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There are six weeks left of time here in Cameroon. Each day is filled with the usual complex patients at the hospital. Inpatient rounds, outpatients, surgeries, and periodic calls at night. The evenings are spent with Audrey and Sarah, often packing a few boxes, in preparation for shipping things back. Time seems to be passing quickly.

We are anxious about where we will work in the future. Anxious about who will come to cover the work here. Will the hospital fall again, as it had before we arrived? We have not yet heard of anyone willing or interested in coming! What lies ahead for us? What lies ahead for this hospital?

I spend periodic nights awake, mulling over things in my mind. I know we need to be back in the US, but there are so many uncertainties. We give the responsibility for the different things we have done to others as it is possible. I pray for Yves often (our administrator) who has been through many tough periods at the hospital. He is a missionary from the Southern part of Cameroon.

Life continues as it has for the past five years. But in the back of all our minds there are concerns for the future here and in the US. This is especially easy if we let ourselves focus on us! When we focus on God and His faithfulness, all worries diminish.

God has demonstrated He loves us. His ultimate sacrifice on the cross demonstrates that very clearly. If the God of our universe loves me, is interested in my life, is interested in this hospital and the lives of it’s workers; then I can sleep at night, knowing that He is in control if I allow Him to be in my life. He is in control of the hospital if He is allowed to be. And who better to be in control than our: all knowing, all understanding, all loving, compassionate God!

When I focus on Him, and not myself, I sleep, and am content in knowing that He is in charge, and despite of my inability to see my future or the future of the hospital, He IS love. And when I allow Him to take charge, He will do what is best for me, best for my future, best for my learning more about Him. Praise Him! Greg

“Could one of you come and see this child?” Jacques asked Audrey and I. The child was breathing fast and was very pale. He is 7 months old, 6kg (about 13lbs), and has a huge anterior fontanelle which is very sunken in (a sign of severe dehydration). His hematocrit was 6% (normal 45%). He had just vomited blood-tinged fluid. As they placed an IV in his arm he did not move or cry. He had pneumonia from all the vomiting and aspiration of the stomach contents, giving him low oxygen. He needed oxygen!

Six days ago the workers emptied the water tank to patch and paint it. They scraped the insides, patched the holes with a tar compound, welded a few spots and then repainted it. This took about 4 days to complete. The fourth day the electricity went out. So we have been “functioning” without water in the hospital for many days now and with no electricity. Two days ago I wanted to do a hysterectomy on a woman that needed it and when we tried to start the large generator the batteries were dead. So without power I decided to put off the surgery till we have power again, and when my OR schedule is open, 3 weeks. So with all this we are out of power when this child is in need of oxygen.

We have started the small generator of the lab and decide to transport the patient into the lab waiting room so that we can use the electricity there to run an oxygen concentrator (there is no bottled oxygen here). After placing a bed in the waiting room and hooking him up he breaths slightly better but needs blood. The mother is the same blood group so she gives to her child. The day passes and it is time to turn off the generator for the lab. The child has received the blood but is still very hypoxic (low oxygen) without the oxygen. Should I run the generator over the weekend for him? How long will he need oxygen? Will the oxygen actually help him survive, or will he die anyway? Should I tell the family that since the generator is running only for their child they would have to pay for gas? If I say this will they refuse treatment? I ask Aud what she thinks. We decide to keep the generator going and not talk to the family about gas for fear that they will refuse treatment.

At midnight I am called because the generator is stopping every 45 minutes. Apparently it is plugging up with gunk in the lines and for air vacuum in the tank. Baya, the nurse who is in the ER, is somewhat mechanical. So I offer tools and ask him to try to fix it. I don’t get called for the rest of the night.

It is Sabbath (Saturday), I plan on sleeping in. I wake up at 7AM to the sound of chickens and immediately think of the child. I can’t sleep any longer because I continue to think of him. I get up and head into the hospital. He is still alive! I have prayed for him a number of times through the evening and night. I am thankful God has spared his life. The generator worked all night after Baya tried a few things. I take him off oxygen and his oxygen stays above 92%. I transfer him to the ward. Our chaplain, papa Sidi, has just prayed for him again.

