MissionDocs.org

Like most women here she started labor at home. It was her first. Her husband went away because it is shameful for the nomadic women if their husband hears them cry out in pain during delivery. She had contractions and around midnight two days ago she broke her water. Then her labor stopped. The following morning she went to a local health clinic and was watched there for some hours. In the afternoon they referred her to the hospital for better care. I evaluated her, felt she had sufficient room to deliver and decided to wait a few hours. I instructed the nurse to call me if the labor didn’t start again. She was more dilated than when they examined her at the health center, so I felt she was progressing even though she didn’t know it. We were called to see others during the evening and I forgot about her. The nurse never called and I slept fitfully. At 4 AM I awoke to banging and crashing sounds. There was a strong wind storm and thunder in the distance. Tree
branches rubbed and crashed on the tin roof making a terrible racquet. Dust was flying heavily in the air and I felt sand all over the bed and between my teeth. I closed up the windows to the house but it was a little late. Every step left a gritty feeling under my feet. I finally drifted off to sleep again.

At morning worship they talked about the woman who was not progressing in labor. She had now been more than 28 hours after breaking her water, too long! I asked Jacques to check her out, and if she was not close to delivering to take her to the OR and get her ready for a C-section. He called me a few minutes later and said she was in the OR, ready. The power was out since the windstorm and so we started the generator. It started and we began the surgery. Audrey and I pulled out a crying baby and were happy that we had done it early enough to save the baby.

I made rounds on the maternity ward. The boy with the puncture wound to his head is doing well. I tell the family that it is God healing him that is keeping him alive, they smile and nod even though I think they do not believe in God. I am thankful I do, and the He is healing this boy! I see the others and then go to the office. In the office I see about 12 patients. Then the next surgery is finally ready. Three hour turn over! I’m frustrated, but go back to the OR. Frustrated mostly because I expect that it will take about 4 hours to take out a pelvic tumor on this next patient, and it is early afternoon.

Audrey and I start the surgery and we find a lot of small intestine stuck into the pelvis to the top of the mass. After much dissection we determine that it is a huge hematoma, likely an ectopic pregnancy. I guess her having a period a few weeks ago was not correct. We evacuate the hematoma and remove what was left of her blown out uterus. She didn’t want any more children so it made it an easy choice.

Audrey, Jacques and I clean the OR as the cleaner has already left. Then off to the ER to see what patients were waiting for us. We see a large row of people still there. It is about four patients with many family members. We see them in each of our offices. Yaouke, the nurse from maternity comes to my office. He asks me what I want to do with the man that came over with the infection near his scrotum, it smells so bad that the patients are leaving his area because of the odor. I had not heard about him. Someone thought that I had. I went and looked at him. The odor hit me about 100 ft before I arrived at the building. I put on a mask to not show my facial expressions. Lifting up the cloth over him, I see a black area on his perineum. I touch it and feel bubbles under my gloved finger, gas gangrene (Forniers Gangrene). He needs to be operated on right away. He has about a 40% mortality if he were in the US and getting good ICU care. I believe his chances are m
uch better here as we will be praying for him. I take him in the OR. As we go through the doors I fight off the mass of flies trailing him. Only a few make it in the OR with him.

Dr. Okudire and I start the debridement behind his scrotum. Brown, foul smelling fluid runs out. We take off a huge chunk of skin all the way down to muscle and down to anus. There seems to be an area tracking up in his inguinal region. We follow it up. We are now on his lower abdomen. The skin looks normal but the infection runs along his fascia (necrotizing fasciitis). We resect more and more. Off come layers of muscle, fascia and more muscle. The infection is deeply seated. We end up debriding off all the skin on the right half of his abdomen up to the right nipple. The infection skims along on his ribs up to here than back to his right back. Finally we get it all open and removed. Raw muscle and peritoneum are showing everywhere. It looks like an anatomy lesson on a live patient. I put dressings on it and we clean the OR thoroughly. I wish I had done it somewhere else. Will I have wound infections with my other cases now? I say a prayer for him again and
give instructions to Ganava. He will be taking care of him tonight. “God, please send your angles to keep him safe and please heal him of all this infection and the insult I have just created.”

I head home to a loving wife and rice and white beans. The salad is wonderful, fresh vegetables!!! I eat my first meal of the day at 7:30 PM. I guess all those pounds I made in the US are keeping me going. I think I gained about 15 and have now lost about 5 already. It is amazing to me how resilient we are. I can gain and loose weight, and this man can live in spite of the odds. Pray for his recovery.

