Dr. Bob Wolf in Cameroon

I just got home from dinner and a Bible Study with 20 medical people, including 14 American medical missionaries and 2 Australians, whom I would never have known if I hadn't come here. Roy Winslow, a General Surgeon from Michigan, came in 2 days ago and will be here for 4 weeks. He has done this for years and spent a lot of time in Rwanda, where he and his wife were evacuated by the Marines in 1994 during the genocide. He, like everyone else I have encountered here, is an amazing guy and model of servanthood. He works in the same multispecialty group that sent Dan and Elaine Metzger, family practice docs who went home Sunday, and Rick and Debbie Bardin, the pathologist and HIV nurse who are here permanently. Their group supports this type of service and has a number of long term missionaries that they fund as well as short term people like Roy and the Metzgers. 

I never knew such work was being done in the name of Christ before coming here. This has been a wonderful experience and I would encourage anyone interested in medical missions in any capacity to just do it. All my fears before coming were basically unfounded, the Christian fellowship was beyond my expectations, and the sense of fulfillment would be difficult to surpass. The blessing that you receive from coming to a setting like this far outweighs the work that you give. And you don't have to be a doctor or nurse to serve in places like this - anyone with a desire to serve can find a role where they can bless others.  

It sure puts life in perspective.

I came here through Medical Teams International in partnership with the Cameroon Baptist Convention, and I am thankful for their leadership. They have many opportunities worldwide for people who are interested. Other organizations like Samaritan's Purse, Global Health Outreach and others were responsible for placing some of the others here, both short term and long term, so there are many avenues available.
 
In Christ,
Bob Wolf

Good day today. Working with chief resident Dugall Mfilia, a 5th year surgery resident from Zaire. Great resident who is going home after he is done and wants to learn as much as possible before then. We did a couple cases that I have not done before and two that I did for the first time last week.  

The first was an 11 month old child with a flexion contracture of the hand on whom we did a multiple Z-plasty contracture release to correct the deformity, which worked quite well. Fixed an inter-subtrochanteric femur fracture with a distal femoral plate and no fluoro - my second one in a week (and in my life), sequestrectomy of the tibia in a child with a bad tibia fracture non-union and osteomyelitis, femur/tibia ex fix removal/i&d on a patient with osteomyelitis and non-union in both areas and probably needs an amputation, and fixed an ankle fracture dislocation in standard AO fashion, which the residents really liked.

Saw vertebral TB (Potts disease) for the second time in my life, then was asked to see another case that may be the same thing. 

Working with the residents and staff here has been great--they are all extremely motivated to learn new techniques, and kind hearted about teaching me how to treat levels of illness I've never encountered before.

I was sitting with about seven of them today and asked them if any had had malaria before. They all laughed at me, as each has had it multiple times. They take it in stride. I am finishing my two weeks here Friday, and have been truly blessed by the experience. 

I will be back again, hopefully for a longer period, to experience the blessing of working in such a wonderful environment. The medical hardship here is intense, but so is the presence of Christ.

Bob

Did a few cases with the residents and saw some clinic patients with tough problems.

The new resident started on my service Monday and is a great guy. He is from Zaire and is returning there to practice when he finishes his general surgery residency this year. A very strong Christian, good surgeon, who cares well for his patients. He will be the only surgeon for his town, that has a population about 250,000. This means he will be on call every night and do all the surgical cases (general, Ortho, ENT, OB GYN, etc.).  

These guys have to be able to treat everything here--a very tall order. We did several cases together - tibial Sign nail, carpal tunnel release in patient with deformity of distal radius and carpal tunnel syndrome from old fracture, ORIF of ankle fracture, ORIF of displaced open patella fx about 6 weeks out, multiple digit amputation right hand same patient for trauma/ infection, I&D of open humerus fracture with severe infection.

They like being taught some of the more simple/low trauma cases because they don't get much of a chance to do these types of procedures with the overwhelming trauma present.

I saw another child today, about 6 years old, with very bad chronic osteomyelitis of the tibia from an old infected fracture, exposed bone over most of his leg, unhealed fracture. Most of the techniques recommended in the orthopedic literature to treat this kind of problem, which I have never seen in the US at this level of severity, are not possible here due to technical limits. We want to avoid amputation, but this may be inevitable with a destructive infection this severe and with limited options. Other patients with neglected hip fractures, femur and tibia fractures, elbow infections, shoulder fractures that we are unable to offer interventions for here. The infections here are very severe due to a number of factors: delayed treatment, poor sanitation and hygiene, limited antibiotic options, no ability to culture wounds and determine the actual cause, high HIV prevalence, etc. These factors result in overwhelming infections with limb salvage often not being an option.

