Malaria and Basketball

In the states, the topic of malaria prevention doesn’t come up in conversation too often during a high school basketball game. Last night at the basketball game Lisa was chasing down Sterling with insect repellent shouting, “I am not going to have anyone in my family die of malaria!” Malaria is alive and well here in Nigeria, especially in the city of Jos where there is standing water everywhere (though we have started dry season and it will get better.) Every day we admit patients to the hospital with suspected malaria. The strain of malaria here is resistant to the basic malaria medications, so we are careful. Lisa dutifully puts out the mefloquine pills every Sunday for Emily, Camille, and me. She has a daily pill dispenser to make sure that she, Sterling, and Hannah are taking their daily doxycycline. Mefloquine often has side effects and was affecting their sleep. We all sleep under mosquito nets as well. All of these precautions are not full proof. Many of our friends have still gotten malaria despite taking precautions and taking prophylactic medications. We are thankful that none of us has gotten malaria so far.

Last night was the season opener for the Hillcrest High School varsity boys and girls basketball teams. You will notice that the court is outside. Hillcrest has one of the best courts in town. There is no indoor wooden court in Jos, a city of 600,000. High school basketball is a favorite source of entertainment for the ex-patriot community and quite the social event. Any game after 6:00 pm is a night game, since the sun always sets around 6:00 pm and rises around 6:00 am, because we are near the equator. Many people without children on the team come to watch the game. Pictured with us are our Lebonese friends, Muhammed and Zaina. Sterling and Hannah are in school with their boys and they recently had us over to their beautiful home where we had the best meal we have had so far in Nigeria—it was a feast.

The game was fun—we won 28-8. Since there are not many courts in town and since soccer is king in Nigeria, the ball-shooting skill of Nigerians is not that great. Nine of our points came from 3- pointers from the other American boy on the team. Sterling was in for almost half the game, which is an honor for a sophomore. He played great defense. He admits he was pretty nervous, so he did not score any shots. I am sure he will be more comfortable tonight when he plays again. Hannah will be playing her game tonight as well.

Michael Mitchell, MD

Patient Profiles: Mr. A and now Daniel

I am sorry to say that Mr. A (featured on Oct. 2 blog) passed away a couple of weeks ago. Fortunately he was at home in his village when he started bleeding heavily, lost consciousness, and then died. I was very sad to hear this as we had spent so much time with him. He was a very determined and strong man, whom I had grown fond of. Despite his determination, he could not overcome his condition.
My current challenging patient is Daniel, a 21 year old. Daniel had an ear condition called cholesteatoma for several years. My predecessor, Dr. Anthis, had even seen him and offered surgery. Unfortunately, Daniel could not come up with the $300 for the surgery and hospital stay. He returned to our clinic two weeks ago with a very severe infection of his ear on the inside as well as an abscess forming behind his ear. He was very sick and would have died without intervention. We tried managing with strong intravenous antibiotics and draining the abscess behind the ear. Unfortunately his infection was too deep and required more extensive surgery. I returned home from our Miango getaway on Friday and had to operate on Saturday. I found bone that had been eaten away and the infection had spread to his brain. He had a large brain abscess. I drained the abscess and hoped the antibiotics would do the rest and that I would have a good report by this time. Though he has been better, he has still been very ill and I have taken him back to the operating room two times, including today, to drain pus that had reaccumulated in his brain.

Daniel has benefited from generous donors who gave to the ENT Poor Fund at Evangel Hospital. His family would never be able to pay the large bill (it may be as much as $600) from this admission. We pray that Daniel will get better soon.