In His Service, Greg and Audrey

Shanksteps # 132

I knew it was going to be a tough day.   We had just finished a C-section at 2:30AM.  Took a shower and headed to bed.  I drug myself out of bed at 6AM.  I made hot chocolate and had my own worship, arriving at the hospital at 7:30.  I had a colon cancer to resect today and was worried about it.  I had diagnosed it on colonoscopy back in February.  He was the head nurse of a health center and had decided to try traditional therapies.  Now after many months he came back to have it removed.  In Maroua (three hours away) they had asked him $400 to remove it.  Here I expected it would end up being about $200.  Money isn’t really an issue for him, but he chose to have it here anyway.
After morning worship and sign-out I headed to the office to see a few patients that were waiting there.  There was the follow-up for typhoid treatment, a bad pneumonia with significant shortness of breath, a child with a cough for months and weight loss- possibly TB.  There was a woman coming to follow up her hypertension, a teenager with a right inguinal hernia, and an old man with prostatitis.  Finally there were no more for the moment so I “ran away” from the office.  The office is kind of like the ER, if you are around their will always be one more question or one more patient to see.  Audrey was making rounds on the pediatric ward with 28 patients (24 beds, some two to a bed).  I made rounds on the maternity/surgical ward as usual.  There were three recovering from prostatectomies this past week, three who delivered a newborn over last night, the girl that we did the c-section on in the morning.  Others were wounds that were healing, a child with chronic constipation r
equiring rectal lavages, and the girl healing from her skin graft following a burn of 2 months ago.    There was the boy who caught his fingers in the grinding mill, taking care of half of three of them, requiring a revision of the damage.  There were two with endometritis after delivery at home and two with threatened abortions after working all day in the fields; another with gonorrhea PID who is pregnant.  Finally we were ready to start the colon resection.
He was a large, short man.  Unusual for most surgeries here, he had a number of inches of fat to go through before reaching the inside of the abdomen.  Intestines and omentum spilled out as he tensed his abdomen.  Ketamine (anesthetic), love it and hate it!  It was taking a lot to keep him from moving.  He did tell me ahead of time that he drank SOME!  After exploring all over I did not see evidence of any metastasis. The tumor was low in his pelvis.  I identified the path of each ureter.  Mobilizing the descending colon, we ensured that there was adequate length to reach the lower portion once we had resected the tumor.  After removing it, how would we put it back together?  Normally I do a hand-sewn anastomosis between the two pieces of bowel.  This was really to low.  I thought we had one circular 29cm rectal stapler.  So it was found. I hadn’t used that style before but was able to create a good anastomosis.  Filling the abdomen with saline (to look for air bubbles – l
ike looking for leaks in a tire tube) the anastomosis proved airtight.  Four hours later we were done.  (seems so easy here, one paragraph!)
I dropped my operating stuff off in my office.  Saw a few patients that were waiting for me.  Amadou called me to see a patient in the ER.  It was the son of the Sous-Prefets assistant.  He had been by the road and hit by a passing motorcycle.  He was conscious and had a wound on his right head behind his ear.  Grey tissue was in the wound.  Oh this looked reminiscent of a few months ago.  I put on gloves and examined him.  Some scrapes and bruises were found on his legs.  His head had a depression that my finger could sink into.  Pupils were reactive.  He needed to have his open skull fracture debrided and closed.  I called Jacques to come give anesthesia and ran home for my first meal of the day, it was 6:30 PM.  I inhaled some potato fries and salad and went back.
After putting him to sleep, I opened up the area on his head.  The skull had been punctured and many fragments bent into the center of the hole, grey and white brain tissue pooled in the area.  With difficulty I removed or elevated 7 pieces of bone.  During the process one artery was uncovered that bled profusely.  After a struggle I was able to tie it off adequately.   I could not find enough dura to close.  I created a patch out of temporalis fascia and sewed it in place.  Placing a drain, I closed the hole.  His pupils were reactive and we sent him back to his room to wake up.
“Doc, can you see this woman in maternity?”  It was Amadou again.  A woman was in labor at home since early this morning.  She had been “worked on” and had a very edematous perineum.  The baby had sounded good to him.  Oxytocin had been started to restart labor.  Now she was having abdominal pain.  Examining her, there seemed to be enough space for the baby to come out, but I found no baby heart beat.   I ran to get the ultrasound.  Baby was head down and the heart was not moving.  I thought I could see the placenta laterally but wasn’t sure.   I attached forceps and tried to help the fetus come down.  It seemed unsuccessful.  Then I realized that she had ruptured her uterus.  So back to the OR we went.  After 30 minutes we were deciding whether to repair the uterus or was it too damaged.  She had told me she didn’t want more children.  It was fortunate because it was very damaged and we needed to remove it.
Yaouke came in and mentioned that we needed to see another kid when we were done. She had eaten a meat sauce with a bone in it and felt it get stuck in her throat.  She had a lot of salivation and couldn’t swallow.   We finished up the operation.  It was 2AM.  We pulled in the girl to the other OR.  After writing my operation note, I went and did a laryngoscopy.  I could not see anything unusual.  I prayed that she would not have any real problems.
I arrived home, showered and fell into bed.  It had been a long two days.  God give me the strength to continue.  Give me patience even though I feel very short tempered.

