MVP's Part 3

Back in Cameroon, I did a couple of posts about some of the MVP's - most valuable patients & people. I thought I could continue that theme, as there have been SO MANY memorable people who have touched my heart, and whose stories should be shared.
Let's dive in, shall we?

The Best Mover & Shaker

When I first met Modou, he was curled up in his bed, blanket pulled over his head, his breakfast untouched on his end table. His sleep cycle was completely out of whack, he was struggling with motivation to eat, get out of bed; more than a little bit of a slump - he had classic symptoms of depression. He had had a long journey, and still had a long way to go.

An accident as a young child left Modou with severe burns to his face, neck, arms, and hands. It is a fair miracle he survived at all; burns to the face often go hand-in-hand with burns to the lungs & airways. These can very easily be fatal without intensive treatment. Modou, clearly, did not receive much (if any) treatment for his burns. Scars and muscle contractures essentially tied his chin to his right collarbone, and his fingers were mostly gone. Only a few little nubs were left on the stump of his left arm to indicate where a finger and thumb might have been. Looking through his chart, there was a furrowed brow and a hardness in his eyes in his pre-op medical photos. It is a stare which many patients have in these "before" photos. It is, far deeper than physically, not a person I recognize any more.

Modou's first surgery tackled the contractures of his face and right hand. Numerous skin grafts were needed to build new, healthy skin which would replace the scars. As such, he had wounds on almost every limb - some where donor skin was taken, others where it was placed.

Modou (L) after his first surgery

After his first surgery, Modou's first few weeks were a struggle. There was very little he could do for himself, as both hands were bandaged, and he still had very limited mobility in his fingers. It was incredible, though, how well he could balance a cup on his stump without spilling. We leave the dressings wrapped, untouched, for 2-3 weeks after plastic surgery; helps prevent infection, giving the grafts time to heal without any outside interference. This meant for over 2 weeks, Modou was just sitting in the ward, waiting. No windows, minimal contact with the outside world, only an hour of fresh air every day. Nurses and dietitians constantly hounding him to eat more, take his supplements, check his circulation, etc. It's no wonder the guy's circadian rhythm went haywire. 

It took some sleep aids, some chaplain counselling, and eventually his mom staying overnight a few times to help get him into a better headspace. And just in time, too. Plastic surgeon Dr. Tertius had decided to offer Modou another surgery on his left hand, to give him as much function back as possible. They would also do a little more work to improve his face. This meant ANOTHER 2-3 weeks (minimum) on the ward. Nonetheless, Modou agreed. 

In these photos, you can see that modou now has a thumb sticking up out of his left hand! If you feel the meaty part of your hand - between the thumb and index finger - that is where Dr. Tertius cut down into to separate the 1st metacarpal bone (all that remained of his thumb) from the rest of his hand. 

While Modou would still have good days and tough ones, overall he grew more and more cheerful, optimistic, and stubbornly pushing through the harder tasks & rehab exercises. 

More than anything, though, Modou LOVES DANCING. Nothing could get him, and everyone around him, in a good mood like a good beat. Nobody could match his moves. And he'd always don his traditional, black & white hound's tooth robe whenever dancing was happening. 

Demonstrating some traditional West African dance moves

Joining in the Bambalela during a birthday party

Jamming to the djembe with a hospital chaplain on Deck 7

3 Months Later...

I had the privilege of being the nurse to decide, on a rare shift in the Outpatients tent, that Modou's wounds were completely healed, and he could be discharged from our care. He would still return for physical therapy for several weeks, so it might not have felt momentous to him, but it sure did to me. I was able to look him in his knowing eyes, say "everything looks perfect," and give him one last high-five/handshake/hug.

I have a lot of memories of Modou, from the Senegalese name he gave me (Mariam Seck), to the other nickname he gave me ('LOTION!' - owing to my constant nagging that he needed to put lotion on his graft donor site), to the chirps and bird sounds over my shoulder while I worked on the computer. More than anything, though, I will remember his eyes. The eyes that stared from his admission photos - distant and cold, his brow furrowed; becoming the eyes of a friend - trusting, mischievous, kind, and permanently smiling. 

