MissionDocs.org

Shanksteps Bere April #11

I started an audio book in the evenings called Cross and the Switchblade- about ministering to NY gang kids.  Im finding it hard to put down to write you all 🙂  I want God to use me like he did David Wilkerson.  Not for kids in NY but however He sees fit.

Today God is using me to help individuals here with their diseases that I can help with surgically.  I make rounds while I wait for the OR crew to get the patients ready.  I start at 8:30 after they’ve had their morning meetings.  At 7AM I went to the Hosptial worship.  It is singing a song in Nangere and then a worship thought that someone has prepared which is translated from French into Nangere.  Or vis versa if the speaker is Nangere.  During rounds I see the guy with the open below knee amputation that I amuptated for wet gangrene of his diabetic foot.  Now he’s granulated and free of infection so it’s time to close it.  I send him to the OR for preparation.  I check on the guy who had pancreatitis and had a lot of pus out his abdomen yesterday.  I see intestine at the wound site- oh no a dehiscence and eviceration.  I tape a dressing on him tightly and send him to the OR so he can be operated on today as well.  He just ate bouii, so he’ll have to wait till later.  The teen with the open neck wound and a feeding gastrostomy tube is doing well so far just very weak from lying around.  The kid with the leg burn that I did the release on is doing well but not walking yet because of pain. I encourage him to walk.  The old guy with head trauma still hasn’t woken up yet, so we continue IV fluids.  The family wants to give him water orally, I strongly discourage this as he will aspirate and then die, which he may anyway!  I see the kid that I opened the femur on for osteomyelitis drainage and do his dressing.  He tolerated it really well but screams at one point.  The people here are so tough!!  His mom cradles his head as I change his dressing.  There are so many painful dressings here, and we can’t take all of them back to the OR for changing as there is to much to do and I don’t want to give sedation I their hospital bed for fear they won’t be watched and could die.  They are used to doing dressings on the ward, and I do it in spite of the pain I’m causing him.  Of course him living with osteo that is draining at different points on his leg is also painful.  So he has dealt with pain a long time. 

 The first surgery is that of the below knee amputation.  He is given a spinal by David and then his leg is prepped and draped.  Then I cut off excess muscle and bring up the flap.  It has shortened some with time so it’s a little tight to bring up to cover the opening.  With a bit of effort and suturing, I bring the edges together leaving a drain going along the base  inside.

Next is a woman with osteomyelitis of her mandible with draining sinuses.  I explore this and nibble away at rotten bone.  Its is somewhat helpful I think but it’s really when there is a sequestrum (dead bone that has separated) that I feel like Ive really done something useful for them.  She also needs her teeth pulled that are the rotten source, I leave this to the nurse who does that.  Though the OR isn’t a bad place to do this!  I pack and put tape on the dressing.

Next is the older guy with dehiscence and pancreatitis.  I had pulled his pancreas drains a few days ago as they weren’t functional any more.  After his spinal, we prep his belly and opening with betadine. Then as I look in is see my suture intact all along with a rim of fascia just ripped off one side.  Did he do a sit-up and just rip it off, or did the pancreatic juice make the fascia weak, or was it the subcutaneous abscess that did it?  Likely a combination of all of this I guess.  Either way I debrede off the edges and take out the previous suture.  I re-close his abdomen with retention sutures and a fascial closure and leave the skin open for packing between them.  I hope this one doesn’t fall apart.  If it does he may need to be dressed open and I guess that will be the next surgeons problem as I leave soon.

Then there is a patient that hasn’t progressed as needed in her labor for a child.  So she is brought to the OR by Dr. Staci for a C-section.  As she does the C-section I see outpatients that have waited all day since morning.  In between seeing the patients with STD’s, infertility, neck mass, goiter, kid who can’t pee (stone), large inguinal hernia…

I go and check on how the C-section is going.  I see the local doc giving a mask to the baby who is blue and not breathing.  He is shoving the mask onto the face of the baby tilting the head forward and trying to mask him.  I ask that the oxygen be brought, and I take control of bagging the baby.  I tilt the head back to open he airway and mask effectively.  Pulse ox that I have put on shows oxygen saturation of 72 (normal above 92).  A nasal cannula is put under the mask and I bag for for a while till the saturation is normal and the kid appears to be breathing on his own without masking.  I explain to the students how to position the head for masking, and hope the doctor is listening.  I leave to go back to the consultations.  I see a older woman with a huge abdominal mass sticking out how her fat abdomen.  It’s likely a huge hernia that won’t reduce.  Another 27 year old woman has uterine prolapse after a delivery of a dead baby.  Another has vague abdominal pain that “starts in my legs, goes up my abdomen to my chest then back to my central abdomen”  I treat him for typhoid and worms. I often find descriptions of symptoms amusing and also difficult to figure out what to do.  But with limited meds, I choose what’s available and likely to help.  

