The Theatre

Before you get too excited, that's the "OR" here. Where do I begin? The patient, the infrastructure, the surgery, the sterile technique....

How can I describe our patient? A 13-year old girl with supposedly a 6-year history of bilateral labial masses, each weighing maybe 2 kilos? Most likely due to lymphatic filariasis, also known as elephantiasis.

For all the non-medical people reading, a brief description: filariasis is a parasite infection that people in endemic areas (most commonly sub-Saharan Africa, next is SE Asia) get from mosquitoes; the larvae mature into worms and live in the lymphatic system. Over time, they cause a lot of inflammation that scars the lymph system, usually in the lower leg or groin, and prevents it from doing its job of draining fluid. Have you ever seen pictures of men with 'elephant legs?' That's filariasis, called elephantiasis when it's so bad.

So that's what happened to our patient, except in her labia. Imagine a bag of 3-4 tennis balls, then put 2 of those bags between your legs and try to walk. It was so sad, it broke my heart. I'll never see that in the U.S., and hopefully I don't see it again -- although my PI, Jeff, has seen it twice in the year he's been here. We took pictures, but I can't post them. (sidebar -- the whole asking-the-patient-for-consent-to-take-a-picture isn't deemed necessary by the local physicians, so we only need permission if we publish it. It definitely felt strange to be taking pictures without asking, even if she was asleep!)

I looked it up (of course -- that will never change, even w/o an iPhone -- just a list of all my 'look it up' questions on real paper!), and 40 million people worldwide have severe disability due to filariasis. And once yearly treatment for 5 years of communities in endemic areas can reduce the prevalence of the disease by.... 70%, at least!

We took out the masses and took the specimen with us -- hopefully to send it to Duke with the next unsuspecting victim returning to Durham. Our hospital recently lost its lone pathologist which, as you can imagine, is just a huge disaster!

Anyway, so the rest of the experience -- you really see 'resource-limited setting' in action. I've never seen an attending ever throw so many interrupted stitches from one suture! The theatre isn't so bad -- it's large enough, I think there's a generator, and they have the basic stuff. I've never seen anesthesia, mostly run by nurse anesthetists here, tape a stethoscope onto a pt's chest and listen all surgery long -- but they don't have the monitoring capacity for all the vitals. As with many things in surgery, you see the differences tangibly and realize that so much of what we can provide is training, teaching, and supplies, but one definitely wonders -- how is this sustainable? I am so glad our group focuses so much on clinical skills and quality improvement initiatives -- yay Jeff! :)

I don't mean to be critical -- it's different but it's the reality of the situation here, and for me, there's so much to learn. New problems, new surgeries, new techniques. I can't wait to go back to the theatre again! (and hopefully at some point this year, maybe even scrub in!)