Vacationing in Cairo

We had a free day on Thursday, a holiday celebrating Egypt reclaiming the Suez canal. I went to see the Citadel of Cairo and looked around two of the mosques. Compared to a church a mosque seems very open and airy, probably because there are no pews, statues, altars or paintings. The buildings themselves were very impressive.

Stop me if you've heard this one. A Buddhist, an atheist and a Jew walk into the mosque one morning...

Thursday evening the plastic surgery department treated us to a cruise on the Nile. We left the dock about half an hour before sunset. Here's a picture of Dr. Jihan Mohasseb, an Egyptian plastic surgeon living in Germany, in front of the Cairo Tower. The tower was built in the late fifties and is lit up at night.

Dr. Riham El-dasouki, the lady below with the big smile, is one of the plastic surgery residents at Aim Shans. She was charged with making our visit comfortable and she did a marvelous job. From the very first day she anticipated our needs and made sure that anything we wanted would appear. The Nile cruise was her last  function and she made it memorable.

The buffet included lamb, turkey, eggplant and a variety of side dishes. The hospitality in Egypt was the best I've encountered in the middle east.

 We didn't talk much about the revolution but I got the sense that it was very much on people's minds. One of the students from Mansoura went to Tahrir square early on and was attacked by the police. He came home with a broken arm, and his father didn't speak to him for three days. He felt terrible about this when he realized how frightened and angry his father felt, but he didn't regret participating. Another guy told me how his friends would organize a demonstration by telephone when the internet was shut down. I think the mood was generally hopeful about the future of a representative government in Egypt. Everyone that I talked to made it clear they were in favor of a secular state, but some of the Coptic students were worried about the possibility of an Islamist government. I think their concerns were justified by the violence that broke out on the day I left.

Wrapping it up at Aim Shans

 One major difference between Egypt and the West Bank is the number of women in medicine in Egypt. Yasmina, who is looking to see if her IV will run, is a senior resident in the anesthesia department at Aim Shans. She is far and away the handiest registrar anesthetist I met and was a pleasure to work with. I've been to Palestine four times and haven't seen any women in the anesthesia or surgical departments.

 Another cute baby!! This little girl has a unilateral cleft that will make intubation difficult. If you put the laryngoscope blade in in the midline, you'll be able to see the larynx but it will be hard to pass the endotracheal tube because the premaxilla, the part of her lip that sticks out in front, will hang down in your way. What you need to do is put the blade in from way over on the left and expose the vocal cords. That way you'll have plenty of room to intubate, passing the tube beneath the gap in the baby's upper lip.

 Young Kim, CRNA from Columbia-Presbyterian, is a great teacher and a skillful anesthetist. Here she's working with one of the female anesthesia residents. She was very well prepared and well-stocked, with a supply of endotracheal tubes and IV accessories that made me green with envy.

The anesthesia equipment at Aim Shans was pretty good. One of the three machines we used didn't have a CO2 absorber so an open system, where the fresh gas comes to the patient close to the mask and the pressure release and rebreathing bag are at the far end of a length of corrugated tubing. The problem was that we didn't have a real pressure relief valve. One way around this is to cut a small hole in the end of the rebreathing bag. This works fine so long as you have the dexterity to control the pressure in the system by partially or completely closing off that hole. I've never been good at that, so I used something I saw in Gaza last spring. I made a slit in the barrel of a 3 ml syringe and then stretched the opening in the bag around the business end of the syringe. With this I could vary the release pressure by moving the plunger. It made it easier for me to concentrate on managing the airway, and gave me a chance to show off my Leatherman!

Treating vs. Teaching

Give a man a fish, feed him for a day. Teach a man to fish, feed him for a lifetime. Every mission has a tension between sharing experience and operating time with the local doctors and doing as many cases as we can while we are in town. Teaching is a vital part of our mission in Egypt, with the medical students in Mansoura and the registrars and junior lecturers very interested in observing and participating in the surgery. Here, Dr. Jihan Mohasseb (at the head of the table) talks one of the Ain Shams plastic surgery residents through the closure on a lip repair.

In the recovery room, the patient's mother is very happy with her son's new lip. And check out the embroidery on her sleeve!

Now we are in Cairo

For the second week of the mission we moved to Ain Shams University Hospital in Cairo. Our first day was spent screening patients: out of the many children who presented, we had to decide who would benefit from surgery now vs. later, and who was healthy enough for surgery now. It's a complicated process and made for a long, but interesting, day. Here's a photo of Carole Hart, the team pediatrician, discussing a plan with house staff, patient and parents.

