Shanksteps of faith #6

administrator Greg No Comments

What an irregular day- it began normal and ended with me putting a chest tube in and taking a bullet out.  

The first surgery was a boy about 5 with a bladder stone.  Operating on the smaller ones isn’t fun for me as everything is small.  A small incision, a small bladder, a small opening- making it difficult to see and operate.  But I pulled a stone out of his bladder about 3/4in in size.

Next was a 65 year old woman with a uterine cancer as was seen on ultrasound.  I also did an ultrasound and just saw a lot of irregular tissue in the pelvis.  It seemed mobile so I decided to try and take it out.  Upon entering the abdomen, I find old blood and large old clots.  The bottom of the uterus seemed normal, but the top was very large.  I gradually worked around it and freed it up from the omentum and small intestine that were stuck to it.  Now it looks somewhat like the top blew out of the uterus.  We work down either side and eventually get to the end of the uterus and cervix.  I suture up the tissues and look for bleeding.  There is a little so I tie that too.  My resident, Anna, says there are studies now that say the fallopian tube can get ovarian cancer.  So we take the remaining fallopian tube, leaving the ovary.  I seem to remember that the ovary helps with osteopenia (weak bones) in post menopausal women.  

Audrey asks me to see a guy on the adult ward that has severe abdominal pain and has typhoid, and peritoneal signs (perforated intestine?).  I go to see him and he’s sitting up eating bouie (This is like a rice/flour/peanut porridge)  Hmm, If he’s really sick he shouldn’t want to eat.  He tells me his pain has been intense like this for two weeks.  He hasn’t been vomiting but once yesterday.  He has had some diarrhea, and also had some today.  He says he keeps down small amounts of food over these past two weeks.  His abdomen is quite tender with percussion tenderness, guarding and no rebound.  I’ve seen this before with someone here who just had very irritated intestine from their typhoid.  At the operation on that person they had red irritated bowel but no perforation.  I do a bedside ultrasound and see no fluid in the abdomen.  I order a upright abdominal X-ray and am told by one nurse we cant do those and only flat X-rays,  and by another we can.  I head back to the operating room where they are preparing my next patient.

I see a man in the pre-op area that has blood flowing out his foley catheter.  I ask the nurse who put in the foley if they blew up the balloon before or after getting urine/blood.  He says the guy has had frank hematuria for 4 days and worse the last two days.  There was straight blood coming out before he inflated the balloon.  I do a rectal exam and feel a very large prostate which is very soft.  Prostate cancer is my first suspicion and prostatitis my second.  I don’t know if prostatitis can cause frank hematuria.  I have the nurse put in a three way foley and start bladder irrigation.  Either way the type of prostatectomy I do, won’t help with a cancer as it leaves the capsule.  So I’ll treat him for prostatitis and hope that it stops.  I’ve had very poor internet while here, so I can’t look up things like I’d like to.

I walk back in to the OR and my next patient who has a pelvic fracture and a broken femur is sitting up because the anesthetist wants to put a spinal in.  I’m shocked that he sat up at the anesthetist’s insistence with a broken pelvis.  Since he’s already sitting up I tell Phillippe to go ahead with the spinal.  This guy was making mud bricks at the edge of a large termite mound.  They can get about 7-10 feet tall.  As he dug out dirt from it, it fell on him, breaking his femur and pelvis.  He came in with the traditional wood splinting.  I asked the nurses what the traditional healer would charge to do that and they guessed $40 equivalent.  We took off the splint and prepped his lower leg and I put a steinmen pin in the tibia for traction.  I’ll send a picture with either this email or the next with him in his bed.  It was quite a work of ingenuity, that involved a number of people.

