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Chad #8 2019

            There is fluid between the liver and the kidney, Dr. Sarah told me this afternoon after I had completed a hernia, prostate, and hernia.  (By the way, the prostate was the largest I have removed, about an orange in size).  There seems to be sediment in the fluid.  It may be an abscess.  The guy is sitting stone-faced, on the chair in front of me.  He shows me his belly, which is distended.  I have him lie down on a stretcher.  He doesn’t seem to have percussion tenderness nor rebound, but definitely doesn’t like me pushing on his abdomen.  He is the usual thin Chadian guy about 5ft, 8in tall.  He probably has a BMI (Body mass index) of about 15.  I don’t know what he has but I think we should operate on him.  So I do a digital CT. (that is cut and touch with a finger).  That’s the best diagnostic tool we have!  As I examined him lying down, I did have the sense that as I tapped on his belly, there was a slap against the organs- making me feel like there must be free air in the abdomen, even though the rest of the exam didn’t seem like that.  We had the nurse start an IV and I operated on a guy with difficulty urinating.

            This guy had had a prostatectomy here before and apparently had a small 0.6 cm bladder stone.  I had tried to pass a foley a day or two ago and there was a urethral stricture about mid-penis.  So I couldn’t even get in  the smallest.   I had planned on operating on him that day, then after he paid and before I got to him, he urinated “well”.  He wanted reimbursed, so I wrote for that.  Next I see him the following afternoon, and he’s saying he’s not urinating well, and wants the operation.  I send him again to pay for the operation, and I see in the computer Friday afternoon that he’s paid.  At the end of our other surgeries Friday, we call his name and he’s no where to be found.  So we left.  They thought he may be at the mosque for Friday prayers.  Finally I see him Sunday and he says its’ still hard to urinate.  So we schedule him for today guessing that he must be getting some urine out, as he wasn’t in the “ER” for it.

            His bladder was distended, which makes the operation easier, as it pushes the intestines up and out of the way to cut down to the bladder.  As I cut down to the bladder through his previous scar, I had barely gotten through the muscles when I entered the bladder in the scar tissue.  Urine flowed out.  I enlarged the opening.  I felt around in the bladder and didn’t find a stone.  Since I hadn’t been able to pass a foley from the outside I  passed one from the inside.  It seemed to get hung up in the same place about mid-shaft on the penis.  So I used metal dilators and dilated up the urethra.  After getting up to a 22F size, I still couldn’t get a 20F foley in(smaller).  An 18 wouldn’t go in.  so I put a dilator backwards from the bladder out, attached a suture, then pulled the suture through.  Then I tied the 18F foley to the suture and pulled from the bladder side, to pull the foley in.  This worked. I closed the bladder in two layers and then the fascia then the skin.

            Next I thought would be the guy with a broken nose to elevate the pieces, but they had told him to go home and come back tomorrow.  So next was the guy with a distended abdomen.  He got the usual spinal, then I prayed for his as I do with all my surgeries.  Since we thought the fluid was more in the upper abdomen by the ultrasound report I started up there.  I asked Phillipe to give ketamine, and after he had I cut along the middle from top down to the umbilicus.  As I got in the abdomen there was a rush of air coming out.  I didn’t find much else initially, but as I searched around, I got LOTS of pus flowing up.  2 liters of pus came out.  As I finished one pocket of foul smelling stuff, I’d find another.  I had everyone in the room give their guess as to the source.  Abouna- infected ascites, Phillipe- infected ascites, Diana-wouldn’t commit, and I chose a perforated stomach ulcer.  I should’ve known better just by the smell.  But I figured upper abdomen, either that or perf typhoid.  I kept getting more pus the more I searched.  I kept on opening down, further and further, till eventually he was open from xyphoid to pubis.  There seemed to be a little fullness in the right lower quadrant.  I looked for the appendix and then felt like I got a different smell, and worried that I had pushed a finger into the colon.  As I explored the spot more, and gradually identified structures from all the inflamed tissues, I eventually realized that this was below the cecum and not the small intestine.  I identified the ureter and then followed it down, protecting it.  Then I discovered it was a rotten appendix that had perforated.  I did and appendectomy and we washed and washed the abdomen.  I decided that I would plan on another washout in about 24-48 hours.  I closed the fascia and left the skin open. My cloths smelled like the other day- stink!  I have blood and pus on me! I wish there were impervious gowns here!  After surgical cases like these- my soap and shampoo always smell especially wonderful!

