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|  Equator
Last view of Bongolo Hospital in the eary morning mist. 
 The flame tree above the triplex
We left Bongolo about 6:20 AM. The road had not changed. But Karen, the missionary driving the vehicle, did not "challenge" the potholes and rough sections with the aggressivenes of the driver coming toward Bongolo, so my bones and joints fared much better. I also took some ibuprofen right before the start of the trip. Dr. Anatole, one of the new surgical residents, had to personally go to a government office here in Libreville to obtain his residency visa papers, so he was also making the trip. I had already enjoyed getting to know him some during the month at Bongolo, and the long ride back to Libreville provided more opportunities to hear the story of his background and family and education. Karen has worked as a missionary nurse in the Congo and in Gabon, so we had some good hours of conversation among the three of us. Anatole is quite willing to speak up and enter into a conversation, partly that is because his command of English is quite good and partly it is personality. Some of the residents will not not talk much unless you are in a one on one discussion with them. The trip was so long that Anatole and I both fell down in our duty to help keep Karen awake, because we each fell asleep during parts of the trip.
There are few clean places to stop along the way to use the restroom. It is easier for men, since we can stop and step into the bush a few steps, but for women it is harder.
We each carried some water and food, but we were ready to stop and stretch our legs by the time there was somewhere to stop. It is not routine that gas stations (which are few and far between to start with) have restrooms, and fewer of them have clean restrooms. Lambarene is a city on the Ogoue River, which had a service station with a clean restroom.
 There are some places beside the road to stop and eat. In this city (the site of the Schweitzer Hospital- -which I was surprized to learn Anatole had never heard of), Karen knew of some places that were OK to buy food at. Buying food directly off the grill should be OK.  A sad thing about this picture is that they are burning tropical hardwood for fuel to fry plantains. This wood is extremely expensive in other parts of the world. The Chinese are building highways in Gabon in exchange for logs of this wood. The plantains were good though.
And she knew of a sandwich shop that she felt was OK, the Cafeteriat du Fouta Djalon, which was cleaner on the inside than the outside She is standing behind the wooden post and you can only see her elbow sticking out.  She bought a sandwich at the Cafeteriat, and Anatole and I bought skewers of meat from the grill and some fried plantains then went down to the sandwich shop for to get a baguette of "French" bread to make sandwiches of our own.
Between Lambarene and Libreville we crossed the equator, so we stopped for Karen to take a picture of Anatole and me in front of the sign marking the spot. The road in the left side of the picture is the only north-south highway in the country. It is paved (mostly) in the northern half, from Fougamou northward. It is unpaved (mostly) from Fougamou southward. The southern half is what the Chinese are working on.
Having a paved road that runs the full length of the country from the northern border with Cameroon to the southern border with the Republic of the Congo (usually known as Congo Braazaville, to distinguish it from its neighbor across the river, the much larger country of the Democratic Republic of the Congo, known as the DRC or Congo Kinshasa, each country having the name of the capital city added on for clarification) , would be a big help to the development of the country. There are parts of Gabon that have crops rot due to lack of transportation to the cities, while prices are quite high in the cities due to shortages of food. As a side benefit it will shorten the trip by car from the Bongolo Hospital to Libreville by several hours and make the vehicles last longer, since they will be driving on pavedd highway the whole way.
We arrived at the guest house in Librevilled at about five o'clock in the afternoon. Anatole and I are sharing a room, actually a small apartment, at the guest house. We have a bed room with three single beds, a bathroom and a kitchen. After supper he showed me pictures of his family on his computer. I had said in an earlier post that he was Catholic, but his father is actually an Anglican priest. His family are mostly serving Anglican church in the eastern DRC. Several are ordained priests. He shared that he had grown up poor, but his father always was ready to share with others. Sometimes when he was older he would even question his father's willingness to share with others when the needs were so great within their own family. This last year he wrote a letter and asked for his father's forgivenss for questioning his generosity. Anatole has been the recipient of the generosity of Christian families in the DRC and in the UK and USA. He wrote his father that just as his father had been looking out for other people's children during their own family's hard times, now other people were looking out for his son in a generous way. We both slept well last night
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|  Today was my last working day at Bongolo. I managed to put together a complete sentence in French in morning chapel to say good-bye and thank everyone for the privilege of working here. One of the residents later told me that he thought people would think it was signficant that I made the effort to say something in French (they all know I don't speak French).
We had "quick" teaching rounds, interrupted by the sudden deterioration of our patient with the facial trauma (who had already had CPR once in the operating room). He had developed pneumonia and started having a lot of trouble maintaining oxygen levels, despite giving him the highest oxygen concentration available. His blood pressure dropped and his hear stopped. Annalise started CPR and he came back after some IV adrenaline. But when this wore off, he quickly dropped again and they did CPR again. We started a dopamine drip (way over the recommended amount, but still couldn't maintain his blood pressure). To come to the bottom line, he did not survive the morning. The residents had all been involved in his care and were all involved in this last ditch effort to save him. They were all pretty discouraged and quiet afterwards. We all dragged ourselves onward to go on through the activities of the day. The resident who was assigned to give the lecture went ahead and presented his powerpoint.
We went on over to the operating room and tried to see what we had the resources to do today. We had been planning to do an anterior spinal fusion for a young lady with Pott's disease (tuberculosis of the spine that had destroyed two vertebral bodies causing her to double forward and risk paralysis of her legs). This was the big case that we didn't want to do without a nurse in the recovery room. About 12:30 the most senior resident presently here let us know that there wouldn't be a recovery room nurse. I told him that I just didn't think it was a good idea to do the case. Unfortunately, that might mean her surgery would be postponed for several weeks, due to waiting for the return of the regular full time attending staff. Annelise had never seen one of these and didn't feel it was appropriate to do her first one "out of the book." I did my first one "out of the book" in Yemen many years ago, but then there was no-one who would be coming back in a few weeks who could do it.
