MissionDocs.org

Bere 2018 #3

As my father in law used to say “It’s a good tired”.  I’m tired at the end of a long day.  Here the day starts at 7:30 with a hospital worship.  I couldn’t fall asleep last night till about 2 so didn’t make it in on time.  But one of the nurses was having a teaching on tuberculosis.  It was quite informative about the countries methods of dealing with the disease and its treatment in different circumstances.  For example, a pregnant woman, a person who has had negative sputum’s then turns positive again, patients with HIV, children, those who get inpatient treatment and those outpatient…  After that we went and looked at the new OR that is being built.  They have a building structure that is metal (termites cant eat it), and are building block walls on the inside to create 2 operating rooms, preop, postop, instrument cleaning, and instrument storage areas.  Dr. Sarah Belinsky ( I guess she goes by Dr. Sarah so Ill call her that now) and I make some construction decisions, I head to the OR to verify whether they are preparing the first patient- and they aren’t.  So I try to hurry them along, it always seems like a slow start each morning as I recall. Dr. Sarah calls me into the ultrasound room to see a 20 year old girl.  She has a palpable abdominal mass.  It seems mid abdomen.  Oh NO!  It has to be cancer.  We look on the ultrasound.  I see ascites (abdominal fluid), which is a bad sign, and a large solid and cystic mass.   We look for the ovaries, and they seem normal as well as the uterus.  Liver doesn’t seem to have any metastases.  I feel terrible as I tell her and her older brother who brought her about our diagnosis.  We have no chemotherapy drugs nor pathology for a true diagnosis, so the only thing I can offer her is to explore her abdomen and take out the mass if I’m able to.  If she was an old woman, I wouldn’t offer as I don’t think it will be successful.  But a 20 year old, I’m going to try tomorrow.  I head back to the OR and they’re not ready.  So I head to make surgical rounds. I’m still completely stumped by a 15 year old kid who had 1-2 inch pitting edema all over.  I’ve thought and treated, congestive heart failure (heart seems a little big on ultrasound- not accurate in my hands), wet Beriberi (thiamine deficiency), treated his malaria and typhoid, nephritic syndrome as he is dumping protein in his urine.  Its these patients that I’m most frustrated by not having appropriate tests.  For surgical problems, if I open their abdomen, I can almost always diagnose and usually treat, even if I can’t figure it out ahead of time with the ultrasound.

Back to the OR and they are finally ready for a right leg amputation on a 60 year old lady that had been bitten by a snake a few weeks ago.  Most of the skin on her leg sloughed off and muscle died.  They have been doing dressing changes and now both her tibia and fibula in the lower leg are exposed for almost their whole length.  Pus continues to drain out of her foot.  It hurts her to have me touch it anywhere, except above the knee.  I decided to do an above knee amputation.  She hurts every time she moves and is lifted onto the OR table.  She is given a spinal anesthetic and I start my work.  The “tourniquet” that is on the leg is a normal blood pressure cuff that looses air constantly.  So one of the nursing students stands near by constantly pumping up the cuff.  I am very pleased that the cautery machine that I brought last year is still working.  Between the ‘tourniquet” and the cautery there is very little blood lost.  Once I’ve cut through all the muscles and tied off the arteries and veins, it’s only the bone that is left.  There is a little saw, that I use to cut thought the bone.  I’m tired after sawing a few minutes and hand it off to my assistant to continue.  Eventually we get through.  The saw is quite dull and likely has been used for a half century.  I close the muscle layers over the end of the bone then the skin and wrap it with an ace bandage.  Next was a inguinal hernia.

Then there is another inguinal hernia that is strangulated.  He’s had pain and not eaten for three days.  Says he’s vomited some.  I’m guessing he has dead intestine in it.  I open this area up and I see black tissue.  As I dissect around it, it seems to be coming through a small hole.  Eventually I open it once I’ve gotten to good tissue.  It is a necrotic hernia sac.  This usually means that there is dead bowl inside.  The fluid I get is clear and all the intestine I can find from this hole, looks normal. Disconcerting! It seems the same size as when I started, so I don’t think anything has reduced spontaneously.  I then have two options, open him up along the middle and look around or finish what I’m doing and see if he improves or worsens.  I decide to watch him after this operation.  (if you surgeons differ with me, let me know).  I’ll know tomorrow if I made a good choice or not.