I see another girl that is 16 with severe headache and neck pain overnight. I do a lumbar tap (take spinal fluid) to evaluate for meningitis; I also treat her for cerebral malaria.

I leave the hospital hopeful for the child who has survived the night. Greg

My frustration know no end as I write this addendum. It is Saturday evening. The nurse on today did not observe my patient well. He calls me when the child is really dypnec (short of breath). They put him back on oxygen to late. He died.

Diagnostic dilemmas are constant here. This comes from the fact that to diagnose different diseases there are a limited number of tests available, and even those are made more limited by patients refusing to do the ones we desire. Most often they want tablets but not tests. The Nigerian patients that come here want both. They are a select few who have some money, are unsatisfied with their own medical system and come here because there is a foreign doctor. They frequently request ultrasound and x-rays because they feel that that is where their pain (“worry” as they describe it in Pidgin English) will be diagnosed. They often want to see where the wound is that hurts them inside.

So an old, very thin (likely between 80 and 90 lbs) sees me in the office. She is deaf and mute. Her son talks to her with gestures, which make no sense to me at all. He somehow has deduced that she has pain in her chest. He says that she has had this for about three months. She has not had a cough but just pain. I listen to her chest and hear breath sounds on the left but very muffled ones on the right. I tap and hear a dull sound, she is full of fluid. I request an x-ray, and they agree and go to pay the $7 to get it. She is lucky because this day we happen to have electricity. It has been out every day for 1-10 hours for the past 5 days. The chest shows a complete white out on one side. I do a tap with a needle and find dark yellow fluid that the lab says has some gram + cocci in it. Infection? Contamination of specimen? It is unclear. But the fluid needs to be drained.

When I first arrived at Koza there were no chest tubes here and I used a urine catheter for my first one. Today we have two sizes so the student missionary and I select the smaller size and numb up the area of insertion. We prep her side and hold her hands out of the way as she is contaminating the field demonstrating where her pain is again. Her son and another nurse hold her arms. We put the tube into her chest and get 1300ml of fluid. She coughs and appears worse for a little while. Maybe I should have let off the fluid a little more slowly.

Over the next few days she drains about 800ml a day. She is getting thinner by loosing all the protein every day in the fluid. Or I assume that’s what’s happening. So if I take out the tube all the fluid will reaccumulate and I don’t have anything for plurodesis (making the lung inflamed and stick to the chest wall, effectively stopping the fluid collection). So eventually I talk out the tube. She reaccumulates the fluid and I let her go home. I’ve treated her with broad spectrum of antibiotics; we are currently out of TB medications. The government supplies these for free but when we ordered them they said they had run out in the far north. So free TB meds doesn’t help when there are none. And since they are free none can be bought either, because there is no black market desire for them. So she reaccumulates her fluid and goes home in a day or two. Another dilemma unsolved.

The same thing happens in the room next to hers. There is a man with huge ascites. I drained off about 15 liters the other day. He had a tense belly for a month. I drained a lot off and he lost 9kg with the fluid extraction. His abdomen was large but then not tense. The peritoneal tap showed no bacteria. I treated him for schistosomiasis, TB, abd peritonitis, other worms, and a loop diuretic (water pill). He does not appear to be improving either. Is it cirrhosis from his long time millet wine usage? Possibly, but I can’t treat that other than, encouraging him not to drink. So another dilemma unsolved. I know these same dilemmas can happen in the US, but it is so much more frequent here. This is the frustrating reality of third world medicine. Greg

It is Friday evening near sundown.  Maliki comes to my door to have me come see a 13 year old boy.  He says the boy may have meningitis, but is not sure and having bizarre reactions.  He has borrowed the motorcycle of the man who brought in the boy so I hop on the back and we head into the hospital.  Nearing the hospital he has difficulty slowing down as he finds out he breaks are not working well.

