A Class Act

“Watch out for the Ureter, I think I see it under there…” Ryan Hayton (General surgeon) exhales as he lifts the tissue with a right angle. “Don’t worry about the Ureter, I’ve got the Ureter” David Hadley (Urologist) asserts as he picks up the lymph nodes with his DeBakey (long tweezers). “It’s so nice to have your company in my case” chuckles Casey Graybill (OB/GYN), glancing up from her dissection of the bladder away from the uterus. The three graduates of the LLU SOM class of 2005 pause amidst their banter to delegate the important parts of the case to each specialty represented at the table. “I normally have to worry about that darn ureter”, says Ryan, while David responds, “I told you, I’ve got the Ureter. You worry about the bowel.”  Graybill reminds her classmates and colleagues, “Let’s make sure we can keep one ovary, she’s only 36.”

(Casey Graybill, Ryan Hayton, David Hadley)

The patient on the table is Linly Thamu.  She came to Malamulo’s Women’s Center (which began under the direction of Dr Cristy Shank SOM’ 04) for a routine check up. When Linly was examined in the Women’s Center Dr Graybill suspected she had cervical cancer. A biopsy confirmed that Linly had cervical cancer so she was referred to Ryan Hayton for a pre-surgical work up to see if the cancer was resectable.

When Ryan Hayton arrived in Malawi in 2010 he was a new graduate from a 5 year general surgery training program at St John Hospital in Detroit, MI. There was no OB/GYN at Malamulo and he quickly found his skills as a general surgeon needed expanding to include OB/GYN, Urology and Orthopedic capabilities. Ryan’s father an OB/GYN SOM ‘73B had worked at Malamulo from 1985-1991 and was delighted to return to Malamulo to assist Ryan ‘see one, do one, and teach one ’ with a focus on difficult cases such as VVF, RVF and Radical Hysterectomies. Adding to Ryan’s depth of knowledge and skills was Ron Mataya (OB/GYN who trained under Bill Hayton in Taipei Taiwan), Danielle Mason SOM ‘05 and Scott Nelson SOM ‘96 who came out to Malamulo to teach and equip the hospital’s only surgeon during 2010-2014. With each exposure to an OB/GYN, Urological and orthopedic case, Ryan increased in comfort and skill.

Despite his newly found love for other specialties, Ryan was undoubtedly the happiest person on campus when he was joined in late 2014 by Dr Arega Fekadu (PAACS general surgeon Graduate from Ethiopia) and in 2015 by Dr Casey Graybill OB/GYN and his SOM ’05 classmate. I often joked that I could tell what type of cases dominated the OR schedule. If he came home in a terrific mood I would surmise, “hernias and appendectomies today honey?” or if he wasn’t totally happy, “Hmmm, lots of hysterectomies and ruptured ectopic’s hey?”  

Malamulo surgery department has seen rapid growth over the last 5 years. With many interested people and organizations collaborating with the hospital to drive a new focus on training and educating within Africa. The surgical department has expanded to two full time general surgeons who teach under the PAACS program with 3 African residents learning how to become competent, compassionate, Christ-centered surgeons for Africa. Dr Mark Reeves SOM ‘92 and the LLU General surgery department offers their 4^th year general surgery residents a chance to rotate at Malamulo, and the department stays engaged and active in the work being done in Malawi as a result of this external rotation.

Now I was watching as David Hadley (on his second trip to Malawi) scrubbed in to do surgery with Ryan and Casey. Operating Theatre One was being prepared for a TURP procedure that David had scheduled. But for now he was content to bring an extra set of competent hands to the Radical Hysterectomy in Theatre Two.  Linly was awake on the operating table, although unusual she was given a spinal for anesthesia from the junior anesthetist. Hayton inquires (of the anesthetist), “George, when the spinal runs out, what’s your plan for the patient?” Silence. The blips on the machine become louder with no one speaking.  “George – the spinal will run out, this is a radical hysterectomy, we have at least 3 hours to operate and we are not half done yet.” Graybill prompts a response. George’s eyes (showing between his face mask and surgical hat) look towards the surgeons and with a nod of his head, he is communicating “don’t worry, there will be a plan when there needs to be plan”. They keep operating.

