Month 9

May 13, 2015 Kristen A. Austin

Too much. Too much. Just too much.

A few days ago I thought I would be documenting the progress and continued challenges to expand cervical cancer screening in the Gondar region as well as starting a gynecology outreach program to improve referrals and hopefully improve the perinatal and maternal mortality rates here. And I was going to talk about Josh getting walloped by an older teen as he walked back to our apartment a last Friday night. But no. Instead I shall chronicle the last four days. It is all a bit surreal. Truly surreal. Really true.

Early Sunday morning, May 10, 2015, Sonja woke up screaming in pain. It was about 2 or 3 in the morning. Mark had gone to bed that night with the statement, “Tomorrow morning I need to sleep in, I am so exhausted from recent late work nights.” Often times Mark will get up when the kids wake up in the middle of the night. This night I decided to get up and see what the matter was. I helped Sonja down from her top bunk and into our bed.

“What is it, Sonja?”

“Momma, it hurts! Owe! Owe! Owe!”

“Where does it hurt, Sonja?” She points to her right lower quadrant with her finger tip. She points to just above and lateral to the inguinal ligament. Inside, my stomach sank. I asked Sonja questions, hoping the answers would lead me away from my sinking suspicion. “What does the pain feel like, Sonja?” I asked. She told me it felt like a sharp knife was stabbing her.

“Does the pain move?” Her response, “No, it stays right here,” and points again to her right lower quadrant.

Question: “Are you hungry?” Response, “No.”

Question: “Do you feel sick and nauseated?” Response: “Yes.” And then later she validated that answer.

So I examined her, gently pushing on her belly, and then releasing pressure. “Sonja, does it hurt more when I press or let go?”

Mark woke up and asked me what was going on. “I think she has appendicitis,” I said. Mark has had appendicitis, was hospitalized a couple of years ago and treated medically. He woke up right away and started rummaging around for our international travel health insurance. Within 20 minutes he was talking to someone from International SOS. He explained the circumstances to the insurance company and began the international medical insurance process. This involved confirming our insurance numbers, supplemental insurance information and reviewing Sonja’s symptoms with a medical team. The process was incredibly challenging, because the telephone network is very unreliable, and several conversations lasted less than 3 minutes with up to an hour elapsing before being able to connect again. Eventually, Mark and the insurance company resorted to email exchanges. After several hours, email exchanges and multiple dropped telephone calls, International SOS sent us an email that they did not recommend she have surgery anywhere in Ethiopia and they thought Sonja should be medically evacuated from Ethiopia.

Sonja and I slept for almost 3 hours. Dr Getachew woke us up with a phone call to ask how Sonja was, and then said he would arrange an ultrasound evaluation. There is no CT scan at the hospital. Dr. Getachew arranged for one of the senior radiologist physicians to perform Sonja’s ultrasound. We met the radiologist Dr Temesken at the hospital and he completed Sonja’s ultrasound. Her appendix was 5.95mm in diameter. Greater than 6mm is considered abnormal. Overall, Sonja was feeling much better, although she still had pain directly over her appendix. Dr. Temesken then gave me the senior consulting surgeon’s phone number and I called Dr. Solomon. There are no pediatric surgeons in Gondar. There may be one in all of Ethiopia. Dr. Solomon is a general surgeon and apparently does most of the pediatric cases here. He is an extremely kind man who looks to be in his early 50’s. He arrived, listed to my account of Sonja’s symptoms and gently examined Sonja. “I think the appendix needs to come out.” Ugh. I did not want to hear this. I knew it, but didn’t want to hear it. I asked if we could at least try a conservative approach with intravenous antibiotics. He replied that this option was controversial and he didn’t do that here in Gondar. But, as Sonja was clinically stable he would allow a period of observation. He also suggested we return home for the period of observation. The hospital is overcrowded, dirty, and we would be a white foreigner spectacle. He thought Sonja would be more comfortable in her home. He then drove us home in his SUV. It is the nicest SUV I have seen in Gondar, similar to a Toyota RAV 4.

Throughout the day Dr. Solomon communicated with me via texting. We tried to make phone calls, but the network was intermittent and unreliable. Sonja continued to feel better. He suggested we try some clear liquids. She tried some of Josh’s Christmas present, powdered PowerAde drink. No problem. Josh entertained Sonja, and they both watched multiple episodes of “Jessie.” Around 5pm, Dr. Solomon returned to our Guest House apartment to re-evaluate Sonja. Dr. Solomon is the head of the surgery department, and he made a house call. A house call. He arrived at the tail end of a wedding ceremony in the Guest House courtyard. Sonja had just slept through wall-shaking blaring traditional Ethiopian music. This seemed to be a positive sign. Sonja’s abdominal exam improved as well. She was not completely comfortable, but the tenderness had improved. Dr. Solomon and I both thought that maybe, just maybe Sonja was going to be lucky. He left, reassuring us that he would have his phone on all night and we could call him anytime. He also suggested Sonja have some food, some plain food. Sonja chose rice.

