Will the real Mamie Kankor please stand up?

Yesterday morning we were expecting a 34 year old woman named Mamie Kankor to arrive for surgery. Mamie had extensive burns to both her legs, the scar wrapping all the way around her thighs and impairing her ability to walk. She had been seen at our screening early on in Febuary and later by Dr. Tertius, our South African plastic surgeon, who agreed that she would need skin grafts to her burns so that she could move about freely again. So when we called out her name and she came in, we went through the usual procedure of getting her demographic information, checking her blood pressure, heart rate, temperature, and weight, and of course explaining to her the planned surgical procedure and getting her consent for them. She readily agreed and signed all the neccesary paperwork. After being processed by the admissions nurses she moved to my desk so that I could do a history and physical and deem her fit for surgery. It was just another routine patient in another regular day.

Except that it wasn't. "Show me your problem," I asked her. She gestured in the direction of her head and neck. "No, I mean the problem you came here for," I said, as I pointed towards her thighs. "You mean do I have pain in my knees?" she asked as she lifted up her skirt to reveal smooth unscarred skin. I stared at my admissions packet, which had the words, "circumferential burns to bilateral thighs" printed in the diagnosis section. I looked at her again, now truly confused. She pointed to her neck, and I saw a navel orange sized lump at her Adam's apple. She had a goiter.

It's a long story.

Mama Korkor is a 40 year old woman who went to an ear, nose, and throat specialist at JFK Hospital, Monrovia's largest public hospital. There, the doctor diagnosed her with a large thyroid gland. He also noticed that her eyes were more protuberant than usual and after questioning her, found that she had been losing weight and frequently felt her heart racing. These are all signs of an overactive thyroid gland, and since he did not have the ability to perform thyroid function tests at his hospital (a very commonplace test in the United States but not here-people need to travel to Ghana to get this test), he sent Mama to us.

Mama arrived early in the morning to the dock. There, her referral letter was collected along with those of the other patients waiting to be screened and brought in for our patient care coordinator, Ans, to see. Ans went out and called, "Mama Korkor." She was brought in along with Comfort, one of our translators and apparently a friend of the patient. Ans, and later our ENT surgeon, Mark, noted that although the patient did have a lump in her neck it was not an enlarged thyroid gland, but rather something called a thyroglossal duct cyst, a congenital abnormality. She was given an appointment card to return in July to have the cyst removed.

However, Mama had never seen Ans. Someone else did. Mama was sitting on the dock, waiting patiently, until our hapless admissions nurse had called out, "Mamie Kankor." Perhaps unable to understand our English, perhaps afraid to miss her opportunity to be seen, she leapt up and identified herself as Mamie Kankor. Thus chaos ensued.

We often kid ourselves into thinking that we are perfectly clear when we are not. Mama had signed a consent form saying she would accept all the risks associated with putting her under general anesthesia and placing skin grafts on her two perfectly good legs. Thankfully the error was caught early on but this just goes to show how great the power differential is between us and the patients who come to us for help. The vast majority of the patients suspend judgment the moment they receive these precious green appointment cards for surgery, and place themselves under the care of Mercy Ships with complete childlike trust. I now think back on all my prior patient interactions here and wonder if a careless word I said could have crushed someone's self esteem or buoyed someone's hopes up. May we have the wisdom and discernment to do the right thing for those who come to us for help.

Can we pull a Moses?

The rains are getting worse.

I ventured out to downtown Water Street with fellow crewmember Megan today. Although overcast, the weather was great. A slight breeze ruffled our hair as we clomped down the gangway in our flip flops and made our way to the main gate. Before I left my cabin, I briefly debated bringing my umbrella. However, a misadventure last weekend had left a small explosion of SPF 50 sunscreen all over it, and so I decided to leave it behind.

It started out as a relatively lucky transportation day. As we walked out of the main gate we started making a lateral chopping motion with our hands (the only proper way to hail a Liberian taxi). After about 5 minutes we were in a run-down yellow cab crammed with 6 other people, on our way into downtown Monrovia. At Broad Street, our driver turned to us and told us we had to switch cabs, to another one going to Sinkor. And so we hopped out and started to search. Buses and taxis passed us by, all too full or too busy going somewhere else. Finally, a guy driving a Cellcom service van stopped and we hopped in, on our way to Sinkor.

We had a quick lunch in Sinkor, and then tried to find another taxi. Again, an unfruitful expedition. Finally, we were picked up by a well-meaning Lebanese contractor, who gave us a ride back to downtown Monrovia.

Hitchhiking has never been my thing. However, in Monrovia, with NGO and UN workers totaling over 10,000, it is often a better bet to get a ride in one of their vehicles than to take your chances with a yellow cab. Yellow cabs here are often crammed 7 people to a car (2 in the front passenger seat and 4 in the back, plus a driver), have cracked windshields, and lack door or window handles. These Nissans and Sunnys are the most prevalent vehicles on the road, and are often plastered with slogans like "City Boy" or "God's Choice." Or worse.


Water Street is known for its fabric shops. The larger, more prosperous shops are Lebanese-owned, with proprietors who travel as far as Dubai where there is a large fabric exchange. Cloth vendors converge from all over the world to hawk their wares, and these fabric shops sell anything from cotton prints and tie-dyes to fine Japanese lace and velvet leopard print. Smaller shops usually line back alleys, and are more wooden shacks with plastic tarp than anything else. Finally individual women and boys carry lappas (one lappa is 2 yards) bundled together in plastic tubs and perched on their heads. These vendors usually sell only African prints, which are always a swirl of color, and on closer examination reveal a repeating motif—chickens, crustaceans, giant tubes of lipstick, or tree stumps.

