Bere 5/2025 #6

administrator Greg No Comments

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!!!!

Bere 5/2025 #5

administrator Greg No Comments

Bere 5/2025 #5

Long night

I was told about 10 PM that the ambulance was gonna go out tonight to get a patient from Lai. At about 1130 I was called to see a patient that had intestines hanging out. I came into the ER and that’s exactly what I found. A 50-year-old guy with intestines hanging out his left side. Both large intestine and small intestine and a whole bunch of poop. He had been stabbed with a cow horn. There seemed to be no further history than that. He said that he did not hurt anywhere else.  So I called Phillipe the anesthetists and we went to the operating room. The ER Nurse had started two IVs, and then had put some Dakins solution over the exposed intestines that had poop all over them. After the patient was in the operating room, I tried to call my nephew Zack a number of times and he didn’t pick up. So I went to his house and beat on the door. Apparently he was fast asleep. So I shown my light in the window and beat on the window and eventually he woke up. He came to help me with the operation. In the operating room, the 50 year old man was intubated by Phillipe and then I prepped the abdomen and prepped all the intestines with Betadine and tried to wipe all the poop off of them. The size of the intestines and omentum that were out of the abdominal wall were approximately 8 x 10 inches in size.  He was hypotensive from the start. His heart rate was good, but his blood pressure was low and he’s been in septic shock ever since.

I take a scalpel and open the skin along the midline lower abdomen.  Through skin, fat to the fascia.  Then into the abdomen. I get a fair amount of blood and suction what I can and the rest spills from the patient down the sides of the table.  With in a short while I feel his blood has seeped through my cloth gown and through my scrubs to my skin. Yuck. The intestine has been stuck outside since this occurred at 5PM (I found out later) and I’m operating at midnight.  So the intestines that are stuck out are a bit purple and hard to get back inside.  After I work them back in through the hole they start to pink up and look as normal as the traumatized intestines can.  As I look around I find that there are two places the small intestine has been torn in two and there is a section of transverse colon that is devitalized (dead) because the mesentery was ripped off it.  So I take out the small part of intestine between the two torn pieces of small intestine and tie off the mesenteric vessels.  Then I do a single layer hand sewn anastomosis.  This is a series of small sutures about 1mm apart that reconnect the intestine back together all the way around the opening.  After about 45 minutes Im done with this one and work on the large piece of intestine that is devitalized.  I cut out the dead piece then re-anastomos it the same way.  There is still bleeding coming from somewhere.  So I feel up for the spleen- it’s lacerated too.  I open the skin all the way up to the sternum.  Now I can see the upper abdomen better and there is a cross shaped spleen laceration over the whole surface that is bleeding some.  As I inspect further, I see there are two holes in the diaphragm.  One laterally is about 10 cm and one right in the center of the left hemidiaphragm is about 2 cm.  I stick my finger through and feel lung.  So I get better exposure and suture up the diaphragm.  The patient keeps moving because he is only getting Ketamine as his anesthetic as the anesthetist didn’t think his BP was tolerating the isoflurane inhalation anesthetic.  So the patient would start tightening his abdomen like a sit-up and I’d have to ask him to give more.  This took a while.  After that I put a chest tube in to re-inflate the lung.  Surgery had been going on about 5 hours now and I verified there wasn’t any additional bleeding.  Again I washed out the whole abdomen with a lot of fluids. (The solution to pollution is dilution- so diluting out all the poop and bacteria in the abdomen ).  I closed the fascia and then skin loosely.  I went to the old OR to get one of the pleuravacs (container that attaches to chest tube) I just brought.  I plugged it up and then started my paperwork as he was extubated and taken to the recovery room.  About 5:30AM.  I did my paperwork and did one of the most lengthy notes here.  In case anyone else has to re-operate on him.  As I go out to the recovery room, I see Phillipe bagging the patient.  Oxygen saturation is in the 40%.  He hasn’t called me to tell me there was a problem.  How frustrating!!!  So I take over bagging and the patient is posturing decerebrate.  This is usually a sign of brain damage.  Finally I think the Holy Spirit prompted me to give Valium.  So we give that and the posturing stops and he relaxes.  Slowly the oxygen level rises.  If he wasn’t brain injured before I suspect he will be now.  I pray for him and ask for Gods healing and command the devil to leave him alone, this is Gods hospital and we are Gods people.  The devil has no right to harass him.

