Why

“It is worth asking why a health care professional who is capable, respected and experienced would leave his or her home, job and loved ones to go to a challenging, exhausting and possibly dangerous destination.”

This sentence leads off a very insightful section in the Global Humanitarian Medicine and Disaster Relief chapter in Wilderness Medicine, a fascinating textbook in the medical library here. 

According to the authors, providing medical relief is the primary motivation for most involved in this work. This relief first involves action such as a surgical procedure or consult, then being with patients physically and emotionally in their suffering and then bearing witness so that those suffering do not do so alone.

It has been helpful to read a concise list of potential answers to this “why” question, to reflect on my own motives and to understand where others involved in this type work might be coming from. Each reason listed in the chapter has merits and drawbacks and it is noted that many ideals are “mulled over” in the course of these deployments. Here are my take-home notes from the textbook on this subject.

1. Help people in need / relieve suffering - This is a laudable goal that the world could aspire toward more. One drawback is when the “helper’s high” or “doing something good” can be self-serving and used as a means to a personal end. This desire might not suffice if the culture served in has no grid for “volunteering” and assumes an ulterior motive for the service. While volunteerism is commendable it can lead to financial and domestic difficulties if not done with balance.
2. Testing oneself - In the absence of diagnostic technology or readily available specialists, an austere environment might hone physical exam skills, resurrect knowledge from medical school days or push some into learning new procedures. In contrast - skills needed in your home role might be neglected and require re-learning.
3. Medical tourism / adventurism - Our credentials can be a ticket to world travel. Having a “cross-cultural experience” has many benefits but this attitude might segue to “voyeurism and reductionism that can trivialize patients and their situation.”
4. “Check-mark syndrome” - Working in an emergency situation is just “one more box to tick off the list of having done it all.”
5. Fleeing a negative situation / finding oneself - Some may be looking to get away from personal relationship failure, professional frustration, or disillusionment with values of their home society. They might find a cause to channel their energy toward. 
6. Personal conviction, philosophy or religious belief - These ideals can serve as a sufficient motivation to serve and advocate. People of this mindset might feel that the suffering they see needs be shared with a wider audience and speak up on behalf of their patients. Local governments might not share the worker’s sense of social justice or beliefs which can limit their advocacy in the interest of patient or team safety.  Challenges arise when “there is discordance between foreign ideals and local culture, politics and traditional power structures.”

The section in the textbook concludes with an observation that we are all complicated humans who sometimes experience boredom and ambivalence in the midst of joy and fulfillment. However, we better understand the human condition when we enter into and see the “beauty and brutality” of the lives of others. This challenges our ideas about how the world works. Also, we see what we have in common can transcend great distance and our differences in language and culture.

Lassa

This is a very well-written recent article about a disease that surfaces in this part of the world at this time of year.

Lassa Fever Erupts in Nigeria - the New York Times

Because people with Lassa Fever who need to be hospitalized are often quite ill, they tend to be the more severe cases and have high viral loads that increase the risk of transmission to healthcare workers.

My friend Todd died of this illness and was the index case in this region two years ago. The date of his death (Feb 26) is actually the anniversary of the opening of the hospital that he was so instrumental in building.

Some of our teammates here have spent amazing amounts of time to get us prepared for this season. Any time a patient presents with a fever, we have to run through a checklist to profile their risk of having Lassa Fever and it adds another dimension to the stress and ethical complexity in caring for these patients. It is a gut check to consider our love for our patients and if that love is enough to conquer fear.

I remember thinking soon after Todd died that this horrible disease needs a protective vaccine against it.  So, I am very excited to learn of the funds and collaboration being directed by the Bill and Melinda Gates Foundation, vaccine companies and others toward this goal! There are two sometimes competing thoughts in my mind about these sorts of healthcare disparities in the world. On the one hand - you “change the world by changing systems” and on the other you change it “one life at a time.”

...Got the T-shirt

It was such an encouragement to host friends from back home for a brief stay earlier this month. My dad and an orthopedic surgeon friend travelled a long and weather altered route from Indianapolis - (scratch Detroit) - Atlanta - Amsterdam - Casablanca, Morrocoo - Conocou,Benin - to here….. for an 8 day stay. Predictably their luggage was lost in the shuffle but the bulk of it made it eventually. 

We worked hard to see and facilitate operations for many patients with long-standing orthopedic problems. There were times of high yield learning and fun adventures too. 

It was a rare privilege to have my dad in the operating room with us.

It is a blessing to have a wise, energetic and adventuresome dad for me and grandpa for my children. He liked off-road motor biking more than I would have guessed. I found something he is actually afraid of. Hippos!

However, I think the memory of going to see them was worth it.

Baby

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Trauma Stewardship

I recently read Trauma Stewardship - An Everyday Guide to Caring for Self While Caring for Others by Lipsky and Burk. It wasn't an easy read and is not a particularly well written book, but it did shine a light on challenges of staying healthy in the midst the heartbreak that is so prevalent here.

It’s not that any one scenario has been overly traumatic, but there is a steady dose of suffering, death and frustrating experiences in this type of work. The most beneficial section of the book was the list of “trauma exposure” responses, as I recognized some of my own tendencies in the list. Here are the ten that resonated the most with me including my personal examples and each with a supporting comic illustration from the book.

