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“Could one of you come and see this child?” Jacques asked Audrey and I. The child was breathing fast and was very pale. He is 7 months old, 6kg (about 13lbs), and has a huge anterior fontanelle which is very sunken in (a sign of severe dehydration). His hematocrit was 6% (normal 45%). He had just vomited blood-tinged fluid. As they placed an IV in his arm he did not move or cry. He had pneumonia from all the vomiting and aspiration of the stomach contents, giving him low oxygen. He needed oxygen!

Six days ago the workers emptied the water tank to patch and paint it. They scraped the insides, patched the holes with a tar compound, welded a few spots and then repainted it. This took about 4 days to complete. The fourth day the electricity went out. So we have been “functioning” without water in the hospital for many days now and with no electricity. Two days ago I wanted to do a hysterectomy on a woman that needed it and when we tried to start the large generator the batteries were dead. So without power I decided to put off the surgery till we have power again, and when my OR schedule is open, 3 weeks. So with all this we are out of power when this child is in need of oxygen.

We have started the small generator of the lab and decide to transport the patient into the lab waiting room so that we can use the electricity there to run an oxygen concentrator (there is no bottled oxygen here). After placing a bed in the waiting room and hooking him up he breaths slightly better but needs blood. The mother is the same blood group so she gives to her child. The day passes and it is time to turn off the generator for the lab. The child has received the blood but is still very hypoxic (low oxygen) without the oxygen. Should I run the generator over the weekend for him? How long will he need oxygen? Will the oxygen actually help him survive, or will he die anyway? Should I tell the family that since the generator is running only for their child they would have to pay for gas? If I say this will they refuse treatment? I ask Aud what she thinks. We decide to keep the generator going and not talk to the family about gas for fear that they will refuse treatment.

At midnight I am called because the generator is stopping every 45 minutes. Apparently it is plugging up with gunk in the lines and for air vacuum in the tank. Baya, the nurse who is in the ER, is somewhat mechanical. So I offer tools and ask him to try to fix it. I don’t get called for the rest of the night.

It is Sabbath (Saturday), I plan on sleeping in. I wake up at 7AM to the sound of chickens and immediately think of the child. I can’t sleep any longer because I continue to think of him. I get up and head into the hospital. He is still alive! I have prayed for him a number of times through the evening and night. I am thankful God has spared his life. The generator worked all night after Baya tried a few things. I take him off oxygen and his oxygen stays above 92%. I transfer him to the ward. Our chaplain, papa Sidi, has just prayed for him again.

I see another girl that is 16 with severe headache and neck pain overnight. I do a lumbar tap (take spinal fluid) to evaluate for meningitis; I also treat her for cerebral malaria.

I leave the hospital hopeful for the child who has survived the night. Greg

My frustration know no end as I write this addendum. It is Saturday evening. The nurse on today did not observe my patient well. He calls me when the child is really dypnec (short of breath). They put him back on oxygen to late. He died.

Diagnostic dilemmas are constant here. This comes from the fact that to diagnose different diseases there are a limited number of tests available, and even those are made more limited by patients refusing to do the ones we desire. Most often they want tablets but not tests. The Nigerian patients that come here want both. They are a select few who have some money, are unsatisfied with their own medical system and come here because there is a foreign doctor. They frequently request ultrasound and x-rays because they feel that that is where their pain (“worry” as they describe it in Pidgin English) will be diagnosed. They often want to see where the wound is that hurts them inside.

So an old, very thin (likely between 80 and 90 lbs) sees me in the office. She is deaf and mute. Her son talks to her with gestures, which make no sense to me at all. He somehow has deduced that she has pain in her chest. He says that she has had this for about three months. She has not had a cough but just pain. I listen to her chest and hear breath sounds on the left but very muffled ones on the right. I tap and hear a dull sound, she is full of fluid. I request an x-ray, and they agree and go to pay the $7 to get it. She is lucky because this day we happen to have electricity. It has been out every day for 1-10 hours for the past 5 days. The chest shows a complete white out on one side. I do a tap with a needle and find dark yellow fluid that the lab says has some gram + cocci in it. Infection? Contamination of specimen? It is unclear. But the fluid needs to be drained.

