free range to eat what they can find. Seems to be one of the most popular meats other than fish and beef (not much pork in a Muslim country).



Another street.



On the way home, we walked. It was interesting to see the various streets, shops, and the bustle of life away from the hotels. The sky behind us had turned very dark and a wind began to blow. It was clearly about to open up. The wind began to stir up the dust and sand, and if I smiled or said something, my mouth was filled with grit. Wished I had Moustafah's head scarf!



While hustling home, we were behind a young woman with a tiny baby on her back. She had him covered completely, either because of the size or the blowing sand, or both.



Finally the rains started to pour and we scampered across the streets just in time to make it to the hotel. In spite of the rain, it was very hot and it felt good to have a wet shower and a clean towel. Each piece of luxury is noticed and appreciated!

Bamako, Mali 10/01/2010

Fridays are usually lighter days to avoid having patients needing close attention over the weekend. Most of the team is planning a trip to Mopti and area NE of here; I am staying back with the coordinator Chuck (or Jacques) and the hand therapist Pam. We are planning to roam the city and go to Oumar's wedding. I wouldn't miss it!




One of the patients today especially struck me. He had a bad burn on his foot, but the good care under the guidance of our nurse educator Katie (at left, with PACU nurse Vicki) gave him a clean wound that could be skin grafted. This patient is five years old, and like many of the children, sat quietly on his parent's lap, but upon closer inspection I could see a tear brimming over and running down his cheek. He could not speak English or French, so we could only mime to him what to expect, and I could never erase the look of confusion and fear on his face.

When the time came, he climbed off his father's lap and started to hobble with me. I immediately realized that it was painful for him to walk and picked him up for a ride, but not before I could tell that if he had to walk into the OR, as little as he wanted to, he was going to do so. Such a brave little guy, and we are not even using the pre-operative sedation that we do in many other situations.

These kids are amazing. They spend most of their early life wrapped close on their mothers' backs, and have such a close sense of personal space. When we hold them in our lap to breathe them to sleep, rather than kick, push away, and have a tantrum, they give in and lean into us much sooner and closer than I am used to in U.S. They wander all over the neighborhoods as soon as they can walk, and have large extended families that include neighbors and friends. Very different sense of trust and community. There really have been very few children who have fought us, and it humbles me to watch them be so stoic through this experience.

There is an anesthesia resident who comes and spends time with me and I am learning so much about how they do things. His fund of knowledge is very good, but what they have to use is very limited. He asks very many good questions, and in the process it provokes me to think about how we do things, and especially if maybe we need to approach the patients here a bit differently than we do.




The chief nurse, called Major, has been very helpful with care on the ward. There are many here who function with us as part of the total team, and without whom we could not do the job well. It has been amazing to come together with them and partner for better care of the patients.






Everyone leaves in the morning at 5 a.m. I'll report on their trip when I hear about it, but for now it will be the three of us having adventures in Bamako.

Bamako, Mali 09/30/2010

Today started like any other - up for croissants, conversations and joking among the team, plotting for the day, and rehashing the day before. March down the street, wave to the banana ladies and the bus drivers, walk in to the hospital through the car entrance (a privilege we requested after swimming upstream with the hoards of people making their way to the clinics), get the tables ready for the day, and arrival of the patients.

The team has two coordinators who help us with all the schedule and administrative tasks, translate our English into French if needed, bring the patients back for us from the ward, and any other tasks left undone. Chuck is from Belgium and is a powerhouse of energy and organization. Manon is a lovely woman from Canada, and we could not do this without them. Manon brought me my first patient.

As with any other day, there were some surprises. Earlier in the week our team leader Steve and Deb (both anesthesiologists) went to consult on a patient elsewhere in the hospital. He had been scheduled for a procedure but had to be canceled because the local anesthesia personnel could not intubate him. Steve and Deb scouted the patient out, and found him to indeed look like he would be difficult to tube. He had large teeth, large tongue, small mouth opening, stiff neck (elderly), and a large mass on his cheek the surgeons were planning to remove. All red flags to us that the tube we slide around the corner behind the tongue and between the vocal cords into the trachea would not pass as easily as usual. Plus, attempts had been made and failed.

