On Being the Doctor - Very long post....

I must start this by saying it is hard to know how to summarize the many experiences of this trip in a concise manner. First a little background. Most of the readers know that I am in my 5^th post doctorate year, in my last year of residency (specialty training) in OBGyn. For some time I have felt called to take part in short term mission trips to use my training for good. It was about December of this year when pastor approached me with the possibility of doing a medically related trip to Africa over the summer… this was a small answer to prayer in that I had been searching for some opportunity to go abroad to do an OBGyn trip.

My pastor and his wife visited the DR Congo the year prior through the same ministry. When they were there many people begged them to come back with a medical team, and especially needed an OBGyn because of the problems there. During the Congolese war (AKA The African World War) close to 5 million people died, and countless were injured. The multiple militias of the war used brutal rape as a weapon. Many women were subjected to gang rape, sodomy with a machete, bottles, bayonet, and in some cases were doused in acid, or even sodomized with a gun and they pulled the trigger. Many women were deliberately raped by HIV+ men. This often didn’t just happen once, but multiple times in some cases.

The war in the Congo is difficult to fathom. It started with a government established by a civil war, but that government was destabilized by a coup in 1998. After the coup multiple countries, governments, parties within the Congo, warlords, and other independent militias all started to fight for power and influence over this poor land with vast amounts of natural resources. When one militia would take territory, they would do as they pleased to the people, then later another militia would gain it and do the same. A very sad part of African society is that when a woman is violated, it is considered her fault. They are shamed and shunned from their home and family when this happens. Many women were displaced to find somewhere to live on their own, and often in refugee camps. Sadly even in the refugee camps these same women were victimized again and again. The effect this had physically was extreme. Many women developed what are called fistulas, in which things like the bladder or bowel would drain out the vagina – and again in African society this is another reason you can be shunned. The effect mentally, well one can’t begin to understand. This was the premise of why I might be needed there. Our team also brought social workers with us. Because of the society in Africa victimized women would not speak with Africans about their lives. They would talk with white people though.

The war in the Congo by definition stopped in 2003, but even today there are still pockets of fighting occurring between rebels and the government. This is where Congo International Ministries (CIM) comes in. This ministry is responsible for reaching out to many of the victims in its region, and is where the new medical clinic was constructed. As it has been described before, CIM was established in a village called Nyangezi, which is about 25 km south of Bukavu (a major border city with Rwanda). This is a peaceful region currently since the end of the war, but obviously still reeling from the effects of it.

In the US the typical OBGyn would maybe encounter a small number of fistulas, typically in relation to childbirth or cancer treatment. They would never see anything to the extent that many of the women in Africa likely had. So as my position as a senior resident I pursued the trip with a certain degree of uncertainty. What would they expect me to do? Do they have the ability to take care of these women? Would I have the skill needed to repair the damage that was done? Are the doctors there already taking care of these women? For this me and my wife had a lot of discussions, talks with people I respected, and a great deal of time in prayer regarding my decision to go or not to go. It became obvious that I was being called to go. So let’s fast forward to the actual part of the trip…

So I came to find the Poll clinic operates much like an urgent care does here. There are some loosely held appointments, but it opens sometime in the morning and people come in and wait. The clinic also has an OR, a small limited lab, and some patient beds where people could stay to recover. The bathroom, well outhouse, was a 100 meter walk from the clinic and consisted of a hole in the ground. I was surprised to see that, unlike America, people really came in who needed to come in. This may be because the people have to pay a fee to be seen (because it is a ministry they pay close to nothing compared to what it would be at other hospitals). In America much of what comes into the ER, or urgent care is really not emergent and really not much of a big problem.

My typical day was to come in the morning, check on the “inpatients” and then start seeing the line up of patients with the doctors at the clinic. Sometimes surgeries would be scheduled, but often changed around depending on when we had power to run the autoclave. Other times they would have patients wait for hours in order to get an ultrasound to aid in their diagnosis. I described before that there were two younger docs, and one more experienced one. My general impression was the younger ones were eager to learn, and expand their abilities. The older doctor, a surgeon, was very nice, but seemed to be more motivated to show off to the American. Now I come to a part that makes me nervous to post, as I really don’t want to generalize and sound all narcissistic. I have been told by many sources that the medical education system in Africa is outdated, not very thorough and in some ways bad. But it’s the best they’ve got. Knowing this I approached the situation with an open mind, with a hope that they would surprise me. I am happy to say that in some ways they did, and in other ways frustrated me to no end. I found that the doctors had a fairly complete knowledge base as far as basic science and pathology. I did find that they had very little to no clinical medicine experience / knowledge to use.