Modou came to us as a young man covered in scars; scars which held him back, forced him to depend on others for all his needs, and caused him pain to the point where only his mother's presence would comfort him. He left us with different scars; scars which granted him joy, freedom, independence, and confidence. Modou will never look "perfect."

But he is certainly beautiful.

À la prochaine,

-D

Out Like A Lamb...

Christmas and New Years have come and gone like a whirlwind, and 2019 has come to an end.

It has been a bit of a wild one for me, let me run down some of my...

Thank you, Original Broadway Cast of Hamilton.

Highlights

• Ringing in 2019 on a night shift, then celebrating with family and friends in my apartment - using up as much food as possible before...
• Joining the ship in Guinea, meeting old friends and making new ones
• Watching in awe (and in tears) as kids got to see for the first time in their lives
• Deciding to return for a full field service
• Watching the slow, painful, but eventually joyous healing process of one particular ortho patient
• Playing SO MANY games of Deception in midships
• A wonderful summer at home with gardening, beach dates, work, yard sales, and brunch
• Crossing an international border and great lake by tiny car ferry
• Catching up with friends from abroad (and explaining to the TSA agents that I was meeting friends from Africa...but they're actually from New Zealand, but they live in the UK...)
• Returning to the ship in Senegal
• Rehearsing and performing acapella with the Key of Sea
• Transforming empty, packed-up wards into bustling centers of care & healing
• Being given a Senegalese name by a plastics patient ("Mariam Seck")
• Sharing a traditional Senegalese meal of Thieboudienne at our day crew's home
• Getting to document our patients' journeys as a ward photographer

One of my fav photos

• Living around baobab trees - enjoying their fruit, their beauty, their canopies!
• Cucumber Nativity (ask me later)
• Watching Modou (a particular plastics patient) dance

1 second a day from my time in Senegal!

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Now, I did promise a bit of Q&A about screening back in December, and I was able to quickly chat with Screening Nurse Maddy.

The Q&A's of Yes's & No's

Q: How does screening work here in Senegal?

A: The Senegal Ministry of Health decided to run their own pre-screening, selecting about 1000 potential candidates in each of the 13 regions. This resulted in over 13,000 patients for us to see, which we did over the course of about a week in each region. About half of the screening team goes upcountry for these screenings, while the rest of us work here on the dock. Only about 1 in 10 patients we screen will get into the dockside screening. The vast majority are no's - but in many cases it's a simple matter of 'we don't have the right kind of doctor to fix the problem you have.' Those are easier no's. The hard ones are when we could help, but we've simply run out of space.

   Once they get an appointment for dockside screening, we'll give transport money to help them get to Dakar (if needed), and a lot of them will stay at the HOPE Center. They're seen one more time on the dock to do a more thorough nursing assessment, and sometimes to start treating any co-morbidities (like high blood pressure) that might make surgery more risky. Sometimes we have to delay their surgery to follow up on something, like a patient recently who had a large wound on their leg. Goiter patients need several months of medication before surgery, and monitor them every week.
   Eventually, when the surgeon for that specialty arrives, they'll see every potential patient on their list, and decide exactly what surgery will be done (if possible), and when. Then they're passed on from us to the Admissions team.

Q: Have you ever gone out of your way to make space for a particular patient?

A: Yes. Sometimes we know we only have 10 slots for a certain specialty on a certain screening day, and I'll try to hold out for the patients who could benefit the most. I remember seeing Mohammed in line and thinking, "That's a good one for Dr. Gary, we've got to save a space for him!"

 Mohammed before (above) and after (below) surgery to remove a facial tumor.

Q: Do you ever refer patients you can't help to a local hospital?

A: Yes, but it depends. Although we try to make our information campaigns clear that we treat mostly chronic injuries & conditions, we still have patients arrive at screening with what is clearly an acute illness. Something that should be treated within days. Local hospitals are better equipped to treat these types of problems than we are on the ship, and in a more timely fashion (our surgery dates are often months after the screening has taken place). If we find a minor problem, we may recommend the person seek help from a doctor when they can. If it is a major, potentially life-threatening problem, we can and have arranged transport to a hospital and transfer care to a local physician.

A little peek into screening in Senegal with Christelle, a Ghanaian screening nurse.

