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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!!!!