MissionDocs.org

#175 Shanksteps

I first saw her in clinic.  Her nomadic, bright colored attire, hid her frame.  She said her stomach had been growing.  I asked how long, and the response was 10 years.  Hernia? Cancer? Baby? (the time frames I am given often do not apply to the current episode of things happening, but may be an accumulation of events that the patient relates together).  I examine her and fine a huge abdominal mass that seems to be little mobile, maybe 10X10X13 inches.  I did an ultrasound.  It appeared solid and cystic (little fluid pockets). Likely a cancer.

She took the “standard” bowel preparation the day before yesterday.  She took it all and had NO stool.  So she did it again yesterday with even more bisocodyl. Finally she had a lot of diarrhea and cleaned out.

She lies there with cachectic arms and legs, with a VERY protuberant abdomen.  Lying on the operating room table, she takes up a small portion of its 1.5 feet width.  She looks embarrassed as we uncover her to start the preparations for surgery. We administer Valium, atropine and Ketamine; prepare her abdomen with betadine, and lay on all the cloth drapes.  She has NO fat on her body.  So once I’ve cut through the skin I’m nearly inside.  Usually when I’m working on a belly this protuberant I’m apprehensive because I’m wondering if the baby is going to be OK.  Now I’m apprehensive because I don’t know exactly what I will find.  Where it will be coming from and if I’ll be able to take it out.  I see intestine stuck to the surface.  Huge vessels feed the mess.  I feel below it and don’t feel a free spot, neither on the sides and top.  So I slowly start freeing the intestines from its surface.  There is oozing everywhere.  We give her Vitamin K in hopes that she might be low in Vit K and that this would then help.  It doesn’t seem to.  I control the bleeding with some sutures.  We continue the slow work.  Freeing up here and there around the sides of it.  Now I’m behind the large intestine and behind the stomach.  The pancreas is in view, it’s rather stuck to the cancer.  I realize that all the large vessels that feed the intestines are within this cancer.  It is impossible to remove.  So we decide to close.  The nurse giving the anesthesia recommends that I call a family member into the operating room to see what we have found and to explain why we cant take it out.  I call in an uncle that is a person I recognize as having seen before.  The nurse puts a mask on him and a cap and he comes in the door.  The nurse stands behind him to assure that if he passes out he doesn’t hit the floor.  He takes it all in without emotion.  Thanks us for trying, and states it is God’s will.  Though I desperately disagree with the last statement,  I say thank you and he leaves.  We close up the abdomen and take her back to her room to wake up.  I instruct the nurse to get vital signs on her every hour for four hours, knowing it will only happen if he has nothing else to do. G

An older woman sits in front of me in clinic, her husband on the chair beside her.  She says that something is coming out below when she walks, and has ever since she had her last baby a few years ago.  I examine her and find it’s her uterus coming out

Another young man is having rectal bleeding for the past few weeks.

A third had an accident on his motorcycle a couple days ago.  The huge swelling on the side of his face is improving.   He arrived unconscious and now is thinking clearly.  He says that one tooth doesn’t seem to be in place.  I examine him closely, and find that he has a mandibular (jaw bone) fracture right before his last molar.

These are the surgeries for today.  The older woman took her bowel prep which consisted of a bowel stimulant (Bisocodyl) and water. She is placed on the operating room table.  The preparations are made and I put on my cloth operating gown.  It’s cut real small for my long arms, and when it get’s wet with blood or other fluid, I’m wet with it too.  I help Dr. Solomon put his on, as I’m particular about sterility even though others don’t seem to see the necessity of all that I do.  This is probably the cleanest she’s been in 60 years of life.

I open her lower abdomen.  She has essentially no fat!  I open the skin down to fascia in one fell swoop.  Cautiously enter the fascia and peritoneum.  I search her pelvis for the uterus.  I grasp it between my fingers and pull it into the wound. It has been prolapsing so far that it comes up easily.  It turns out to be one of the easiest hysterectomies I’ve done.   I didn’t bring large enough suture to do hysterectomies so use a smaller than normal one.  For her tissues it turns out fine.

The next was the young man for a colonoscopy.  I finally find the colonoscope again and all the things that go with it. I look inside and find a very inflamed intestine.  Colitis.