If you're interested in the nitty-gritty stats of screening, plus numbers from all our programs so far in Senegal, check this out (click to embiggen - or try this link).

That's all for now. Sorry for such a long radio silence!
À la prochaine.

Yes's & No's

One of the more difficult things to wrap your head around about the work being done on the Africa Mercy is the "no's."

There are a number of reasons patients would be disqualified from receiving surgery on board. They're all very good reasons, formed over decades of experience.

That doesn't change the fact that it's hard to say no. It often hurts.

The seemingly endless lines are sobering - though I've never seen them in person, I have met many people throughout the country who ask, "I have a hernia, can you help? My uncle is blind, can you help? My mother can't walk, can you help?" I have also had to explain to patients, on occasion, that although we had tried our best, there was nothing more medically that we could do to help.

One of my friends (and current cabinmate) Maddy is part of the screening team - the ones who decide who to say yes to, and who we must turn away. They have, without a doubt, one of the hardest jobs here. There is a lot more involved in the screening process than meets the eye, however, as I've learned from Maddy this year.

The first (and most visible part) of the screening job is to select, from thousands upon thousands of hopefuls, the best candidates for our surgical programs. Here, in Senegal, the Ministry of Health is also involved in this process; local physicians in each region of the country are doing initial assessments before our screening teams arrive. Those who fit certain criteria are then asked to return when our screening team visits that region.

Risk vs Reward

There is a very specific list of surgeries and procedures we can perform on board, and a very specific list of factors that would immediately rule surgery out. It is not easy to rationalize these decisions when staring into the face of someone who is hurting. It's hard to think about the big picture when facing an individual in a difficult moment. The fact of the matter is, however, that charging into any kind of humanitarian work headstrong and reckless often causes more harm than good, despite the best of intentions. I don't think I can say that what we do is the best solution, but it is one carefully thought and developed in collaboration with local professionals, officials, and experts in this field. 

The goal, in essence: provide the greatest possible improvement in quality of life, for the greatest amount of people possible, with as little risk of harm as possible.

Easier said than done.

The most clear-cut factor we consider is a patient's age. Over the age of 70, the risks of most surgeries far outweigh any benefit that might be gained. Recovery tends to take longer, have more complications and setbacks, and (harsh though it may sound), younger patients will have more to gain from their improved quality of life after surgery. More years to make the most of their new mobility, restored dignity, or repaired vision. Life expectancy in Senegal is only 67 years. 

The list of surgeries we can offer our patients is limited, in part, for similar reasons. Some surgeries would be incredibly high-risk, with very poor odds of recovery, and would be genuinely unethical to attempt. Some we simply don't have time or space to fit in, with our limited schedule and resources. Sometimes we don't have a surgeon who is willing to serve with us who has the necessary training and experience for a certain procedure. 

The resources of our host countries are also taken under consideration. With more and more of an emphasis being placed on mentoring and capacity building, we want our surgical programs to mirror those which exist (or are at least feasible) within West Africa. It is no good teaching a surgeon laparoscopic surgical techniques if laparoscopy is (for the foreseeable future) unattainable in most African countries. 

The 'C' Word

Another challenging factor to consider is cancer.

Tumor removals, of various kinds, make up a large part of our surgical programs. We advertise widely about it in our screening announcements. 

Things get complicated if we believe a tumor to be malignant. In most cases, surgery alone is not an effective treatment against cancer. Radiation and/or chemotherapy is usually necessary, and, unfortunately, is hard to come by around these parts. Available - potentially - but expensive. This is a really good article by the BBC about the barriers facing cancer patients here in Senegal.

You'll notice I said 'most' cases. There are a few situations where we do consider surgery for patients with confirmed, cancerous tumors. If our imaging shows no metastases, if the cancer is very localized to one area, if it can be removed intact with wide margins, and if it's believed removing it will provide a reasonable extension of life...then and only then will we consider surgery for them. In almost every other case, as we cannot provide long-term, ongoing oncology care, it would be unethical to operate. We would be causing pain, trauma, and a lot of risk for little to no benefit.

