Bere 5/2025 #2

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Bere 5/2025 #2

Sunday- second day in Bere.  Sundays are usually slower because we have no planned operations and don’t see surgical consults like every weekday.  I did rounds with Dr. Laurel on both the surgical ward as well as the maternity wards.  We saw the usual variety of patients.  One thing new here is Dr. Andrew has learned to do TURPs.  So basically rather than taking out the prostate to help old men pee better, he is able to ream our the inside with a hot loop and get them to pee better.  That’s exciting.  So we saw a patient who had had a TURP, some burn patients, a child with hirshprungs (disease where the nerves of the large intestine are absent and it doesn’t contract well) who had a colostomy a few days ago, a broken arm, post surgical wound infection, diabetic ulcers, osteomyelitis of a hip that needs debridement, and more and more.  Then on the maternity ward, there were many women who had delivered a normal baby and ready to go home, others who had a baby with an unknown infection that were there for antibiotics for the baby, and others with C-section and one after hysterectomy.  Many were frustrating because they didn’t have paperwork or it couldn’t be found to easily see why they were there or what meds they were getting.  We ended up looking at medications paid for and asked a lot of questions to figure out why they were there.

After rounds I took the call phone to start taking call.  When Im here I often bring insecticide to spare in all their houses, to help kill mosquitos.  It’s suppose to last 4-6 months, so it should help each family especially as the wet season is coming up.  So I sprayed about 7 houses today to kill flies, mosquitos, cockroaches, ants…. About mid way through I got the message that lunch was ready so I detoured for lunch before going back to spraying.

When I was about done with spraying, I got the message that there was a woman who was to have her first baby who was footling breach (butt first).  So they recommended that I do a C-section.  She had had a previous C-section and wasn’t dilating with usual measures. (Usual measures like a foley catheter put through the cervix and balloon inflated to get the cervix to dilate).  So I took her to the OR for the C-section.  My nephew Zach would assist me.  She got about 1500ml of fluids than a spinal anesthetic by David.  I cut across the lower abdomen through the skin, fat, then to the fascia (like gristle).  Opened the fascia and separated it from the muscles.  Then opened down to the peritoneum exposing the uterus.  I incised the uterus and took the bladder out of the way.  Then I continued opening the uterus until I got a small about of amniotic fluid.  Sticking my hand in the uterus I felt around for a part of the baby to grab.  I found the butt.  I pulled on either hip and delivered the child out butt first.  The head stuck a little, as it’s the largest part of the baby.  But with a little twist and maneuvering the head came out.  The baby was floppy, but the new (she’s been here 2 weeks) midwife was at the OR bedside to take the baby so I clamped and cut the umbilical cord and passed off the little boy to her.  As I sewed up the bleeding uterus, I started to hear the baby cry with the midwifes help getting the baby going.  It is always a wonderful sound to hear the newborn cry!!  Happy Birthday!  Thank you Jesus for another live baby!  After closing the uterus and putting the bladder back into place, the rest of the layers were closed leaving a barely visible scar.

I head back to my room and get a text asking if I saw the kid with a facial laceration?  I heard they were at the pediatric department so I went there to look at him.  I called David to stay around till I found out wether it could be repaired under local or not, but he was already home.  The kid and family had gone to the lab to get bloodwork drawn.  I got out my headlamp and looked at him.  He was a boy of about 5 years old, with a gaping hole and cut on his upper left lip and cheek. I could see muscle and some loose teeth.  He had been kicked by a donkey in the face.  The blood work looked good and I took him to the OR.  Two of the pediatric nurses and Zach came with me.  I called David so he would come back in to do anesthesia.  The pediatric nurses rummaged around to find the supplies to get an IV.  Eventually one was in.  Then it blew the vein, so another one had to be placed.  Finally another was in and we started.  Under ketamine he did pretty well until he started vomiting food.  The fatter told us he had eaten 8 hours earlier but that didn’t appear to be the case.  Fortunately he didn’t appear to aspirate the food so he continued breathing well as I worked on his face.  I discovered that 4 teeth were loose.  Loose from the bone and also a maxillary fracture.  I asked for arch bars for the maxilla, and they didn’t have any.  But David could find wire.  So I wired a bad tooth on each Side to the good tooth next to it.  Not really stable but better than just leaving that peice move as it would.  Then for the laceration on his lip and face.  I took off the dead tissue and then brought the obicularis muscle back together.  Then I reapproximated the remaining muscles and tissue.  I closed the skin and the boy woke enough to go to the ward with his father.  I checked with the maternity and there were no concerns there.  I went by the surgical ward and they were concerned about the swelling of the abdomen on the kid with Hirshprungs disease.  His belly was distended but not very tender and his colostomy looked good.  So I reassured the family and headed home.  After writing to you, I showered and went to bed dripping wet, in hopes of falling asleep before I got too hot.  I dried out but was able  to sleep.