More good fellowship with the other doctors. We commiserate with each other and try to help find solutions. Please keep praying for these people.

Thank you and God bless. 
Bob

More surgery, more admissions with problems that are hard to fix, more learning new ways to reach an endpoint. 

I fixed a intertrochanteric hip fracture in a Fulani lady first. We usually use a compression hip screw or IM nail under fluoroscopy but none of the above available so we had to improvise. I  used a distal femoral locking plate and a combination of 6.5 and 4.5 screws and made it work. I was praying about that one last night.  


Also did a quadriceps tendon repair that was torn for at least several months (also had ankle fracture in same leg), ex- fixed an open, comminuted supracondylar femur fracture, took out a retrograde femoral nail and hardware that was causing knee problems, reduced a distal radius fracture and placed a femoral traction pin in a morbidly obese lady with a hip fracture that we can't fix here. I saw a child, about 6 years old, with severe osteomyelitis of the tibia. He had an open wound on his leg from his upper tibia to ankle with exposed, contaminated tibial bone that had been present for several months. We will try to clean it up and mobilize the surrounding soft tissues enough to get some coverage and try to prevent amputation. We can't do the types of flap transfers that would help with this. Another patient with external fixators on both femurs and left tibia that have been there for about 3 months has an infection so severe that he needs an above-the-knee amputation, another guy needs part of his hand amputated, more of the same. It's a bit depressing when there are so many people with bad problems that could probably be fixed in the US - but I'm not in the US. God is good and we do our best.

Going to dinner at Rick and Debbie's house tonight - he's a pathologist and she's a nurse in the HIV ward, both Americans who live and work here now as medical missionaries. The fellowship has been great. Everybody understands the stresses of being a medical person here and they try to keep you going. 

I went to the school for the deaf, about a quarter mile from where I'm staying, with Rick and Yvonne Snell yesterday. Rick does general surgery and Yvonne has been working in the school for the deaf while here for a month. There are about 130 kids of all ages who live there as a boarding school. They are beautiful kids and were very happy to see us. Yvonne organized some crafts and Rick and I did our best to help. They loved getting their pictures taken, so we did a lot of that. Came home last night and had 7 REALLY BIG spiders on the wall above my bed - killed about half, the rest are under my bed I think.

Please pray for my patients, especially the kids, and for wisdom in providing care for them. 

God bless.
Bob

Here is our OR team. Great, hardworking guys that are doing good work in very limited facilities. A joy to work with.




Many of the motorcycles on the road have Christian messages on the back. 
  

The lady with a back injury and fevers that we were working up for malaria actually has HIV, for which she will now get treatment. I don't know the prevalence of this in surgical patients, but likely to be high. The medical ward is about 80% HIV positive. One interesting trait of the medical people I have met here is their relative lack of concern for all the things I got worried about when planning this trip. Malaria, schistosomiasis, leishmaniasis, filariasis, dengue fever, sleeping sickness, HIV, TB, meningitis, yellow fever, etc, etc are supposed to be endemic here, which could certainly make anyone from the US hesitant to come and certainly a little anxious. 

But these people exude a spirit of trust and confidence in God's provision which makes those fears evaporate. They are not foolish and do take appropriate precautions, as they are medical professionals who may treat these diseases here and witness their manifestations. Three of them that I know of have had malaria despite taking the prescribed prophylaxis in the past, so they have more intimate first hand experience also. Many of them have decided to live in places like this despite these risks. But they share the common trait of a living faith that manifests itself in their willingness and enthusiasm to come to areas of the world where no one else wants to go, treat people that no one wants to touch, and maintain a peace of mind and spirit derived from a true knowledge of the goodness of Christ. They are the hands of God.

Went to church at Mbingo Baptist Church today. Great message, focusing on the promise for suffering and not luxury in the Christian life here on earth, with the reward of an eternity with our Lord that will wipe away the pain we now experience. He really came down hard on the false teaching of prosperity gospel, noting that the poor people suffering in our hospital were not there because of their sin or lack of faith, but because we live in a fallen world. It reminded me a lot of the sermons our pastor in Birmingham often preaches, except that this service was a little longer - 3 1/2 hours! 