When I first arrived at Koza there were no chest tubes here and I used a urine catheter for my first one. Today we have two sizes so the student missionary and I select the smaller size and numb up the area of insertion. We prep her side and hold her hands out of the way as she is contaminating the field demonstrating where her pain is again. Her son and another nurse hold her arms. We put the tube into her chest and get 1300ml of fluid. She coughs and appears worse for a little while. Maybe I should have let off the fluid a little more slowly.

Over the next few days she drains about 800ml a day. She is getting thinner by loosing all the protein every day in the fluid. Or I assume that’s what’s happening. So if I take out the tube all the fluid will reaccumulate and I don’t have anything for plurodesis (making the lung inflamed and stick to the chest wall, effectively stopping the fluid collection). So eventually I talk out the tube. She reaccumulates the fluid and I let her go home. I’ve treated her with broad spectrum of antibiotics; we are currently out of TB medications. The government supplies these for free but when we ordered them they said they had run out in the far north. So free TB meds doesn’t help when there are none. And since they are free none can be bought either, because there is no black market desire for them. So she reaccumulates her fluid and goes home in a day or two. Another dilemma unsolved.

The same thing happens in the room next to hers. There is a man with huge ascites. I drained off about 15 liters the other day. He had a tense belly for a month. I drained a lot off and he lost 9kg with the fluid extraction. His abdomen was large but then not tense. The peritoneal tap showed no bacteria. I treated him for schistosomiasis, TB, abd peritonitis, other worms, and a loop diuretic (water pill). He does not appear to be improving either. Is it cirrhosis from his long time millet wine usage? Possibly, but I can’t treat that other than, encouraging him not to drink. So another dilemma unsolved. I know these same dilemmas can happen in the US, but it is so much more frequent here. This is the frustrating reality of third world medicine. Greg

It is Friday evening near sundown.  Maliki comes to my door to have me come see a 13 year old boy.  He says the boy may have meningitis, but is not sure and having bizarre reactions.  He has borrowed the motorcycle of the man who brought in the boy so I hop on the back and we head into the hospital.  Nearing the hospital he has difficulty slowing down as he finds out he breaks are not working well.

I walk into the ER and see an old woman holding the abdomen and back of the boy.  I ask Ibrahim (the boy) what is bothering him. He says that for two days now he has had sudden pain in his abdomen that then goes to his back.  Or it grabs his throat as if choking him.  As I am talking to him he cries out and grabs his throat with two hands.  About ten seconds later he appears fine.  I ask him about taking any drugs, or stuff others gave him, he hasn’t.  An uncle says that the day before this started he had a homosexual experience with another boy his age. The nurse starts making a clicking noise (surprise).  I remind the nurse to be professional, and that he should not display any reaction to things the patients tell us, whether we are surprised or not.  I give the boy water to drink and he gulps it down without problem.  I think of tetanus, rabies, meningitis, cerebral malaria, syphilis, and demon possession.  Doubt the last is on your differential in the USA, though maybe it should be!  Papa Sidi (our Chaplain) happens by and I ask him to pray with me for the boy.  The boy says he is Muslim and believes in Allah.  I tell him to trust in Allah and we are going to pray to God for help and healing.  The two of us, the nurse and student gather around the boy and we pray. Pray for healing and protection for this boy.  I look for some medications in the pharmacy to start his treatment for some of my differential diagnosis.  When I come back the boy is crying out and naming the names of sorcerers that he says are choking him.   The family decides that this must be his real problem.  They take him home to find a more powerful sorcerer to help him. I pray that God will protect him and that God’s name be glorified rather than a sorcerers.  Please pray for Ibrahim.
Trying to follow Him, Greg

#156 Shanksteps

Wednesday it was unbearably hot.  It was 113deg F in the shade as it has been but then it felt much hotter.  We had finished work and had gone home.  About 5 PM the wind kicked up.  It started really gusting.  Dust was thick in the air and we could not see across the soccer field in front of our house.  Even out to our own gate it was difficult to see.  We rapidly closed all the windows.  The power went out.  Wind with the power going out is usually a bad sign, it usually means that the power lines and poles are down somewhere between Mokolo and Koza.  This means that it will be many days before we get our power back.  It in fact is still out!  No power means no autoclave, no X-ray, even when our generator works.  It also means no water!