This plaque used to say that the clinic was a gift from Suzanne Mubarak.

We finished clinic fairly early, time for a quick trip to the pyramids. We were too late to go out on the desert and get close to them, but I had a nice Turkish coffee and took a picture.

Third and last day in Mansoura

30 September 2011

Lorena (above) just plain ran out of gas last night, had to be helped back to her room, and (predictably) insisted on working today. She did let me put an IV in her and said the additional fluid helped.

The medical students in Mansoura were hard-working, helpful and interested in the surgery and anesthesia.

Pink is popular with girls all over the world. One of the fellows bought a bag like she is carrying for Katie.

My second day in Mansoura

29 September 2011

I didn't think this young man could get any cuter until we put the plastic shoe-cover on his head (in an effort to keep him warm during his lip repair).

I was the float anesthesia person on my second day. I circulated between three operating tables: starting IVs, cleaning equipment in between cases, giving breaks and checking patients in pre-op and PACU. Not a glamorous job but I had a good time explaining what pipe cleaners are while I was using them to clean the endotracheal tubes that are special-made for oral surgery. I also got to do some emergency plumbing when I dropped a small laryngoscope blade while cleaning it and it went down the drain in the scrub sink. I had the panel covering the bottom of the sink off in thirty seconds and the drainpipe taken apart in another minute. The nurse watching me thought I was crazy (good for a first approximation) but was reassured when I pulled the hardware out of the pipe.

Hans Kesper is our pediatrician, from Germany. He worked in the clinic during screening and took care of the children post-op.

Tom Flood is our team leader. His motto: "If you're not five minutes early, you're late!"

First day of work in Mansoura

28 September 2011

Laparoscopic surgery is routine at this hospital, but not on children this age.

We left for the hospital promptly at 7:30. I was assigned a slower room with the general surgeon. We did a rectal dissection via laparoscope and an anoplasty on a child with imperforate anus. It was a long but uneventful procedure. We finished about two-thirty. I gave a couple of lunch breaks and was then told that we had an added case, an 11 month-old boy with a diaphragmatic hernia. It was more along the lines of a hiatal hernia, but he had so much guts stuck up in his chest that the breath sounds were diminished on the left. A little bit disconcerting but I finally convinced myself that the tube position was okay and we proceeded. It was another long but uneventful operation.

During the course of the day I was called over to the other room where they were doing plastic surgery, two tables in one room. One of the children for a cleft palate repair was difficult to intubate, but they put the tube in just as I got there. Later, during a break, I helped manage this kid’s airway in the PACU. That was when I noted that he had a very small mandible. I later found that the child started to bleed in PACU and had to be returned to OR. He had a very rocky course after that and was ultimately transferred to the CCU for ventilation and pressor support. So no complaints from me about long, boring surgery.

When we returned to the hotel a wedding party was arriving for their reception. It seems the Hotel Marshal is quite the chi-chi reception venue. The bride was gorgeous; my picture doesn’t do her justice.

Flight into Egypt

26 September 2011

I arrived in Cairo at 6:30 pm yesterday, about thirty minutes late. It seemed like it took forever to go through immigration. I waited in line for twenty minutes only to be told I first needed to buy a visa. So off I went to another kiosk where the guy took my $15 and gave me a piece of paper with a shiny sticker. Fortunately the immigration officer let me jump the line to get my passport stamped. Customs was no problem and I met Ahmed and Mansoura as soon as I left the customs area.  I sent a photo of myself to Ahmed and that made it easy to recognize me. My first task: Mansoura handed me a $100 and told me to pick up four bottles of wine and a bottle of whiskey at the duty free shop.

 This is the hospital where we work. The operating rooms are good, with adequate light and plentiful soap and water. The anesthesia machines were unremarkable with piped in oxygen and functional ventilators.

 Here's a view from the balcony outside our room. We also got a ring-side seat for the fireworks display during a wedding reception. Smog is a big problem in urban Egypt.

The drive from Cairo to Mansoura was long and uncomfortable but the hotel is comfy. They had WiFi in the lobby so I was able to send a note to Rosanne. Ahmed and I met Betsy and Young in the restaurant. Betsy is a peds CCU nurse and Young is a CRNA from Columbia; both seemed very nice.