We have completed our work for this visit to Njinikom Cameroon and have started our return trip to the United States.  Our final day in Njinikom was busy with goodbyes to patients, staff, new found friends  and of course the Sisters who were such gracious hosts to us.  We had an 8 hour van ride from Njinikom to our destination city Douala where we got on the plane for a midnight departure.  It was a long overland trip and we imagine that there aren’t many places in the US that take 8 hours to reach an airport. Security checks at the airport were extensive but complete within an hour of standing in lines that seemed to never move.

Since our work is finished we have reflected on our time in Cameroon and the St. Martin de Porres Hospital and the people in rural Cameroon.  There is so much need for medical care and there are so many challenges to the average person.  Poverty definitely adds another dimension that in many instances is the root cause behind many illnesses and complicates care and access to care.  Medical personnel are tremendously outnumbered and most have a real sense of dedication to their patients and their country.  Many more people are needed to service the overwhelming demand for basic medical care.  The most basic items for medical care including dressings and medications and access to a pharmacy are often in short supply or totally lacking.  Once you leave the area of the hospital these items are completely unavailable .

Our local hosts the Franciscan Sisters and St. Martin de Porres Hospital were there to help us deliver reconstructive surgery services to these people who rarely have the opportunity to have this type of care.  We greatly appreciate their support.  We also want to thank our local contacts from the USA who were there for us in so many ways.  We are referring to Dr. Brent Burket and his wife Dr. Jennifer Thoene who are in Njinikom on a 3 year Mission sponsored by Mission Doctors.  They are there with their 4 children who are attending the local school and supplementing that with home schooling.  Christopher is the oldest followed by Elizabeth then JulieAnn and Nicholas is the youngest.  The children are a delight to be around and keep their parents busy when they aren’t in the hospital. Drs. Brent and Jennifer met in Portland during their training years and both had a love for medical mission work that was a common bond that has grown even stronger with time.  They have worked in Ghana, Guatemala and now in Cameroon to name some of the places where they have dedicated 3 years of their lives to the people of each of these countries. Their deep Catholic faith sustains them in the difficult task of being a full time medical missionary.  They also have the help and support of family and friends.  There certainly are many challenges to a missionary including a life of financial struggle and self denial as well as the isolation from friends and family.  However, they both feel God’s call to help the poorest of the poor and the least of his people who have such a great need for assistance. They are both specialists in Family Medicine which is a basic need for these people.  Rosemary and I are in awe of their zeal and commitment. 

We are almost home how and continuing to reflect on this surgical mission and praying that we will be able to continue to work in the mission field for some years to come.  We are already talking about our next trip to Njinikom and have a long list of items needed for next time and a list of patients to see again as well as new patients needing surgery when we return. Part of that planning includes efforts to get increased funding or grants for the hospital and the services it provides.  God has truly blessed us and we only ask that he will provide us with the health and resources to continue to work to help His people.  We want to thank all our friends and family for their support during our time in Cameroon. If you have the financial ability to help support mission work please do so.  Mission Doctors Association is doing wonderful work around the world and deserves our support.

Until the next time we meet may God Bless You All.

Thursday Mass at the Sister's Convent

Rosemary with happy post op patient

Another beautiful flowering tree

WARNING: this blog contains graphic medical images. 

