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Chad #16 2019

            I left Bere just after sunrise.  It had rained during the night.  Olen had offered to take me in a truck if it didn’t rain.  When it rains they put barriers across the road so that vehicles can’t destroy it.  Well that already happened decades ago.  It’s a dirt road that isn’t maintained.  Mud and sand!  I like a moto ride too.  The wind in my face, I just want to be driving and can’t.  So I bring my stuff out to the gate where they are waiting.  There are two guys, one I’ve seen his face before.  I’m poor at bartering the price but I try anyway.  I offer them 2500CFA each.  I think that’s the lowest price I’ve heard some local people pay in the dry season.  He says 4000, the roads are terrible.  But just because it rained doesn’t mean it takes more gas or more wear and tear on the moto, I interject.  He smiles.  I offer 3000.  He says, give 4000 each and we’ll go.  I know I paid 4500 last year, but that was suppose to include a boat ride across the river, for us and the moto.  We talk a little more and I give in to the 4000.  One moto gets my luggage, two bags.  And I go behind the other guy.  It’s cooler because it just rained.  People are just getting out and around, so it’s rather quiet in town still.  We head out the road past the fields that are not yet planted.  They guy with the baggage is in front and is going fast or slow depending on the puddles but keeping a safe speed.  My moto guy seems to like to accelerate.  So he accelerates up behind the guy in front, and when we are about to touch his back tire with our front tire, he pulls in the clutch and puts on the brakes.  Then a short distance is created, and he accelerates again, to brake again.  Accelerate, brake, accelerate, brake, accelerate, brake, accelerate, brake, accelerate, brake…………..

I think you get the picture.  My back and stomach are getting a minor workout.  I ask him to stop doing it, and he says, oh you don’t like that?  Nope.  So he does a little less aggressive than before, for the rest of the trip.

            It takes about an hour and forty five minutest to get to Kelo.  We pass people with their cows yoked together with a single blade plow, going out to the fields.  They just leave the plow on it’s side and the cows drag it out to wherever they are going.   There are others riding bikes with hoes, chickens, small sacks or whatever on the rack in the back.  And others walking.  Once in Kelo I go get my ticket while the guys unload the baggage, and the baggage handler sticks it underneath in the bus.  I pay them and then head across the street to get some roasted peanuts that Audrey wanted.  They come in1.5 liter water bottles.  I choose the oldest lady to buy them from.  I prefer to purchase from the old, assuming that the younger ones have more options, and the old likely have only that.  A young girl about 15 keeps shoving her’s in front of me as I look at the old ladies peanuts.  Finally I tell her to stop and Im buying from the old lady.  She looks angry and says something I don’t understand.  After that I get on the bus and wait.  I sometimes have the energy to sit out and interact with all the people that are selling things or the little Muslim boys that are begging, but today I don’t.  I just hope my diarrhea doesn’t occur today as the bus doesn’t stop but once in about 7-8 hours.  That’s usually on the side of the road, and Id rather not have diarrhea there either.  Olen and Denae thought I should have taken a diaper and offered their kids version with a laugh.   After about 25 minutes of waiting, the bus is full enough that they leave.

            During the ride music videos and a movie plays.  The movie appears to be about Americas shooting Muslims, which is terrible.  The music videos look like about three different styles.  We stop in Bangor and they fill the few remaining seats that are left.  A business man from there sits down next to me.  He sleeps for a few hours, and when he awakes, he says hello and starts conversation.  I find out he’s a Muslim, as I expected from his attire.  His name is Hamidou, he has two wives and 12 children.  We talk, and as the music videos play I ask him about each.  Most are about love.  They are in Housa from Nigeria, Arabic from Sudan, and some in Fulbe.  There is one where a man is singing out in the open in front of a crowd on benches.  It appears as if wealthy men are coming up and sticking bills of money individually to his forehead.  After each is put there if falls to the ground and a little kid is there to pick them all up for the singer.  This occurs with bigwig after bigwig.  I ask him about it.  He says it’s a guy who was brought in to sing, and before singing, he asks someone for the names of the rich people in town and memorizes them.  Then as part of his singing, he names specific people.  When they hear their name, they feel obliged to honor him back, by giving him money in this way.

            I ask Hamidou if he’s done the Hadje (sp?) to Mecca yet.  He says he hasn’t had the money to yet.  He says it costs at least a million, or about $2000 minimum.  He says over the past 8 years he’s been supporting his brother in med school.  Apparently Guinea is the cheaper place to go to med school, about $2200 a year, which is about half what it costs in Chad.   His brother recently got done, so he thinks in the next few years it may be possible.  It’s required for all Muslims who have he means to do it.

            We have an uneventful trip up to Ndjamena and part our ways.  He says next time I’m down in Bongor to call him and he’ll come visit me.  

