MissionDocs.org

Bere 2018 #11

There’s a knock at my door. Avava (a friend from Cameroon) and I have been sitting her talking. I open the door and its one of the student missionaries with the two AHI lab guys, Ben and Erik, that just arrived yesterday to set up lab equipment. They’ve come over for the Friday night singing and worship that the missionaries do every Friday. I didn’t know it was going to be here, but I’m happy it is. We have plenty of room in our place to host it. Eventually everyone show up and we sing hymns, in English. Then, as they’re used to doing, everyone goes around the circle and shares what they are thankful for this week. I mention that I’m thankful for the prompting of the Holy Spirit. He helped me decide to operate on the 17 year old kid that had vomiting without other signs of bowel obstruction. That he is doing well and I am glad that I operated on him. After out thanksgiving, we sang hymns. I really enjoyed as everyone sang and there was at times 2 or 3 part harmony. We than shared food. Some we had here and some they brought. We talked for a few more hours.

After everyone left I went to the hospital to pick up the ipad that I place orders on. I had left the ipad on the pediatric ward, where the only charging cord happens to be. A child of about 2 years old had just come into the hospital and the nurse wanted me to see him. He was eating a banyee (a small deep fried lump of bread, kind of like a doughnut without a toping). His abdomen is very distended and rock hard on the left side. His father says his abdomen is the reason he came. He eats fine, poops fine, and doesn’t vomit. Recently started to have a cough a couple days ago. He has an ultrasound report from another place. I can’t read all of it, but it seems to say he has something on his kidney. I wonder if this is a huge cystic kidney? Even though its 11pm I decide to do the ultrasound then, as the next day is Sabbath and I hope to go to church and not get stuck in the hospital. I take them to the ultrasound room, put ultrasound jelly on his abdomen and take a look. I see a huge solid tumor. This is cancer! I cannot get pathology here so there is no point in biopsying it. I also can’t treat whatever it is, even if I could biopsy it. I share the bad news with the father and they head back to the pediatric ward. The nurse doesn’t really speak his language so there isn’t great communication. I head to the other wards, to ask if they have any problems that I need to deal with before going to sleep.

As I lay in bed, I read my book and also think about that little boy. I look forward to Heaven, when we won’t have any more pain and these diseases will not affect people any more. And most of all we will be with Jesus.

Bere 2018 #10

I’m on the moto (motorcycle), riding along the mud road. Periodically children are yelling “Nasaraaaaaaaaaaaaaaaaa”. There are huge pot holes everywhere. An S pattern best describes my continuous way of going around them. There are tire tracks from the many motos that have traveled this road on the way to Lai. It’s the next biggest town to our east. I weave along the main road through Bere and continue towards Lai. Women are walking with a load of about 4 ft long grass in a bundle laying on their head, with little children strapped to their backs. Boys aged about 8-16 are naked on the side of the road and a few are still playing in the rice field. They must be laying down, as it seems that the water in a rice field cannot be very deep. Or maybe a little stream that I cannot see since the whole thing is flooded. Other little boys stand on the side of the road with about a 10 ft cane of some type, and with a string and whatever- are fishing in the rice field. Others are slowly moving along on their bicycles in groups of 1 or 2. I pass a group of about 8 guys that have been out working the fields as they have the curved cutting implements laid across their shoulders. The special tree comes in to view. I pull up near by and get out the computer. I get out my phone and I create the hotspot. After connecting my computer I send my emails. I try to contact my wife, but she is already at work, so we aren’t able to talk.