We are now down to the last few work days in Cameroon.  This week we have divided our time between our home hospital St. Martin de Porres here in Njinikom and the Mbingo hospital.  There is a team of hip surgeons that provide hip replacement surgery that arrive tomorrow evening and they are coming from Italy.  The main operating rooms here have been closed for thorough cleaning for at least 3 days to prepare for their first day of surgery on Friday.  We operated here today for the final time.  We have a full day of surgery on Friday at Mbingo since we can’t work here.  We have OPD Clinic here tomorrow and Saturday to followup our cases. Looking at the list of cases we have done here in Cameroon it is quite different from previous missions to other parts of the world.  We saw only one patient with cleft lip and palate who was a tiny 1 month old with multiple congenital problems and too small to safely give general anesthesia.  He will have to put on some weight and get bigger before surgery is an acceptable risk. Likely that will take several months.  On most of our other trips about half of all our cases are cleft lip and palate and other congenital birth defects.  There is a cleft surgery team that comes here in the Spring each year from Germany so they will probably be able to operate on this child. We have been busy with coverage of large chronic wounds primarily of the lower extremity but some involving other areas.  These require skin grafting and that has been the commonest surgery.  We also have operated on many patients with burn scar contractures usually a result of the patient having an epileptic seizure and falling into a cooking fire.  This has happened to people of all ages.  Most of these patients never had any initial skin grafting so they have incredibly severe contractures.  Again these patients require skin grafting to obtain lasting results.  The post operative care of skin grafts is much more time consuming and labor intensive to obtain a good percentage “take” of the grafts.  I have been teaching grafting techniques to the staff at both hospitals and I am hopeful it will help them to have improved results when they graft these patients in the future.  Another category of patients that we have seen often is those patients with keloid scars.  Some of these are incredibly large and frequently they are painful and itch all the time.  They also can become infected and drain.  Some keloids are removable but the majority are not and can only be treated with injection of Kenalog a cortisone type medication.  Many respond to a series of these injections but it again is a labor intensive treatment program and there are too few resources for physicians to treat very many of these patients.  Healthcare manpower is very limited in Cameroon and many conditions don’t get adequate treatment until they are very advanced.

Well I will end this for now.  More to follow as we finish up our work here for this visit.

More beautiful flora of Cameroon

Leg wound of 3 years duration

Patient with chronic leg ulcer 10 days after skin graft

Woman with large earlobe keloid from piercing

Same woman after keloid removal & reconstruction

Keloid that was removed 2 1/2 inches

We had 2 overcast days without rain this week and then the rain returned for the weekend.  It rained all yesterday afternoon and all through the night. Unless there is loud thunder it is nice to have the sound of rain on the roof during the night.  The dry season which really starts in November is said to begin like the past week with some dry days and a little rain.  We aren’t there yet.  I did some research and the average monthly rainfall for Njinikom in August and September is 12 inches per month.  October averages 8 inches.  Not too far from here is Mt. Cameroon and the slopes of that mountain are one of the wettest places in the world with an average annual rainfall of nearly 40 feet, not inches.  So we are happy to be here where it averages less than 10 feet annually.

There are 2 growing seasons here and it keeps the farmers busy.  As I mentioned earlier most of our Njinikom patients are farmers.  Peptic ulcer disease is common here in the general population but more so with farmers which is also true in the USA.  If worry aggravates ulcers then farmers have a lot to worry about and much is in the control of the weather which must be accepted for what it is.

We are in our last full week of surgery here and also followup of our operated patients.  Things have generally gone well, especially considering the circumstances and limitations that exist here.  We adapt to these conditions but I am not sure we could live with them on a long term basis. Many of the large amount of supplies we brought are exhausted now and we must use whatever is available and that is often non-existent.  Our staplers ran out 10 days ago and we wish we had brought more.  They save so much operative time when doing skin grafts and we have done so many grafts. Without the staplers we must use individual sutures which are much more time consuming.  We also are nearly out of dressing supplies and the local dressing supplies are minimal.  Elastic bandages which are so useful with many of our surgeries aren’t available here.  Sister Martha in the OR has asked for us to bring them with us next trip.  Having been here now we are compiling a “Must Bring” list for next time.  We hope to be able to obtain donations for much of what is needed as the items are expensive to purchase.