Chad #7 2019

Bon Soir (good evening), le Soir et bon (the evening is good).  I greet and the return greeting is given.  It’s about 9PM and I’m walking around the hospital letting all the nursing departments know that I’m the one on call.  I start with the peds ward, and there are 3 nurses and students hanging around.  Some of the nurses were on earlier, so they’re just hanging around talking.  The nurse asks if I can see a workers children and treat them, as the nurses aren’t suppose to treat workers. (but everyone else they can prescribe for).  There is a 10 year old boy and a 12 year old girl. Both have malaria on their tests, and the girl also has typhoid.  I cant remember peds dosing, so it takes me a little while to look up the dosing and calculate what to give them based on their weighs.  At the surgical ward the guy with a bunch of pus in his belly is having fevers to 40 deg. (about 104).  He could have an abscess again in his belly or have malaria or both.  He is still very distended and his drain is putting out some chunks of yellow stuff mixed with clear fluid.  He’s passing gas today.  His nasogastric tube, that’s attached to a urine bag sitting on the floor, has l lot of bile from today.  I decide to treat him as if he has malaria and he may need a look and a washout.  Wish I had a white cell count and a CT scan, though 3 days postop, a CT scan would be difficult to help know what to do as well.  I tell the nursing students (that’s who covers the surgical wards here at night) to order IV quinine for him.  The ER nurses are sitting outside chatting, so nothing going on there yet.  The maternity nurse is making her rounds and giving medicines.  One woman is in labor who had a baby in a cephalic presentation (that’s good).  This will be her fourth delivery (also good, the road out has already been tested).  As I walk back to the place I’m staying, large fruit bats are flying all over in the moonlight, eating from the large mango trees.

I made it out to that certain tree to send emails tonight.  I did three hernias today and there was another guy with a bladder stone that said he couldn’t pee, but when we went looking for him he was no where to be found.  Guess ill do him on Sunday or Monday.  So I got done about 2 today, it was 102 by one thermometer in my room by one and 107 by the other.  I brought thermometers with me because I was curious how warm it was.  I knew it was hot and worse in the sunshine.  This afternoon,  Dr. Sarah, Gabriel, Diana, and Dr. Stacey and I, all went to that special tree to get 3G service and do stuff online.   This was a different tree than I had been to before.  I guess it works there sometimes, and at other times they have to go further to the other tree if it doesn’t.  It worked well today and thus you see the emails I sent.

Throughout the night I wake up a number of times and feel hot.  Then this morning after I’m up and drinking water.  I start to hear thunder and it rains.  Things are finally cooling off.  Its 86 degrees inside and about 60% humidity.  I think we’ve been running about 40% humidity.

I go in and see a few of the surgical patients.  One lady I removed a breast cancer this week.  It was in a difficult place in the upper breast near the clavicle.  Removing it appropriately and then having enough skin for closure was challenging.  The cancer was large, about 15x10cm and went down to the chest wall but didn’t appear to invade the pectoralis muscle.  She also had a lymph node near by that was enlarged.  I ended up closing her with a lot of tension at the incision, meaning I had to pull the remaining edges together with a lot of force on the sutures.  She is doing well now but has a headache so I check her for malaria.