The 30 year old guy with the mandibular fracture is next.  I take him to the OR but cannot find the materials I need. I need arch bars (metal bars for the teeth) and wire to attach them to his teeth.  I need to wire his mouth shut for two months to let things heal.  After opening a number of sterilized packs, I finally find the one that has the right equipment in it.  I wire the arch bars to his teeth then, the arch bars together.  I find that I cannot include his last tooth so the fracture is still loose.  At the end I realize I will still need to wire his bone itself together as I don’t have any metal plates to put on it.  I’ll wait till the swelling goes down then attempt to finish.

I return to the clinic to finish seeing the patients that have been waiting for hours.  See more malaria, typhoid, pneumonia, and another malnourished kid who is 2 and weights about 14 pounds.  I head home to a meal of millet paste and sauce (my actual favorite here).  G

It is Saturday, Christmas Eve, and I was at church. I’m called out in the middle of it to see a patient that was in a moto accident. One of the health center workers was riding at a “slow speed” and hit a rock and fell over. He lay in the dirty suture and dressing change room moaning. I asked Bouba, the nurse to find a stethoscope. I had forgotten mine in the US. He ran to the ER and came back with one. The man complained of his shoulder only. I listened to his lungs checking for a pneumothroax that could kill him, and they sounded normal. So I examined the rest of him. I only found a broken clavicle. I put him in a figure-8 dressing to help put this in place. I checked on a couple others lab results then headed back to church. Right at the end of church they called me again.

There were three that had been on a moto. Two men and a teen girl. The girl had a fractured wrist, one man had a fractured wrist and a hematoma on his head. The third man had a fractured wrist, broken femur (upper leg bone) and a ankle fracture. They were laying in their hospital beds moaning. After checking each one out I asked whether they wanted to be treated here or by the traditional bone setter. Two wanted to leave and the one with multiple fractures wanted to be treated here. I have always had to fight with them before, so I knew what was coming. I decided since they were adults they could choose badly for themselves, and besides, though I have shamed many people in the past for not doing what the doctor ( me) wanted, they still wouldn’t let me do it. So when these decided to not do it, I wasn’t surprised. It ended up after the x-rays that even the lawan (the local low level chief of a certain area of the village) with three fractures, he decided not to do it either. So I left and went home.

We prepared a special evening meal. In the late afternoon our friends from Chad arrived on a surprise visit. And the power went out. So we filled up every available pot, jug, and glass with water before it ran out in the water tower. We had a wonderful candlelit meal. It consisted of home made everything; gluten, beef stew, stuffing, green beans, salad, potatoes with margarine, rice. Later we opened the few gifts we had brought for our guests and the student missionary here, while sitting in front of our decorated tree branch that we cut from a tree. Decorated with toilet paper streamers, paper figures, and cutouts from a magazine. We had a great time. We think we appreciate a simple Christmas, as theses have been our favorite. G

I sit against the operating room wall holding a small baby in my lap. He is wrapped in a dirty blue towel that has amniotic fluid and meconium all over it. He had come out of the cesearean section that I just performed with a big cry and apparently breathing well at the beginning. I was doing a surgery on a woman with a small pelvis that had been in labor for three days before making it to the hospital in the evening. I had done the same girls previous surgery a couple years ago. She says that her girl is still living. She wanted to have her tubes tied after this surgery. Her husband agreed. As we finished up the surgery, Yaouke was suctioning the baby, Dr. Solomon and I were closing the uterus, and abdomen. Yaouke said the baby wasn’t breathing well. At the end I checked the baby. If a black baby can be blue this one was, or at least his lips were! I put oxygen on him. He had small grunting sounds. I sat there against the operating room wall will the nurses cleaned the room. As I sit there I cradle this new life in my arms. I try to wipe meconium off my finger by wiping it on a “clean” area of the towel. I place the oxygen monitor on the baby’s finger. The whole hand fits inside, but eventually I get a reading. When the baby wiggles around and the oxygen comes off his nose, his saturation drops to 77% (normal >92). He desperately needs the oxygen. The next thought that runs through my mind is how long should I sit here holding the baby. As we have been back here it is easy to fall back into my previous roll and concerns. Again, how long will I sit here taking care of this baby. It’s a little different this time because I only have to have enough energy for two more weeks, not a year. So I sit there longer. After about an hour there seems to be no change and everyone is done with their cleaning and other tasks and ready to head home, 10PM.

