Shanksteps Bere 2017 #7

Shanksteps Bere 2017 #7

I awaken before dawn again. I wasn’t woken up all night. I feel pretty good, but lay there awake anyway. Audrey has left back for the US, as she couldn’t get the same time off that I could. It is quiet and lonely in the place I’m staying. I’ve been told that since Chad has been taken off the list of places US citizens should go, a few years back, there haven’t been any more student missionaries. The birds are chirping, roosters are crowing, and Chad is coming to life. Days have passed since I arrived. Many hernia repairs, and a smattering of other interesting surgeries. Each day there is a list of 8-10 to be done. Most days we get the majority done and the rest wait till the next day. I’ve seen patients from Ndjamena, near the sudan border, near the border with CAR and from Nigeria. I was told today that if you want to be seen in a gov hospital, that you may wait weeks just to see the doctor. He/she may see a few each day then go off to their own clinic through a back door, leaving the rest just sitting there. Here they see a doctor, usually the day they arrive, are consulted for the surgery and can be done in a few days. Each day is filled with as many surgeries as the surgeon and staff can do- one after another.

An old woman is laying on her hospital bed in the corner of the room. Surgical patients line the walls on both sides. A few relatives stand around different patients fanning them with small woven grass fans. It is relatively quiet for the number of people in the small room. We start with the old woman. Her dressing is unwrapped and I see a large patch of black skin covering most of her forearm. This was apparently burned. Pus drains out from under the black skin. I expect to see maggots but none are present. We recommend taking her to the operating room for a surgical debridement.

Another in the room is the gentleman that we drained a psoas abscess on. His drainage tubes are full and haven’t been emptied overnight as they needed to be. Pus is draining around the tube that is full. I guess at least it is making it’s way out. I empty the bulb and thick pus with a bad odor is drained into the basin. Flies hover around the smell I’m sure they can sense a mile away. As the rounds continue, I head back to the OR to check if the first patient is ready. We find a child that has had a hernia stuck out for about 4 days. He is crying and looks sick. He needs a hernia repair right away. A different young man with an inguinal hernia is lying on the OR table, so he is done first.

The second is the young boy of about 10 years. I do his operation with the help of Christian. He is given some inhalational anesthetic (have no idea what was used) and ketamine. I’m glad to have brought a cautery machine that was donated by my hospital in the US. This helps a lot to minimize bleeding. The drape has much to large an opening and nearly exposes the boys whole abdomen. I put clips on the edges to make it a smaller circle. As his hernia is exposed I see dark necrotic (dead) tissue. I open the sac and find dead intestine. I have two options- open my incision into the abdomen to resect dead bowel or open a separate incision to do the same. We choose to extend our current incision. I open up the muscles into the abdomen and find an edge of a loop of intestine is the dead spot. I am able to cut off the dead piece and reconnect good intestine to itself. I re-close those layers and finish the operation.

The next is a gentleman who had difficulty urinating and a large prostate. On the ultrasound report, he was thought to have a large prostate as well, and maybe a bladder stone. He is a bit overweight- uncommon for here. He lays on the OR bed stark naked, is shaved and water is put in the urine catheter till his bladder is full and large. This moves the intestines out of the way so when we go into the abdomen we get directly into the bladder rather than intestines. I make an incision and have to cut down through the fatty layer then the abs. I’m then on top of the bladder. After opening the bladder I feel around inside. The prostate feels like a normal size inside, but there is a bladder stone about a centimeter in size. This can act as a ball valve, plugging off the ureter when it’s down at the bottom. I remove his stone and close him up.

Christian is out debreding the old woman’s arm. Pus and dead tissue are in a pile on the drapes next to where he is working. A lot of the skin of the arm has had to be removed. I’m glad we chose to debrede it today!

After a number of other surgeries I head back to the room where I stay. I’m grateful to eat food with Olen and his kids. Then back to my room to read, write, and eventually take a cold shower and fall asleep.

Shanksteps Bere 2017 #6

Shanksteps Bere 2017 #6

It’s Sunday and Audrey just had to leave this morning. I’m missing her already. She, Deborah, Jent all left for home today. I wish Audrey could’ve had the time off to stay with me the whole time, but am also grateful that she was able to come at all. Olen dropped them at the bus station about an hour away this morning. I woke up early to see them off. It is to quiet now in the place I’m staying.