Another woman awaits a curettage after not getting all of the placenta out after a delivery.  She is very nervous about it.  We bring her family in and explain everything again.  She agrees and we walk her into the OR.  She starts crying and says she doesn’t want to do this.  So we take her outside to her family.  We all gather our stuff and I go to check things on the surgical ward- about 5PM.  WE are called back to the OR for a C-section.  A lady has not been progressing all day and apparently has been in labor a number of days at a dispensary before coming here this afternoon.  She arrives and sits on the OR table for her spinal.  After the spinal is in, she is laid back and we prep her for surgery.  The cloth covered C-section pack is laid on a nearby table and opened.  A fly is flying around the room and lands on the open pack.  We wave it away and as it is the only C-section pack “sterile”, we use it anyway.  I am totally convinced that God protects our patients, as infections for clean surgeries are very rare in spite of the conditions.  Dr. Sarah does the surgery and I assist.  The baby comes out with meconium everywhere.  But breaths and cries- Yeah the sounds of a live baby!  The area is closed up and she heads back to her maternity bed.

I’m asked to see an old man who had a prostatectomy before I came, and has urinary retention now 7 days after surgery.  This morning when I saw him he was still with dark bladder irrigation.  Likely meaning he is breaking down blood clots that remain in his bladder.  He is eating and in pain from a bladder that is visible when I look at his abdomen.  I flush his urine catheter and try repeatedly to clear the blockage.  Finally I just remove it.  He is able to urinate.  I hope that he continues to urinate or I may need to re-explore his bladder again.

I head back to the place I’m staying and eat the food that was prepared by a guy I’ve hired to make my food while I’m here.  He’s prepared and left me some millet paste with an eggplant/tomato sauce!  Not exactly my favorite, because we had something similar so often in Cameroon.  But I’m hungry and so I eat till I’m full.  I realize that the phone credit that I purchased yesterday evening is nearly gone.  I haven’t used much that I can think of today so I go through my phone again and try to turn off everything I can find that is sucking up my phone credit CFAs (Central African Francs).  I head out to the market to get some more.  It’s all dark but a few cell phone lights can be seen.  I find the guy selling the Tigo credit and tell him I want 5000CFA ($10).  He punches in a certain number on his phone and I get a text message that that much has been added.  He also sells brown soap, tomato paste, some soda drinks, Chinese batteries, pens, paper, a few types of shower soaps, flour, rice, different types of small cookies and crackers, powdered milk, garlic, small onions, maggii flavor cubes and many other small things.  I head back to my place.  In the dark on the walkway I feel like I stepped on something.  I flip on my headlamp and see that hundreds of termites are building a mud mountain that is half way covering the concrete walk.  They start scattering and kind of raising up toward the light.  It’s a strange site.  In the day, these always look like nothing is happening, but it’s slightly taller.  They are very busy tonight.  Guess Ill be looking at them every evening when I come back, for interest sake.  I hope you all are enjoying these stories.  If you’d like to hear about something specific, then email me back.  I’ll respond, even if I’m back home wh

Bere 2018 #2

Got to Bere Hospital last night. Had a few hours sleep and was awakened to help with a C-section. I told them to call me if anything happened or they wanted help. So I get myself together, find my scrubs, cap, mask, headlamp, keys, and OR shoes and stethoscope and head in. When I arrive Dr. Belinsky is already scrubbed and the patient has a spinal in place and they’re waiting for me. This young woman has been pregnant 6 times and all the babies have died. This time, she is at term, and is in a transverse position with a hand and umbilical cord coming out. For those of you who don’t know, babies can some out head first (preferable), feet first. Transverse doesn’t come out! So either the position needs to be changed or a C-section. I scrub and assist. Once the baby comes out, he is a little floppy, but with some drying and rubbing, he starts crying. This is a wonderful sound in any C-section- live babies cry!!! She gets closed and wheeled out the the preop/postop area. There are a couple patients needing to be seen by me that have been saved for when I arrived. One is a lady with recurrent breast cancer with large, hard lymph nodes in her arm pit, and metastases in the liver. I share the sad news with her that I cannot do anything to help her. We have no chemotherapy drugs here, especially the specific ones that can sometimes help. She starts to cry and lift her hands towards heaven. The nurse says I should encourage her. I think he means that I should gloss over what I’ve said and make it more palatable or less direct. In my western mindset, I think everyone should know exactly what the doctor thinks, and he’s asking me to not tell the whole truth. I tell him that I wont. Then he tells me, no maybe share something spiritual. I finally get it! I ask her what her beliefs are, and she is evangelical. I encourage her to focus on God and His love for her and that He doesn’t want this situation for her either. I share that we don’t have to fear the future or death, because we will be with Him. I pray for her, asking for Gods healing. And asking if God doesn’t heal her that he give her strength and peace for the coming months. She seems more at peace and leaves the room.

