Bere 2018 #15

admin Greg No Comments

Bere 2018 #15

The first thing I do when I get into the hospital this morning is to check on the woman with the tracheostomy tube. The student missionary, Diana, has taken good care of her throughout the night. She has suctioned the tracheostomy a number of times and the woman is awake and not pulling on it. She is motioning that her stomach hurts. I try to have her sit up and swallow some water. It obviously doesn’t go down well. She is struggling to swallow. I’m glad I put a trach in her and wish I had a bronchoscope and EGD to look at the internal parts of the repair. I wish I had a tracheostomy with a number of inner cannulas. These are the parts that are changed out when they get plugged with secretions. Do I need to make a big hole in her neck so that it cant close up for months? The family didn’t even want to get her antibiotics. They said that the person with the money was coming. But when they arrived they didn’t go to the pharmacy. Eventually after they talked to her she grabbed the roll in her skirt and gave them a key. I assume that is to wherever she keeps her money. I told the men around that they should be ashamed of themselves. That their momma has to pay for her own care when it is the mans job to do so! (at least that’s culturally appropriate for men to do here, they are the ones with money). I discuss with them many times during the day to go and purchase the medications. I still don’t know if they actually did it like they said they were going to.

I do dressing change rounds (surgical rounds) on the surgical ward then do rounds on the medicine ward. Then I go to the “ER”, a room with 6 beds in it lining the walls. There are no diagnostic machines, no monitors, nothing that demonstrates this is an ER other than it says “Urgence” on the wall outside. I’m asked to see a guy who came in last night with a tender abdomen. It’s been tender for 3 days. As I talk to them I lay my hand on his belly. He winces. I give a slight tap with a finger, he grimaces. I do a normal exam, and he has a rigid abdomen. All signs that he has perforated intestine. I need to do a digital CT. here this does NOT refer to a CAT scan like in the US. It refers to cut and touch with fingers. So I put in all the orders into the ipad (they have a simple system called Open Kims, that was donated and is very useful.) So I put the orders in and the family goes to the pharmacy to purchase the medicines. When he has paid and gotten the medicines- His bill comes to about $150, they get him ready with a spinal and urine catheter. Dr. Sarah is done with rounds and so she joins me. She does the majority of the surgery. As we get through the skin, non-existant fatty layer, fascia, and peritoneum we then get pus. As we look around feeling for something that might be suspicious we don’t find anything by feeling. So we start pulling out the intestine out of the incision and look for holes. In the distal small bowel, we find a small hole in the intestine. I freshen up the edges, excising the hole and making it a little larger with good edges to close it. Then I close it with interrupted silk sutures. As we look around we find two other spots that are soft and necrotic and nearly holes. So we excise these two spots and Dr. Sarah and I close them. WE wash out all the pus we can and clean the intestines. We put them back inside with difficulty as he also has had ketamine from the start as the spinal didn’t cover that high on his abdomen. It’s kind of like the patient is doing a sittup, his muscles are real hard. Eventually I shove them all in and we are able to close the abdomen.

I’m very frustrated tonight. I got called into the hospital to see a 2 year old boy who has a rectal prolapse. This is when the rectum turns inside out and sticks out the anus. I also have seen an intussusception present this way. This is where the intestine invaginates on itself and sucks one piece of intestine into another. So I suspect this is more likely. I walk in by the light of the moon with my headlamp off. I go to the peds area where they receive kids. There is a mother with two guys and a child with lying on his belly, with a wet cloth covering a bulge at the anus. I lift the cloth off and see a looped piece of intestine sticking out the anus. As I feel around it at the anus, I’m convinced that this in an intussesception. He needs surgery to remove dead intestine and to reduce whatever intestine is still living. I do the usual things of asking the family to go to the pharmacy to buy medicine and pay for surgery. The total comes to an equivalent of $120. They say they have no money, as everyone says, and I say they should go to the pharmacy or send a guy home to get it. As I go to the maternity ward, there is a pregnant woman there that the nurse is not sure if it is a head presentation for a delivery. I take her to the ultrasound room and confirm that she is a cephalic presentation. Then I check on the woman with a tracheostomy that is now on the surgical ward and has a suction sitting on the floor next to her. She is breathing fine for now. I head back to peds. The family has left with the child to see what his uncle can do to help them pay the bill. I am very frustrated. I want to operate on the child. I also want to respect that the hospital needs to pay its bills and workers, and therefore needs paying patients. I feel like I have failed to show Christ’s love to this patient tonight. Would Christ pay the bill for them? Would He help create the feelings of things being done for free at this hospital? No he would put a hand on them and it would be healed. I guess I didn’t think of asking Him to heal the child in that moment. I am praying that they will return soon to allow me to operate on them. I am praying for healing now- though that feels woefully late. Again, I look forward to the day when the pain, sorrow, and sickness of this world are gone, and you and I can live forever in peace and health and joy with God for all eternity.

