Sooooo, I feel like I have escaped from working in the clinic in the US… to do clinic in Guinea. When God arranged for us to come here, we did not know that they would be short one doc. We arrived just as the Gen Med doc left, so it was fortunate that we came when we did. I have worked in the clinic each day and am finally getting the hang of it. I have had to translate the medications they have available into something I recognize in English so I can treat the patients as well as possible. Between the 4 of us docs (2 from Cote d’Ivoire – 1 a surgeon and 1 an OB/GYN) we are seeing 50-90 pts a day.
When I was originally asked what type of doc I am, I told them that I work in an Urgent Care. They translated this into calling me an Emergency Room Specialist (Urgence means ER in Africa). Therefore, I am called for all ER visits in between the clinic patients. I have seen patients with everything from Malaria to Traumatic Brain Injury.
Right after we arrived, a young gal around 12 years old fell out of a mango tree onto her head. She was brought in unconscious. When she arrived, her pupils were reactive but she had a lateral gaze (bad sign) and didn’t move arms or legs even to painful stimuli. It was heartbreaking to think that this young girl would probably not make it. Over the next several days and through the weekend she started to move, then open her eyes. She still wasn’t talking or eating. At each improvement we all (the entire staff) breathed a sign of relief. As of this morning she is walking, talking, answering questions and smiling. And to top it off, her name is Sarah (like my kiddo:-)) I give God all the glory, because by all counts, here in Africa, she really should not have made it.
Last week I had two young adults come in right after each other with hemiplegia. Neither had high blood pressure. I have not idea what could cause that here but guessed the both may have had a stroke. As the hospital right now has no anticoagulants, I ran home to grab some of my own aspirin. It was a gamble giving them aspirin without a CT scan, but I suspected they were more likely to have a clot in the brain than a bleed. When I came to check on them the following day, I found out that their families had taken both of them to Conakry (the capitol 5 hours away) where there is a CT scanner and a good Neurologist. I breathed a huge sign of relief. This is something I have not had available in Chad or Cameroon.
Overall this trip has been a wonderful experience. The people here are very nice. We have several wonderful families that have taken very good care of us. One beautiful lady (Deborah) has been feeding us great W. African food every night and taking care of all of our needs.
We are indeed very blessed. Please pray for the people who work here and the patients who come here for care. Although we are at the crossroads of the country, the medical care here is still very limited.
Monday is supposed to be the busiest day of the week as far as patients coming to be seen in the offices of the doctors. Today was definitely such a day. As we went in to worship, it seemed like no one was at worship so we waited. About 15 minutes after eight a nurse came by and said they needed us in the ER. That there had been an accident and many people had been injured in an accident when minibus hit a parked semi. Later we found out that the minibus had broken down and that the driver decided to have it towed by another vehicle. As they were being towed, the towing vehicle went around a parked semi that had broken down on the road and the minibus driver didn’t miss the semi. So he crashed with many people in his minibus. As we walked into the ER there were patients in all the beds and IVs were running and all was very still. That’s unnerving. Severely injured with brain injuries and the non-injured lay still. Others should be writhing around in pain. Apparently it had occurred about 6am. But none of the doctors had been called till now. The other surgeon also happened to go by then so he stopped to help figure things out. It seems like he does 80% of the work at the hospital when it’s only him and the GYN here. We don’t know what it’s like when the general practitioner is here, he’s on vacation. I quickly start glancing at each patient to try do decide who is most injured and most likely to have something fatal. Audrey zeros in on a kid who has blood all over his face and is still bleeding. He ends up being the most injured. They all have small cuts or abrasions and bruises as does the driver of the minibus. We each choose a patient and start taking their story of where they hurt and examining them head to toe, focusing on the areas that hurt or look deformed.
Bed 0- old woman had pain in her left hip and right wrist was deformed. Later x-rays showed she had a normal appearing pelvis and a right wrist radius fracture. So late in the day she was sent to have the OR crew reset her wrist and place a cast
Bed 1- middle age heavy woman had pain around her right eye with swelling at the temple, and a hole at her right elbow. Some pain at her right knee. I ordered x-rays of her face, elbow and knee. She refused all. But later in the day I took her to the OR to fix her elbow laceration and I was concerned about the olecranon being fractured so I opened the skin a little more so I could feel it well. Yes there was a fracture. So I washed it out well and closed the skin, and gave her antibiotics and then she agreed to an X-ray. With the views obtained I couldn’t see the fracture anyway.
Bed 2- a man who had a headache and had no apparent injuries other than a scrape on his shin. And a child with a forehead laceration that was small and superficial and didn’t need to be closed.
Bed 3- was the one Audrey chose who was a 5 year old that had blood all over his face. He cried out in pain whenever he was touched. I ended up taking him to the OR to close his facial lacerations, pull some glass out of his face and felt a small depressed skull fracture. Some of his skin was gone, but I closed what I could. Xrays of his head showed a slight depression in his skull. I admitted him and gave him antibiotics and dressing changes and antibiotic ointment for his face
There was also an old woman with him who complained of neck swelling. I got out my ultrasound and looked at her neck. It appeared her swelling was a thyroid goiter, but she was adamant it was new. So we just asked her to stay with the boy and I checked on her many hours later and she was unchanged and felt a bit better.