The main case where we would do often go ahead with surgery is breast cancer. It turns out that surgery alone is a reasonably effective treatment for breast cancer, although, most of the data on the subject is decades old. Recruiting research candidates for something potentially life-threatening, when a certain treatment regimen is proven to be quite effective - again, kind of unethical. What research we do have (from the 90's) seems to indicate a 5-10% higher risk of the cancer returning when treated with cancer alone. Not ideal, but if it's the only option you can afford, I daresay it's better than the alternative. We can potentially extend life by 10 years or more with just surgery. Worth it. 

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Next blog I'm going to have my friend and cabinmate Maddy (a screening nurse) answer a few FAQ's. If you've got any questions about the screening team's responsibilities, or the patient selection process, please drop them in the comments below, or on facebook.

À la prochaine,
-D

Pics or It Didn't Happen

It's been a bit. I've been here over two months now, and that means two things:

1. A lot of the nurses I've gotten to work with and love are leaving me now...
2. Photos of said nurses and our wonderful patients are now available!

Really grateful I've been given the opportunity this year to do ward photography, which allows me to give the rest of you a little window into my work environment! I use the term 'work' loosely. As you might have heard me say, and as these pictures show, it often doesn't feel like work. It's a privilege and a joy to spend time caring for and loving on our patients, and often very entertaining!

I've probably said it before, but I think it's worth reiterating that any patients in official photos which are shared outside the organization (including these ones) have signed (or their guardians have signed) a release form permitting us to do so. Time is taken to explain to each one that they will receive the same care whether they agree to promotional photography or not. It is a weird thing for most of us in healthcare, but it is these photos that give supporters like you a way to understand the plight and transformation of those we have come here to help. We are very grateful to those who are willing to share their stories with the world, because they pave the way for us to help others like them. 

This is Aliou, and he is so stinking cute. The past month or so has seen a lot of plastic surgery patients come through our door, and many have burn scar contractures like his. As you can see, the scars prevent him from extending his arm, greatly limiting his functional capability. Contractures like his also often worsen as kids grow - our lead Plastics surgeon, Dr. Tertius Venter, spoke of one young woman he treated in Guinea who was essentially  locked in the fetal position due to her burn injuries.

Osuman here, giving Dakota a lovely braid, had a similar burn to Aliou. As you can see, though, she's had her surgery (which usually involves cutting the scar out, pulling a flap of localized, healthy skin over the joint, then transferring skin grafts from elsewhere to the rest of the arm), and her arm is all bandaged and splinted up. Movement is the numero uno danger to those grafts healing well, so the dressings usually stay intact for at least two weeks. You may have also noticed the little tube in Osuman's nose. Because our patients' diets are often lacking so much of the essential building blocks of the immune system and the healing process (proteins, vitamins, and minerals), we build them up with as much extra nutrition as we can. This includes protein supplements in liquid, powder, and paste form. New this year, we've been trialling adding an extra "meal" in the form of overnight tube feeds - which so far seems to make an incredible difference in the speed of healing.

It takes a lot to grow all that new skin, so we try to give each patient the best chance possible.

These looong extended stays in hospital, waiting for that first dressing change, mean that we get to know these patients very well. They are a family, truly and honestly...and everything that comes with it. Sleepy-head teenagers, teasing and bickering, and covering for each other when one doesn't want to drink their nutrition supplement. There are beautiful moments too, though, like a father ducking out into the hallway to eat so his son (fasting for surgery) doesn't get upset. Comforting another patient who's in pain, or a baby whose caregiver stepped out to make a phone call. Painting each other's nails, and helping each other open containers with their non-bandaged/splinted hands. It really is one big, uniquely beautiful family.

A great group of moms brought together by their children's differences

A Ward evening crew!

Beautiful Mame Diara & Tenin with nurses Amy & Alyssa

TECHNICAL (POSSIBLY ICKY) JARGON BELOW 

Last night we had the privilege of hearing Dr. Tertius speak about the plastics program, and the new procedures that have been pioneered right here on the ship. With each procedure, there is a "design" stage of surgery, where the skin for the graft or flap is selected, and the planned incisions are drawn on. The most remarkable procedure he explained is the Hemi-Scalp Flap or "Africa Flap" - developed by Dr. Parker to treat noma patients. In this procedure, a U-shaped flap of the scalp is taken, rotated down over the face, and the end sutured in over the defect. This leaves a bridge of tissue, including the blood supply, from the origin of the flap to the new site. I've done my best to illustrate this below. The flap stays in place until the blood supply is well established and the flap has begun to heal, then the excess is put back in place. The crazy thing about it, though, is that the direction of blood flow reverses in this flap after it is moved.