We were happily browsing on Water Street when the skies opened up. The erstwhile roads and sidewalks quickly became a mess of trash, mud, sewage, and water. With no drains and a fierce tropical storm, we were quickly left knee deep in filth. As we debated how to reach higher ground, the local Liberians, huddled underneath awnings, started to shout things like "Roll up your pants!" and "This is Africa!." That's when Megan turned to me and asked, "Can we pull a Moses?"

Sparks

Forgive me bloggers, for I have sinned. It has been 11 days since my last post.

And I can’t promise that this one will be altogether all that uplifting. I had to say no to two patients on Friday; saying no is the hardest part of this job.

Ballah
Ballah* is a sixty-five-year-old woman who, for the past six weeks, has noticed a swelling of her jaw. It’s a painful swelling, interfering with her eating, and causing her to lose weight (or, as our interaction went, I’ can peeyⁿ me. I caⁿ ee’ freely. Ohhh, I be reducing. Because of the worry... I’m going to miss Liberian English). She had been prescribed antibiotics for the jaw swelling, and had been sent to our dental clinic for further work-up.

God bless our dental clinic. They are the front-lines. Firmly ensconced at Redemption Hospital, a former MSF hospital turned over last year to the Liberian government, our dentists, dental assistants, dental coordinators, dental sterilizers, and a vanguard of translators occupy the former pediatric ICU (which sounds significantly better stocked than it actually is. It's a room. With fans. And numbers on the wall).

They see everyone. Jaw swellings. Ma-too’-be-hurtin’s. My-breasts-be-too-bigs. And Vicki, the indomitable whirlwind of a woman who runs the clinic, brings them in or sends them away with a gentleness and a care that rivals many.

Ballah, she sent to the ship. Unfortunately, Ballah’s jaw swelling was inoperable. See, it wasn’t a simple swelling that was paining her. It wasn’t worry that was causing her to reduce. Ballah had a carcinoma of her gums, a volcanic eruption of uncontrolled tissue growth that had eroded through the bone of her jaw and out her skin, completely replacing normal tissue across about 75% of her mouth. Back home, Ballah would have required a pretty massive operation, and, after an entire day on the operating table, would still have had a significantly greater chance of succumbing to her tumor than of surviving. We would have thrown the proverbial sink at her—surgery, radiation, chemotherapy—to give her that chance.

But, here, there is a bizarre economy. In a situation in which radiation and chemotherapy are not available, in a world in which heroic measures fail more often than not, in a culture in which surgery for palliation is not understood, what is the right way to deal with Ballah? And with the other patients who would, by necessity, not be able to get surgery if Ballah did?

It’s an economy I still struggle with.

Joseph
Joseph’s* story is not much different. Fifty-five years old, retired, with a six-year history of an eye tumor, pushing his left eye forward and causing pain. It was a small thing, externally. Not one of those tumors you look at and immediately start calculating how many nerves you’re going to have to sacrifice getting it out.

Its appearance belied its actual size. A CT scan revealed a large tumor in his frontal sinus, with extension directly into his brain. And the economy reasserted itself. We have no neurosurgeons on-board. What we have is the ability to do a few, basic neurosurgical things, should they be necessary. But nothing more.

Joseph, too, succumbed to the economy. And, having experienced the Liberian health-care system first-hand, I know what we were sending him away to. It makes saying no exceedingly difficult.

But, let me tell you the story of Precious:

Precious
Precious* is Liberia. Her problems are the problems of the health care system of a developing nation. See, on February 5, Precious tripped on her way home from school. She scraped her knee and her elbow. She probably cried. She probably ran home to her mother. She probably got a hug. At home, she could have featured in any number of brightly-lit, quotidian Tylenol commercials. But not in Liberia. Here, there are no manicured front lawns with sun-dappled trees and a stay-at-home mother smilingly washing dishes over a white formica countertop. No soft-focus filters here.

Precious’s mother—a woman who commands amazing respect for the amount she has given up to care for her daughter—brought the girl to the big white hospital ship that had just, that day, arrived in Monrovia. Patients weren’t being seen for another two weeks, and, regardless, Precious wasn’t the sort of patient we could have given anything to. But mom tried. And she was sent off to one of the local hospitals to treat the cellulitis that had set into her daughter's knee.

There, Precious received appropriate antibiotics. Except that she was allergic to them, unbeknownst to anyone. Her face swelled up. Her knee and elbow got no better. And then, slowly, the facial swelling turned into outright death. The tissues on her face succumbed to a condition—unique to the malnourished developing world—called noma. Or, in its more grotesque nomenclature, cancrum oris. Noma is an opportunistic infection that attacks a slightly depressed immune system (usually after measles; sometimes after other infections), almost exclusively in the undernourished child. The bacteria that live in all of our mouths decide it’s time to feast. And feast they do.

Precious was—relatively—lucky. She lost her lips. They turned black and fell off. I’m not making that up.

But she could have lost more—others have lost lips, noses, and eyes. Her mother did not give up. Precious had been befriended by one of the receptionists on the ship, who visited her at the hospital daily. Three months later, during which time her mother had not once been home, not once left her daughter’s side, the infection had been successfully controlled and the noma had run its course.

Precious was brought on-board for reconstruction of her lips. It’s a long, four- or five-month ordeal, with six or seven stages (for those of you facile with lip reconstruction, this is like nothing you’ve ever seen before). She has finished stage I. And, for the first time in three months, mom has been home to sleep in her own bed.

What happened to Precious would never have happened at home. At home, kids eat too much. At home, they get vaccinated against measles. At home, when they scrape their knees, mom drops her dishes, runs out under those sun-dappled leaves, concern dancing in her eyes, antibiotic ointment in hand. At home, we make feel-good commercials about the very thing that has permanently scarred a little girl like Precious.

Man is born into trouble, wrote the ancients, as surely as the sparks fly upward.