2016 Togo Blog

Dr. Cheatham and his family have been serving since 1986 on short-term medical mission trips through Samaritan's Purse & World Medical Mission, Inc. In August, we will be serving at Karolyn Kempton Memorial Christian Hospital (KKMCH) in Togo, West Africa. For those that are interested, I will be maintaining a blog detailing our experiences. Internet access may not always be reliable, but I will try to post interesting cases and photos on a daily basis. If you have questions about what we are encountering here, feel free to drop me an email.

July 29, 2016
We headed to the airport today to begin the first of four flights from Orlando to Lome, Togo via JFK, Paris, and Niamey (Niger). Our flight to JFK was initially delayed 30 minutes by weather in New York. Thirty minutes became 60, then 90, and ultimately 6 hours. Since we missed our connection in New York, we were advised by Delta to rebook on a later flight. Given an airline strike by Air France, there were no seats available to Togo for 2 weeks. After 7 hours at Orlando International Airport, we retrieved our baggage off the JFK flight and returned home to regroup. We are now scheduled to depart for Togo on a different airline on Sunday. This delay will give us some much needed family time as well as the opportunity to pick up some medicines that are needed at Hopital Baptist Biblique that were unavailable until today.
A Cheatham Family selfie as we prepare to depart Orlando (or so we thought).

July 30, 2016
We spent most of this morning trying to rebook our flights to Togo. The Air France pilots have started a strike yesterday and there are no seats available to Togo for the next two weeks. We tried to rebook on KLM, but they do not have any seats available until the end of next week. We were finally able to locate seats tomorrow evening on Ethiopian Airlines. We are currently scheduled to fly up to Newark tomorrow afternoon on Jet Blue and catch our new flight to Togo!

July 31, 2016
We awoke this morning and prepared to return to Orlando International Airport for our noon flight to Newark. As I was printing off our new itinerary, I received an email from Jet Blue informing me that our flight had been cancelled...again! Bad weather in the northeast was again the explanation. Jet Blue proudly explained in a voice mail that they had rebooked us for tomorrow. The problem is that Ethiopian Airlines does not fly to Lome again until Tuesday... We are working to rebook our flights.

August 1, 2016
We left Orlando today and flew to Newark a day early to be sure that we are there to catch our flight tomorrow evening to Togo. We took advantage of the extra day in the northeast to drive down to Susie's parents. We had a delightful visit with them in Maryland.

August 2, 2016
We returned to Newark and made sure that we were at the airport in plenty of time to ensure that we did not miss our flight. Ethiopian Airlines was very nice. Surprisingly, the flight was not full as had been the issue with most of the other airlines we had tried to rebook on. We all breathed a sigh of relief as our flight left the ground and departed for Africa.

August 3, 2016
We landed in Lome, Togo, a bit after noon today. Our flight from Newark was uneventful, a welcome change from the previous few days. All of our luggage arrived and nothing had been pilfered during the trip as in previous years. The Lome airport is brand new, beautiful, and much different from our arrival last year. We loaded our luggage and drove up-country to the hospital. It was great to see old friends as well as make many new ones upon our arrival. We turned in early as all six of us were exhausted from the travels of the past few days.
Entering Kpalime, Togo. We followed this truck for many miles and none of the 12 guys in the back fell out...thankfully! It was great to finally arrive!
How many potential trauma victims can you count? No wonder we see so many road traffic accidents in Africa.

August 4, 2016
Our first day at Hopital Baptiste Biblique (HBB)! Dr. Eric Miller is the new full-time surgeon here having just started on August 1. Dr. Sam Williams, a fellow World Medical Mission volunteer, is here until this Saturday when he returns home after a one-month stay here. For the next few days, the three of us are providing surgical coverage for HBB.

Eric Miller and I started today with an exploratory laparotomy for possible lymphoma. The tumor was quite large and unresectable, involving multiple small and large bowel loops as well as the superior mesenteric artery. We had planned on performing a palliative gastrojejunostomy, but were concerned by his poor nutritional status. We decided that the risk of a leak due to a poorly healing anastomosis outweighed the risk of imminent obstruction. We therefore biopsied an omental implant to send back to the States for pathology in the hope that 1) this represents a lymphoma and 2) he can receive chemotherapy here in Togo.

We then took a young woman to the theatre for thyroidectomy. She has had a goiter for over 5 years. She has complained of voice changes and tachyarrhythmias, the later of which are controlled on beta-blockers. Despite four attempts to intubate her, however, the anesthetists were unable to secure an airway. Eric decided to cancel the case until an anesthesiologist is available given her difficult airway and the lack of a mechanical ventilator here.

As we exited the theatre, word came that there was a 7 week old baby with persistent vomiting and failure to thrive. A barium swallow study revealed a distended stomach. Palpation of the epigastrium identified a classic "olive" consistent with hypertrophic pyloric stenosis. We took the child to the theatre and Eric performed a pyloromyotomy. It was very gratifying.