The next surgery, is a 20 year old guy with “appendicitis”, who has had pain for 9 days. So here’s a short surgical lesson- appendicitis is short term, day or so and it bursts or gets better with surgery or sometimes antibiotics. The ultrasound saw a mass and an inflamed appendix. I have little faith in the ultrasound interpretations and consider doing one myself. I figure it won’t change the fact that I need to operate on this guy, so I head in to explore him. He has a fullness on his right abdomen and it’s quite tender. The rest of his abdomen doesn’t hurt at all. Samadi, the old nurse who has done operations for years here, assists me. He’s been doing them the past months here as the surgeon was gone, but when we talk about who will do the surgery, he says that I’m the surgeon and I should go ahead. I, of course, agree with him and we move on. I’ve forgotten how difficult it is to open a persons abdomen here. The skin is tough and the scalpels aren’t real sharp. I slowly go through the skin, small layer by layer. After about three slices, I’m finally through his skin. There is a thin fatty layer and I’m at the fascia. I open the fascia and spread into the peritoneum. No puss or air or stool in the abdomen- good. I feel for the mass. It seems that the omentum (fatty layer in our abdomens that helps sequester infection) is stuck up to the abdominal wall. I slowly push my finger in that area separating the omentum from the abdominal wall. Puss rolls out, my nose, immediately catches the whiff too. I eventually figure that the guy had perforated typhoid that his body walled off. I put a drain in and washed him out. I also decided to remove his appendix, so that it wouldn’t be the cause next time either. I close him up and he is off to the surgical ward.

Next is an older man with a broken ankle that has been here about a month. He has a huge open wound and an ankle that rotates 90 degrees out, making the sole of his foot point off to is right. This occurred because of an accident on a moto. I agree with the others assessments that he needs an amputation, for the infection and because this is a non-functional foot and likely osteomyelitis (bone infection). In the operating room he gets a spinal anesthetic, then I go about removing his leg below the knee. I have to leave the amputation site open because of the infection and hope he is able to get some sort of wood prosthesis in the future. Ive heard they can be made about 4 hours away.

Then there is the mid 20’s guy with a small left inguinal hernia. We bring him into the operating room after the staff has cleaned it and Ive seen a couple more consults. I consider using mesh again and realize that most of the “sterile” packs have not changed color of the marking tape. I ask the guy who sterilizes stuff in the autoclave to put these packs back inside as they aren’t sterile. I again decide that I won’t use mesh during this visit. I’d prefer to have a chance at leaving the missionaries here a hernia recurrence in the future than a mesh infection. So I resect the hernia sac and use suture to reinforce the area.

A woman comes in from an outside hospital a few days ago. She had a very foul vaginal discharge and had apparently had a delivery that some repair had been done afterward. Her uterus looked very irregular on ultrasound and the nurse who does ultrasound thought that there was a perforation of the uterus. Samadi took her to the OR and opened her up and didn’t find any perforation. She continues to have a foul odor and so we took her for a uterine curettage. We were able to get small amounts out retained placenta out of the uterus, but just as Dr. Belinsky and I were finishing up, we see that there are large areas of necrotic tissue on either side of her upper vagina, near the cervix. The baby’s head usually causes pressure necrosis against the bone in front, so I’m not sure what caused this problem. I’m surprised that she is not deathly ill. So we debrided off whatever dead tissue we could and packed some gauze into both sides. I imagine that she will heal this, but it will take a while and she will smell bad until it heals. I warn her of these things and we wrap up the day.

Tomorrow holds a hernia and amputation of a lady’s leg that was bitten by a snake, and both bones in the lower leg are exposed for the majority of their lengths. I try to sleep tonight, but sleep is not coming, likely jet lag. So here I type. I hope to get out the forked tree about 10 minutes up the road to send these in the next couple days (yes that’s real). Apparently if I go 20 minutes away the cell signal is even better. Guess I’ll see what I can do.

Bere 2018 #1

I’ve been looking forward to my next mission trip and here it is.  And as usual it ISN’T boring.  I left home Saturday afternoon, and arrived in Bere, Chad on Tuesday night after midnight.  My longest flight was 11 hours (Newark NJ to Lome, Togo) this time rather than 18 if I went through Addis Ababa, Ethiopia.  After arriving in Chad I stayed the night with some friends then headed to Bere on the public bus the next morning.  It’s always good to catch up with old friends!  One of my worries while traveling in some African countries, has been the harassment of being stopped by police or army and being my documents and them trying to get money from me for, not having the correct paperwork…  I always have the correct paperwork, visa… but it’s a method to get some pocket money.  This is rather abrasive to me, and an unpleasant exchange of words.  So as I headed towards the bus, this is one of my worries.  Another, was that of getting my stuff on the bus with all the people jostling around me and making sure nothing gets stolen.  I’ve not had anything stolen, but, another thing I worry about.  We pulled up to the bus station and got a ticket for the 8 hour trip to Kelo.  Then we are told that the bus is leaving from the other side of the busy, two lane road with a concrete barrier down the middle.  Now it’s not really 2 lane, but 2 each direction, with a lot of cars, motos and buses.  So I get two guys who ran up wanting to help me, carry my luggage through the traffic, over the center barrier, then through the traffic on the other side to the waiting bus.  My boxes are loaded on and I go and find a seat beside a guy that’s around 20 years old.