God help the people I’ve seen today to heal and gain their health back.  Help them to know how much You love them!  Give me Your words to speak to them!

Shanksteps Bere April #9

It rains near by in the early evening and the air cools from 95 to about 86.  I sleep well.  I am called at 5:30 to see a woman who is 26 years old with RLQ pain since last night.  She says the pain is constant and strong.  She points to her Right flank.  She’s vomited a couple times.  Her tests show she has malaria and doesn’t have typhoid.  Though I know the type of typhoid test we have here is very inaccurate.  She also is not pregnant.  She denies any vagnial discharge and hasn’t had any problems with BMs or urination.  I ultrasound her and see a normal appearing kidney on that side.  I can’t see an appendix.  But based on her symptoms I think this likely represents appendicitis.  So I ask them to keep her NPO (nothing per Os.  Nothing by mouth).  Get an extra IV going and we will plan on operating on her this morning.

Later on Im told she is feeling better and doesn’t want surgery.  I think good, maybe I was wrong.  Then I see a text from Dr. Staci, appy lady, have I seen her.  She sends her over to the OR where I’ve been all day.  As I examine her she says she feels somewhat better and doesn’t want an operation.  I take this as a good sign, and decide Ill examine her again in the morning.

My first surgery this morning was an old guy with prostatic hypertrophy for a prostatectomy.  I wish I new how to do a TURP and had the equipment.  That would be best, but I do what I know how to do and it does help them.  I do tow old guys today in the same manner as Ill describe now.  They get a spinal anesthetic.  Then fluid is put into and distends their bladder displacing the intestines up and so when I cut down in the lower abdomen, I get to bladder rather than intestines.  His abdomen is prepped then I cut through the various layers to the bladder.  I sweep the peritoneum (covering of intestines) up and out of the way.  Then I open the bladder, sucking all the fluid that we had just put in there.  I stick my finger in the bladder and feel a large prostate.  Slowly I shell it out.  There are two large pieces.  My fingers and ligaments ache a bit as they really get taxed when I do this.  I close the bladder in two layers and then leave a sterile piece of glove as a drain, and close the rest of the layers.

The next is a woman who has cervical cancer and vaginal bleeding and keeps on dropping her hematocrit as we give her blood.  So I decide waiting isn’t helping her so I decide to proceed.  We give her two bags of blood then start the surgery.   As the foley is inserted it drains blood.  I re-look at her carnet (medical booklet) and it definitely says vaginal bleeding with mobile cervical cancer.  So I open her abdomen and find a small uterus.  And something hard in her omentum.  I take the hard part out of the omentum and don’t find any evidence of metastasis on liver or peritoneum.  I clamp, cut, tie down the sides of the uterus and each tie really stresses my fingers again.  These also stress my finger ligaments as it takes a lot of force to tie these tight so the vessels won’t bleed afterwards.  Finally I come across below the uterus, cervix across the vagina.  I look at the cervix on the specimen and it looks normal.  Hmmm, well sure doesn’t look like cervical cancer to me.  Back to ? Bladder cancer.  I can’t feel anything abnormal in the bladder.  But Ive decided even if I see a bladder cancer again I will likely not do any surgeries for it.  It is many hours of surgery and I don’t want to do anymore ileoconduits and don’t think it really prolonged their lives in the past.  So I close.  Even tonight as I type I can feel my index finger is tired.

I do the other prostate guy in the same way as above.

Then the last one of the day is a 20 something woman with huge swelling of her face she says has gone on 3 years.  And worse these past 4 days.  So does she have a cancer that now has become necrotic??  So many unknowns here!  I did an ultrasound yesterday and think there may be an abscess underneath.  With the most being right where the facial nerve lays in front of her ear.  Her eye is puffy and I think it must be pus.

While Im waiting for her to be ready I see many consults.  One sticks out in my mind.  It is a guy who has a cancer on his nose.  Dr. Denae biopsied and sent to Ndjamena and apparently it is a squamous cell carcinoma.  He smells awful!  His septum has been eaten away.  I think that if I do an aggressive resection I may be able to get it all but he will have a horrendous looking face afterwards.  Maybe if he survives, someone could do  a plastic reconstruction afterwards.    So I offer a very disfiguring surgery to them and the want it!  I have a difficult time explaining what he will look like afterwards, but they want to proceed.  I take about 45 minutes to explain.  They go to pay for the surgery.  God help me to get it all out and for it to be worthwhile for him to be disfigured like this!