While talking about donations I want to explain the cost structures of all the hospitals we have worked at in Cameroon and most hospitals in the country.  The costs to patients seem extremely cheap by our US standards but in light of the degree of poverty and extremely limited income of most people even these reduced costs are unaffordable.  Therefore many people don’t come for care until the last moment and sometimes nothing can done for them at that point. Registering to be seen for the first time in the Outpatient Clinic is only $2 US and revisits are $1 without the cost of any medications or special treatments.  Hospital bed day rate is $1 and dressing changes done daily are about the same.  However the average length of stay of a patient with a large wound and daily dressings is often several months. Sometimes they leave the hospital because of finances even before their problem is solved.  Skin grafting these large wounds greatly shortens their hospital stay when the graft is successful.  The local success rate with grafting is however low and requires multiple efforts.  I was able to teach some better techniques to the residents at Mbingo and here to the staff and hopefully this will help.  The equipment for grafting is in poor condition and primitive which is part of the problem.  Another big issue for patients is the cost of surgical procedures which are very difficult to afford in spite of the relatively cheap cost.  A major operation here is $100-300 US which would cost $10,000 plus at home in the States.  As visiting surgeon many of our patients can’t afford our services in spite of the fact that my surgery fee is $0.  We have decided to assist the majority of our patients with their bill or they would just have to walk away without having the much needed procedure.  On our next trip here we hope to fund raise in advance so more people can be helped.  Mission Doctors does have a fund to help some of these patients but it is limited by donations.  If you are reading this and so inclined to help then I would encourage you to consider a donation to Mission Doctors.  This is tax deductible. You can be assured your donation is going to help the truly needy.

Well, I will wrap this up and we are headed to the hospital to change some skin graft dressings and make rounds.  Until next time stay well and please pray for us and our patients. 

Foo Foo (white doughy cornmeal ball)
& Njamma Njamma (similar to spinach)
THE staple daily food

Typical stacks of bananas sitting at
roadside waiting for truck to market

Franciscan Sisters threw a party for the Medical Staff--Yum!

8 yr old girl with severe burn scar
Contractures of right hand

Same 8 yr old girl on OR after release
of contractures & skin grafts

It is Sunday afternoon and the rain has been off and on since 6 AM.  By now we are used to the rain and usually won't leave for anywhere without our rain gear or an umbrella or both.  Our rubber shoe/boots are one of our best purchases for this trip.  We haven't really worn our leather shoes since the first day.  We did our wash of our essential wardrobe yesterday and surprisingly today it is dry.  We hang our laundry indoors to avoid the Mango fly laying eggs on wet laundry outdoors. If the clothes hung outdoors aren't ironed then your body heat will hatch the eggs and the larvae of the Mango fly will burrow into your skin and have to be removed surgically. That is a strong incentive to dry your clothes indoors.

Watching the people in their daily activities makes us appreciate how much we have back home.  As visitors here our lodging is comfortable but not by US standards.  However, it is better than most Cameroon people have.  The average village family has neither electricity or indoor plumbing. Most people have to carry water for long distances from the water tap to their homes.  Cooking is usually done over an open wood fire either in the house (where there is no stove or chimney) or just out under the eaves for protection from the rain.  Where we are in Njinikom there is a very bumpy muddy dirt road that is passable from the blacktop that is 1/2 mile away. Beyond our village the roads to the outlying villages are mostly accessible only to motorcycle or bicycle or foot traffic as they aren't wide enough for a car or Jeep.  Even so, most people travel by foot.  Our local Priest, Father Pascal walks 2 hours to some of his outlying mission churches. He is the younger of the 2 Priests here and therefore takes it upon himself to do the outreach work that is the most strenuous. Between the 2 Priests they cover at least 7 outlying Missions and the local Franciscan Convent, St. Martin de Porres Hospital and the local Parish church.  They have a full schedule of weekend Masses in the Parish church and say daily Mass for the Sisters in the Convent.

