Shanksteps Bere April #10 with pictures

Shanksteps Bere April #10 with pictures

As you read in my last Shanksteps Ive fretted a lot about wether I should take this old guys nose off for a squamous cell carcinoma, leaving him looking very deformed with a large hole in the middle of his face.  I thought a lot about it last night as I was trying to go to sleep and also this morning as soon as I woke up.  I do that when I have sick or difficult patients.  When I got in there this morning to the OR, the crew told me he had decided against surgery and had gone home.  So I was at peace then.  I was looking through an Indian textbook of surgery and realize  again, that we are not the only ones who see advanced cases of cancer and other diseases.  It’s probably indicative of being in a third world country where there is very low income, minimal health care, and inability to get to where there is healthcare.

I examined another woman today between surgeries.  She was one of the many medical consults I saw today.  She could speak in French quite well.  So as I talked to her I got the story that she is about 5 years after her period ended and she noticed about 2 months ago she was having vaginal bleeding.  She also has some hematuria (visible blood in her urine).  I suspect cervical cancer.  So I do a vaginal exam and find that she has a large hard cervix that is attached anteriorly to the bladder.  So it must be invading the bladder causing her to bleed with urination.  I have to tell her that she has cervical cancer and it is already to advanced to take it out.  If she has means, she can go to Cameroon and see if she can find chemotherapy that may help.  I think that is only in the capital.  I have to give information often to people- and I don’t like having to do it.  It makes me sad and uncomfortable and it certainly does for the person who hears it.

First surgery is a prostatectomy on an old guy who can’t pee.  The second is on a young boy ?8, who can’t pee either.  But his problem is a bladder stone.  David wants to intubate with ketamine.  I question wether this will work, but figure he must have learned this with Dr. Olen recently so I question him about the dosing.  He tells me how many mg he wants to give and it sound correct to me.  So he gives some and goes to intubate with me looking over his shoulder.  The kid clamps down hard on the laryngoscope and I worry about him breaking his teeth.  He gives him more ketamine.  Then again, Finally I ask him how much is he planning to give? 7ml.  For his weight Im guessing less than two would be way more than enough.  He tells me how he calculated it and how many cc’s that is.  He calculated correctly but thought there were 50mg/10ml.  In reality its 50mg/ml.  So he has way overdosed.  The kid keeps on breathing and so I decide Ill proceed and Ill ask him for more if the kid really starts moving.  We fill his bladder with water and start the surgery.  After opening the bladder we find a stone about the size of a pencil eraser- large enough to plug the exit of the bladder.  I closed him up and checking on him later he seems to be doing well.

On rounds, I ask the kid with the open neck to try a swig of water.  It pours out his neck in a different place.  So we will just keep with G-tube feeds for a while before trying again.  He is starting to heal, and I’m hopeful that he will survive.

I was called in tonight to see a guy who had had an accident on a motorcycle yesterday in a town about 2 hours away.  They left the other hospital to come here.  He has been unconscious since the accident.  He has a cut on his head that they repaired.  As I examine him I find he had normal pupils, hardly reacts to painful stimulus and has a broken clavicle and loose ligaments in his left knee which is also swollen.  I don’t find any other abnormalities.  His glucose is normal, and his blood count a little low but reasonable.  He has a urine catheter in place, but it’s in the wrong place because the bladder is full without it coming out.  So the nurse will replace the urine catheter and start IV fluids and we will watch and see if he recovers from his traumatic brain injury.  Im called back in because the foley catheter can’t be re-inserted.  And he’s bleeding after the last one was removed.  Yep, the balloon must have been blown up below the prostate.  I hate it when people do that- it makes for a lifetime of urethral strictures- if he survives his brain injury.  I go in and there is blood all over  coming from his penis.  Sure enough, I can’t get a foley in because the urethra was burst with a blood inflation.  I try a number of times.  Finally I give up and put in a suprapubic IV catheter.  This will get him through the night so I can deal with it tomorrow.

PICS- Below are the burn kid post-op leg contracture release, and the old man with squamous cell eaten the inside of his nose.