Counting on HIM, Greg

#131 Shanksteps (of faith)

I was in the shower when I heard someone crying.  I knew that Greg was on the phone with his family so I thought that probably he was instead laughing hysterically. When got out of the shower, I realized that it was true crying; not the kind of wailing that the women do to announce to the village that someone has died, but true, honest, heart wrenching bawling. When I walked into our living room, I was met with a peculiar site. Greg was sitting on the floor with his arm around our nurse Mbaitomo. The nurse’s wife was sitting next to them. Mbaitomo was pouring out his heart to Greg. Mbai is the kind of guy that always wanted a son to carry on the family line.  However hard he tried though, he ended up with 8 girls. Two days ago he found out that one of his youngest was pregnant, and took some kind of traditional concoction to abort the baby.  He found out because she was bleeding all over their house.  After consoling Mbai and his wife, Ruth, we told them to bring the girl in
so we could check on her.  Sure enough, she was pregnant; but not just one or two months like I assumed; not even four months like she claimed; but the baby was almost 7 months along; and now dead (confirmed by ultrasound). To make matters worse, she had already ruptured her sac of amniotic fluid, and the baby was transverse (sideways). This meant that we wouldn’t be able to turn him so he could come out head-first (or even feet first).  What it really meant that this baby wasn’t coming out at all except by Cesarean section.  This was not what Mbai and his wife wanted for their 15 year old (unmarried) daughter.

So, Greg and I took her to surgery.  She weighed about 80 pounds, with a protuberant belly. She had a fever of about 104  F.  The surgery was like any other C-section (with a stillborn) except that we were now doing it on a friend. Fortunately God blessed and we were able to remove the dead fetus without too much difficulty.  We finished at 2:30 am and went home to bed – very sad that her bad choices had to turn out like this.  She is starting to heal but still very sick from an infected uterus. Please pray for her physical, emotional, and spiritual healing. Pray that she will be able to have children in the future. Please pray also for forgiveness from her family.
In His grip, Audrey

#130 Shanksteps (Shanks steps of Faith)

