Shanksteps #10

administrator Greg, Shanks No Comments

It’s Monday and my last day.  I’m doing a hysterectomy and I hear there is a woman who is out there that has a neck infection.  Oh no, another one?  Most commonly from a dental abscess that’s untreated a long time.  Its near the end of the day, and in between cases I go out to look at her in the pre-op area.  The whole area smells aweful!!!  She is laying on the one bed in the area alone and semi conscious.  I call the family in and tell them to stay at her bedside so she doesn’t fall off the bed.  I look over her and they say she has been sick about 2 weeks and in an altered mental state for three days.

So I ask myself why bring her in now?  Because they have had pressure by family or friends to bring her in.  They have already tried the traditional healer (witch doctor) and not gotten better.  And now that she is ready to die, they bring her in so that she can die at the hospital and they will be able to say they’ve done everything they could.  So that the neighbors and distant family will not criticize them.

Well at this hospital we operate on emergency cases without requiring money first.  That sure is a great thing, because they would never give money for her in her condition- they know she will die.  I KNOW SHE WILL DIE.  But it is God who can do something about her situation that we have no control over.  I pray for her and send the family to the pharmacy to buy medications…  I ask the “nurses” to start an IV and get fluids going.

I do my last surgery that was scheduled that day and come out to check and see if she is ready.  The family didn’t go to the pharmacy, as I anticipated they wouldn’t.  She does have and IV and we take her to the operating room.

I will not attach pictures, but if you’re interested you can email me at my usual email directly and I can send some.  They are graphic and disturbing of the reality of her surgery.

What follows is graphically descriptive- if you do not want to hear it- then skip the next paragraph.

GRAPHIC paragraph- I want Phillippe to give some ketamine, but he is concerned about her airway as she can’t open her mouth because of trismus.  If I push on her neck she will slowly grab my hand a push away, but definitely altered consciousness.  Im going to be debreding her neck so I think a trach is a bad idea.  He doesn’t think a nasal intubation is a good idea.  So to say there are no good options.  He finally gives a whiff of Ketamine and we start.  She groans at each cut but is less conscious and will not remember this.  The resident, Anna, who is with me does a lot of the debreding.  It is a horrible process. We open where there is a open area of her neck with pus and grey tissue.  At each movement more of the dead smell wafts out.  We start cutting off dead tissue and go from her left ear, down her neck to her upper chest.  We can put our finger undreneath all along this area easily.  Underneath this flap of semi-dead skin, there is a grey layer of fat, then under that some black muscle and some live muscle.  The platysmus muscle is partially alive a and partially dead.  We end up taking off all her skin in an area of about a 10 x 10 inches of chest in the center and then back up the other side of her neck to her other ear and a little on the side of her forehead, then around the base of her chin to complete the area.  We then take off all the grey and dead tissue we can get off.  All while she is groaning at times and Im asking Phillippe to give a little more- which he doesn’t want to do.  As he is conservative with it, she does breath fine and keeps her saturation up during the entire thing.  We take off a little more skin in some areas and the area is looking and smelling better.  (Im grateful in cases like this, that my nose doesn’t work as well as some peoples)  So she survives the surgery and as we bring her out to her family with all the dressings covering everything.  I tell them it is their turn.  They brought her here to die, but I have asked God to heal her and help her live.  They need to go to the pharmacy and get the IV and medicines that she needs now!

We leave the next morning.  I hear that she survived. Then a couple days later I hear that a NG tube was put in for feeding and later that day she died.

The other girl with pus coming out her mouth and ear is doing well and has minimal pus on the dressings now.

Shanksteps of faith #9

administrator Greg No Comments

The 18 year old girl with pus coming out of her mouth and ear- from her jaw; is still alive!  Praise God!  She still has trismus and can’t open her mouth far, but seems like she’s a little better.  I saw her on rounds today.  There is still pus on her dressings but seems better.  

Have I mentioned that I have to operate often on suspicion rather than a diagnosis?  Have I also mentioned that I find it hard to operate on missionaries without all the information I’d have in the USA?


Friday afternoon I hear that D (a missionary here) has abdominal pain and has just returned from a trip for supplies in Moundou.  Should we treat him for travelers diarrhea?  Well I need more information, so I have some time and so I go to talk to him in his house.  He is in pain and moving around a bit.  He hasn’t eaten anything on the trip and only drank bottled water.  But he does have significant abdominal pain.  He says his pain started early that morning, and started all over the abdomen, and is still all over.  I examine his abdomen and find it’s definitely more tender in the right lower quadrant.  It could be: appendicitis, a tumor, a blockage, typhoid, kidney infection…  We start an IV and get him some IV diclofenac.  I also start empiric antibiotics.  Later I go to evaluate him again and his pain is much better, but now in the right lower quadrant.  I then think it’s appendicitis.  We talk about operative and non-operative management.  He wants to accept the risk of recurrent appendicitis and have non-operative management if it will work. He’s quite tender all over but I don’t think he has generalized peritonitis.  I pray for him, for healing and for wisdom as to whats best to do with him. One of the nurses takes care of him all night.

