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Bere 5/2025 #16

Continued…

I’m about to drift off to sleep, laying there wet and evaporating in the fan when I get a call.  It’s difficult to hear what the nurse is saying as there is a lot of background noise on his end.  I think he says someone can’t pee and has a catheter in and is in a lot of pain.  

I had seen a man brought into the recovery area carried by his family members because he wasn’t peeing with a catheter in.  One of the other docs was out there and I was trying to get to my next surgery so I walked away to my surgery figuring they would figure out what was going on.  So as I get my self together and grab my bag of stuff (water, stethoscope, headlamp, butterfly ultrasound, kind bars, batteries for headlamp) and head to the hospital, I wonder if it is for that same man.  Wondering if the foley balloon was blown up below the prostate, breaking the urethra and causing a stricture in the future…

I walk through the ER and adult wards looking for the patient.  Not there.  So I go to the surgical ward and he’s there.  It is the same old man.  Three women are fanning him with handheld fans- a sign that he is in distress.  They fan when someone is after surgery and when they are really hurting or agitated.  The man is grunting and I ask him what’s going on.  He tells the nurse that he can’t pee and his abdomen hurts.  There is only about 5cc of urine in the tubing not making it to the foley bag.  And so I suspect it is misplaced in the urethra so I feel for a distended bladder.  I don’t feel one.  Hmmm.  Same foley of earlier today? Yes.  Same bag as earlier when you were in the OR? Yes.  Is he not making urine?? I feel around his abdomen and he cries out in pain.  Peritonitis.  I get my Butterfly ultrasound and look for his bladder.  I can barely see it for all the other fluid in his abdomen.  So I attribute this to a leak from his intestine or stomach causing the peritonitis and lack of urine output.  I see his CBC was ordered today by another doctor in clinic and they don’t have the paperwork but I can see on the computer his WBC is 20 and Hb- 17.1  So he’s very dehydrated, has peritonitis, not making urine.  He hasn’t had a set of vitals, and I know I need to take him to the OR.  So I call in Phillipe and try to get the medical student Caleb on the phone to help me.  Caleb doesn’t pick up with multiple calls.  So I walk to his house, shine my light in his screen window at him and say his name louder and louder till he awakens.  Then I head back to open the OR and get the patient over there.  It is now midnight.  The surgery ward nurses put in another IV – good job, without my thinking of asking.  I ask them to bring the patient to the OR and go and start unlocking the OR and turning on lights and machines.  They wheel him in on a stretcher.  While I wait for Phillipe I hook him up the the anesthesia monitor and start the BP cuff.  HR- 120 BP 70/30.  I start pouring in the fluids.  He’s very dehydrated, likely in shock.  Phillipe and Caleb arrive and after a few liters of fluid his BP and HR are better.  He’s also looking a little better though very sick.  I wish I had an ICU for him.  I open the OR pack, select my suture, scalpel blade, cloth sheath for the cautery, pack of the reused suction tubing, our sterile gloves, gauze, and get everything ready.  I prep his abdomen with betadine then go scrub.  I scrub with the brown bar of soap then go back in to the OR, dry my hands and put on my sterile cloth gown and gloves.  I gown and glove Caleb.  We pray for Gods guidance and keeping this man alive during and after the operation and we start.  I cut through the skin and very small fat and into the fascia and abdomen.  As soon as I enter the intestinal contents start flowing out.  We suck all of it we can but it still pours all over getting our gowns (and us) wet.  I start in the middle looking for a hole and then extend my incision top to bottom looking for it.  I see a dark patch in the terminal ileum, but see no hole.  AFter looking at all the bowel and stomach again, I come back to the dark patch.  I now squeeze intestinal contents towards the area and sure enough, I see a small pinhole leaking.  So this has been leaking a while to get all this into his abdomen!  Phillipe says START CHEST COMPRESSIONS!  What?  He hasn’t told me the pressure has been real low and up and down the whole surgery thus far.  I start compressions. I ask him questions.  The patients BP has been between 80 and 40 systolic and now not registering.  I reach in the abdomen and feel the heart still beating.  He gives a slug of ephedrine into the side of the IV container and its running wide open.  The SBP picks up to 40 then 60.  I need to be done this operation as soon as possible.  I wish I had staplers but I don’t.  So I take out that section of intestine with clamps on either end. Phillipe is giving two units of blood.  I think the patient may not need blood, but he does need a blood pressure and he tells me he’s given many more liters fo crystalloid already.   I choose to oversew the distal end in the sake of time and bring out the other end as an ileostomy.  I wash out the belly with multiple liters of fluid that goes all over.  I close the fascia and the patient is still alive- barely.  I put the stitches to form the ostomy and leave the skin open in the sake of time.  Phillipe extubates him after about 30 min and he goes to the “recovery” room.  Meaning he gets out to a room where there is a monitor and the family can come and see him.  The women start fanning and everyone just stares at him wondering if he is alive and looking for breathing.  I tell the family what we did and show them the piece of intestine we took out.  I suspect it’s a typhoid perforation.  It’s 4:30 and Phillipe says he’ll start with the patient.  I head back to sleep.  I get 3 hours before my alarm goes off to start today…

I am deep asleep but know I must get up.  There are 6-8 patients scheduled for surgery today and no way to get through them if Im not operating.  I go in and find that David is doing anesthesia and Phillipe hasn’t come in.  Drs. Andrew and Steven are doing a thyroid that is huge soon and so I head to do rounds where I find my patient still alive, women standing at bedside fanning and the patient minimally responding to questions.  Again I wish I had an ICU with ICU nurses, monitoring and meds…. Wish for so many things.  My cow horn goring guy wants to go home.  As I think another operation will just delay a day or two the inevitable, I agree and discharge him home. I pray with him asking for Gods miraculous healing and encourage him to keep his trust in God till the end.

I go to clinic and am there till my last patient is about 3PM. Phillipe isn’t coming in today so only on room can operate.  The OB/GYN is getting ready to do a hysterectomy (take a uterus out) on a woman with a huge uterine fibroid.  Her uterus is well above the umbilicus.  I wait till her patient is intubated to make sure it goes well then I head to say goodbye to the other missionaries.  Missionaries  I rarely see because they are spouses of the doctors or others that don’t work in the hospital and I don’t run into often.

