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Chad #12 2019

            Today was Saturday, the day I choose to go to church and worship God.  I woke up with the sun today as I have been for a while now.  I’ve been listening to The Jesus Dialogue by Herb Montgomery from Renewed Heart Ministries while I’ve been here.  It has really blessed me and given me a renewed view of Gods love for all humanity, including me.   So I listened to another part this morning.  I ate some ripe mangos- which are awesome this time of year!  Then I went in to see some patients that I was worried about.  Both guys with perforated appendicitis and pus everywhere are doing well.  The man with an ostomy and stool everywhere inside, from a sigmoid perforation, his ostomy is coming off and he has stool all over his dressing.  Lovely for the incision…  I found a couple more ostomy bags and gave them to the nurse so that he could change it.  The ER nurse asked me to see someone with typhoid, I immediately thought of perforation, but the was walking around and was an outpatient.  So I prescribed him treatment. 

I then made it back to where Jonathan was meeting a few of us to go to a bush church.   They’re all bush churches, but this one is further away from Bere.  I take Olen’s moto so that if I get called to the hospital, then I can leave and come back separately.  I prefer to ride the motorcycle anyway.  I enjoy the breeze in my face and the view.  They indicate the directions of how to start to get there, so I head off ahead, so I don’t have to eat the vehicles dust the whole way.  

I head out of Bere towards Lai.  It’s market day in Bere, so many people are walking along the road with things to sell or trade. Two wheeled carts with car tires are pulled along by either a small horse or a pair of cows.  They’re often hauling mud bricks, roofing reeds, or sacks of grain to sell.  Basically whatever is to heavy to carry on one’s head.  A few people are riding donkeys.  I drove ahead till I reached a town near by where they were going to turn off the main road.  I waited about 15 min till they caught up with me.  As I waited, I watched the variety of people going by towards Bere.  After Jonathan caught up with me, I followed him at a distance.  We took a winding path through the village that was really to small for his truck, as he often had dragging branches on both sides of his vehicle.  When there was a breezed from the side, I’d ride closer to him as the breeze took the dust away.  There were kids playing with sticks and rocks under the trees in little groups.  Women were out with wood mortar and pestle pounding rice and then pouring it in the breeze to get the chaff off.  Others were at their open wells, drawing water for the family or for animals.  After we left the village, we went through fields that were not yet planted.   There are many types of palm trees around this area.  There are a few coconut trees, and many of a smaller round looking fruit that’s hard too.  Apparently it takes about 20 years for these to grow big enough to produce the hard, small fruit.  There are little paths leading off everywhere and we pass other small villages.  A few times we take a wrong turn and backtrack a little.  It has been two years since Jonathan has visited this church.  Eventually we pulled into the village of Kalme.  

We went through Kalme and had to get directions and redirections to make it to the church.  After we pulled up to the church, a horde of children crowded around us.  Olen and Denae ushered the kids into the children’s Sabbath school and we could hear the singing during the adult Sabbath school.  I went to the adult class.  It was in Nangere and wasn’t being translated, so I heard they were discussing Samuel and the way God called him, so I read that story in my bible again.  After Sabbath school, the kids joined us in the church and they lay a tarp on the ground for the kids to crowd on, the tarp covered the dirt floor and diminished the dust inside.  You know how kids fidget, and there was a constant cloud of dust as soon as they were in there.  

I always find it amusing and sad, the way people have been taught the western traditions of church.  The people that were participating up front, all went outside, and then at a certain song, walked single file, in and up to the front.  They prayed then sat down.  [In our church in Cameroon, everyone up front wore a tie, so they would go behind the pulpit and get a tie, then tie it on whatever they were wearing, and then file in with their ties in place.  I think a sad thing to have to do in this heat]  They sand some songs with clapping and homemade metal drum.  Jonathan gave a sermon in French that was translated into Nangere. We had a visitor Charles from Orlando Hospital, here to look at the OR design.  I translated from French to English for him.   