A good example is when you go to your doctor for say, stomach pain, your doctor should ask a series of questions to narrow down the possibilities that could cause your symptoms. They first ask questions that reassure them that no serious problem is occurring. Then as they get closer to what your problem is between a couple different things, they do an exam and order tests to come to what you are diagnosed with. Then after they know what the problem is, treating it becomes a simple issue. In Africa the doctors knew the treatments, but weren’t very skilled at asking those questions that differentiate the diagnoses… So in the case of stomach pain: When did it start? Where in your belly does it hurt? When in relation to eating does the pain occur (before, during, after, or no relation)? Do certain foods bring the pain on more? Does anything make the pain better? Worse? What other symptoms do you have (nausea, diarrhea, weight loss, etc.)? This would then help you differentiate between simple reflux, gall bladder, pancreatitis, gastric ulcer, stomach tumor etc.

One day we had a woman come in with complaints that sounded like reflux, with the exception that it was a constant pain. That didn’t fit the pattern. Instead of just treating her with an antacid, I insisted we should do an exam. We found she had a 10cm stomach tumor. Now the symptoms she had were probably because the tumor was pulling on the valve and she was refluxing all of the time. To the younger African doctors credit he knew how to treat reflux. He didn’t catch that her symptoms didn’t quite fit the pattern, and that warranted more of an exam. Had the woman come in saying she had a lump in her stomach, which she did, it would have been easier. But that is why clinical medicine is not always straight forward.

There is a saying, “if you give a man a fish, he will eat for a day, but if you teach him to fish he will eat for a lifetime.” Not long after I arrived to the Poll clinic I realized my role there would need to be that of a teacher. Even on the first day some of the things that were being done weren’t what was really needed and in a place where resources are scarce one needs to be frugal. My first day there was spent unpacking all the supplies we were able to bring with us. There was a good portion of it that was completely foreign to them, clue number one. Then I was asked to help them do ultrasounds. They have a nice ultrasound machine. They do only have a transabdominal probe (the other type is a vaginal probe that is useful for many gynecologic conditions). The type of ultrasound they have has a few good uses such as pregnancy, gall bladder, kidneys, but it not powerful enough to see bowel or a nonpregnant uterus. That afternoon they had patient after patient coming in for an ultrasound for such things as infertility, abdominal pain, ulcers, hernias… all things that are not at all helped by an ultrasound. But one of the doctors acted almost as if the ultrasound itself would fix the problem for these patients. I equated it almost like giving a remote control to a toddler. They think they know what to do with it, but really have no clue. Later in the day a woman came into the clinic in labor. Being her fourth baby one would expect her to deliver without a problem. I was told the nurse on at night time took care of that and to not worry. Well the next morning the doctor came to fetch me for a c-section at breakfast. When they arrived they saw she was still in labor, so they called a c-section. When I arrived they had her all ready to go, so I wasn’t able to do any assessment. This was my first experience in the OR there. Very different…

First thing that was obvious was the gowns. They didn’t have any clean ones (we brought many with us, but they weren’t sterilized yet). So we had to don floral print scrub jackets that were sterilized, and wear them backwards so they buttoned along your back. Mine was tight. Next there was virtually no noise. In the OR in the US you will hear a few different types of sounds of monitors, fans, climate control, music, talking, etc. In that OR you could hear a pin drop. Next came the surgical prep – and lets just say old school and outdated. Another thing in Africa, they do things the way they do because it is how it is always been. They are taught that the bikini incision causes infection, so they do all of their surgeries with midline up and down scars. The bikini cuts are more stable, heal better, and look better. They do not get more infected. So most of the people in that OR had never seen one done like that. As c-sections go, it was routine, but there were many things that you tend to take for granted that didn’t happen there that made the repair much more difficult than it had to be. I naturally found myself teaching how to do each step of the operation. They were likely shocked as I didn’t do some steps they placed great importance on, that I know from practicing and reading are good to avoid (closing the peritoneum, and sub Q). The mom did well, and her baby did well too. She did name her son Brad, but not by my suggestion. These are the two new 'Brad' residents of Nyangezi.