Then there was a guy who had been about 10 hours north about a week ago.  There was conflict in the area and he was shot. Apparently he had a chest tube that was taken out and he made his way down here to be treated.  The nurse thought to get away from the area of conflict.  He has a whited out lung and a bullet in his back that’s palpable.  My student went away to the house of the guard to have some goat.  So I put in a chest tube in the OR and took out the bullet.  I got about 400ml of dark fluid (old blood) out.  I incised the area of his back with the bullet and pulled out what looked like a 223.  He was breathing better at the end of the procedure.  He walked to the surgical ward with his pleuravac canister in hand.

God, please give us wisdom to help these many different diseases and unknowns!

Shanksteps of Faith #5

Greg Greg No Comments

I walk into the OR (operating room) and they tell me that my patient isn’t ready.  It’s 10:30, and they’ve had plenty of time (since 8AM) to get them ready.  Im frustrated but hold my tongue.  They don’t llke to work late but also don’t start at any reasonable time either.  I go back out to the pre-op area to see some consults that are waiting while I wait for them.  I see a 8 year old girl with a huge cystic mass under her armpit.  It’s not painful and has been there about 8 months.  The cyst is getting larger and they want it taken care of.  What is it?  I don’t feel any nodes anywhere.  I ultrasound it and it seems like simple fluid with a couple small solid areas in it.  Is it a cystic tumor?  She has not been injured there nor any infection there.  So i offer to take it off, not knowing wether I will be helping her or not.  I don’t think Ill be hurting her.

I go back into the OR and Philippe has my patient intubated and asleep.  The patient has a transverse colostomy.  About 8 months ago he was in a town on the border of Sudan and was stabbed and had the ostomy placed at that time.  His records don’t show how much intestine is left nor where along the intestine the ostomy is so that I can plan what to do.  So blindly I start the surgery.  I go through the previous scar and get into the abdomen.  I’m into  a lot of adhesions.  All of the scissors in this package are horrible.  none of them can cut the tissue Im trying to cut.  I ask if they have any scissors that work and they only find one pair of eye scissors.  they were very small, but they cut.  After a while of cutting scar tissue, I found they had brought up the side of the transverse colon as the ostomy.  Likely the area that was stabbed.  I was able to take this down and make a repair.

Another consultation conundrum was a 22 year old guy with a huge neck cyst that was very soft.  It started at his jaw angle and went down to his clavicle.  I ultrasounded his neck and just fluid.  What is it?  I have no idea.  So I take his number and will see if we can come up with something and then decide whether to take it out or drain it.

The next patient has lost their records from before and also has an ostomy.  WOW, Im seeing so many ostomies here this time!  I operate on her and cut the many adhesions to try to find out where the part of the colon is to attach this part to.  After about an hour of searching I find what I think is the piece way down in the pelvis.  I have one of the nurses in the room do a rectal exam and sure enough it is WAY DOWN THERE.  There are no rectal dilators and no EEA staplers, and it is to low for me to make an anastomosis without this, so I have to abandon my efforts to try to reverse her.  When I tell the family postoperatively, they seem unaffected.  They ask if the smile train doctor coming in a month can fix it?  I tell them he won’t have the equipment either.

It is now 5PM and there is a 40 year old diabetic with a gangrenous foot.  I had seen him yesterday and asked the family to give blood and we would operate.  One person tried but was Hepatitis B positive so I asked them to get other family members to give.  We are still low on blood so we are trying to push all the operative patients families to give, this helps their loved one and also if we don’t use it- it helps the rest of the hospital for emergency needs.  Abouna gets the patient ready and as he has been doing surgery before I came thought about debriding it.  But he felt crepitance (gas in the tissues).  This is a horrible sign of gas forming bacteria and can kill someone quickly.  So I tell him a simple debridement of tissue won’t work and he needs his leg amputated below the knee.  I also call in his brother and explain it to him.  They say do whatever is needed.  In the operating room we don’t have a tourniquet, so the nurse wraps two urine catheters tightly around his leg.  He still bleeds a lot and I wonder if the tourniquet is just stopping the venous return but not the arterial flow- actually making it bleed more.  I get down through the muscles on either side of the bone and then get the bone saw to cut the bone.  This is a well used saw and isn’t sharp.  Anna, a FP resident here for a few weeks, tries to cut and then I take over and with a lot of effort, I saw through the bone.  I take a blade and cut off the rest of the muscles quickly and then control the bleeding.  I leave the area mostly open as I want to treat infection and evaluate for crepitance in the morning.