Rounded on our patients and did my best to get them the treatment they need. It's been hard to figure things out here on multiple levels: language barriers (they speak French, Pidgin, English, and tribal languages), medical terminology barriers (the same meds have different names, different meds are used, and the ones I use are not available), and constantly trying to determine what level of intervention we are capable of providing without offending anyone's sensitivities. 

It's hard. Went to the theater (OR) to try to find the implants I will need for the cases scheduled for tomorrow - I think we'll be OK. More stuff I've not done before without a lot more technology - God's in charge.

Bob

Less work is done today, only "emergencies", which are hard to define. Almost everything on the ward here  - correction, everything on the ward here - would be considered an emergency back home. I rounded on the A Ward, which includes about 25 or 30 beds with orthopaedic trauma, all in the same room. The residents are very good from what I've seen. They may lack alot of the technological advancements we have back home, but they make up for it with the intensity and volume of medical and surgical illness they encounter. 

I was able to go on a hike up into the mountains to one of the waterfalls on the back side with the Streatfields (Australian anesthesiologists) and Mark and Yvonne Snell. Mark is a general surgeon in Washington state, retired Air Force, who is on his 10th medical mission. This is his 4th time to Cameroon, and he has also been to Liberia a couple of times, Nigeria, Ecuador, and Venezuela.  The hike took 4 hours, as we went from about 5000 feet to 8000 feet elevation, through the jungle, up to the waterfall. We saw some Fulani horseman and some of their cattle on the way. They graze them on the mountainsides, which are very steep. The Fulani are Muslims, as opposed to the Bantus, who are largely Christian Cameroonians. 

Got hit pretty hard with the rain on the way down, and it hasn't stopped since. It usually rains very hard here once or twice a day, and then dries off. Rainy season runs from the spring through November, which is why everything is so green. This is good for crops, which include papaya, pineapple, guava, banana, coffee and cocoa among other plants. During dry season the dust blows off the Sahara, which makes it hard to see and causes a lot of breathing problems I am told.

I will go to the Snells' for dinner if I am not called by the residents for something urgent. One of the great blessings of being here has been the fellowship with the other physician families, and hearing of their experiences now and in the past doing medical mission work. They give me a level of support that is sorely needed and greatly appreciated. Please continue to pray for my patients.

God bless
Bob

Ended up doing 3 cases after being bumped for emergencies. Femoral nail, bridging knee external fixator for bad infected/open supra/inter condylar femur fracture, ex fix/ carpal tunnel release for distal radius with traumatic CTR, all without fluoro or X-ray. Lots of cases that had to wait including open femur fracture, intertroch fracture we will try to fix with what they have here, another we'll treat in traction, open patella with ipsilateral acteabular fx (fix patella), and saw lots of cases I can't do much for due to our technical limitations. 
 
Need prayer for the young patient with the infected open humerus fracture that was ex fixed - bad infection, hopefully will get better with the treatments we are giving. Also for all the people I can't help.

Had dinner with two docs from the US, who both used to work together in Michigan. Rick is a pathologist (lots of pathology here) who lives here with his wife, a nurse who works on the HIV ward. They've been here 2 years and are planning to stay forever. They both were medical missionaries in Nigeria in the 90's with International Mission Board, went back home, now are here to stay. Dan and Elaine Metzger are family practice docs from Michigan who have been here for a month and are leaving Sunday. Their group is a Christian multi-specialty  group that encourages its partners to do mission work. Very cool. They worked on a medical ship called the Mercy Ship in Sierra Leone in the 90's and also lived there caring for the sick for a couple years, kids and all. Kind hearted people who I've eaten dinner with each night. Please pray for safe travel. Lots of doctors and nurses here and elsewhere doing good work, often for months and years at a time, sacrificing for the welfare of others, whom I as a physician never even knew existed before coming here.

Bob

Church at 640, surgical meeting with residents and staff next, then rounds and surgery. Lots of severe orthopedic trauma in the ward : beds all right next to each other with people with open fractures, multiple fractures, infections, etc. One man had external fixators put on both femurs and left tibia 3 months ago and is not close to being healed, multiple others waiting for surgery, little kids right next to adults with amputations, fractures, osteomyelitis, a lady with a back injury and high fevers getting worked up for malaria, all kinds of bad problems. One patient came to the clinic a week out from an MVA with quadriplegia - not much we can do, no way to image the spine other than X-rays, which were suboptimal. Another with an open arm fracture 7 days out, etc, etc. 

