Bere Chad #3

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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

.

Shanksteps Bere 2024 #2

Greg Greg No Comments

We

We are back in Bere, Chad. It is the HOT season. Our room is about 95 to 97deg F in the
evening. Im able to fall asleep for about 2 hours then Im awake again, hot and jetlagged. I lay
there till morning. I get up and all I want is cold water. It’s a choice. We have a refridgerator in
the place we’re staying, but the more water or things we put in it the hotter the room it’s in
gets, as expected. So its a tradeoff. Denae and Steven are doing a very difficult surgery in the
morning before she leaves. It’s a enterocutaneous fistulae (connection of the intestine to the
abdominal wall that makes stool to leak out a hole onto the belly). As they work on that I go
and make rounds. Emma, the surgical ward nurse, is knowledgeable about their different
reasons for surgery and rounds go fairly quickly. I look at all the wounds that are granulating
and change the dressings. One dressing stands out: This guy of about thirty has seizures and
during a seizure fell in the fire and burned his foot and head. I have yet to ask him what
contortion allowed this to occur! But he came in a couple weeks ago with three toes burned
and his head charred. After taking off his dressings i see that the three toes are super floppy,
almost like they don’t have any bones in them?? One has a bone because it is sticking out the
end of his toe. As I take off his scalp dressing I see that he has good granulation around the
outside and a patch of about 2x4inches of exposed skull. I know that skin grafting doesn’t
work on a bone, so this will need special attention. I see the patients with vessicovaginal
fistulaes that Dr. Denae has operated on and they are in various stages of their 4 weeks with a
urine catheter. Some have been “discharged” to the outside to save bed space for other
patients, and they come in to be seen while rounds are made. others have had hystorectomy,
hernia repair, hydrocele- that ended up being a hernia stuck to a testicle and they had to take
the testicle (orchiectomy). I see a boy with a humerus fracture that he got climbing in a tree
and falling out of it. Thats how most of the children break bones, climbing in a mango tree to
get mangos and falling to the ground.
I head back to “my” house, which by the way is the place I’ve stayed in before. I think it’s the
place James and Sarah Appel first built when they started building stuff in Bere. I unpack
some things and then go and check how things are going in the OR. i do some other surgery –
which i don’t remember now. Then we get done earlier since its a Friday and we like to be out
for Sabbath if possible. We really value Sabbath rest as Jesus observed it. Im able to visit with
old friends (missionaries) and it’s a nice evening.
Im called in to see 4 accident patients. The nurse says one has an open knee and the others
with broken arms, but not open. They were on motorcycles that hit one another. I remember
that most patients once they’ve been diagnosed with a fracture, want to be treated by the
traditional bone healer. So i tell him, whoever wants me to treat them, have them stay. if they
want the bone healer they can go. So when i get in there to see them, only the guy with the
open knee fracture is left. So I look and all is see is pieces of his patella (knee cap) sticking out
at odd angles. As i touch it pieces come off in my hand. Dirt and sand is everywhere. I ask for
an X-ray, but the nurse tells me the person lives to far away and phones are not working. So i
tell them to send someone to get him and someone to get the OR crew of Philipe and David.
Only David comes in. But the guy who does the sterilization of instruments says he can help.
So I go to the OR after waiting about .1.5 hours to get ahold of the right people without
success. In the OR i help the assistant gown up as I don’t think he really knows about sterility.
Not that this knee is sterile- it has dirt and sand in it. I find there is no identifiable knee cap. i
see a piece of the end of the femur chipped off and no other identifiable structures. I open it
up more and more and still cant identify any remaining structures. So i wash it out and close
the skin and plan on an Xray tomorrow. To see if that gives me any more clarity as to what can
be done. I head home.
i shower and get into bed dripping wet. I sleep for maybe an hour then lay awake most of the
night tossing and turning. it’s still hot!!(In the next day or so, i am informed in the operating room that this guy wants to go home. And
he signs out against medical advise)