Tonights meal is rice with a peanut vegetable sauce.  I’m very hungry and it is delicious.  Audrey and I sit in front of the fan for the evening and catch up on our day.  We try to catch up each evening as this is one of the things that help us feel closer to each other.  Then it’s a cold shower (that’s all there is, and also all I want) then off to bed dripping wet.  Hoping I fall asleep before I finish evaporating. I awake this morning to some birds singing loudly outside my open windows before the sun has risen.

Shanksteps of Faith #4

administrator Uncatergorized No Comments

Im waking up shortly after dawn now which is my preference.  So i guess my brain has finally changed time zones.  I think it’s about a day per hour of time change to feel normal again.  I feel cool- wow that’s awesome,  it rained in the late evening and it doesn’t feel hot.  i guess my body is changing temperatures too.  I don’t know a time frame for my body to acclimatize.  A  couple weeks I think.  I drink a lot of water in the morning preparing for the day of surgery.  So I down about 1.5 liters.  Then head to the hospital worship.  though they speak french and I have difficulty understanding many times.  If someone is speaking to me I can communicate and understand.  After worship I make surgical rounds on my post operative patients.  I see about 20 people in various stages of their convalescence.  Some are there only for dressing changes as they heal their wounds from a wound infection.  Ive seen all the wounds the first day so I let the nurses do the dressings the rest of the week and just tell me if their concerned about one.  The prostatectomy guys all have bladder irrigation going and I decide who to stop and who to slow down.  
Then on the the crowd outside the OR.  People gather there that are family of those going to be operated on and also people who have paid the about $3 if they saw the nurse first and got whatever the nurse ordered in labs, or $12 if they only want to see the doctor.  I greet the crowd and some thrust their little medical booklet towards me.  I assure them that the nurses will get their “carnets” shortly.
in the OR things seem to be moving slowly and the patient is still getting IV fluids before their spinal anesthetic.  The 22 year old that had agreed to a hysterectomy the other day after what appeared like a cancer in her uterus- has now refused because she wants to have more children. So as they get ready the old guy with a bladder tumor, I go and talk to her.  I get my little ultrasound out and re-verify that I think it’s uterine cancer.  I see what is in the form of a uterus and appears very irregular.  So again I recommend a hysterectomy, for her health, and tell her she I doubt she could have a child with this uterus and that it will kill her with time and we should remove it.  She and her husband hear me out and eventually decide to proceed with the hysterectomy.  
An old guy with a tumor in his bladder that was seen on ultrasound is prepared and I operate on him. I ultrasound him a few days ago as well and saw what they had seen and so I chose to operate.  I make a vertical incision because i may need more exposure to take out the tumor.  It’s more anterior which should make it easier to get to than one posterior where the entry and exit is to the bladder.  I open his belly and go into the bladder.  Looking around inside- it looks very irritated but not anything that seems like a tumor, no stone, no thickening of the wall that is palpable.  So after really opening it and really looking around I decide just to close him back up and treat him with antibiotic for cystitis (bladder infection).  He was given blood at the beginning of the surgery because the anesthetist was worried about a lower hemoglobin of ?8.  I thought we should wait and see if I got into bleeding, but he gave it anyway.  I didn’t force the issue.  At the end of surgery he started to ooze from it seemed everywhere.  I thought of a reaction to the blood he received, causing his blood not to coagulate, so I texted the group of doctors here, and surprisingly it went through. (we’ve had very spotty cell service since being here this time).  they said we had dexamethosone as the steroid and cimetadine as an antihistamine.  So we gave him both.  I check on him later in the evening and he appeared to be doing well.