Another man I saw as a consultation between surgeries.  He has diabeties.  When I saw him, they said he had had a wound on his foot for a long time, and they mentioned something about a bone.  The nursing student helping me translate took off the bandage around his whole foot.  I could see his lower leg was swollen to above the ankle.  I’m amazed by what I see.  There is the bone of the big toe sticking out of the foot.  Just the bone, not tissue around it.  It almost appears like someone did a toe amputation but forgot to remove the bone.  As I push on his midfoot, pus flows out around the open wound with the bone.  Since he has diabetes he doesn’t feel his foot- which is why, I guess, this has gone this long without being addressed.  I took him for the amputation the next day.  They had an interesting way of preparing him.  Abouna attached a rope to his ankle and strung up the let to an IV pole.  Then they tied a foley catheter “real tight” around his thigh as a tourniquet.  I thought that the leg should be put down for the amputation, but they said they always did it up like that.  So I did it strung up like that.  On this one I wanted to use the cautery.  They have developed a method to keep the cautery probe sterile without putting it in a bleach bath.  They made a long sleeve for it out of cloth and then they autoclave these cloths.  So we stick it in the one end then slowly work it thought the cloth and then the tip is put in alcohol and then placed through the end into the cautery wand.  So I used it.  I cut thought the skin then controlled bleeding with the cautery.  As I came to the different named vessels, I tied them off. The muscle I divided with cautery, and that diminishes the blood loss.  We used a saw to saw through the tibia and fibula.  As I divided the last of the tissue behind, the anesthetist, took the leg and placed it in the trashcan.  I used a rasp to take off the sharp edges of the bones and we removed the foley “tourniquet” and no additional bleeding occurred.  I realized that the incision was a little off and I had to take more on one side to make it look equal and for it to close well.  He is not in much pain today.  I am amazed at the difference in pain medication use in the US and the lack of pain medications here.  Everyone here gets Ibuprofen and Tylenol.  Yes they have pain, but they tolerate it well.

I finish looking at the patients I was interested in and see another that they wanted me to see.  I found out Diana was going to a bush church and no one else seemed to today.  So I asked if I could go with her and her translator.  So today I went to church under some mango trees! I took Olen’s moto and followed them down the road towards Kelo.  Once we crossed over the big river  we took a left on the dirt path. (HaHaHa, all the paths are dirt here, as is the road we were on).  We went for a fairly short distance then found about 8 people sitting under some trees on two benches.  We pulled up and they made room for us on the benches and someone went to get another.  The kids were a short distance away on a large mat.  I found out they usually have a kids story during the adults lesson.  I hadn’t planned on doing anything, but then offered to tell a bible story to the kids.  The translator appeared pleased and so I went with him to do the kids story.  He thought it good that we tell about Noah and the arc and the subsequent story about the tower of Babel.  The kids seemed interested at first with the picture I was showing, then they got to squabbling amongst themselves and pushing and lost interest.  I tried to redirect them but I couldn’t keep their interest so I cut my story short.  We then joined the adult lesson.  It didn’t rain enough to make it through the trees while we were there and only sprinkles on the way back.

Chad #6 2019

            They are working on the air conditioners in the OR when I arrive- yeah!!!  I do rounds on the surgical ward.  It seems the guy with the pus in his abdomen is doing better and another with an appendectomy isn’t doing well.  I wish I had a CT scan for him.  He is distended, says he’s drank some bouille (rice milk and peanut butter porridge) and says he’s passed gas.  I’m concerned but decide to wait and not re-explore him today.  The lady that had an amputation for a leg cancer appears to be doing well but no one around can speak her language to really know.  She just smiles and points and rubs certain spots near the lower leg stump.  Another 14 year old kid with abscesses on his head- appear to be granulating well.  The perforated intestine man is doing well and starting to eat.

            While I wait for the OR to be ready, I’ve found out there is a cloths washer behind one of the other volunteers houses, so I go outside the hospital compound to get some laundry detergent.  There are small bags of three different types.  I choose from the biggest pile, assuming that that one is sold the most.  I give the guy 2000 CFA ($4) and see what he gives me back, rather than asking the cost.  He gives me back 1800.  So these small bags cost about 10 cents each.  I need to do laundry because all my scrubs are dirty now.  You remember that I had that guy with pus all over- I hope this soap is good and takes care of everything.  So I put in a load and go to the hospital.  Later I come back and hang my stuff on a line that’s hung under some huge mango trees.  The missionaries and volunteers are in a compound that’s behind and attached to the hospital and have large mango trees all around.  I asked other volunteers here if my cloths would be stolen and they said they hadn’t had any problem with people jumping the brick wall that’s about 7 ft tall.  I guess they wont see what’s in here unless they climb the wall