About 6PM I get a call can I come help the OB/GYN in the OR.  I hear there is bleeding and it’s a real tough case.  It’s her first time in Bere and I wonder if it’s real hard or she she’s not used to the lack of equipment… I glance in the room before scrubbing.  There is blood all over the abdomen and down the sides of drapes onto the floor.  How could I doubt her!  It looks bad.  The patient is getting blood and a low BP but not life threatening low.  I choose to forgo the plastic apron, because of it’s heat, and dawn the cloth gown.  I later regret this decision.  I take the place of the medical student and he becomes the scrub tech handing instruments to us.  Which in this surgery is very helpful!!  I pull hard on the uterus and it doesn’t budge.  It is the size of at least a football, nearly a basketball.  I pull to the side trying to expose for her and we get 1cm between it and the pelvic sidewall.  OOHHH! This is terrible.  No wonder she needed help.  This is the worst I’ve seen for lack of visualization.  We do our clamps, cut tie, down the sides further.  ¼ in by ¼ in.  Very small increments.  We hug the uterus hoping we are not coming close to the ureters or iliac vessels.  Usually as you go down the uterus becomes more and more mobile and comes up into the incision more and more  exposing the next area to take.  This one doesn’t move.  We march down the sides with very little space to see anything, praying we don’t get into deep bleeding that would kill her before we could control it.  As I work I soon realize the lack of the apron is making the patient blood soak through my gown, scrubs and underwear.  I hate that feeling.  Knowing I’m wet from someone else’s fluids…  I mention maybe if wee took the posterior peritoneum, if we can get there, maybe we would get a little upwards movement.  So she divides posterior and we are into the uterus next to the fibroid.  It starts pealing out of the uterus.  In 20  seconds we have the top of the uterus off with it’s huge fibroid and now we can see.  We start controlling the bleeding and she packs some surgical and other hemostatic agents she brought into he area we just tore the fibroid out of.  Now we start looking for the ureters.  The left we don’t see and the right we find very distended and know it’s tied off.  So we start taking down the ties, which causes more bleeding and eventually get off the tie that is on the ureter.  We realize we have tied, cut and divided the ureter.  This is terrible an neither of us have done this before nor encountered it before.  But we have both read what is to be done in this situation.  We need to either repair the two ends back together or implant the end we found into the bladder.  Her bladder is large and easily reaches this area so we plan on that.  We cut up the ureter a short distance to (spatulate) or make the opening larger so that our anastomosis will be larger and less likely to stricture with healing.  Then using PDS we suture the ureter to the bladder.  As we close we take a ureteral stent and put it through the abdominal wall, into the lower bladder, then up through our area of anastomosis.  This will help it stay open while it heals.  We are both spent.  The patient has stabilized and our visualization is tough with the intestines pushing into the area.  We search for the other one unsuccessfully and check that there is some urine in the foley bag so we decide to close.  It’s about 8PM.  I have handed my call phone off to Dr. Stephen so I know I won’t get called tonight.  But I need to eat supper and pack.  I leave at 5 AM on a Moto for Kelo to catch the first bus to Ndjamena.  Dr. Leslie and Caleb, med student, start closing and I head out for supper at Dr. Andrew and Dr. Meghans house. Instead I head to my room for a shower, because I look like I had a circumcision in the village.  (They use the pull the foreskin and cut, technique in the village).  I have about a 2 foot circle of blood coving from my lower chest to thighs.  Yuck!  As expected, in the shower that same area has blood on my skin.

At supper,  Dr. Leslie calls, there’s not more urine in the “recovery” room and she thinks we need to look again at the other side. She has flushed the foley and there is no blood clot obstructing it.  We all decide it can wait till morning and I head back to my room to pack.  It get done about midnight and sleep deeply till my alarm awake me at 4:30.  After I’m dressed I take my bags out, see Rebecca is waiting to say good by, and my luggage is strapped to the back of the Moto and I and the driver load up and we are off for the 2 hour ride to Kelo as the sun comes up.

I thank you each for your prayers and for your interest in the mission work God has been giving me over these many years.  I pray for His continued Guidance in my life on a daily basis.

If you want to support Bere Adventist Hospital this is a link you can use for financial support:

https://www.paypal.com/donate/?hosted_button_id=8JLSUCVBGG7Q8

If you want to volunteer your abilities, time, and talents and whatever God has given you knowledge of- contact me via phone or email.  All different abilities are needed.

God bless you as you serve Him wherever He leads you!

Bere 5/2025 #15. I had a number of surgeries today.  But the one that I enjoyed the most was also the most stressful.  It was the last one of the day and I started about 4:30.  He had a wound on his leg about 3 months ago, and his family put scalding water on it and burnt his leg.  This created a chronic wound and a significant knee contracture.  I enjoy releasing contractors as it changes someone life significantly.  It is stressful because anatomical structures can be pulled into the scar tissue and arteries and nerves can be in the wrong place and be injured.  I have friends that have worked in burn centers and Im sure are much better at dealing with this than I am.  But this patient has me.  I’ve done some before in Cameroon and here, but I still have angst until it’s released and I haven’t injured anything and they have function after.

His knee is bent almost 90 deg.  And can’t straighten.  We prep the leg all over and also prepare his thigh for taking a skin graft.  I use cautery to cut into the scar going across it so that it opens up longer.  It is really thick.  I cut about ¾ inch deep and still in scar tissue.  Im starting to worry about popliteal vessels and nerve when I hit some bleeding.  I suture the small vessel.  I go to a different areal and continue.  I get in a good plane and head towards the area where I got bleeding.  I find his pedal pulse and then compress this vessel.  It isn’t the popliteal as his pulse remains strong.  So I cut across it and realize Im still a far bit away.  I get to an area where my cautery is making his leg twitch.  So there is a nerve near by.  I slowly dissect and find a small cutaneous nerve.  I have gotten about 30 degrees of extension with this cut.  So I move higher an make another.  And also do one lower.  As I take these deeper I get more and more extension.  After I get full extension Im able to relax a little.  Now I realize if I put skin graft on it like it is.  He will have thick and thin areas giving the back of his leg a very bizarre appearance.  So I cut off a lot of scar tissue and this evens it out some.  Using the dermatome I shave off a half layer of thigh skin in  two swaths.  Then Caleb (med student) and I start the long process of sewing these to the site we just opened.  It has to stay put because if the skin graft shifts on the wound bed, it then dies. So it has to stay in one place.  After suturing about an hour, we put xeroform dressing and build a plaster splint to help hold his leg straight and then attach everything before the plaster dries.  I hold the leg straight about 15 min, till the plaster is very hard.

Another I had that day was an older man who was about 60 and had been in a Moto accident about 3 months ago.  He had a patellar fracture and the two halves of his patella were separated by about 1.5 inches.  I walked with a cane and could flex his leg about 30 degrees.  I had seen him in clinic and told him that I could repair the patella but he would require a splint or a cast afterwards and would likely not be able to flex his leg in the future without much physical therapy (which is now available at the hospital).  I’m skeptical that fixing his patella will give him any more mobility at this point and may make his leg straight forever.  After discussion all this with him, he still wants it fixed.  So in the OR I cut down to his knee.  The scar tissue is thick and hard to remove.  I remove it from the ends of the bones too and rongour the edges to get fresh bone exposed.  I free up to get mobility of the upper segment so that it can move back down to where it belongs, as the muscles have pulled it up and away from the bottom half.  I don’t have screws to put the halves back together so I use what I have- suture.  I suture the halves back together.  I fount a huge 5 suture with a sharp needle so this one I go through the bone with too and after about 6 different sutures I get the halves about ¼ in. apart.  I then cut down on his side over the pelvic bone.  I expose the rim of the pelvis and nibble away pieces of this to place in the gap that will be new bone to encourage new growth.  After filling the gap with these pieces, I suture the skin back together in layers.

It’s been a long day and Im tired.  One more day to go.  I shower and go to bed wet, with a fan blowing on me.  I hope to sleep before I finish evaporating.  I’m just falling asleep when I get a call.  A man can’t pee and he’s moving in pain.  At least that’s what I think I hear.  So I go in.

To be continued…

Bere 5/2025 #14

How do I tell the guy who was stabbed with a cow horn that I think another operation isn’t useful.  That a proximal ostomy isn’t survivable here.  It would require taking the contents of the ostomy and putting it back into the mucus fistula (the other part of intestine coming out too) and re-feeding the other end,  so it can continue on down the intestines.  That them doing that if they did it well, he would still very likely die.  Die with renal failure, with persistent malnutrition, with infection.  These are the thoughts Im having as I’ve seen him and start my first surgery of the day.  The dressing was done in the morning and intestinal contents poured out of the glove drain I left in him.  I hear this from Dr Andrew who was doing rounds.  The older brother isn’t there so the conversation can’t happen yet.