I head in to help with rounds after eating some pancakes with Dr. Rollin and Deloris. Pancakes with peanut butter and mango sauce. I’ve not even walked into the surgical ward with the stench hits me! Now I’m not one to be bothered by smells as my nose I inherited from my dad. That means it doesn’t work all that well, which in my line of work is usually a benefit. In the US, nurses may be retching around me and I’ll be doing just fine. But this one was strong! I walked in to see Christian changing a leg dressing. There lay an old woman on a bed, clouds of flies swarming around her, writhing in pain, as Christian loosened the bandage on her rotten leg. Pus flowed down her leg, across her bed and pooled on the floor. She had been admitted the night before and we were looking at it for the first time. We immediately felt like she would likely need an amputation, but could start with a operative debridement to evaluate it further. A new dressing was placed and we continued on rounds. There were many wounds to dress. Were they infectious tropical ulcers, burullies ulcers (from tuburculosis), a spider bite necrosis, a snake bite… So many options as to the causes of things that look similar. Most improve with dressings and proper care. The 23 year old woman without children that I took out two uterine fibroids, one the size of a large grapefruit the other an orange, was doing well. I doubt she will be able to have children even with them out, but at least she still has her uterus. A woman who cannot have children is not valued at all in this society. Their worth is their children. Usually when you ask a woman how many children she has, she will answer, “I’ve had 8 children and 2 are living.” This was the response yesterday when I asked a woman. So still having the chance to have children is very important to the 23 year old. We see the man we drained a psoas abscess on. He looked like death warmed over when we operated on him. He appears to be doing better and is in pain but better. His drains are working. Of course he is in pain! We only have ibuprofen and Tylenol to treat pain here. But every one of my patients here is up and walking the next day! It sure is nice not to have the negative side effects of narcotics though.

After rounds Christian and I head back to the OR to debrede the old womans leg. Now the OR smells like the surgical ward did. Somehow the masses of flies didn’t make it in there with her. [As a side thought: There are sterile flies and non-sterile flies. Non-sterile ones- are those that fly around the operating room landing in the open abdomen of the patient or on the sterile field. Sterile flies- are those that are cooked in the autoclave and found in the sterile pack when it is opened at the beginning of the operation.] It is useless to prep her leg with betadine to make it “sterile”, but I do it anyway. Pus drains onto the area I just prepped. I kick a trash can to the side of the OR bed just in time, the lake pus on the bed, drains into it. She has an open area about mid-calf that has granulation tissue but pus pooling around it. I probe with my finger and the skin is separated all around. My finger easily goes from the wound up to her knee and way beyond where I can reach going down her leg. We open the spaces. She ends up with open areas from her knee down to her ankle on two sides. Necrotic tissue and pus is removed. I know I will smell like pus, until I get a shower and change my cloths. Sometimes the smell clings to my nose even after that! I think she needs her leg removed, but will wait a few days before telling her that. It is easier for the patient to accept bad news when they have come to the same conclusion themselves. I see a few other consults and prepare them for surgery in the upcoming days.

I head home to shower and get the stentch off of myself. The cold shower feels wonderful!

Shanksteps Bere 2017 #5

Shanksteps Bere 2017 #5

I awake about 4AM.  The sound of bats outside in the trees is deafening.  The hospital has electricity 24/7 due to a generator running non stop (that must be a lot of diesel).  Since there is electricity, I have a fan on us at all times when we are in bed, that makes sleeping possible in the heat.  I lay there awake trying not to wake up Audrey, she is all covered up like it’s cold!  I lay there and read my devitional book (Jesus Calling) then continue where I’m reading in the New Testament in John 16.  This is always a peaceful time of morning.  About 6 AM the sun starts to rise and the room slowly gets lighter.  Olens mother-in-law Deloris had left us some granola to eat for breakfast.  She also made us some bread.  I discover during my time here that she is very giving of food, and I never have to go hungry.  It’s a Monday and the busiest day of the week in Bere.  Hospital work occurs all the days, minimal rounds are made on Sabbath, and emergencies attended to.  Sunday there are many consults and full hospital rounds to be made on the 80+ beds.  By Monday there are many people waiting for elective surgeries.  They run anywhere from 10-160 dollars.  The highest being for a prostatectomy, because old guys usually have the money and are definitely willing to spend it on themselves.

At 7:30 we head to the hospital for worship.  It is spoken in French and Nangere.  It takes place in the waiting area for the ER, which is a number of concrete benchs under an awning.  The ER is a room with about 3 beds.  It has no moniters or other signs that it is an ER other than the sign on the door that labels it the “Urgence”.  After the worship thought, the nurses give signout about what happened the day before to all the nurses and doctors.  This all wraps up about 8:30 or 9 and I head to the OR with Rollin and Christian and Audrey.  It appears that there are about 11 people on the waiting list.  It appears to be about 7 hernias, 2 incision and drainage of abscess, and a hysterectomy.  I asked Dr. Rollin and Christian what they wanted me to do and it was decided Id operate.  I like to do hernia repairs with mesh due to the fact that they are longer lasting and the risks are low.  Dr. Rollin doesn’t like using mesh because they’ve seen a number of infections after using them here.  So, since they will have to deal with whatever complications arise after I leave I choose to do the hernia repair with just suture in the method that they are used to using.