Since there was no nurse, I said that I would just go back to the triplex and pack to leave tomorrow morning. But before I actually got up to leave, the resident came back in and said that a nurse would be arriving for the evening shift and would be here by the time we finished the operation. So I encouraged them to try to get it going as soon as possible, since it would be a long case. We actually did start then close to one o'clock and I left five and a half hours later as the resident was still closing the skin.
Not everything went just as I would have liked with the operation and there is no brace to put the patient in afterwards. It is recommended that they stay in a "clam-shell" brace for six months. But the resident said the ones that they've done here before, they have just treated with six weeks of bed rest after surgery.
It was not the "last day" I would have planned.
But now I'm packed and ready to go. I'll spend a couple days in Libreville, the national capital, before flying out on Sunday.
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| Tuesday, November 9, Bongolo Evangelical Hospital, Lebamba, Gabon  Morning mist rising from the river in the rain forest  Mist beyond the hospital  This chicken appears to be a permanent resident of the pediatric ward courtyard. I don't know if it is destined for some one's cooking pot or not. I haven't seen any other chickens wandering around the hospital.
This is the unit of the triplex that I'm staying in. Telephoto view from the hospital 
  There are some sunny hours with blue skies on some days. I've come to realize that that means the day will heat up and get quite uncomfortable. It is more pleasant if it just stays cloudy all day.
 In clinic each patient gets a number on a blue wooden plaque when they register. The residents accumulate the plaques as they see the patients and treat them or schedule them for surgery.
I have been results, goal and productivity oriented all my life. That meets up against a different cultural set of values in most African countries. Most of the time since I've been here, we have had surgical "productivity" hampered by lack of some essential service. We start late or cancel and reschedule cases due to a variety of problems. We have had a shortage of anesthetists. One day there was no oxygen in one of the operating rooms. Sometimes the anesthesia machines have not worked. There is no medical equipment technician to fix them. Currently there is an American volunteer here doing maintenance engineering with the Gabonese crew. But in the U.S. he managed an apartment house and did repairs and cleaning of properties. A new anesthesia machine arrived and he was delighted to start putting it together (some assembly required) and found the 83 page instruction manual to be in German. He e-mailed the company and they e-mailed back the English version which he found almost as difficult to read. He was looking for someone to translate it into "ordinary English." Today we thought we were set to do a big case (blood donors had been arranged at the last minute--there is no blood bank--this sometimes delays cases), and we found that there was no recovery room nurse. We decided not to do a case that might run three or four hours under general anesthesia if there was no nurse to stay with the patient in the recovery room afterward. There would not have been a specialised recovery room nurse, just any nurse. So maybe this case will be the last case I do here tomorrow, before I leave on Thursday (or maybe not, depending on what problems continue to be present or what new problems arise).
So this has left time to talk to the residents and establish some relationships that hopefully will go beyond clinical surgery. Taking time for relationships seems to be more important to their culture (though they actually come from varied cultures, from different African countries). One of the residents was expressing some impatience with the situation, but most shrug and keep working. Works always seems to expand to fill the time you have available. There is a strong family atmosphere among the residents. One of the single residents had picked some bananas from behind his apartment and brought them down to share with everyone else today. One of the other residents told me he was going to miss me on teaching rounds, because my questions made him think. So my time here has not been as "productive" as it has been on some other trips, but in some ways perhaps more worthwhile. | | |
| Monday morning, November 8, 2010  "Weeds" beside the path.
This morning we had the usual teaching rounds. The last two men with the burned feet were discharged today. Their burns are not completely healed, but they no longer need care in the hospital. Both of the men who are being discharged today had burns that went down to the bone of the little toe, and they each had a pinkie toe amputated on the worst foot.    The white color is medicated ointment to prevent infection.
The man with the bad facial trauma has not waked up yet. The longer it goes, the worse it looks for him. All his vital signs are stable, so we continue to just care for his wounds and give him IV fluids. The family may take him up to Libreville where he can get a CAT scan. This little boy had a blunt injury that burst his pelvis open. Previous pictures showed him in a pelvic sling (one with sunglasses). He is starting to sit up now.
This lady had a fractured femur and Dr. Olson put a long rod down the middle of it to stabilize the fracture.  She is ready for discharge today.
One of the residents started a lecture on Head and Neck Surgery today. He was only half through after an hour and a half when we called “time.” He will finish next time. There continues to be the dynamic tension between learning the material in an American textbook that they need to pass their exams and the practical knowledge that they can apply here. Dr. Simplice Tchoba gave the lecture today. In a previous post I said he was a first year resident and actually he is a second year resident. It’s important to him. He is the only Gabonese resident here and I have been told that he will stay here at this hospital after graduation.  He could potentially eventually be the main surgeon here as the missionaries phase out. He looks very tired in this photo.
Here is one of the cook houses with wood smoke wafting out the open sides.
This evening, it has been raining fairly hard off and on for the last three or four hours. I was invited to eat at someone’s house and was expecting to get somewhat wet, even using the umbrella. Then someone else who was to be a dinner guest called on the phone and offered to come by and pick me up in her car. It’s only about an eighth of a mile, but it’s enough to get pretty wet with it pouring the way it is.
Becky Thompson loaned me a flashlight for the last few days I will be here. I have started returning things I’ve borrowed from various people, in preparation for leaving the hospital Thursday morning. Dr. Loua still feels bad about not being able to take me to eat at the restaurant in town, so he brought me apples and bananas yesterday. I had to give away some of the bananas, since there were more than I can eat before I leave.
The rain is really pounding down right now. It has cooled things off nicely. | | |
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