Cameroon Shanks steps of faith #12

Cameroon Shanks steps of faith #12
9-25-05

He’s three days old and ate well the first day then
has had vomiting and his abdomen is very distended.
His mother says he has not had a bowel movement yet.
So I examined the child and found an imperforate anus
(an anus without a hole to have a bowel movement). So
for this child this was an emergency. I asked if the
patient had urinated that day. Mom said she thought
he had never urinated. This raised suspicion for me.
Especially since this malformation occurs frequently
with other problems. I have only read about this, but
unfortunately have never seen or operated on someone
like this. And the nearest pediatric surgeon is
possibly in the capital 800 miles away or further. So
I began to tell the family about the problem and that
it required surgery. Their first question is how much
it would cost. The nurse said probably 100000CFA.
Well this was a bit exaggerated an I didn’t know if it
would be only a small covering of skin over the anus
or anal atresia (inadequate development of the anus or
rectum) So I couldn’t tell how much surgery was
involved. I could tell by their faces they were
considering not doing anything. So I convinced them
to let me see if I could at least do the “small”
surgery and if more was needed I would talk to them
before proceeding. So this child was taken to the
operating room. We have no preoperative studies
available to see how far down the rectum and anus are
open (x-ray or other studies). So without studies I
figured I should be able to put a needle into where
the anus should be and if only a skin was covering it
I should be able to aspirate meconium (baby stool). I
attempted and could not. So I figured it must be anal
or rectal atresia (malformation up higher). So the
child needed a colostomy (bringing out the colon to
open on the skin of the abdomen). So I discussed
things over with the parents telling them this was
necessary for the life of the infant. Well they said
I should do whatever I think is best. So I continued
on with the surgery. Upon opening the tense belly the
intestines spill out onto the table as they are very
distended and trying to escape the confining space. I
choose a site to bring the intestine through the
abdominal wall and then attempt to close the incision.
This is very, very hard, as the intestines don’t want
to be confined to the small abdominal cavity.
Eventually with much effort we get them back in and
suture the ostomy in place. When opened it pours out
stool. The large intestine was about 10X normal size.
It took a lot of Ketamine to put the child to sleep
enough to do the operation. So during the middle of
the operation the child stopped breathing. I notice
the bowel getting purple instead of pink and ask the
nurse if the child is breathing. He says “yes” just
fine. I look for signs of respirations and there are
none. They start doing CPR on the infant, which is
ineffective. So I break sterility and bag the infant
myself. He pinks back up and starts breathing slowly.
I bagged him about 15 minutes then continue with the
operation as the nurse bags him. I believe this is
the medication we have given him are the cause. Dr.
Hamza who is operating with me thinks it’s the
distended abdomen. Again with difficulty I try to
close the abdomen, the bowel turns purple and I bag
again. Finally I am able to finish the case while the
nurse bags the child. I continue bagging the child
hoping he will live for another hour. Finally he
starts breathing on his own. I stay with him on the
operating room table a few more hours. Only the
on-call nurse has been with me since the end of the
operation. I know the child may not live. I remember
what the mom said about the urine so I attempt a
urinary catheter, it doesn’t pass. So there IS a
problem with the urinary system. I place a needle
into the bladder through his belly. I get 30ml of
urine (large amount for 6 pounds infant). He is
finally breathing well enough I feel ok with leaving
him with the “nurse”.
The next day the child is doing OK and the ostomy is
putting out a lot of stool but the child is crying
constantly. I place a catheter through his abdomen
into the bladder. He tolerated it well.
Now here we are 3 days later. Nothing has been paid
by the family but the husband has gone to sell his
grain supply to get money to pay for the
hospitalization and all we have done. It will likely
not cover the price of it all. The child’s intestines
still haven’t woken up and he is vomiting. I place a
nasogastric tube into his stomach and get many cc’s of
bile. He is dehydrated and his IV fell out overnight.
The nurse is now asking me, if they haven’t paid
anything should we continue with the catheter and
continue to do all this things when he is likely not
to live. If he does live with the urinary catheter he
will have repeated infections and more surgeries… and
more that the family like this will not be able to
support either here at our hospital or even frequent
treatment at dispensaries. I would not make the
decision on what to do. These decisions on whether or
not to continue are easier when I know there is no
chance of survival. But in a child who CAN live I
can’t make the decision on whether to stop treatment
or not. That is the families place not mine. For me
“First do NO harm” (In the physicians oath). So we
placed the IV tonight to rehydrate the child and await
the fathers return. We have seen so much death that
the chance of a life saved even if very sub optimal is
great. I don’t mean to say that we haven’t had
successes with Gods help, but there is enough death to
be very discouraging. Mostly because they come in at
such a late date, and are in bad shape when they
arrive. But also some young (example 14yo girl) who
come in and look just kind of sick but then have a
release of malaria trophozoits in the blood stream and
then decline rapidly. These are also hard.
Fortunately that is rarer, its harder to deal with
mentally because they don’t look like they are ready
to die like the others when they come in. But such is
the life of physicians working in this part of the
world. (Se la vie)
I think what is necessary as in everyone’s life is to
trust in God more. We are not here for our purposes,
or the patients, or hospital workers. We are only
here, because this is where God wants us! I do
believe it is to help the patients and hospital
workers and teach those who do not KNOW GOD about Him.
This is the most important. With some patients it is
easier than others. Also with some hospital workers
it is easier to show God’s love than others. But
that just reconfirms our need to become closer to God
and rely on Him more to be able to deal with these
people as God would and not as we feel like treating
them.
God please help us treat our patients like your
children. Help us to work with the employees who
betray us as you did with those who betrayed You.
Give us your strength as you promised in Isaiah 40:31.
Give us wisdom as You promised in James 1:5 when we
do not know how to treat your children best and what
medications to give them. As in
Psalms 62:2 be my rock and salvation, my stronghold,
and I will not greatly be shaken. Thank you for all
your promises in the Bible to comfort us in the times
of distress and disappointment and ignorance. And
thank You most of all for sending your Son as a
sacrifice for my sins that I can one day be with you.
Thank you Lord. The Shanks