They first install a new air conditioner that was somewhere else in the hospital and it works.  We do our first hernia of the day.  Then they want a little to install the old air conditioner that has been repaired today.  We work with that one running the remainder of the day.  The OR starts out the morning at 95 degrees.  After running all day we end the day at 85 deg.  This feels so wonderful after being at 101!  At 85 I still sweat, but I can stand in front of the AC and cool off enough to not sweat for a little while.  I also feel like I’m not dehydrating nearly as much.

Around the OR anyone waiting for an operation is sitting on a bench or the ground.  Any time I walk out, there are questions as to when their patient will be done.  I explain again and again that we do it in the order they paid.

I do a couple of hernias then there is a combination hernia with a hydrocele.  His scrotum is about 13 inches long and about 7 inches in diameter.  As he lays on the operating table I pull it up and put his legs together and it sits high on top of his legs.  We prep and drape him as usual and now the room is cooler and I’m not dripping on the patient with my own sweat constantly.  I’m very grateful for the AC.  I work through the outer layers and get to the hernia.  It is inflamed and stuck to the surrounding tissues.  Slowly I separate out the hernia sack and am able to reduce the intestines back into the abdomen with a bit of difficulty.  I do a suture repair of the area after taking off the sac.  For the hydrocele I make a separate incision and go down to where the testicle is.  A large sac of fluid surrounds it normally in a hydrocele.  His sac appears dark.  I wonder if he has bled into his hydrocele.  Or is this a cancer.  After dissecting all around I pull the sac out of the scrotum with it still attached at the vessels and I open the sac.  Dark brown fluid with chunks comes rolling out.  This is disgusting!  I try to keep it away from my incision of the scrotum to not contaminate that area.  I decide this must be cancer, and decide to do an orchiectomy.  I tie off the vessels and spermatic structures and put that off to the side to open more later.  I close up the empty side of the scrotum and decide to leave a glove finger as a drain.  After I finish this operation I cut the “hydrocele” open further and find what appears to be a necrotic tumor.  It’s difficult to tell though, it doesn’t look like anything I’ve seen before.  I show pictures to Dr. Danae and she says she’s seen it a number of times.

After a few more cases I finish and I am walking out the OR door as I see a carnet (little booklet) of a consultation waiting.  I feel a little perturbed that no one told me there was still someone waiting. I have them call the patient in and my irritation disappears.  The patient is waiting with her mother to be seen.  Dad comes in too.  The child has an abscess on her neck.  This is no Dr. Pimple popper abscess (I’ve never seen her show), but a huge abscess that is so big on the right side of the neck that the head is tilted off to the left at a fairly sharp angle.  I’m surprised by how large and hard it is.  I hear from the father that the abscess started and later they took a knife that was heated in the fire and stabbed it, draining pus.  Then it re-accumulated.  It’s been going on 2 weeks now.  Abouna says they just lance these without anesthetic, but I feel sorry for the child and give local anesthetic.  It works somewhat and she screams before I touch her.  I sit down on the bed next to the child and immediately realize that was a bad idea.  My butt is very wet!  The child had urinated then when I sat down, I became the lowest place in the mattress, making all her urine flow to me.  AHHHH,  everyone else has a good laugh.  I incise the neck and very thick pus flows out.  I poke my finger in the hole to ensure I’ve opened it enough and to make sure there aren’t any loculations (compartments) that have to be opened.  My finger can go in the side of the neck and as I feel around, I feel the back side of the trachea (wind pipe).  This is horrible!!!  I don’t think there is a connection between this abscess and the trachea or the esophagus because she’s not coughing nor vomiting pus.  I flush this with Dakins (dilute bleach) solution and pack what I can with gauze.   After we finish and send her to the surgical ward, I and my wet butt head back to the place I’m staying for a change of cloths and some food that Zache has made.