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Bere 2018 #22

I’m on the plane from NDJ to Addis Ababa.  It is just sundown and two seats behind me and to the other side, a Muslim man starts what to me sounds like the Islamic call to prayer.  He sings the song for a number of minutes.  Maybe its more than the call to prayer maybe it is the service that they normally attend.  As a non-Muslim, I’ve never been inside a mosque at the call to prayer, though it does interest me.

The day before yesterday I did rounds with Dr. Sarah on maternity and told her about the patient with the tracheostomy and what I thought would be a reasonable timeframe to take it out.  I wanted to let her know what I was doing and had done for a few so she wouldn’t be in the dark after I left.  In the early afternoon I took a kid to the OR that had broken his leg in January.  It must have been an open fracture based on the fact that now, bone was sticking out.  He had been unable to walk for about 3 months, then was able to walk,   At this point he is walking and playing football (soccer).  He is about 8 years old, and has shorts on with a handkerchief wrapped around his mid-lower leg.  I unwrapped the handkerchief, and saw about 6 inches of tibia.  The upper end was sticking out a little, the rest was exposed with a bridge of skin about an inch wide in the middle.  It seemed firm, but I suspected that if  I took him to the OR, enough time had gone by that I’d be able to remove it.  I suspect a sequestrum.  That’s when your body takes an infected piece of bone and starts pushing it out over time.   The bone behind or the periosteum can create bone behind that allows the person to have an intact bone.  Healing behind the infected piece.  So in the OR, he was given ketamine, and the nurse prepped his leg with betadine.  After it was prepped and draped and he was asleep,  I cut the skin over the middle.  Then we grabbed the end that was out the most, and it seemed a little mobile.  I rocked it back and forth.  I realized that a spike of bone was still under the skin in the upper area, so I cut the skin above that spike.  After releasing the spike the rocking motion easily dislodged about a 6 inch piece of the anterior tibia.  Behind was all granulation tissue.  Dressing changes should help him heal this nicely.  A dakins dressing was placed and off he was to the preop/postop room to start to wake up.

Next was a 15 year old kid with a mass on his  foot that had been there about a year.  He said a piece of wood had stabbed him there before.  I suspected a reaction to retained wood pieces.  The mass was on the top of his foot and was about 1.25” across.  I expected to have to leave it open, but I was able to get the skin closed with some tension.  He was pleased that I was able to close it.

I thanked each of the OR staff members and thanked them for their work.  As I grabbed my bag and walked out suspecting this was my last surgery in Africa for this trip.  Then they said I was needed in the ultrasound room for a suspected ectopic pregnancy.  I put back my bag and head over there.  As I look at the ultrasound screen and run the probe over the woman’s belly, I realize it must be an ectopic (extrauterine pregnancy).  So I write orders and send the husband to the pharmacy to get medicines and send her to the OR to start getting her fluids so a spinal can be done.  After the spinal Dr. Sarah and I opened the lady’s abdomen, and as I described in previous posts, there was a lot of blood!  Three to four liters of blood came out in the suction canister, all over the drapes, and pudlded on the floor.  She was getting blood as we started, and I could see welts starting all over her.  She was having a transfusion reaction.  They haven’t really started crossmatching blood yet.  Though apparently the lab has just learned how to do it.  We gave her dexamethosone, gave her a benedryl tablet under her tongue and I wondered whether she would go into DIC (a bleeding disorder) from the transfusion.  Her hemoglobin was 5 before any dilutional effect.  At the end of the surgery Dr. Sarah tells me there is a woman in maternity that had a C-section before and is trialing for a vaginal birth.  If she stops progressing then she will need another C-section.