Performed 3 surgeries: IM nail for femur fracture, ex fix for open tibia fracture, bridging elbow ex fix for open humerus fracture after motorcycle accident at least 7 days ago already infected. No X-ray or fluoroscopy possible for any of them - good thing I have X-ray vision.

Gave a talk on open fracture management to the PAACS residents despite the fact that they treat a lot more of this stuff than I have ever thought about.  Most of the treatment protocols we use in the US are ridiculously impractical here, but they were very interested in our approach to this problem. 

The surgical residents and staff all had a Bible study before my talk, with everyone present. The topic was Jesus' approach to judgement and humility, and the importance of the evidence of that teaching in our daily walk. The specific verses came from the incident where Christ forgave the woman caught in adultery and told those who wanted to condemn her that he who was without sin should cast the first stone. The interaction was insightful, and the idea of a surgery conference focusing on humility and servant-hood was certainly something new for me. 

What a blessing. The staff have a Bible study tonight that the Streatfeild's (Australian medical missionaries) lead and I'll be going there shortly

Bob

Chapel, rounds, then 3 cases and some clinic. The boy with the arm infection was a little better. First case was a carpal tunnel. Next a guy with a femur fx above a Sign nail that was placed retrograde.  The distal fx was healed fairly well but not completely. Took the nail out first, then went antegrade but the nail came out medially through the older fx, which was healed in a slightly translated position, and the nail was too short to go antegrade and cross both fx sites adequately.  This was the longest nail they had, so went back retrograde and buried it, which worked. Next a sequestrectomy on a 6 yr old boy with chronic osteo of the ulna. Poor child. Lots of open fractures from MCA's [motorcycle accidents] on the ward. The Chinese started selling cheap motorcycles here about 10 yrs ago and trauma has skyrocketed since.  

We were discussing Cameroonian healthcare with the residents and other staff during a break and some interesting facts came out. The PAACS and CIMS training programs are Christian programs which make the residents commit to practicing and serving in Cameroon or Africa after graduation. There is another program in Cameroon where the residents universally leave the country, usually for France, after graduation, I am told. The US has 11% of the worlds healthcare burden/need and 30% of its physicians, while Africa has 30% of the world's need and only 5% of the physicians. While this is easy to understand in view of the economic luxury of living in the west versus the countries here, it creates the neglect and desperation that is so evident here. Two of the American physicians here lived in Sierra Leone with their kids during the 1990's before the civil war, where the situation was much worse. 

50% mortality for children before the age of 5, such that parents often did not name their children because they would not want to get too emotionally attached, only to lose them. 

Another physician resident in the PAACS program was born in Angola and lost both of his parents during the Civil War there. He has a wife and 5 children, three of whom he adopted at home in situations similar to his. They are nearing high school graduation now and he will adopt more. He plans to return to Angola to help rebuild after finishing here. Christ came to inspire us to such acts of mercy.

Four cases so far tomorrow: Sign IM nail for mid shaft femur fx; ORIF of intracondylar distal femur with plate (large frag plates with 4.5 screws available, nothing fancier) - should be interesting with no fluoro; ORIF inter troch fx with same plates as above no fluoro again; ex fix open distal tibia; i&d, ex-fix open humerus fx. 

I also am scheduled for Chapel, a surgeons meeting, supposed to give a lecture and have a Bible study on the Book of Luke tomorrow night.  Should be busy.

Bob

Introduced to the staff this morning at the 6:40 chapel service, which is held every morning, with attendance expected! Rounded on the ortho ward with the staff - lots of severe trauma, neglected treatment, BAD stuff. Did my first case - subtrochantic comminuted femur fracture - with a Sign nail. No fluoro like I'm used to, new technique, but it worked. I was quickly broken of my sterility paranoia by the way they do things here, kind of like a MASH unit. They do a great job considering what they're dealing with. The best part was praying for the patient as a group before cutting skin - including the patient himself, if it is a spinal.