I take the baby to the nurses sleeping room, office. I set up the oxygen concentrator, monitor, and voltage converter to keep all running. The nurse finds a padded foot of the bed to move into place on the floor. I place the baby on it and tape the monitor to his foot that is moving constantly. It seems to pick up his vessels and oxygen concentration. Tape the oxygen cannula to his face and cover him with all the cloth the family was able to come up with. A couple small pieces. I watch the pile on the floor move a few minutes and everything seems to be working.

I check on the 17 year old girl that had a bad motorcycle accident. She arrived unconscious and on palpating her head I felt she had a depressed skull fracture. I had rushed her to surgery yesterday afternoon. I explored her scalp. There was a large hemotoma (blood collection), but no apparent skull fracture. I closed up my incision. I talk to the family who is sleeping on the mats beside her bed. They say she has not moved or done anything since surgery. I uncover her from the large blanket that is on her and she feels hot. She’s about the age of Sarah, and I worry about her, knowing I can do nothing more. We get a glass thermometer and check her temperature, its equivalent to 104.5 deg F. Is she having malaria, or a central (brain) fever? Well I can treat malaria and not the other, so I treat malaria, and give her IV asparin to help bring down her fever. IV asparin is the only med here to give for fevers.

I check on the small pile of fabric in the nurses room. It’s still moving with the baby boy inside. The oxygen numbers seem OK, so I head out to the ER, on the way home. There I am stopped by a nurse who just brought a pale baby to the the ER from the pediatric ward for oxygen. A hematocrit (blood count) has been ordered since 2PM but not done. I ask them to call the lab tech and get it. Then to verify the blood of the mother who is present to give it to her baby. They are instructed to call me if there is no match as I am O+ and can give to most people. I head home.

…

I am thanking God! HE protected the child through the night and the kid had breast fed a couple times before I saw him. Mom is complaining of pain, but then again why not, I forgot to write our strongest pain medicine, Ibuprophen! The mom is laying in her bed on her back. She is covered by panye (colorful cloth) from the waist down, the top bear with the baby attached to her right breast. She is smiling because her baby is alive. This one moment makes my hours last night worth ALL of it!

It was Sunday, market day in Koza. I awake with diarrhea at 4AM. I cant sleep after this. Have diarrhea a few more times by 7:30 when I head in to the hospital for morning worship and signout.

Sunday means that hundreds of people are in the market and extra people are in the hospital too. Dr. Roger and I saw about 24 outpatients. One had a huge abdominal tumor that was a little mobile, and we will attempt surgery, another had a muscular tumor in her upper tricep that appeared separate from the important vessels on ultrasound, a 5 month old child with Pertusses (whooping cough, that normally children, even here, are vaccinated against), a child with Beri Beri and malnutrition, and another malnourished, dehydrated and with malaria, and the rest were pneumonia, malaria, typhoid and dysentery. Also saw one of the workers boys who had a huge leg abscess. It had begun with ankle swelling, then the leg swelled and they drained out pus at the ankle and mid calf. I looked at the leg and after giving the kid Ketamine to help him sleep, I felt his joint. At the opening I can feel the ankle joint exposed. I filleted open the leg from about mid calf down, exposing the musculature below. Drained a lot of pus, and packed it. Saw a few patients in clinic again. Then by 4PM made it home for lunch. G

I went to bed last night with my belly all distended. I felt like diarrhea was coming but it wasn’t happening. Finally about 10PM I drifted off after flopping around in bed. The night before there must have been a mosquito under our net as Audrey and I had bites in the morning. I fall asleep with the buzzing sound, not knowing whether they are outside or inside the net. About midnight I wake up with abdominal cramping and go quickly to the bathroom…diarrhea. I fall back asleep and wake up at 4AM as I turn over and my belly makes a huge gurgling sound. I cant fall back to sleep. Guess the time change is still affecting me after a few days here. I go to the bathroom and squirt some more. Guess I’ll stay up now and write you all. I am tired but can’t seem to go back to sleep.

Yesterday was a special Sabbath day. We had the usual church service. A Sabbath school, followed by a church service. That consisted of choir groups singing and a sermon. This was a special Sabbath because it was a baptism day. Outlying churches walked many miles to come to the communal church today and bring their candidates for baptism. They slowly showed up during the whole service. At the end of the service, the fundamentals of following Christ and wanting to be a part of this church were read, with the candidates verbally agreeing after each statement with a “halaow”. The service ended and a water immersion baptism ensued. Each was given a white robe over the cloths they wanted to keep on. The baptismal water is a concrete structure built into the ground outside. It is filled with water. They enter four at a time with the pastor and elders performing the baptism, four at a time. It took a while for about 120 people to be baptized.