During the day I spoke to Dr. Iain Carroll, the visiting British anesthesiologist. Dr. Iain had only arrived 6 days prior, taking Dr. Liz’s place as the visiting anesthesiologist lecturer. He was new to this system, and he was the only anesthesia physician in Gondar. Dr. Iain is a “registrar.” This means he has finished the bulk of his anesthesia training, and is completing the last few years before becoming a true “consultant.” Post doctorate training is different in the UK than in the U.S. In the late morning I told Iain about the possibility that Sonja may need an appendectomy, and asked that he be present should surgery be deemed necessary? He readily agreed.

I discussed with Iain that International SOS recommended Sonja be medically evacuated, but we had not heard how or where this would happen. He remembered a friend of his worked for a medical evacuation company based in Kenya. He couldn’t remember the name of the company, but he emailed his friend and within a couple of hours had a reply. Iain came over to our apartment and emailed to International SOS the medical evacuation company’s name and the name of a recommended children’s hospital in Nairobi. By 2pm, International SOS called us and told us they were trying to scramble a plane to leave Nairobi at a 3pm take-off window. They asked about Sonja’s condition and I told them she was currently stable. They told me that if they missed the 3pm take-off window, the next option was 10pm. Would that be okay with us? I told them that I didn’t know. Sonja was currently stable, but if she deteriorated we would need to proceed with surgery her in Gondar. The woman on the end of the line said she completely understood. We needed to do what was best for Sonja.

Mark continued the communication with International SOS, emailing passport and visa copies, yellow fever documentation, supplemental insurance information. They needed Sonja’s height, weight, medical history. Mark brought out his scale and tape measure. I had no idea we had scales and measuring tapes in the household. What was I thinking? Of course he had a scale and tape measure handy. He is an engineer. Mark then helped to pack our bags. Sonja could go with one parent, and we decided that the physician parent should go. The engineering parent would be sure everything was organized and worked.

Accordingly, Mark worked on our parallel plan for surgery in Gondar. We had complete faith in Dr. Solomon, Dr. Iain and the anesthesia head who said he would help. I have seen surgeons and anesthetists do extremely complicated surgeries here with very little equipment, sometimes with power outages, lack of blood products, and anesthesia machines that break in the middle of surgery. They manage. We were not concerned about the skill level of the individuals who would potentially help Sonja. We were worried about the system. The environment. The intermittent power outages and the fact that the hospital has not fixed the generator for months. Mark and the bio-med engineering department knows that only one surgery department autoclave is functioning properly, getting up to adequate temperature to sterilize equipment. How do we know Sonja’s surgical equipment would be properly sterilized? I know that there are no checklists, no pre-op, intra-op, or post-operative protocols. What if they forget that Sonja has an allergy to penicillin? I also know that the nursing care is woefully inadequate. You only need to walk through the hospital once to see that it is frightfully old, dirty and overcrowded. We know that the hospital buys cats to help deal with the rat problem. Yes. We know these things.

Knowing these things, Mark worked on the most important issue, ensuring Sonja would have power for her surgery. He convinced the Guest House manager to lend us a generator, then finagled a van to drive it to the hospital. Mark hooked up this generator outside the OR, locking it to a tree. Should Sonja need surgery, he planned to run an extension cord from the generator up to the OR. Brilliant.

We called Dr. Kiros, an obstetric resident, and previous hospital CEO to ask that the appendectomy surgical equipment set be sent through the functional autoclave. I discussed my concern about the OR sterility, and Dr. Solomon assured me they would take extra precautions.

Yes, we were a bit manic. All this time we hoped Sonja could be airlifted out of Ethiopia to a more functional hospital.

At 4:30pm, International SOS called us to say that they had missed the 3pm take off window. Not only that, but Ethiopia would not allow them to land at Gondar in the dark. That meant that the earliest they could arrive in Gondar would be 9am the next morning. At this point Sonja was still quite well. We agreed to plan for the next morning airlift transfer. I told Dr. Solomon about our plan. He reassured me that Sonja would be well cared for at the University of Gondar Hospital and not to worry. He also told me he understood my concerns.

At 9pm Sonja’s pain returned. It worsened. Josh tried entertaining her with episodes of “Jessie” on his Kindle Fire. Even Josh and sitcoms could not distract Sonja from the pain.