I stay for an hour, then decide to go back to the room while Phillipe stays at the bedside.  I eat some breakfast of toast with PB and mango sauce.  I shower then go back in.  Phillipe has started an Epinephrine drip.  As the day goes on I adjust that drip to try and keep his pressure up to the 80’s.  I go through my day of operations checking on him between cases.  I also see come of the consultations.  At about 4:30 Im crashing hard.  So I’ve finished the last surgery and go back to my room to drink a cold electrolyte drink and then go to Meghans house with Zach to eat.  I go home and lay on the floor in front of the fan- and I’m out.  I awake after 3 hours having missed calls from Dr. Andrew and texts.

I go in to check on the patient again and Dr. Andrew has been at the bedside for hours and they’ve set up and “ICU” with oxygen, a monitor and a norepinephrine drip.  I relieve him so he can go home and sit at the bedside till 9PM when the night nurse comes on.  I tell her about the drip (things they have never seen), and to leave the rate alone.  As well as all the nursing students.  Sure wish I had an expat ICU nurse with me tonight!  But I know I’ve done all I can do for this man.  And to be functional I need to sleep. I feel like I’m wound down enough to sleep again. 

I’m not called all night so I sleep fairly well.  I check on him at about 6AM when I awake and he has made it through the night.

God heal this man!  Show Your power and love to him.  Be glorified God by what you do in this hospital.  Help us to recognize all that You are doing here.  Give me wisdom and strength for today.  Amen.

Bere 5/2025. #4

administrator Greg No Comments

Bere 5/2025  #4

I slept through the night- yay!  The missionaries here are amazing!  So much to do, so often little sleep.  Dr. Andrew was up 5-6 hours last night with a child who was dying.  So sad and so many advanced diseases.  I think I say that every time I’m here.  It’s always very hard and very good to be back.  All the missionaries here are amazing and have such a heart for God.  They are wonderful people to hang out with.

I went to morning worship at 7 then found out there were no meetings after that.  So I thought of starting rounds or operations right away.  Well no nurse on surgical ward, and no one except patients sitting around with IVs in their arms in the OR.  So I go wandering around looking for workers.  I found the anesthetist chatting with a surgical patient.  I told him I was ready when he was, so he headed to the OR.  Since it is the hot season most of the patients and families spend their days outside.  They have to be collected from out under the trees, to come inside to round.  So after about 15 minutes I was able to go to the OR and start a surgery.  

The first guy had what was suppose to be a hernia and possibly a hydrocele.  After his spinal I thought it was likely a hydrocele.  But in palpation I got the sense of a hernia too.  So after we prepped him and put the cloth drapes on- I made an incision for a hernia figuring if it were a hydrocele (fluid around the testicle) that I would just extend down to it on the scrotum.  I did the usual exposure down to the fibrous layer and then opened it.  Still couldn’t reduce anything.  Eventually I got a little to go back in.  But the scrotum was still at least grapefruit sized on one side.  I finally opened the sack and found what appeared to be omentum (fat) as well as intestine.  The omentum was stuck to the sack.  So I tied and cut through the omentum.  Then the area I was unsure of, the area that could be intestine still wasn’t clear.  So I slowly dissected it.  After a bit of work it was more omentum that was encapsulated, weird.  So I took off the hernia sack and repaired the hernia with a mesh patch.  It’s the first mesh I’ve ever used here.  I’ve always been worried about infection.  But they have been using mesh lately and said they’ve not had many hernia wound infections.  At least there was an indicator in the pack that showed this pack was sterile!  The rest of that surgery went smoothly.

I saw a patient or two in the consultation room, which is now in a separate building, while I waited for the next patient to be made ready for the operation.  The next was a guy with two suspected liver abscesses.  As I ultrasound his scaphoid (concave) abdomen, I find a smaller superficial abscess and a larger deep abscess.  I numbed up his abdomen and put a needle catheter into the more shallow one and pulled out 30 ml of thick pus that slowly rolled into the syringe.  I couldn’t reach the deeper one and didn’t want to use a sharp spinal needle to do it.  Fortunately my hospital had a few pigtail catheters that were post dates that I brought.  So I stabbed one of those into his liver and into the second deeper one.  I drew about 50 ml pus out of that one and left this drain in that one.  Did the pigtail and also sutured it into place.  