Linly seems nervous when the heart rate monitor changes tone or increases in speed or volume. I let the camera dangle around my neck so I can touch Linly’s arm and in broken Chichewa advise her that the surgery is going well. (As far as a homemaker with a BA Business can tell…)  However, Linly never complains. She is trusting in the doctors who have their hands in her belly. I crouch down in the theatre and point my camera up towards the OR lights, and it occurs to me, that this is a pretty special moment. Leaning in towards the patient, three heads from the SOM class of 2005 are literally touching together as the Doctors diligently work on Linly’s surgery. Beside Dr Hadley stands our fourth year rotator from LLU Dr Matt Surrusco, and next to Dr Surrusco is Dr Kamwendo our 2^nd year PAACS surgical resident. An hour later and Dr Lijalem our PAACS intern and Tedean Hunter '16 a 4^th year LLU medical student join the team, eager to learn.

“Dr Hadley, we’re ready for you in Theatre One” calls the scrub nurse on duty. Trusting the watch of the Ureter to his classmates, David scrubs out and exits OR 2. Ryan asks me to follow Hadley into the theatre where the team have prepared a patient for a TURP (Trans-Urethral-Prostate-Resection). I ask David to teach me about the equipment he donated to Malamulo but really only understand the explanation when I see the bipolar button vaporizing tissue on the monitor. Wow! Neat. I have to ask, “What about the Ureter? Are you nervous of burning the Ureter?” David must be wondering if I heard him in OR 2, but reassures me (and the patient) “I’ve got the Ureter!” Dr Kamwendo is monitoring the fluids used during the procedure as Dr Hadley is trying to use only 5 litres of fluid (since fluid in Malawi is expensive and supplies are limited), where in America he might use up to 20 liters per case. Dr Kamwendo now has the chance to use this new equipment under Dr Hadley’s direction, and his face is the epitome of concentration and elation mixed together. David asks Elmoore (Kamwendo) “when you graduate in 3 years, and you’re out somewhere in Malawi wanting to do TURPs, how will you get the equipment you need to get started?” Elmoore says, “I’m not sure, what would you suggest?” to which David chirps back, “you call me! I’ll come and bring you equipment and brush up your skills.”

Again, I am reminded that we need people all over the world working together for the greater good. The people in Malawi, who benefit from Ryan’s surgical care, also benefit from donations (of time, money and equipment) that so many family and friends have sent to Malamulo. Just as it takes a village to raise a child, it takes a team to run an operating theatre.

(Dr Hadley teaches Elmoore Kamwendo a TURP)

As the TURP procedure concludes, Dr Hayton rushes into the room. “Kamwendo, hurry – I need you in the minor room, we have a transfer from Thyolo District Hospital, and she is bleeding out.” A moment later the scrub nurse scurries in, pushing the suction machine out to the minor room.  Hadley wraps up the TURP, carefully placing the instruments in the box ready for sterilization. The TURP patient is wheeled out to wait for a ward transfer, OR 2’s Radical Hysterectomy is still in progress (and the spinal has been augmented with ketamine), the minor room has just saved the life of a woman sent with a botched tubal ligation, and a crash C-section had successfully delivered a healthy baby in maternity theatre.

(David Hadley instructing PAACS 2nd year resident Elmoore Kamwendo, with Ryan Hayton)

(Emergency case transferred from TDH)

(Theatre scrub nurse Rose and I)

For the first time, I caught myself thinking, “I could enjoy doing surgery! I have spent almost 4 hours in the theatre and it only felt like 20 minutes!”  Yet, as I un-gowned and took off my surgical hat and face mask I looked around at the company I was keeping and thought “the Ureter, bowel, and uterus all scare me! I better leave it to the SOM class of 2005…”




Of Note: Malawi has the highest rate of cervical cancer in the world.
Cervical cancer is the number 1 cause of cancer deaths in women in Malawi.