It's a rough drawing, but the purple arrows show the usual direction of arterial blood flow up into the scalp. Within 10 seconds of excising the flap, Dr. Tertius said, the blood begins to flow the other direction through the section of flap that is rotated.

Just wild. There's a big document here that goes into quite a lot of detail (and pictures!) about these types of reconstructive procedures, that you can check out HERE.

I have to go, my friend just arrived with scissors to help me try to DIY one of my favourite board games. So with that, I shall leave you.

À la prochaine,
        -D

Where are we?

What country are we in?

The Captain asked that question at the weekly communication meeting.

I'll give you a hint - it's not Senegal.

I may have mentioned it before, but the flag state of the Africa Mercy is Malta. As long as we are aboard the ship, we fall under Maltese and EU law. I've never technically set foot in Malta, nor does my passport carry a Maltese entry stamp, but every time I step down off the gangway - in theory - I'm leaving Malta and entering Senegal. The screening, outpatients & rehab teams down on the dock sure have a heck of a commute if you think about it that way!

Gives a bit of a different meaning to our 12 month, multiple entry, Senegal visas (which we were still waiting on up until the last couple weeks).

The Maltese flag flies from our stern, and the Senegal flag from our foremast. Another example of how this ship feels like being in 50 places at once.

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We've had some challenges with getting our regular supply shipments released from customs (which is usually par for the course). This has made for some creative meal solutions by our galley crew, but we've had an ample supply of beef, in any case. This is in part thanks to the Senegalese President's promise to provide us with a cow every day we are here. He is Fulani, a culture of nomadic herdsmen in West Africa, and so this gift is both practical and meaningful coming from him. Sadly, we have not seen any of these cows walking up the gangway...but they're getting in somehow. Our meals have been evidence of that. He's also providing us with fuel to keep our generators running - keeping the lights on in this place - which is no small contribution either. 

It is a good reminder that we are visitors in this country, here to serve the Senegalese - but at their invitation - and they have graciously welcomed us with love.

Our worship service this Sunday took place up in the open air on deck 8, under a half-moon, and was a beautiful time of old songs & new, from close to home and from afar. It's always encouraging to see the whole crew, from so many different countries and cultures, coming together in song.

Baba Oluwa Oshe - "Thank You Father God" - a Benin classic.

Hospital Update

 The ward I call home (A Ward) is full of 'visitors' at the moment - overflow from the MaxFax and Plastics wards. This is a challenge as one of the people who newer nurses go to for questions! These are not the specialties I have the most experience with, so it has been very much a team effort, with a lot of help and hand-holding from the other wards, to give these folks the best care possible.

I say it a lot, but it never gets old how happy and willing to help everyone is in this hospital. Even when we're dealing with colds (which are rampaging through the crew at the moment), everyone from the bottom of the food chain to the tip-top managers are powering through.

A few days ago we had a bit of a brutal storm rip through very unexpectedly, which caused some damage, mainly to our tents & dockspace. This one you see below, Jane, our gracious Ward Manager - who could have very easily delegated this off to any number of underlings - was right there in the sweltering heat lugging supplies around and re-organizing so we could continue our programs without interruption.

Don't worry, that's not a real patient. ;)

I promised updated photos of Saliou (the very first surgical case this year), so here's some!

I've been granted permission to do ward photography this year, which means I'll actually get to post photos I've taken in the hospital (with - of course - written consent of the patients)! Stay tuned for that. 

Also, you might have seen this photo circulating on social media recently, of all the ward nurses:

I'm there, I swear, but I'm short and hard to see. See?

I had a dear friend depart last week, and it certainly feels a bit different without her around to hang out. She is, however, returning in January, so I'm eagerly looking forward to that!

Last meal out with Suzanne (second from Left) ♥

With that, I shall sign off for now or I will miss lunch. 