Back at home I sit in front of a fan and sweat!  It feels real hot tonight.  Finally with sitting and cold water I stop sweating.  I take a shower and head to bed wet, hoping to fall asleep before I evaporate.  I do fall asleep and about 1 hour later am awakened by a knock at the door.  Someone who has been stabbed in the back, is in the ER and I need to evaluate them.  I grab my headlamp and head in, expecting to need to operate, they don’t make short knives here.  So I anticipate internal injuries.  I see a young man writing around in pain with a crowd of about 20 onlookers.  He stops writhing as I examine him.  I see a small ½ inch hole just to the left of midline in his lower back.  I also see a ¼ inch hold that is in the midline.  Did it hit his spinal cord?  Either way I cant do anything about it, but I’m curious.  He seems to have normal sensation in his legs, but pain on one leg more than the other.  I prep both areas with betadine and grab a needle cover to probe the wounds.  The one in the middle goes straight in about ¼ inch.  The other one goes in about 3 inches but runs just under the skin.  I decide to leave both of them open with a sterile dressing.  Give him antibiotics and tetanus vaccination and expect him to get better.

I go to maternity to see how the woman is progressing with her delivery.  Dr Sarah is there and the patient isn’t progressing.  So to the OR we go.  We get a live, crying baby out with lots of meconium (baby poop, meaning fetal distress).  I head to bed about 2 AM after another shower to get the blood off me and cool down again.  We are scheduled to leave at 5 AM for our trip back HOME.  It was a short night!

Bere 2018 #21

Today ended up being the day of pus!  I planned on removing a mass on a 1year olds head, but he was given ketamine without any atropine so he had excessive secretions, which is normal without atropine.  He was coughing and spewing sputum.  Listening to his lungs, he had crackles, and I wasn’t sure whether he had them before or not.  So I decided to treat his lungs and wait to take the thing of his head.  There was also a woman with uterine fibroids that I was going to remove the fibroids.  But she had a blood pressure of 220/113.  She would likely end up with Ketamine when I didn’t get done in time or if the spinal “didn’t work”.  Ketamine increases your blood pressure and heart rate.  So I didn’t want to cause a stroke.  Neither one was very happy about not getting the surgery done.  I did rounds on surgery and did all the usual dressing changes and the postops from yesterday.  Also another guy who somehow made it on the surgical ward with only malaria that needed to be treated.  In the OR I did a small hernia on a 8 year old boy.  Then I went and did rounds on maternity.  There were a number of kids with neonatal infections that were being treated.  A woman who had her 5^th child, was found to be at 13 weeks on ultrasound and no heart beat.  So we started her on cytotec to start the delivery process.  Cytotec is precious here because it can’t be bought locally.  So I place the medicine and we will see if it works.   Most women were doing better.  The one with the dead cervix from yesterday is slowly improving but hadn’t gotten her antibiotics.  I talked with the older sister who said she would now go and purchase them.  I also saw a baby that id seen for the last few days that was delivered at home.  He had what looked like bruising on his back and some fluid underneath.  Initially he had high fevers and those had resolved.   She has started breast feeding again and is generally looking better.  But the fluid seems to be more.  I initially thought it was bruising from the trauma of delivery.  Now a little bit of skin seems to be sloughing off.  Hmmm, is this pus?  I clean a  spot and insert a needle on a syringe.  I pull back on the plunger.  Nothing!  Then slowly, pus starts rolling into the syringe.  This kid needs to have the abscesses drained.

After finishing rounds the baby has apparently just breastfed, so I decide to use only local anesthetic rather than wait a few hours.  I inject some lidocaine after calculating the max dose that I can give.  The skin is so thin over the pus that I cant even numb it up well.  I don’t want to sedate her so I just incise it.  A huge amount of pus comes out her left lower back.  Then I do the right lower back, and get another huge amount.  I open it widely so that adequate dressings can be done.  This is terrible!  I wish I would have put a needle in it the first day.  I hadn’t because if it were blood, then that is a great medium for bacteria to grow and I didn’t want to chance introducing infection.  Fortunately at a week old, the girl will not remember the incision nor the many weeks of dressing changes that will be needed to heal all this.