The young woman with a uterine cancer I take next to the operating room.  Her uterus is up to her umbilicus, that’s about the size of a 20 week pregnancy.  She gets the spinal then is prepped and I open her abdomen.  Upon entering the abdomen, I find a large mass.  Then I see some dark blood in the abdomen.  That’s not usual for a cancer.  Omentum and small bowel are stuck to the mass.  Slowly I free up the connections.  I then realize there is a small uterus stuck to the front of it.  So this is not the uterus, it must be a ectopic pregnancy.  this make me very happy!  An ectopic pregnancy (pregnancy outside the uterus) is only happy in this one instance, at least i can’t think of another time.  Now I will be able to leave her other tube and ovary and her uterus and she will have a chance of getting pregnant again.  Having children is the value of women here, so real important to them.  So I take out the bleeding ectopic and then the oozing won’t seem to stop.  I packed the pelvis and waited 5, then 10 minutes.  Still oozing, so I ask if we happen to have surgicel, which looks like a gauze that stops bleeding.  We do have ONE!  (I will need to remember to try and ask and see if I can get any from my hospital at home if we can get any surgicel for here).  I pack it into the pelvis and pack again, then when I check again it appears much better.  So i recheck the other places I stripped off, wash out the belly one more time and close.
In between surgeries I go out and see some consults in the pre-op/post-op area.  A guy is there with a tick in his ear.  I say how do you know its a tick.  He only answers that it is.  So I go back into the OR and ask if we have an otoscope.  I look in his ear and see half a tick and legs off that side, and it’s walking.  I ask him if it hurts, and he says it’s not bad.  I ask for some long sinus forceps.  Im able to reach these in and touch it.  This is a very sensitive area.  I tell him not to move and he doesn’t.  I can tell Im really hurting him but don’t know how to make it better but to get done.  I try to grab a leg unsuccessfully.  Finally Im able to pin it against the tympanic membrane and grab it and pull out the tiniest tick Ive seen.  He was incredibly tolerant of my getting it.  These people are amazing for their pain tolerance.  We have NO narcotics here.   So no matter what surgery I do- you get ibuprofen and tylenol, try that on your next surgery!
The last one I start at about 5 PM and it’s an ostomy reversal, so I know it will take a couple or more hours. Their belly is prepped, and I incise around the two lumened ostomy.  I free up the tissues down to and through the fascia.  As I pull it up to start to make the connection of the two ends, the appendix comes up too.  Well I guess I’ll take that too.  Then they won’t have appendicitis in the future.  i make an anastomosis with multiple stitches, about ?50.  Then I take off the appendix.  I finish a bit late for the worship that is happening at one of the other missionaries houses.  But I go check on a couple patients and go over there anyway.  They hadn’t really started yet, so I get to attend all of it after all.  
At home I have rice and beans that were prepared earlier that day and then shower and go to bed wet- hoping that I will be asleep before I evaporate.  I do, and don’t get any calls and get a good nights sleep- thank you God!