I called Dr. Solomon. I told him Sonja needed to come into the hospital for treatment. I still was worried about the surgical environment. Dr. Solomon expressed his concern that I would prevent my child from having the surgery she needed. He even called Dr. Getachew and had him call me to convince me that Sonja would be fine. So I took a few deep breaths and became the doctor-mom. In as calm and reassuring a manner as I could muster I explained to Sonja what was going to happen. Josh cheerfully said good night and good luck to Sonja, then went to stay with our Guest House apartment neighbor, Pascale. Mark, Sonja and I went with Dr. Solomon in his SUV. We brought Dr. Iain along, as he is also living in the Guest House. We went to a senior anesthetist, Semachew’s house and picked him up. Dr. Solomon then drove us all to the hospital.

There was another child waiting for surgery, sitting with his mother outside the surgery doors. A man with necrotizing fasciitis waited on a gurney. We walked by and settled into the couches of the operating note writing room. In our world it would be the dictation room, but they don’t do dictations, they hand write all notes.

Dr. Iain donned his pediatric scrub hat, I think it had pictures of balloons, flowers and rainbows. He was great with Sonja, this was not his first pediatric case. He started the routine history and anesthesiologist abbreviated physical exam. You know, the physical exam that consists of opening up one’s mouth and sticking out the tongue? This made me smile. Dr. Solomon repeated the abdominal exam with the sure hands of an experienced surgeon, watching Sonja’s face during the entire exam. No doubt. The appendix needed to come out.

Dr. Kiros (obstetric resident and previous hospital CEO) appeared to facilitate the administrative aspects. He ran around the hospital campus to get a chart, OR medications, intravenous antibiotics, IV fluids. These are activities that the patient’s family is usually expected to do. We received royal Gondarian treatment.

Mark disappeared for 10 minutes as he ran an extension cord from the generator through the OR window to a power strip. He returned shortly to the couches and waited with Sonja and me. Initially he planned to literally stand by the generator during Sonja’s surgery, but it was pouring down rain and we figured we would know if the power went out just sitting in the building.

By midnight the OR was ready. I carried Sonja down the hallway and lay her on the OR table. I noted that the rusted and old blood stained OR table was covered with a new sterile drape. The patient drape they gave me to cover Sonja was still damp. Laundered, but not completely dried in the sterilization process. Breathe Kristen, breathe. I continued to chat to Sonja about the normal things that were happening. Explained the bed that moved up and down (and fortunately it did function). She asked what that big round thing hanging above her head was, and we explained that was the light. Yes, it worked. Dr. Iain started her IV in a flash. A pediatric oxygen mask appeared. Sonja remained calm and inquisitive. A braver girl I do not know. I stroked her cheek and held her hand as she drifted through the induction anesthesia phases. I was then invited to leave the OR, and I did, glancing back once to see Iain place the laryngoscope into Sonja’s mouth.

An hour later, Dr. Solomon stuck his head into the room and gave us the thumbs up sign. “The appendix is out. It was inflamed….and very long!” The surgery resident handed us Sonja’s appendix, in a lidocaine bottle. We were instructed to bring it to the pathology department in the morning. Uh, okay?!? I put her appendix in my pocket for safe keeping. Another 15-20 minutes went by while the anesthesia team woke up Sonja. This was my most terrifying moment of our entire ordeal. You see, two weeks ago a 6 year old little boy did not wake up from anesthesia from the same operating room. I knew this. Mark didn’t. He does now, though. My grip on his hand informed him.

We rolled Sonja through the recovery room. We were given the option of staying in the recovery room for the rest of the night. It is a room about 20 x 40 feet. There were probably 20 patients in the room. I asked if we could have a pulse oximeter if we left the recovery room. An affirmative answer and the stench of body odor mixed with sterilizing alcohol, body fluids and rotten flesh (from the necrotizing fasciitis patient) convinced me we needed to stay somewhere else. Iain offered to help watch Sonja for the first post-operative hour and we decided to take her directly to the general ward. Out into the night air we went, the rickety metal gurney wobbled down the door ramp, bumped along the asphalt path and then up the general ward ramp. An intern met us at the door. Iain gave her a nice, concise post-operative report. She nodded, smiled, said she understood and then disappeared. We didn’t see her again for another 5 hours. We never met a nurse that night, either. Mark went home and returned with Dr. Solomon with some clean sheets. We forgot that we needed to provide our own bed sheets. Silly us. Solomon then drove Mark back home to be with Josh.

After Iain left I continued to observe Sonja, checking her O2 sats every 15 minutes, then every 30 minutes, then every hour. When her O2 sats drifted to 91% I woke her up and asked her to take deep breaths. She complied quite nicely. Around 6am her pain worsened, so I gave her some acetaminophen suppositories. Mark had packed a thermometer from home, so I took her temperature which was a tad elevated, but not unusual for the post-operative period. We figured out how to void in the large metal bowl that lay beneath the bed. Then used the same bowl for post-operative vomiting. I found a bucket of water that was collecting water from a leaking shower head, and used that to clean out the bowl. Not a single person came to check on us all night. The urge to sleep continued to attack me, and I succumbed to lying next to Sonja on her bed.

