MissionDocs.org

#175 Shanksteps

I first saw her in clinic.  Her nomadic, bright colored attire, hid her frame.  She said her stomach had been growing.  I asked how long, and the response was 10 years.  Hernia? Cancer? Baby? (the time frames I am given often do not apply to the current episode of things happening, but may be an accumulation of events that the patient relates together).  I examine her and fine a huge abdominal mass that seems to be little mobile, maybe 10X10X13 inches.  I did an ultrasound.  It appeared solid and cystic (little fluid pockets). Likely a cancer.

She took the “standard” bowel preparation the day before yesterday.  She took it all and had NO stool.  So she did it again yesterday with even more bisocodyl. Finally she had a lot of diarrhea and cleaned out.

She lies there with cachectic arms and legs, with a VERY protuberant abdomen.  Lying on the operating room table, she takes up a small portion of its 1.5 feet width.  She looks embarrassed as we uncover her to start the preparations for surgery. We administer Valium, atropine and Ketamine; prepare her abdomen with betadine, and lay on all the cloth drapes.  She has NO fat on her body.  So once I’ve cut through the skin I’m nearly inside.  Usually when I’m working on a belly this protuberant I’m apprehensive because I’m wondering if the baby is going to be OK.  Now I’m apprehensive because I don’t know exactly what I will find.  Where it will be coming from and if I’ll be able to take it out.  I see intestine stuck to the surface.  Huge vessels feed the mess.  I feel below it and don’t feel a free spot, neither on the sides and top.  So I slowly start freeing the intestines from its surface.  There is oozing everywhere.  We give her Vitamin K in hopes that she might be low in Vit K and that this would then help.  It doesn’t seem to.  I control the bleeding with some sutures.  We continue the slow work.  Freeing up here and there around the sides of it.  Now I’m behind the large intestine and behind the stomach.  The pancreas is in view, it’s rather stuck to the cancer.  I realize that all the large vessels that feed the intestines are within this cancer.  It is impossible to remove.  So we decide to close.  The nurse giving the anesthesia recommends that I call a family member into the operating room to see what we have found and to explain why we cant take it out.  I call in an uncle that is a person I recognize as having seen before.  The nurse puts a mask on him and a cap and he comes in the door.  The nurse stands behind him to assure that if he passes out he doesn’t hit the floor.  He takes it all in without emotion.  Thanks us for trying, and states it is God’s will.  Though I desperately disagree with the last statement,  I say thank you and he leaves.  We close up the abdomen and take her back to her room to wake up.  I instruct the nurse to get vital signs on her every hour for four hours, knowing it will only happen if he has nothing else to do. G

An older woman sits in front of me in clinic, her husband on the chair beside her.  She says that something is coming out below when she walks, and has ever since she had her last baby a few years ago.  I examine her and find it’s her uterus coming out

Another young man is having rectal bleeding for the past few weeks.

A third had an accident on his motorcycle a couple days ago.  The huge swelling on the side of his face is improving.   He arrived unconscious and now is thinking clearly.  He says that one tooth doesn’t seem to be in place.  I examine him closely, and find that he has a mandibular (jaw bone) fracture right before his last molar.

These are the surgeries for today.  The older woman took her bowel prep which consisted of a bowel stimulant (Bisocodyl) and water. She is placed on the operating room table.  The preparations are made and I put on my cloth operating gown.  It’s cut real small for my long arms, and when it get’s wet with blood or other fluid, I’m wet with it too.  I help Dr. Solomon put his on, as I’m particular about sterility even though others don’t seem to see the necessity of all that I do.  This is probably the cleanest she’s been in 60 years of life.

I open her lower abdomen.  She has essentially no fat!  I open the skin down to fascia in one fell swoop.  Cautiously enter the fascia and peritoneum.  I search her pelvis for the uterus.  I grasp it between my fingers and pull it into the wound. It has been prolapsing so far that it comes up easily.  It turns out to be one of the easiest hysterectomies I’ve done.   I didn’t bring large enough suture to do hysterectomies so use a smaller than normal one.  For her tissues it turns out fine.

The next was the young man for a colonoscopy.  I finally find the colonoscope again and all the things that go with it. I look inside and find a very inflamed intestine.  Colitis.

The 30 year old guy with the mandibular fracture is next.  I take him to the OR but cannot find the materials I need. I need arch bars (metal bars for the teeth) and wire to attach them to his teeth.  I need to wire his mouth shut for two months to let things heal.  After opening a number of sterilized packs, I finally find the one that has the right equipment in it.  I wire the arch bars to his teeth then, the arch bars together.  I find that I cannot include his last tooth so the fracture is still loose.  At the end I realize I will still need to wire his bone itself together as I don’t have any metal plates to put on it.  I’ll wait till the swelling goes down then attempt to finish.

I return to the clinic to finish seeing the patients that have been waiting for hours.  See more malaria, typhoid, pneumonia, and another malnourished kid who is 2 and weights about 14 pounds.  I head home to a meal of millet paste and sauce (my actual favorite here).  G

It is Saturday, Christmas Eve, and I was at church. I’m called out in the middle of it to see a patient that was in a moto accident. One of the health center workers was riding at a “slow speed” and hit a rock and fell over. He lay in the dirty suture and dressing change room moaning. I asked Bouba, the nurse to find a stethoscope. I had forgotten mine in the US. He ran to the ER and came back with one. The man complained of his shoulder only. I listened to his lungs checking for a pneumothroax that could kill him, and they sounded normal. So I examined the rest of him. I only found a broken clavicle. I put him in a figure-8 dressing to help put this in place. I checked on a couple others lab results then headed back to church. Right at the end of church they called me again.