Michael Mitchell, MD

Residency Inspection

We have had some excitement with our resident training program over the past 6 weeks. Evangel Hospital has a Family Practice Residency. Residency is the practical training that doctors receive after medical school. In the U.S. a family practice residency lasts three years. American family practice residents are trained in managing most medical problems. They have training in obstetrics and gynecology as well. They have a small amount of training in surgery, enough that they can often do some very minor procedures like removing lumps, bumps, skin lesions, etc. The training program here at Evangel Hospital lasts 4-6 years, depending on when the trainees can pass their board exams. They have much training in general surgery, orthopedic surgery, gynecology, and urology. Fifty years ago and in some rural areas of the U.S., you may have had your GP (general practice) doctor remove an appendix or perform a tonsillectomy—a rare occurrence now. That and much more is common place at this hospital. Dr. Aboiyar is the fellow that I am currently training. It is clear that he is very skilled in surgery, along with his skills in general medicine, pediatrics, and obstetrics. Last week when I was gone, he took care of a couple of Ear, Nose, Throat emergencies using skills he had just learned from me in the past couple of months. What is amazing is that earlier in the day, he had done two prostatectomies. Ask your family practice doctor when was the last time he did a prostatectomy!

Dr. Aboiyar with his first tonsillectomy patient. A 3 yo with Down's syndrome.

The excitement at Evangel started last month when we were suddenly informed that our residency program was no longer accredited by the West African College of Physicians. This was quite a blow, since a couple of residents were just about to sit for board exams, and were not allowed to take the exams. Our program is well known and well thought of, but there seems to have been some politics going on. After some petitioning and scrambling, the college agreed to inspect our program and consider recertifying our program. The inspection team was at the hospital today. Though a visit of my clinic had not been scheduled, they did manage to pop in on me while I was seeing patients. As an entourage of six people barged into the exam room I explained to my patient, “Excuse me, I need to show the inspectors around. I will be back shortly.” Fortunately, my patient was a physician on staff who understood the situation.

The postop recovery area. No nurses, no monitors.

This afternoon the “consultants” (board certified staff physicians) met with the inspection team. The team seemed to be fairly impressed with our program. There were some criticisms of the hospital facilities though. I was happy to hear that somebody besides me thought that soap and running water would be nice to have in the wards. We hope that the decision to re-instate our program will be swift. We now have four residents who would like to sit for board exams at the next opportunity in April, including my fellow, Dr. Aboiyar.

Hot and cold water in the male ward.

Michael Mitchell, MD

Jobs Around the Hospital

My resume is expanding every day. In the ENT clinic I have worked my way up the ladder from janitor to scrub tech. I started out mostly as an observer, watching my dad and Dr. Aboiyar see patients and occasionally getting to look in a patient’s ear. After a couple of weeks I started organizing the stockroom, which turned into a much longer project than I was expecting. The building in which the ENT clinic is currently located was not actually built until after Dr. Anthis left, so all of the ENT supplies were moved over later. Junk and medical supplies were haphazardly jumbled together on the shelves and allowed to accumulate three years of harmatan dust. After one month of dusting, sorting, organizing, and labeling, the stockroom finally started to look orderly. Much remains to be sorted, but the organization is at a stopping point until the ENT clinic gets some shelving for the office and theatre.

Shortly after I finished organizing the stockroom, a visiting dentist named Dr. Maxwell asked for my help in the dental clinic. I observed more than helped, but I learned how to read X-rays and got to take out a tooth that Dr. Maxwell had already worked loose. I observed tooth fillings, root canals, and complicated wisdom tooth extractions. I learned how to make mouth molds, how to do an effective nerve block to numb one side of the mouth, and how to extract difficult molar
After a week in the dental clinic I returned to the ENT department. ENT runs four days a week: Monday is theatre day, Tuesdays and Fridays are clinic days, and Wednesday is set aside for audiograms. During my first couple of months in the clinic I was organizing on clinic days and just observing on theatre and audiogram days. Not so anymore! Wednesdays are becoming my busiest days of the week ever since I have been trained to do audiograms. I now do most of the audiograms at Evangel Hospital, freeing the other ENT employees to get other things done around the clinic.

Mondays have also been getting busier since ENT was given two operating rooms instead of one. I am present for most ENT surgery days because I am the department’s only circulating nurse. Every Monday I walk through the waiting room to the changing room passing rows of mothers holding newborn babies bundled up heavily with knitted hats and sweaters despite the heat; in addition to being ENT theatre day, Monday is circumcision day. Circumcisions were done in the second operating room (we would hear babies screaming all day long from next door), but since the ENT operating schedule is getting more and more packed, ENT took over the additional room. Now Dad and Dr. Aboiyar jump back and forth between the two rooms, with anesthesia getting the next patient ready so that they can begin immediately when one case is closed. Sometimes they even split up, with one operating in the first room and the other operating in the second. In order to enable this arrangement I am being trained as a scrub nurse. So far I have assisted on some minor procedures and a couple of tympanoplasties. On the most recent tympanoplasty I even got to suture the skin when the case was over.

