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Cameroon Shanks steps of faith #12
9-25-05

He’s three days old and ate well the first day then
has had vomiting and his abdomen is very distended.
His mother says he has not had a bowel movement yet.
So I examined the child and found an imperforate anus
(an anus without a hole to have a bowel movement). So
for this child this was an emergency. I asked if the
patient had urinated that day. Mom said she thought
he had never urinated. This raised suspicion for me.
Especially since this malformation occurs frequently
with other problems. I have only read about this, but
unfortunately have never seen or operated on someone
like this. And the nearest pediatric surgeon is
possibly in the capital 800 miles away or further. So
I began to tell the family about the problem and that
it required surgery. Their first question is how much
it would cost. The nurse said probably 100000CFA.
Well this was a bit exaggerated an I didn’t know if it
would be only a small covering of skin over the anus
or anal atresia (inadequate development of the anus or
rectum) So I couldn’t tell how much surgery was
involved. I could tell by their faces they were
considering not doing anything. So I convinced them
to let me see if I could at least do the “small”
surgery and if more was needed I would talk to them
before proceeding. So this child was taken to the
operating room. We have no preoperative studies
available to see how far down the rectum and anus are
open (x-ray or other studies). So without studies I
figured I should be able to put a needle into where
the anus should be and if only a skin was covering it
I should be able to aspirate meconium (baby stool). I
attempted and could not. So I figured it must be anal
or rectal atresia (malformation up higher). So the
child needed a colostomy (bringing out the colon to
open on the skin of the abdomen). So I discussed
things over with the parents telling them this was
necessary for the life of the infant. Well they said
I should do whatever I think is best. So I continued
on with the surgery. Upon opening the tense belly the
intestines spill out onto the table as they are very
distended and trying to escape the confining space. I
choose a site to bring the intestine through the
abdominal wall and then attempt to close the incision.
This is very, very hard, as the intestines don’t want
to be confined to the small abdominal cavity.
Eventually with much effort we get them back in and
suture the ostomy in place. When opened it pours out
stool. The large intestine was about 10X normal size.
It took a lot of Ketamine to put the child to sleep
enough to do the operation. So during the middle of
the operation the child stopped breathing. I notice
the bowel getting purple instead of pink and ask the
nurse if the child is breathing. He says “yes” just
fine. I look for signs of respirations and there are
none. They start doing CPR on the infant, which is
ineffective. So I break sterility and bag the infant
myself. He pinks back up and starts breathing slowly.
I bagged him about 15 minutes then continue with the
operation as the nurse bags him. I believe this is
the medication we have given him are the cause. Dr.
Hamza who is operating with me thinks it’s the
distended abdomen. Again with difficulty I try to
close the abdomen, the bowel turns purple and I bag
again. Finally I am able to finish the case while the
nurse bags the child. I continue bagging the child
hoping he will live for another hour. Finally he
starts breathing on his own. I stay with him on the
operating room table a few more hours. Only the
on-call nurse has been with me since the end of the
operation. I know the child may not live. I remember
what the mom said about the urine so I attempt a
urinary catheter, it doesn’t pass. So there IS a
problem with the urinary system. I place a needle
into the bladder through his belly. I get 30ml of
urine (large amount for 6 pounds infant). He is
finally breathing well enough I feel ok with leaving
him with the “nurse”.
The next day the child is doing OK and the ostomy is
putting out a lot of stool but the child is crying
constantly. I place a catheter through his abdomen
into the bladder. He tolerated it well.
Now here we are 3 days later. Nothing has been paid
by the family but the husband has gone to sell his
grain supply to get money to pay for the
hospitalization and all we have done. It will likely
not cover the price of it all. The child’s intestines
still haven’t woken up and he is vomiting. I place a
nasogastric tube into his stomach and get many cc’s of
bile. He is dehydrated and his IV fell out overnight.
The nurse is now asking me, if they haven’t paid
anything should we continue with the catheter and
continue to do all this things when he is likely not
to live. If he does live with the urinary catheter he
will have repeated infections and more surgeries… and
more that the family like this will not be able to
support either here at our hospital or even frequent
treatment at dispensaries. I would not make the
decision on what to do. These decisions on whether or
not to continue are easier when I know there is no
chance of survival. But in a child who CAN live I
can’t make the decision on whether to stop treatment
or not. That is the families place not mine. For me
“First do NO harm” (In the physicians oath). So we
placed the IV tonight to rehydrate the child and await
the fathers return. We have seen so much death that
the chance of a life saved even if very sub optimal is
great. I don’t mean to say that we haven’t had
successes with Gods help, but there is enough death to
be very discouraging. Mostly because they come in at
such a late date, and are in bad shape when they
arrive. But also some young (example 14yo girl) who
come in and look just kind of sick but then have a
release of malaria trophozoits in the blood stream and
then decline rapidly. These are also hard.
Fortunately that is rarer, its harder to deal with
mentally because they don’t look like they are ready
to die like the others when they come in. But such is
the life of physicians working in this part of the
world. (Se la vie)
I think what is necessary as in everyone’s life is to
trust in God more. We are not here for our purposes,
or the patients, or hospital workers. We are only
here, because this is where God wants us! I do
believe it is to help the patients and hospital
workers and teach those who do not KNOW GOD about Him.
This is the most important. With some patients it is
easier than others. Also with some hospital workers
it is easier to show God’s love than others. But
that just reconfirms our need to become closer to God
and rely on Him more to be able to deal with these
people as God would and not as we feel like treating
them.
God please help us treat our patients like your
children. Help us to work with the employees who
betray us as you did with those who betrayed You.
Give us your strength as you promised in Isaiah 40:31.
Give us wisdom as You promised in James 1:5 when we
do not know how to treat your children best and what
medications to give them. As in
Psalms 62:2 be my rock and salvation, my stronghold,
and I will not greatly be shaken. Thank you for all
your promises in the Bible to comfort us in the times
of distress and disappointment and ignorance. And
thank You most of all for sending your Son as a
sacrifice for my sins that I can one day be with you.
Thank you Lord. The Shanks