It seemed as though each day I had the opportunity to teach something new, or challenge an old way of thinking. I recall having discussions with the doctors there about some of the major differences of American versus African medicine. One thing I learned that impacts how medicine is practiced there is patient expectations. In Africa the people need to feel as though you do something physical such as giving an injection or doing a surgery to address the patients problem, or else it is as though you did nothing. This is backwards. A message I really struggled to get across was that surgery by its nature was invasive, dangerous, and should be reserved as a last resort. It was not uncommon to meet many women with vague abdominal pains with 9 surgeries – major open abdominal surgery. In the US we say lets watch this and see if it gets better or worse, and check back on it. For some reason the doctors didn’t feel they could do that. As a result the majority of the surgeries that were done during my visit there were not really indicated, or in other words didn’t need to be done. This bothered me greatly. I was okay with doing ultrasounds with an illusion that you thought you saw something that wasn’t there, but I was not okay with people getting surgery that was inappropriate and getting hurt by it. As the trip went on I really found that it was the African surgeon who was finding all these people that needed surgery. They quickly put a question to bed, no, the doctors there were not paid and more or any less for doing any of these surgeries. But along the lines of African medical school, the surgical methods that are used are old, and by my standards outdated and dangerous. This also was a great concern to me. Below is a picture of me and Dr Roy. He was one of the younger more eager learners. Here we are closing after finishing a hernia repair. Dr Roy was really excited to learn a new (different) way of doing procedures.

I would have to say that the real rewarding part of the ministry there was being able to see and treat some of the neglected women victims of the Congo. To my surprise I did not see a single fistula, or injury from a rape. I suspect many of the women with injuries either died as a result or went to Panzi hospital in the area, that was touted to be able to fix vaginal fistulas. I can’t really comment, as I am not sure how good of job they do there. I was able to evaluate a few women who had been neglected since being ostracized by their villages. One woman was 65 years old, and had been raped brutally 8 years prior. Since then she wasn’t able to really walk or work. Just the fact that the white people came and listened to her gave her great joy. The day after our social work team visited her, they arranged for a handful of women to come and see me in the clinic. The 65 year old woman had what is likely to be an advanced vaginal cancer that is spreading – and had developed one of the worst yeast infections I have seen. Another had a prolapsed bladder, and another woman had developed chronic muscle spasms from guarding from the pain she experienced from her rape. No fistulas. I was able to admit them and give them treatment, food, and a bed to sleep on for a few nights. The next day I was able to perform a bladder suspension surgery for the woman, which made her very happy. A day later another woman was brought from a similar community who also had significant bladder prolapse, and again I was able to help her in the same way.

My favorite day was the day I had my own translator, Roland assigned to be with me. All the other days me and the other doctors were forced to try to communicate in whatever ways we could. Thankfully they spoke some broken English, so I would guess we could talk at a second grade level, and some of the medical terms in French are pretty close to those in English. The day with Roland was good though. It was good because it was busy, and we were able to really see many patients and talk with them and about their problems. For the first time I was able to thoroughly explain how certain treatments would work, and you could see the light go on for the doctors I was working with. Roland was also a new Christian too, so it gave me some time to get to know him and encourage him in his new faith.

One patient, however, was more troubling. In Africa, or in times when you have limited resources, it is important to recognize your boundaries. The patient was a 6 year old girl. She had been having worsening seizures. They had started months prior, but as time went on they continued to worsen, to where she was having close to 20 in a day. A few days before coming to the clinic she awoke from a seizure and didn’t talk any more. After examining her it became obvious to me that she either had worsening status epilepticus, or a growing brain mass. She already had been on the most powerful anti-seizure meds they had there. It was hard to tell her mother that she had something we were not powerful enough to fix. Thankfully that was really the only truly sad case we encountered. In the US we would likely be able to intervene and figure out what was going on. In the DRC the best we could do was to plead to God for help, and refer her to a bigger city where some of the stronger meds, and tests were more available. Although sad, the mom was still honestly grateful we tried to help.

Even though my role there was to help teach and treat the people there I have to admit I felt somewhat jealous of some of the other people on our trip. They were able to go out to the people and directly share Christ’s love and the good news to many people eager to hear about it. My pastor had some people hike over a 100 miles to learn from his teaching. I just did what I knew how to do, and tried to tell the patients that God is real and cares for them. None of the work I did there was miraculous, or will make any sort of dent in all the problems of that region. A team member reminded me that my ministry was the work I did there, and that just being there was a blessing for the people. The locals know that the CIM clinic is a Christian clinic, and that CIM is primarily there to strengthen the church. As I have been home for a month now, I reflect and really feel my ministry in the DRC was not only to the patients there, but to the doctors working at the clinic. I think God is challenging those young Christian Doctors to rise above the status quo of African medicine and treat their patients a bit differently and accurately. If you have made it this far in my weave of thoughts and stories please remember to pray for the Poll Clinic in Nyangezi. There is still much to be done, and I know that God will use my experience there in many different ways. I just hope that it will add to the work the Church is doing to help the Congo recover from its wounds, and grow stronger as a result.

Thank you for taking the time to read all of this. I know it wasn’t short.