Let’s take a second to talk about a really amazing opportunity and experience I had this weekend in a town called Bahar Dar.
This small city situated on the intersection of the Blue Nile river and Lake Tana (largest lake in Ethiopia) happens to be the hometown of Yilkal (the head of the department here). As such, his friends and family serve as the eyes and ears of this water-loving city. A couple of weeks ago we received word of a child with some type of airway disease with failure of some type of airway surgery in Addis. The request is received as simple: could I evaluate the child to see if anything could be done? The government had already tried to find her options in Europe and the U.S. with no luck.
With conflicting reports on everything, including the patient’s age or whether she had a trach, we decided it would be best if I traveled to Bahar Dar and assessed the child in her home town. For those of you who know me, or know me through this blog, you can understand how this is a dream of mine come true. To visit a faraway city to provide a surgical consultation.
Boarding the plane in Mekelle’s modest “international” airport, I felt the same sense of pride I had disembarking here just 4 months prior. As the large twin propellers of the iconic Bombardier Q400 surged independently to find their harmonic frequency on takeoff, my brain couldn’t help but interpret this loud, invasive noise as musical and pleasant.
As a consequence of continued civil unrest between ethnicities, the direct route by car or bus is blocked and considered too dangerous to travel currently. Thus, I had to take the long way around, first flying unnecessarily south to Addis, and then back up to Bahar Dar.
As a clear show of pride from the local pilots, on the approach to Bahar Dar, the plane took an exaggerated left turn to showcase the beauty of Tana Lake. Then, when stepping down the airplane’s stairs I was reminded of senses forgotten. The interpretation of neurological signals indicated increased atmospheric pressure and humidity confirming my proximity to lowland water. Something I haven’t felt in months. Although I was still in Ethiopia, everything was different.
The airport’s walkways were clean with efficient baggage service with beautiful tiled floor leading outside to a well-organized pick up location. On the drive into town, I started cataloging differences from Mekelle with increasing admiration. The road was pristine, wide and with organized construction on either side. Passing these scenes in real-time essentially created a real-life movie of how to efficiently construct a road barrier. A clear pattern emerged. Huge rock crushing machines would transform excavated boulders to slightly smaller ones that the next rock crusher would mash into man-powered sizes. A team of men and women would then take the rocks and short them based on shape, or size or weight, I’m not sure. Then, at the leading boarder of un-finished barrier, a new team would lay rocks as others poured concrete until the convoluted mass obtained the exact dimensions of the previously laid barrier. I was mesmerized. The infrastructure of Bahar Dar was impressive and the city was well organized, clean, friendly and was socially advanced.
I couldn’t help but think about what happened just a week prior. A large group of Tigray elite (the region where Mekelle sits) were coaxed into a meeting of sorts in Addis. Once they arrived, the doors were shut and they were all arrested. The government then released a long list of wrong-doings apparently committed by these individuals that painted an impressive picture of long-standing political corruption. Whenever we ran over a large pothole in Mekelle, the drivers would always curse the corruption, but I guess I didn’t understand it until I witnessed the organized infrastructure of Bahar Dar.
The plan was made for me to go to the local hospital the next morning along with Melesse, a general surgeon who had just finished his Head and Neck fellowship with Dr. Fagan in South Africa. Melesse is a soft-spoken, but extremely intelligent and forward thinking. I would later learn that he has solidified fellowships for his future co-workers in rhinology and pediatric otolaryngology (both fellowships in South Africa).
Walking through the gates of the hospital in Bahar Dar is a completely different experience from that of Mekelle. This sixty-some-odd-year hospital was situated among the huge trees and plants that populate Bahar Dar’s wet climate. Rows of outdoor hallways with uneven, broken cement floors interconnect the scattered buildings that house patients. Just as in Mekelle, patients litter the hallways. The difference here is just the sheer lack of physical space to house patients. Their beds and attendants spill into the outdoor hallways, essentially sleeping outside. Their haphazard organization makes it difficult to maneuver from one building to another.
I met the patient and her father just outside the singular, open-walled room that doubled as an office and ENT clinic. She was a short, shy and her red turtleneck sweater probably seemed out of place, but I knew hid the reason for my travels this weekend. After introductions, she retracts the sweater’s neck to reveal an 11mm Jackson trach. This is a metal trach with an inner cannula that is often given to patients that will have a permanent tracheostomy. We sit down and talk with the help of Melesse interpreting. I learn that in early summer she developed renal failure due to an acute food-borne illness and required intubation. At extubation, she developed respiratory failure quickly and a trach was placed. At some point, it was determined that she had tracheal stenosis and some type of airway surgery (most likely a resection/anastomosis) was completed by a general surgeon in Addis. Soon after extubation, she again experienced respiratory failure and a trach was replaced and then upsized to this 11mm Jackson. She had no other past medical history and I was told a CT was performed sometime after her last event of respiratory failure.
Because Bahar Dar did not have appropriate bronchoscopy equipment for an airway analysis, I decided to perform an awake bronchoscopy using a flexible laryngoscope I brought from Mekelle (and a lot of 4% lido). As you can see from the video, there is 80-90% stenosis for the suprastomal trachea and you can just see the hint of the light reflex from the Jackson trach distally. Through the stoma, a prolene suture can be seen and the distal airway is normal and plentiful. The proximal airway couldn’t be visualized through the stoma.