My morning started at 4 AM with a call that the knee cap accident guy wasn’t doing well.  And as I change into cloths they call me back saying he’s dead. I had gone in to see him last night and no body in ER or surgical ward knew of the guy I had been called about.  I try to go back to sleep unsuccessfully.  In the morning I find out he had been in the ER but the nurse didn’t get sign out about him at shift change so she didn’t know about him at all.  I start my first surgery with the previous thoughts of the cow horn guy going through my mind.  It’s hard to be focusing on one thing and mulling over another.  So I focus not the patient in front of me as best I can.

My first surgery is a TURP (transurethral resection of the prostate).  I’ve done many open prostate surgeries and now I’ve seen a TURP, done one with supervision and now this one is for me to do.  I get all the tools set up which are quite extensive.  The patients spinal has taken effect so I stick in the cystoscope.  I look down the tube of the penis as I insert it through the penis into the bladder.  I see a ureter on either side of a huge prostate.  I realize this will be a difficult long surgery.  I use a loop wire I can see out the end of the scope to burn off a first groove of prostate.  It bleeds and I cauterize the bleeding.  Another pass makes another trench and I continue to control bleeding. After about an hour I get into some bleeding I can’t see where it is.  The blood is swirling around the camera.  I push the camera real close to the surface to try to see.  I search and cauterize.  It takes another half hour before I have really controlled it so I can see again adequately to continue on.  It takes me about 3.5 hours to do this prostatectomy.  The patient won’t have an incision and will heal quickly but it is now about 2PM and there are many other operations to do.

My next one is a guy who calm in last night and has an open femur fracture making his knee and foot point off at a bizarre angle.  He stinks so bad that the nurses didn’t give him a bed in the ward but just put him on the veranda of the OR.  There are always people sleeping there so it’s not a bad place, they just want the stench out of an enclosed space.  He was in a motorcycle accident 10 days ago.  The family carries him into the OR and he drips pus the whole way and a swarm of flies follow him as they carry him in to the OR.  By the time he is laying on the OR table there are only a few flies that made it that far.  No one does anything about it and I can’t seem to kill them so I carry on. (In the US, a fly anywhere in the area of the OR causes an uproar.  Rooms are closed until the fly is isolated and killed.  Then work can go on).  We go on anyway.  His leg is tied up to an IV pole to raise it off the bed so we can prep it all around, more pus runs out of little holes along the side of his thigh.  I do an open above knee amputation about mid upper leg.  As I cut through the muscles of the leg I get into two huge pockets of pus that drain all over my surgical field.  I tie off the large vessels and cut off the bone with a dull stainless steel hand saw.  There is a tiny file inside I use to round off the sharp edges of the bone.  Then I put a dressing over the open end.  We will change the dressing daily till it looks clean enough to close.

My perforated appendix guy is looking bad with a high heart rate and a breathing rate about 45/min.  His belly is all distended.  I had evacuated 2L pus in the original operation.  There was also some necrotic retroperitoneum at that time.  So I take him back again for a washout. I find the same nasty looking area in his retroperitoneum and try to take off more tissue along the ureter and close to the vena cava.  The bowel doesn’t look happy in a few areas because of what to me appears like typhoid effects.  Beefy red intestines.  There are no palpable thin spots so I decide not to take any intestine out but decide to take another look in two days.  I recluse him.   No open abdomens here, no vac dressings…

It has been a long day so I head back to eat some supper at a missionaries house.  I have some beans and rice and a great mango.  I am spent, and head back to get some rest

Bere 5/2025 #13

Second miracle

So I told you in a previous email that there was a woman who had a thyroidectomy and the recurrent laryngeal nerve was cut as it was in an abnormal position.  And that rather than having a hoarse voice, she spoke normally.  And answered prayer and a miracle!

Today we had another miracle answer to prayer.  A lady came into the hospital barely breathing and in a coma.  She did nothing other than breath.  We suspected infection and have been treating her and praying for her daily.  And she just lay there breathing.  No reaction to painful stimulus.  Today she sat up and started talking.  Incredible!!! A Miracle!  She is very weak from not eating and laying there days, but conscious and appropriate.  We praise God for allowing us to see miracles!!  I know He is doing much more than we realize, but it is always so neat to see His working!

Another one I’m still praying for a miracle is the guy who was stabbed with a cow horn.  He is still doing poorly and still necrosing more of his side and back skin.  I operated on him this Sunday morning.  And found an anastomotic leak again, in one anastomosis, and fortunately the other one looked good.  He had pus up near his diaphragm and cloudy fluid over the rest of his abdomen.  I put in some glove drains so I can tell when the abdominal fluid is bad again and closed his abdomen.  I may need to take him back and look in a couple days.  The family was ready to take him home to die.  But I convinced them to stay.  I think they are out of money and either don’t want to spend more or they think it’s futile.  I kind of think it’s futile too, but I won’t say that yet.  I think his nutritional status is so poor that he isn’t healing.  I debriefed more dead skin and muscle off his side but seems less today.  They keep saying they have no money so Im covering the post meds for them. About $60 equivalent for a few days IV meds.  I think with his previous two surgeries meds (Surgeries were emergencies so not charged), they’ve paid about $300.  So it has been quite a lot of IV’s he’s used.  

After doing that and helping the visiting OB/GYN with getting set up for D&C I check on a few people on the ward and head to get my tools.  Dr. Laurel wants a cat door put in and I think others have helped me find the tools needed.  So I spend the next couple hours cutting holes in a door and in a wall to install two cat doors.  Then she has some spray foam so I go around and fill all the holes in the house that mice and rats could run through to get in.  I feel fairly successful in plugging everything.

I eat some supper and then have good conversation with some of the missionaries.  Then Im called to see a woman who the maternity nurse can’t find a fetal heart tone.  She is correct, the babies heart isn’t beating.  I leave and then get called back 15 min later.  Another one the same question.  This one has a heart beat that is normal.  

Bere 5/2025 #12

Sabbath has been very hot.  I thought it may rain today as it felt humid, but it didn’t.  We went to the sacred forest this morning to look for whatever was living there.  We found some little red bugs, a host of ants eating a dead lizard, and some different plants.  We went to church and I sat with the missionaries doing the Childrens songs and sabbath school story.  We had a church service that I translated to the medical student that came this week, as he didn’t speak French.  Then on to my favorite meal here, potluck after church.  All the missionaries get together and bring a wide variety of dishes.  Indian rice, a boiled leafy dish, some dense meat like substance made form pumpkin seeds, white been fried blobs with a very nice hot sauce on the side, cabbage salad kind of like coleslaw, and mango cobbler for dessert.  The company and the food were excellent.  A visiting OB/GYN came today.  Great for Dr. Staci who is always overworked with OB being only one of the many things she does.  After potluck I went in to see a comatose man who came that way yesterday.  He has a liver tumor or abscess.  Ultrasound wasn’t clear.  His BP is low, so I ask the nurse to give more saline.  I get back to the group and the nurse calls again.  Another patient is also in a coma and isn’t breathing well.  I go to check on them.  I see they are being treated for malaria.  Family says at noon she was talking.  So I imagine Quinine has dropped her blood sugar.  Her glucose is 71, low.  So I ask the nurse to start glucose right away and to call me if she doesn’t wake up soon.  A group is going out to the monkey forest so I join them.   We drive about 20 minutes and then walk into the forest on a very small path.  We get to  a place where there are large trees with a lot of under brush, and vines are growing on the trees.  They said when they’ve been there before the monkeys get curious and come to check them out.  We wait for 30 minutes then give up.  A guy walking by says that the forest is about 2km in a direction.  I had no idea it was that large.  Morning about 6-7 is best he says.  On the way back I get a call from the ER saying there is a guy with a bowel obstruction for 2 days.

