Bere 2018 #2
Got to Bere Hospital last night. Had a few hours sleep and was awakened to help with a C-section. I told them to call me if anything happened or they wanted help. So I get myself together, find my scrubs, cap, mask, headlamp, keys, and OR shoes and stethoscope and head in. When I arrive Dr. Belinsky is already scrubbed and the patient has a spinal in place and they’re waiting for me. This young woman has been pregnant 6 times and all the babies have died. This time, she is at term, and is in a transverse position with a hand and umbilical cord coming out. For those of you who don’t know, babies can some out head first (preferable), feet first. Transverse doesn’t come out! So either the position needs to be changed or a C-section. I scrub and assist. Once the baby comes out, he is a little floppy, but with some drying and rubbing, he starts crying. This is a wonderful sound in any C-section- live babies cry!!! She gets closed and wheeled out the the preop/postop area. There are a couple patients needing to be seen by me that have been saved for when I arrived. One is a lady with recurrent breast cancer with large, hard lymph nodes in her arm pit, and metastases in the liver. I share the sad news with her that I cannot do anything to help her. We have no chemotherapy drugs here, especially the specific ones that can sometimes help. She starts to cry and lift her hands towards heaven. The nurse says I should encourage her. I think he means that I should gloss over what I’ve said and make it more palatable or less direct. In my western mindset, I think everyone should know exactly what the doctor thinks, and he’s asking me to not tell the whole truth. I tell him that I wont. Then he tells me, no maybe share something spiritual. I finally get it! I ask her what her beliefs are, and she is evangelical. I encourage her to focus on God and His love for her and that He doesn’t want this situation for her either. I share that we don’t have to fear the future or death, because we will be with Him. I pray for her, asking for Gods healing. And asking if God doesn’t heal her that he give her strength and peace for the coming months. She seems more at peace and leaves the room.
The next surgery, is a 20 year old guy with “appendicitis”, who has had pain for 9 days. So here’s a short surgical lesson- appendicitis is short term, day or so and it bursts or gets better with surgery or sometimes antibiotics. The ultrasound saw a mass and an inflamed appendix. I have little faith in the ultrasound interpretations and consider doing one myself. I figure it won’t change the fact that I need to operate on this guy, so I head in to explore him. He has a fullness on his right abdomen and it’s quite tender. The rest of his abdomen doesn’t hurt at all. Samadi, the old nurse who has done operations for years here, assists me. He’s been doing them the past months here as the surgeon was gone, but when we talk about who will do the surgery, he says that I’m the surgeon and I should go ahead. I, of course, agree with him and we move on. I’ve forgotten how difficult it is to open a persons abdomen here. The skin is tough and the scalpels aren’t real sharp. I slowly go through the skin, small layer by layer. After about three slices, I’m finally through his skin. There is a thin fatty layer and I’m at the fascia. I open the fascia and spread into the peritoneum. No puss or air or stool in the abdomen- good. I feel for the mass. It seems that the omentum (fatty layer in our abdomens that helps sequester infection) is stuck up to the abdominal wall. I slowly push my finger in that area separating the omentum from the abdominal wall. Puss rolls out, my nose, immediately catches the whiff too. I eventually figure that the guy had perforated typhoid that his body walled off. I put a drain in and washed him out. I also decided to remove his appendix, so that it wouldn’t be the cause next time either. I close him up and he is off to the surgical ward.
Next is an older man with a broken ankle that has been here about a month. He has a huge open wound and an ankle that rotates 90 degrees out, making the sole of his foot point off to is right. This occurred because of an accident on a moto. I agree with the others assessments that he needs an amputation, for the infection and because this is a non-functional foot and likely osteomyelitis (bone infection). In the operating room he gets a spinal anesthetic, then I go about removing his leg below the knee. I have to leave the amputation site open because of the infection and hope he is able to get some sort of wood prosthesis in the future. Ive heard they can be made about 4 hours away.
Then there is the mid 20’s guy with a small left inguinal hernia. We bring him into the operating room after the staff has cleaned it and Ive seen a couple more consults. I consider using mesh again and realize that most of the “sterile” packs have not changed color of the marking tape. I ask the guy who sterilizes stuff in the autoclave to put these packs back inside as they aren’t sterile. I again decide that I won’t use mesh during this visit. I’d prefer to have a chance at leaving the missionaries here a hernia recurrence in the future than a mesh infection. So I resect the hernia sac and use suture to reinforce the area.
A woman comes in from an outside hospital a few days ago. She had a very foul vaginal discharge and had apparently had a delivery that some repair had been done afterward. Her uterus looked very irregular on ultrasound and the nurse who does ultrasound thought that there was a perforation of the uterus. Samadi took her to the OR and opened her up and didn’t find any perforation. She continues to have a foul odor and so we took her for a uterine curettage. We were able to get small amounts out retained placenta out of the uterus, but just as Dr. Belinsky and I were finishing up, we see that there are large areas of necrotic tissue on either side of her upper vagina, near the cervix. The baby’s head usually causes pressure necrosis against the bone in front, so I’m not sure what caused this problem. I’m surprised that she is not deathly ill. So we debrided off whatever dead tissue we could and packed some gauze into both sides. I imagine that she will heal this, but it will take a while and she will smell bad until it heals. I warn her of these things and we wrap up the day.
Tomorrow holds a hernia and amputation of a lady’s leg that was bitten by a snake, and both bones in the lower leg are exposed for the majority of their lengths. I try to sleep tonight, but sleep is not coming, likely jet lag. So here I type. I hope to get out the forked tree about 10 minutes up the road to send these in the next couple days (yes that’s real). Apparently if I go 20 minutes away the cell signal is even better. Guess I’ll see what I can do.