1) Feeling helpless and hopeless - thinking that what you are doing doesn't really matter in the end (systematically).

2) A sense that one can never do enough - but that you must still try to do enough.

3) Hyper-vigilance - double checking and micromanaging.

4) Inability to embrace complexity - preferring the simplistic explanations in my mind like "they just don't care" over "there is probably   a cultural explanation for their lack of urgency."

5) Minimizing - My wife and kids can out me on this one whenever I ignore their complaints and explain they "don't know how bad some people have it."

6) Chronic Exhaustion - I am trying to give myself space on this, learning from a senior surgeon that you just don't have the same stamina in this climate (I take 12 minute power naps after lunch almost every day).

7) Inability to Listen / Deliberate Avoidance - I am prone to this when facing patients who I can't offer a quick solution to and prefer to have someone else deal with them or make the interaction as short as possible.

8) Sense of persecution - thinking that my credentials back home carry little weight here, I just have to "fit into the system" and I don't get respected if I can't communicate well.

9) Anger and Cynicism - I really try to avoid this but I suspect this tendency is proportional to time spent here. New people come in and see the beauty and the hope. The long-term teammates buried their founding colleague out by the soccer field....life is hard... there is opposition around every corner.

10) Grandiosity: An Inflated Sense of Importance Related to One’s Work - I want to take credit for good outcomes but not bad ones.

Joyeux Noel

We miss family and our culture and Christmas cards from our friends these days - especially the increasingly rare white Christmas! It felt cold this Christmas morning here too - down to 69 degrees overnight.

It has been refreshing, even if feels odd, to take a breather from some of the holiday hassle which allows us to focus on the deeper meaning of Christmas. "God with us" is a global phenomenon indeed!

Here is the latest picture of our clan.  It seems like a long time ago since our we sent our last Christmas photo referencing a summer surprise - he has been a highlight of our year and is perched on my lap in this photo.  It has been a year with plenty of moving and packing for us as we sold our home in March, lived in a rural rental home for the summer, crammed into an apartment in France for language training time and are now settled into hospital compound life in Togo. We are enjoying our friends, the people here and all the ways these experiences make us think.

If you sent us a Christmas card - hopefully it was forwarded so that we can view it when we return to the US (scheduled for June) and we can update you on our new address with a mailed card next year.

Wishing peace and togetherness and joy to all our friends and family back home!

Love,

The Hubers

Big Radius Surgery Group

Healthcare organizations think strategically about their catchment area - the population they draw their patients from. Along these lines, I came up with a “name” for our small, two-person surgery group here - Big Radius Surgery Group. 

Dr. Nattier is the kind of guy you just want to bust through walls with. It is good to be here to work with a close friend. I hope he doesn’t get tired of me because, as the surgery roster shows, we are slotted to spend a lot of time together over the next 1/2 year.

We have seen our fair share of challenging cases lately, many in pediatric patients from as far away as Nigeria and with advanced stages of disease. We alternate call every other night and often end up with our “own” patients which is efficient and much like my practice back home. However, we tackle the more challenging cases together.

A lady presented to our clinic recently with Grave’s Disease - an autoimmune disorder that results in the thyroid gland enlarging and overproducing thyroid hormone. This can be treated with radioactive iodine but that isn’t available here. 

This patients had the characteristic bug eyed appearance of the disease and all the signs of thyrotoxicosis - pulse in 130s, profuse sweating, an enormous thyroid taking up the entire width of her neck and with so much vascularity that you could feel the bruit hum of blood flow when you touched it. We started with medications to slow thyroid hormone production and slow her heart rate. When she didn’t show for the next appointment, I fretted that she had died and regretted not admitting her at that first appointment. Thankfully she resurfaced with many of the symptoms under control and desiring the risky operation of thyroidectomy in attempt for cure of her hyperthyroidism and to relieve the pressure that her enormous thyroid placed on the other structures in her neck. 

There is a lot of give and take conversations in these two person operations - 

“Do you think that’s the nerve?” as we search diligently for the recurrent laryngeal nerve that moves the vocal cords…. “Oh - there is the parathyroid gland!” as we try to preserve the body’s calcium regulating gland that sits right next to the thyroid…. “I think you got it” when the bleeding stops after a delicately placed suture.

She is recovering well after her subtotal thyroidectomy. We tried to leave enough thyroid gland behind to minimize her need for thyroid hormone replacement and we continue to monitor her for that. When she removes her head covering her neck looks a lot different now. Her bug eyed appearance (proptosis that is due to Grave’s disease) is waning. She has a strong voice and can breath and swallow normally. These are little things that we sweat over before surgery and rejoice to see afterward.

Another challenge was this million dollar smile boy from Benin with a huge mass (sarcoma) in his right thigh. It had been growing for many months and was starting cause pain and affect his gait. We weren’t certain from examining him that it what relation this mass had to his femoral artery or if we would be able to salvage his leg. Thankfully - we were able to get what appeared grossly to be a complete resection, sacrificing a significant part his quadriceps in the process. 

The pathology results aren’t available yet but we do have some chemotherapy options here for these types of tumors so we are prayerfully optimistic about this little boy’s life! He is walking and smiling with his adoring mom. 

The big radius encompasses many wonderful people. It is a joy to be here among them.