            After the church service the head elder invited all of us from Bere, to his house for lunch.  They put benches under the mango tree, shewed away the dogs and chickens and put a bowl of rice bule and a bowl of sauce to eat.  One of his teen sons, brought around a bucket of water to pour over our hands and wash them.  Then we dug in.  Take a small piece of bule in your hand, smash it into a spoon shape, dip it onto the green leaf sauce and put the whole thing in your mouth…repeat till your full.  Then we washed our hands again to get the bule and sauce off.  Charles and a couple others were worried about dysentery, so they didn’t partake.  The rest of us, polished it off.  After we ate, the elder wanted to show land that was given for a school, so Gabriel, Sarah and some others went to see it.  About 4 teen boys gathered around, so I asked them questions.

When do you start planting the fields?  They said when the rain has saturated at least 20cm down into the ground, then if you plant, things will grow.  So they are waiting for more rain.

What things will you plant?  Around Kalme- rice is the primary crop.  Though in places not far away they grow, peanuts, millet, watermelons, black eyed peas.

How long does it take for a planted mango tree to bear fruit?  About 4-5 years to bear it’s first fruit, and the one we were sitting under was likely 20-30 years old.

Do you till the field by hand or with cows?  Two cows are used with a plow for the initial turning.

We talked for a while and the ones that went to see the school property returned.  As we said our thank yous and good bys to the elder and his family, a guy wanted a ride back to Bere.  So he got on the moto with me.  He led us back a different way that was more direct.  A lot of it followed a very deep sandy path.  In some places I wondered if it was a dry stream bed.  It was a bit challenging driving on the sand with his added weight, as he was heavier than I.  We almost went over once.  Also the road was even tighter for the truck.  It was a fun ride anyway, and it was good to be out of the hospital compound.

Later on all the missionaries got together for a potluck lunch.  I brought koolaid drink.  They are a bunch of good cooks, so we all ate well.  It was umbearably hot, and when they asked what Charles and I wanted to do next, we decided a cooler river would be nice.  So we went for dip in the hippo river, in a shallow area that the hippos don’t go to.  It was so nice to just lounge in the water and be cool.  It’s also the area of the river that people bring their sheep and cows to cross to the other side.  So as we were there a few herds went through the water.  What a peaceful evening!

Chad #10 2019

            I’ve taken a shower with nice smelling soap, scrubbed everywhere, and my hands still smell like pus and stool.  I guess the gloves are thin enough that they must let fluid through or I got it in the sleeves.  It’s hard to say, because my hands are wet early on in the case from sweat.  The OR air conditioner didn’t work for a month apparently before I came but they’ve fixed it and it runs constantly during the day.

            I saw a guy yesterday that had what the carnet said was a strangulated hernia.  It was after I had finished my last case.  He was a little distended in his abdomen and had a right inguinal hernia.  I was able to reduce it, and gave him an order for surgery.  The total for the surgery and the meds after came to 58000CFA, that’s about $120.  I see that he’s paid and on the list this morning.  After a couple hernias, and a tubal ligation and a washout on the guy I did a few days ago with a perforated appendicitis and lots of pus, eventually we got to him.

            He was about 55 years old and walked into the OR with a stick as a cane.  I took a feel of the hernia which was visible and he got his spinal and we started.  Dr. Stacey wanted to do it with me as she is feeling a little better after dysentery.  We did the usual entry in the groin at an oblique angle and down through the layers to the inguinal structures.  We dissected out what looked like a hernia sac with stuff in it.  It seemed thick.  I squeezed it to empty it and if felt like I was just pushing out air. 