The girl is ready and so she is given propofol and ketamine.  I cut into the side of her face in a way that I think won’t hit the facial nerve.  I stuck a needle in and so I know there is pus down there.  I go deeper and deeper and eventually hit pus.  It flows out. It was a significant pocket.  As I flush it out, the nurse thinks the fluid is going into her mouth.  Wow, these neck infections and dental abscesses are awful!  Ive seen so many this time.  I pack the hole and she goes out when she’s awake.  

Another dental abscess is draining on another patient’s mandible and we pull out a piece of dead bone out of her upper neck.  These people desperately need dental care!

I think there are only a handful of dentists in the whole country and likely most are in Ndjamena.

I will do the nasal cancer guy tomorrow.  God help me!! I need your knowledge! I’m so inadequate to deal with so many things here.  HELP ME!

Shanksteps Bere April #8 with pictures

Yesterday was different at the hospital.  There were a few surgeries scheduled and one lady for a hysterectomy had a low hemoglobin and needed transfused first, the other two or three ate that morning, so I suddenly had no surgeries to do.  I did rounds with the nurse and about 6 nursing students.  I looked at everyones incisions, opened all the dressings on those with chronically healing wounds, and it took about 2 hours to round this way on about 28 people.  The ward is full and I even saw a few that are living under the trees, discharged but Dr. Denae still wanted to check on periodically.  I got done early afternoon.

So I went and ate some lunch at Netteburg’s and then decided to go out to Bendele where a missionary friend of ours just flew in with his plane a few days ago.  He has a plane that can carry a number of people and still take off and land in a short runway.  I think i mentioned that i often come here with a perimeter spray to help with mosquitos and other insects that infest or eat a house.  So I wanted to offer to spray the missionaries house down there too.  So I rode a motorcycle down there.  It was hot but nice to be outside.  Im on Doxycycline for my malaria prophylaxis so the sun feels especially hot and I burn easier with it.  So by the end of the day Im a little sun burned.  I spray Deietrichts house.  Then I help in the hanger.  He wants to pull a large motorcycle down to the hanger from the hospital.  It’s not been used for years and he wants to get it going.  So we go back to the hospital on one other large motorcycle with a rope.  The one that’s been sitting has flat tires, and eventually we find a pump that works and then he pulls me motorcycle to motorcycle back to Bendele.  We don’t have a key for it so can’t do much.  We move planes around and get one that’s been sitting started and it needs a lot of work.  So i help with a few things till dark then head back to the hospital.  It’s nice to see long time friends again.

Today I did rounds and I had the patient with an open neck drink water while I watched his neck.  It poured out his neck.  His neck is finally starting to granulate as he is getting some nutrition.  So he has survived the infection, will I be able to convince the family not to get him enough food for him not to starve to death.  It’s hard for people to give adequately when it’s not going in their mouths.  They showed me the bouii (porridge) that they were about to give and it was scalding hot.  I told them it would burn his stomach and only give him cold bouii.  Since it’s Friday we only schedule a few cases as we expect other hospitals to refer patients in to us on the weekends when their doctors don’t want to work.  I guess there are 1-2 distant hospitals that do this at times.  So the first person I operate on is an older woman with a large lipoma (fatty tumor) on her back.  It is lobular and takes a while to get it all out.  She tolerates it well, and I though she would need sedation, but they said do it under local, and she did well.

The next was a a boy about 10 with osteomyelitis (bone infection) of his left femur (upper leg bone).  I looked at his X-ray and it appeared to be the whole bone.  He has had osteo of his fibula on the other leg and Dr. Denae had removed that a number of months ago.  Now he has pus coming out the side of his upper leg near his knee.  So the treatment of this in these rural locations is not months of antibiotics but open drainage.  So in the operating room he is given a spinal.  Then I make a long incision down his later upper leg and slowly go down through the muscles with cautery.  I get into a few pockets of pus.  To open the bone is challenging with the tools we have here.  I have a drill in a sterile pouch and a chisel. So I drill numerous holes in two lines down his femur and then use the chisel to get the bone in-between out.  This opens up the medulla and allows for drainage of the internal pus.  I worry about my chisel action cracking the bone across, creating an open bone fracture than he cannot walk on- likely ever again.  I’m grateful that didn’t happen.  Cleaned out all the medulla and packed a dressing into it.  He will be here for months of dressing changes now.

In the evening we all get together for Sabbath vespers at Netteburg’s house.  Vespers here is one of the highlights of my week.  We worship God with songs and words and say what we are thankful for this week.