The plan was for the local team to pick a day later in the week or next week, schedule the case based upon our availability, and check with us when this could happen. As is usual on these trips, we got a surprise this morning. The patient was already in surgery and the surgeon was waiting for us to get the tube in. Luckily it fit well between some cases we were doing and we agreed to come over and give it a try.

One of the surgeons walked us across the courtyard into another building. We were taken back to a fairly dark room with sparse contents. There was an anesthesia machine with isoflurane, a monitor of an unknown make, an old black OR bed with manual cranks, and a wire rack with some packs and a few other items. I was struck with how empty if felt; it was nice to not have to climb over and around various electronic toys, cords, and bags.

Steve and I brought a bag of various equipment items and settled in for our procedure. There were about eight people in the room - no idea who or why - who were all interested in what we were doing. One anesthesia person dived right in and started giving drugs, and we had to stop him so we had time to set up our equipment and give the drugs we normally use. They actually had some very familiar drugs, but we use a slightly different recipe when tip-toeing around a difficult airway. There is a time during intubation when the patient can no longer breathe for himself and we take over, but we want to be sure we can do this. It is very scary to suddenly realize one cannot breathe for a patient who has stopped breathing!

Steve did a great job of setting up - made his plan, laid out what he wanted to use, took control of the room, and proceeded. Monitors checked, IV checked, tools checked. Meds in, bag and oxygen working, patient paralyzed after confirming ability to breathe for patient. Just like a cock-pit check list. Luckily we had our new video Glidescope, and when the time came to look at the airway, the scope slid in, we could see the vocal cords and trachea right away, and in went the tube. Pretty slick, Steve!











Back with all our tools to our OR, clean up and set up, and more cases on the way. Next one was also a difficult airway case - a large keloid of the neck. One of the surgeons described it nicely - when a scar heaps up within the boundaries of the original injury, it is a hypertrophic scar (overgrown). When it grows over almost like tumors of the scar, larger than the injury borders, it is a keloid. It is like a cancer of scar, except cutting it all out often results in regrowth. All the skin does the same thing. It is difficult to avoid, and for this young man, could well return. But he is seventeen, cannot button his shirt over this eggplant-sized mass, and wanted to give it a try.


Holding the mask over his face was difficult. His chin and jaw line could not be felt, so the mass was held as part of the face to make a seal. We put out video scope to work again, got a good view, and got the tube in. Hurray! Another good result when the surgeons were done, with a neck collar to compress the graft down on the skin.



There is one very sweet sixteen year old patient that the nurse educator has been working with the week before we came to get his wounds cleaned up. He is tall and skinny like a gazelle. He grabbed a live wire and got a bad electrocution injury, leaving both legs without skin, almost like a bad burn. One leg even appeared to have the calf muscle pulled loose and pulled down around the Achilles tendon. He has been battling with the pain and misery for months.

I had gone earlier to try to get an intravenous in him, and he was so cheerful and helpful, smiling even as a tear made its way down his cheek when I had to poke him. It was all I could do not to cry! He was even handing me things and holding now and then to help me. Very nice young man. He got some skin grafts and dressing changes done in the OR today. His mother and baby sister were waiting for him when he came out.





Another interesting patient was a three year old with an abscess on her leg. When it was cleaned up by the local doctors, they found it was down to bone. She came to surgery, and our artists fashioned a cover for it from the calf muscle of the same leg. The muscle was tunneled and placed over the wound as a flap, which will allow the defect to heal and fight infection.




I don't know if you remember the Grand Pooh-Bah from Happy Days, but his brother works here...




Lots of good teaching going on. More people coming each day. Not all the people coming are exactly up to speed on sterile technique the way our surgeons like to see it, but each day is
getting better and the students are doing more.









One of Deb's patients today surprised us all as we got him ready for his surgery. Sometimes patients will write little notes or do silly things that make us laugh, but this patient quite innocently wore his Obama underwear. We were all delighted.













Poor Oumar was the next one to be found asleep. He is trying to get ready for his wedding Saturday, seeing patients, helping us with surgery, translating, bringing blood, and generally making the impossible happen. No wonder he is totally exhausted!

Come to think of it, so am it. Off to bed, and more tomorrow.

Bamako, Mali 09/29/2010

Today may be the hardest day I can remember on these trips. I think we all agreed Monday may have been our most difficult first day, but today gives competition for the hardest day EVER...