I walk to the ER and see a 60 year old man laying on a mat with a round belly and a foot propped up on a bench.  He is grunting in obvious pain.  He says he hasn’t pooped in 10 days.  Wait I thought 2?  No 10 days of no BM, vomiting and feeling awful.  The guy is very thin with a taught belly.  He doesn’t seem to have peritoneal signs.  So what will I find with my digital CT.  (using my digits to Cut and Touch :)) I try to call Phillipe- no answer.  I try to call David- no answer.  A radiology nurse is just leaving so the ER nurse asked him to go by Phillip’s house to get him to come in.  I ask her to call me when he gets there.  In about 30 more minutes he’s there.

In the OR Phillipe prepares for general anesthesia.  I choose the OR pack wrapped in cloth that I think is an exploration pack.  I choose the suture, gloves, covering for the bovie cord, and suction tubing also wrapped in cloth.  I try to find the one that feels like the silicone tubing I brought last year as it makes it through the autoclave better.  The med student Caleb puts in a foley catheter and I prep the patients abdomen with Betadine.  Philippe intubates this patient without any problem.  I scrub at the sink with the bar of brown soap and then put on my cloth gown, then gloves.  There is an under apron I could put on to keep the patient fluids from soaking through to my skin, but Im so hot already and sweats running off me, that I don’t want to add heat to what Im doing.  I slice open the skin with a few swipes.  The skin is tough and the non-US scalpel isn’t very sharp.  I go through the layers and when I get a small hole into the abdomen pus flows out.  Really? He didn’t have peritonitis on my exam.  So obviously he’s really tough and didn’t demonstrate the pain he was in.  Pain he has been in for at least 10 days.  I don’t know where he’s from, but the travel here must have been terrible.  We suck 2 liters of pus out of his abdomen.  Then the search is on to find the source.  I think it must be the stomach or appendix.  As I feel around more loops of bowel separate and more pus comes up.  The right lower quadrant seems a bit stuck and firm.  I search for the appendix and find it necrotic with an appendicolith in the abdomen.  I try and get out all the necrotic stuff I can, including the appendicolith.  I tie off the base of the appendix and take the offending organ out.  I run the small intestine through it’s length looking for any injuries I may have caused getting the adhesions to release and there is a spot likely effected by typhoid but nothing is thin in the wall so I leave it alone.  We wash out the abdomen with many bottles of saline.  Then we close the abdomen.  I close the skin loosely allowing for a wound infection to drain out.  

As Caleb cleans up the room and Phillipe extubates the patient, I sit off to the side and write my op note and write orders for his post-op antibiotics and his Diclofinac pain med.  I’m still waiting for the extubation so I get some scissors that I’ve been trying to sharpen and start working on sharpening them.  Something bounds towards me on the floor, I reflexively KICK, and a rat is hurled across the OR and scurries back under and into the rack of urine catheters and all the other OR stuff in the room.  I can’t believe a rat just ran towards me.  Well it was very surprising and then again, of course there must be rats, they’re in peoples houses and missionary houses, so why not the OR.  I will try to get a rat trap from somewhere to help that not occur again!  After extubation I head home at 11PM to try to wind down and sleep.

Bere 5/2025 #11

Take back cow horn gored guy

Today was the whole day in the OR starting after worship and then another meeting the hospital workers have.  My first patient was a young boy of about 8 with a bladder stone.  He was rather stoic as we brought him into the or his dad at his side.  He lay on the OR table without a word.  He was put to sleep with Ketamine and valium and atropine.  I filled his bladder with water so that I could feel that first after I cut into his abdomen.  That way the intestines are out of the way.  So I cut down through the layers and into the bladder.  I sweep a finger around and find the stone.  I stick in some ring forceps and feel around with them till I feel the stone and grab it.  It looks about the size of a very large grape and is yellow with small bumps all over it.  We close up the layers as usual.

Next was an older guy with two bladder stones.  I could see them on ultrasound.  I did the same surgery but this time since he was an adult he got a spinal anesthetic. I pull out two stones that are smooth and dark green.  Im amazed at how many colors and shapes bladder stones are.  I wonder what makes the differences?

The next is a 10 year old boy with two areas of draining pus on his left arm for a few years since he broke his arm.  Pus drains out constantly.  The X-ray shows a healed fracture with a piece of bone poking out the side of the radius.  It is a sequestrum (dead piece of bone).  There looks like there could be another piece further up his arm where the other area of pus is draining.  After he’s asleep with ketamine I use the cautery to cut down to the bone in the distal arm.  I get to the moveable piece of bone and free up the end and pull out a 3 inch piece of dead bone.  I try to decide wether to go for the other area or not.  But he’s asleep so I proceed.  I decide to open up his old scar in this area figuring it’s unlikely to contain his radial artery or nerve.  I get about 1cm cut and blood quirts me in the face and down my front all over my scrubs.  I get a finger compressing it and try to decide what to do.  I can’t even get a look at it or it squirt me.  Finally I find a place off to the side a little where I ca put pressure and neither end will bleed.  I know with this such back pressure from the ulnar artery, even if I tied off the bleeding vessel, he would have enough collateral flow to not kill his hand.   Dr. Laurel came in the room and recommended I fix it so that’s what I did.  After suturing the artery back together, He had a good palpable radial pulse.  Fixed!

Dr. Andrew had done rounds today and said the guy that was injured with a cow horn needed to be explored.  He is getting sicker and has peritoneal signs.  So something changed in his abdomen.  I see him on the gurney and I know his intestines are leaking.  The drainage on his dressings has changed from a day ago.  Intestinal contents.  He’s perforated again.  It’s 4PM and I’m starting a potentially very Long surgery. I also have seen in the past few days a large are of skin necrosis lateral to where the cow horn went into his abdomen.  (For you medical folks maybe a Morel-Lavallee lesion).  So he’s in the pre-op area with his family around fanning him.  He’s grunting in pain.  I notice that the dressing on his side where the cow horn was, now is draining stuff that looks like pus with intestinal contents.  So the characteristic of the drainage has changed.  So I take him in and the anesthetist decides to give ketamine as well as intubate him.  As David goes to intubate I give the Ketamine and the Succinocholine.  He uses the one Glidesope we have here to intubate and does a fine job.  I’m at the ready to take over if he struggles.  We prep his abdomen and then reopen our incision that is about 7 days old.  I see the top has already dehisced.  Succus (intestinal contents) start welling up with every breath as I open. We suck it into the canister and more pours onto the drapes and down the sides of the bed.  I suction out everything I can and then look for the source.  I find my small intestine anastomosis is leaking on the antimesenteric side.  The possibilities are quite a few.  I didn’t do the first anastomosis correctly, he had low blood flow from his low blood pressure for a long time, he was on neosynephrine drip, his poor nutritional status, his very contaminated abdomen.  Or maybe all conspired against him.  I take out the stitches that hung to one side. And freshened the edge and reclosed this section.  I looked for my other anastomosis.  It also had a leak along one side wall.  It also was about 7mm in size.  The transverse colon seemed to be folded in this area, so in addition to the above factors effecting it, he also may have ended up with tension at the spot.  So I freshened and closed this too.  I washed out the whole abdomen removing all the fibrinous exudate I could easily remove.  I looked at the front and back wall of the stomach and then ran the bowel again.  Other than irritated, it all looked OK now.  No areas of necrosis. I closed his abdomen and included retention sutures.  I went to the side where his Morel-Lavallee necrosis was and started cutting off dead skin.  I ended up taking off a patch of about 6x10in about 3/4in deep.  Dead muscle too.  I put a large dakins soaked gauze dressing on it.  After extubation we wheel him back to the ward where the surgical ward.  Another nurse had set up a saturation machine and oxygen machine at his bedside.  I couldn’t order the meds for him as the electronic system was down.  But I told the nurse to take the family to the pharmacy and get him saline, Ceftriaxone and Flagyl right away.  He called me about an hour later saying the family didn’t go as they said they didn’t have money to pay for it.  It’s so frustrating when people say they have no money.  Do they really not, then I’ll pay for it.  Or are they just saying that in hopes that I will pay.  I decide to wait.  There are many family members around that patient so I think they will come up with the money.  In my American mindset, I just wish they were honest.  But honesty isn’t necessarily a value here.  Conserving relationship is more important than honesty I think, which is hard for my mind.  I’m beat so I head to bed.  In the morning I find they didn’t get the meds for a while but had gotten them eventually.  Someone took him off oxygen in the morning.  Just turned it from 5L O2 to nothing.  So I ask them to check the oxygen saturation.  A nurse shows up with the device and it reads 94%.  So we didn’t kill him.  He’s still very likely to die, but we haven’t caused it.  I keep praying for a miracle of healing for him.