There ended up being no scheduled cases today but I found one and Dr. Sarah found another. I had done the rounds on the surgical ward and then went to the medical ward. There was a kid there who was about 16, and had been vomiting a week now. The last two days I thought he was improving. As I step up to his bed he grabs a bowl and pukes a huge amount of green stuff into it. Part of it hangs in a string from the side of his mouth, and the dad grabs the stringy saliva and drops it into the bowl. His belly is not really distended, but he’s been vomiting a week they say. When I re-ask about bowel movements, this time he says it’s been a week. But he passed some gas yesterday. I finally decide he must have a partial bowel obstruction that must be real close to the stomach, since he doesn’t appear distended. I tell the father that we need to operate on him and send him to the pharmacy to purchase supplies. The whole surgery with postop medicines comes to 65,000CFA ($130). They pay it right away. He is the first surgery, and we start about noon. Fluid and then a spinal anesthetic is given. I smile to myself again, as to why we are giving a spinal to a guy with upper abdominal surgery a spinal anesthetic. If it were to actually work, then he would stop breathing, then there would be many hours of bagging him with a mask. I’ve told the anesthetist that many times, and he does it anyway so I don’t say anything. Dr. Sarah joins me and we scrub. We put our cloth gowns on and sterile gloves. We put four drapes around the abdomen that has been prepped, then apply the clips in the four corners. The large cloth drape with a hold in the middle is placed last. Now only the abdomen with it’s vertical, near top to bottom, scar is visible. I expect this to be difficult so I do it and she helps me. I cut through old scar, and eventually get into the abdomen in an area there doesn’t seem to be any scar tissue on the inside. I am glad, as sometimes intestine is stuck there and it is possible to make a hole in the intestine as you enter, even if done cautiously. Once I can feel the inside, I extend the incision where I can. Other places I have to use scissors to take down the intestine from the abdominal wall. There are adhesions everywhere. I slowly dive in cutting them, in areas I can see. As I get about a quarter of the way down, I see a loop traversing underneath others. As I free this up, I realize that this was the point that was pinched and blocking the flow of intestinal contents. I am happy that I chose to operate on him as this will fix his problem. It takes another 45 min or so to take down the rest of the adhesions. I decide to do an incidental appendectomy (means the appendix is not inflamed but I take it anyway), as I’d hate to be in this abdomen again, though it does add a little risk of infection. Eventually we recheck everything, wash out his belly, and close him up. He immediately pulls out the nasogastric tube in the postop/preop area, when the nurses aren’t watching him closely. The nurse sent out his father then left him lying there by himself. I reprimand them gently and I reinsert it. Then I have one of the nursing students hold his hands so he can’t pull it out again. I seriously doubt it will even last a few hours, but I hope it does.

Next there is a 18 year old girl with a wound infection who was told not to eat about 9 this morning. Instead, she ate breakfast after that, and had a glass of water at about 1pm. The anesthetist wants to put her off till tomorrow, and it seems reasonable to me, so we get the next one.

Next is a 18 year old girl who just had a delivery and has some parts of the placenta retained. Dr. Sarah is doing rounds on peds and asks me to go ahead. So I do a curettage to get out the pieces of the retained placenta. Im done by about 3:30 so I head out on the moto to send emails. What a beautiful afternoon! The sun is out, frogs are croaking, birds are singing, children are yelling Nasarraaaaaaaaaa. It’s beautiful!

Bere 2018 #9

***READER BEWARE: very descriptive anatomy below, read as adults, not with children. ***

The list has a mastectomy, two hydroceles and a tubal ligation. That’s the operations that were to happen today. We did the middle two today. After worship and a lengthy meeting afterwards we finally started rounds at 8:30. Did the usual dressing changes and of interest to me was the guy with the intestinal volvulus from the other day. He has started passing gas and his belly is softer, a good sign. Things are working. Also the other guy with a strangulated necrotic hernia sac is doing great and is eating and pooping without any abdominal pain. I’m grateful. There are a number of them I pray for daily, which I’m concerned about. I pray for all the patients in the hospital globally but specifically for some.

A woman is lying in the preop area with a IV running and under the sheet I can see one breast standing up. For those of you who may not have done breast reconstructive surgery, it’s not good when a breast stands straight up. Normal breasts fall to the side and flatten some when lying on the back. So I suspected this was the lady for the mastectomy. I hadn’t seen her before. She saw a nurse who set her up for surgery after her husband paid and someone of the family gave a pint of blood (as in all elective surgeries). They got her back to the OR and I had a look at what we were doing. She is about 28 and had noticed a lump about 3 months ago. When I look at the breast the skin looks like an orange with little dimples in it. It stands straight up and very firm. There are two open draining areas on the skin. In her armpit there is a large- 5cm lymph node. As I move it up and down it does move some but I can tell it’s attached to the underlying pectoralis muscles. I also do not think there will be enough skin left to close the hole if I took it off her chest. Through the anesthetist translating I tell her I think I could take it off. I don’t think I will be able to get the skin closed, that she will loose some function of her arm, and that I don’t think it will really help her live longer as it has already spread. I use round about language to get to each of these points, making sure she understands each. I recommend that we not do the surgery, that even if we were successful at removing and closing the skin, that the cancer would come right back. I ask if there is family here. She says we should call her husband. He isn’t out there, but her older sister and mother are. They are brought into the OR and I tell them all the same things. I tell them that I expect it to get larger, the openings in the skin to get large and start to stink, and that she is unlikely to live a year longer. This is a really difficult discussion all the way through. I keep thinking of the gravity of what I’m telling her and trying not to tear. I ask who or what she believes in. She says she is and evangelical Christian. I try to encourage her that God loves her, even though she is going through something terrible. And that one day we will be in Heaven, where there will be no more cancer, nor more pain, sadness, and we will have healthy bodies forever after. I encouraged her to keep her faith in God and Him only. They say the husband needs to know all I’ve said and make a decision. This is a patriarchal society and women have no say in decisions even that concern her health.