The 60 year old man had bilateral hydroceles,  one medium hydrocele and a large hydrocele on the other side.  This fluid around the testicle I think is related to the shistosomiasis here.  A disease you can get from being in the rivers or a lake.  The solution is to dissect out the sack, resect the excess and evert it over the testicle and cord.  As I dissected out the side where Zach was standing it suddenly burst splashing testicular fluid all over his front and his shoe.  He was a trooper and took it and kept working.  The larger side had I bet about 800ml of fluid in it.  Quite large.  I resected both sacks and everted them and then sutured the testicle back to the base of the scrotum and closed the skin.

I saw a consult or two and then Dr Andrew said he had another surgery for me.  One I hadn’t seen before but they’ve done here a few times.  A hippo bite.  I understand that Hippos can be very territorial and you don’t want to get near one in the water nor on land.   They are large but can run almost twice as fast as a human (unless you’re Husain Bolt).  This teen boy was bitten in the leg.  He had a gash at his knee, a number of smaller punctures and a gash on his calf.  He got a spinal then we prepped his leg with betadine after washing it with soap and water.  So between the river water and the hippo mouth, I’m sure there are plenty of bacteria in the wound!  I loosely closed it, intentionally leaving space between each suture for pus to come out if it were to get overtly infected.

This evening I had a wonderful conversation with a missionary who has been helping people become free from devil harassment and oppression.

God please continue to guide them and Lord, use me in any way you want to, to advance Your kingdom!  I want Gods will do be done on this earth as it is in heaven.  (i.e.- Gods will isn’t being done on earth- His will, was the garden of eden…) See. Genesis Chapter 1 and 2.

Bere 5/2025 # 3

administrator Uncatergorized No Comments

Bere 5/2025 #3

Ohhh power just went out as I start to write and get ready for bed.  I certainly hope they figure it out or me sleeping without a fan will be very difficult!!  Today was my second day of operating.

I woke up early and did the things of the last post.  At 7AM I went to morning worship and then soon there after the power went out.  I knew there was suppose to be a woman with a large thyroid to operate on this morning and that would take a while.  There were some texts going back and forth about what was happening with the generator so I went to try and find out.  I found a number of guys I don’t know.  I guess they were newer than when I was here last year.  One was the mechanic, who can fix about anything.  At least he listed off a bunch of things.  He told me that the generator stopped because the voltage was zero in the battery.  He shows me a panel.  It has numbers and digital readouts.  So I know it wasn’t zero!  He showed me where the panel said 0V, but it was under the heading generator.  So the generator was off- thus zero volts.  I asked him for a electrical multimeter.  He said they were bringing it.  I was around there another 15 minutes with lots of discussion.  Finally they purged the diesel system of air and got a car battery and started the motor.  It ran fine .  Then they changed back to the “old” battery while it was running, putting the other battery back into the car.  

I was suppose to round and the other surgeons operate.  Then the first surgery, a large thyroid goiter was hypertensive.  So the other surgeons cancelled her.  So I was up for removing a young girls bladder stone.  Phillipe the anesthetist put the patient to sleep with propofol and some inhalation isoflurane and bagged her with a mask.  Her sat dropped temporarily then back up.  I scrubbed and we prepped the skin and put on the cloth drapes.  The nurse David had filled the bladder so it was near the umbilicus and then as I go in I will get into bladder and not intestines.  She’s about an 11 year old girl so she’s quite petite.  I cut through the skin low in the abdomen.  Split the muscles and identify the bladder.  She desaturates again, low this time, 40’s. Phillipe doesn’t have suction ready and he takes a bit to get it together.  Im trying to let the anesthetist do his job but Im about to scrub out to help him when it starts slowly improving.  I have a nursing student call in Dr. Andrew to assist.  He’s doing consultations.  The oxygen saturation is pretty good when he arrives.  So I continue the operation.  Andrew leaves and shortly thereafter the power goes out.  I always wear a headlamp so I’m the only one in the room with light.  I immediately worry will the patient desaturate and die for lack of the oxygen machine and anesthesia machine?  I try to hurry up as I just ready to retrieve the bladder stone.  I get it out and it’s about the size of filbert nut.  The patient slowly starts to desaturate.  I try to work as quick as possible.  About the time she’s in the 80’s for saturation the power comes back on and she slowly climbs back up to normal in the mid 90’s.  Wow that was stressful surgery.  So many things out of my control and many can kill or make a bad outcome.  