for more mission stories visit our mission website www.missiondocs.org

for information on our missionary and pastors oasis visit www.lifeimpactministries.net and click on Safe Haven Oasis

Bere 2018 #14

admin Audrey No Comments

Aud’s in Bere, Chad

So, I am writing my first note from Bere at 1am on Wednesday night/Thursday morning. Why at 1am you might ask. Well, this is the first time I have had to sit and reflect on my journey here.
I left my house in OR around 2pm on Sunday afternoon after my sweet kiddo made me an awesome lunch. I drove to Eugene to hit Costco for some last minute goodies to bring to our friends here in Africa. I suppose it was a funny site in the parking lot of Costco as people drove by watching me weigh and re-weigh my trunks so they wouldn’t exceed the 50lb weight limit. 2 people offered to help me get them in the car, not realizing that I had picked those trunks up dozens of times already to max out the space. Finally happy with the weights, I started driving to Portland. I got to the parking area and again had to lug the trunks from he car, to the shuttle, to the checkin. I was so happy when they finally disappeared with tags for N’Djamena, Chad.

My flights were uneventful. Ovenight from Portland to Chicago; 15 hrs Chicago to Ethiopea; then on to NDJ Chad. I was able to get through customs with no hassel at all- a first for me coming into a West African airport. The only glitch in my travel was the miscommunication of landing time, so I had to wait at the airport for awhile. It was extremely hot, especially after coming from 50 degree Oregon, and I didn’t have a phone to call, or a contact number for my ride. I finally borrowed a phone to call Greg, who called our friends that were to give me a ride. I met up with Gabriel, Dr Sarah’s fiancé and Sarah Appel and went on to Sarah A’s house on the farm.
I spent a nice afternoon at her place, walking around and taking the best cold shower I’ve ever experienced. We ate at 6pm and by the end of dinner I was almost falling asleep on my plate, so went right to bed, sleeping deeply until I had to wake at 5:40 to eat and get to the bus terminal.

I got on the bus around 8am. Now, I wish I could show you pictures of this bus. Imagine a grayhound bus, with curtains, and window decorations, and tassels, and streamers. (Last year’s bus even had beachballs hanging from the ceiling). Now add lots of people and kids in all shapes and sizes, with all of their individual smells- some amazingly sweet, others not as pleasant. Plus the luggage. There were largs sacks of onions blocking the aisle of the bus, and everone was required to step over and around, no matter what kind of skirt or wrap you might be wearing. Fortunately on this trip we were not stopped by police or army to inspect, and re-inspect our travel documents. In the past we have had 3-7 stops just for police to try to extort money. Not so this time, a very pleasant surprise. The bus made numerous stops to pick up and let off passengers. We stopped in the middle of nowhere and everyone started getting off. I soon realized it was a potty break-just stand next to the bus and do your business… The next stop was Bangor. This was the only major “city” on the route. It was also a good place to get crackers, soda, water etc. So, I got some “roadside meat” which was delicious, and yes, I tried fried crickets. Pretty good mixed with hot pepper spice. Finally off we went to my final stop of Kelo where Greg was there to meet me.

Greg had decided to not repeat his trip into Bere with getting the truck stuck, so he came to get me on a motorcycle. We hired a 2nd “clandoman” (moto driver) to bring my two 50lb trunks and off we went. Fortunately it hadn’t rained for 2 days so the dirt roads weren’t slick mud, but were still covered wih huge puddles. I knew this would be an adventure when Greg said, “ok, with this puddle, you need to lift up your feet or you’ll get wet.” Sure enough, the water came up over the tires but we made it through. All in all, the 2 1/2 hr ride was very pleasant, getting in just 30 min after sundown (with a crummy headlight).