The barium swallow for the infant with hypertrophic pyloric stenosis. Note the enlarged stomach.
The completed pyloromyotomy.

August 5, 2016
The infant with pyloric stenosis from last night is tolerating feeds without vomiting this morning. It always amazes me how a simple operation and the availability of a hospital to perform the procedure can make such a big difference for both patient and family.

Dr. Neil Martin, an OB/GYN from Florence, Kentucky, arrived last night after several days of travel difficulties such as ours. Neil allowed me to assist him with a Caesarean section this morning which was a good refresher for me. Eric and I followed this with a 7 week old who presented this morning in respiratory distress and oxygen saturations in the 80's. Chest x-ray revealed large bilateral pleural effusions. We took the child to theatre and inserted bilateral 12 French chest tubes (!), evacuating pus from each hemithorax. We currently have the infant on CPAP to try and recruit his collapsed alveoli and improve his oxygenation.

Malignancies are common here. I performed a lymph node biopsy on a young man with probable sarcoma of the leg this morning while Eric performed a similar biopsy on a man with obvious Burkitt's Lymphoma of the face and neck. These biopsies will go back to the United States for pathology with the results being emailed back to Togo in the coming days. After lunch, I performed a bone marrow biopsy on a young lady with splenomegaly. The microscopic slides made of her marrow were photographed and emailed back to the States this afternoon to be read by an oncologist there. We should have the results back by tomorrow. The Internet is a wonderful tool for missionary medicine.
An aerial view of Hopital Baptiste Bliblique also known as Karolyn Kempton Memorial Christian Hospital.

August 6, 2016
I was on surgical call last night, but the night was quiet, likely due, in part, to the rain that fell most of the night. I am also on call today. Eric Miller and I start every-other-night surgery call this weekend as Sam Williams will be heading back to the United States later today. It will be interesting to see what the day brings!

We started this morning with breakfast at Michael and Cheryl Gayle's home. Michael is the Medical Director for HBB and it was great to catch up with them. We then headed to the wards to begin morning rounds. Sam and I made rounds together so that he could checkout a number of patients that he has been following for chronic wounds. By the end of rounds, we had identified five patients that will all need split thickness skin grafts this coming week. This is on top of the elective cases that are already scheduled (including a mastectomy, multiple inguinal hernias, and three anal fistulas). Skin grafts are commonly required procedures on the mission field, but few hospitals have much in the way of skin grafting supplies. We have a Padgett dermatome here (my favorite!), but no debriding knives. As a result, I now carry a Weck knife and Watson knife with me which should come in handy this coming week.

We discharged a number of patients this morning. The Burkitt's lymphoma and the sarcoma patient will go home to await return of their pathology results in 3-4 weeks. The abdominal lymphoma patient was also discharged, but will stay at the "Cuisine", an area of the hospital grounds where patients can stay if they live long distances away and still receive daily dressing changes, etc... at the hospital. We also applied two wound VACs to patients in preparation for skin grafts this week. Michael asked me to see a middle-aged woman who presented with right lower quadrant abdominal pain. In the States, we would have been thinking acute appendicitis. In Togo, this was certainly on the differential, but typhoid became more likely given a normal WBC count and a negative ultrasound.

Since I have to stay on the hospital compound for call, Susie and the girls are hiking up the nearby valley to the local waterfall. We enjoyed this hike very much last year. Since Amelia was not with us last year, this seems like the perfect opportunity for her to see it as well.

The local waterfall which is a 1.5-2 hour hike up the valley. It is a beautiful wake through villages and farms growing cocoa, bananas, tea, and coffee.

August 7, 2016
My first two nights of surgical call at HBB have been uneventful. Eric Miller and I made rounds this morning on the surgical patients so that we could review each of the patients that Sam Williams had been caring for. This took us until noon even though the surgical patient census is not very high right now.

After lunch, Susie, the girls, and I walked up the road that crosses back and forth up the mountain that HBB sits at the base of. We hear the horns of cars, trucks, and motorcycles navigating the hairpin turns of the switchbacks at all hours of he day and night. It was finally nice to see the surrounding valley from an elevated position. We hiked about two miles up the road (avoiding the cars, trucks, and motorcycles whizzing past) before we reached the top and turned around and came back down to HBB.

Tonight we had devotions with the missionary staff and desserts afterwards. Susie and I went down to check on the 7 week old with bilateral empyemas. He continues to drain purulent fluid and we are placing him on and off CPAP every 3 hours to try and recruit his lungs. We will obtain a chest x-ray on him in the morning to follow his progress.