Many people greeted us after all was finished. Each stated they were happy to see us shaking our hands, asking how our families were, how our parents were, how our siblings are. We in turn asked the same questions of them. Nearly each stated their desire for us to come back.

In the evening we ate some spaghetti with home made sauce and as I went to bed early, I felt bloated all over my abdomen. Suspecting diarrhea would be coming, I went to bed. I lay there tossing and turning, thinking about my patients, and finally convinced myself that I am not in charge here and was able to fall asleep. It’s easy to fall back into the same thoughts and feelings as before. G

The second day of the Christian wedding;

It was supposed to start at 11AM, and it was announced to be there at 10:30. We arrived at 11 supposing everyone to be later. We were about the 10th person to arrive. The church ceremony was in the outside tin-roofed structure. It holds more people and isn’t as hot. People slowly filtered in to the “hangar”. We were the guests of honor since we are good friends with both sides of the family and had come the farthest. We were seated on the groom’s side in the second row. Slowly people came. At the beginning, a bible boy and flower girl came down the isle. The flower girl was spreading little hole punches of white and pink paper, as the flowers. She ceremoniously spread them all over the red carpet that went up the middle between the white plastic lawn chairs that had been moved from the previous site to here. There are a defined number of these in town, so any event requires borrowing them from the school, mayors office, sous prefet… to get enough to have a large crowd sit down in one place.

After these entered then teenaged boys and girls danced their way in, on the red carpet down the center. The music was a classical march on the speakers. A small step forward with the left foot. Shake the right foot out in front of you. Boy and girl face each other, the girl bows, she rises then twirls facing away. Grasps hands with the boy behind her, and does a few right foot pumps in the air about a foot off the ground. Then twirl back to him, and grasp hands again and make an arch with their arms. Then forward one step and REPEAT…. Till they have arrived at their designated seat along the isle. They all join hands across the isle and make an arch that the bride walks through with her one bridesmaid. She arrives in a small red Toyota four-door car. It has been decorated with pink toilet paper ribbons and toilet paper flowers. All stand. She slowly walks down the isle underneath the arch of arms, to a tune by Enya, tripping over her long white gown periodically. Arriving at the front of the arch her groom meets her. Everyone sits down. The bride and groom are sitting on chairs facing each other in the front. They have been decorated with a shiny white cloth and some toilet paper flowers. A row of balloons crosses the front of the stage, and a gust of wind rips it off at one corner, making a trail of balloons fall to the side. There is an audible gasp, but all continues as planned. The maid of honor and best man are on chairs directly behind the groom and bride.

The service continues with music by several choirs, some visiting from Maroua, about three hours away, where the bride is going to her last year of high-school, very uncommon for a local girl to make it through high school. Here there are about 100 that graduate each year. About two are girls, and usually one if from the south, as her parents are here as teachers, or government officials. The choirs end their songs, and the pastor has a short sermonette about love and working out differences and being faithful to each other for the rest of their lives. They each say rehearsed vows. Rings are exchanged as a symbol of their unity. And they march out to the car decorated in toilet paper.

They head out to the reception that is to follow by invitation. Food and drinks for MANY people. We are seated under the circular tin roof with all the important people and the married couple and their close family. Food consists of chicken, beef, goat meat, plain noodles, salad with dressing, popcorn, a green bitter vegetable, fried plantains, boiled taro root, fried sweet potatoes. All eat till they are full. When the foods done, everyone leaves. The family looks tired. Audrey, Sarah and I get on the small motorcycle and we head home. G

He lay crying on the emergency room table, grabbing his lower abdomen. He got up and slowly walked outside, all bent over. Nearing a tree he lifted his gandara and tried to pee. Nothing! With a grimace on his face he walked back in. He had come to the hospital a couple weeks ago. He had taken the antibiotics and felt better for a little while. Yesterday he couldn’t pee, so he went to a hospital in Mokolo and they put in a urine catheter. After his bladder was empty he felt pain and the need to pee but nothing was coming out the tube so he asked for it to be removed. He went home that evening and couldn’t pee all night. Then he came to “our” hospital.