_______________________________________________
Missionnews mailing list
Missionnews@missiondocs.org
http://missiondocs.org/mailman/listinfo/missionnews_missiondocs.org

Shanksteps Bere April #9

Shanksteps Bere April #9

It rains near by in the early evening and the air cools from 95 to about 86.  I sleep well.  I am called at 5:30 to see a woman who is 26 years old with RLQ pain since last night.  She says the pain is constant and strong.  She points to her Right flank.  She’s vomited a couple times.  Her tests show she has malaria and doesn’t have typhoid.  Though I know the type of typhoid test we have here is very inaccurate.  She also is not pregnant.  She denies any vagnial discharge and hasn’t had any problems with BMs or urination.  I ultrasound her and see a normal appearing kidney on that side.  I can’t see an appendix.  But based on her symptoms I think this likely represents appendicitis.  So I ask them to keep her NPO (nothing per Os.  Nothing by mouth).  Get an extra IV going and we will plan on operating on her this morning.

Later on Im told she is feeling better and doesn’t want surgery.  I think good, maybe I was wrong.  Then I see a text from Dr. Staci, appy lady, have I seen her.  She sends her over to the OR where I’ve been all day.  As I examine her she says she feels somewhat better and doesn’t want an operation.  I take this as a good sign, and decide Ill examine her again in the morning.

My first surgery this morning was an old guy with prostatic hypertrophy for a prostatectomy.  I wish I new how to do a TURP and had the equipment.  That would be best, but I do what I know how to do and it does help them.  I do tow old guys today in the same manner as Ill describe now.  They get a spinal anesthetic.  Then fluid is put into and distends their bladder displacing the intestines up and so when I cut down in the lower abdomen, I get to bladder rather than intestines.  His abdomen is prepped then I cut through the various layers to the bladder.  I sweep the peritoneum (covering of intestines) up and out of the way.  Then I open the bladder, sucking all the fluid that we had just put in there.  I stick my finger in the bladder and feel a large prostate.  Slowly I shell it out.  There are two large pieces.  My fingers and ligaments ache a bit as they really get taxed when I do this.  I close the bladder in two layers and then leave a sterile piece of glove as a drain, and close the rest of the layers.

The next is a woman who has cervical cancer and vaginal bleeding and keeps on dropping her hematocrit as we give her blood.  So I decide waiting isn’t helping her so I decide to proceed.  We give her two bags of blood then start the surgery.   As the foley is inserted it drains blood.  I re-look at her carnet (medical booklet) and it definitely says vaginal bleeding with mobile cervical cancer.  So I open her abdomen and find a small uterus.  And something hard in her omentum.  I take the hard part out of the omentum and don’t find any evidence of metastasis on liver or peritoneum.  I clamp, cut, tie down the sides of the uterus and each tie really stresses my fingers again.  These also stress my finger ligaments as it takes a lot of force to tie these tight so the vessels won’t bleed afterwards.  Finally I come across below the uterus, cervix across the vagina.  I look at the cervix on the specimen and it looks normal.  Hmmm, well sure doesn’t look like cervical cancer to me.  Back to ? Bladder cancer.  I can’t feel anything abnormal in the bladder.  But Ive decided even if I see a bladder cancer again I will likely not do any surgeries for it.  It is many hours of surgery and I don’t want to do anymore ileoconduits and don’t think it really prolonged their lives in the past.  So I close.  Even tonight as I type I can feel my index finger is tired.

I do the other prostate guy in the same way as above.

Then the last one of the day is a 20 something woman with huge swelling of her face she says has gone on 3 years.  And worse these past 4 days.  So does she have a cancer that now has become necrotic??  So many unknowns here!  I did an ultrasound yesterday and think there may be an abscess underneath.  With the most being right where the facial nerve lays in front of her ear.  Her eye is puffy and I think it must be pus.

While Im waiting for her to be ready I see many consults.  One sticks out in my mind.  It is a guy who has a cancer on his nose.  Dr. Denae biopsied and sent to Ndjamena and apparently it is a squamous cell carcinoma.  He smells awful!  His septum has been eaten away.  I think that if I do an aggressive resection I may be able to get it all but he will have a horrendous looking face afterwards.  Maybe if he survives, someone could do  a plastic reconstruction afterwards.    So I offer a very disfiguring surgery to them and the want it!  I have a difficult time explaining what he will look like afterwards, but they want to proceed.  I take about 45 minutes to explain.  They go to pay for the surgery.  God help me to get it all out and for it to be worthwhile for him to be disfigured like this!

The girl is ready and so she is given propofol and ketamine.  I cut into the side of her face in a way that I think won’t hit the facial nerve.  I stuck a needle in and so I know there is pus down there.  I go deeper and deeper and eventually hit pus.  It flows out. It was a significant pocket.  As I flush it out, the nurse thinks the fluid is going into her mouth.  Wow, these neck infections and dental abscesses are awful!  Ive seen so many this time.  I pack the hole and she goes out when she’s awake.  