As soon as we arrived, Greg went in the hospital to see a woman who had been injured by a bull. For you squeamish types, this might be where you should stop reading. The old woman had been charged by a bull, slicing her throat with its horn. She was still alive and breathing when Greg got there. Dr Sarah thought it had gone through a small bit of her trachea and possibly esaphagus. He was then notified of a 2 yr old with a strangulated inguinal hernia. Greg called for me to come and do the surgery with him to repair the neck and then repair the hernia on the kid. When I saw the woman, I could feel air escaping her neck with every breath. Already a miracle that she was alive. We prepared for surgery. It should be known now, that there are no ventillators, no gasses to put people to sleep, no pain medicine stronger than Ibuprofen. She was put to “sleep” with Ketamine and then Greg started to explore the injury. The injury was just above the trachea in the soft tissues. Not great, because this area will swell up terribly if injured and will become easily infected. All this to say that soon she would not be able to breathe through her windpipe. We decided to do a tracheostomy below the injury so she would have a secure airway. “Do they have tracheostomy set up here?”, Greg asked. No! So he started to do a trach, inserting a endotrachael tube, getting it set, then cutting it shorter so it would‘t stick out so far. By the time we were doing this, she had stopped breathing so it became emergent. We had a very hard time keeping her oxygen normal. The nurse doing anesthesia was bagging her in attempt to bring up her saturations. Greg, meanwhile was trying to repair the bull induced injury of her neck. I finally broke scrub to listen to breath sounds finding them only on the right. When we pulled the tube back a bit, she was then able to breathe using both lungs. She was still only taking a breath irratically so Phillipe continued to bag her. With the neck repaired as well as could be expected, we now had the challenge of managing a tracheostomy in an old woman, with none of the nurses trained to do so, no respiratory therapy, no ICU. I stayed by the old woman trying to keep her oxygen level as close to normal as I could. Greg did the next surgery on the 2 year old boy with inguinal hernia with a sweet nurse from South America who has been working here for several years. Fortunately for the kid, his bowels were still healthy and so it was a quick surgery. Meanwhile, I was suctioning, intermittently bagging, and manually giving oxygen to the woman. Her breath sounds were becoming very wheezy and diminished so we gave her IM Salmeterol (like Albuterol), IV Dexamethasone, Epi down the trach, then injected. She finally started really breathing on ther own, but was still fairly unstable. After doing as much as we could, we left her with Dianna, the nurse who had done the hernia operation with Greg, and decided to come back to the house to have dinner. It was now midnight. We ate rice and beanballs (like meatballs but bean based) in a tomato sauce. Greg went back in to check on the old woman, and I took the second best cold shower of my life. So here I am, writing while Greg showers. An exciting first day in Bere.
Total travel: Sunday at 2pm to leave the house- arrive Bere Wednesday night around 7pm.

Update: Afte sleeping until almost noon today, I went in to find the old woman doing well, considering… She has not pulled out her trach. She is breathing comfortably. Her lungs finally sound good. If only her family would actually pay for the antibiotics she needs, she might just make it. She will probably need the tracheostomy for some time to allow her neck to heal. She is having a hard time understanding why she is breathing through a tube in her neck, but has finally accepted it and is not fighting it. With patients and cases like this, I have to give all the credit to an awesome God who loves us and her, as she really should not still be alive.

Bere 2018 #13

admin Greg No Comments

Bere 2018 #13

“Quesque tu fait ?” I am trying to figure out what’s happening as the anesthetist and the student nurse get the very old blind man off the OR table and he starts to squat to the floor. They kick a bedpan underneath him. At first I think that he needs to pee, then I hear it’s to poop. NO NO! Go outside. They stand him up and slowly go out to the preop area to have him poop in the bedpan. I don’t want to stand in that smell for the next couple hours as I fix his strangulated inguinal hernia and his accompanying hydrocele. I also don’t want that contamination in the OR. Though it seems that frequently when someone gets their spinal, at the end of surgery there is poo between their legs. Finally he finishes and they get him back on the OR table for his spinal anesthetic. He has had an incarcerated hernia for about a week. His scrotum is nearly the size of a US football. The cautery grounding pad doesn’t seem to be working so I disassemble the connections and recreate the metal grounding pad. It works. He is prepped and draped with cloth drapes. This pack they had resterilized paper gowns, so I feel like I’m in luxury with sleeves long enough for my arms. As I get down to his hernia and open it the identifiable structures are difficult to find. I identify the fascial layers and the nerves. But the cord structures with the hernia sack is really edematous and difficult to figure out. After dissecting around for about 15 min. I finally enter the sack. It seems to have intestine stuck to one wall. After about another 15 min, I figure out that it seems to be a piece of large intestine with the appendix on it. But the intestine occupies one wall of the hernia sac and I can’t separate it. I kind of close it back up and then am able to reduce it back in the abdomen. I compete the suture repair of the hernia and then look at the hydrocele. As I dissect around the testicle, there isn’t a hydrocele, just a lot of edema. So I put it back in the scrotum. I close up the various layers finishing the surgery.

There was a lady that came in with a low hemoglobin 4 (normal >12), and received 4 units of blood last night. Today she is 6 (should be around 8). Her belly is distended and tender. I decide she needs an exploratory laparotomy. Eventually they get her form the ER to the OR and she is the first surgery of the day, well before the one noted above. Phillipe (anesthatist) gets her ready as I make rounds. I send home a number of people. Some of them just have dressing changes and have been here a long time. After she is ready, I call Dr. Sarah and she is done with rounds, so she joins me. Since her pain started all over her abdomen, Im not sure what I will find. So I make an incision in the middle of her abdomen. The blade seems dull for her tough skin. When I get into the abdomen yellow fluid comes out. There seem to be adhesions everywhere. They are fairly weak adhesions and most I can just divide with my fingers. I don’t see anything obvious for a while, so I keep looking. I don’t see any pus, no stool. Eventually I look around the stomach after extending the incision up as high as I can. Then I see some dark tissue on the anterior stomach. Eventually I see mucosa coming out a hole near the pyloris (exit of the stomach). She has a perforated stomach ulcer that is huge. I try to decide wether to close it or just cover it with omentum. I do both. Freshen up the edges. Reapproximate the edges and then suture up some omentum over the area. I have the anesthatist put in an NG tube and I leave a drain through the abdominal wall to the area as well. She will need antacids too!