Bed 4- had a mom with three little kids. Two of them had small superficial lacerations on their heads. The third was more concerning. She was a little girl with a chubby face that mom said her chin hurt. She appeared to be drooling and crying. I felt around her neck and couldn’t feel anything wrong. I ordered an x-ray to see if her mandible was broken. Later I found it wasn’t. I rechecked the kid a few hours later and she was still about the same, crying and so I examined her further. Her two bottom teeth seemed stable, but now under the tongue I could see a bruise. Ohhh. So a sublingual hematoma is more important. I verified that the child wouldn’t breast feed and was still crying intermittently. I have no way to intubate here and airway protection was a concern. So I told the mom we should admit them here an watch her and if she got worse then we may need to operate on the child (which would be awful to try to evacuate a hematoma under the tongue and neck.) The mom said she wasn’t ok with that and would go home with the child. The nurse in the ER today was a very poor translator and all communication seemed to take forever. She was also very disorganized with the charts, so I knew that trying to reason with the mother was impossible so I just told her I wanted to keep the child and do what was best for her. I think they left.
Bed-5 was a 6months pregnant young woman with some arm pain. She later got an ultrasound that was normal and her arm X-ray was fine.
Bed 6- The driver of the minibus who had some small lacerations above his right eye, which the OR crew sewed up. Also another man standing by who wanted some pain medicine but was just bruised.
Bed 7-A 30 something guy who has a deformed wrist and broken wrist on x-ray and right chest pain without any deformity. So his arm was later aligned and casted by the OR crew.
I know Im missing some because we saw 13 people total in about an hour and a half.
Then I was off to do the suturing in the OR of the boy and the woman mentioned above. Audrey went to the office. I think between she and the other surgeon a total of 82, where she saw somewhere near half. It was blazing hot and humid today, supposedly about 92. HOT in an office with minimal ventilation and no AC.
One that I saw there was a boy of about 15 who had a lump on his outer lower leg for more than a year and has been growing. Then this past month grown much quicker. He was seen in the capital where a CT scan was done and he was told he needed surgery. The family was convinced by people of their village that it could be treated in the village so they took him home for their treatments. Now it’s bigger and painful. X-rays today show a tumor eating the bone- likely a cancer called osteosarcoma. Now he also has enlarged inguinal lymph nodes. So it’s spread. He needs chemotherapy and radiation and an amputation. So we sent him back to the big hospital he had seen before to be treated. Very sad that when you don’t know certain things – you can be easily convinced to do the most simple thing- more frequently wrong medically. Am I biased- yes. I believe in surgery and also in medical treatments that are supported by researched studies and not personal beliefs. I’m not interested in pushing anyones agenda or business. I just want the best for my patients and people I encounter.
After a busy day we got home about sundown, 7PM. It’s in the 80’s and we are still sweating. We are tired! Plan on a cold shower then hope to be able to sleep in the heat with a fan.
This weekend has been much more relaxed then our weekends in a long time and different than any time in Africa. As most of you know, we attend church on Saturdays. For Jews and us it’s Sabbath. The reason we worship God on that day is because it’s the day that God asked us to remember at creation and also the day Jesus observed. And as far as I can see in the Bible it was never changed. There is no seventh day church here that I could find or hear about so we spent our Sabbath reading and praying and resting mostly in our house with a short trip to the hospital to round, but I arrived a little late and the other surgeon had already seen the ones he wanted to see. So I turned around and came back to the guesthouse. We also listened to a lot of music, one of our favorites is the group Selah. They used to be missionaries as well.
Today, Sunday, Audrey and I decided to go in and check on a few patients. I would guess there are about 15 total in the hospital. There are two nurses at work today. It seemed very vacant, without anyone in the ER, waiting area, no one at the cashier or pharmacy, We walked around till we found the nurse then went to see the few patients we were worried about. After seeing them we went back to the guesthouse and changed into church clothes. Then we went to the Evangelical church that is a part of the hospital compound.
We sat near the back where there was space, but were shortly thereafter ushered to the front rows where a wall fan was moving some air. The song service started with the mic’s turned up really loud for the resonant space we were in. And we all started praising God. There was a drummer, a guitar player and harmony amongst the song leaders. And in some songs there was dancing before the Lord. Made me think of David in Psalms. They were enthusiastically praising God. We hadn’t heard any of the songs and the ones in French we understood, the ones in local languages or Congolese we couldn’t. I guess they have learned many Congolese songs. As I learned later by asking the song leader, he said that christianity began in Congo and so many of the christian songs are from there.