            As I’ve thought about this trip I think I may have discovered something new about myself.  I constantly struggle with patients that say they can’t pay whether they can or not, and the internal struggle that gives me.  I could help, but don’t know when to.  And if I paid for everyone, that’s counter productive in the long term for whoever is left after I leave.  So the other night I realized that is one thing I like about the US system.  I don’t worry very often about who can pay for surgery except in private pay patients for elective surgery.   I do have to struggle with insurance companies to get them to pay for what they should be paying, so the patient can get their surgery paid for, but especially not in an emergent situation.  The things that really bug me about the US system are multiple, but probably the worst for me are the litigious society we have, and electronic medical records that make less time with patients and more time on a computer.  So where would I find these things- no litigation- just do what’s best for the person in front of you, no EMR, and no payment for me to worry about.  Refugee camp hospitals?  I assume they’re funded?  Maybe someday I’ll see what one of those are like.  You have other ideas?

            So these are my thoughts as I wrap up my trip.  If you’re interested in previous stories, please look up our website www.missiondocs.org  If you’re interested in financially helping mission hospitals that I visit or have worked in, or want to help some Cameroon hospitals get X-ray stuff it can be sent to my parents church as before:

Summersville SDA Church

70 Friends R Fun Dr

Summersville, WV 26651

Please specify if you have a specific desire for your funds

This is tax deductible.

Again, to those few that helped me make my dream of an X-ray machine in Bere a reality- THANK YOU SO MUCH!!!!

I hope you have enjoyed my musings and thoughts and that it spurs you to choose to volunteer some of your time and effort, to those in need around you either close to home or far away.  God bless you!  Until next time—

Chad #15 2019

            I’ve operated on a few very young children in Africa.  They always seem to die.  So when I saw this child with an omphalocele, I think should I try or let the infection take him?  An omphalocele is where the umbilicus hasn’t completely closed and there are intestines covered with some tissue but not skin.  This is a defect in development somewhere around the 12^th week of fetal life.  I feel I need to try again.  I wonder why they always seem to die.  I read about it again and see something new, a silo.  When we do a long trauma operation and sometimes the intestines are edematous and cant be fit back in the belly, we sometimes have to make a temporary closure of the abdomen with a large plastic IV bag, sewn over the top of the open abdomen to keep things in place.  Once the edema has gone down, and the bag has been rolled down, the bag can be removed at another surgery and the abdomen closed.  So this is thought to be the way to close omphaloceles from my reading (if there are any pediatric surgeons on this email list- please comment back to me your thoughts).  This makes the pressure of putting all the intestines back in the abdomen occur more gradually and doesn’t collapse the inferior vena cava (big vein in the abdomen), or cause respiratory compromise.

            So I take this baby to the OR.  I ask Dr. Olen to help with anesthesia as Phillipe says he doesn’t give ketamine to babies who “don’t have an age yet”.  I questioned further, and I think he said less than one year.  I guess on the carnet they are bebe ..moms name.  After they are 1, then that number is put on the carnet as it’s a spot for years not earlier.  I prep his belly and the edematous sac over the intestines with a dead short segment of cord attached with string around the end.  I cut off the dead cord to prep better.  I then dilute the only lidocaine they have, add adrenaline, and calculate the dose that’s the maximum, to avoid cardiac arrhythmias… Then I inject all the way around.  He cries and squirms.  Dr. Olen gives him a drip of ketamine and I begin.  I cut in at the bottom of the sac and enter the abdomen.  Then with scissors I cut off the sac and free up the intestines that are stuck.  There is some pus between the sac and the intestines.   The IVs here are bottles, but we find an IV sac that’s residual in the OR and I cut off a corner to make a plastic silo.  I suture this all the way around.  The baby does well and he is taken out to the preop/postop area and his mom is let back in.  She has been in and out of that area many times during the surgery, concerned over her baby.  Later that night I was called back to see the baby that was breathing poorly.  Fortunately it just required that I extend the babies head and he breathed better.  In the morning he was still alive and had taken a little mild that the mom expressed for him.  He wasn’t breast feeding yet.

            I open the carnet of a consult to see between surgeries.  A lady has had tooth pain and swelling of her cheek for about 2 weeks.  I ask one of the nursing students to call her in.  She walks in and makes a slight groan with every breath.  Her left cheek is hugely swollen and taught.  I don’t see any drainage point on the outside.  I ask her to open her mouth and she gets her teeth about ¼ inch apart.  She cant open any more.  I try to push her teeth apart- no budging, and she winces more as I do this.  I see a dead tooth, pushed up in the mass effect of the infection, I can rock it but cant pull it without more space.  I feel around on the skin and find a soft area in all the hardness.  She definitely has pus in that cheek.  I numb her up as best I can (abscess are impossible to numb adequately).  I incise over the numbed area and molasses thick pus flows out.  I put a finger in to sweep around, and break up any loculations.  The pus cavity goes to the mandible, and up to the zygomatic arch.  This is a huge pocket to be in a cheek.  I flush it out with the hospital “dakins” solution (dilute bleach water) and put a gauze soaked with the stuff up in to fill the pocket.  As she had before, she continues a soft groan with every breath.  I order IV antibiotics and send her out to be admitted to the surgical ward.

