Be’re’ Chad 2024 #6

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6 bere 2024

It’s my least favorite thing here in Bere, neck abscesses from dental cavity infections.  I am sitting in the worship area which is a metal awning outside the ER.  Someone is giving a worship thought to the hospital workers in French and its translated into Nangere, the local language.  Im distracted by chickens walking by and pecking at something on the ground next to me.  There is a muslim man sitting in the front row waiting for the ER to open and just stayed there when worship started.  Another younger muslim guy walked up and starts talking to him, someone asks him to be quiet as we are having a meeting.  Then one of the nurses that asked me to help him with his schooling last week, walks up to me and says his uncle isn’t doing well and would i come see him.  I had admitted the uncle the day before.  He had swelling of his chin and neck and I did an ultrasound and didn’t see anything to be drained. It had be the rotten tooth cause.  He couldn’t open his mouth for me to see anything in it (trismus).  So I treated him with IV antibiotics.  I go over to where he is and his family is carrying him from under the tree to his bed.  He is sitting rocking back and forth and looking weaker and weaker.  They get a sat monitor and his sat is 47.  He is dying… I tell them to carry him to the OR NOW.  they grab him and I run for the OR.  I get the stuff and as soon as he’s on the table I try to intubate him.  I don’t expect to be able to open his mouth at all and also think of an emergency trach.  But I try, and it opens some.  My mac intubation blade is to small.  I find another and try again.  I intubate him and we start CPR.  The nursing student stays in the room and the other family members leave.  I pray for God to save him as I do chest compressions once the anesthetist is there to bag him.  I switch off with Audrey and a couple of OR guys.  We do chest compressions and bag him for more than 30minutes.  His pupils are fixed and dilated.  We stop.  He is still dead..

Another of my least favorite is a similar issue of a woman who was admitted over the weekend.  I found her on rounds Sunday morning.  She had an ace bandage around her neck that was wet with pus and her whole upper chest area was red and was like a big fluid pocket- pus!  So I told her to not eat or drink anything and she needed to go to the OR.  I wanted to sedate her but when in the OR i realized she couldn’t open her mouth but about a quarter of an inch.  So I cant sedate her and she will have to be done with local anesthetic.   This never works well, but is what is necessary.  The OR staff doesn’t want her in the OR because she smells awful, like dead flesh. (Think decaying animal).  So we do it on a bed in the consultation room.  She is sitting leaning against another woman.  I put betadine on, I know is useless, and then inject lidocaine in a few areas.  This is painful and she pushes me away.  She says she is going to die.  I think to myself that she probably will.  I incise the different areas that I injected and cups of pus flow out.  There is a dead patch of skin on her neck and I cut that off with scissors.  I realize that when she coughs a well of pus flows up from behind her sternum.  I see dark black tissue bubble up too.  I grab it with a forcep and pull up a huge piece of dead tissue from behind the sternum.  I grab the Dakins bottle (dilute bleach) and drown the area with it.  More pus flows up and out from behind the sternum.  The guy standing by helping hold her and the woman holding her, both nearly pass out.  The stench is awful.  im glad we are not in the confined room of the OR.  After there is pus everywhere and I cant smell anything but dead smell, im done.  I’ve pack everything I can and I go to wash off all my exposed skin I can.  I don’t think i got it on my skin, but I feel very dirty…

So i hate that the people here have no available dental care or way of getting to it.  And even when they have rotten teeth they often want to keep them because they’re the only teeth they will ever have.  We, in the first world countries, are very blessed to have access to care many other people in the world have no access to at all.

God help me to demonstrate Your love to these suffering people!

Bere Chad. Miah Davis

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Dear reader,

My name is Miah Davis. I am 17 years old, and am graduating high school in June of 2024. I shall be attending Walla Walla University to take either medical or nursing prerequisites, and aspire to be either a CRNA or anesthesiologist someday. 

I was granted an opportunity to go to Bèrè, Chad as part of a medical mission trip team. I embarked on the journey with no expectations really, but I gradually became astonished by the rusticity of Bèrè Adventist Hospital. When I first walked into the various wards—maternity, pediatrics, adult, surgical—the simple spaces were not a surprise. It was not until I went on rounds and spent many hours in the operating room (OR) over the next few days that I realized two things: 1) how lucky I, as an American, am to live in a country with such advanced health care and 2) how great of a God I believe in. 

I have heard many people in the US complain about the cost of healthcare, whether that be the cost of birthing in a hospital, attaining cancer treatment, or getting insulin needed to survive with diabetes. I do agree that such things are dreadfully overpriced in the US, but I have now seen a place without them. In the US, there is consistent pre-natal care and multiple options for a safe birth, In Bèrè, birthing mothers can only be monitored, given epidurals, and taken in for c-sections. Sometimes the beds the women give birth on break during labor. Cancer treatment is surgery, and if surgery cannot get rid of it, there is nothing more the doctors can do. Diabetics are given a syringe and enough insulin to last a month. At the end of the month, the individual comes for a refill and a replacement of the now very dull syringe needle. Therefore, despite the hardships, I think that US residents should be more grateful for the medical technology it has. 