God help this man to survive all the insults his body has gone through.  Please heal him!  We can’t do any thing more to help him.  Only You God can help.  Please intervene and heal him.  Amen 

Bere 5/2025 #10

A MIRACLE! Thank you God!!!!  

I attend the morning worship and concentrate on listening to the one translating into French.  He reads a worship thought from a book called the Desire of Ages, a book about Jesus.  At least that’s I think what he’s reading from.  All the book covers here look different than ours so I’m not sure.  As I listen to the worship thought, daily life is going on past me on the other side of the fence that is around the hospital.  Horse and cow drawn single axle carts go by.  A small pack of dogs bicker with each other.  A young man appears to be harassing a woman who then picks up a small switch and goes after the young man.  Everyone is laughing except the woman who must at least be insulted.  A moto taxi pulls up with a couple people on it, bringing them to the hospital.  I find it hard to concentrate on the message as my brain is all over the place.  

After worship there isn’t any meeting so I go to the OR and tell them Im ready to work.  I do this to help them get going, otherwise they linger and do whatever else they do in the morning.  Like talk to a patient that is a friend and gab a while.  I also go by the surgical ward and tell them Im ready to round.  This gets both locations going.  But I just stand around waiting in the surgical ward.  So they get going.  The dressing cart is prepared faster and Emma changes from his street cloths into his scrubs and we start.  I see all the patients Ive already told you about.  The guy that was gored by a cow horn is better but is complaining of pain on his side where he was gored.  Some pus is coming out the drain I left.  But as I look with a flashlight at his dark skin, I realize he has some dead looking skin on his flank.  It looks like he was burned.  I asked the family and they decline knowing anything about it.  They’ve been very attentive to this man.  There are at least two people fanning him day and night.  It’s nice to see them so engaged.  I’m not sure what to make of it.  I wish I had a CT scan…… and so many other things to diagnose him further.  He’s still eating some boui (porridge) and pooped yesterday.  Great signs. I’ll keep an eye on that spot.  I leave most of the dressing changes for the nurse to do.  The next one is a woman who is a sister to Emma.  She had a thyroidectomy and we are certain the recurrent laryngeal nerve was cut which was repaired and would make a person hoarse.  She seemed hoarse the first day and now her is clear!   It’s a miracle!!!!  I’m excited to share this with the one who did the operation.  It has been many stress filled days of knowing this woman will be hoarse for months or permanently.  BUT SHE IS HEALED!!! We have been praying for that.  Thank  you God!!!!  We pray for so many people to be healed of physical or spiritual things and I don’t understand why it happens like this some times and other times it doesn’t.  But I’m so grateful to see healing when I do.  Later that day I share it with the surgeon and we just sit in the moment of relief and thanks to God!

Back to the OR and they aren’t ready yet.  Phillipe is concerned that we are starting a long difficult abdominal surgery and since the generators have been cutting in and out the last many days- is it safe to do this surgery.  He mentions that there is a generator specifically for the OR that hasn’t been started in about a year.  Could we make sure that one is functional first.  I think that’s a good idea.  So I ask Dr. Andrew how to arrange that, he makes a call then goes off to find out.  As always, missionaries, have so many different tasks to manage, and are pulled in so many ways.  It would be so much less stressful, if we were able to only stick to what we know- medicine….  So we prepare another patient in the second OR.  This one is a TURP (transurethral resection of the prostate).  We figure if the power goes out we can stop that surgery in the middle if we have to.  He is also known to have a large stone in his bladder too.  So the first patient waits all day and we never do get the go ahead from a generator standpoint.  So he is postponed till the next day.  The prostate is slowly shaved off using that same method I described in my last email.  Only this time each movement I make is bumping against a bladder stone.  If feels large, but then again, everything is magnified in this cystoscopic image.  It takes us a few hours to complete the resection of enough prostate so he should pee well.  We search many times for the ureters and never find them.  Thats a crucial part of the surgery.  So we are continuously bothered by that.  We need to see them and protect them.  But the stone has created so much inflammation we can’t identify them.  So we stay more in the middle where we know they aren’t.  After we decide we’ve done enough for the exposure we have. Then we transition to the surgery on the abdomen to remove the stone.  After going through all the layers of the abdomen and bladder, I try to grab and pull out the stone.  It is large and I have to enlarge my bladder incision twice before I can pull it out.  It is about 2.5inches wide and black with lumps all over it.  Each bladder stone is different and this is unique in it’s color and shape.  Wow, that must hurt being in there, and have been in there a long time.

The next patient needs a foot debridement.  No one in the room really understands her language.  So what I hear is she was normal 4 days ago then she an infection started.  I take off the cloth she has wrapped around her foot and the whole top of her foot is dead.  Dead skin and pus everywhere. (I’ll attach pictures).  Zach and I use scissors to cut away all the dead stuff till we get to bleeding, live tissue.  It smells awful!. We chip away at the dead stuff till it looks much cleaner but I’d be surprised if she doesn’t need a foot amputation.  I bathe the food in Dakins solution and then put wet dressing.  Ill check on her in the AM to make sure her infection isn’t getting worse or one of the rapidly progressing necrotizing infections.  Later in the night I’m in seeing another patient, and I see her leg is already less swollen than it was at the time of surgery…improvement.  I’m grateful!  Thank you God for the improvements I see in our patients.  The others are so hard to see and it’s great to see the good ones.  God give me strength for the bad outcomes too.   Amen

Bere 5/2025 #9

Monday is usually a busy day.  I’m called to see a woman at 2AM who isn’t progressing in labor.  It’s the nurse I don’t have confidence  in so I’m not sure if I should start Oxytocin or not.  Unfortunately I awaken Dr. Staci and ask her.  She thinks it’s less risky to just wait till morning.    At 7AM I’m in worship when the nurse finds me again and says I need to see the same woman after worship.  I go there and nothing has changed.  Dr. Staci comes in and we decide after watching her contractions and how the babies heart slows down with each contraction and takes a little while to improve- that we should do a C-section.  So we find the husband who is avoiding us, because he doesn’t want to pay for anything, to go and get the lab work paid for and so we can proceed.  We keep telling the woman not to push because it hasn’t made a difference all night.  She can’t or won’t stop.  Looking between her legs suddenly the baby head has dropped down and is on its way out.  With another push the child is on the bed and crying.  Yay! She didn’t need a C-section after all.  Thank you God!

One of the first operations today is a TURP- transurethral resection of the prostate.  I’ve always done Friers prostatectomy.  Andrew was learned to do TURP and so I watched him set up the complicated thing then using the TURP wire, it it a loop of wire, it shaves off a little trench in the prostate and then the same loop cauterizes. Then another trench of tissue and cautery of the bleeding.  He showed me the landmarks to use and had me do quite a few.  It is a neat way to take care of excess prostate.  But I think I’ll need some more training on landmarks to be certain where to do it and where is deep enough.  We worked on shaving off pieces for a few hours.  When we were done it seemed like a bloodless field and we left a foley catheter in place.

