Shanksteps #2

administrator Greg, Shanks No Comments

Am I too jaded, calloused from being overseas and seeing too much death and terrible diseases?  I think I want to feel what Jesus feels when He looks at our pitiful state here on earth.  I want to have His compassion and love for those around me.  And partially I do, but I also have gotten more calloused, maybe a protective barrier to patients plights in Africa.

Yesterday I evaluate a girl who is 14.  she is a thin girl with a gigantic breast mass that is painful.  She has a history of some kind of cancer that was diagnosed during an abdominal surgery. A piece was taken to Poland and pathology from them just came back with B-cell lymphoma.  she came in this time because she heard on the radio that I was here.  She wants the painful breast removed.  As i see her, I note a huge breast on one side and a tiny one on the other.  I feel her abdomen and she has masses in there too. I’m sad as I evaluate her.  I don’t know if a mastectomy will help or hurt her.  No chemotherapy is available here.  It may help her pain for a while but will it heal?  It does seem a little mobile from the chest wall, and that may be a good finding.  Or it could  be attached to the muscle and the muscle moving.  I tell them I’m willing to do the surgery and give them the most likely postoperative events.  Today she is laying in her bed just holding her hurting breast, stone faced without a sound.  When I ask she says it hurts.  The dad is in Ndjamena and they are waiting for him to send the $80.

Another one came in because they heard I was here, and she has a mouth tumor that has been present for 2 months.  She appears about 10 and the tumor is on her lower teeth and is about the size of a medium sized lemon.  I run my finger around it and it starts to bleed.  I give her a gauze and she spits blood for a while, while they hold pressure.  She also has a few enlarged submandibular lymph nodes.  So likely spread to those as well.  I don’t know what this would be but would be awful to have that in the front of your mouth bleeding and making it difficult to eat.  I plan on taking this out tomorrow, and Im worried about blood loss, and how soon it may come back.  God help me do what’s best for her!

Todays surgeries were a prostatectomy, an abdominal hysterectomy on a old lady with uterine prolapse, an involcrum window and trying to drain pus of chronic osteomyelitis going on 10 years, and exploration of a guy who presented with peritonitis.  He had 3 days of pain and yesterday intense pain everywhere.  The ultrasonographer thought of appendicitis. I’m thinking , it could be: appendicitis, typhoid perforation, gastric perforation, perforation colon…. So which incision to make.  We need a CT abdomen.  Instead i’ll do the Chadian Digital CT.  Digital (finger) Cut and Touch!  So we fit him in between the other surgeries.  In the OR Phillip puts in a spinal and David puts in a urine catheter and preps the abdomen with butadiene.  I wash my hands with the bar of soap that is available.  No other hand scrub is available now.  I make a midline incision in the center of the abdomen as I don’t know wether I will need to go higher or lower as i don’t know what’s really happening inside.  I get a little bit of pus when Im in the abdomen.  I feel around and feel an enlarged appendix so I extend down the abdomen.  I can see that the side wall of the appendix is blown out.  So after freeing it up, I tie it twice and take it off.  then I make a purse string around it with suture and duck the stump in.  Then we (Ted an family practice resident and I)  irrigate the abdomen a lot with saline.  Once the fluid we are sucking out of the abdomen is clear we close.  

I go home an find a number of people in our home.  There are many short term volunteers here at the moment.  a couple  are physical therapist, a PT, a couple family medicine residents, and then the missionaries that are here.  We have hired a guy to cook a meal in the evenings for us so that when Audrey and I get home from the hospital there is food to eat.  So we asked this guy to make more for about 10 people. So we are eating in the evenings with a number of people.  It makes for better community and a meal is sure nice when we are done with work.