            That evening I head to bed about 10PM.  At about midnight, Dr. Stacey calls me to help in a C-section.   The mother had presented with an arm sticking out and a live baby.  As I mentioned in a previous story, when an arm is the first thing out in a delivery, then this means that the head and body are shaped in a U and the arm is at the bottom of that U.  And babies don’t come out shaped like a U but more shaped like an I.  Meaning that they should be head or butt first, not folded in a U.  She received IV fluids, then the spinal.  We went through the abdominal layers, took the bladder off the front of the uterus and then incised the uterus.  Meconium flowed out.  We grabbed the head of the baby and pulled her out.  No crying.  I suctioned her nose and mouth and got a short gasp, then nothing.  I did it some more and ruffed up the kid and started drying her.  Finally she started breathing and crying.  I grabbed her slimy body, covered in vernix, and passed her off to Phillipe (the anesthetist nurse) to dry and keep the kid breathing.  We sewed up the uterus then closed the abdomen.  I was about to have diarrhea again so, I left before skin was closed.

            I fell asleep about 3 and was called at 4.  As you probably can tell now, whoever is on call for maternity ward is very busy day and night, and the surgeon is too.   Dr. Stacey wanted to know if I can do a suction delivery or use forceps.  Yes, so I head in.  There are two women on 2 of the 5 delivery tables present.  The one that needs help is on her 9^th vaginal delivery, but she started pushing to early and it seems has run out of steam to push any more.  She is fully dilated, and when she gets a contraction the head comes down, but when the contraction stops, the head rises back up.  Is the baby to big?  I feel around and there seems to be space, there is definitely a hematoma or edema on the top of the head from being stuck there a while.  It doesn’t seem like suction would work and attach to this form of head, so I choose forceps.  They are still in the OR, so I go back to the OR, unlock it, get them, and relock it.  I’m able to slide each half in without difficulty and lock them together.  I wait with one hand on the forceps handle and one on her abdomen, feeling for the next contraction.  One comes, so I start pulling, gentle, constant, traction.  The babies head comes down and then starts coming to fast.  I stop pulling and put my hand on the kids head as it crowns at the opening.  Slowly lets tissues stretch, and there is less likely to be a tear.  Finally the babies head is out and the forceps are off.  We clamp the cord and Sr. Stacey gets the baby breathing and crying.  I massage the uterus through the abdomen and try to get the placenta to deliver.  Gentle traction on the umbilical cord and eventually it delivers.  It seems like there is a piece missing, so Dr. Stacey reaches inside the uterus and scoops out some more.  Her hands are much smaller than mine, and it is easier for her to do this maneuver.  We look around and there doesn’t seem to be any cervical tear and only a very small skin tear.  I head to bed.

A couple hours later on rounds Dr. Stacey finds the woman is pale, short of breath and has bled, and the nurse didn’t notice the clots in the cloth she was wearing between her legs.  We take her for a curretage and scrape out residual pieces of placenta.  Im concerned about the amount of bleeding she is having even thought she has gotten 2 unites of blood and a 3^rd is going in.  I decide we should stop, give her more blood and if she continues bleeding to, curretage again.  She does continue bleeding, and after we’ve caught up on blood a little longer, Dr. Denae does a curregate, fills her uterus with 4 foley balloons and does a vaginal pack.  Apparently there is a nice large balloon made for this in the US, but of course, not available here.  She finally stops bleeding!

Chad #14 2019

            The X-ray machine I brought is working great.  The pictures are good quality.  I do worry about the cords that are attached and constantly being moved, as I expect them to break at some point and not work anymore.  A charging DR plate with wifi would be awesome but that is likely 40,000 to $60,000 and would require new software too.  So we will see how long this one lasts and get new cords when needed.  One is like a long USB printer cord, and the other is the Naomi power cord.  Today we did X-rays of a woman with 3 months treatment of TB looking for residual disease and she had some residual TB in an upper lobe.  Another was a woman who had been in a moto accident and was having some abdominal pain.  I told them an ultrasound was the answer we had, but they wanted an x-ray and as expected was normal.  Then there was a man who had been in an accident with finger pain, who had evidence of an old fracture.  Apparently one of the hospitals about an hour away in Lai doesn’t have X-ray either.  So now they will be sending all their patients to us to take them.  