The nurse tried to place a urine catheter, but it wouldn’t go in. I walked back into the room as the old man is yelling, grunting and deep breathing, trying to tolerate the placement of a catheter that was trying to enter the prostate that is to tight to even let urine through.

So I get on sterile gloves and give him a hand. More yelling ensues. I get it partially in, but not enough to get urine. As I pull it out it tugs significantly and he jumps and yells some more. The curtains the we put up have been removed between patient beds in the emergency room, so the 13 year old girl who has pneumonia and is breathing at a rate of 50/min, looks on at the commotion. Neither he nor she seems to be bothered by the indecency of the situation. I call for the nurse to bring me a smaller catheter. The pharmacy doesn’t have one. Dr. Roger, a Congolese doc that is covering for a while, walks in and says he thinks there are smaller ones. No one can seem to find them. I take off my gloves and check out the stock. Fortunately for the patient, we find some and it goes in much easier with only short yelling and grunting. We send his family off to the pharmacy to purchase all the materials for a prostatectomy.

I take a look at the 13-year-old girl. She came in that morning after 4 days of not breathing well. She is thin, in the first stages of puberty, and breathing fast and deep with a LOT of effort. She had been started on penicillin. Her bed is in a sitting position, and she was leaning forward to try to get in more air. The oxygen concentrator was giving her 2L of oxygen. I ask for the oxygen saturation monitor, and they tell me both have been broken. I ask for one of the nurse’s motos and go home and get a finger monitor that my anesthetist in OR, gave me to come over with. I head back and check her oxygen, its 77%. I listen to her lungs and there are crackles all over, with quite a bit of wheezing. Let’s see, what antibiotics do we have right now? Amoxicillin, Ampiciillin, Chloramphenacol, Cipro oral, and metronidazole, penicillin. What bacteria are possible here? What’s common here? I’ve forgotten what I used to think when here! I start her on Ampi and Chloramphenacol, thinking it will cover Strep, Staph, and H. flu. (common bacteria in the US). In the US I would intubate her, here I just hope she keeps breathing.

The family returns, having paid the materials for the prostatectomy. I’m surprised, but then remember that they had been home preparing to come back for surgery, when they heard that I was coming. I head off with Audrey to go home and change cloths to attend the wedding of Avava and Valantine that we came for.

After the wedding I head to the operating room with Dr. Solomon (The other Congolese doc that’s covering here). They have done one prostatectomy and the patient didn’t do well, so they have been telling the old men with urininary problems to come back in Dec, when I arrived.

Ketamine, Valium and Atropine are given and the old man is off to sleep, making the funny faces people make when hallucinating on Ketamine. We open the pack of sterile equipment and find they are out of gowns and have put yellow, infectious gowns in the packs. These are a thin, see-through, material that is NOT sterile. We open other packs till we find the one with cloth gowns. We put these on and I have to say something to the other Doctor about sterility as he grabs his gloves with his bare hands and pulls them onto his gown. We change the gloves and continue.

I press the blade against the dark skin, and it fillets open showing the white and yellow inner layers. It’s been a while since I’ve operated on dark thick skin. Essentially no fat is there. I divide the fascia and open the space above the bladder. I fill the bladder with saline, and then open it. My finger examines a huge nodular prostate at the apex. Cancer? I crack the prostate anteriorly with finger pressure. The other doc feels the same area. I realize that my thin gloves must have a microscopic hole, as my index finger is wet under the glove. I double glove. I attempt to shell out the prostate unsuccessfully. I think about a different approach, and decide that it’s not wise under my current circumstances. I have opened the prostate enough that he should be able to pee again, but the prostate will stay. We close the bladder, fascia, and skin, leaving a glove piece as a drain. Wish I had brought in the drains someone gave me before coming! I always worry about part of the glove tearing off inside as I try to pull it out a few days later. As we are closing the irrigation starts filling in the wound. The catheter must be blocked. I irrigate it and a large clot comes out. I reinforce with the assisting nurse that is giving Ketamine that this is the reason we need to be vigilant of the irrigation. He assures me that they are. (even though it is truly the family that does the irrigation and empties the urine sac).

I return to see the 13-year-old girl in the emergency room. She says she’s breathing better, but looks about the same. Her oxygen saturation is better after increasing the amount, but she is still breathing very fast.

I head home to prepare for the evening party of the married couple for close friends and family. That night I pray for all our patients, but specifically the old man and the young girl. “God protect them from poor care, dirty surroundings, and their disease. Thanks.” G