Morning arrived with chirping birds in the OR courtyard just outside our window. The intern reappeared and proceeded to ask me what medications had I given Sonja, what had she received intraoperatively? Did she have any problems since the surgery? Any vital sign abnormalities? This was truly surreal. I was absolutely exhausted. We had been up essentially two nights in a row. The previous night at home when her appendicitis attack started, and then this night immediately postop. Another intern showed up and asked me where were Sonja’s intravenous antibiotics? I told her I didn’t know. She then recognized me and said she would go buy them for us, don’t worry. A nurse appeared shortly thereafter and gave Sonja her IV antibiotics. Well, she started them, and then told me to stop the antibiotics after she received ½ the bottle and to reconnect her IV. No one recorded a single vital sign in Sonja’s chart until post-operative day #2. A new intern arrived that 2nd day and asked me where was Sonja’s vital sign chart? I told him she didn’t have one. He looked somewhat surprised and alarmed, and went to fetch a fresh sheet of paper. The senior consultants were making hospital rounds. I don’t suppose they were too pleased no vital signs were recorded the first 36 hours after their 8 year old patient’s surgery.

Around 9:30 in the morning visitors started appearing. News spreads quickly in this small town. Mark brought Josh in to see his sister. He then watched a parade of people come in and out. Sonja was often sleeping. A dozen ob/gyn residents stopped by to check on Sonja and ask how we were managing. A couple of them suggested we move to the one private room in the general ward. We moved that afternoon. Dr. Semenawit popped in, took one look at Sonja and me and then left for about 20 minutes, returning with a double macchiato and an egg sandwich. She didn’t even ask me what I needed. She just brought it. Semenawit and her mother returned that evening bringing dinner for the family. Dr. Getachew and Dr. Birhanu, two senior ob/gyn consultants stopped by, our favorite bajaj driver, Tewodros and his brother (an orthopedic intern) visited. Tewodros drove me home the first afternoon so I could shower, then drove me back to the hospital before our second hospital night, no charge. Rajat, Mark’s bio-medical engineering colleague visited. Our household worker, Worke learned about Sonja’s hospitalization from the Guest House manager who had lent us the generator. She visited, then brought us dinner on hospital day #2. The owner of the hotel my mom and dad stayed in during their stay came and checked on us, coming with our Simien mountain guide. He offered his van to bring us home when Sonja was discharged.

Throughout this entire ordeal International SOS continued to call and ask for updates. Mark and I spoke to several nurses and doctors, all knew our story as if careful records were kept and communicated to the next team. They kept a plane ready and said that as long as they could leave Nairobi by 3pm they would be able to pick us up and transfer us. In fact, Sonja and I are still approved to be medically evacuated at any time.

The system here is weak. But the people are strong. People survive because of these strong individuals. And God.

Almost everyone offered their prayers, or statements, affirmations of God’s will. “God will care for you.” “Pray that God will bless you.” “She will recover, God willing.” These were not prayers asking for God’s guidance or asking that God give us strength. No, these were prayers stating only God knew Sonja’s fate. He would not only decide her outcome, but also provide her outcome. God did not work through the surgeon’s hands. No, God was in charge. There was no responsibility placed upon the health care providers. Only God was responsible.

Interesting. So now we are home. It is postoperative day #3 1/2. Sonja is doing well. She is thankful that she learned to take her malaria pills earlier this year, because now she has six pills to take every day. Her pain is minimal. Yesterday she took one dose of acetaminophen. Today nothing. Josh is thrilled to have sister home, although he laments he is not allowed to wrestle with her for a few weeks. Instead he takes to verbally teasing her to make her laugh, although laughing still hurts. Mark and I are relieved, but still cautious. Infection continues to be a risk, although less so every day. We have slept well the past two nights. Josh went back to school. Mark is at work this morning. I will head in just to pay our hospital bill and drop off the final draft of the cervical cancer screening pilot study. Sonja has made a list of things she wants to eat as soon as we get home.

• Breakfast: bacon, waffles with raspberries and maple syrup.

• Lunch: fruit salad with blueberries, raspberries, strawberries, pineapple, mango, and sweet oranges. Lettuce salad with baby cherry tomatoes, avocado, broccoli, carrots and ranch dressing. Grilled cheese with real cheddar cheese.

• Dinner: Annie’s macaroni with pieces of Costco bacon in it. Dessert: Vanilla bean and chocolate chip cookie dough ice cream with whip cream and two cherries on top.

Yes, I think if bacon is the first thing on the menu, then Sonja is feeling better.

Previous Article
Dealing with Vaginal Prolapse

Women's bodies change with time, and as I advise my patients, it takes conscientious effort to counteract g...

Next Article
Office Location Changing June 8, 2015 from First Hill to Madison Valley

As of June 8, 2015, Sandra C. Walker will be relocating her practice to Seattle's Madison Valley.