Today was Sabbath.  I was able to “sleep in” till 6:30 when they called.  Actually I woke up at 6.  My body used to one time won’t let me really sleep in.  I go in to see Nafissa.  The woman who I talked about in #128.  I had seen her during the night when she went unconscious after getting up to use the bathroom.  I found out she was hypoglycemic with a glucose of 16 (normal >70)  Now I find her conscious but breathing very rapidly and seemed to be doing worse.  Her bleeding had stopped a few days ago, her nasal bleeding also.  There was no more diarrhea.  She was still anemic and had received 1.5 liters of blood since she came to the hospital, I believe a record for someone here.  All three family members that were here, were willing to give.  Her lungs sounded like she had pulmonary edema, her body puffy, as it has been for the past few days.  The nurse had put her on oxygen until the power went out again.  It flickered back on, so we restarted it.  She was breathing bett
er with it.  The nurse gave her medications and I went off to see other patients.
There was a question about a child with a hematocrit of 10% who they were not finding blood for and was unconscious, a woman who had a seizure at home and was now combative, and a 2 year old that had just arrived with anemia and a fever of 105.5  These were the beginning.   I saw them and headed home for a bite to eat and planned on going to church.
After preparing, I left to go to church, only to be stopped by the guard, Allah-Hokki, telling me that they needed me at the hospital again.
I placed my Bible on the ER table and started examining a woman with severe epigastric pain.  I saw a few on the wards that the nurse had questions about and did a lumbar puncture for meningitis on a 2 year old.  I walked back to church just as everyone was leaving.
The afternoon I admitted a couple more.  About 4PM I decided to go for a motorcycle ride.  Audrey had a migraine so she stayed at home.
I ride out of the village.  All is green as it is the rainy season.  Millet stalks 9 feet high sway in the breeze.  Bugs hit me in the face.  Large cumulus clouds hang in the sky.  I ride past three little boys, each pushing a bicycle tire with a stick.  Little kids are sitting in the dirt pouring it on their legs.  Mangy dogs, with flees and ribs showing, give me a sideways glance as they make sure they are out of the way.  Men sit in groups under trees playing cards or speaking the latest gossip.  I pass some women carrying wood on their heads, headed for home.  Near the government protected forest, I see little thatch roofed shelters along the road with boys, a man, or woman sitting outside them.  I stop beside one to ask why they sit there where no one is and where there is no village.  The boys tell me that they are protecting their crops, across the road, from the baboons.  They say the baboons especially like corn.  I go on up through a shallow river bed and on to the
mountain with red dirt.  I figure I have been gone long enough and need to get back to see if the hospital needs me.  I am refreshed once again.  I ride back past all the same things.  Many people are in the same places.  Life is slow and purposeful.
I stop my motorcycle outside the “urgence’ (ER) and immediately I hear wailing.  It is coming from maternity.  Nafissa!  I cringe and walk to inside.  Jonas confirms it was her.  Also another 10 year old boy we had been treating for an arm infection, who has been getting better for the past week; went out side to use the latrine and he died as he walked.  Crying could be heard from the adult ward as the woman with seizures and meningitis died.  I go back to see the man who was breathing hard and we had put on oxygen.  The power had just been cut off again for the third time today and he was breathing his last.  No time to get my little generator out for the oxygen machine.  Four deaths within an hour.  We have sensed a spirit of death here before, and have had much prayer asking God to remove it.  We ask God to guard the physical and spiritual entrances to the hospital with His guardian angels.  Please pray with us that the devils power at the hospital be overthrown by Gods
power, and that whatever is allowing the devil freedom to work here be made null.  Pray that my life and in the workers lives are put in harmony with Gods will that His power can be manifest through us and that we reflect His love to these people.  We appreciate your prayers and letters.  In His Service, Greg

Shanksteps #129

She was there when I arrived at the hospital. She was about 18, lying on her side on her bed. Gaunt eyes looked up at me. I approached and asked how she was doing. She said OK, but almost inaudible. I saw a small piece of gauze hanging from her left nostril. It looked like dried, maroon colored blood. Her abdomen protruded with a gravid uterus. She was 7months pregnant. She had come into the hospital with a hematocrit of 10%. Her husband had already given her 250ml of blood and her mother also 250ml. Her repeat hematocrit was 16%. Her husband again gave 500ml of blood. She had developed epistaxis again overnight and had had her nose repacked by the nurse. I checked her conjunctiva and she was very pale. She noted that whenever she sat up she got very dizzy. Her BP was 110/60 and her pulse 136. She needed more blood. As I examined her she was having abdominal pain. I checked her abdomen and found a very firm uterus. The nurse had not tried to get a fetal he
art rate, so we searched for it, but found none. She was having contractions. I asked them to try to find more blood as I continued rounds. After only a couple patients her mother came to get us. She thought she was delivering. The nurse ran to get gloves while I finished with a patient. As I go back to her room I find a still born lying on a small white sheet. Jacques is massaging her uterus, she is bleeding vaginally now, as one would expect. Running to the lab I encounter her one other family member who was being checked out. She did not match. Kanas didn’t want to take my blood as I gave a little yesterday. I sit in the chair. My left arm is swabbed with alcohol. A LARGE 12G needle is inserted into my bulging anticubital fossa. “Red life” flows from me into the bag on the floor. Soon it is bulging with 500ml of blood. I run back to maternity. It seems the bleeding has slowed.
I continue my rounds. After seeing about 6 outpatients, Jacques comes into my office, “Doc, she is still bleeding!” I hurry the patient in front of me out of the room and run to the delivery room with my headlamp in hand. Pools of clotted blood surround her buttocks. I perform curettage and remove some pieces of retained placenta. The bleeding subsides. Her BP is 90/40 and her pulse 145. There is no one else able or willing to give blood. Fluid slowly brings down her pulse.
I am called to see her again. She is having copious, watery, diarrhea. She is very thirsty. We pour in more fluids. Her husband looks concerned. He is happy that her bleeding has stopped but is still worried if she will do all right. I am concerned too. God made us incredibly resistant, but at some point it becomes “to much!” There is no power for two days now. The water has just run out of the tank. We make sure each nurse has batteries in their flashlight and we head home for bed. We have just heard that tomorrow our order of medications is arriving from the south; we must go to Maroua to pick them up. I am thankful to have friends at Meskine Hospital where they will arrive. I call them and they agree to keep them a few days for us. I can operate as planned on the old woman with a partial bowel obstruction and do the circumcision on the 18 year old I saw today in clinic.
God, give me peace and rest for tonight.