I’m sound asleep. I hear tapping, and eventually am conscious enough to realize it’s someone at the door. I look at the phone and see I’ve been asleep about 45 min. I get dressed and walk outside. The moon lights up the sky and ground. The maternity nurse says she has a woman in the delivery room that bled a LOT at home and continues to bleed here. She thinks she is near term pregnancy. She doesn’t hear the babies heart beat. She did a vaginal exam and felt what she thought was placenta. Diagnosis: placenta previa. This is where the placenta covers the birth canal and as the cervix dilates, the placenta starts detaching from the uterus and bleeding. This often kills the baby and can kill the mother as well. I am AWAKE NOW! I follow her in, and get the ultrasound on my way. The 25 year old girl is lying on the delivery room floor, having just vomited on the floor. She lays in a puddle of blood and blood is all over her wrapped skirt. I put the ultrasound machine on the floor and squat beside her and do the ultrasound. I find a baby that is alive but 32 weeks and has a heart rate of 71 (normal is 130-150). This baby is dying, and is to early to live here. No neonatal ICU here- just mom and grandma giving him breast milk. The girls hemoglobin is 6 and I think this is falsely high. Her eyes could not be any more pale than they are. I see NO vessels whatsoever! I call he anesthetist to come in and figure ill call Dr. Sarah too. Then one of the student missionaries, Diana, comes by and she says she can scrub with me. So I scrub with her, and let Dr. Sarah sleep. She is blood type A-, and I think, it’s unlikely we have any blood that may work for her. Fortunately the blood bank fridge is in the OR, so when we get her in there I check. Yesterday we had a woman who had an ectopic pregnancy and we gave 4 units of blood to. Everyone the lab tested was A and the patient was O. They gave anyway, and we used O from our fridge. Now I see that God was working everything out YESTERDAY! As I look in the fridge, I find 5 units of A- blood. WOW!!! I hang one, and the anesthetist gets there soon after. We have a unit of blood going on each side, wide open. We do the usual prep and drape with cloth and I pray out loud and start. As I cut into the abdomen she bleeds, but I can tell it’s diluted blood. It almost seems see-through and doesn’t coagulate. I use cautery and clamps, and cause as little blood loss as I can. I cut into the uterus- and it always bleeds a lot. Then I pull out the baby. I strip the umbilical cord towards the baby to give it as much blood as I can. I hand him off after cutting the cord. He is trying to breath- Im not hopeful for him. As I close up the mother, I see the baby moving a little but no sounds. The nurse says he’s breathing. I ask God to save the baby again. I finish up and the mother is doing well. The baby has been taken out to the family and I head to bed.

The next morning as I get to the hospital I ask about that baby. I am told that he is doing well and has breast-fed already! PRAISE GOD!!!! A miracle!! I couldn’t have imagined he would ever make it.

 

for more mission stories visit our mission website www.missiondocs.org

for information on our missionary and pastors oasis visit www.lifeimpactministries.netand click on Safe Haven Oasis

Bere 2018 #12

admin Greg No Comments

Bere 2018 #12

Malaria is a killer! I’ve been seeing adults with malaria that have low hemoglobins of 7 from malaria. Others have scleral icteris (yellow eyes) from blood breakdown from malaria. Some have large spleens from malaria. About 445,000 people die of malaria each year. More than half of those are children

I finish rounds on the surgical ward and the medical wards. I head over to pediatrics to see what Dr. Sarah wants me to do next. She has one more patient to see. As I talk to her, that last patient dies of malaria. The mother is crying and runs out of the building. The aunt that was holding the baby continues to hold it and shut it’s eyes. The nurse takes the IV out. It is pointless to do CPR. We are sad at loss of another life. With the quantity of child death in Chad, it remains one of the major health issues in the country. Each mother when you ask them about children, they cay how many they’ve had and how many are living. I was doing an ultrasound on a lady the other day, and asked that question. She said she had had 8 children and 3 were living. Others have more living children than dead. Most seem to have at least one child gone.

I continue to pray for each of the wards of patients, that God would continue to heal them and that they would know Him. He is the only one that can give you peace in this world of turmoil.

for more mission stories visit our mission website www.missiondocs.org

for information on our missionary and pastors oasis visit www.lifeimpactministries.net and click on Safe Haven Oasis