Sabbath morning I go to check on him again.  He is much better and pain remains now only in the right lower quadrant.  I’m content he is improving.  I check on him a number of times that day and he seems relatively the same but maybe more distended.  I wonder if he is really getting better with antibiotics or now not?  His typhoid test is normal (about a 50% accurate test, so NOT accurate), and his white count as read by counting cells is 5.  Various missionaries hang out with him all day, and another nurse continues to give him his meds.

Sunday morning  I go to see him and he seems a little worse with pain in both sides of lower abdomen.  I consider this a failure of non-operative management.  He also just vomited before I arrived, about 500 mls of bile.  He wants to talk to the other missionary docs before doing anything else. I go outside and am able to get a signal and talk to his wife and tell her I think he should be operated on right away.  I go into the hospital to make rounds and inform the others.  After rounds I go back to see what the discussion has been.  He’s been walking around trying to see if that would help. It hasn’t.  One of the other docs did an ultrasound looking for the appendix and found fluid on the right side.  Then all three of us docs go and talk to him together.

We discuss that MAF has the ability to fly him to Ndjamena, there is a Air France flight that night and he could be in France by the following morning.  The other option is for me to operate.  I try to make it real by telling him, with these circumstances, I’d be operated on here.  The other two docs are divided as to whether they’d stay or try to get to France.  He contemplates it for a while and decides to accept the risks here rather than the risks of travel (someone would have gone with him).

We are all suppose to go to one of the Chaddian workers houses to eat lunch, because she invited all the missionaries to come.  We have to cancel this just as we were suppose to be there- what a bummer!  We head to the OR ahead of him to clean it real well and get it ready.

After cleaning I head back to his house and he decides to walk to the OR.  We have a wheelchair at the ready in case he changes his mind.  About half way there he uses it.  He’s a tough one.  

We prep him and I make the incision.  He is getting Ketamine and Valium as some of the missionaries were concerned about Phillipp’s general anesthetic, and I know Ketamine will work if he gives enough- he’s a bit conservative with it.  D is light with it and I keep asking Phillippe to give more.  We have some propofol so eventually he gives that.  The other doctors are at the head of the bed too, monitoring vital signs…

As I open his abdomen I find dark serosanganous fluid. I feel around the cecum and can’t feel an appendix.  Then I fell a little release and a loop of maroon bowel comes up.  I can tell a band of tissue had been across it cutting it off and leaving a line on it. So it’s either a band partially blocking his intestine or could be a bad patch of typhoid.   I feel around and can’t feel anything left that’s unusual.  I realize his appendix is tucked behind the cecum.  So I free it up and do an appendectomy.  At least that won’t be a confusing factor in the future.  I look around and find nothing else abnormal.  Now I’m worried if he will heal his typhoid or perforate in a few days.  I close him up and we take him back to his house where one of the missionaries will be with him constantly for many days.

UPDATE:  At the time of sending his bowels are opening up and he is starting to drink and advance his diet.  I thank God for his healing.

