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Shanksteps Bere April 2023

I go in this morning to see who is on the list for surgeries today.  There is a girl with an abdominal mass, a old woman with an abdominal mass, an old man for a prostatectomy.

The girl is about 8 years old with a abdominal mass that feels quite a bit larger than a soft ball.  She is on the OR table after her spinal anesthetic has been placed.  The mass feels mobile but attached.  I ultrasound it and find a solid tumor.  Is it a mesenteric  mass like Dr. Denae thought, intestinal mass, ovary.  More importantly will I be able to get it out or will it be stuck to everything and be unresectable?  I open her abdomen and am staring at a large mass.   It seems more mobile than I thought.  I open from pubis to above the umbilicus before I have enough length to get around this.  It’s huge for her little abdomen.  i get around it and pull up, it pops up through the incision.  YAY!  It isn’t stuck everywhere.  I soon figure out it is an ovary and the pedicle seems long and it has momentum (fatty layer in abdomen) stuck to it.  I clamp, cut and tie, the portions of the a omentum off and then do the same for the vessels leading to it, which are huge.  I take it out and then inspect the rest of the abdomen.  She has a few larger lymph nodes in the omentum.  These are probably metastasis.  So I take them out too.  I look at her liver, and peritoneum (covering of the abdomen) and don’t find any more evidence of tumor.  Her other ovary looks small and normal.  So we close her up.

The next older woman has more body fat than most here so I know she will be more challenging to operate on. I ultrasound her abdomen and find what I think is a large uterus and a huge fibroid in it.  I ask for them to interpret for me and find out if she wants more children.  She says she’s had 9 and doesn’t want anymore.  Plus she’s past the time of her period anyway.  So I plan on a hysterectomy or mass excision if Im wrong about its source.  As I go to see consults, Olen says.  Oh look at that, her blood pressure is 210/114.  She doesn’t know that she’s hypertensive and so we cancel her surgery and tell her to come back in a few weeks once her blood pressure is better controlled.  The staff look at me like Im crazy.  So I tell them the possible problems with it in the OR and they translate for her.

Next is an old guy who who can’t pee and has a large prostate on ultrasound done here and has a urine catheter in.  We put water into his bladder to distend it and clamp the foley catheter.  Then prep and drape him.  It’s been since I was here last, since i took out a prostate.  I make a low phanynsteal incision and go down to the distended bladder.  I open it and find a large prostate.  slowly I shell it out with my finger.  It’s always kind of difficult and taxing on the ligaments of my finger.  I change fingers a number of times as one starts to hurt.  I get out two large lobes and a smaller one.  The bleeding is constant as it usually is.  So I suture up the posterior area.  i put in a large 3 way foley for continual irrigation and close the bladder.  I start the irrigation as soon as i close the bladder in the first layer.  This irrigation will continue for days until it is clear enough to stop.  It is the only thing that keeps blood from making clots in the bladder and a need for reoperating.  

I walk through the surgical ward because I’m done earlier than expected.  I see the guy with the chest tube and people are propping him up and he’s breathing fast.  I check his chest tube and all appears normal.  there is fluid where there’s suppose to be and everything connected correctly.  There is about 1.7 liters of pus in the container.  His heart is racing.  I don’t see neck venous distention.  He’s sweating because it’s real hot today.  I want a chest Xray to make sure the chest tube is keeping the lung expanded.  I go and tell the chief nurse who is also the person who takes X-rays and does ultrasouds.  They run to get me and say that he’s not doing well.  There is a crowd of people out around him.  He is sitting on the ground and apparently passed out as they tried to walk him to the Xray.  He’s conscious, but real tachycardic.  There are a million things that could be going on.  Of them, what are some that I can diagnose or suspect to treat here?  I ask if he’s eating and they say no, and not taking much water either.  So maybe he’s dehydrated, I ask for IV fluids to be run in quickly.  He’s peed twice today and it was dark tea color.  His blood pressure is low about 90/60 sitting on the ground, and HR 120.  we carry him back to his bed and give him fluids.  I guess he can’t make it to the Xray.  No bedside Xrays here.  I check on him later with Olen.  We ultrasound his chest and Olen sees normal lung on the other side and consolidated lung on the affected side.  No pneumothroax (air around lung) and no hydrothorax (fluid around lung), and pus continues to drain out the tube.  As I feel his pulse again it’s less but now seems irregular.  slow then fast alternating.  Maybe he’s in atrial fibrillation.  We consider our only anticoagulant aspirin.  And decide to see if he is still irregular tomorrow.  This is the first time I wish we had ECG here. (no machine and those little pads- we use those up like crazy at home.  they don’t stick well at home, i can’t imagine they’d work at all here.)  