Somewhere around 4AM Im called to see two patients in maternity.  So I walk over there with my bag containing my ultrasound and other stuff.  It goes with me everywhere here.  The first patient the nurse shows me is a woman who has her 10th pregnancy and is at term and dilated cervix to 4cm.  The nurse can’t find the heart rate and the mother hasn’t felt the baby move since yesterday.  She’s having some contractions but hasn’t lost her amniotic fluid yet.  So I get out my ultrasound to see if the baby is still alive.  As I look around I can’t find any movement.  Then I see what looks like a still heart.  The baby is cephalic presentation (head first) which is good.  I tell the woman and the father my findings.  They remain stoic.  The nurse tells her to start walking around to help stimulate the cervix to dilate more and we will check her later to see how she is progressing.

The next woman she shows me is a young appearing woman who was in bed under her mosquito net.  She heard a commotion and when she opened her eyes a cobra was under her net in front of her and spit venom in her eyes.  Her husband killed the cobra and brought it in, in a sack.  They washed her eyes and face with water and came in here.  Apparently their cat had been stalking the cobra to kill it when it went into her mosquito net.  I haven’t encountered this before so I was able to have a good enough cell signal to look it up.  So I irrigated her eyes with Ringers Lactate solution until her eye no longer hurt much.  About 20 minutes.  Then I gave her antibiotic ointment and will check on her later today.  I asked the husband to show me the snake so he dumped out the pieces on the floor.  Im guessing if I put the pieces back together it would have been 3 feet long.

Now the sun is up and so am I.  I usually can’t fall asleep again when I go in, in the night anyway.  So I sit here in the cool of my fan, not sweating yet, to write you.

Please pray that God give me wisdom and strength for each patient I see while I’m here and that He give me the words to speak His love to each of them.  And that the devil is blocked from influencing or harassing me in this work.  Thank you!!!!

Bere 5/2025 #1

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Bere 5/2025 #1

I’m back in west Africa.  God and missionaries keep calling me back.  I came with my nephew Zach a nurse who is aiming for med school.  Audrey couldn’t come this time because she had  a recent knee replacement and is still recovering from that.  Not yet the time to run through airports to try and catch the next plane.  Also our dog, Tucker, is getting old and hobbling around and takes more care.  I have had a quite busy last month with Audreys surgery and a variety of things going on that I didn’t end up packing till the day before and day of my travel.  I signed out in the morning to my surgical partner and continued packing then left that evening for Portland to fly out that night.  All the flights were on time and I made all of them arriving in Ndjamena  mid day.  I stayed the night to meet Zach who came in on a flight later that evening.  We got the required police stamp with our taxi driver helping us.  We have used the same taxi guy since coming here at least 13 years ago.  He’s very dependable, drives a 1993 very beat up Corolla, and crams all our luggage under his hatchback that he has to tie down using the wiper blade as the attachment point up top.  I always find this humorous but it works.  We got on the bus to Kelo about 10:30 in the morning.  