Shanksteps of Faith #8

Audrey Audrey No Comments


Audrey here. I don’t usually write much because Greg’s stories and pictures are so much more interesting.  I figured I should at least say a word before we leave on Tuesday so y’all wouldn’t think I did nothing. 🙂  I have been rounding every day on pediatrics and medicine wards.   Peds  can be extremely sad or very rewarding. The majority of the kids come in very sick, but after 2 days of treatment (usually for anemia and malaria) they are feeling better and running around. It is wonderful to see so many kids turn around so quickly and go home.  Of course there are some that come in very late, or very sick; often convulsing and sometimes with a hemaglobin less than 1g/dL. It is amazing how many of these kids do well with a transfusion of blood and a couple doses of quinine.  BUT there are the kiddos that succumb, and don’t make it home.  Those are the sad days.  The adults on the other hand seem to NEVER get better. This week I had a full ward of men and women, all with ascites from various different causes. Some had liver cancer, some cancer of the spleen. Others had nephrotic syndrome, or Congestive Heart Failure.  In others, the cause was a life of drinking way too much alcohol (usually rise or millet wine- bili bili). There are others with hepatitis, or HIV, or Schistosomiasis.  Almost all the adults I saw could have benefited from lasix to pull some of the fluid off. BUT… the hospital doesn’t have any. So… they were all sent to the market to find lasix. Some is probably legit, others may be blackmarket or not lasix at all. When I finished rounds Friday, I had 12 adults on the wards. This morning (Monday) there were only 2. The rest just disappeared. Discharged, or ran away without paying the bill. Two women last week had seizures and went into comas due to low blood sugars. I found one, Greg the other. Both came out of it with a bolus of dextrose and a bit of sugar under the tongue. Neither were there this morning.  I have heard that they both died when they arrived home. Some left to go to the witchdoctor? To try traditional treatment? I will never know.   Today I was called to peds to examine a 13 yr old girl who was “violated”. The story was a bit difficult to figure out. As well as I understand: The 13 yr old is brought by her father to find out if she is still a virgin. The father says this boy had sex with her. The girl says she had sex with the boy.  The boy denies everything. I am supposed to be the “tiebreaker”.  Is she still a virgin? Will she bring shame to the family?   I explain that even if her hymen is no longer intact, it is impossible to determine if it was from sexual relations, or riding a bike, or using a tampon, or, or, or… The father seems to understand but still wants her examined, and the results documented. Their plan was to take the boy to the police if the girl was no longer a virgin.  Can you imagine doing that in the US? One amazing story that I can tell you about my time here is about a little baby named Toungou. She is a twin, born 3 weeks before. I met her.  She was brought in to the hospital after being taken to 2 different health centers for 2 days of convulsions.  When I saw her, 2 of our volunteers here (an RT and a PA) had been trying to ressussitate her. She had stopped breathing twice already and had been bagged and given CPR.  We checked her sugar, which was normal. Hemaglobin was normal. Malaria smear was negative. No nuchal rigidity or bulging fontanelle. I helped bag her for several hours. We would stop, and she would breathe on her own. Then the breathing stopped. The heart slowed and stopped. She was pronounced dead. For 30 sec, 40sec…Then she would convulse and start breathing again. She did this 4 times and we decided that she really wanted to live.  Fortunately, the midwife here, who is also doing amazing things with preemies and very tiny babies, has a portable cpap machine. Little Toungou just needed to keep breathing to trigger the machine. She was given Rocephin, Dextrose, and put on cpap. Mom agreed to have us take care of her in our homes, so she spent every moment with one of us volunteers. Nights at one house to be watched carefully; days elsewhere.  I was fortunate to be able to hang out with her after rounding until she went home with someone else for the night. Within 3 days she started to look better. She was no longer seizing. She was being given mom’s milk by tiny NG tube. She was still receiving Rocephin for probable meningitis.  After 4 days with us night and day, she was given back to mom to take care of during day, and just spending nights with one of us.  After 6 days, she started breastfeeding on her own. The NG tube was removed and she went home yesterday. Glory Be To God!
I am now sending this from the capitol of Chad, N’Djamena. We are on our way to spend 3 days in Istanbul before flying back to Oregon. This has been a difficult trip for me (maybe more to follow), but baby Toungou and many of the other kiddos have made it beautiful as well.   

Shanksteps of faith #7

Greg Greg No Comments

Horrible details follow, read only when you’re ready to be touched by someones hurt.

She is 18, she has pus coming out of her mouth.  She cant open her mouth because of a muscle spasm called trismus.  She is laying in the pre-op area and the whole place smells like horrible pus.  She appears to be in pain and has the very sick look to her.  Some of you will know what this looks like.  She has had dental abscesses for a week or two.  They brought her here on a two wheeled push cart.  They put the cart “en gaauge” to pay for her medications and treatment.  This means they have money coming but that the cart is the security that money is coming.  As she lays on her side I push around on her neck and she spits out some more thick pus.  She looks swollen like a chipmunk in her cheeks.  I feel they are both very soft around the mandible.  This pus near her mandible must communicate with her mouth.  She is the last surgery of the day and we take her back to the OR beating off the flys that accompany her.  Phillippe doesn’t want to give her any anesthetic as he thinks this will kill her.  I tend to agree that intubation is impossible, a tracheostomy has killed two patients here that I know of in the fact that they eventually mucus plug and the patient dies of asphyxiation.  Ketamine may be risky, I think a little would help.  He doesn’t want it and I don’t push. 

As I look over her face and neck, I push on the left chin and more thick pus flows out of her ear.  WOW!!! This is horrible.  I certainly do not think she will live through this.  I put in the local anesthetic after prepping her with betadine.  I cut in about a cm and don’t get pus like I expected by palpation.  So I use a syringue and needle and aspirate deeper.  I get air first, and this happens twice.  Oh even worse than I had thought.  She has gas, necrotizing bacteria.  God, I pray out loud, help this girl, heal her God, she will die unless you heal her!! If it is most merciful to let her go, then do it, otherwise heal her!!

I cut deeper and chunks of pus flow out.  I put my finger in and feel around the angle of the mandible, and then down her neck.  This is a big pocket.  I incise the lower part to of the pocket.  All of this is causing her pain, and she’s groaning with each push of my finger.  I irrigate out the hole with Dakins solution (a dilute bleach solution).  MORE pus and blood flows out.  I pack both holes and the bleeding subsides some.

The other side I decide to start lower at the angle of the mandible.  I inject lidocaine and incise.  Pus flows out of the hole Ive made and as I stick my finger in to feel the size and extent of the pus cavity, pus flows out her ear again.  So she has pus up the the base of her skull and it’s  coming from her inner ear out.  I flush and flush this one too.  Then I pack it.  Her heart rate stays about 140 and has a blood pressure in the 90’s.  She got Amp, Gent, and Flagyl.  Wish I had some clindamycin.

The nurses take her to the ward where she’ll sleep on the stretcher for the night because there are no beds on the surgical ward available.

GOD HEAL HER!  THAT’S  HER ONLY CHANCE!