Shanksteps Bere April #6 with pictures

BEWARE_ The attached picture some may consider gruesome.  That is the reality here!

I’m adjusting a little to the heat but sleeping is still the hard part.  I go in and see my surgical patients while I wait for the first surgery to be ready.  I round on the ward that has about 20 people.  Here is a brief summary: There is the teen girl with bladder extrophy, multiple vessico-vaginal fistulae repairs, guy with a hippo bite to his arm with tendon repair, bladder stone boys, Achilles tendon repair boy after bicycle accident, osteomyelitis on the foot boy which is granulating. repeat repeat bladder repair after stone extraction. above knee amputation infection, and open neck teen.  Im called back to the OR as Olen has intubated my first baby.

The baby is about 1 year old and has a retinoblastoma.  That is cancer of his eye.  His eye looks very abnormal and appears to be growing out of his face.  I can’t remember if Ive taken out a retinoblastoma before in Cameroon or not.  I know Ive seen them before.  Either way I think of the possibility of a lot of bleeding deep in a hole I have difficulty of controlling.  I pray over each patient before operating and do the same for this baby. (I don’t like operating on babies!!  here they die to often of unknown problems)  After prayer I start by prepping the face and I scrub my hands with the bar soap that is available.  No normal surgical soaps available here.  I probe around the eye and realize the lower lid is invaded by the cancer but the upper lid isn’t.  So I save as much of each eyelid as possible to be able to put those into the cavity that’s left so that less granulation will be needed. to close up the space.  I gradually cut and dissect around the eye, initially its fairly easy but as it gets further deep in the hole of the eye socket it becomes more challenging.  Finally I’m back to where I imagine the optic nerve and vessels to be.  I place a right angle clamp and work it around the eyeball down to the base and clamp.  I hope I have whatever bleeder is there as I have to now cut off the eyeball to seee what I’m doing behind it.  I cut and there is no bleeding.  I realize as far back as I can go there is cancer or at least it looks like that to me.  I reclamp as deep as I can and take off a little extra cancer.  I see it also appears to have invaded towards the nose side.  I knew this was palliative not curative- but it’s still sad!  i suture in the eyelids as much as I can and pack the rest of the space.

Next one is a 7 year old boy who was burned down the back of his leg a couple years ago and has a large contracture from his buttocks down to his ankle.  It creates a large web of tissue going down that pulled his heal towards his buttocks.  His knee he cannot straighten beyond 90deg because of it.  So he stands perched on one leg like a flamingo.  I plan on a Z-plasty,  which takes the forces of contraction and changes their direction so as to not make the same contracture again.  I finish my rounds on the surgical ward as Olen intubates him teaching David while he does it.  Since it is hard to find surgeons and anesthetists to come here they are teaching local nurses to do anesthesia and surgery.  If you want to help in this way please contact me and I’ll put you in contact with Dr. Davenport.  I’m called after he’s intubated.  We turn him mostly prone and prep his legs.  I prep the second for a skin graft if I need it.

First I cut the cord on the back of his leg the part that is really contracted up and firm.  Then I gradually mobilize a flap of skin on each side.  I start making my cuts in these flaps and then have a hard time figuring out how to create the Z-plasty with them.  I ask Olen to open a book for me and my incisions are correct but I still can’t figure out how to make it look good.  Eventually i find an acceptable way but  it seems to have areas of tension and areas of laxity.  So I have probably chosen a poor location to do a Z-plasty.  I free up everything that feels tight and still the knee doesn’t go straight, even with a lot of pressure there is still about a 20deg bend.  I guess it must be his knee then.  so I continue closing, which takes me a long time and a bunch of suturing to get this closed. There is a small open area left at the top so I fashion a piece of skin I cut off into a skin graft and suture it in place.  I put his leg in a splint after placing a large dressing.

There is a guy waiting in the consultation area that Olen says needs a chest tube.  While my next patient is being gotten ready I take this guy into the other OR and place a chest tube.  As soon as I get it in he takes a huge breath and coughs.  Pus from his lung space spews out the hole and all over me and shoots out the chest tube hitting boxes and the floor about 10 feet away.  This is disgusting!!!  I suture it in place and he continues to cough but now I’m ready.  I’ve had coughing later as the lung expands but not at the beginning like this.  I put a dressing and hook up the reused reused pleuravac.  I put him to suction and it appears to be working.  I attack the little foot pump suction I brought here last time and show the family how to pump it to create suction.  Later that evening he has put out 1500ml of pus into the pleuravac.