Throughout the bus ride of 8 hours we watched the outside scenery go by and also watch the TV screen up front what showed African comedy, some Saudi music sung by very stoic women, and movies they showed like Delta Force. (Basically Americans killing muslims)  Still makes me feel a bit awkward as I don’t want to be associated with that.  I’m pretty sure Jesus came to save muslims too, and Buddhists, and Jews, agnostics, atheists, and you and me… I.e. everyone!! About 6 hours into the bus ride we stopped at the Bongor bus station.  Walked around about 15 minutes and looked at all the things the local vendors were selling.  To many things to mention, but ill list some: grilled chicken or beef, dates, apples, oranges, carrots, fried crickets, crackers, cookies, sodas, sandwiches, lettuce, onions, gum, sunglasses, belts, bananas, on and on…. The bus started honking it’s horn and we all got back on.  Traveled the last two hours then arrived in Kelo.  We pull off in Kelo and at the little bus station I point out the bags associated with Zach and I and also Dr. Eddie who’s bags hadn’t come a few days ago.  Then the taxi Moto guy finds me and we take all the bags to his motorcycle.  He negotiates the trip with two other motos and they load all our luggage onto two and Zach and I with the moto driver I knew.  It’s a two hour moto ride to get to Bere. About 40 minutes into the ride we realized one moto wasn’t with us.  So we stopped and waited, and waited.  Some passing motos said that he was back there fixing a flat.  Then others said he was going, then others say fixing a flat.  After about an hour of waiting our moto driver decided to go back and see what’s happening.  Apparently the roadside mechanic packed the tube.  He drove a short distance and a flat again.  Second time same thing happened.  The third time the mechanic removed the metal out of the tire when fixing the tube 🙂 then, surprise, it didn’t go flat again.  We made it to Bere about 8:30PM.  So traveling from my house Tuesday afternoon I arrive in Bere Friday night.  Long trip.  I ate supper at a missionaries house and we talked a while and I finally got to bed about 1AM.  I awoke at 5AM- jet lag…

Today was sabbath, the day I go to church (as Jesus did).  I wanted to go to the “mango tree church”  I like it because it’s under a mango tree and has lots of kids.  Well they have a new church building, so it wasn’t quite the same.  I got in the back of the truck with Zach and many others.  Held on to the roll bar and it took about 30 minutes to get there.  As we weave through the village we hear little groups of young children yelling “nasara” (white person) and waving.  I wave back.  Near our destination some run after us and jump on the back bumper to ride the last little bit to the church.  It’s a game to see if they can catch up and jump on- at least it appears like a game to them.

I joined the kids sabbath school singing songs under the mango tree and the adults were in the church.  We sang songs like, Father Abraham, God made the animals, and many more, most of which I knew.  After a talk about Jesus growing up and him being left accidentally in the temple by his parents.  We joined the adults for church.  I translated from French to English for Zach.  Church today was about Abraham and him being a man of faith in God.  And how he had lapses of faith when he went to Egypt calling his wife Sarah his sister and later on doing the same thing with the Philistines.  And how God made Sarah have a child even though she was in her 90’s.  And how God blessed Abraham when he chose to follow God even when God asked him to sacrifice the promised child Isaac.  Then God keeping him from doing that.  Summarized Genesis chapters ?8-15.  Was a thoughtful sermon.  This afternoon we had the potluck with all the missionaries and later spend some time at the river.  Had a great first day.  Tomorrow I plan on rounding with a surgeon and learning the patients, then likely start taking surgical and OB call.  Pray that I will do what each patient I see needs, and that God will show me what that is! 

Be’re’ Chad 2024 #12

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12 Bere 2024

It’s my last day in Bere and we have planned a long day, and it just gets LONGER!!  I start with a number of scheduled cases then have to cancel some scheduled to accommodate emergency after emergency.  I realize it’s Friday and there are no meetings so i go in earlier about 7:30.  I find Phillipe in the OR and ask him when i can start.  He said the kid with the cheek abscess is ready and we should do him early so that he can eat.  So I tell him to put him to sleep and Ill get ready.  he gives him a little Propofol and I lance his cheek and get nothing.  It felt fluctuant and  the dad said pus had been draining out of two small holes.  I go deep and get nothing.  So I probe the holes and they are real superficial.  So I biopsy a large lymph node near by and then close back up the hole I made, suturing it shut.

I run over to the surgical ward and tell the nurse, Emma, Ill try to round with him later, but to go ahead and do dressings… and let me know if there are problems.  He says the emaciated woman that Ive been watching and I wrote about in 11 Bere 2024, is nauseous, so I decide to give her metoclopramide to see if stimulating her bowels will resolve her issues.  Later she’s vomiting and then I chose to operate on her like i previously mentioned in the last Shanksteps..  So that was an emergency later in the day.  So after talking to him I continue operating.