We all made our way down to breakfast and then to the hospital, as usual. It is fun to watch the locals pack into the buses. Fare is 20 cents, but the ride is wild.






Today for some reason many people forgot their scrubs. Richard, well over 6 foot something, loaned me a pair of his. Very sweet, except they were larger than I needed. But they worked!

Walking up the stairs this morning, we had to share with a wheelchair being moved with a patient on it. There are no elevators, and later in the day someone else had to carry a patient down the stairs. These are electronics and luxuries we all take for granted. Consider the logistics - the wards are upstairs, while the clinics, testing, and other essentials are downstairs. Some of the wards we use are downstairs, and surgery is upstairs...









The first cases were a three and a four year old. My first patient was the three year old. He was the spitting image of his father! Both very sweet, and they traded off who wore the hat as the day progressed.
















Verathon was kind enough to let us use a Glidescope Ranger. This is a very portable video scope that allows us to place tubes in people that otherwise might be too difficult to do. We have used it many times, but three times it proved to be critical. I think we all have used it now and are very thankful to have it.













There is a wonderful woman who cooks our meals and serves them up with her son and daughter. She has two other daughters, one of whom is in Los Angeles. Her son speaks English and they are all very friendly. And great cooks!




The case that made my day feel so long was the release of a burn that ended up being longer in duration and more complicated than any of us expected. It took a long time to get everything done, the patient was very tired after the case, and we all spent much time and attention to get him perked up and ready to send to the ward. We finally all headed home after dark, had a quick dinner, and fell into bed.

Which is where I am headed now...

Bamako, Mali 09/28/2010

Last Wednesday, 9/22/2010 was the 50th celebration of Independence in Mali. Even Mouammar Kadhafi showed up. The two team members who came first were in Mali a week before we arrived. Apparently the hotel tried to have them leave so that Kadhafi's security guards could stay here. They held fast and it sounds like it was an interesting week. There are still a few "unusual" looking guys in the lobby as I type, and no wimmin...

There was a thunderstorm during the night – the loudest crash-bang of trash cans and metal I have ever heard, then the sound of a large splash like buckets dumping out on concrete. This all lasted only a few seconds; very bizarre. But it woke me and took awhile to figure out what was going on.

The rain leaves the dirt along the streets a dark red, with many riverlets of water weaving through it. There are many troughs built along the road with depressions that empty into them. Many pot holes and cracks, so the dance over the obstacles can be tricky.

Once we got to the hospital, we began to set up for our second day. A little boy wandered into the operating area and was giving out handshakes and hugs. He was not due to have surgery, just curious and friendly. His visit set us up for a great day.

Our day was long, but many medical visitors came and went. We had several of the surgical trainees working with us and even helping with cases. This is gratifying, to see them learn and work side by side with like professionals who do not always speak the same language or share much in common. But everyone gets along, finds a way to communicate, and works together on the common goal of patient care.

One of the surgical residents was trying to understand the term "Steri-strips". These are little band-aid like paper strips that are

used to help hold a wound together. He couldn't get all the sounds or understand the meaning, so I explained in French and wrote it out for him to see so he could sound it out. I said it for him a few times, and then he tried. I never think of myself as having an accent, but I suddenly heard what sounded like he was trying to imitate John Wayne. Do I sound like that?!!

The anesthesia team rotates each day. Two of us work the two surgical stations, while the third stays out to see patients, give breaks, help start and end cases, and watch the recovery area. It is nice to have extra hands while setting up and starting

a case, not only to lighten the load but to make it safer.

A nice lady makes us lunch each day. Yesterday was couscous and yams (I passed on the meat), and today was pasta and beef heart. I wasn’t interested in trying the heart, but a couple of people said it could not be beat …

One young woman today was so frightened but had a very good procedure done. The back of her armpit had been burned so that the skin webbed from upper arm to back and she could not raise her arm from her shoulder. She was not very happy going to sleep, but she is going to be delighted at her new range of motion.

Couple of very cute kids, and amazing to watch our caring recovery nurses working their magic. Everyone works so hard – our surgeon even caught a cat nap.

Stopped and bought a mask on the way home. I bought masks for my sons last time – this one looks very much like my cat AND my dog. Think they will appreciate the thought?