The hard part is the level of trauma and neglect present before treatment - these would be hard cases in the US under optimal conditions. Second case was a tibia fracture nonunion 1 1/2 years out - osteotomy, takedown of nonunion, Sign nail.  Third was a boy with an open humerus fracture from a motorcycle accident at least several days out with a terrible infection - possible necrotizing fasciitis - which I cleaned out and will bring back for an ex-fix in a couple days. I pray that he is doing better then - this is a bad place to have an infection that severe. No vancomycin, poor hygiene, and no cleanliness - a set-up for amputation or death. 

Last case was a young boy (about 7) who had a crush injury to the right hand about a week ago that was pinned and then the fingers died.  Had to amputate his thumb, index and middle finger. Also saw some cases from clinic where they needed advice. Two year old boy with congenital tibia deformity - probably neurofibtomatosis, which I've never seen in practice- who may need amputation eventually - I pray not. Other cases not as bad. 

Had dinner with a medical missionary couple , typing, then going to sleep. There's a dog howling right in front of my window so that may be tough.  I'm really starting to appreciate clean water, which is thankfully available here. They filter it and give it to you in plastic bottles - I've been drinking it and am not sick.  The guy docs want to take me for a hike Saturday and see the waterfalls from the mountain tops - in one spot you can see 7 different ones at once. That would be great.  

Praying for a blessed day tomorrow, for my family's safety and comfort, for good news from home.

Bob

We drove 7 hours to Mbingo this morning and afternoon. Through the city and into the country on narrow 2-lane roads most of the way, people driving in both lanes in both directions, lots of motorcycles with no helmets, buses and cars overflowing with passengers - very chaotic.  Security stops every so often and a lot of markets along the road where people stop traffic and sell fruit, just trying to survive. Through banana plantations and papaya and pineapple orchards up into the mountains. The roads were pretty dangerous- my son Luke would not have enjoyed this.

Finally got to Mbingo and the hospital. Beautiful surroundings in this isolated area. Steep green mountains with waterfalls surrounding the hospital, eucalyptus forests, cloud-covered peaks. Nice and cool - actually cooler than back home!  Mbingo was founded as a leprosy hospital in 1952 by North American Baptist Missionaries -hence it's isolation. The hospital is actually quite amazing - 4 surgery "theaters", 5 wards for patients, training programs for internists (CIMS - Christian Internal Medicine Specialist program), surgeons (PAACS - Pan-African Assoc of Christian Surgeons), CRNA's, and other support staff. 

The patients stay in group wards without any walls or dividers and must have a caregiver stay with them to provide food and care to get admitted.  The care givers sleep outside on the ground--true dedication.  

People travel from far away to get here, which is very difficult due to the isolation, because the medical care is too costly in the city.  One of the wards is called the "ulcer ward" because it used to be for the lepers, who developed neuropathic ulcers from the leprosy bacillus invading their nerves. It's for diabetics now because leprosy is rare. HIV is not. 80% of the medical patients have it, and TB is common too.  

God will protect us. We are covered by the blood of Christ. Desperate need is everywhere here, where suffering is great.

Bob

Flying over the Sahara desert. Hundreds of miles of desolation as far as I can see from 20,000 miles up, for hours of flying now. Over three hours at 600mph and nothing but desert - now starting to see some trees. Will be in Douala in 90 minutes. Here we go. Lord please help me with getting my medical supplies and personal belongings through customs. Amen!

Airport was unnerving, but got through security without problems. The baggage claim area was complete chaos - people trying to get your luggage for you - for a price- lots of harassment , but they're just trying to survive. My bags actually got here - a miracle of God! - and got the medical supplies.

I was picked up by George Ngwang from the Cameroon Baptist Convention (CBC), who was a true blessing. He took me to the European Baptist Guest House, where I collapsed in comfort. Slept under a mosquito net for the first time - kind of hard to relax under that. Met some nice people there,  Keith Streatfeild and his wife, who were medical missionaries from Australia, as well as some others including Jim May, a retired Marine from Lebanon, PA, near my hometown, who was doing mission work and outreach in Douala. These people really blow me away. Keith and his wife started this in 1983, after he finished his anesthesia training, in India for a group called the Navigators.  He treated lepers, who had great difficulty finding medical care from anyone else. He filled me in on the manifestations and treatment of this terrible illness on our way to Mbingo. They also lived in Ethiopia for 6 years and have done two 9-month stints in Cameroon.

Bob