Shanksteps 2022 #1

Greg Audrey, Greg No Comments

Shanksteps 2022 #1
Here we are again on another trip to volunteer in Africa.  We are going to the same hospital in Chad we’ve been to a number of times.  Currently there is no general surgeon there, and hasn’t been for a few months.  If you know of any general surgeons who want to go and live in Chad, one or two are very needed.  (They could contact me for starters).  
We leave home Tuesday and stay in Eugene to catch the 5AM flight.  Then to Seattle for a long 12 layover.  Then a 9 hour flight to Istanbul.  We are there a couple hours then on to Ndjamena, Chad on a 8 hour flight with a stop in Niger along the way.  Each flight is progressively more “african” in nature.  By the last flight there is no calling of sections to load the plane.  Everyone just forms into a mass of people jockeying for a position at the area where you go past the attendants taking our boarding passes, and we know this so we stand near the front and end up in the first quarter of people loading.  this is advantageous because then there is still luggage space above to put our carry on luggage rather than it taking up floor space near our feet.  
We land in Ndjamena on Friday at 2AM and go through immigration and customs after collecting our baggage- which all made it! then on to find our driver L.  He has picked us up many years of going there and is always punctual and has also arranged for us to be able to change money at this hour of 2AM.  L is definitely more expensive ($40) than he used to be, but still worth it to have someone we know waiting for us.  We ask him what bus we should catch from Ndjamena to Kelo- and he recommends the 5AM bus.  We like this bus because its a large one with a defined seat and has airconditioning that helps some.  so we could go to the mission we were to stay at for an hour or just go to the bus station.  So we decide to head to the bus.  the streets are empty but at the bus station there is plenty of people getting ready to travel and others trying to sell their wares to them.  L gets me a guy to sell me sim card for my phone and credit for it.  The sim doesn’t seem to work and then it does after all.  L gets us our tickets and we load the bus with our luggage stored beneath.  We choose a seat nearer the front as this is usually less bumpy than near the back.  We start out before completely full so we stop at various spots along the way to pick up other people.  At one area we stop at a military checkpoint and all the men have to get out and get patted down and show what’s in our bags.  This goes off relatively well and we all board again.  A bit later there is a little commotion as water starts running down below the seats on the other side and down the isle.  Someone thinks its water, and then another says someone peed in the back.  I don’t smell anything like pee so Im grateful and also grateful it didn’t get on the bag i have at my feet.  We arrive at Bongor the bus stop for changing some passangers.  we wait here for about 15 minutes and mill about the small area.  there are many vendors there selling things like- potatoes, taro, other roots I don’t know, roasted beef, lamb, goat.  My favorite to see is the huge pile of fried grasshoppers.  I don’t have the courage to try them, though Audrey has and didn’t get any.  We all load back on the bus when they start honking and we head on to Kelo.  
A little after noon we arrive in Kelo.  We anticipate someone from the hospital picking us up in a vehicle but they are not there.  We get out our luggage and pay a guy with a cart to move everything off to one side where our thing can sit without worrying too much about them.  We sit down on a bench that is near by to wait.  After about 30 min we get a hold of the guy who was to get us and his car got full of water crossing a large water area on the road that was deeper than expected,  and died and was being towed back to Bere by a tractor.  He then tried to arrange another vehicle.  After about an hour we hear that it would be best to go by motorcycle  taxi the last ?2 hours.  He wants to arrange the motor taxi for guys from Bere as they don’t charge double like the other moto taxi guys may require.  We wait another hour and  a half.  People are coming, but they don’t show up.  
During this trip I realized my Keen sandals soles are falling off.  I only brought them and OR shoes.  So i ask around and find a guy sitting under an umbrella who is fixing shoes.  He says he can fix them for 2000CFA ($4).  So I sit near him on a bench and another guy starts talking to me.  Id guess he’s about 20 and seems drunk.  As I sit there I realize the guy who fixs shoes is next to a woman who is selling vodka, wine, and other spirits in little plastic bags.  So this guy is drunk.  He asks lots of questions and talks about how hard english is to learn, and why I won’t drink with him, or buy him another bag of drink.  The guy fixing my shoes warns me to watch my phone as the kid next to me may steel it (thank you).  He glues the sole on with some contact cement used on a bicycle repair kit after cleaning off all surfaces.  It seems like a weak repair.  So he then sews across the front and back of the sole to secure it better.  This seems to work well.  And later on I am very grateful to have them fixed as you will read.