À la prochaine,

        -D

A Whole New World

I guess it's been almost 2 weeks since my last post - which, to be fair, is probably the standard I should be setting for myself anyways. Finding time to write every week is challenging!

During those 2 weeks, we've had a very successful run of general surgeries, where we treated many a hernia and lipoma (soft tissue tumor). Our ward has by far been the least busy, with most of our patients going home day after surgery - allowing us to close completely over the weekends.

Things are about to change, however.

For the next 4 weeks we'll be home to the double load of MaxFax (Maxillo-Facial) patients that are about to roll in. Normally these all live on D Ward, but with two ORs and four surgeons rolling, their 15 beds will very quickly be MaxFaxed out (see what I did there...). We will be taking mainly less complex and/or more healed patients, but it will still be quite a different sort of nursing care. I've floated over to D Ward plenty of times, but there's just so many diverse types of MaxFax surgeries that there's still always new and unfamiliar things to learn. Though it does mean dealing with a good deal more saliva/drool than I'm used to...at least it also means I get to love on the little cleft lip kids like Saliou! He was the very first surgery done here in Senegal.

Hopefully soon I'll have more recent (post-op) photos of Saliou. He's cute as a button.

In the meantime, a couple pics from Deck 7 play time!

This cat looks cute but he can be a little bit of a troublemaker...

Bubbles & Jenga & Balloons - the Deck 7 Trifecta! (notice me hiding in the back?)

As we're stepping into this whole new world of MaxFax on A Ward, the Academy teachers shared a relatable rendition of the Disney classic during karaoke night a few days ago:

To adapt to hospital life, substitute "syringes" for "pencils" rolling away,  and "magic stretcher ride" for "magic lifeboat ride."

Also...this happened. 

It is fun to stay/work at the AFM. 

Right now I'm on an extended long weekend, which has been a nice time to unwind after 2 very busy weeks. I'll be starting into night shifts Wednesday to Sunday, though, so if anyone wants to catch up and chat, this is a good week for it! 

Substitute "shift work" for "traveling"

Well, that was a bit of a hodge-podge of a post, but hopefully by next time I'll have more patient pictures and stories to share.

À la prochaine,

-D

Speaking the Same Language

I just happened to start listening to the Come From Away soundtrack the other day. I haven't seen the show - didn't get the chance this past summer - but the soundtrack seems to tell just about the whole story.

If you don't know anything about it, Come From Away tells the story of the 38 aircraft that were diverted to the small town of Gander, NL on this day, 18 years ago. September 11th, 2001. There's some language in the soundtrack (they're Newfies after all), but it sure is powerful.

One of the songs struck a chord with me. Just for context, this is after the passengers were held on the tarmac (some for 28 hours), released (some after questioning), and carted off on busses (many still not knowing the day's events) to various community buildings. This particular moment between a passenger and a bus driver really gave me pause. Have a listen.

"And that's how we started speaking the same language."

Whew. What a little window into the confusion and fear of being in a foreign place surrounded by strange people speaking a strange language. So many of our patients must feel this way when they first come aboard. Fortunately, we have help in speaking the same language.

At Peace

Wolof is the language spoken by about 40% of Senegalese, along with a number of variant dialects, and a couple dozen other languages in various regions inland. In Dakar, an urban dialect of Wolof is spoken - a blend of Wolof, French, and Arabic. Coming from the strong Arabic & Islam influence, "Asalamalekum" is the most common greeting. Much of the language (particularly greetings) revolves around peace, and, as in most "hot cultures," greetings go beyond "Hi" and "how are you" to "how's your family, your home, your health, your journey, etc, etc, etc..."

Thanks to our lovely day crew I've picked up a few key phrases; ready for a survival Wolof primer?

Asalamalakum (Peace be upon you)

     Malekum salam (And you also) 

 Na nga def? (How are you?)

     Mangi fi / Mangi fi rek /Jamm rekk 

     (I'm here / I'm here in peace / I'm at peace) 

Jerrejef (Thank you - literally, "the act was worth it")

     Nyoko bok (No worries)

Baal ma (Excuse me), Massa (Very sorry)

Waaw (Yes), Deedeet (No)

There you go. Now you can survive - or at least bring some peace into the conversation - if you ever visit Dakar.

Be benen yoon ('Till next time),
-D