The ultrasound nurse asks me to see a man he things has peritonitis with fluid in his belly.  The guy looks sick as I see him on the ultrasound table.  When I touch his belly it hurts.  When I tap on it, it doesn’t seem to.  He has no rebound nor guarding.  I ultrasound and only see lots of fluid.  I want a CBC, a CT scan and better history than I am able to elicit with French and English.  He says he speaks English, but I can get more information from him in French as he is using some form of Pidgin English.   I grab a syringe and prep the skin and put a needle into the pocket of fluid I see.  I get yellow cloudy fluid.  He has been being treated for typhoid at the Kelo hospital.  So I suspect a typhoid perforation.  If the fluid were regular ascites, then it should look like urine, not cloudy.  So I decide he needs a Bere digital CT (digital Cut and Touch).  I do the orders, and they head off to the pharmacy to get medicines and to pay for surgery.  The total will be 100,000CFA ($200), and that includes postop IV meds and oral meds too.  I see a few consults before the staff brings him in to the OR.

He looks in obvious pain as he walks in and lays down on the OR table.  The anesthetist wants to do a spinal, so he gets a 1-2 liter bolus of fluid and then they get that done.  His belly is prepped and I get on my cloth gown.  Cloth drapes are placed on him.  As I opened the pack of instruments, I see that this pack is actually sterile, the indicator that was placed, really shows sterility.  I’m pleased and show everyone.  I ask David to continue to sterilize the packs the same way. As I cut into his abdomen, we get pus flowing out.  I guess the sterility of the pack, didn’t matter quite as much for him!  We end up suctioning out 1000ml of pus!  The intestines are stuck together and slowly we separate them and get more pockets of pus.  There is a bad odor.  The typhoid perforation I did a few days ago looked like this but didn’t have a foul odor.  As I look around through all the small intestine I don’t find a hole.  I look at the appendix and the tip I see doesn’t look bad.  I look at the stomach, and then the back side of the stomach.  Nothing other than more pus.  Eventually I look at the large intestine and I find the hole.  It is just at the base of the appendix.  Perforated appendicitis that apparently started 6 days ago.  That means he’s likely been perforated about 5 days.  I complete an appendectomy and wash out the abdomen more.  We close up and head back home at about 5:30.  Both of us want to get out of the hospital compound.  So we take Olens moto for a ride.  It is great to feel the wind on our faces and see the beautiful fields of rice.  On the way back, after sundown, there were quite a few bugs hitting our faces.  We were glad to have gotten out.

As we are eating supper, I hear a rapid knock on the door.  They nock a couple more times even before I can get to the door.  The nurse says that the old lady with a tracheostomy isn’t breathing well.  I asked if he suctioned her, and he said the machine wasn’t there.  I had specifically asked David to put it next to her bed after the last surgery.  I run to the OR, grab the machine and huff my way to the surgical ward.  She is barely moving air.  All of her ribs are heaving, her neck muscles retracting.  Trying to get every ounce of air she can.  The secretions blocking the tube are very thick and barely are able to be suctioned out.  After about 10 times suctioning her, she is breathing much better.  I get some sterile water and squirt it in there to soften the secretions up.  She coughs some more, and finally sounds clear.  She is very tolerant!  During all this suctioning and mess she didn’t try to stop me from suctioning, as most people would do when they know it causes the intense coughing.  I am glad her life is saved tonight! I fear for her future!  I wish I were here longer to decide when to remove it.  I think it is still to early to do it now.  I wish I had a bronchoscope to look down from above and see what the upper airway looked like.  I pray for her again as I do each night, that God protect her from her secretions, from anything the family may do to harm her, from the devil and his plans to destroy her. (1 Peter 5:8)  I pray that the nurses will be vigilant in her care.  And I pray for my other patients and the patients of the hospital in general.  Thank you Lord for saving her tonight.