Shanks steps in
Cameroon #11
Hi! Sarah here. The reason I’m writing because
we’ve gotten a few letters asking about me. Thus, I’m
writing.
Lot’s of things have been happening. The
highlight of my kid brain is the fact we found 2
hedgehogs. We kept them in a little box and fed them
bugs. Pierre (Our guard.) caught big inch long ∏ inch
wide bugs for them. Now, I’m not a girl that gets
grossed out by bugs, but when you see a can full of
big wiggling hopping bugs, you can get a little
grossed out.
I ended up letting the hedgehogs go.
Unlike my mom and dad, I have no great medical
stories. I don’t like the hospital for multiple
reasons. One, I think blood is cool! But 1 part of my
brain disagrees. I faint. I can’t explain it! I like
seeing blood, really! But I just get faint.
The other reason is because babies’ cries make me
nauseas. (I never really liked babies.) Trust me,
there are lots of babies in the hospital.
And the other reason I don’t like the hospital
is because seeing people so sick also makes me
nauseas.
Mostly, I do the staying home and praying part.
My day is made up mainly of home school, (Where
I teach myself until Mom gets home.) reading, and
drawing. So unless you want to hear that 109,786
divided by 10 = 10,978 r6, I’ll skip that part of my
life here.
I’ve made a few friends here even thou I can
only speak some French. I have learned that they like
Duck- Duck- Goose a lot. The 3 year olds to the 19
year olds play it with us.
Mainly the boys play with us. I think the girls
are shy, or they are just doing too much work. The
little children do very interesting jobs. Like the 3
year olds taking care or a big herd of cows, all with
horns at least 5 inches long. It’s kinda funny seeing
a boy 2 feet high hitting a cow with a stick and the
cows’ 5 feet high!
Many other funny things you see here are goat’s
tide to the tops of mini buses as they speed past. Big
satellite dish tied to a motorcycle ( Moto’s as they
say here.) with the man sitting in it as he drives by.
Bulls walking past our house. And ducks, goats, sheep,
donkeys, and an occasional horse in the road. We know
a man with 50 children! True story. There is only one
way describe Africa. Crazy.
One of the biggest problems I have here is not
enough books. I go through books fast. I read 315 page
books in 1 day! I’m so desperate for books that I’m
ready to read that one book I found here from the last
missionaries, The Basic Fundamentals of Golf.
The other draw back is not enough cheese or
chocolate. Sigh… Chocolate…
I like chocolate. Who doesn’t?
Africa is a different world. The mountains,
animals, plants, houses, weather, electricity, sand,
customs, cloths, weather, music, illnesses,
treatments, languages, food, bugs, people, all are so
different. Life here is more interesting than you can
imagine unless you’ve been here. We have been here for
about a month and are not yet settled down. We miss
every thing we left behind. Please pray we do well
here and start feeling comfortable.