#1 Bere 2024

Greg Greg No Comments

Shanksteps Bere 2024

We are back in Bere, Chad. It is the HOT season. Our room is about 95 to 97deg F in the

evening. Im able to fall asleep for about 2 hours then Im awake again, hot and jetlagged. I lay

there till morning. I get up and all I want is cold water. It’s a choice. We have a refridgerator in

the place we’re staying, but the more water or things we put in it the hotter the room it’s in

gets, as expected. So its a tradeoff. Denae and Steven are doing a very difficult surgery in the

morning before she leaves. It’s a enterocutaneous fistulae (connection of the intestine to the

abdominal wall that makes stool to leak out a hole onto the belly). As they work on that I go

and make rounds. Emma, the surgical ward nurse, is knowledgeable about their different

reasons for surgery and rounds go fairly quickly. I look at all the wounds that are granulating

and change the dressings. One dressing stands out: This guy of about thirty has seizures and

during a seizure fell in the fire and burned his foot and head. I have yet to ask him what

contortion allowed this to occur! But he came in a couple weeks ago with three toes burned

and his head charred. After taking off his dressings i see that the three toes are super floppy,

almost like they don’t have any bones in them?? One has a bone because it is sticking out the

end of his toe. As I take off his scalp dressing I see that he has good granulation around the

outside and a patch of about 2x4inches of exposed skull. I know that skin grafting doesn’t

work on a bone, so this will need special attention. I see the patients with vessicovaginal

fistulaes that Dr. Denae has operated on and they are in various stages of their 4 weeks with a

urine catheter. Some have been “discharged” to the outside to save bed space for other

patients, and they come in to be seen while rounds are made. others have had hystorectomy,

hernia repair, hydrocele- that ended up being a hernia stuck to a testicle and they had to take

the testicle (orchiectomy). I see a boy with a humerus fracture that he got climbing in a tree

and falling out of it. Thats how most of the children break bones, climbing in a mango tree to

get mangos and falling to the ground.

I head back to “my” house, which by the way is the place I’ve stayed in before. I think it’s the

place James and Sarah Appel first built when they started building stuff in Bere. I unpack

some things and then go and check how things are going in the OR. i do some other surgery –

which i don’t remember now. Then we get done earlier since its a Friday and we like to be out

for Sabbath if possible. We really value Sabbath rest as Jesus observed it. Im able to visit with

old friends (missionaries) and it’s a nice evening.

Im called in to see 4 accident patients. The nurse says one has an open knee and the others

with broken arms, but not open. They were on motorcycles that hit one another. I remember

that most patients once they’ve been diagnosed with a fracture, want to be treated by the

traditional bone healer. So i tell him, whoever wants me to treat them, have them stay. if they

want the bone healer they can go. So when i get in there to see them, only the guy with the

open knee fracture is left. So I look and all is see is pieces of his patella (knee cap) sticking out

at odd angles. As i touch it pieces come off in my hand. Dirt and sand is everywhere. I ask for

an X-ray, but the nurse tells me the person lives to far away and phones are not working. So i

tell them to send someone to get him and someone to get the OR crew of Philipe and David.

Only David comes in. But the guy who does the sterilization of instruments says he can help.

So I go to the OR after waiting about .1.5 hours to get ahold of the right people without

success. In the OR i help the assistant gown up as I don’t think he really knows about sterility.

Not that this knee is sterile- it has dirt and sand in it. I find there is no identifiable knee cap. i

see a piece of the end of the femur chipped off and no other identifiable structures. I open it

up more and more and still cant identify any remaining structures. So i wash it out and close

the skin and plan on an Xray tomorrow. To see if that gives me any more clarity as to what can

be done. I head home.

i shower and get into bed dripping wet. I sleep for maybe an hour then lay awake most of the

night tossing and turning. it’s still hot!!(In the next day or so, i am informed in the operating room that this guy wants to go home. And

he signs out against medical advise)