I am getting a lot of medical experience here that I would not have had the opportunity to get in America until much later in my training. Every month that I am here the list of jobs on my resume gets longer: stockroom organizer, dental assistant, audiologist, circulating nurse, and scrub tech. I have passed through a lot of job titles, but I like the one that our driver Alphonsus gave me the best. He just calls me “Small Doctor.”

Emily Mitchell, 19

From One Extreme to the Other

Michael wrote you about our time at Miango Rest Home. I second everything he said . . .the beauty and peacefulness of the surroundings, wonderful friends to fellowship and recreate with, and best of all food, gloriously easy food! Food that I didn’t have to:
· make a list out for
· send Alphonsus to shop for
· explain to Alphonsus what the word on the list meant
· count out money for
· make sure Alphonsus was able to get
· count money back in for
· make sure Zainab bleached properly so we don’t get sick
· reshuffle our tiny frig around to fit in
· tell Zainab to cook
· make sure Zainab cooked at the time I said
· make sure it didn’t get burned in the oven
If I ever complain about grocery shopping in the US again upon my return, you have my permission to “abuse me” (as Nigerian kids say frequently.)

On the road to Miango, we saw another memorable achaba with passenger and cargo. See the picture. This was a highway we were driving on!

At Miango, we had a great hike on top of a volcano that blew a long time ago. There are actually two dormant volcanoes side by side. You can see one of them in the picture. Right now, the countryside is lovely and green. In just another month or two, that will change as the dry season gets well under way.

Upon our return from Miango, our peace and solitude was quickly shattered by a huge Muslim revival and trade fair just outside of our gates (see the picture.) We were trapped on our compound for a couple of days. Ever try to go to sleep with 3 huge PA systems blaring motivational speakers and prayer calls until 2 am?

Ahh, the extremes of Nigeria . . .

Lisa

Miango Break

We just returned from a three-night holiday at the Miango Rest Home. It is a retreat center that was established in the 1940’s as a place for SIM (our organization) missionaries to vacation and get out of the heat that oppresses the rest of Nigeria. Miango and Jos are on a 4,000 ft plateau so the temperatures are much milder. Most of the year temperatures are 70-80 degrees Fahrenheit, though it is fairly humid most of the time. It is very pleasant if you are sitting in the shade with a nice breeze. Miango is in a lovely location, about 50 kilometers outside of Jos, where we live. It is next to a small village in a rural location surrounded by weather worn granite formations and farmland. We found it a nice change from the city living. The constant beep-beep of motorcycle taxis was noticeably absent.


The retreat functions more as a group retreat center now and not as many missionaries come for rest only. Two missionary groups were having regional conferences while we were there. We were one of three families there for rest and relaxation only. Activities included, tennis, hiking, volleyball, games, movie-watching, shopping, car driving lessons, teenage hanging out and goofing off, reading, and much visiting. All meals were provided, so Lisa had a nice vacation.


Highlights of the trip for me included a hike to the top of a nearby small dormant volcano with a panoramic view of the plateau. We packed 16 adults, teens, and kids into the van and drove a couple of miles down the road for that little outing. Another highlight was the tour of the Miango Rest Home and Kent Academy , which is the boarding school that was established in 1945 and part of the campus. The guide was Dr. Bill Ardill, who was born in Jos and went to school at Kent Academy. He is now the general surgeon here at Evangel Hospital, where I am working. His knowledge of the area and history of the mission is vast.