About a half hour later there is a full bus and we leave.  Fortunately this is the large bus that is air-conditioned and has an individual seat for everyone.  The inside of the bus is decorated with flowing drapes and lace covering all the windows.  We have a Muslim driver, so I assume it’s a Muslim decoration, but don’t know for sure.  We take off, honking often.  Some it seems to warn others of our presence and others that are longer, to get people out of the way.  The streets are crowded with vehicles of all types.  And the edges of the road with people walking.  It is very green right now, because it’s the end of the rainy season.  A video was showing in the front of the bus, It goes from some music videos, to an action movie dubbed into Arabic, to other American movies in French.  Some voices are so loud it hurts my ears, other so soft I cant understand it at all.  We go about 5 or 6 hours then stop in a village for the driver and the other Muslims on board to have their prayers.  About 4:15 in the afternoon I arrive at Kelo.  Gabriel is suppose to meet me, so I collect my luggage and stand next to it.  People are milling about hawking their bananas, peanuts, shoes, flashlights, medications, cloths, perfumes, incense, legumes, little deep fried breads, sugar cane…  I wait about an hour, then I get word that the truck is broken down and they’re trying to fix it in Mundou.  About sundown, the director of the bus station says I should move inside to be safe from thieves.  So they help me move my stuff in to an open, lit area that they keep their motos in.  It starts to sprinkle on me and then quickly stops.  About couple hours later another truck comes to pick me up.  It’s loaded with stuff bought to fix up the OR and other numerous projects that are being done.  We pile my luggage on the top, and they tie it down.  One of the passengers gets on top and lets me have his seat.  We had about 5 minutes of black top, then started the mud road with huge mud puddles.  Most puddles were at least 12-20 feet across.  Other areas covered 50 feet or so.  As the driver wove in and out of the puddles I could see the water was easily up to our doors often.  A couple of times the front submerged enough that the headlights couldn’t be seen.  All was black for a few seconds and as the mud dripped back off of them we would see where we were driving again.  I was worried that muddy water would get in the air intake, as there is no snorkel on the vehicle.  But it kept running.  About 3 hours into our 1 hour drive (that’s one hour in the dry season), we encountered a few long areas where the end of the water couldn’t be seen.  It was at least larger than 100ft.  The driver chose the center, which I assumed was the deepest part, but he was making it till we stopped abruptly.  He tried to go forward and back and just spun.  We had high centered on something.  He took off his shoes to get out and lock the front wheels in, as apparently he was in two wheel drive this whole time!  As he opened the door, mud flowed into his side of the truck.  He locked it in, and now had front and back tires spinning.  Three people were walking by and he asked for help.  Two more showed up.  They discussed helping for $20, he said no $10.  A half hearted push was not successful.  I offered to get out and help, and he thought I should stay dry.  We could now see a number of flashlights coming our way.  A group of 6 more arrived.  They discussed that more people were needed and they needed $20 for everyone to help.  After that was agreed on, I could feel them lift the back of the truck some, but it didn’t budge.  Now a crowd was gathering.  Now they decided that the truck needed to be unloaded and the stuff taken to dry ground and then they could push us out.  Now they wanted $50 to do it.  After discussion they agreed on 13,000CFA about $26.  There were many people that then took metal doors, other metal parts, luggage, groceries and everything else in a procession to the “dry” ground in the distance.  There were probably now 50 people watching from the side of the road.  With a large push and a lift, we were out and driving to our pile of stuff.  Just then the other broken down vehicle (which apparently had a fire in the engine area) arrived.  After reloading the truck, the people wanted 14,000CFA ($28).  Finally they were given 13,000 because that was what was agreed upon, with a gift of 1000 to make them happy.  We later asked what they would likely do with the money for so many.  He said they would likely get drinks for everyone that pushed.  I figure that’s  a lot of bilibili.  (millet wine).  Or I guess it could be about 28 bottles of soda.  Other than periodic stops to re-tighten the load, we made it back the remaining 30 minutes without incident.  I got into the house that I’m staying in, and unpacked enough stuff, so that if I was called in the middle of the night for surgery, I’d have scrubs and a headlamp ready.  At 2am I still lay there trying to fall to sleep.  Eventually I did, and was awakened at 8am for a C-section with Dr. Belinsky.  Thus started my first day working (next story).