Then about 4pm Im starting to worry, if we get started too late it will be dark and more difficult to travel., and darkness also increases the price and chance of a fall.  I know the road is muddy and apparently had large amounts of water in some places.  He calls a guy at the bus station and this guy helps us get some motorcycles from another town beyond Bere.  But they seem only partially interested and also charge a lot.  WE want three motorcycles and there are only two of them.  Then finally two from Bere show up and say they are here to take us to Bere and load our gear on their motorcycles.  They strap our four plastic luggage boxes on one motorcycle with the driver sitting on the gas tank, and put Audrey and I on the other.  So both are very loaded.
Then the fun begins.  We travel through Kelo then head off the main road.  Ive not been this way before and know it must be to avoid water on the main road as it gets huge deep mud puddles.  We wind through many small villages with stretches of farm land in between.  Here a left there a right.  Nothing distinguishes it from any other trail to follow.  Most of it just wide enough for the motorcycle, so only foot paths we are following.  We go through patches of puddles and our feet are wet.  The motorcycle is making a strong clicking sound with each rotation of its tire and I wonder if we are going to break down on the way- but our driver Sebastian says its not a problem and will get us there fine.  about an hour into the trip its getting dark and we are going through some deeper water and getting stuck in the mud.  I have to get off in the mud to push.  I have mud up to mid pant leg now.  We nearly fall over a number of times in the mud and in other sections in deep sand.  Then when its fully dark we hit the big sections of water.  We go about 100 feet into the water and we hit a rock or log that stops us abruptly.  i have to get off and push and water is up to my knee.  He continues on with Audrey and I walk for a way till he stops and lets me get back on.  Then there is a section that he says we have to walk through and they will push the motorcycles and meet us on the far side.  We meet up with the missionary Charles who had planned on getting us in his car that died with water in its engine.  He had come to help us in this section.  So we walk with him.  Carry on back pack on our back and walking through the water.  We walk through a section of water that was about 100m and about thigh deep.  Charles says the day before this was passable with a car and that it had risen to this.  We walk on and get to another large area of water.  There are no motor or people.  just a tractor pulling a large trailer loaded with grain, through the water.  Audrey, Charles and I walk for probably a mile through water that varies from ankle deep to Audreys waist.  I am very thankful my shoes were fixed and are working well.  After about 45-60 minutes of walking in water we arrive at dry ground again.  the same motorcycle have gone some other way and meet us walking on the dry road again.  It’s only a few miles left to get to Bere.  We are glad to be there and meet some other missionaries.  We are taken to the house we will stay in for the month and shower and sleeeeep!  We left home Tuesday evening and arrived in Bere Friday night. Thank you God for helping us get here safely and giving us rest.

Chad 2022 #11

Greg Uncatergorized No Comments

I’m spent mentally but am happy too.  I asked special prayer from some of you that i had whatsapp contact with and God answers prayers.  He doesn’t always answer the way I want but today WAS the way I wanted.  The boy woke up after the surgery and could move his legs.  I intubated him at 9:30 AM and we extubated him at 4:30 PM.  Phillipe and Ndilbe couldn’t figure out the new anesthesia machine for the vent so they bagged the patient on isoflurane for the entire time.

Andrew (the missionary surgeon here) and I have been planning this surgery for a few days now that we were able to see the CT scan.  I saw the kid in the outpatient area a couple weeks ago and Andrew sent the boy to Ndjamena to the government hospital for a CT scan.  The boy had a huge mass on his back.  its been growing since he was 5.  He and his father went to Ndjamena and spent a week trying to get a CT scan done and apparently did other tests that whomever they saw ordered but the CT was never completed.  So last weekend the local chaddian doctor took them back to Ndjamena and took them to the hospital and with his contacts there, got the CT done and onto a USB drive so we could see the images.

We saw what looked like a mass coming from the spinal canal about L1,2,3 as the spinous processes in that area were deformed.  We decided to try to take off this mass and so that was the only surgery we planned today.

In the pre-op area i talked to the boy and his family about the complications that were possible.  I spoke to the chaddian doc, who talked to the boys uncle, who translated again to the boy and his mother.  I mostly wanted them to know that he could bleed to death or be paraplegic afterwards.  They understood and wanted to proceed.

After he was asleep, we turned him prone, which seemed to make me more nervous than the two doing anesthesia.  I marked the large vessels in the mass with a sharpie so i would know where they were after prepping.  We washed his back and the mass with soap and water then prepped it with betadine.  Then I put on the sterile drapes.  I cut first with a blade, to see how much bleeding would occur (a way to check where there is no bleeding times or INR…, then I used cautery.  As we came to large veins Andrew and I would ligate each of them.  Small ones we cauterized (electrically burned).  We created a flap above and a flap below to allow enough skin to cover the hole that would be left after we removed the mass.  We then gradually cut down on either side till we reached the back muscles and then cut towards the center.  We intentionally left a bit more tumor in the center of the back were we suspected the nerves of the spinal cord could be present.  After the tumor was removed it weighed in at 37lbs.  I gradually got the skin edges together for closure.  It wasn’t pretty as the line made kind of an “S”.  I guess I cant cut on two sides of a LARGE thing and get it to look as good afterwards.  for a breast tumor I do much better.  We kept him deep on anesthesia till we could flip him back over.  Then he took a while to wake up.  Eventually he was able to be extubated. He moved his legs!! Yea!! Thank you Jesus!