Shanksteps Bere April #12 with pictures

Greg Greg No Comments

Shanksteps Bere April #12 with pictures
I go in for the last day at Bere Hospital before I leave.  Went to morning worship then back to my room to prepare stuff while they have another meeting.  When I go back in I do rounds with Abouna, a nurse who does quite a number of surgeries as he’s been trained.  He’s quite intelligent.  I do rounds with him so that he knows what I plan for each of my patients and can tell the next surgeon when he comes next week.
The first patient is ready, he’s an old tall Arab guy with a large prostate on ultrasound and can’t pee.  I start to cut his abdomen and though the nurse said he was ready he feels it!  So I wait till he gets some ketamine before I continue. I make a phanynsteal incision, cutting down through the skin and fascia, split muscles along the midline and then spread above the bladder sweeping the peritoneum and intestines up and away from the bladder.  I open the bladder and suck out all the liquid we’ve put in the bladder to distend it.  I feel inside and feel a huge prostate.  Hmmm, is this cancerous?  I don’t feel nodules, but it is large.  Slowly I break the anterior prostate and gradually shell it out with different fingers.  As each one gets tired, I use a different finger.  Usually my right index and middle fingers. I have to make my incision in the bladder a little larger as it won’t come out of my original size incision.  After removing it, I sew up the back wall down low where most of the bleeding occurs.  Blood is constantly welling up and it’s hard to see.  Eventually with the stitching it slows down.  I put a new foley in and inflate the balloon.  I check to find that both ureters are still putting out urine and I hadn’t caught either one in my stitching.  They are working well, so I close the bladder in two layers like usual.  I leave a piece of sterile glove as a drain and close up the rest of the layers, irrigating at each layer.  We take him out to the “recovery room” and bring the family in to show them how to take care of the bladder irrigation.  It’s sad that I feel more confidence in the family doing well with the irrigation than the nurses.  But the families here are used to caring for their patient and they’re invested.  Once they understand what I want them to do they usually do it.  It just takes repeated translations to tell them.  And I do it differently than Dr. Denae, leaving the foley on tension, so it’s a learning curve for the nurses too.  Once I think the family understands, I see some consults about a leg mass, neck mass, infertility, a hernia, Then go into the next surgery that’s ready.
The next was an old lady with a black dead foot.  Yesterday when I saw it, it was dry gangrene, dead and shriveled black without an odor.  Today the whole pre-op area smells like dead with pus! Wet gangrene.  She is taken back and a spinal anesthetic done.  Her below knee amputation goes well.  There isn’t as much blood flow as normal so I wonder if she will heal this amputation site.  I do it with a nursing student as Abouna had to go to the government office because he’s involved in some sort of land dispute.  They call him and say come now, so he leaves work and goes and deals with it.  A few hours later he’s back at work.  The student helping me is helpful, but I have to direct him quite a bit on what to do.
I see some more consults, and then there is a older woman with a hernia in her central abdomen about the size of a foot ball.  Initially when I saw her I wasn’t sure wether this represented a hernia or a mass, but I suspected hernia.  After her spinal we are able to reduce it, hernia!  I cut down into the large fat layer and gradually around the hernia sac.  I open and resect the large sac.  I then close the fascia with a large suture.  I suspect she may have a large seroma (fluid collection) in the fatty layer, so I leave a piece of sterile glove as a drain.
One of the consults I see next is an old guy who can’t pee.  He says he had a foley catheter in that didn’t work but when they pulled it he had a lot of blood in his penis.  Once again I be the foley was placed and the balloon blown up below the prostate and not in the bladder.  Then  suprapubic foley was placed.  He hasn’t been able to urinate with his penis since.  The foley in the lower abdomen fell out a week ago.  He went to the hospital in Kouseri (Cameroon) and they wanted 200,000- 300,000 CFA ($400-500) for the surgery to fix him.  He decided to come to us about 12 hours away.  But it took him about a week to find money and get here.  He says that he can’t pee and small amounts of urine come out his abdomen.  I do an ultrasound with my Butterfly and see a very full bladder up to his naval.  He pays at the pharmacy for a foley and bag and I take him into the operating room as I know this will be difficult as the tract has closed up.  I anesthetize his skin and cut back open the skin.  I know Im going to do this blind along a tract that has closed, but I hope I can re-open it and get a foley in the same place.  So I probe the tract with a sterile heavy blunt probe that usually used for vaginal stuff.  Im gradually able to shove it down the tract into the bladder.  I feel a pop then pull it back out.  No urine.  I know I was in deep enough it was easy after the pop.  And I know I have a huge target of urine to hit.  So I put the heavy probe down a foley catheter and push it down.  It’s tight but I think I get it in.  The probe is difficult to pull out.  After getting it out- only a small amount of urine in the foley.  I use a force to cram more foley in the hole.  Urine comes welling up in the foley.  I very grateful.  I blow up the balloon, which doesn’t cause any pain, so the balloon is in the right place.  He drains about 2 liters of urine and feels much better.  
I look at the registry of surgeries since Ive been here.  35 surgeries in 2.5 weeks.  That’s a good number.  I’m looking forward to being home with my wife and in cooler weather.
Pic of large prostate and a prostate patient.