I walk into the ER and see an old woman holding the abdomen and back of the boy.  I ask Ibrahim (the boy) what is bothering him. He says that for two days now he has had sudden pain in his abdomen that then goes to his back.  Or it grabs his throat as if choking him.  As I am talking to him he cries out and grabs his throat with two hands.  About ten seconds later he appears fine.  I ask him about taking any drugs, or stuff others gave him, he hasn’t.  An uncle says that the day before this started he had a homosexual experience with another boy his age. The nurse starts making a clicking noise (surprise).  I remind the nurse to be professional, and that he should not display any reaction to things the patients tell us, whether we are surprised or not.  I give the boy water to drink and he gulps it down without problem.  I think of tetanus, rabies, meningitis, cerebral malaria, syphilis, and demon possession.  Doubt the last is on your differential in the USA, though maybe it should be!  Papa Sidi (our Chaplain) happens by and I ask him to pray with me for the boy.  The boy says he is Muslim and believes in Allah.  I tell him to trust in Allah and we are going to pray to God for help and healing.  The two of us, the nurse and student gather around the boy and we pray. Pray for healing and protection for this boy.  I look for some medications in the pharmacy to start his treatment for some of my differential diagnosis.  When I come back the boy is crying out and naming the names of sorcerers that he says are choking him.   The family decides that this must be his real problem.  They take him home to find a more powerful sorcerer to help him. I pray that God will protect him and that God’s name be glorified rather than a sorcerers.  Please pray for Ibrahim.
Trying to follow Him, Greg

#156 Shanksteps

Wednesday it was unbearably hot.  It was 113deg F in the shade as it has been but then it felt much hotter.  We had finished work and had gone home.  About 5 PM the wind kicked up.  It started really gusting.  Dust was thick in the air and we could not see across the soccer field in front of our house.  Even out to our own gate it was difficult to see.  We rapidly closed all the windows.  The power went out.  Wind with the power going out is usually a bad sign, it usually means that the power lines and poles are down somewhere between Mokolo and Koza.  This means that it will be many days before we get our power back.  It in fact is still out!  No power means no autoclave, no X-ray, even when our generator works.  It also means no water!

So the wind is howling and dust is in the air.  Then it starts to rain.  We usually get one solitary rain in April then it waits till June to start the rainy season.  The wind is whipping trees back and forth.  Branches are falling all around.  The tin roof over our truck is now loose on one side and waiving wildly in the wind.  Hail starts to fall all around.  On the tin roof of the house it gives a deafening sound.  Water starts to drip though our ceiling at different places.  Some the same as last year, others different.  I try to catch some in buckets, moving things out of the way.  The rain pelts the ground for about half an hour. A small river is flowing through our yard and leaving under the gate, and through the chain-linked fence. After the rain we hear chopping. There are many downed branches and people are running from all over to claim a down limb and start chopping on it.  I guess after it is downed it is not considered stealing, but only when it is still up on the tree. So I decided to go to the hospital and see the damage.  After walking out of my house I see our power lines are going down to the ground. A large tree branch has fallen on them and the bear wires are pulled down to the ground.  Further on I see a large power pole down.  A building behind my house had half of its tin room blown off.  On other hospital buildings there are tin pieces pointing to the sky or gone.   Workers saunter by telling how either their house or neighbor’s houses had lost their roofs during the storm.  Some houses even fell down with the rain and wind.  I ask how the patients did, and everyone is fine.  The nurse was just getting ready to call me when the storm began, so he asks me to see two patients in the ER.
To the right as I walk in is an 11yo boy laying on his back very still. His left leg is shorter than his right and pointed off at an oblique angle.  I can immediately see a large gash on his left knee going around to the back of his leg more then 10inches long.  His right foot has a huge gash that has separated the skin of the sole of his foot from the foot itself in a huge flap connected at the heal.  He appeared as if he was in significant pain but didn’t make a sound until I examined the leg that was pointing off to the side.   He had a femur fracture too.  The uncle who brought this boy into the hospital said that the two were playing on a rock when it rolled and crushed their legs beneath it.
To the left was a 10 yo boy laying on his side moaning.  His foot was wrapped in a cloth.  As I unwrap the cloth his toes and sole of his foot hang, detached from the rest of the foot that is left.   A metatarsal (midfoot bone) sticks straight out from the top of his foot, as does the bone going to the smallest toe on the same foot.
Both the boys need to go to the operating room.  I send someone to call Ganava and Jacques.  I return home and change cloths and head back with the medical students currently here.  Ganava is not in town and Jacques is late in coming.  The students and I set up the two in different OR rooms and we start cleaning the injuries.  Since there is no electricity, and the generator will not start, we work by headlamp.  First each gets an IV, Valium, Ketamine, antibiotics.  Then the scrubbing begins.  One med student on each child and myself and another giving meds, going back and forth between each room.  Jacques arrives and helps Travis on the child with a femur fracture and large lacerations.  I help in the other room where Elisa is cleaning, Kalaza, the boy with the badly crushed foot. We complete the amputation about mid foot.  Taking off the bones that are sticking out.  In the other room the huge lacerations are closed with drains.  I then go back in there and place a pin in his tibia (lower leg bone) to put him in Perkins traction for his femur fracture. Both boys are taken to the pediatric ward and the bed adjusted to accommodate traction.  Meaning, bricks put under the foot of the bed, weights placed with a string to the tibial pin, and the framework holding up the mattress let down so the leg is flexed at the knee.  We head home in the darkness, watching intently for scorpions.  It is their season now and I don’t want to experience one again.
It’s about 9:30PM and the temperature has cooled off to about 97degF.  It makes for difficult sleeping conditions. I shower, don’t dry off, and drip my way to bed.  I lay trying to not have any part of my body touch another part.  I drift to sleep before drying.  I awake a couple of hours later drenched in sweat and repeat the shower process to sleep again.  It makes me very thankful for electricity and water when they do come back.  We are now five days after the power has gone out and still no sign of the electric repairmen.  We are praying for repairmen.  Greg