Another dental abscess is draining on another patient’s mandible and we pull out a piece of dead bone out of her upper neck.  These people desperately need dental care!

I think there are only a handful of dentists in the whole country and likely most are in Ndjamena.

I will do the nasal cancer guy tomorrow.  God help me!! I need your knowledge! I’m so inadequate to deal with so many things here.  HELP ME!

Shanksteps Bere April #8 with pictures

Shanksteps Bere April #8 with pictures

Yesterday was different at the hospital.  There were a few surgeries scheduled and one lady for a hysterectomy had a low hemoglobin and needed transfused first, the other two or three ate that morning, so I suddenly had no surgeries to do.  I did rounds with the nurse and about 6 nursing students.  I looked at everyones incisions, opened all the dressings on those with chronically healing wounds, and it took about 2 hours to round this way on about 28 people.  The ward is full and I even saw a few that are living under the trees, discharged but Dr. Denae still wanted to check on periodically.  I got done early afternoon.

So I went and ate some lunch at Netteburg’s and then decided to go out to Bendele where a missionary friend of ours just flew in with his plane a few days ago.  He has a plane that can carry a number of people and still take off and land in a short runway.  I think i mentioned that i often come here with a perimeter spray to help with mosquitos and other insects that infest or eat a house.  So I wanted to offer to spray the missionaries house down there too.  So I rode a motorcycle down there.  It was hot but nice to be outside.  Im on Doxycycline for my malaria prophylaxis so the sun feels especially hot and I burn easier with it.  So by the end of the day Im a little sun burned.  I spray Deietrichts house.  Then I help in the hanger.  He wants to pull a large motorcycle down to the hanger from the hospital.  It’s not been used for years and he wants to get it going.  So we go back to the hospital on one other large motorcycle with a rope.  The one that’s been sitting has flat tires, and eventually we find a pump that works and then he pulls me motorcycle to motorcycle back to Bendele.  We don’t have a key for it so can’t do much.  We move planes around and get one that’s been sitting started and it needs a lot of work.  So i help with a few things till dark then head back to the hospital.  It’s nice to see long time friends again.

Today I did rounds and I had the patient with an open neck drink water while I watched his neck.  It poured out his neck.  His neck is finally starting to granulate as he is getting some nutrition.  So he has survived the infection, will I be able to convince the family not to get him enough food for him not to starve to death.  It’s hard for people to give adequately when it’s not going in their mouths.  They showed me the bouii (porridge) that they were about to give and it was scalding hot.  I told them it would burn his stomach and only give him cold bouii.  Since it’s Friday we only schedule a few cases as we expect other hospitals to refer patients in to us on the weekends when their doctors don’t want to work.  I guess there are 1-2 distant hospitals that do this at times.  So the first person I operate on is an older woman with a large lipoma (fatty tumor) on her back.  It is lobular and takes a while to get it all out.  She tolerates it well, and I though she would need sedation, but they said do it under local, and she did well.

The next was a a boy about 10 with osteomyelitis (bone infection) of his left femur (upper leg bone).  I looked at his X-ray and it appeared to be the whole bone.  He has had osteo of his fibula on the other leg and Dr. Denae had removed that a number of months ago.  Now he has pus coming out the side of his upper leg near his knee.  So the treatment of this in these rural locations is not months of antibiotics but open drainage.  So in the operating room he is given a spinal.  Then I make a long incision down his later upper leg and slowly go down through the muscles with cautery.  I get into a few pockets of pus.  To open the bone is challenging with the tools we have here.  I have a drill in a sterile pouch and a chisel. So I drill numerous holes in two lines down his femur and then use the chisel to get the bone in-between out.  This opens up the medulla and allows for drainage of the internal pus.  I worry about my chisel action cracking the bone across, creating an open bone fracture than he cannot walk on- likely ever again.  I’m grateful that didn’t happen.  Cleaned out all the medulla and packed a dressing into it.  He will be here for months of dressing changes now.

In the evening we all get together for Sabbath vespers at Netteburg’s house.  Vespers here is one of the highlights of my week.  We worship God with songs and words and say what we are thankful for this week.

  

 

Shanksteps Bere April 2023

Shanksteps Bere April 2023

I go in this morning to see who is on the list for surgeries today.  There is a girl with an abdominal mass, a old woman with an abdominal mass, an old man for a prostatectomy.

