Days 15: Coming to A Close
*The pictures in this post are of the specific children being discussed. I think there is value in being able to put faces to their names when you are learning more about their stories
Prof arrived back from his trip to Ethiopia on Sunday, where he performed nineteen surgeries and saw 127 pre-op patients and 50 post-op patients in just three days! Monday’s morning meeting discussed many of the post-op cases I’ve been sharing frequently here.
Eshetu, the nineteen-year-old girl who had a severely myelopathic spine (spinal cord was very compressed), is now six days post-op. She is feeling sensation in her lower limbs, although they have no voluntary movement motor power. This may change with time and is due to the previous and prolonged condition her spinal cord was in. She is currently in physical therapy and can withdraw her legs from painful stimuli. She is being closely monitored.
Esther, the younger girl who had the first of two operations almost two weeks ago, will undergo her second procedure tomorrow. She had an anterior (side approach) release twelve days ago to increase spinal flexibility, and will now undergo a posterior spinal fusion. She, along with many of the other post-op patients in the ward, had malaria last week and was treated. This is extremely common here, as the blood used for transfusions typically carries malaria because of how widespread it is. Because malaria is treatable with medication and there would not be enough donated blood if malaria positivity was an eliminating factor, all patients receive blood transfusions and are then tested for malaria and treated accordingly. Esther’s hemoglobin levels are higher than ever, but she still may receive a unit of blood pre-operatively to be cautious.
Mengistu is six days post-op and was also treated for malaria this weekend. His alignment looks great and his current obstacle is an abnormal gait (walking movement) on his left side.
This week Rediet, a sweet nine-year-old female that I’ve gotten to spend a lot of time with, will undergo a posterior spinal fusion and vertebral column resection for her very high risk posterior kyphosis. She was in a halo for around four months, which reduced her kyphosis from 138 to 114 degrees. She is extremely skeletally immature, so the procedure will inhibit some of her growth.
Another pre-op case for the week is Haliya, who is also a nine-year-old Ethiopian girl. Haliya is a fascinating casse. She arrived with a severe neurofibromatosis (spinal tumor) and congenital kyphosis that had inhibited her from walking for four months prior to her visit. Her bowel movements are controlled, as is her urinary system now that she has taken medication, which is important in determining her risk of paralysis. After putting her in halo traction, Haliya became able to walk during walking traction. I witness this when I accompany the children on their walks, as Haliya’s friends always help push her because she has a more difficult time in walking traction than others. She is a very quiet girl who is extremely polite and will warm up to you after a few funny faces. Her vertebral body has been dislocated, so she has two vertebrae side by side instead of stacked up and down. Much of her surgical plan will be determined when she is opened and they can assess the severity of the situation.
An additional pre-op that I found interesting is Agnes, a fifty-eight-year-old Ghanaian female in need of a double knee replacement. Her more severe knee will be operated on first. Agnes’s knees are in such bad condition at a relatively young age because of her weight. She is obese with a BMI of 40.5. Activity level, or fitness, is often more important than weight in patient outcome. To optimize Agnes’s post-op outcome, the doctors want her to engage in some type of activity, which is difficult given her weight and two bad knees. Some ideas included walking, walking in water, and stationary biking.
Emanuel, a three-year-old Ghanaian boy, will be operated on this week for the same condition that another three-year-old whom I previously discussed, Franklin, had: arthrogryposis. Emanuel’s condition is in his arms, unlike Franklin’s, which was in his legs. This causes Emanuel’s elbows to be frozen so that both of his arms are stuck extended. He will have bilateral radius and ulna shortenings.
I then shadowed Prof in clinic at the Out Patient Department for the majority of the day, which was an incredible experience. We saw many patients whom I have become familiar with, as they are pre-op or post-op cases staying at FOCOS. However, many new and old patients traveled far just to have an appointment with Prof. Some of the patients we met had come from Nigeria, Sierra Leone, and parts of Ghana far from Accra. My favorite appointments to shadow were post-op patients coming in for their six month or one year check-up. It was so incredible to see how these patients, mostly children, were flourishing and resuming daily life. Looking at their pre-op and post-op x-rays side by side, all while being able to see them standing tall in person, was truly an incredible experience. We even saw one Ghanaian adolescent patient who was being seen because her scoliosis curve was observed early and being monitored. She is nearly done growing and has a 26 degree curve, so she will likely never need treatment. It is mind-blowing that this type of appointment is the norm in the US, yet it is the first of its kind that I have observed here at FOCOS.
One of the patients we saw was Abraham, an enthusiastic and intelligent young boy living at JB House that I have taught often. Abraham had surgery exactly one month ago, but his deformity is more visible than ever. Before his operation, Abraham had severe kyphosis. From the side, his spine looked like a lowercase "r" with the top vertebrae not even creating a curved hunchback, but rather a completely horizontal hunchback. This severe deformity needed to be corrected immediately, so Abraham had a spinal fusion. However, because of his young age and small size, which prohibits the doctors from using stronger, larger implants even though his spine is persistently growing, he has developed kyphosis below his fusion. This means that his spine is now forming a hunchback under the implant in a location lower than the original problem. Prof debated whether he should extend Abraham's instrumentation now or let him go home to Ethiopia and observe him until a second procedure becomes absolutely necessary. The reasoning for the latter idea is that it would give Abraham more time to grow; he is still very young and short, and any part of the spine that is fixated with instrumentation will stop growing. Because Abraham's rod is very close to his skin due to the new curvature, Prof decided to keep him at JB House and reevaluate in six weeks.
I spent what time remained in the day hanging out with the children and enjoying some music-making and dancing before walking traction. I cannot believe that my time here is coming to a close and am so grateful that I was able to learn more inspiring stories in clinic.