            No I believe the Holy Spirit prompts me to do things some times and if I follow it, things turn out better than when I don’t.  I felt a prompting to tap his abdomen.  I put one hand on the hernia sac and one on the abdomen and tapped the abdomen.  It seemed to pulse in the hernia sac.  I deduced that the hernia sac was full of air, meaning there was a hole in the intestines.  But the sac still felt thick like there was intestine in it.  And to thick to see through.  I decided I had to progress one way or another, so I cut it open.  Air and liquid stool flowed out!  OH NO! I must have just cut into the colon.  I put my finger in and felt the usual sac with an entrance into the abdomen and I could feel intestines in their normal position inside.  I was relieved that I hadn’t hurt the man and worried about what I was to find next.  I made an additional incision down the middle starting at his umbilicus and extending down to the pubis.  When I entered the abdomen, more air and stool came flowing out.  The room wreaked of stool.  Every area of the abdomen that I started separating the  stuck intestines, more pus and stool would flow out.  It saturated both sides of the bed and ran to a large puddle on the floor in spite of us sucking up liters of it with the suction.  My whole front felt wet through the cloth gowns, which is a disgusting feeling considering where it was coming from.  The whole small intestine appeared like it had typhoid and I expected to find a typhoid perforation and found none.  I identified the appendix and it didn’t appear inflamed.  Liquid was up around the liver and spleen after opening up higher in the abdomen.  On initial view the colon that I could see seemed fine.  I looked at the anterior stomach, no hole.  The posterior stomach was so stuck that I couldn’t see it nor seem to get to it.  Eventually I discovered a hole about an inch in diameter in the sigmoid colon.  There was some thickening there, so I assume it was a perforated colon cancer.  It could be a diverticular perforation, but I’ve not seen diverticula here before.  I assume I haven’t seen it because of their generally high fiber diet.  I resected the segment and decided to close the distal end and bring out the proximal end as an ostomy.  I hate giving people ostomies here, a there are no supplies for ostomy care.  But with all the contamination, he needed to be diverted, and not re-anastomosed.  About this time Dr. Stacey was didn’t look well.  She’s been suffering from dysentery so I asked how she was feeling.  “Not good”, so I asked her to scrub out and ask Abouna to come in to help me.  Once he scrubbed in, I sewed off the distal colon end in two layers, then I brought out an ostomy of the upper cut end of colon.  The intestines were to swollen to get back in the abdomen.  I had Phillipe put in a nasogastric (NG) tube to evacuate his stomach, and then milked all the fluid that I could, in the small intestines, back towards the stomach so it could be sucked out the NG tube.  Then I looked at the closed end again.  It was dusky and didn’t appear good.  So I cut off a couple more inches, and reclosed it again in two layers.  I brought out the proximal cut end through the rectus muscle as an ostomy.   There seemed to be insufficient length so I freed up a bit more of the descending colon to give more length to the ostomy and brought it back through the rectus and through the skin.  With quite a bit of effort the intestines were crammed back into the abdomen and the fascia was closed.  Before closing the abdomen I had to finish my inguinal hernia repair.  I resected the thick hernia sac and oversewed the end.  I did a suture repair, then felt it from the inside.  It seemed secure.  We closed the rest of the layers in the groin.  Then back to the open abdomen for closure there.  After getting the midline closed with loose sutures I “matured” the ostomy.  That is that I sutured it to the skin in a way that makes it stick out, kind of rolled out on itself making a somewhat mushroom appearance.  Dr. Stacey was back in the room and found an ostomy bag for us and we placed that as well as a bulb on the drain I had left in the pelvis.

            I’m called in the night because the family is refusing to get meds for him.  I tell the nurse he needs meds as he has a huge infection and will die without them.  He goes back and apparently the family came up with a little money to buy meds for the night.  A nock at the door again at 4 AM, and the nurse says that the patient is demanding water and pulled out his NG tube.  I’m sure he needs more IV fluid and is dry. I don’t think it will make any difference for me to go talk to the patient and think that administration should consider whether he needs meds for free?  So I tell the nurse the complications again and ask them to address it with administration- which I’m sure won’t happen till morning.

            During rounds this morning I discuss how crucial the antibiotics are for the man to the 4 younger men with him- likely his sons.  I get on their case about not doing what is necessary for him.  At the end of rounds they have gone and bought his medicines, so after 12 hours without antibiotics in a perf sigmoid, finally he has antibiotics.  Unfortunately, I am still jaded from my time in Cameroon, where everyone claims to have no money.  Even the Koza chief who drove an old mersades, and had 4 wives and numerous children, claimed to not have money.  Obviously I could help financially, and it is hard to know when to and when to push the family to fork it over.  So is still struggle with it.  I think hospitals should have a good Samaritan fund that is run by an honest local who can differentiate who really needs the help and who is not wanting to contribute to their care.