The girl is about 8 years old with a abdominal mass that feels quite a bit larger than a soft ball.  She is on the OR table after her spinal anesthetic has been placed.  The mass feels mobile but attached.  I ultrasound it and find a solid tumor.  Is it a mesenteric  mass like Dr. Denae thought, intestinal mass, ovary.  More importantly will I be able to get it out or will it be stuck to everything and be unresectable?  I open her abdomen and am staring at a large mass.   It seems more mobile than I thought.  I open from pubis to above the umbilicus before I have enough length to get around this.  It’s huge for her little abdomen.  i get around it and pull up, it pops up through the incision.  YAY!  It isn’t stuck everywhere.  I soon figure out it is an ovary and the pedicle seems long and it has momentum (fatty layer in abdomen) stuck to it.  I clamp, cut and tie, the portions of the a omentum off and then do the same for the vessels leading to it, which are huge.  I take it out and then inspect the rest of the abdomen.  She has a few larger lymph nodes in the omentum.  These are probably metastasis.  So I take them out too.  I look at her liver, and peritoneum (covering of the abdomen) and don’t find any more evidence of tumor.  Her other ovary looks small and normal.  So we close her up.

The next older woman has more body fat than most here so I know she will be more challenging to operate on. I ultrasound her abdomen and find what I think is a large uterus and a huge fibroid in it.  I ask for them to interpret for me and find out if she wants more children.  She says she’s had 9 and doesn’t want anymore.  Plus she’s past the time of her period anyway.  So I plan on a hysterectomy or mass excision if Im wrong about its source.  As I go to see consults, Olen says.  Oh look at that, her blood pressure is 210/114.  She doesn’t know that she’s hypertensive and so we cancel her surgery and tell her to come back in a few weeks once her blood pressure is better controlled.  The staff look at me like Im crazy.  So I tell them the possible problems with it in the OR and they translate for her.

Next is an old guy who who can’t pee and has a large prostate on ultrasound done here and has a urine catheter in.  We put water into his bladder to distend it and clamp the foley catheter.  Then prep and drape him.  It’s been since I was here last, since i took out a prostate.  I make a low phanynsteal incision and go down to the distended bladder.  I open it and find a large prostate.  slowly I shell it out with my finger.  It’s always kind of difficult and taxing on the ligaments of my finger.  I change fingers a number of times as one starts to hurt.  I get out two large lobes and a smaller one.  The bleeding is constant as it usually is.  So I suture up the posterior area.  i put in a large 3 way foley for continual irrigation and close the bladder.  I start the irrigation as soon as i close the bladder in the first layer.  This irrigation will continue for days until it is clear enough to stop.  It is the only thing that keeps blood from making clots in the bladder and a need for reoperating.  

I walk through the surgical ward because I’m done earlier than expected.  I see the guy with the chest tube and people are propping him up and he’s breathing fast.  I check his chest tube and all appears normal.  there is fluid where there’s suppose to be and everything connected correctly.  There is about 1.7 liters of pus in the container.  His heart is racing.  I don’t see neck venous distention.  He’s sweating because it’s real hot today.  I want a chest Xray to make sure the chest tube is keeping the lung expanded.  I go and tell the chief nurse who is also the person who takes X-rays and does ultrasouds.  They run to get me and say that he’s not doing well.  There is a crowd of people out around him.  He is sitting on the ground and apparently passed out as they tried to walk him to the Xray.  He’s conscious, but real tachycardic.  There are a million things that could be going on.  Of them, what are some that I can diagnose or suspect to treat here?  I ask if he’s eating and they say no, and not taking much water either.  So maybe he’s dehydrated, I ask for IV fluids to be run in quickly.  He’s peed twice today and it was dark tea color.  His blood pressure is low about 90/60 sitting on the ground, and HR 120.  we carry him back to his bed and give him fluids.  I guess he can’t make it to the Xray.  No bedside Xrays here.  I check on him later with Olen.  We ultrasound his chest and Olen sees normal lung on the other side and consolidated lung on the affected side.  No pneumothroax (air around lung) and no hydrothorax (fluid around lung), and pus continues to drain out the tube.  As I feel his pulse again it’s less but now seems irregular.  slow then fast alternating.  Maybe he’s in atrial fibrillation.  We consider our only anticoagulant aspirin.  And decide to see if he is still irregular tomorrow.  This is the first time I wish we had ECG here. (no machine and those little pads- we use those up like crazy at home.  they don’t stick well at home, i can’t imagine they’d work at all here.)