Mean(s)

For all the drama and good of medicine, what is obvious to me is that its impact is only as large or small as the next step.  After all the beeps and drips, the pumps and technology, the one-on-one diagnosis and medical proclamations, in the end, the patient goes home to deal with the remnants of disease and/or the world that put him/her at risk in the first place.  I saw this as a medical student when after lancing and bandaging abscesses of the homeless, we then sent them back to live on the street.  No doubt it felt really cool, especially as a young professional, to be able to assist a person with an acute medical problem for which one received a thank you.  But there was also a feeling of disingenuousness too as the man or woman hobbled off with tattered often stinky clothes out the emergency room door. One could not help but think relative to the layers of the situation and used, stained and bloody gauze on the floor, what exactly did I do? 

​Baby with temporary anus

I see this now with many patients under our organizations care at JDJ Hospital:  Princess, a seven year old with new onset diabetes, the baby with a heart defect puffing away in the corner of the ICU and the cute baby born without an anus, who thanks to our doctors now has a temporary anus pouring contents into a bag on the left side of his abdomen, but not for long, because without additional intervention he will die.  That last baby was ironically the cause of our medical team’s premature high fives, which in retrospect was like gesturing mission accomplished to the enemy prior to a protracted war.  The baby had been transferred to us from an outside clinic literally about to explode.  His abdomen was so distended it was pushing into his lungs making it difficult for him to breathe.  He was undoubtedly in severe pain but too sick to cry. I had never seen a baby with anal atresia before, but simply put there was no anus where anus was supposed to be. There was only a dimple.  My immediate association was to the character Pilate in Tony Morrison’s Song of Solomon, who didn’t have a belly button. Then I thought of the acronym VACTERL, which helps doctors remember other findings for which they should be suspicious in a child born without an anus such as vertebral defects, cardiac problems and short radiuses, only I couldn’t remember the other findings making me think what a crappy acronym! (versus crappy doctor)

What to do about such a baby?  For a while we debated about whether to transfer the baby to JFK, the national hospital in Sinkor.  But a) we didn’t think the baby would survive the forty minute ride and b) if he did, our experiences was that without prerequisite fame and fortune he would die waiting for care  (the baby was not famous).  So we operated on the baby. Under local anesthesia, because our nurse anesthetist was scared of babies, we made a small incision on the left side of the abdomen exposing a distended loop of bowel.  We isolate the loop, placing it gently on a sterile drape, as if it were a precious organism.  We then carefully cut across it expelling an odorless thick black sticky mix of fluid and meconium.   We then inverted the ends of each loop and carefully stitched them to the skin of the abdomen, obliterating the opening between outside and in.  And wah lah! The baby was happy again.  I have never seen a transformation as startling and quick; from sick to healthy; from hell to heaven; from constipated to free flow.  It was very satisfying. 

Anal atresia baby #1 gave us confidence to fix anal atresia baby #2, who miraculously came to us two weeks later as sick.  He too did fine.  In the U.S., these babies would be fine.  A pediatric surgeon would also create ostomy sites to reduce the obstruction, but six to twelve months later, s/he would detach and reconnect the two severed bowel loops, create an artificial opening between the legs, find the blind rectal pouch, and connect it to the opening at the appropriate angle, using the muscular pelvic floor as an on and off valve.   And like that, a functional anus in the right place-- Gods creation with a little human help.  The perfect collaborative.  Without such a procedure, the babies growth—usually a good thing-- will eventually lead to a stretching of the abdominal skin. This will lead to tension on the affixed bowel wall, eventually fraying it, opening up the peritoneum to the outside world of bacteria or shit leaking directly into the belly.  If this frank  description is not gross enough, either of these things happen and the baby dies.  And then you have both a stinky baby and a dead baby to give back to parents having provided the baby with months of “life saving” medical care.

​Baby with abdominal masses who will die

So we need a pediatric surgeon.  Simple as that.  No beans.  No excuses.  Not only for anal atresia baby but for the baby who needs the hole between her two ventricles patched otherwise she drowns or the adolescent who needs  a pancreatic isle cell transplant to cure her of diabetes otherwise she starves. But there are barriers.  Right now in Liberia, there are only four pediatricians in the entire country and I am one of them.  There are no pediatric surgeons.   There are many physicians who perform surgery in Liberia, some with considerable skill, but none and probably this is a good thing operate on babies.  A babies heart is the size of a walnut.  The gut like vibrant swollen spaghetti.  Adults don’t have size and root cause problems like this.

I have a few connections.  The president’s son has set up a program whereby American trained medical residents come to JFK hospital for two weeks.  I have met doctors in this program who are great and could possibly provide with arrangement the appropriate expertise.  I play basketball with the Vice President’s son as a stop gap.  Also, the VP of IRC International Programs, upon visiting JDJ, was moved by many of our patients’ stories and would like to connect us with powerful NYC folk, many related to Columbia and NYU, but honest I am not entirely sure what this means until I see it.  Finally, I should just write a million dollar grant to bring the right people into town two times a year. They can use our hospitals and we can organize the patient load.  Organize it and they will come.  Now I just need to find that dastardly grant.  If all of this sounds daunting it is.

​Contrasts.  Health happy baby at JDJ