There were many clinic patients to see so I headed over to the next building.  Now a day later, can I remember what I saw? Only some of them.  I saw the teen with drainage coming from a previous fracture site only in the rainy season- 8 months ago, maybe a sequestrum, but definitely not obvious.  I could see something on the X-ray.  Told him if it starts draining again, to come back then.  Rain started and it was a downpour.  Rained for a while and cooled everything off, even through the evening.  Another patient in clinic was an older woman with body aches, saw a few with bladder stones on ultrasound who couldn’t pee well and were set up with orders for a stone removal surgery and sent to the pharmacy to pay the equivalent of about $40 for the surgery.  By the way, some of you sent me with some money to use here.  They have an indigent care fund, and that is what the money went towards. Other patients I saw were a kid with a huge splenic cancer I could see on ultrasound.  Another was a pastors wife with one of the largest spleens I’ve ever seen.  Covered her whole abdomen, except for a small portion of the right lower quadrant.  Spent the whole afternoon in clinic.  When I was done and walked out of the building- what a refreshing feel.  It was a cool 75 and smelled like it had just rained.  Other than being awakened by a call at 3 AM, I slept quite well that night!

Bere 5/2025 #8

Sabbath was a peaceful day.  Dr. Andrew took his kids to the “monkey forest”  and they saw monkeys pretty close early in the morning.  I had a peaceful morning and then rode the big motorcycle to church with Zach on the back.  I went to the same church as last week.  It was unbearably hot with rain clouds all around but no rain at potluck.  Some people went to the river again and that was what I was hoping would happen.  I was cooler than the air and lovely to lay in the shallow brown cow poop shistosoma filled water.  In the evening I hung out with some missionaries and talked.

Sunday AM I am awakened about 5AM for a woman who has had 5 babies and all of them died during labor.  Her last one ruptured the uterus.  This one doesn’t seem to be progressing.  So I go in thinking she likely needs a C-section.  This nurse I remember I haven’t had much confidence in, in the past.  I see that the babies head doesn’t descend much during a contraction and I ultrasound the baby.  As I watch another contraction I see the heart rate slow down and it stays slow after the contraction.  Fetal distress.  I call in the team for an emergent C-section.  The maternity nurse brings the patient to the OR and we get her ready as Phillipe gets there.  It seems to move along faster than normal.  She has a previous scar on her lower abdomen from the uterus repair before.  It seems like a keloid (thick and large and hard), so I excise the previous scar.  Her scar tissue is pretty dense. After opening the muscles I find the bladder quite stuck and I can’t even drop it down out of the way.  I imagine this is because of the previous site of rupture and scaring.  So I have to make a higher transverse incision on the uterus than normal.  I reach into the uterus to grab babies head and it is wedged into the pelvis.  I work my fingers hard to try to get around the head to pull it back up.  It’s real hard to get my fingers around it then the suction of the pelvis holds my hand there, finally a bit of air goes around my hand and the suction is broken and Im able to pull up the head.  The baby is floppy.  And since I don’t trust the nurse I keep the baby on the wound in front of me for a little bit and get him breathing before handing him off to her.  The closure of the abdomen is uneventful and after about 5 minutes her and the anesthetist working on the baby, he’s breathing well.

The next patient we are suppose to do is a liver abscess but the power went out again.  This time I think they’re filling the generator.  They have two new generators that they say have oil cut off sensors that are bad?? Unlikely on a new generator.  More likely poor oil amount or quality.  So since I don’t have power I go to make rounds.  I take my headlamp and see all my patients in about an hour.

I go back to the OR and about then the power comes back on.  So they bring the patient in and I decide to ultrasound his liver to decide whether I’ll do it with a pigtail drain or open drainage.  There is no abscess.  I check the paperwork and it says a bladder stone on the ultrasound.  Is this the patient in bed 9 with the abscess?  Yes.  The anesthetist steps out to find out more.  They come back with the correct patient who’s been out under a tree so some other patient took that bed.  Ultrasounding the correct patient, I see there is a deep abscess in the posterior liver up near the diaphragm and heart.  OOOhhh.  If I miss the direction I could stab the heart and kill him.  I think about not draining it.  But it won’t get better without drainage and in the posterior liver, draining it with open surgery will be nearly impossible too.  So decide to put in a spinal needle in the direction I think I should go and watch on ultrasound.  I get right into it.  So I take the much larger pigtail catheter and feed it in till I see the tip in the middle of the abscess.  I withdraw about 80ml of pus.  I flush it with saline and attach a bulb for suction.  

The next woman is HIV positive and has had abscesses all over her chin and neck from tooth decay and infections.  She has a remaining hole just above her sternum that when she coughs or lifts something- pus drains down her chest from the hole.  I decided this must be a retrosternal collection.  So I numb her up and open the hole to probe it further.  I worry about wether the internal jugular vein has been pulled or displaced by scar tissue- will I get into significant bleeding that is difficult to manage.  I open a small amount at a time.  I probe the pocket with an instrument and feel that it’s not to big.  I had hoped to get my finger in, but I stop as Im not in bleeding and down want to cause it.  I put a piece of glove in as a drain and put a dressing.

There are not many cases scheduled on the weekend so we are done.  I head over to another missionaries house about 10 min drive away on a motorcycle. Unfortunately and fortunately they are just ready to have a late lunch.  So we are invited to eat.  We have a nice meal together and I spray the areas of their house they want sprayed with the insecticide I brought.

Back at the hospital I make it back in time to be a part of a party for one of the Cameroon missionaries here.  Two of the families here made cake- and they taste real good!  We take turns commenting on how we appreciate the person who’s birthday it is.  It think this is a nice way to party.

Just at the end of the party there is a call for a woman who isn’t progressing in labor and has a face presentation.  Normally the back of the head is the presentation part an this comes out easier.  The face is to broad and doesn’t deform like the rest of the head for a vaginal delivery.  We wait for the generator people to put in fuel as the power just went out.  Then she starts bleeding vaginally.  Now it’s an emergent C-section.  We pour in the fluids and get a spinal in the dark by headlamp.  We can’t wait for the power to come back on.  We must get the baby out as soon as possible.    She may have placental abruption (separation of placenta from uterus that will kill baby and make mom hemorrhage a lot).  As soon as the spinal has taken effect quickly cut into the abdomen, down to the fascia.  A quick cut and scissor of the fascia and separation from the rectus muscle.  Move the bladder down out of the way then open the uterus.  I immediately get some clots.  I reach in and fish the baby out.  He looks weak but starts little breaths.  The midwife is there to receive the baby and she takes her, and starts working to get the baby breathing well.  I close the uterus as fast as possible to help staunch the flow of blood mom is loosing.  Then tie off some other bleeders.  Mom is getting a transfusion at the same time.  God help this mom and baby!  I hear the baby start to cry- what a joyous sound!.  The power flickers back on for about 1 minute then fades out again.  Sweat is pouring in rivulets down my back and legs.  I slowly close up the different layers irrigating between each layer.  Mom has stabilized with more blood and all I feel now that my adrenaline is less- is HOT!!  After we are done and wheel the patient to maternity, the slight breeze outside is sooo refreshing.  The power takes a while to come back on.  More plastic bag in the generator fuel lines I hear.  Eventually the power comes back on and I’m able to sleep. Till 2AM when I’m called again.