I started the hydrocele surgery and midway through, I heard that the husband wanted to cancel surgery and go do traditional healing. He didn’t believe in cancer and that a traditional healer (witch doctor would get rid of it). When I was done with the surgery I called the family into the preop/postop area to talk about it again. I covered all the same stuff again. There was no crying, no visible responses, any of the times I discussed it. All were very stoic. Eventually the husband decided not to try with surgery. I encouraged him strongly that since he believed in Jesus that he should keep all his hope in Christ alone and not in any time of other healing or traditional things. That those things are not God’s things and that they should not attempt anything else. If and when there was pain, that she should see us again to get some pain medicine. They affirmed they believed in God and had no more questions. I felt very sad as I started my second hydrocele repair.

After that hydrocele repair was complete there was an old woman with a uterine prolapse for repair. As I saw here a few days ago, her whole uterus (about 5 inches) was prolapsed out between her legs all the time. I decided to do her operation abdominally as I feel I can get better suspension of what’s left from that approach. She is given fluid and then a spinal anesthetic. Dr. Sarah wants to do the surgery so we do it together. We choose a low incision along the ‘bikini’ line. I expect her uterus will easily come up and out of that incision as it has plenty of movement already. After we are inside, it seems more stuck down that I expected. There is some small intestine stuck to it and some loops stuck behind it. Slowly I’m able to free them up. As I free up these loops, I get into some small pockets of puss. So apparently when she had abdominal pain that I treated with Cipro for her typhoid, had apparently caused these pus pockets. She was better the following day but I was getting into them now 5 days later. One side of the uterus seemed to come up better now, so we started working on that side. Next to the other side. Clamping the vessels and tying them as we moved down each side. Eventually we get down to the bottom of it and finish taking it out and then suspend what’s left so there shouldn’t be any prolapse any longer. I decide to leave a drain, down to where the pus was. She definitely will stay on antibiotics. Of course every surgery is to help to minimize post op infections.

Can you guess what the next operation was?

Did you guess C-section? No. How about hernia? No. Well if you guessed ectopic pregnancy- than you were correct. Our 4th one this week. There are a host of reasons that women can get a tubal pregnancy. Most of them have to do with anatomical problems with the tube for one reason or another. So another belly full of blood in an anemic woman who was pregnant. And another small 2 month (2 inch) formed baby with arms and legs, that has lost it’s life and the mothers too, if she hadn’t come for surgery and received blood too. It’s been a productive day. We had water all day and electricity for almost all of it.

I convinced David to try and run the autoclave 2 hours instead of 1.5 from start to finish. I think it needs about 1 hour at temperature. But since the pressure gauge and thermometer don’t work any more, well, I just want longer. With this time frame it did get the indicator tape black finally. So I feel that these at least might be more sterile. I found some of the small indicator strips I brought last year, so I may try putting one of those in a pack to see what happens. I’m not really sure I want to know, but I do. There are so many possibilities for postop infection. Many in the USA, and even more possibilities here.

For those of you who have been in Africa- do you remember flying termite night? Well this is it. Hundreds of flying termites are buzzing around each light that is lit tonight. It only happens about one night a year. People in Koza would put buckets of water out and slap the termites into it. This catches their wings. Then the wings can be plucked off; they’re fried, and eaten. “Very tasty”, but I haven’t had the courage to try it.