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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