Liberia #24

A few days left in here than home to my wife!  For the past
few days
we?ve been running at capacity, about 36 beds.  We had a bed or two
for pregnant patients, and a couple for children.  The child?s beds
are not full length so adults cannot use them.  The private,
semi-private, common rooms are full.  Yesterday I admitted about 3
stroke/hypertensive patients.

Yesterday afternoon: ?Doc, dis man hurtin!?  Where?  ?His stomak
be hurtin.?  How long? ?Since dis morning? Does the hurting come
and go, or is it constant?  ?It hurtin!?  No, is the pain, strong
then small, strong then small? ?it be hurtin strong!?  Eventually I
decide it is a constant pain that hasn?t let up since it woke him up
this morning at 2 AM. He points to his right lower abdomen.  So kidney,
bladder, appendix, colon, typhoid are all within possibility.  I palpate
his abdomen and he is quite tender in the exact spot where I would
expect the appendix to be.  But to be sure I ordered a CT scan, got a
CBC to check his white blood cell count, and verified his kidney
function numbers.  NOT! We cant do any of those, so I ask some more
questions, decide that appendicitis is at the top of my list, and tell
him that we need to operate to take out his appendix.  I tell him that
if I am wrong I will fix whatever is the problem and take out the
appendix anyway, so that next time he has right lower quadrant pain, it
is not appendicitis.  Later when the operating room team is ready we
start.  I cut the skin with a scalpel over the area of pain.  Blood
starts oozing out.  The cautery cord will not work, so I put little
clamps on all the bleeding areas and continue in.  At the muscle layers
I spread them apart rather than cutting them.  Once in the belly, I feel
around for the typical firm feel of the appendix that is inflamed.  I do
not feel it.  So I find the base of the colon and follow it.  I free it
up from the abdominal wall and then find the appendix running up behind
the colon.  Slowly I free it up.  It is very long and has early signs
inflammation.  It seems to go all the way up to the liver, and from the
incision I?ve made is quite difficult to get high enough.  After
struggling for some time and extending my incision, I eventually get it
out.   I close up the different layers, irrigating with saline a number
of times, to minimize the chances of a wound infection.

Today I started with rounds after the morning devotional.  The
old woman
with and infected foot, who had debridement, is doing better day by day.
The woman with the breast cancer is doing well, and wants to go home.
The 9 guys who were from the industrial accident, with burns and body
aches are all doing well.  An old man who came in, in a coma, is doing
well.  His hypertension and diabetes under control now.  The patient
that we did a hernia repair on a few days ago, is ready to go home.  The
appendectomy patient from the last paragraph is going great, and has no
pain.  Really, I cut you open and you have no pain?  He says he did this
morning a little, and it is gone now.  Some people are very tough with
regards to pain.  The younger guy next to him with diabetes, high blood
pressure and chest pain, feels good today and wants to go home. I
reiterate for the 3rd time that he has to take his medicines for the
rest of his life and he should never stop.  That he is at risk for
stroke, heart attack, kidney, eye, and vascular problems.  He again says
he understands.  Two old men in another room, both with strokes.  One
seems to be improving the other one now comatosed, he will likely not
make it through the day.

I go and do some dressing changes, which Dr. Seton has not
yet, they are looking better each day.

I see a patient with HIV in clinic that we treated for a bad lung
infection, and she is doing great.  I decide to go find Dr. Seton, and
show her the patient as an encouragement.  The nurses say that she is in
E2- a private room.  So I saunter down there.  As I walk in, I see
nurses opening packages, a tank of oxygen standing in the middle of the
room.  Dr. Seton doing chest compressions on an old woman on the floor.
I ask if she wants help and she does.  I open the bag mask that the
nurses can?t figure out how to assemble and start bagging the patient.
We hear a couple ribs break (fairly common when doing adequate chest
compressions on old people).  With time she regains a hart rhythm and
respirations.  She was moved to the floor so that she was on a hard
surface for the chest compressions.  We lift her and place her back in
bed.  she has an oxygen mask on and an oral airway in place.  We do not
know whether her brain has survived the lack of oxygen.  We decide that
if her heart stops again we will not do any more compressions.  She has
been running in and out of a fast heart rhythm about 160.  And we have
no medicine to treat this, nor and EKG to determine what exact rhythm it
is.  I later come back to the floor, as Dr. Seton is filling out the
death certificate.  That patient died.

Later on I am called to come quickly.  This usually means
someone died.
So I go to the floor.  There is another old woman who came in with a
stroke and her consciousness has been declining today.  Her tests show
she was HIV positive.  I decide that based on these findings we will not
do chest compressions as the chance of reviving her is zero.  I tell the
young woman at the bedside that I am sorry, and she starts wailing and
beating the wall.  Another of the 5 patients in the room, start crying
as well.

We have some really sick people, and not the best resources to
care for
them, so it isn?t surprising that many of the sickest ones die.
Though I feel we sometimes go to far in keeping people alive in the USA,
I am once again thankful to have been born in a third world country
where there is good health care.  If you are from Liberia, you have no
options outside this country and limited inside the country.  We, on the
other hand, can get in a plane, fly around the world, and see a doctor
in Europe, Mexico, or Philippines, to get our plastic surgery, eye
surgery, or whatever we want.  We are very blessed!  I hope you take a
minute and reflect on the many blessings you have, to live in the place
you do and have the things you have. You have many more things than 90%
of the inhabitants on our globe!

Liberia #24
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