Day 4: Dakar
Morning coffee in the hotel is wonderful. Dark and strong. Senegal was a French colony until declaring independence just over 50 years ago. One of the lasting tributes to French culture is the pastries and cafés you can find in most restaurants and hotels. Other than the French language as the official language of Senegal (most prefer to speak their native tongue of Wolof), it is difficult for me to see the distinct influence the French had here. Dakar is a modern African city that predates colonization. An important port and airport established in the early days of flight with changes now being made. The new international airport is to open in 2015. Take a side street off the Place de Independence and you are in a different world. Just a few blocks from center city is Medina, a local neighborhood where no tourists venture; minarets tower above the low apartment buildings (98% of the population is Muslim). People are in the street everywhere. Animated discussion, neighbors congregate at all hours, children playing and vendors selling their wares. The cacophony of sounds from street traffic that clashes between horse-drawn carts and motorcycles, tro-tro’s, dented and rusted-out taxis, to the call to prayer five times a day. This is not Mt Lebanon.
Our OR schedule was disrupted by the loss of a long case. That gave some time to see some old patients; kids we hadn’t operated on in years. The families were really happy to see us. The connections made between families we have cared for have endured. Not only do we care how the children have done, but they somehow seem like family or friends that you don’t see often, but once together no time is lost. Although, I usually do not remember all my patients, I can imagine how they have grown over the last year and thrived, and sometime that is due to the work we do. But that is not what this project is all about – our mission is to teach doctors like ourselves how to care for these children.
A very common occurrence in Africa is trauma, mostly motor vehicle related. There are few sidewalks, and driving in Dakar is a free-for-all. Kids get in the path of a car and the resulting pelvic crush injury causes significant damage to the urethra, usually tearing it away from the moorings of the pelvic floor. We see many kids with rubber catheters placed through their lower abdominal wall into the bladder to manage the inability to urinate normally. While local doctors do the correct acute response, a suprapubic tube is a poor long-term solution. These patients are kept in a holding pattern until more experienced surgeons can help. Reconstruction of the urethra close to the sphincter is complicated and could result in difficult problems to manage such as incontinence or re-occlusion due to scarring. We managed to take care of two patients with urethral strictures in two different manners. In one case, the scarred urethra was excised and rejoined deep in the pelvis to the prostate. In the second, an unfortunate 19-year-old boy; body wasted away from poor control of his diabetes and the size of a 12 year old, developed a long stricture due to repeated catheter trauma and infections. A two-stage procedure was felt to be the best option, replacing the urethra with buccal mucosa (inside lining of the mouth). In a year when we return that tissue, quite similar to the urethra, he will have gained blood supply from the underlying tissues and will be ready for reconstruction.
We also received good news. The family of the bladder exstrophy patient was granted some government money to pay the hospital. His case is now back on.
Fran Schneck, MD