I go to see what’s happening in the other OR.  I find a nurse doing a hernia repair with a nursing student.  No one doing anesthesia.  I asked him where is his anesthetist?  Well he had done the spinal then started the operation.  I told him I thought that was very unsafe, decided not to make further comments and tell the missionaries that are here. That way they can address it if they wish.  It is quite different being in charge of a hospital like I was in Cameroon, vs visiting and trying to asses how to help without ruffling feathers.

The next one was a young girl of about 12 who had a broken leg about 3 years before and keeps getting infections in her skin.  She has some right hip pain as well.  So she had had an X-ray so I went to look at it.  It shows and involucrum (a thickened irregular bone associated with boney infection) and likely a sequestrum- a piece of dead bone that is an infection source.  The other doctors think this is the source of her various infections around her body.  I have no other explanation and this definitely looks like it’s a likely source.  In the operating room I open the outside of her hip bone and eat away at the soft bone down to the marrow.  But the infection seems to have been replaced with normal marrow and not full of pus like is usually the case.  So I wonder if I have missed the part with pus inside.  So I open the skin down to the bone quite a bit lower on the femur.  Here the bone is hard and normal and I can’t even make a window into it by trying to nibble away at it.  I ask for the nurse to search for another missionary to come in and help with their thoughts.  Two come and after discussion I decide to close up and they will send this info to the ortho friends they have to see who has better ideas.

When Im done with that David has done the other hernia case and there are no other planned cases today.  2PM- wow I don’t think Ive ever been done at that time.  So plenty of time for emergencies to be taken care of.  Zach and I head back to our rooms and get more water to drink.  When we’ve cooled off a bit in front of a fan, we go to the small market area just outside the hospital and I show him the types of things you can get.  We get some Gato (kind of like large donut holes) and sugar for them and for kool-aid I brought.  We also get toothpaste, and some little things that look like kit kat bars.  Back at my room we eat these and enjoy them.  

Im called to see a woman in labor who may need a C-section as the midwife says the baby is having some decelerations (heart slows down- a sign of fetal distress) with the moms contractions.  It’s this moms first child.  I go into the delivery room where there are rows of beds next to each other for delivering women.  There are two delivering women with many other women standing around.  The nurse tries to get the women to leave and some file out.  We ultrasound the one Im to look at.  The babies heart rate is good and its head down with the placenta not near the exit.  These are all good things.  But the baby isn’t coming out.  So I attach suction to the babies head which is right at the vaginal opening now.  With successive contractions I try and pull the baby with the suction attached to its head.  It doesn’t help much.  It seems the babies head is a little to large for the pelvis of the woman.  So the options are C-section or symphisiotomy (separating the pelvic bone symphysis to enlarge the pelvis).  I was taught symphisiotomy by an old OB/GYN while in Cameroon and this seems like an appropriate patient.  So I decide to do that.  Zach goes to the OR to collect a few things for me and the midwife gets some other things.  In between contractions, I place a foley (urine) catheter and then numb up the skin in front of the symphysis pubis (the connection of the front of the pelvic bone. I make a small incision in front of the bone and with the scalpel “feel” my way down to the ligament connection between the bone.  I put my finger in the vagina and push the foley catheter to one side so its not down the middle.  So with one finger inside the vagina and a scalpel cutting the ligaments I slowly divide the ligaments.  When it’s near the end I can feel the blade on the other side of the skin of my finger in the vagina.  If I go to deep I open the vagina and slice my own finger.  There is a pop and the bone opens about a fingers width.  The contractions keep coming and after the symphisiotomy the baby comes out in about two pushes.  Wonderful!  However the baby is floppy and there is meconium everywhere.  I pass the baby off to the midwife who takes him to the side table and starts suctioning his lungs and getting him breathing.  It takes about 10 minutes and more time on oxygen- but the baby appears to be doing well within about an hour with the midwife spending most of that hour with him.  While she helps the baby to live I sew up my small incision with a stitch and the nursing students clean up all the blood, placenta, meconium and mess.  I am always thankful to have a live baby – thank you Jesus!  Also thankful that this woman didn’t need a C-section- meaning a scar on her uterus, that gives her an increased risk of uterine rupture in the future.  Her pelvis will heal with a wider opening and her next delivery should be easier.

God help this baby to live and to grow to know You!  Give me strength for each day and wisdom for each patient I see.  Help me to support the missionaries here and help me to share Your love with all those around me.  Amen

Attached a picture of bladder stone.