The most poignant part of the tour was the small cemetery behind the chapel. SIM missionaries who died in Nigeria are buried there. There are many stories of children and adults who lost their lives. There is a pilot who died on a test flight. Also buried is a four year old boy who drowned in a small pit that had been dug by the gardener without the knowledge of the parents. An elderly woman missionary who died in her sleep is there; she was known for always walking the long road between Miango and Jos. Two of the first known cases of Lassa fever are buried here; one was the missionary patient, the other was the physician who cut herself during the autopsy and contracted the disease. Several infants were buried there, including the Ardill’s own baby who died at birth. Many of the names on the tombstones were familiar to us as we have learned the names of the SIM community. It is clear, that there has been sacrifice among the families that have served in Nigeria.

Greater love has no one than this, than to lay down one’s life for his friends. John 15:13

Michael Mitchell, MD

Varsity Basketball

This past week Hillcrest had tryouts for the basketball team. We had about 35 or 36 players tryout so Coach split us up into three teams, Varsity, JV 1, and JV 2. I was the only sophomore that made varsity. I have found that sports is the best past time for me here. If I am not playing basketball on our compound or at Hillcrest I am playing soccer with Gwakman, Victor, and the other Nigerian boys in the neighborhood.

Sterling, 15

Solar Powered Hearing Aids

We encounter many patients with hearing loss. Many have loss due to infections and large holes in their ear drums or missing bones. Some of these patients can be helped with surgery. Many have nerve damage that cannot be helped with surgery. Often the nerve damage (sensorineural hearing loss) is the result of a strong antibiotic that is used to fight life-threatening infections. We use the same antibiotic in the United States but we are able to better control the blood levels of the medicine. I have seen many deaf and partially deaf patients here in Nigeria. Many can be helped with hearing aids. We are fortunate enough to have a fairly good audiometry booth that is sound proof and reasonably well equipped. It is certainly the best facility in our region. Audu and Ben, assistants in the ENT clinic, fit many patients every week with hearing aids. Because most hearing aids require batteries that don’t last long, we have solar powered hearing aids for the poorer patients. These were developed by a non-profit ministry called ComCare, Inc. They sell the aids to ministries for the cost of their supplies. These aids work very well for our patients who cannot afford to replace batteries on a regular basis. The aids are also rugged and can last a few years. Our Hausa language teacher is still wearing his solar powered hearing aid that he was given 5 years ago.
I have included a couple of photos of patients. One young woman has been blind since she was a baby. She is continuing to lose her hearing. We have been able to help her with an aid. Another woman had a life threatening infection after an abortion. She was treated with the antibiotic that poisoned her inner ear. She is orphaned and has no family to help her with the cost of medical care, much less a hearing aid, a common situation in our region of Nigeria where there is no medical insurance. Patients pay cash for all medical care. They often go to family to help pool the finances to pay for medical care. Thanks to generous donors, we were able to provide both young women with solar powered hearing aids. One will now have better opportunity of communicating in her dark world. The other will hopefully be able to find work since she can better communicate.Michael Mitchell, MD

Victor

I thought I would take the time to introduce you to Victor. Our family is quickly becoming attached to this 9 year old boy and his 14 year old cousin, Gwakman. Victor reminds me of a young male, Nigerian version of Camille: very charming, very bright, talkative, and precocious. He wanders over to our house daily to visit us as well as enjoy some of the things that you see pictured on the table, very luxurious things at that: clean, tasty water; high quality English books, and best of all plentiful food! In addition to these items, he is always hopeful of getting a chance at playing electronics which he has to work for in the form of reading English for 20 minutes (by Emily’s orders!)

This Saturday morning, Victor was at our door with his bright smile at 7am. Good thing we are always up around 5am! He came to retrieve a forgotten item from the movie night before. There is always a little hopeful look in his eyes . . . I can’t blame him since he usually only gets one meal a day. I promptly told him to go around to the back patio which is just outside my kitchen door. While I got busy in the kitchen with breakfast dishes, Victor enjoyed his peanut butter sandwich and water, happily chattering my ear off.

Today’s topic was school. Victor really likes school except for when the teachers beat him with a bamboo cane! Not just him, but all the students! This is an accepted form of discipline in Nigeria. Forgot your homework? Made a failing grade? Disrespectful behaviour? There is one solution for all. (No wonder my students at the seminary treat me with such respect!) Victor would like to be either a doctor or an agricultural scientist so he can feed lots of people. He makes very good marks in school and also speaks three languages: Tarok, Hausa, and English. We have great hopes for this little boy who has captured our hearts.