#153 Shanksteps: Malaria: A Study

Day 1: It is Friday evening. Greg was called away to a meeting Monday- Wednesday so I was left to “hold down the fort”. It truly wasn’t too bad; there were no surgeries; I was able to sleep for 8 hours during the 3 days. I took Thursday off to “recuperate”, so why do I feel sooooo tired. MALARIA. And I thought my stomach hurt because I was drinking too much coffee. Again: MALARIA. That dizzy spell I had on Monday in the middle of clinic that I thought was due to not drinking enough water. MALARIA. The nightmares and difficulty sleeping – could it be due to stress or…MALARIA. I mentioned something to Eliza today and she said that I ought to get tested. Afterall, the test is free and the lab was on my way from the Peds ward to the Clinic. So, after telling the lab tech to take my blood, but not expect to find anything, was I surprised to find MALARIA. So, that’s why I’ve been feeling to crummy lately.

Since I feel like I’m going to die every time I take Quinine, Greg thought it would be educational (entertaining) if I kept a malaria journal for the next 7 days and explained to all of you what I was experiencing. So, welcome to my world of malaria and quinine.

Day 2: Saturday morning. I’ve only taken 2 doses of Quinine and already I feel like my brains have been replaced with cotton balls. Quinine causes cinchonism – or in non-medical terms, “buzzing” in the ears. In some ways this is a blessing. I sleep better with “white noise” (ya know: waves crashing, birds singing, fan turning etc), so the quinine has given me an involuntary, never-ending “white noise”. However, it also gives me nightmares (none too serious yet), and dizziness. I experienced the latter on the way to the bathroom. Good thing our hallway is not too wide as I used both sides to steady myself. I must have looked like I drank a little too much millet wine last night…

Some people have PTSD (Post Traumatic Stress Disorder) after experiencing a terrible event. I am sure I have PQSD – Post Quinine Stress Disorder. Every time I take Quinine, I feel like I’m going to die, or wish I already had. Fortunately, this is only the 4th time I’ve taken it in the 5 years we’ve been here. So, this morning I prepared my stomach for the assault. I ate egg gravy and toast to thoroughly coat my stomach with something resembling paste, as I am convinced that each and every quinine particle has a razor edge, or maybe teeth, in which to eat through my stomach. So far so good. My stomach is still hanging in for the fight. My tongue is another matter altogether. When the quinine tablet hits the back of the tongue, it is a gentle reminder to the rest of the body of what is to come. Quinine is terribly bitter – much more so than sucking on Aspirin. Once the quinine has infiltrated the body, all food and drink tastes a bit like quinine – and it gets stronger each day. YUM!