Here the rain is so frequent and so heavy that houses and other buildings have concrete trenches that are a foot wide and about as deep to handle the runoff from the roofs of the structure.  Without that there would be severe erosion near every house and it would be difficult to get in or out during the rainy season.  Most houses, ours included, have corrugated tin roofs and the sound of heavy rainfall is almost deafening to the point that it is necessary to use headphones to listen to a CD or DVD during such rainfall. There is no Ebola virus in Cameroon as of now and we pray that it stays that way. There was an European Orthopedic Team that was scheduled to visit here and do Orthopedic Surgery for at least a week in November but they cancelled due to Ebola fear.  They come here each year and usually send and entire shipping container of supplies and equipment that is important for their surgery but also to help the hospital with supplies for surgery for the rest of the year.  The impact of their canceling will have a major effect on the hospitals supplies and finances as they will have to purchase much more to make up for the shortfall in donated goods.  There is a Hip Surgery Team from Italy who are coming October 15th for a week of surgery and they are still planning to come and that is a blessing.

That is all for now.  I hope there is time for more later in the week.

Concrete rain trench around house

3 or 4 on a motorcycle is common

7 y. o. Boy with lip/chin burn scar contracture & open mouth

Same boy after scar release & skin grafting. Normal lip position.

WARNING: this blog contains graphic medical images.   

We have spent this week working at Mbingo Baptist Hospital which is about 30 minutes by car from Njinikom.  The hospital was initially a Leprosy Hospital and they still see a few cases of leprosy.  However it is now primarily a general hospital.  They have a general surgery residency program with 10 residents.  I have been working with them this week to teach them some plastic surgery techniques and they have been eager learners.  We have been working with their large number of chronic open wounds that need skin grafting.  There is an almost endless supply of these cases and the wounds are often very large.

We return to Njinikom tonight and have OPD Clinic tomorrow which is Saturday.  We are seeing a number of our post op patients who have left the hospital.  We are looking forward to the Catholic environment that is so comfortable there with the presence of the Sisters and morning prayer and of
course the Mass on Sunday with the students singing.

At Mbingo the patient’s family members stay close by and also do the cooking and laundry for their relative in hospital.  Here they often sleep outside under cover for the rain which seems to fall all night most of the time. This is the routine at most hospitals in rural Cameroon.

This past weekend we had a day trip to Bamenda which is 3 hours drive from Njinikom and there is some really bad road with serious potholes on the way..  Bamenda is the 4th largest city in Cameroon and must be close to a million persons there.  This is the capital city of the Northwest Region of
Cameroon.  It is where the Cathedral church is located and the Bishop’s residence.  We saw the Cathedral which is about 40 years old and the environs.  In addition we did some shopping and Rosemary found a fabric for a tablecloth which is a typical Cameroon design.  It is very beautiful.  We also bought some minor food items that are not available in Njinikom.  We
bought milk that is in cartons and doesn’t require refrigeration until opened.

Well I better end this and head off to our last day of surgery here.

Bamenda Market on Saturday

Beautiful flora of Cameroon

Leg of woman with massive leg wound for 2 years

Same patient in OR after skin grafting

We have had an eventful week of surgery and Outpaitent Clinic.  Our usual start of each day is to awaken at 5:30-5:45 and begin to get ready.  We make coffee and tea and then have a breakfast of toast and a piece of fruit or sometimes we have scrambled eggs.  We have not seen anything like breakfast cereal or oatmeal. The coffee is grown here in Cameroon and there are 2 varieties of coffee trees.  The Robusta is from the lower elevations and is regarded as the less desirable.  Arabica is grown in the highlands and we are in the highlands so we have the Arabica.  It is very delicious and I like it with my breakfast almost every day.  If it is a surgery day we are in the OR Theater by 7:30 and our first case usually starts by 8 AM.  Prayers are said when the patient arrives in the Reception area for surgery  each AM.  The staff of the hospital usually has prayer service for  themselves and for patients who are ambulatory from 7 AM- 7:20 or so.  If it is not a surgery day for us then we have OPD Clinic that starts about 8:30.  Before that or during the morning we make patient rounds and do dressing changes or wound checks on our patients.  There are at least 5 different wards where our patients are residing.  The entire St. Martin de Porres Hospital here in Njinikom is a series of mostly one story buildings except for the main building that houses OB/Gyn and Pediatrics. quite a few of our patients are of pediatric age but they are staying in the surgical male and female wards with adult patients.  Usually a family member sleeps on the floor beside the patient and is there also to cook the food for the patient as well as do their laundry.