Bere 5/2025 #6

Long good day with a nurse induced overdose of a child

I  check on the guy who had been stabbed by a cow with it’s horn.  He is still alive.  Still in septic shock with a norepinephrine drip that no one is really monitoring.  I just ask the nurse to not touch anything.  I go to worship at the Hopital then back home to have my own time of reading and prayer asking God to heal my patients and to give me knowledge of what to do with the ones I will see today.  

I have some bread and PB and head in to work.  Dr. Andrew is going to do surgery on a 4 day old with a meningomyelocele.  (Undeveloped lower back with nerve tissue exposed to the outside on lower back the looks like a healing wound about 1.5 inches across).  I go to make rounds.  The OR nurse will do a hernia repair in the second room in the OR..

I make rounds with Emma who is the long time day norse of the surgical ward and he is easy to round with as he knows all the patients.  The ones that stick in my mind now after a day of operating are:  Guy malled by a cow horn, teen girl burned all over body when she had a seizure and fell into a fire, teen boy with hippo bite, Old man with TURP, two old men with hydroceles, two old guys with inguinal hernia repairs, old man with arm with tumor removed and skin grafting, guy nurse with buttocks abscess after antibiotic injection at that site, boy with bladder stone removed.  Took me about an hour to see them all.  I left some of the dressing changes for Emma to do.  I notice a box of carnets (the little booklets that is the medical record that the patient keeps). I asked Emma what that was?  He said that those are all the patients he’s following for tuberculosis.  And there is a real problem with inconsistency of the supply of medicines.  He will get medicines for two months, then none for a month of two, then get them again.  I realize right away this is a terrible set up for medication resistance, which I had heard was already becoming an issue in this area.  A guy at that moment stopped us to ask Emma for his meds, and Emma was out of his meds and couldn’t get them.  I encouraged the man to go to Lai (Emma said they’d be out there too), or to go further away till he found them.  I hope he does find them- seems like an impossible task for a local person.

Back to the OR, and Dr. Andrew was just intubating his patient as Phillipe had been unsuccessful.  It looked like a hard intubation.  I asked if I could help him as I have tried to repair meningomyeloceles before in Cameroon, but hadn’t ever seen one done properly.  He agreed.  We lay the baby prone to expose the back and put the cautery grounding plate under him.  I prepped the kid with betadine and we dawned our cloth gowns after scrubbing our hands with brown colored bar soap.  Dr. Andrew cut around the skin beside the open raw looking area- the dura.  The anatomy was so hard to figure out.  Zach helped use Andrews phone to dial a neurosurgeon in Kenya for a video conference to ask his opinion.  The connection was terrible but with some creative hotspot thinking, a better connection was made.  The neurosurgeon said this was abnormal anatomy for this disease and gave some pointers on what to do.  It’s invaluable to have knowledgeable people, who understand the situation and limitations here, to give their opinions!  With a very tedious long dissection we removed the fascia off muscle, bone circumferentially. The power went out so we had to stop about 10 minutes, because we were using cautery and a bloodless field was crucial.  The fascia  was so thin over the bones the some holes were made which wasn’t good, because it needs to be water tight to hold in CSF (cerebrospinal fluid).  Next we undermined the skin all the way out to the sides of the abdomen.    We closed the dura in a running layer then the fascia was pulled over that and closed folding the dura in.  Then closed the skin in a running layer that was also to be water tight.

I went to the next OR to operate on a child that had a bladder stone.  The OR lights don’t work in this room and so I operated by my headlamp.  I had a hard time seeing and initially I thought it was my eyes are older and don’t want to focus close, especially after the last surgery that was all very close.  About midway through I realized my headlamp was very weak, so Zach turned on his and voila, I could see clearly… So other than the power going out some more the surgery went well.

Dr Staci had come from maternity and said that there was a C-section that needed to be done as the patient had come in labor and had a C-section before and was told to always have a C-section after that.  Phillipe had prepared her in the other room so I switched back to that OR.  This abdomen was quite scarred as I opened it through the previous incision. Muscles were stuck, bladder was stuck.  I opened the uterus to a gush of amniotic fluid.  I pulled the babies head out, and found a nuchal cord (cord wrapped around the neck) so I undid the wrap and delivered the rest of the baby.  He cried right away and I passed him off to the maternity nurse.  The closure of each layer went well and she didn’t have any vaginal bleeding from the uterus at the end of the surgery.  

The next young woman had had an early miscarriage and some retained  placental products in the uterus that could be suspected on ultrasound. So back in the other OR I did what is called a dilation and curettage.  Where we basically use some metal instruments to scrape the inside of the uterus clean of any retained pieces of placenta  so that the woman will stop bleeding and also diminish the risk of infection.

I found Dr. Staci on the maternity ward and looked at a patient in the delivery room.  Staci was getting ready to do rounds at 7PM as she had been busy all day with administrative stuff and still hadn’t had the time to make rounds. ( I’m convinced that she does a job that really should be three different people.  Director of hospital, only doctor on maternity, and director of AHI Chad. So if you are good at any of those jobs and want to live in Chad Africa, contact her or I).  Back to the work… I decided to offer to make rounds for her.  I’m not as competent as she is but figured that the nurse who was on was a good one and that she would know the patients well.  So I made rounds in stead of Staci.  Even my help is beneficial when it relieves the load some so that overworked doctors can have a little less.  I make rounds and discharge the patient I did a symphisiotomy on a couple days ago.  She is walking well, denies any pain.  Hasn’t washed the spot of the incision because her mom told her air would enter and she must keep it covered.  So I looked at it and it looked fine, and I encouraged her to wash it daily with soap.  I’m pleased that her next vaginal delivery should be easier for her.

I walk through the surgical ward on my way back to my room and to go get some supper- 8PM. I check on the cow horn injured man and his family is sitting him up and he’s requesting some water.  I tel them they can give him sips.  The nurse says the baby we did in the morning has a high fever of 40deg C, or about 104 F.  They gave Tylenol and it didn’t come down.  She says the Tylenol is nearly finished.  What?? The Tylenol bottle is 1000 mg and a baby takes about 30mg… So I have her show me the bottle.  It’s about 80% gone.  I asked her if the baby got all that in a dose.  She said yes.  So the meningomyelocele baby who we operated on for hours, was given about 800mg of Tylenol in stead of 35mg.  Thats about 20x a normal dose or 2000%.  A huge overdose!  I told her that this will kill the baby, not immediately, but in a few days or week.  She said, well what do we do about his fever?  I don’t think she grasped at all the critical error that was made.  Later I found out it was her who had started the drip and had overdosed the kid.  So if the kid survives his meningitis and fever, he won’t likely survive the liver failure that will result from that error.  How terrible…

God, only You can save this baby, only You can save this cow horn injured man.  LORD HELP THEM!  Save them from their injuries caused by disease, caused by us as we care for them.  HELP us!!!!

The boy is about 22 yo and I saw him yesterday afternoon and they were thinking of adding him on since we appeared to be done a little early.  He had a hemangioma (mass of large blood vessels) on his inner thing that was about 4×10 inches.  Some of the blood vessels were as large as my fingers.  i said he should be the first case in the morning as it could be very hard to do.  So this morning is the day.  I ask him about how long this has been there as he lays on the OR table.  It been present since birth and has slowly grown larger and larger.  He says it hurts.  I can imagine if it grew quickly it would hurt but not at a slow progression.  That matter not- Im taking it off today.  I scrub with one of the local docs who is doing surgery learning for 6 months.  I start cutting around it and right away get into a few vessels.  This gets my heart rate going.  im trying to explain how he can help me and im finding it challenging.  He isn’t really a good assistant.  I need someone who knows what they’re doing.  Dr. Steven comes in to check on me and I ask him to help.  Then it goes much better.  We are able to go back and forth whichever of us has an easier angle to dissect and the other of us cuts with cautery or ties a small vessel.  We slowly peel it up including the underlying fascia or just above that.  We finally define that it only had two small feeding veins.  These were tied and it is off.  Now how to close.  I pull on the skin and realize I may be able to get it together with a lot of tension.  So I start in the middle with a stitch, then in-between with more stitches.  Until with about 30 stitches it all comes together.  I’m glad to have gotten it together.