Well, it’s 9am and I’m off to take a nap – my first of many for the day. Only 18 more doses to go. Talk to ya again tomorrowJ

Aud

If any of you would like a similar experience, please come and visit any time…

#152 Shanksteps- Malaria
Day 1: Today is Friday. Greg was called away to a meeting Monday- Wednesday so I was left to “hold down the fort”. It truly wasn’t too bad; there were no surgeries; I was able to sleep for 8 hours during the 3 days. I took Thursday off to “recuperate”, so why do I feel sooooo tired. MALARIA. And I thought my stomach hurt because I was drinking too much coffee. Again: MALARIA. That dizzy spell I had on Monday in the middle of clinic that I thought was due to not drinking enough water. MALARIA. The nightmares and difficulty sleeping – could it be due to stress or…MALARIA. I mentioned something to Eliza today and she said that I ought to get tested. Afterall, the test is free and the lab was on my way from the Peds ward to the Clinic. So, after telling the lab tech to take my blood, but not expect to find anything, was I surprised to find MALARIA? Plasmodium Falciparium! So, that’s why I’ve been feeling to crummy lately.

Since I feel like I’m going to die every time I take Quinine, Greg thought it would be educational (funny) if I kept a malaria journal for the next 7 days and explained to all of you what I was experiencing. So, welcome to my world of malaria and quinine.

Wandala was grunting and holding his abdomen. He is an elder in a nearby church. He has had abdominal pain for two days. He has an IV dripping into his right arm. He lies on his side to relieve the pressure from all the bloating. I palpate his distended abdomen, which has no signs of peritonitis. He says that he had diarrhea yesterday and that he has eaten bouille (porridge) today. I get a typhoid test that is positive and hope that with treatment possible intestinal inflammation will resolve. I also place a nasogastric tube.
The next day is our “day off”. Which essentially means that we don’t make rounds and they call us less often. This day it means that we have a few calls that we take care of in their carnet (little medical record) then Jacques calls about 10AM and says I need to see a child. He has had also had a distended abdomen for two days. This one has a small hard mass at the umbilicus. A strangulated umbilical hernia. I ask them to get him ready. I see a few other patients the nurses ask me to see. Then to the OR.
I open up under the hernia. As I get into the abdomen cloudy fluid comes out. As I inspect the bowl from the small opening I see a black area. After pulling this out, I see that it is a necrotic piece of bowl, Richter’s hernia. I resect the dead area and go about making the anastomosis. As there are no staplers here, I do a hand-sewn anastomosis that takes some time. I write my note and leave the OR, I examine Wandala again, he says he feels better and has passed a little gas. I do a few ultrasounds before returning home. Audrey is sewing OR masks and hats and table drapes.
Today Audrey is helping out with the nationwide polio vaccination. She is climbing mountains looking for vaccination teams. She is to evaluate whether or not they are maintaining the vaccines in a cooler properly, filling out the paperwork for the vaccinated kids, and marking the houses of the families vaccinated correctly. I go in the hospital at 7AM, before morning worship, to evaluate Wandala. He is still very distended. Says he had a stool last night. He does not really appear to be improving.
The blade slides through the skin, then fascia. Intestines burst from their entrapment. They are very dilated. There is a twisted area of sigmoid volvulus that has blocked off the bowl. Fortunately for him, none is necrotic. I decide to close and await another day to prep him properly and resect the redundant bowl.
As I step outside to head to my office to see outpatients, it’s cooler today, 102F. I dread what it will be at the end of March. HOT! Greg