After song service the sermon was given by an elderly gentleman who was very energetic and explained he has been a christian 3 years. He used to be a witchdoctor and go to the forest to perform sacrifices. But Jesus transformed his heart and he became a follower of Jesus. He used to think he was someone important as a witchdoctor. Now he recognizes his position in relation to God and is serving Him with all his heart, mind and spirit. His talk was about the transforming power of Jesus in his life and in each of our lives. He spoke in French and we understood almost all of it. They had a song at the end of praising Jesus for what God had done in the presenters life. I really appreciated how joyfully they praised God.
My prayer: Lord God creator of the universe help the people of this area and nation know who You really are. Make Yourself known to those who are ready to hear about You. Bring people that are ready to hear about You to this hospital and help them to hear Your words spoken here. Help Audrey and I to share Your love God, with those we are with right now. God continue to fill us with Your love for those around us, that they may see You when they look at us! Amen
I had a restless night turning a lot as I touched the top and bottom of the bed. I’m sure that jetlag has a lot to do with my interrupted sleep. 8 hours difference should take about 8 days to get “normal” again. I awakened to my alarm at 6. I keep plenty of time for my personal time with God and then breakfast and whatever I want to get done before going go the hospital. At 8 I went into the hospital for their morning worship. After praying, singing and listening to the morning worship thought we went to check on one of the patients Audrey and I were concerned about. Not much change over night so at least not worse. (She may tell you about this patient later). I did rounds with the local missionary surgeon and we saw the patients he had then discharged the two SIGN nail femur fracture guys who were ready to go, even though they thought staying longer would be a good idea. We needed to have the beds freed up for our patients we were to operate on today.
After rounds we went to the OR for our first hernia. This guy had a small hernia by the African standards that I’m used to. He was first given a spinal anesthetic then we put on our sterile garb and prepped the patient with betadine. I assisted the other surgeon and he made an incision in the groin and separated the layers down to the hernia. It was a direct small hernia, meaning it came straight out and didn’t follow the testicular structures. This was repaired by sewing over the hernia with surrounding muscle and tissue (shouldice repair). Then those dissected layers were closed back together.
The next surgery was on a man with a moderate size hydrocele (fluid around the testicle making the scrotum look larger on one side. In his case about 3 times as large) The other surgeon was occupied so I did the surgery with the two scrub nurses. After I scrubbed my hands and arms and got myself gowned I prepped the patient with betadine after the nurse had shaved the surgical spot. I used electrocautery (a device that can cut or stop bleeding using electrical current) to incise the skin of the scrotum and go down to the fluid sac. Then I freed up the sack using my finger sliding around it. I opened it and drained the fluid out then removed most of the sac and reversed the remaining part and sewing it back and down into the scrotum again. Then sewed back up the cremasteric muscles (muscles that raise the testicle when cold) and closed the skin. Now I need to remember to treat him for shistosomiasis, a contaminated water disease that is a frequent cause of hydroceles in these parts.
Later in the day, as we were ready to leave, the ER nurse asked Dr. Audrey to see a patient. When I finished with a patient in the office that had a small rectal prolapse, I went to check on her and found her walking towards me. In the ER was an old guy who said he was peeing blood and was obviously hurting. So I thought it’s most likeluy a bladder cancer or a bladder stone. So I got out my butterfly ultrasound and attached it to my phone and then looked in his abdomen with the ultrasound. I found what looked like a huge irregular prostate and irregular stuff filling the bladder- blood. Cancer! He wanted immediately to try and go pee again. But as blood clots won’t come out the penis, he feels the need to constantly evacuate but can’t and the bladder stays full of blood and clots. I sent him to pay for a suprapubic catheter placement. It was 300,000 FG which was about $35. He went to the toilet and his brother and wife went to the cashier. I went and called the other surgeon to find out how to get the OR crew for this surgery. He called the person who has the key (the scrub nurse) and the anesthetist. Fortunately both were still here otherwise I guess we don’t do surgeries in the night or weekends- if I understand correctly. I guess the staff live in town 15km away. So the anesthetist the other surgeon and I took the patient in to the OR and as I didn’t want to wait for fluid loading and a spinal anesthetic, the patient got ketamine for the operation, which I later regretted. We prepped after collecting all the material we needed. Then opened the lower abdomen and went down to the bladder which was huge up to the belly button. We opened it and sucked out a lot of blood and clots, I’d say nearly a liter. I felt around and felt a huge prostate but no obvious cancer even though that’s what I had expected. We put in the large foley catheter put some sutures in the bladder to close up around the foley. It was quite hard as we were working in a small hole and the patient kept tightening his abdomen. We closed up the other layers on the way out, leaving a drain in place in case the bladder leaked. We wheeled him to a room and found his wife to take care of him. We told her when she could give him water and food and left an irrigation drip running, which she will pour bottled water in to throughout the night. I left to go home and the other surgeon went to fill out governmental paperwork from the days clinic patients. (Lots of redundant paperwork here)
At home Audrey met me with the good news that the person who is cooking for us while we are in the hospital, had made spaghetti without our prompting. Spaghetti is our family Friday night tradition, since living in Cameroon. We were both pleased!