Patient Profile: Mr. A’s Laryngectomy

Left to right: One of Mr. A’s 50 children, Mr. A, Dr. Mitchell, Dr. Aboiyar (ENT apprentice)

Mr. A is a 65 (best guess since birth dates are often not recorded) year old male from the Tiv tribe. He was evaluated by a local ENT surgeon and found to have cancer of the larynx. The surgeon recommended laryngectomy, which is the surgery that removes the voice box and leaves a hole in the neck to breathe through. Another option is radiation therapy which is the usual initial therapy in the states, and has very good results. Radiation is not as controlled or as effective in Nigeria. Mr. A decided to have radiation in March 2008. It did not work and his cancer returned and was blocking his airway by July 2008. He was to have surgery at the University Hospital, but there were logistical problems and the surgery was going to be postponed until September or even November. The ENT surgeon asked if we could do the surgery here at Evangel Hospital. I agreed and I assisted him in the laryngectomy in late August.
Unfortunately things have not gone well and the patient has had multiple complications. His wound completely broke down and opened up. His feeding passage (pharynx) opened up as well. Much of this was a result of the radiation which causes poor healing in the tissues that have received radiation. Mr. A has gone back to the “main theatre” (operating room) four times to try and close the wound. We have taken tissue from his chest and put it up into his neck to try and cover the wound. He has remained in the hospital for 5 weeks. I have been seeing him daily. The University ENT surgeon has left the care to me. He did not foresee the long hospital stay, and the ENT surgeon has actually gone to India for a six week training course. Fortunately one of Mr. A’s sons has been staying with him for the entire time and doing excellent nursing care. The son has been doing the tube feeding, dressing changes, tracheotomy tube cleaning, and even monitoring his oxygen saturation with a pulse oximeter.
We are discharging Mr. A to his home, though he is not healed. He lives in a village about a 6 hour drive from here. He was supposed to go home yesterday, but his hospital bill is 200,000 Naira ($1,800), and he did not have the money on him. A patient or family member must pay in cash in full before the patient is allowed to leave the hospital. If the patient dies, the hospital will hold the body until the bill is paid by the family. Fortunately Mr. A is a relatively wealthy farmer. He has made a lot of money from his crops over the years. He has had seven wives, four are now living. He has 50 children that his accompanying son is aware of. One of his sons is coming later today to pay the bill. Mr. A will return to our clinic in 2 weeks. We pray that some healing will have taken place.

Michael Mitchell, MD

Happy Nigerian Independence Day

Today, Wednesday, October 1st, is a national holiday in Nigeria. We congratulate Nigeria on 48 years of independence. The Federal Republic of Nigeria is a federal constitutional republic comprising thirty six states and one federal capital with a population of about 140 million. Nigeria gained its independence on the 1st October, 1960 and became a republic on October 1st, 1963. Nigeria re-achieved democracy in 1999 ending almost thirty three-years of military rule between from 1966 until 1999. The last major uprising here in Jos was in 2001 when there was sectarian violence between Muslims and Christians. Other than the rebel group in the far south, Nigeria is politically calm for now.
The celebration in Jos is subdued, compared to American Fourth of July festivities. Most workers have several days in a row off. Elective and routine care at Evangel hospital is shut down and there is no school today. As a matter of fact, school has been out for 3 days. Monday and Tuesday were last minute holidays in observance of Sallah, the end of Ramadan. Muslims have had their own celebration as they are completing a 4 week period of fasting. During the day, roughly 6:30 am to 6:30 pm, they did not eat or drink. Roughly half of Jos is Muslim. Many of our patients at Evangel Hospital are Muslim, despite our strong Christian emphasis.

Please join us as we pray for the country of Nigerian: for strong leadership and for strong leaders full of integrity who will work hard to make a better life for all Nigerians.



President Umaru Yar'Adua




Michael Mitchell, MD