Many of the things we take for granted in US hospitals are either lacking totally or sporadically available.  Sutures and dressing supplies including elastic wraps  are very scarce . We brought 4 large trunks of sutures and dressing supplies, staplers, drains and supplies for anesthesia with us.  If we had not brought them we would not have them.  We also were asked to bring suture for general and orthopedic surgeons to use.  The general anesthesia agent of choice here is Halothane which is also used in many parts of the developing world because it is the least expensive agent available. That agent has not been in common use in the States for 15 or more years.  Our USA hospitals are a dream for the waste disposal people as very little of our supplies are reused.  Here and in other similar countries nothing is thrown away until it doesn’t work anymore. We could learn something from these people about repackaging and reusing items whenever possible.  Most hospitals in developing countries, including here, rely heavily on donations from abroad and from those supplied by volunteers who come to work in the hospital.

Patients here are truly patient and wait for their care often for hours.  There is about one MD for every 50,000 people.  This means auxiliary healthcare personnel are numerous and have more responsibility than in the US.  Often the care a primary care MD would provide is given by a Nurse or medical assistant.  Sadly many well trained MDs including surgeons who are native to Africa seek better conditions and much better salaries working in the Middle East, Europe or the USA.  It takes a really committed physician to stay in their home country or another African nation and work with their people. Most of these individuals who do stay have a very strong religious faith that keeps them committed to their people.

I better sign off now and rest for tomorrow.  Keep us in your prayers.

Man with neck mass excised-1 week post op

Keloid scars from very minor trauma like insect bite or scratch are common
problem

We have now been operating for the last 10 days and our surgeries have been going well.  The local OR crew of RNs and Nurse Anesthetists have done a great job for us.  The equipment we are using is very satisfactory and we also have our own surgical instruments and sutures we brought with us.
There are some things it would be nice to have that are lacking but they are not creating any significant problem.  Medical supplies and sutures are very expensive and often difficult to obtain even if they could be afforded. The staff here has learned to adapt and to make very good use of what is available.  We knew ahead of our coming of items to bring for them as well as for our own surgeries.  Thank God for modern communications that allow for rapid correspondence!  When Rosemary and I first started our volunteer work in Nepal in the 1980's there was only very limited telephone service that was almost impossible and the mail service which took 6 weeks each way.
What a change with the internet today. Even when it is often down or delayed it is lightning speed compared to that. 

HIV is very common here and we see patients here every day who are HIV+ and have already operated on a couple of them.  Of course we are careful to take appropriate precautions so the risk to us is low.  If we did get stuck by a needle we would have to take the antiviral drugs we brought with us as a prophylactic measure.

I will include a couple shots from the "Theater" as they refer to the OR here.

God Bless You All and we appreciate your prayers and support.

Rosemary, Nurse Canisius and me in OR with 4 year old burn patient

Pole stretcher assembly to move patient

Man with huge tumor on back of neck for 15 years

We had a rainy weekend but enough sunshine to be out a few hours each day.

Today we had surgery until noon & then saw new patients in the outpatient clinic as well as on the wards. Many patients have chronic wounds that need skin grafts. Some of the wounds have been open for 2 years or more. Today we saw an elderly man who travelled 9 hours by vehicle to come here because he heard we could do skin grafts & he has 2 large leg wounds from a motor vehicle accident in 2012.  We scheduled him for surgery. Healed burn wounds with severe scar contracture are another common problem. These require a release of the contracture and skin grafting.

We are blessed with a really good OR staff that are very helpful. All the other MDs here have also been helping us get settled in.

Many of the patients can't afford to pay for their care or surgery and we have decided to pay for them when necessary which seems to be often. The average farmer or laborer works a 12 hour day 6 days a week and earns $30/month or less. Nurses here make about $100/month. Very few people have cars. A motorcycle of 125-250cc made in Asia is most common gas powered transportation.     However most people walk for transport or take minibus.

God Bless You All.
Keep us in your prayers.