The first man is lying on the bed.  his scrotum is larger than a grapefruit with intestine in it and his legs splay far apart to accommodate it between them.  One of the nurses lifts it and puts the legs together and it then sits on top of them.  It’s been a while since I’ve seen one this big.  The patient is given fluids and then a spinal is placed with him in the sitting position.  I discover almost all cases are done with spinal and then some ketamine is given if the incision goes to the upper abdomen.  After the spinal the patient is laid flat and I scrub with Audrey.  It’s been a while since I’ve operated with her and we both enjoy it.  I make an incision in the groin and it barely scratches the skin.  I’d forgotten how hard I need to push with these blades to get through the skin.  After about 5 cuts, I’m finally through the skin.  The scalpels blades are new but not as sharp as I’m used to, and the skin is thicker too.  I slowly dissect through the usual layers to the hernia sac.  I dissect out the hernia sac from the scrotum and separate it from the testicle.  After opeing the sac, I discover that everything is stuck in it.  There is colon and small bowel.  I struggle for about a half hour to make heads or tails out of the mess.  The inside of the abdomen isn’t free either.  Eventually I make the opening in the abdomen larger and shove the whole thing in.  I do the suture repair.  This is about the longest hernia I’ve done in a long time.  I close the various layers and then skin.   I’m tired of my first case here.

Next is a woman with an inguinal hernia.  Less common and also much smaller.  She is about 45, 5’2” tall and weighs in the neighborhood of 100 lbs.  It’s nice to be operating on thin people.  After the spinal she lays there stark naked and is shaved and prepped for surgery.  She is shivering even though the room feels very warm to me.  Of course she is cold, the usual parts of her that are seen are her face, ankles and arms.  The head may or may not be covered.  Muslim women cover their heads and many other women do too.  After I scrub, I cover her body with surgical cloth drapes.  The has the tiniest of hernias and it takes me about 20 min to do the surgery.  So I have the most difficult first and the easiest hernia second.  The remainder of hernias this day were “usual large”.

Rollin and Christian finish rounds and come back to the OR.  Next is a uterine fibroid that the two of them do.  I hang out in the entry room seeing surgical consults and being called to help do an ultrasound to check out something the nurse couldn’t figure out on it.  One ultrasound, the nurse cannot figure out whether the woman’s mass is in the uterus or ovary.  I walk past the hoards of people milling round under the trees to the ultrasound room.  I’m thinking to myself, how can he not tell if it’s in the uterus or not?  Unfortunately I find the same thing.  I cannot tell either and am frustrated.  I guess we will need to do a digital CT to figure it out and take out whatever we find.  Here, digital CT means- cut and touch with our digits! Either she has a uterine tumor or an ovarian tumor.  Whichever it is, she doesn’t want any more children and we will take out either one.  Each elective surgery is required to pay and someone of the family to donate a bag of blood before they will be on the surgical waitlist.

About dark we choose to make the others wait till another day.  I head home to a meal that Audrey and Deborah and Jent have made.  I’m tired, jetlagged and happy to get some rest.

Shanksteps Bere 2017 #4

Shanksteps Bere 2017 #4

Today we wake up early and our plan is to head to Bere.  James and Sarah get up early and feed us breakfast (Thank you!)  We then head to the bus station with all our plastic boxes of medical luggage in the back of the RAV4.  It’s dark and we are turning on one path then another, and if James weren’t driving, I’d be totally lost.  But I do see a little glow on the horizon so that can give some orientation.  We arrive at the bus station while it’s still dark.  James gets our tickets and then we realize the bus is on the other side of the road and there’s a concrete barrier between sides. So we go down about a half mile and turn around.  Arriving at the bus, there are crowds of people milling about.  There is a large bus that is air-conditioned, YEAH!  We get our things put underneath and then board.  The pungent smell of urine greets us.  There are decorative drapes on the windows and all around.  Reminds me of what I’ve seen in pictures of busses in India.  We find seats free near the back door and Allah sits behind us.  About a half hour later the horn is blowing and we are moving forward slowly, kind of waiting for the last people to get on.  We take off with a few empty seats.  These are gradually filled along the way by people standing on the sides of the road waiving us down.  As we leave town we are stopped at a number of police barriers.   We stop at some and others drive right through.  It’s getting a little lighter, and I can see temporary shelters and a section with many camels.  I guess this is the area where the nomads are.  They are often the ones with camels and herds of goats, sheep and cows.  A few horses may be seen too.  All the animals are very thin with all their ribs showing.  We also pass a few heavily laden two wheeled trailers that are being pulled by a long horned cow.  About an hour out of Ndjamena we are stopped at a police barrier.  A policeman gets on at the front and slowly asks people for their identity cards or me for my passport.  He is asking men, the women and young he doesn’t ask.  He asks for my identity card and I give him my passport, he asks for Audreys too.  He looks behind us and then gets off the bus with my documents and others cards.  Allah tells me I need to get off and talk to him.  I think that if I wait he will bring it back.  Allah says that the bus will leave either way.  So I get off with him to go talk to the policeman.  He says something to Allah who translates to me that he “wants a drink”.  I understand this immediately to mean he wants some money.  Rather than striking up a conversation like I should, I get angry.  I raise my voice and say I’ve come to help the Chadian people and all my documents are in order.  I demand my passport to show him, and surprisingly he gives me one.  I show him my visa…  I put out my hand for the other, and again, surprisingly he gives it to me.  I walk back to the bus.  As we leave, Audrey reminds me that I need to talk with the policeman on the bus before he takes my documents.  I had forgotten that this helps a lot!  One thing about the culture here is that relationships are very important.   And so if you are friendly and make conversation, this avoids many troubles.  I think they are spot on here, and I (and many in the US) could learn a lot from 3rd world countries in this regard.