August 8, 2016
Today was a very busy day since we are now down to two surgeons. We started with rounds and dressings changes followed by a modified radical mastectomy in a young woman who had advanced axillary nodal disease present. Her chest radiograph suggests bone metastases as well so this was largely palliative. It took longer than anticipated. After a quick lunch, I did a pericardiocentesis in a 17 year old boy who presented with an infected knee joint and sepsis. He has pericarditis by ultrasound and EKG. We sent the pericardial fluid for Gram stain, AFB, and culture. I then headed to the clinic and quickly saw ten or so patients before heading back to the operating theatre with the intent to perform a debridement and split thickness skin graft The infected wound, sustained when a tree fell on the young lady's foot, was full thickness and definitely not ready for grafting. It will likely require a VAC for a week or more before we can place a skin graft. After seeing another group of patients in clinic, I did a quick hydrocelectomy. It was then back to clinic. Eric Miller was also operating and seeing clinic patients between cases as well. Despite this, we still ran out of time and there were probably ten or so patients that we could not see before clinic closed at 6 PM. These patients will have to come back in the morning to be seen.

I am on call again tonight and started off the evening with an emergent suprapubic catheter insertion. The 81 year old man had initially presented to a hospital in Ghana where they were unable to insert a urinary catheter. We then drove all day to HBB where two further attempts by the clinic staff to insert a catheter were unsuccessful. I don't speak his tribal language, but the look on his face said it all once the suprapubic catheter was in place and draining. He must have been miserable! I followed this with a exploratory laparotomy in a patient with an acute abdomen and septic shock. His KUB showed no free air so I suspected typhoid perforation, but we found a perforated peptic ulcer instead. I repaired this with a Graham patch. Upon finishing in the theatre, I stopped by to check on the 7 week old empyema patient. Susie and I drop by his bedside repeatedly throughout the day and evening. His parents have been at his bedside non-stop. He has had a rough day today with worsening in his chest x-ray. We placed him back on CPAP this evening. I irrigated his tiny chest tubes and placed each on its own Pleuravac (we had originally placed both tubes on one Pleuravac to try and save these valuable devices). We will repeat his chest x-ray in the am and see how he does. After a late dinner, and typing this blog, it will be time to turn in and see what else comes in tonight.

August 9, 2016
We started the day today seeing the clinic patients that we were unable to get to last night before the clinic closed. We then had todayís surgical patients to see as well. Eric Miller and I bounced back and forth between the patient wards, the clinic, and the operating theatre where we repaired an incarcerated epigastric hernia as well as debrided and VACíd a young babyís abdominal wall wound caused by necrotizing fasciitis. A young man presented to the clinic with spontaneous rupture of a scrotal abscess which we took to the theatre for debridement and packing.

The 7 week old with bilateral empyemas has had a rough day with bradycardic episodes and lethargy. After discussing the child with a pediatric surgeon and a pediatric intensivist back in the States, we began irrigating his chest tubes this evening with saline to try and loosen up the thick purulent fluid. The chest tubes now appear to be draining better and we will see how he does this evening.

As I was irrigating his chest tubes, I had the acute onset of severe left flank pain. To make a long story short, I am experiencing my first kidney stone! Michael Gayle performed an ultrasound on me. I ultimately ended up with an IV as well as intramuscular Tramadol and Phenergan. I am now an inpatient at HBB! The staff isnít sure what to make of me lying in one of the beds with an IV, but they are providing me with great care.

August 10, 2016
Please remind me to avoid having another kidney stone. Not fun! The HBB staff has been great however. After three liters of saline and a few hours of fitful sleep, I am feeling much better and have been discharged back to the guest house to continue to recover. Eric Miller and I are going to flip call nights tonight.

The empyema baby is much improved this morning. Eric is placing a central line in him as we cannot get IV access and an interosseus catheter placed last night has stopped working. The output from his chest tubes has increased markedly however and he seems to be feeling better.

I am going to take it easy today (Michael Gayle's orders) so that I can get back to work tomorrow. We currently have a number of operative cases scheduled.

August 12, 2016
I was readmitted to the HBB ward early yesterday morning with recurrent flank pain. A KUB reveals a stone in the left ureter. We started the intravenous hydration once again in the hopes that it would pass. After a number of hours of hydration and intravenous pain medications, we have not made much progress. After several long discussions, we have decided that I am more of a liability than a help here at HBB. Susie and the girls are already scheduled to return to Orlando tomorrow so that they can start school on Monday. We have decided that it will be best if I fly back to Orlando with them and continue treatment for the kidney stone there. We are limited here as to what can be done other than waiting for it to pass. We have managed to get two additional seats, for Amelia and me, on tomorrow's flight.

This is very disappointing, but Tom Kendall is ready to start work as a full-time general surgeon here along with Eric Miller. They are two dedicated surgeons who will no doubt change the face of surgical care here at HBB. We will look forward to returning to Togo at some point in the future.

August 14, 2016
I had a CT scan of the abdomen and pelvis last night at ORMC confirming the left ureteral stone. Still hydrating and hoping that it will pass. If not, cystoscopy is planned for tomorrow.

Leaving Togo and HBB, while difficult, was the right decision. I would not have been able to contribute much to the work that is being done there and would only have added to their workload. I cannot say enough about the care that I received at HBB by the missionary physicians and staff. They were excellent. HBB is preparing to enter a phase of significant growth in the coming years that will allow it to become a major referral center for West Africa. We can't wait to see how it all turns out.