Sincerely,

Shanksteps #10
16-9-05

C’est le main gauche. Oh no, not again. This was the
third delivery with “hand presentation” in as many
weeks. What is it with Cameroonian women that the
hand comes out before the head? She started to have
contractions this morning in a nearby village and went
to the local medical personnel. When they checked to
see how dilated she was, they felt a foot and pulled.
Unfortunately it was not a foot, but a hand. So they
sent her down the horribly bumpy dirt road to Koza for
us to take care of. Greg and I ran down to the OR for
yet another C-section. This hand was a bit different
than the others though as the skin had already started
sloughing. We feared what the rest of the baby would
look like. The operation went well but the baby was
dead, and had been for quite awhile as evidenced by
the amount of decomposition. Mom has done well.

She’s eight months pregnant, delirious, with jaundice.
Why? Three days ago she had been fine, they tell me.
I search my brain, Williams Obstetrics text, Current
Medical Management text, and Manson’s text of Tropical
Medicine. We perform the labs we have, only to find
out that mom’s blood is Rh- and her husband is Rh+(so
baby could be Rh+ also). Could this be some form of
blood incompatability reaction? One of the nurses has
seen Rh problems before and said they looked similar.
I go to check on mom again and her heart rate is now
170. Her breathing is irregular and she is thrashing
about. I wonder if mom’s reaction against baby has
been so severe that the baby has died and mom is
becoming septic; I wonder about hepatitis and
encephalopathy; I wonder if this could be a weird
presentation of eclampsia and HELLP syndrome (we had
one earlier in the week). I never found a fetal
heartbeat, but that’s not as surprising using just a
stethascope. All I know is that if the fetus is
causing the problems, we need to get it out. Another
c-section. Baby was dead and mottled. Mom’s vital
signs started to level out once the baby was removed.
I still wasn’t totally convinced that that was the
whole story. Late in the evening Greg was told that
this patient wasn’t doing well. She had Kussmal
breathing (end of life breathing) and altered mental
status. Several hours later she was dead. Why??? At
our morning worship and patient sign-out the next
morning we get an answer. One of the patient’s
neighbors came to the hospital to tell the rest of the
story. The patient had not been feeling well for
about a week. 3-4 days prior to coming to the
hospital she had gone to a traditional healer who had
given her a potion to drink. She did and immediately
fell to the ground and started acting strange. The
family kept her at home like this for 3 days, then
finally brought her to the hospital as a “last ditch
effort”. Unfortunately I do not have a traditional
medicine textbook to refer to. Tribal potions was not
on the differential diagnosis for jaundice in my
medical text. (It will on my personal differential
next time though.)

So many patients wait until the last minute before
coming into the hospital. They go to the market to buy
(prescription) meds; they go to traditional healers
for potions, cuttings, burnings and spells. By the
time they come to us they are in very serious
condition. If we are able to help, very often the
family doesn’t want to pay for the medications and
care and will take the patient home before they are
ready, especially the women and children. Some days I
just want to come home and cry for all the death we
see, and the seeming indifference to it. I feel that
the difference we make is so miniscule that it doesn’t
really matter. But then I remember that we are not
here for us. We are here in Cameroon because God
called us to be here. He has plans for us that we
know nothing about. I have been out of my “comfort”
zone since landing on Cameroonian soil. I have felt
inadequate medically, culturally, spiritually,
emotionally, physically, in language, understanding.
But God is not done with me yet. He continually
reminds me that “My grace is sufficient for you, for
my power is made perfect in weakness.” (2 Cor 12:9)
He has a lot of weakness to work with…
Please continue to pray for our hospital and it’s
spirituality. Please pray for our strength to keep
working for HIM through the life and the death. We
feel your prayers as we are given boosts of energy and
have the privilege to see miracles throughout the day.
In his service,
Audrey, Greg, and Sarah