In His Service, Greg

The sweat beads on my nearly naked body as I lay under my mosquito net. Mosquitoes buzzing around my mosquito net. The power is out in this section of Ndjamena, the capital of Chad. I switch on the ceiling fan just in case it comes on overnight. I drift off to sleep thinking of what has transpired over our vacation to the US.
We left Cameroon discouraged and needing vacation. We decided to talk about Koza whenever there was opportunity. That lead to about six different presentations while we were back. A friend of mine in Chad mentioned that there was a conference about placing intramedullary nails in Washington state. He had been given money to attend and offered to fly me out too. It was a great orthopedic conference where we heard about placing the SIGN nail. I wrote about this in our last email. We received a donation of equipment to start this technique in Koza. This was a HUGE answer to prayer, and a huge improvement to the care we will be able to give the people of Koza with long bone fractures. Then my previous residency in Sayre, PA (Robert Packer Hospital) decided to give us other medical equipment and suture to bring back after doing a presentation there. Also MAP international, who partners with Ethicon, donated suture to take back as well. These were all answers to pray
er.
We arrived at the airport in WV with EIGHT check in bags. Well that was a hit in the wallet as extra bags have gotten much more expensive. After discussion on how to enter extra bags, we were entered with all 8 bags. We had a 6 hour layover in Dullas Intl Airport. We affirmed that all bags had arrived there with the agent. At departure we were called up to the counter. The agent said “Im sorry, but it appears that Economy class is full!” There was a tense pause. Then he said “so we have placed you and Audrey in business class. WOW, God gave us another sign of His continued leading in our lives. We traveled to Paris in the plush, wide seats that recline to nearly flat to sleep, and slept the whole way. In Paris we were also moved to business class, God is amazing.
We arrive in Cameroon with the usual knots in our stomachs. Though God has shown us recently that He is leading we still doubt Him. We are just like the Israelites in Bible times. “God why have you sent us out of the land of plenty to the desert?” We are anxious of what problems await us in the terminal. Audrey renewed her passport this year and her visa was in the old one. In the terminal was different that we expected. We entered the Ndjamena airport, passed immigration without difficulty. Then on to claim our baggage. We found the taxi person that we use ready and with part of our bags already piled together. We waited and eventually got all 8 bags. Our last two flights into Ndjamena we had lost bags so this was amazing that all arrived safely. As we left the baggage area we had to stop by the customs officials. This is usually the most difficult place to pass as we have many bags and they want their pockets lined. He looked at our donation documents and let
us pass with very little harassment. Outside he came to find us, and harassed us for about 10 minutes trying to get money from us. We finally left after much discussion.
We arrived at the Catholic mission compound where we were to sleep, without electricity. With profuse sweating we drifted off to sleep.
I am now awakened at 4:30AM to the Muslim call to prayer. It is Ramadan and it seems especially strong over the loudspeakers this morning. I am unable to sleep any longer. I realize the power is back on, I turn the fan on. the fan doesn’t work. I cannot sleep any longer and choose to write you.
God has again showed His power. It is amazing to me that the God who created the universe has an interest in our lives. He spoke and our solar system was made. He spoke and galaxies were thrown into space. We know of millions of galaxies thanks to the Hubble telescope. So in spite of our insignificant planet in space, God chose to create humans here and loves and cares for each on of us. I praise Him that the God of our universe cares for me and my flight and my luggage! Praise HIM! In His Service, Greg