We continue down the road.  There are little villages here and there, and many miles of open areas with few trees, shrubs, and dried grasses.  It’s the dry season and things are dying.  The hamartan winds are blowing so there is a lot of dust in the air, as it comes off the Sahara.  Northern Chad is in the Sahara, and so we are still very sandy and dry here as well.

A while later we get stopped at another barrier and a military guy gets on in the front and another at the back door near me.  He walks straight up to me and with a stern face asks for my documents.  I start talking as Audrey takes her time rummaging around in the backpack for the passports.  I say hello and that we are doctors traveling to help the people of Bere.  That we will be there about a month and that we have just arrived.  I tell him we have brought medical supplies to bring to the hospital as well and that we are tired from our long trip that had started 2 days before.  He then says he just saw Olen from Bere come by there the day before.  I tell him that I was suppose to be with Olen but that my travels had been delayed.  He notes that he is coming to Bere next week, and I volunteer that he should say hello when he comes.  He smiles, and I show him the covers of the passports, he waves them away and continues down the line.  Others behind me are not as fortunate and as I see others get off after him when he descends down the stairs.  Eventually they get back on and we continue on our journey.  About 3 hours into our voyage we stop for a 15 min stop in a little town and back into a bus station.  We all pile out and they lock the doors so our things don’t disappear.  We go and pay the guy at the toilet the 50CFA (about $0.15) and walk in to the pit toilet.  It is full and the stench is overwhelming.  I am very happy to just need to pee.  I then walk around and look at the people selling various foods.  The one that catches my eye most are the fried grasshoppers.  There is large pile of them and a person is buying a small bag full.  I ask if they are good and I am assured they are and am offered one to try.  I can’t do it- so thank them and decline.  There are also piles of fried doe like donut holes.  Meat grilling on a fire, lemons, oranges, a few apples, peanuts, watermelon, papayas, taro, and a few other vegetables I don’t recognize.  I guess as we are after the rainy season, there is still a variety available.  They honk the horn and we all load again for the 4 hours that remain.  We continued on the paved road all the way.  There were many many large holes in the pavement all the way down.  So there was a lot of slowing down and swerving to hit a shallower area of holes.  If the road were good, we could’ve made it in half the time.  We don’t get stopped anymore and arrive in Kilo that afternoon.  We unload our boxes and luggage and wait for Dr. Bland.  We load up our stuff and head to Bere with him.  Before we leave town we look for gasoline.  Both stations in “town” are out of gas, and we have enough to make it to Bere so we head out.  We pass some girls selling bottles of roasted peanuts, so stop to get some.  As soon as I roll my window down and call them over, there is a mass of people wanting to sell theirs.  About 10 bottles are shoved through the window and dropped in my lap.  I try and tell them to stop and it’s mass confusion.  I finally roll up my window, I try to stop with it a little down- but it is automatic and continues all the way up.  Fortunately no ones fingers were in it when it closed.  I eventually get it a little down and get the excess bottles out.  I then pass out he money and wait for change.  About 3 minutes later the one woman I gave it to, gave me the change back.  Everyone else was unhappy that I didn’t take their nuts and waved them at me to take more.  We drove down the dirt road and into Bere Hospital.  It was dark when we arrived and we were happy to be off the road and take cold showers and get to bed.  Mrs. Bland had made some food and left it in our kitchen.  How nice to have that when we arrived!  It felt very good to get the dust off our bodies and as I usually do in sub-Saharan Africa- I went to bed dripping wet.  I hoped to fall to sleep before I evaporated.  And sleep I did- till the bat noises woke me up at 3 AM as my jet lag kicked in.  9 hours different is difficult for a number of days.