Cameroon Shank steps #8
At times we are up, at others we are down.  It seems
our emotions are like the rivers here.  At times dry
and other times of the year flowing.  A lot of the
feelings depend on whether we feel like we have helped
someone that day or whether someone has died.  As
mentioned before it seems is very much a part of life
here and accepted very differently.  But for us with a
western mindset it’s sometimes harder than it seems
for some of the family members.  I had another child
die in front of me yesterday.  Many children are
brought in by parents very late in the malaria process
when the child is already worn down by repeated
malaria and also malnutrition.  In children like this
even a few days may be too much.  Their hemoglobin may
be very low and they bring them in when there is
difficulty breathing from the anemia and they seem to
die often before or while the blood transfusion starts
running into them.  This is one of our most common
difficulties to deal with.
The other is the constant strain of insufficient
money.  Again this month the workers were paid only
1/3 of their salaries because the hospital doesn’t
have enough to pay them.  We ran out of Quinine today.
This is one of the essential, most used, medications
for treating malaria.  Nearly every patient in the
hospital and clinic receive this.  Today the
“pharmacist” came to us saying they were out.  And of
course the nearest place to get it is 3 hours away in
Maroua.  So the hospital ends up sending patients to
surrounding dispensaries to fill the necessary
medications.  Not a good move to have to take.  But
since we just paid the 1/3 salary we don’t have enough
to buy today.  We may be able to buy a few essential
medications tomorrow after seeing some patients and
discharging others.  It is also hard for us to hear a
worker say “It’s hard to treat the patients well when
you’re hungry”.  Or “My family hasn’t eaten in 3 days
because the salary is late.”  The needs here are very
real and at this time of insufficient funds, are
amongst our staff too.  Often it is more common
amongst those without jobs or income who are waiting
for their crops to produce.  But now since the
hospital is behind a few months the crunch is real and
also amongst those with a job.  Our administrator has
just had a baby boy in the hospital in the capital of
Cameroon.  He hasn’t been able to travel there now for
a week because of lack of funds to go.  Unfortunately
some parents and husbands also make medical decisions
based on cost.  We had a child who’s father took them
home today with cerebral malaria because he was
worried about the bill getting to high for him to pay
so he paid and left.  Another mother came in with a
child with a broken tibia and fibula (leg) and when
the nurse mentioned the child should be hospitalized
and casted she left with the child.  So along with the
joys of working for Him in this place amongst these
very friendly and hospitable people there are real
challenges.  Please pray for us and for this hospital
that we may grow to be the people and institution that
God wants us to be and that we will some day have the
ability to provide more care and aid to those here who
really need it.
We are still not able to use our ham email yet.  We
are waiting for the permit to use it.  Also pray for
this that we may get it soon so that we can stay in
more constant contact with you all.  Unfortunately it
is hung up in the telecommunications department here.
When it is rough I am reminded of the Bible text:
Isaiah 40:28-29, 31 “Do you not know?  Have you not
heard?  The Everlasting God, the Lord, the Creator of
the ends of the earth does not become weary or tired.
His understanding is inscrutable.  He gives strength
to the weary, and to him who lacks might He increases
power.  V 31. Those who wait for the Lord will gain
new strength:  They will mount up with wings like
eagles, they will run and not get tired, they will
walk and not become weary.”  God is giving us the
strength to do what He has called us to do.  We praise
Him for this.  We serve an awesome God who is
interested in each issue in our lives and has
experiences the same difficulties that we have.  I am
very thankful for a God who understands our
difficulties and is interested in each aspect of our
lives.