Chad #9 2019

            It’s mid-day, and I’ve done a hernia and then an old guy with a large prostate. 

I’m asked to see a patient in the adult ward that they cannot get a urine catheter into.  The nurse says it only went in about 1cm then couldn’t go further.   That’s a very unusual place for a stricture so I go, expecting to just be able to place the foley with out a problem.   An old man is lying on a mat on the floor between the beds and appears to not be moving his right side.  He must have had a stroke.  He looks at me but cannot speak since he came in to the hospital.  I try the 16F foley, no go.  I try the pediatric 10F foley, and it wont go in either.  I know I just used our urethral dilators so they are not clean.  I ask the nurse to go to the OR and get a long Kelly clamp.  After a lot of lubrication,  I slide the Kelly clamp in and it dilates up the urethra, the mans good hand grabs mine as he has some pain.  Eventually it’s large enough that I’m able to get the 16F foley in.

After the next hernia case Dr. Stacey asks me to see a patient on the adult ward with abdominal pain.  She says he has typhoid and his abdominal exam has changed overnight and he seems much more tender.  I go to the adult ward and find the nurse and ask him to translate.  The beds are lined up against the two walls.  I stand between two beds facing the patient that I’m to see.  He is about 30 and lies there grunting softly.  I tap on his belly with one finger on top of the other.  He winces at every tap.  I push in slowly, and let go quickly.  He jumps in pain with obvious rebound tenderness.  I think he must have perforated his typhoid.  I make an order in the system and send his family to the pharmacy to pay for medicines.  Later on, this order seems to have disappeared, as he has nothing written when I check it post-op.  [I had an ER nurse change my orders on a patient today, to diminish the length of treatment and add in another two medicines that I did NOT order, in order to “make it cheaper for the patient”)  VERY FRUSTRATING!!!  I addressed that with that ER nurse]  After I wrote for the medicines I informed Phillipe and Abouna about the new surgery.  They send some student nurses to get the patient.  After the spinal and our betadine prep and cloth drapes, we begin.  I expect to find typhoid perforation so I cut in the lower abdomen.  Upon entering the abdomen I get cloudy fluid.  Since he required ketamine at the start too, he is now tensing his abdomen and the intestines are pushing out at me with every abdominal force the patient makes.  So rather than trying to hold them in any longer, I let them pop out all over.  I see some pretty inflamed intestine that is obviously effected by the typhoid.  I don’t see any holes though.  I follow the small intestine to the cecum and there is some pus there.  I search around and start opening up a stuck area near the back side of the cecum and a fair amount of pus flows out.  I find a retrocecal appendix.  I do an appendectomy and then wash out the abdomen.  It’s very easy to wash the intestines as most of them are pushed out onto the abdomen.  Now the struggle to get them back inside.  Abouna and I pull hard on the edges of the rectus muscles and try to stuff intestines back in.  It feels like a loosing battle.  Little by little, we are successful and he holds them back with one hand, once their inside.  I slowly close the fascia from the top down.  I wash the incision again and then close the skin loosely, leaving space for pus to escape if the incision gets infected. 

I check on the consults that are waiting.  The last two I see I worry about if they need operations too.  One is an old man who has had urinary retention for 6 days and says they have been unsuccessful at getting a foley in and at a dispensary they’ve been putting a needle through is abdomen into his bladder to drain it, these past 6 days.  Abouna tried to place a foley without getting any urine.  So I try and slowly get it past the prostate, and about 500 cc of urine comes out.  Next is a man with a strangulated hernia.  He walks in fairly well, and I doubt he’s strangulated.  I push on his inguinal hernia for a little bit and get it to reduce.  I send both of these men to the pharmacy to pay for surgery and then we can do them in the next couple days.