Shanksteps 2022 #3

administrator Greg, Shanks No Comments

I lay awake last night.  Is it still jet lag, or is it that I’m thinking about the 10 year old girl with the mouth mass, or am I still amped up after the difficult ostomy reversal I did till 9 last night with the hand sewn anastomosis?  I don’t know but i was tired and  couldn’t sleep.  Sometime about 1AM I drifted off and didn’t want to wake when I when my alarm went off in the AM. 

My first patient to operate on is the 10 year old with the mouth mass.  It took a while for Phillip to put her to sleep and then when he intubated her, he got the tube in pretty quickly- that was great.  Then she was prepped and drapped and I started.  Just prepping it caused it to bleed.  If her mouth had been open all the way it would have filled the opening, but it was a little off to the side.  The mass was dark pink and her tongue light pink.  It seems to be coming from the area of her teeth.  So I attempted to put a suture around the base of it and amputate it so that I could see what to do next.  The tie didn’t help much as it got stuck on her teeth and not really tight like I wanted.  So I just held pressure on either side of the gums and cut it off.  I cut away all the tumor down to the mandibular bone pulling the two involved teeth.  Then I used a rongour to nibble away at the bone to get all of it off I could find.  Then cautery and packing to get the bleeding to stop.  There was a large lymph node under her mandible on the same side.  I’m sure that was involved too.  So I cut through the skin, fat, platysma, and then shelled out the node and stopped the oozing afterwards.  After closing this one, the tooth area was relatively dry so I left the packing in place.  She was extubated and seemed to be awake and doing well when they wheeled her back to her room.

Another one was the 14 year old girl who I had seen with the breast cancer and B cell lymphoma that I talked about in the last shank steps (of faith).  Every time I see this girl she is only wearing a skirt and no top- which is usual here.  However the unusual part is she always has one or two hands up cradling the breast and when I ask she says it hurts a lot.  So she’s on the operating table and going to sleep.  Philleep can’t seem to intubate her and as I look over his shoulder he is traumatizing the area and it’s bleeding a little.  I ask if he wants me to try and he does.  So, thank God, I was able to get the tube in an we started.  Her breast was huge on the one side compared to the other.  I slowly excised the whole breast taking the surface of the pectoral muscle with it and in some areas that were hard with tumor, went deep in to the muscle.  I feel some enlarged lymph nodes in her axilla, so I take them out as well.  One just falls apart into goo as I try to gently grab it.  That one definitely had the cancer.  Now I have a very large open chest wall where the breast used to be.  So i had planned on doing a skin graft.  they have a large blade with a guard on it and I try to use it on her leg for the graft and make a mess of a few inches of her upper leg.  Then Daveed volunteers that they have a dermatome (cuts off half the layer of skin like the other was suppose to.  This allows the skinned area to grow back and helps new skin to start on the recipient area.) This dermatome is put briefly into the autoclave to warm but not to sterilize like other instruments, as it would ruin it.   I’m pretty sure warming didn’t help but that is what he does.   There are blades with it and I pick one that both of us think is new.  He says old (reused) and new are mixed together.  I pick one I think is new and use it.  The dermatome works great but the blade only half works, meaning it cuts on one side only.  So I make a number of small strips of skin to use.  Then there is suppose to be a machine that cuts small slits in to the graft to make a small piece of skin cover a larger area when it is stretched out.  That isn’t available here so I just use a scalpel and make slits all over.  it works pretty well and then the FP resident with me, Ted, does some and takes time and his looks much better.  We then put all these pieces over where the breast used to be and with a lot of sutures, and time, they are sutured in place.  

There is an old guy with a penile stricture that wants a repair.  It’s been a few years since I did one of these so I look up the post operative care and find that they need repeat urethral dilations every few weeks for life.  He lives a few hours away and though he says he will do it, I decide that it’s not best for him and that he should keep his suprapubic catheter.  He accepts this and I tell him there will be a Kenyan surgeon here in about a month if he wanted to talk to someone else about it and get another opinion.  He says he’ll come back in a month to find out.   

As I’m about ready to leave the OR one of the other doctors says there’s a guy who she thinks needs a chest tube.  We look at him together and do a bedside ultrasound with my pocket ultrasound.  Its not as good as a larger model, but it’s portable!  I can see that there is fluid about half way up the lung.  This ?20 year old guy was stabbed by a cow horn about a month ago and has gotten gradually a bit of pain and a little shortness of breath when he walks.  We put a needle into his chest and get out pus.  So I take him back to the operating room and walk Ted through the technique of putting in a chest tube.  After the tube is put in, there is no pleuravac, so we connect it to a urine bag which immediately fills to 1500ml of pus then some blood at the end.  WOW, that’s a lot of pus in the chest.  No wonder he was a bit short of breath!

Each day is a variety that is interesting.  Many advanced stages of diseases are seen here!  God help us help these people, give us wisdom to know what to do and how to do it!  Guide our minds and hands!