The last guy of the evening is the teen with the open neck that I wrote about a few shanksteps back.  The one who necroses the front of his neck with infection from a tooth abscess and when he eats it comes out his neck.  He his for a feeding gastrostomy tube.  He is given spinal anesthesia and sedated a little unintentionally.  The nurse didn’t realize that one of the IV bottles had Ketamine- even thought it was written on it, and gave it quickly.  So he was out of it too.  Fortunately he didn’t stop breathing and didn’t need to be intubated as that would be disastrous, as he can barely open his mouth.  And a tracheostomy in the open pus field would be awful.  The G-tube part of it went well and he went back to his room.

It was a long day.  A cool shower was awesome!

Shanksteps Bere April #5

In the late evening Im asked to see a guy with significant abdominal pain.  He says it started in the upper abdomen and then progressed to everywhere.  He’s quite tender in the upper abdomen and seems distended.  he has an inguinal hernia that is easily reducible.  He says he hasn’t passed gas but did have a liquid BM that day.  He’s had nausea but not vomited.  Then nurses had asked for an ultrasound and I think instead he needs a abdominal X-ray.  On the X-ray i don’t see any evidence of obstruction nor free air.  So I decide to treat his typhoid and see him in the morning.

In the morning he is still very tender and I think I should do a Bere “digital CT”.  Meaning digital (finger) cut and touch.  So i ask that he be the first one fo the day.  So they get him ready and I open his abdomen.  I get a bunch of fluid that i think looks like it may have come from the stomach.  So I go there first.  I look all over the stomach, front, open the back area, follow down the duodenum around the C curve of the duodenum. It’s difficult and it takes a while.  I find areas of inflammation and swelling in the tissue but no hole.  I run the small intestine from start to finish and see no problems.  I finally realize that everywhere Iv’e seen the inflammation has been most near the pancreas.  So that’s his diagnosis- pancreatitis!  I feel the gallbladder and don’t feel any stones.  It’s also small and not distended so I think i get a pretty good feel.  So i put drains in and close him up.  We don’t have any pancreas labs, so will have to rely on how he feels and when his intestines open up.  But there is nothing to do but watch and wait and hope that he heals.  Im praying for many of my patients.  God heal him!

The next patient Dr. Denae did I assisted her on.  It was a 30s year old woman with cervical cancer that was very hard and filling up the exit of the uterus.  She was bleeding and her baby was about 30 weeks along.  She had broken her water the day before and contractions had started.  So we needed to do a C-section because this baby had no way to be delivered vaginally.  The patient is having a lot of back pain and can’t sit.  So dong the spinal is very hard and we attempt to do it as she lays on her side.  The nurse tried, I tried, Olen tried- no go.  So we gave a bunch of local at the incision site and started.  We wanted to give the Ketamine at the last second so to have minimal effects on the baby.  We got our a crying normally formed baby.  In the lower uterus there was very soft tumor that was bleeding.  We closed her up and pray that she stops bleeding to have some time with her child before the cancer takes her.

The next one is a guy who had a bladder stone.  It was removed her about 2 weeks ago and then the urine catheter plugged up and overfilled the bladder.  Then the front repair fo the bladder ruptured.  So he was taken back and repaired again then developed a leak about a week ago. Now we took him back to repair that leak.  It was terribly stuck and difficult to create any planes of tissues that could be evaluated for closure.  Gradually we found layers to close.  We flushed the catheter with fluids and it didn’t seem to leak, so hopefully it will stay that way.

The next one was a woman who had an injury to her middle finger and the middle joint was stuck straight.   So when she made a fist it stuck out and was in the way.  So I offered to take it off completely or leave her with a small stub that may help some.  So she said a stub would be ok.  So i numbed up her finger at the base.  Once here finger was asleep, I cut through the tissues down to the bone.  then I nibbled away at the bone with rongours.  Made the end smooth then sewed the skin edges back together.

More happened than that, but that’s what comes to mind.  Pray for staff and patients here that they would really know God and follow His lead in their lives.

Shanksteps Bere April 2023 #4

Today is Sabbath, we go to church.  I woke at dawn about 5:30.  Fortunately they didn’t turn off the generator this morning, so I lay there in the fan for a little while.  I get up and drink a liter of water and shortly thereafter Im thirsty again.  I drink lots of water all day.