A woman is brought from the emergency room who has an ectopic pregnancy- one that is outside the uterus.  She has the ultrasound report that says so. I ultrasound her and think I see a rib cage outside the uterus.  I don’t really see all the normal features of a fetus so I ask Audrey to come take a look.  So she comes over from maternity.  She looks around and doesn’t find anything but an irregular looking mass outside the uterus that has the appearance of a uterine fibroid.  We’ve heard of pedunculated fibroids that can hang off the uterus, so assume it may be that.  The patient has a negative pregnancy test which goes against an ectopic pregnancy.  She says she has been pregnant 14 months and the baby hasn’t moved the past 4 months.  I open up her abdomen and do not find a abdomen full of blood as is common with presentation of an ectopic.  I find the omentum stuck to a large mass.  slowly I free up the omentum from the mass.  Then as I free up more from behind the mass I see a hand.  Oh this IS a ectopic pregnancy.  As i identify more I find there is a fetus wrapped in omentum.  It’s head is not fully formed, I think if may be anencephalic.  So after getting it out there remained a mass further in the pelvis.  I free this up and it’s the placenta.  The baby was near term and was fed by blood from the omentum.  I’ve read about this being a possibility in the books, but I’ve never seen one.  Very strange!

The next two operations of the day were the two that I discussed in 11 Bere 2024.  One was the intestinal blockage after surgery somewhere else, and the second was a perforation of intestine of a boy after falling on the handlebar of his bicycle.

Next was a guy that the ER had sent over.  When you think of ER you think of a room glowing with light and different patient rooms and doctors and nurses running around taking care of emergencies left and right.  They’re calling other doctors to come and admit patients to different services in the hospital after getting lab work, CT scans, and X-rays.  Am i right?  The ER here is a nurse with two or three nursing students who jot down the patients complaints in the patient’s little medical booklet they keep with them, or they lose it and get a new one when they arrive.  Then the nurse decides what tests to get and what lab-work seems appropriate to them.  So this guy comes in with a huge scrotum that is painful and he has had a hernia a long time.  So the nurse orders a glucose test, malaria test, typhoid test, and sends him to the OR to be evaluated by us.  Well the last one was the appropriate one.  He has a large hernia that makes his scrotum look like a small watermelon.  I’m unable to reduce it (push it back inside).  So he’s next in the OR.  He gets a spinal anesthetic and then I open his groin. I start opening the different layers and it still doesn’t reduce.  Finally I open the hernia sac and see colon in it.  The colon is viable and so I slowly push it back inside.  Once the sac is empty, I separate it from the surrounding structures and then cut it off keeping clamps on the opening.  I then close the sac.  Then I do a tissue repair called a modified Bassini.  Closing the native tissues over the hole.  i don’t use mesh here for two reasons.  We don’t have much and secondly I still worry about wound infections and therefore mesh infections.  It doesn’t seem like there are many recurrences here, and I think part of the reason is that there are no narcotic pain medications, so people feel when they are pulling on the repair and don’t do things they shouldn’t.  We get done and I see that last of the consults that are waiting and then head back to our room.  It’s about 9 PM and I pray that we will have a calm night.  we plan to leave at 7 AM and I don’t want to do an emergency especially around 7AM when we need to leave and the other doctors aren’t quite back yet.  

We sleep for an hour or two and are called by the maternity nurse for a delivering mother who has vaginal bleeding.  Audrey heads in and I know we will have to operate on her so I head in shortly there after.  Audrey is already headed back to get me.  She says there is blood everywhere and the baby is still alive. I call Phillipe and David (anesthetist and circulator).  I see the patient in the bed of the delivery room.  (The delivery room is a room with 5 beds lined up against one wall.  If there are multiple women in labor they lie on the beds all lined up as they suffer.  The nurse may catch one after another like has happened many times.). So back to the woman at hand- she is absolutely covered in blood all over her cloths and there is a widening 4 foot pool of blood on the floor.  WOW!!!! That’s a lot of blood.  I run to the OR and get out two units of blood of her type and stick one under each armpit to start warming them.  I also grab a couple saline bags and run back to maternity.  I ask the nursing students to get the gurney from the OR and start wheeling her over there.  The nurse is getting in another IV line.  I also grabbed the transfusion tubing.  We start pouring in the fluids.  And we get her headed to the OR.  We get her laying on the OR table and stick in the second IV and get the anesthesia monitors connected.  Phillipe and David make it in and the blood is warmed up and Phillipe starts it as I get the OR kit for the C-section ready.  I get the gloves and suture and gauze…all opened on the scrub table.  Phillipe gives her a whiff of Ketamine and I open.  She groans a little but will have no recollection of it.  I go in all with a scalpel as fast as possible.  Through the abdomen and then into the uterus.  I pull out the baby and we hand it off to David.  I scoop out the placenta and start closing the uterus.  I didn’t take the time to find out why she was bleeding, just took care of the placenta so it would stop.  I ask David how it’s going as Im not hearing the baby cry.  I ask if he wants help and he does.  So Audrey scrubs out helps give the baby CPR.  Giving breaths and oxygen and chest compressions.  It takes a couple minutes before the baby’s heart started and started to breath.  She never really cried but moving extremities.  I close the uterus as best I can by myself and finally David scrubs in to help me.  Mom is doing well with three units of blood and baby is alive.  We leave as they start to mop up all the blood all around.  We are grateful to have a last live mom and baby for this trip!!  We sleep for a few hours then get up to start our three day trip home.