Chad 2022 #10

Greg Uncatergorized No Comments

Chad 2022 #10

Days are long and it’s impossible for one surgeon to keep up, it’s likely two cannot keep up.  when i came there were 70 people waiting for surgeries and there are still 66 on the list.  People are coming from Garoua Cameroun and even further west near the Nigerian boarder in Cameroon.  Ive

I’ve seen people from all over chad, even from the capital.

Yesterday my day started with a patient with a large uterine fibroid.  It appeared she was about 24 weeks pregnant with a bulge in her lower abdomen that went above the umbilicus.  I did a quick ultrasound with my butterfly ultrasound and saw what I thought was cystic, but was read as solid by the previous ultrasonographer. Either way I couldn’t find a uterus so assumed it was all uterus.  She had been prepared for the possibility of a hysterectomy and I confirmed that with her.  She wanted more children but for her health she wanted it out whatever it was.  As I opened her abdomen the mass seemed to be cystic and stuck to surrounding things like intestines and ureter (tube from kidney to bladder).  It took some time to free it up and eventually I found it was attached to a small uterus in the pelvis.  After we removed the cystic ovary I closed up the top of the uterus.  I looked that the other remaining falopian tube appeared scared down and closed.  So i opened it and sutured it open.  That way she’ll at least have a chance to get pregnant, like she wants.

Next was a guy who was about 40 years old.  He had a inguinal hernia.  As i dissected it out it communicated all the way down to his testicle as a hydrocele (sac of fluid around the testicle) too.  I’ve not seen that combination before.  Usually they are separate.  Hernia sac and hydrocele separately.

A 3yo girl was standing next to a fire when her polyester skirt caught fire.  Polyester melts as it burns and sticks to the skin.  So she has burns all over her lower abdomen, genitals, and down both legs.  When she came to the hospital about a week ago she had been burned 5-7 days before hand.  They had put rabbits fur on the burn areas to help it.  It seems like when I operate on those burns quickly they bleed a lot.  So I decided to wait till the burn area starts to lift off the underlying tissue.  This had occurred so I had the nursing students bring her next.  I realized that there were maggots coming out from under the abdominal burn area.  Fortunately maggots only eat dead tissue, they don’t hurt live tissue.  But they are still disgusting!  She got Ketamine to put her to sleep while David and I debreded off the dead tissue with scissors.  We washed her with Dakins solution (a dilute bleach) and placed dressings.  She will need some skin grafting in the near future.

Earlier that day I had been asked by Dr. Megan to see a patient on the adult ward who had a firm abdomen.  After examining her i agreed that the patient had peritonitis and needed to be operated on right away.

As i opened her belly she had nearly a liter of pus come out.  As i looked around for the cause, nothing was initially obvious.  The appendix was normal, the intestines were irritated but not perforated with typhoid.  Eventually i found the most inflammation in the pelvis and found some abscesses there and what appeared to be perforated diverticulitis.  This was really stuck and a mess.  After about 4 hours working on her I had cleaned out the pelvis, washed her abdomen out, taken our the rotten piece of sigmoid, and brought out an end colostomy.  Tired, but two more emergencies to go.

Next was a kid who had ascites (fluid in his abdomen, most often from cirrhosis), and had an umbilical hernia that started leaking the ascites.  It appears like he was peeing from his umbilicus.  This fluid coming out can be a way for the bacteria to go in.  So i repaired his umbilicus and tried to make a water tight closure.

My last guy was about 24 with a rigid abdomen.  Rock hard, and peritonitis.  So I operated the same way on his as the old woman.  Looked around and bile everywhere.  Didn’t find a hole in the small intestine nor large intestine.  I found it on the front surface of the distal stomach.  A perforated stomach ulcer!  I made the edges new and then sutured the hole shut.  Then I reinforced the repair with a piece of omentum (fatty layer in the abdomen).  I put a drain (a cut Nasogastric tube) near by so that if the hole leaked, hopefully the drain would pick up the fluid that leaked.

There were a few surgical consults that had waited all day so I saw those next.  Later we went to Megan and Andrews house to eat supper!  Thank you Megan!  It’s always wonderful to eat after a long day working.