So the wind is howling and dust is in the air.  Then it starts to rain.  We usually get one solitary rain in April then it waits till June to start the rainy season.  The wind is whipping trees back and forth.  Branches are falling all around.  The tin roof over our truck is now loose on one side and waiving wildly in the wind.  Hail starts to fall all around.  On the tin roof of the house it gives a deafening sound.  Water starts to drip though our ceiling at different places.  Some the same as last year, others different.  I try to catch some in buckets, moving things out of the way.  The rain pelts the ground for about half an hour. A small river is flowing through our yard and leaving under the gate, and through the chain-linked fence. After the rain we hear chopping. There are many downed branches and people are running from all over to claim a down limb and start chopping on it.  I guess after it is downed it is not considered stealing, but only when it is still up on the tree. So I decided to go to the hospital and see the damage.  After walking out of my house I see our power lines are going down to the ground. A large tree branch has fallen on them and the bear wires are pulled down to the ground.  Further on I see a large power pole down.  A building behind my house had half of its tin room blown off.  On other hospital buildings there are tin pieces pointing to the sky or gone.   Workers saunter by telling how either their house or neighbor’s houses had lost their roofs during the storm.  Some houses even fell down with the rain and wind.  I ask how the patients did, and everyone is fine.  The nurse was just getting ready to call me when the storm began, so he asks me to see two patients in the ER.
To the right as I walk in is an 11yo boy laying on his back very still. His left leg is shorter than his right and pointed off at an oblique angle.  I can immediately see a large gash on his left knee going around to the back of his leg more then 10inches long.  His right foot has a huge gash that has separated the skin of the sole of his foot from the foot itself in a huge flap connected at the heal.  He appeared as if he was in significant pain but didn’t make a sound until I examined the leg that was pointing off to the side.   He had a femur fracture too.  The uncle who brought this boy into the hospital said that the two were playing on a rock when it rolled and crushed their legs beneath it.
To the left was a 10 yo boy laying on his side moaning.  His foot was wrapped in a cloth.  As I unwrap the cloth his toes and sole of his foot hang, detached from the rest of the foot that is left.   A metatarsal (midfoot bone) sticks straight out from the top of his foot, as does the bone going to the smallest toe on the same foot.
Both the boys need to go to the operating room.  I send someone to call Ganava and Jacques.  I return home and change cloths and head back with the medical students currently here.  Ganava is not in town and Jacques is late in coming.  The students and I set up the two in different OR rooms and we start cleaning the injuries.  Since there is no electricity, and the generator will not start, we work by headlamp.  First each gets an IV, Valium, Ketamine, antibiotics.  Then the scrubbing begins.  One med student on each child and myself and another giving meds, going back and forth between each room.  Jacques arrives and helps Travis on the child with a femur fracture and large lacerations.  I help in the other room where Elisa is cleaning, Kalaza, the boy with the badly crushed foot. We complete the amputation about mid foot.  Taking off the bones that are sticking out.  In the other room the huge lacerations are closed with drains.  I then go back in there and place a pin in his tibia (lower leg bone) to put him in Perkins traction for his femur fracture. Both boys are taken to the pediatric ward and the bed adjusted to accommodate traction.  Meaning, bricks put under the foot of the bed, weights placed with a string to the tibial pin, and the framework holding up the mattress let down so the leg is flexed at the knee.  We head home in the darkness, watching intently for scorpions.  It is their season now and I don’t want to experience one again.
It’s about 9:30PM and the temperature has cooled off to about 97degF.  It makes for difficult sleeping conditions. I shower, don’t dry off, and drip my way to bed.  I lay trying to not have any part of my body touch another part.  I drift to sleep before drying.  I awake a couple of hours later drenched in sweat and repeat the shower process to sleep again.  It makes me very thankful for electricity and water when they do come back.  We are now five days after the power has gone out and still no sign of the electric repairmen.  We are praying for repairmen.  Greg