Be’re’ Chad 2024 #11

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11 Bere 2024

In the last day at Bere I did two intestinal repairs.  now that’s something often done by general surgeons.  One was a “usual” case and one “unusual”

First with the “usual”.  I was called to see a 10 year old boy who was on pediatrics after a fall on a bicycle.  At first I thought I understood he had fallen from a tree on a bicycle.  Then I saw the tell tale sign of a circle impression on his right abdomen.  A handlebar into the abdomen.  he had a rigid abdomen with peritoneal signs.  So I told them to take him over to the OR and start an IV on him.  He will need to be one of the next ones operated on.  I suspect that he may have pinched a piece of intestine between the handlebar and his spine.  This occurred a couple days ago.

As I open his abdomen i immediately get a lot of stool and pus and free air. I suck out all the stool i can and then wash out his abdomen with a lot of saline.  Once it’s coming out fairly clear, I start looking for the hole in the intestine.  I find it mid-jejunum (small intestine).  He has a hole one side of the piece of small bowel and a hole on the opposite side and a small hematoma in the mesentery to that area.  Definitely a pinched piece of intestine making the hole.  So i freshen up the edges of the holes and then suture them closed.  I do a single interrupted closure, meaning one layer of sutures to close the holes.  It takes about an hour.  Finally the holes are closed and we close up the abdomen.

The other one (unusual) was a woman who i had been watching over the week who presented to Bere about two months after a surgery at another place where she had some surgery where they did something and may had cut adhesions.  The patient and family doesn’t know and it’s not written in her book in a legible way.  They said shes been vomiting and cant keep food down two months.  Now that story makes me feel suspicious.  So i admit her and observe.  I give her nausea medicine and she seems to do better and eats some food.  Her stool is hard and she has firm areas in her abdomen that changes position- like intestine moving.  So I decide to stimulate her bowels with medicine to see if she can pass the stool and if thats causing the problem.  I had done an Xray of her abdomen that didn’t show obstruction but I was a little worried about a partial obstruction.  The surgical ward nurse came to tell me shes was vomiting a lot after this medicine.  It was my last day and I had watched her.  I didn’t wan to leave her for the other surgeon after I’d watched her so long- so I said to bring her to the OR and keep her NPO.  I was worried about operating on her because she was so thin she looked like a starvation person.  Meaning that I wondered if she had enough nutrition to heal a surgery!!  Or would she just leak with an enterocutaneous fistulae and die?  I felt forced to do something…. 

As I cut through her skin I immediately came to fascia.  No fat whatsoever.  She is starving to death!  I entered the abdomen and found dilated small bowel and decompressed small bowel.  Definitely an obstruction.  I started at the top where the dilated bowel was and followed it down.  I found an area of previous resection with that being the transition point between dilated and non-dilated bowel.  So to take out that section or just bypass it.  If I took it out I’d have a huge anastomosis to do and it would take a long time.  If i did a bypass, attaching the one piece to the other I could make it whatever size was needed and leave it at that.  So i did a side to side anastomosis. I cut each piece of intestine and started sewing them together with an opening in between.  This took about an hour.  The anastomosis looked good and as soon as I unclamped the intestine, fluid started going through.  Yay!  I closed her up and we went on to other surgeries.

Now a few days later she is post op day 4 and she is able to eat and shes moving her bowels.    And so is the boy of earlier in this message.  Im so grateful.  Always after an anastomosis of intestines Im not at peace till about a week later when everything is working well and there is no anastomotic leak or problems.  Im glad to hear they are doing well.  Thank you Dr. Jorla for letting me know.

Greg