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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!