I do another surgery and then the third one is interesting too.  This kid of about 8, had an infection going on in his leg for the past 8 months.  It was painful and it had some draining pus that came out in different areas.  The X-ray showed osteomyelitis (infected bone).  This looked like a huge fat bone in the leg at least twice the size of a normal tibia bone.  So i took him to the OR to drain it.  I cut down to the involucrum (new bone growth around a dead piece of bone (sequestrum).  I follow one of the holes that has pus coming out of it and find the hole in the involucrum.  I use a rongur to eat the hole away till it’s very wide.  I probe inside the bone in both directions.  I get a lot of granulation tissue but not any dead bone.  I follow another in the upper tibia and do the same thing.  In that one I find a small piece of bone.  It feels slightly mobile.  I wiggle and try to pull on it.  I think this is likely the sequestrum.  I bite it in half with the rongur.  Then one end I grab and am able to wiggle and twist it free.  Yep it’s a sequestrum in the dead bone inside.  The other end slides up into the top of the tibia.  I use a curette and try to swipe it out.  Finally i get a hold of it.  It doesn’t want to come out, but with force it does.  So at least two chunks of dead bone, the source of all this pus is out!  i hope there isn’t more, but I can’f find more so i pack the holes down the center of the marrow after washing it with dilute bleach solution.  He will likely be here months with packing his legs.

Bere 2024 #3

Warning graphic!!

Ohhh, Noooo!  I walk into the preop/recovery room and Dr. Steven is looking at a guy laying on his stomach.  It appears like the mans anus exploded!  what happpenneddd?  He was riding a bike yesterday when he fell of and the pedal went into his anus.  It looks aweful with loose tissue hanging all over.  he has a urine catheter that has blood in it.  I see Dr. Stevens examination and its clear there are more than one hole and its kind of difficult to see what is actually the anus into the rectum.  So we decide to do the hystorectomy case that is already in the OR ready then we will do this guy.

The hystorectomy is the third case of the day.  We did a mastecomy first on a lady with inflammatory breast cancer which is considered pallatative- not for cure but to give her a better life for a little while.  I was able to remove the breast and get some enlarged lymph nodes out of her axilla (arm pit).  It was a bit snug getting her skin back together, but was able to do it.  And i left a piece of glove at the bottom to come out as a drain.  

The next lady had a mass in the pelvis that a previous doctor had thought was uterine in nature.  So we took her to the operating room to attempt to remove it.  As I palpated her abdomen it seemed to be about 10 by 12 inches in size and didn’t want to move around when i pushed on it.  So i imagined it was fixed to surrounding structures.  After she has her spinal anesthetic placed by the anesthetist she is laid down and her abdomen is prepped.  Next I get scrubbed and put on the cloth gown and my sterile gloves.  I put the cloth drapes on the patient and we begin.  After we pray for our patient I make a vertical abdominal incision.  I go through the skin, then a tiny layer of fat, then fascia, then into the peritoneum (inner layer of abdomen).   Next i see intestines and after sweeping them to the side with my fingers, I feel the mass. It appears cystic and it is stuck all along the right side.  i can feel around the back side and it seems there is space behind near the rectum.  Slowly I make an incision along the right side and slowly make it down to where the iliac artery and vein are.  I find there seems to be two main cysts.  Im able to slowly go inferior to the cyst and the later and find the two main cysts off in my hands.  Below that is the uterus that looks fine and the left ovary is normal.  So I close up the fascia, and skin and she goes out to the recovery room.

Next is the guy with the bike pedal to the rear end.  He gets a spinal anesthetic after enough IV fluids were given.  Then he’s put up in stirupps flexing at the hip so we have a good view of the anus.  It really does look like an M80 went off inside.  I swipe poop out of the way and spray down the hole with Dakins (dilute bleach) solution. As I look around the anus, I realize there’s a hole anterior to the anus and then realize that the hole is between the prostate and the rectum. The prostate normally is directly next to the rectum. How did he get a hole between two small structures the don’t come apart easily.  As I evaluate the rectum it appears intact.  I think a diverting ostomy would be best, but after discussion with the doc that’s always here, decide to not do that yet.  An ostomy is hard to have here as there are minimal ostomy supplies available so no real seal on the abdomen.  I have patients at home that will give me supplies, but it always seems there are more important things to take in my ?6 pieces of luggage.  I decide to leave a large drain deep in the hole and suture it out to the skin.  Then I excise the dead tissue and suture skin back to the anus- or whats left of it.  I sincerely doubt he will have any continence, but then again, there did seem to be a little anal tone left.  I had warned the patient before the surgery that I thought he may be incontinent after this accident, forever.  

i go out to the preop/postop room and start seeing the different surgical and medical consults that are there.  A young kid with a vascular mass on his inner thigh, a kid with enlarged cervical nodes, an old woman with abdominal pain going on 3 years, a 30yo man with an abdominal mass that fluctuates in size and i think i see a mass on ultrasound, an old guy with eye itchiness and a cornea that is completely whited out…. After about 10-15 pateints i head towards home and make it about 20 feet.

The nurse from maternity sees me walk by and says “doc I was just going to look for you” Well it was said in French…. So there is a woman who has just arrive with her 4th pregnancy at about 8 months and shes having vaginal bleeding.  The babies heart rate is normal, but blood and clots continue to come out.  She’s not in labor and is at one centimeter cervix dilation.  They just are drawing a hemoglobin level and getting an IV going.  I do a bedside ultrasound with my Butterfly (small ultrasound that i attach to my iphone).  I find the placenta appears intact and not covering the cervix and babies heart rate is good.  I decide to go get some advise from my wife and another nurse here.  I find them painting a house in preparation for a doctor that is moving here soon.  After their advise I go get some supper of rice and beans and then go back to see what the hemoglobin and results are.  She continues to have bleeding.  So i decide to do a C-section.  I try to call the two guys back to the OR.  I cant get either one.  So the nurse goes to use the  “hospital phone”.  It has no cell credit so they cant make calls either…. I ask the maternity nurse to do something or send someone.  Normally I’d be quite mad by now, but I made an internal pact to push gently when encountering problems here this time and let people make poor choices if they make them.  So i sit for about 45 minutes before the scrub tech shows up.  Then he tells me he also does anesthesia now if I can find someone else to assist me.  So I go find Audrey and ask her to assist.  She is willing and eventually we start. I make a low pfannenstiel incision (bikini) and go down to the muscles.  I divide them along the middle and open to the uterus.  I make a low across incision on the uterus and get immediately quite a bit of blood.  OHhh, placenta abruption (the placenta separating from the uterus and it bleeds in between).  I find the bulging sac of amniotic fluid and open it.  Gush, I feel the blood and amniotic fluid run over the front of me and I feel the wetness through my gown from my belly button to about mid thigh.  I don’t like that feeling!  That’s the side effects of cloth gowns- not impervious at all!  I pull out the babies head and suck out the nose and mouth.  Then pull the rest of the kid out.  She starts to cry as we cut the umbilical cord.  Yay!! A live baby!  So many come so late that we doctors usually see the worse cases and baby deaths.  The normal deliveries are done by the oncall nurse.  I pass off the baby to the nurse near by.  Audrey and I then close the uterus and then the abdomen.  Mom and baby are doing well.  I head home to slow down and shower and get to bed late.  It was a long but good day

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