There were three that had been on a moto. Two men and a teen girl. The girl had a fractured wrist, one man had a fractured wrist and a hematoma on his head. The third man had a fractured wrist, broken femur (upper leg bone) and a ankle fracture. They were laying in their hospital beds moaning. After checking each one out I asked whether they wanted to be treated here or by the traditional bone setter. Two wanted to leave and the one with multiple fractures wanted to be treated here. I have always had to fight with them before, so I knew what was coming. I decided since they were adults they could choose badly for themselves, and besides, though I have shamed many people in the past for not doing what the doctor ( me) wanted, they still wouldn’t let me do it. So when these decided to not do it, I wasn’t surprised. It ended up after the x-rays that even the lawan (the local low level chief of a certain area of the village) with three fractures, he decided not to do it either. So I left and went home.

We prepared a special evening meal. In the late afternoon our friends from Chad arrived on a surprise visit. And the power went out. So we filled up every available pot, jug, and glass with water before it ran out in the water tower. We had a wonderful candlelit meal. It consisted of home made everything; gluten, beef stew, stuffing, green beans, salad, potatoes with margarine, rice. Later we opened the few gifts we had brought for our guests and the student missionary here, while sitting in front of our decorated tree branch that we cut from a tree. Decorated with toilet paper streamers, paper figures, and cutouts from a magazine. We had a great time. We think we appreciate a simple Christmas, as theses have been our favorite. G

I sit against the operating room wall holding a small baby in my lap. He is wrapped in a dirty blue towel that has amniotic fluid and meconium all over it. He had come out of the cesearean section that I just performed with a big cry and apparently breathing well at the beginning. I was doing a surgery on a woman with a small pelvis that had been in labor for three days before making it to the hospital in the evening. I had done the same girls previous surgery a couple years ago. She says that her girl is still living. She wanted to have her tubes tied after this surgery. Her husband agreed. As we finished up the surgery, Yaouke was suctioning the baby, Dr. Solomon and I were closing the uterus, and abdomen. Yaouke said the baby wasn’t breathing well. At the end I checked the baby. If a black baby can be blue this one was, or at least his lips were! I put oxygen on him. He had small grunting sounds. I sat there against the operating room wall will the nurses cleaned the room. As I sit there I cradle this new life in my arms. I try to wipe meconium off my finger by wiping it on a “clean” area of the towel. I place the oxygen monitor on the baby’s finger. The whole hand fits inside, but eventually I get a reading. When the baby wiggles around and the oxygen comes off his nose, his saturation drops to 77% (normal >92). He desperately needs the oxygen. The next thought that runs through my mind is how long should I sit here holding the baby. As we have been back here it is easy to fall back into my previous roll and concerns. Again, how long will I sit here taking care of this baby. It’s a little different this time because I only have to have enough energy for two more weeks, not a year. So I sit there longer. After about an hour there seems to be no change and everyone is done with their cleaning and other tasks and ready to head home, 10PM.

I take the baby to the nurses sleeping room, office. I set up the oxygen concentrator, monitor, and voltage converter to keep all running. The nurse finds a padded foot of the bed to move into place on the floor. I place the baby on it and tape the monitor to his foot that is moving constantly. It seems to pick up his vessels and oxygen concentration. Tape the oxygen cannula to his face and cover him with all the cloth the family was able to come up with. A couple small pieces. I watch the pile on the floor move a few minutes and everything seems to be working.

I check on the 17 year old girl that had a bad motorcycle accident. She arrived unconscious and on palpating her head I felt she had a depressed skull fracture. I had rushed her to surgery yesterday afternoon. I explored her scalp. There was a large hemotoma (blood collection), but no apparent skull fracture. I closed up my incision. I talk to the family who is sleeping on the mats beside her bed. They say she has not moved or done anything since surgery. I uncover her from the large blanket that is on her and she feels hot. She’s about the age of Sarah, and I worry about her, knowing I can do nothing more. We get a glass thermometer and check her temperature, its equivalent to 104.5 deg F. Is she having malaria, or a central (brain) fever? Well I can treat malaria and not the other, so I treat malaria, and give her IV asparin to help bring down her fever. IV asparin is the only med here to give for fevers.

I check on the small pile of fabric in the nurses room. It’s still moving with the baby boy inside. The oxygen numbers seem OK, so I head out to the ER, on the way home. There I am stopped by a nurse who just brought a pale baby to the the ER from the pediatric ward for oxygen. A hematocrit (blood count) has been ordered since 2PM but not done. I ask them to call the lab tech and get it. Then to verify the blood of the mother who is present to give it to her baby. They are instructed to call me if there is no match as I am O+ and can give to most people. I head home.

…

I am thanking God! HE protected the child through the night and the kid had breast fed a couple times before I saw him. Mom is complaining of pain, but then again why not, I forgot to write our strongest pain medicine, Ibuprophen! The mom is laying in her bed on her back. She is covered by panye (colorful cloth) from the waist down, the top bear with the baby attached to her right breast. She is smiling because her baby is alive. This one moment makes my hours last night worth ALL of it!