Our first day of surgery went well & the patients are now in their 2nd post op day doing fine.

Yesterday we went to Saturday Market. That was a great experience with lots of new fruits & veggies to look at and buy. Also it was a great opportunity to see the people in a normal setting rather than in the clinic or hospital. We continue to love the openness and warmth of the Cameroon people.

Today we attended Mass for the second Sunday here. The students were back, all 250 of them & their singing presence was wonderful. The Priest announced that there would be a second informational lecture on Ebola for all who are interested as well as he gave some advice himself. There is as yet no Ebola in Cameroon but it is in Nigeria which is on the western border of Cameroon.  Patients come to our hospital from Nigeria quite often.

It is sunny right now and warm. The day is beautiful.

By the way, we saw glimpses of the Oregon/Wyoming game at Drs. Brent & Jennifer on the internet. Reception here is slow so it was in video "bites" that we saw at least 2 of Oregon's scores. GO DUCKS!!

We have a full OR schedule for this coming week.

God Bless You All.
We appreciate your prayers.

local produce and vendors

Rosemary and Nicholas Burket-Thoene

Shopping for clothes in market

Dr. Brent Burket & Student Sean Igelman of Medford working on HIV Research Project

We are here safely since late last Friday. Trip was long but no problems and all our luggage/supplies arrived with us. It was a long ride from Duala to Njinikom and raining off and on.  Weather here is tropical as expected and not too hot. So far it has rained every day, usually for a few hours.  We do not have internet or wifi, TV, radio or newspapers.

Our phones are useful for texting but it is taking several days for us to receive replies to our texts.  I am using a computer in the cyber center at the hospital and the power goes off frequently and I have to start over.

We have seen patients in the Outpatient Clinic every day this week and have a full day of surgery tomorrow as well as next week.  The Sisters, Doctors, Nurses and Staff are all very friendly, helpful and welcoming. The hospital equipment is quite satisfactory for our surgeries and we are looking forward to working in the OR tomorrow.  Rosemary has met with the OR staff to get acquainted and to go over our routines and equipment needs.  We brought a great deal of the supplies and instruments we will need for our time here.

We were met and welcomed by long term Missionaries Dr. Brent Burket and his wife, Dr. Jennifer Thoene. They have both been of great help to us and have worked with us daily to get oriented and settled.  They are truly a vital part of the Medical community here. Their 4 children are a joy to be around and we are getting to know them well.

More Later. 
God Bless You All
 

View from our front porch

Dr. Jennifer and Rosemary

Hospital Njinikom

Packing

We are now in the final stages of packing and preparation for our surgical mission to Cameroon. We are flying from Medford, OR on September 3^rd and will be in Cameroon 2 days later.  These past several weeks have been filled with getting our supplies ready as well as finishing up our vaccination schedule. It will be a relief when the last piece of luggage in finally packed.  We are really excited to be going to Njinikom, Cameroon where we will be working with long term Mission Doctor Volunteers Brent Burket, MD and his wife Jennifer Thoene, MD who have now been there for one year.

In this first post I will fill in a little bit about myself and my wife Rosemary.  I am a Plastic and Reconstructive surgeon and Rosemary is an Operating Room/Surgical RN.  We began our volunteer surgical missions in 1983 with a  month long mission in Indonesia.  We followed that with annual missions to Nepal for approximately the next 22 years.  In between we have worked in India, Turkey and most recently we have been going to Antigua, Guatemala for the past few years. I retired from active practice on July 1 of this year and now have the time to go for longer mission trips.  We have always wanted to go with a Catholic organization and work in a Catholic setting.  In addition we have wanted to work in Africa.  So that brings us to the present endeavor.  We attended the Spring Retreat for Mission Doctors in Los Angeles this year and began to make plans for the Cameroon mission.  The time has passed very quickly since that wonderful meeting and we are ready to embark. We will try to post to our blog with some regularity for our friends and followers.  We ask that you all keep us in your prayers.

Rosemary Packing Supplies