I go in to see the surgical ward before going to church.  I ask the on call nurse if there are any concerns and there aren’t.  So I go with the nurse and the students to the one patient I want to do the dressing on- the teen with the neck infection where I can see all the muscular neck anatomy I talked about last shanksteps.  He still says that when he swallows that fluid comes out his neck.  I change his dressing and see a fair amount of pus and saliva on it.  Though that is a little difficult to tell exactly.  But i have yesterdays experience to know that’s so.  I change the dressing and then talk with him and the guy with him that we need to place a feeding tube.  They seem to understand, but the ones that can make that decision- the older brothers- aren’t at the bedside.  So I will need to explain it again later to them.

It’s another sunny, hot day here.  At 8AM the temp on the little thermometer I brought reads 94.  I don’t feel sweaty as long as I’m not moving and sitting in front of a fan, but know Im evaporating constantly.  

I go with the Netteburg to the church with the kids under the mango tree.  We drive there in the truck with me and the kids standing in the back, sun beating down on us.  It’s nicer in the breeze than the inside of the truck i imagine.  People walking along the road are enveloped in the dust cloud behind the truck.  Little groups of kids playing under trees near the road wave and yell “nasara”  their word for white person.  Nnaasssaaarrraaaaaaaa…..  It takes about 15 minutes to get there.  We pull up under some large mango trees and kids and adults flock around.  As we get out of the truck they ask if I’ll tell the kids a bible story.  I’d like a little more time than that to think, but agree to do it anyway.  Olen starts with singing with the kids songs that they have sung many times.  the kids join in exuberantly with singing and the motions.  When they are done singing, I tell the biblical story of Jonah and his hearing from God what God wanted him to do and Jonah choosing to do something else and run away.  And how God saved his life and brought him back to doing Gods will.  It took about 15 min with the translation and me speaking in French.  Denae repeated the story with questions along the way and the kids were very excited to respond with the answers.  Each kid who answered got a sticker. They were very excited.

We drove back home and hit a few dust clouds too as we passed some larger trucks taking the same road.  It appears they are doing some sort of road repairs.  It’s a weird time to do dirt road grading and repairs just before the rains start and they get destroyed again.  At home it’s 110 outside and 100 inside.

We gathered early afternoon for a potluck meal.  Food was excellent as I always find it at potlucks.  And as far as I could tell everyone had food.  We were thinking about walking around afterwards but there was a patient that needed to be watched as her labor progressed so we didn’t go out, had good conversations and played with balloons with the Netteburg boys that were left over from the wedding party.

Later on there is a patient who came in pregnant and wasn’t progressing and was found to have a dead fetus.  She was followed and given pitocin and still didn’t progress.  So when a C-section was needed, I offered to do it, so the other doctor could have some rest.  Olen did the anesthesia and Douri assisted me.  The baby’s head was high and not descending.  She had received enough fluids via IV so Olen placed the spinal anesthetic.  We prepped and dropped her abdomen and I did a phanynsteal incision (low transverse above pubic line).  I went in through the skin, fat (very thin), and split the rectus muscles opening into the peritoneum.  The uterus looked normal. I opened it in the lower section transversely. It was difficult to get the baby out.  I found the head was large and deformed.  So the head was likely to big for this woman’s pelvis.  I put clamps on the uterine edges to slow the bleeding.  Delivered the placenta, then started to close the uterus.  After controlling the bleeding spots, I saw a hematoma forming on the left side.  I opened the hematoma and put some sutures there.  The left uterine artery had torn when I pulled out the large head of the baby.  When there was no more bleeding then I closed the rest of the layers of the abdomen and she went to the maternity ward.

After a night surgery it takes me a while to wind down to be able to sleep.  Im able to text with my wife at home and finally when I feel tired I go to bed.   I got in bed around 1AM and lay there till about 3AM my brain going about random things- frustrating!  At 5:30 IM called about the patient with his neck open with infection.  He is bleeding from his neck again.  I race in and find he has about half a liter of blood clots in a basin in front of him.  It is coming from his mouth and doesn’t appear to be from his nose nor his outside neck wound.  Is he bleeding from his jugular vein?  I can’t see anything in his mouth bleeding and don’t think looking in his throat would help me even if I identified the spot on the inside.  I wouldn’t be able to stitch it… It appears to have stopped, so I order a hemoglobin and send the family to be tested for blood type in case we need to give him blood.  His previous hemoglobin was normal at 15.

I try to sleep again but it is impossible.  I am never able to sleep in the daytime.

God give me Your wisdom to know what to do with this boy. Help him to stop bleeding. Heal his terrible neck wound.  Help this boy to know Your love for him, and use me however you want to use me.