            We put off some surgeries today as Olen, Denae, and I were all having diarrhea.  Sarah, Gabriel and Stacey had it the week before, so I’m not sure if we got it from them or from eating at the elders house after church the last week, as they didn’t eat there. 

            I find amusement out of peoples reactions on Ketamine.  Often there are different facial contortions people make and sometimes sounds too.  Often these sounds are yelling someone’s name repeatedly, or talking randomly.  We had a woman recently coming out of anesthesia from ketamine who started singing hymns. It was in Nangere so I didn’t know the words but some of the tunes I recognized.  I asked the nursing students if she was making sense.  They said she was singing perfectly.  Often we call in a family member into the preop/postop room, to watch the patient so they don’t sit up and fall off the stretcher.   So this woman’s husband was called in.  We explained that she didn’t know what was happening and that he needed to watch her.  A short time later as she sang with a loud voice he joined in and they sang hymns together.  They did this for many songs, until she was wheeled back to the surgical ward.  It was so joyful and pleasant, it made my day!  I’ve not seen anyone else that came out of ketamine singing.  

            Stacey asked if I had any vet friends.  I said Audrey does, what’s up?  She wanted to spay her cat and Sarah wants hers neutered.  So I offered my services.  I’ve done our cat in Cameroon with a vet, and I’ve spayed two dogs as well.  And neutering, I figured, I can definitely do that! I’ve done that for men, and well, I guess I’ve done the surgery for women as well- but a bit different in a cat.  So Stacey and Sarah purchased the supplies needed and we headed to their house to make their animals sterile.   I warned them that my concern was the sedation needed.  How much Ketamine is needed? I remembered that it was the same as humans and Stacey was able to figure it out.  We held the male cat and shot him in the muscle with ketamine- he made a horrible sound and then looked drunk shortly there after.  Not enough.  So we gave another half dose and waited another 15 min.  Still he just sat there with his head wagging back and forth as if he was a live bobblehead!  We gave another half dose and with each one he made a terrible meow!  After about 5 min, we put him on his back and put a clamp on the scrotum, the bad meow again.  So we gave him the “full” dose again.

            I want to give a brief background why I’m hesitant to sedate cats up till now.  When we were in Cameroon, Audrey was back in the US with her mom who was dying of cancer.  I was back in Cameroon and Audrey’s favorite cat became sick and was having diarrhea, and eventually got so dehydrated that he couldn’t walk.  I had one of the nurses come to our house and try to start an IV in the cat.  It worked for a second then with the cat thrashing about it came out.  I decided the only way I could hydrate the cat was to sedate it first.  I called the local vet, who only treated local cow diseases, I thought.  He said that he knew how to sedate a cat with Ketamine.  So he drew up what was much larger a dose than for a human.  I told him my surprise that it would take more than a human, and he said that’s the normal dose.  I didn’t know any better and I know that different sized creatures have different metabolisms, so a smaller animal has a faster heart rate… maybe they require more ketamine.  So he injected the cat into the muscle.  In about 2 minutes he was calm, then stopped breathing.   I was frantic, this was Audrey’s favorite cat, I didn’t want him to die.  I exclaimed that he gave to much, and he calmly says, oh it’s OK, they always do that then start breathing again.  Well, he didn’t, and I found myself giving mouth to nose respirations on Tiger for about 30 minutes before I finally gave up.  So my hesitation about sedating the cat and giving small doses repeatedly.

            So this stripped yellow cat is finally asleep, tongue out a little, eyes wide open and fully dilated, and breathing.  I clamp his scrotum and no reaction.  I prep him with betadine, though I believe vets have told me that sterility is nearly impossible and really doesn’t matter (I hope to confirm that again when I get back).  I pull the testicle down and choose a place to cut.  We briefly considered shaving, and then realized that seemed impossible.  I cut down onto the testicle.   I expressed it through the incision and then, clamped, cut and tied off the vessels.  I got the other testicle to the same incision and did the same.  Then I sewed up the skin.  He was wrapped in a towel to stay put and we got the female cat.

            I recall that the female cat uterus seemed long as well as the fallopian tubes, compared to a human, so I planned a higher incision.  We went through the same halting, repeat injection of ketamine for this cat as well, and eventually were successful with a sleeping, breathing cat.  I shaved her belly in the lower area and made my incision.  WOW cat intestines are tiny compared to humans.  I searched and searched for the fallopian tubes.  Hmmmm, I must have forgotten the technique on grabbing them, I say.  Eventually I am able to sweep them up and take off the tubes and the ovaries.  The two cats didn’t eat or drink that evening.  The next day the male cat was back to normal, and the female was subdued and ate a little, so was on the mend.  A successful day in the home OR.