In the US, sanitation and privacy are highly valued. The Bèrè wards, excluding the OR, contain beds lining the walls, no privacy anywhere. There are curtains for doors, and concrete floors. Doctors and nurses do most of the physical exams without gloves to preserve the limited supply of gloves for the cases that truly require them. 

The Bèrè OR is the most basic an OR can be. Patients have consults in the OR waiting area, and do post-surgery stuff in a partially partitioned off space behind the waiting area. The two operating rooms are the two rooms in the entire hospital compound to have air conditioning despite the extreme heat (at least to us Americans). Unlike the US OR’s and their seamless floors and positive pressure, the OR floor not only has atmospheric pressure and seams, but there are also holes and bloodstains on the floor. The anesthesia machine only relays blood pressure and heart rate. It does not show the telemetry or the information from the cardiac monitor. There are often up to 10 aspiring nurses crowded into the room during an operation trying to learn. IV’s and syringes are reused, and fluid is often transferred from non-sanitary to sanitary syringes. Glove fingers are used as drainage capsules. Surgeons from the US will often ask for a certain tool only to be told that the hospital does not have one. Scrubbing down for surgeries is taken very seriously, but I am sure many US doctors would still gasp in horror. 

I have seen many patients here in Bèrè with afflictions—typhoid, abscesses from dental infections, malaria, etc—that are virtually non existent in the US. I have been able to observe, and assist in surgeries that teach me so much about the human anatomy. I have experienced what it is like to not have advanced medicine like the US does. Most of all, I have seen the human body and its interworking parts in ways that only further solidify my belief in God Our Creator. The body heals wounds, protects against internal foreign objects, and recovers from surgical procedures. In my mind, this can not be in accident. It is a beautiful masterpiece of God’s craftsmanship. 

This trip has been life changing. The people here—locals, missionaries, and OR staff—have found their way into my heart, and I am so grateful that I have the chance to spend two weeks in Bèrè, Chad. 

Sincerely,

Miah Davis

Bere Chad 2024 #5

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The boy is about 22 yo and I saw him yesterday afternoon and they were thinking of adding him on since we appeared to be done a little early.  He had a hemangioma (mass of large blood vessels) on his inner thing that was about 4×10 inches.  Some of the blood vessels were as large as my fingers.  i said he should be the first case in the morning as it could be very hard to do.  So this morning is the day.  I ask him about how long this has been there as he lays on the OR table.  It been present since birth and has slowly grown larger and larger.  He says it hurts.  I can imagine if it grew quickly it would hurt but not at a slow progression.  That matter not- Im taking it off today.  I scrub with one of the local docs who is doing surgery learning for 6 months.  I start cutting around it and right away get into a few vessels.  This gets my heart rate going.  im trying to explain how he can help me and im finding it challenging.  He isn’t really a good assistant.  I need someone who knows what they’re doing.  Dr. Steven comes in to check on me and I ask him to help.  Then it goes much better.  We are able to go back and forth whichever of us has an easier angle to dissect and the other of us cuts with cautery or ties a small vessel.  We slowly peel it up including the underlying fascia or just above that.  We finally define that it only had two small feeding veins.  These were tied and it is off.  Now how to close.  I pull on the skin and realize I may be able to get it together with a lot of tension.  So I start in the middle with a stitch, then in-between with more stitches.  Until with about 30 stitches it all comes together.  I’m glad to have gotten it together.

I do another surgery and then the third one is interesting too.  This kid of about 8, had an infection going on in his leg for the past 8 months.  It was painful and it had some draining pus that came out in different areas.  The X-ray showed osteomyelitis (infected bone).  This looked like a huge fat bone in the leg at least twice the size of a normal tibia bone.  So i took him to the OR to drain it.  I cut down to the involucrum (new bone growth around a dead piece of bone (sequestrum).  I follow one of the holes that has pus coming out of it and find the hole in the involucrum.  I use a rongur to eat the hole away till it’s very wide.  I probe inside the bone in both directions.  I get a lot of granulation tissue but not any dead bone.  I follow another in the upper tibia and do the same thing.  In that one I find a small piece of bone.  It feels slightly mobile.  I wiggle and try to pull on it.  I think this is likely the sequestrum.  I bite it in half with the rongur.  Then one end I grab and am able to wiggle and twist it free.  Yep it’s a sequestrum in the dead bone inside.  The other end slides up into the top of the tibia.  I use a curette and try to swipe it out.  Finally i get a hold of it.  It doesn’t want to come out, but with force it does.  So at least two chunks of dead bone, the source of all this pus is out!  i hope there isn’t more, but I can’f find more so i pack the holes down the center of the marrow after washing it with dilute bleach solution.  He will likely be here months with packing his legs.