I asked the father to bring me the CD of the CT scan to my hotel whenever he had the chance. He didn’t speak very much English, but we exchanged phone number anyways.
A few hours later he arrives, I meet him outside, and we sit down together while I download and reformat the images. Our small talk quickly dives deeply into his life. I learn that he had two daughters, but the other had passed away from pneumonia at 3 years of age. As I poured through the sequential images of his daughter’s misfortune, he pours his heart out. I hear the rapid change of inflection in his voice and look up to see his eyes full of tears. He and the government of Ethiopia have been looking for options abroad for him and his daughter without success. He was probably imagining me turning him down as well, as I silently listened and analyzed his daughter’s CT results.
Putting everything together, I envision that her intubation induced iatrogenic tracheal stenosis. A trach may have been necessary and a resection perhaps the correct choice, but the aftermath has left her with severe suprastomal tracheal stenosis and a dependency on her 11mm metallic airway.
With a nearly complete picture of the problem conceptualized, I grabbed a piece a scrap paper from my bag and started to diagram the issues. He’s an intelligent man and follows along well. I explain that we need to get her up to Mekelle to formally visualize her airway with a sedated bronchoscopy and obtain airway measurements. After that, we could possibly perform a number if different reconstruction options. I don’t think dilation alone will work. I made sure to emphasize that not only will this be a very difficult revision surgery, but that the immediate post-operative period is particularly dangerous and she will likely need to remain intubated and relatively motionless for 7-14 days. I think these warnings bounce right off of him and he is still waiting for me to say “no, I can’t help you.”
I thank him for his time, get his WhatsApp number and tell him that I’ll be in contact once I’ve had more time to think about his daughter. I spent the next 5 hours trimming and editing the physical exam video and CT. Pouring over every detail with intensity while being gently caressed by the cool, saturated Bahar Dar breeze. I sent these videos to the best airway surgeons I know seeking their advice and started to think about how I would start training the ICU for this postoperative airway patient.
This was very stressful for me. The prospect of a complicated revision airway surgery alone is stressful enough, but add to it the family’s prior misfortune. I’m driven to help this family, but it MUST be the safest way possible. What she requires is the intelligent surgical approach, not the heroic.
As if sensing my need for escape, a receive a call from Yilkal’s childhood friend, Sol. Turns out he and his friend Misrak were at my hotel ready to take me to see downtown. These two, jovial and beyond kind gentlemen take me on an extensive tour of the city, including to the top of a hill to visualize it’s panoramic view.
If that wasn’t enough, they took me to their favorite place for fish. Situated on a huge lake and serving as the starting point for the Blue Nile, fish here is excellent. The shop is located in the middle of nowhere, is dirty and delicious-smelling smoke billows from it’s numerous stoves and fry pans. Beers and whole fried fish in hand, we stuff ourselves while enjoying wonderful conversation.
At its end, my excitement for sleep is squashed by the suggestion of wine at a local traditional house. I dreaded the idea but politely agreed. Traditional houses in Mekelle are ridiculously loud and the entertainment features endless Tigrinya music. Its fun for a while, but I wasn’t in the mood for this.
We arrived at the traditional house just before 8pm. Although it could probably fit around 200 people, there were currently just over ten and it was stone-cold quiet. I happily sat down and we began to sip our wine. Over the next hour and before I had realized, the place had filled to capacity. At around 9, two unassuming men dressed in traditional clothing sat among various musical instruments on stage.
What would happen over the next two hours was an amazing show of talent from musicians and dancers alike as they systematically rotated through the variety of different cultural song and dance. It was immensely entertaining and up until now, I had never experienced anything quite like it. Occasionally the dancers would move throughout the crowd and pull people up to try the traditional dance with them. As the only white person in the entire place this night, I was singled out every time. I didn’t mind, its fun to try these dances even though I know I performed poorly.
After a particularly intense Somali dance-off between two dancers, everyone on stage seemed to be organizing a skit. Since everything is in Amharic, I had no idea what was going on. But, clearly, there was a teacher with a stick and everyone else pretending to be students. Just then, Misrak leaned over to me and said: “be ready.” Not 5 seconds later was I tapped on the shoulder by one of the dancers and led up to the stage. What happens next is pure embarrassment, but oddly entertaining to the Habesha crowd. I’m regrettably posting the entire 6-minute video here contrary to my better judgment. But, what I realized once the embarrassment had subsided, was that humiliation and bad dancing are wonderful stress relievers. Enjoy if you dare….
The next morning, although admittedly a bit sore, Sol got me in touch with his brother who arranged a boat trip and tour of one of the amazing islands of Tana lake. Since I’ve done enough talking for this post, I’ll let the pictures and videos speak for themselves. It was a beautiful experience and I can’t wait to return.
On the two flights home that evening, I planned for how and when our Bahar Dar patient would come up to Mekelle. Because I was going to join an upcoming mission in Addis in 2 weeks, I decided to have her come upon my return in 3 weeks. And, due to the relatively inflamed airway, I started her on dual acid suppression for the weeks leading up. This story has only just begun and I will update everyone as it progresses.
Global Head and Neck Surgery 