Bere Chad 2024 #4

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Today was a “normal” day.  It rained heavily last night and it is finally cooler and I slept finally after about 3 days of minimal sleep.  I get up about 7:30 and realize Ive already missed worship.  I have my own usual morning worship- consisting of reading from the Bible, praying to God.  I head in to see what’s happening and if any patients are ready to have their operation done.  I know there are at least two hysterectomies on the schedule and the others on the list didn’t register so I guess they weren’t worrisome to me.  The first lady is older and has a painful mass in her lower abdomen.  I examine her belly as shes on the operating table, IV in place.  Her head is covered over the top and her abdomen and chest are exposed and she has some shorts on.  So she feels not well covered but acceptably covered considering shes here.  Womens chest and abdomens aren’t usually terribly private.  A child will pull a breast out of their moms shirt and start sucking.  So i palpate and Im told shes here for a hysterectomy.  She doesn’t want any more children.  I look at her book and it says she would like to keep her uterus if possible but wants the mass gone.  As it is almost up to her umbilicus I know Ill do a vertical incision.

At her operation in a few minutes after seeing some consults outside, I incise her abdomen up and down.   Then into the abdomen we see the uterus is huge.  I feel around and cant feel any uterine fibroids.  So I guess I cant do a fibroidectomy, so a hysterectomy it is.  Dr Steven and I are working together.  So he works down one side and I work down the other.  We get into some bleeding that we are able to control and we get down to the cervix and then take out the uterus.   It looks about the size of a small bowling ball.  Im sure she will feel better with this out.  There is definitely more space in her abdomen!

Next is a younger woman in her 30s who has an ovarian tumor.  She definitely wants more children.  She has had 4 and and only 2 are living, and hasn’t had any for the last 4 years.  Womens value in the local cultures are very tied to how many children they have.  So i want to take the ovary, both to help her live longer and so that she still has a chance to have children like she wants.  I palpate her abdomen and then get my butterfly to see it for myself.  Apparently there was some confusion wether the mass was in the ovary or uterus.  I see a large mass and then a small uterus behind.  I open her thin abdomen and start exploring with my fingers.  It seems the intestines are stuck to the mass all over.  This is a bad sign, more likely to be cancerous.   I slowly dissect some off an Dr Steven dissects other parts off.  Then we get into a cystic area somewhere deep inside.  A dark bloody fluid comes out. We dissect more and find that we end up getting two large cysts.  Then there is a large mass below that is really stuck to the rectum and bladder and i feel we cannot get down to the uterus.  We are bleeding and leaving cyst wall stuck to intestine.  So if this is cancer, there is definitely not a cure here.  And with us dissecting the bladder and rectum the chance of injuring these and blood vessels is very high.  So i tell Dr Steven i think its time to stop and get out, that we are not helping any more.  After assessing it again he agrees and we drain and start closing.  We are both bummed that we couldn’t get it out safely.  But Im also glad to not be threatening her lift TODAY.

I go out and see some more surgical consults as they get the next US proportioned guy ready.  Everyone here is very thin, and this guy isn’t.  He has a mass on the back of his leg, and it is likely a sarcoma.  These need to be removed with a good margin of normal tissue around them.  The anesthetist Phillipe, puts in the spinal and after a number of minutes have past we get 8 people around him to turn him on his side.  His big belly starts to drape off the side of the narrow OR table, so we reposition and prop him so that he is safely on his side and then we are able to work on the back of his lower leg.  I want a centimeter of normal tissue around the tumor.  Now this sounds easy, just measure and cut 1cm further.  Yes that is easy at the skin, once you are deeper it’s harder to be certain that your are one cm away.  To be certain you’d have to cut down to it and then go back a cm to make sure you have it.  But that violates the purpose of staying away that far in being beyond tumor that is microscopic spread.  So it ends up being a feel of how much tissue is between my finger and the cancer.  So i end up cutting a large hole out of the back of his leg down into the muscle.  So after removing it, the spot is about the size of half an orange.  There is not near enough laxity of the surrounding skin to get it any where near back together.  So I can skin graft it or leave it open.  Skin grafting covers this large divot with skin and it will forever look like a large divot.  Or I can leave it open and in about 3 months it will be flat and covered with skin.  So I leave a large hole in the back of his leg for Gods design to take over and heal it.

The next guy I operate on is the guy I referenced a couple days ago that has epilepsy and fell in the fire and burned his toes on his left foot, well the three middle ones, and also burned the top/side of his head.  He has exposed skull that will not heal and cannot be skin grafted, and three toes that are floppy and have bone sticking out of one.  So in the operating room I slowly remove the three toes that need to come off and then I get to the interesting part, the skull.  There is a patch of about 3x5inches that is exposed.  Since this won’t heal the solution is to remove the outer table of the skull and leave the marrow to granulate.  So after prepping the head I get the drill and drill multiple small holes in the outer skull.  Then I use a rongour to nibble off the bone between the holes.  One hole drills quickly and a get a constant squirt of dark blood coming out about 5 inches.  Oh no, did I hit the cavernous sinus, a large vein just above the brain?  I hold pressure for a few minutes and every time i let go the same stream is there.  Dr. Steven has the idea of taking the bone shavings and shove them into the hole, so I do that and we hold pressure and continue work.  This eventually works and we finish up removing the outer skull.  Later that night I check on him before going to bed and and he is not bleeding and he is laying flat and i get him with head up like I want and head to bed.

It’s been a good interesting day.