MissionDocs.org

Shanksteps (of faith) Bere 2017 #10

It’s Sabbath.  The day I worship our creator God and spend time with Him and family.  I like to avoid work (hard to do as a doctor) and here we don’t do rounds, but will address whatever emergencies show up.  It is a camp meeting weekend so there is no local church today as all are off to a village about an hour away for the day.  Christian and Sabrina are having a brunch and worship at their house, so I go over there after reading at “home”.  There is a smattering of dishes to eat as there are many nationalities amongst the few of us there.  There is mata (an Argentinean tea that is shared with a communal cup and metal straw), Cameroonian peanut sauce for rice, Argentinean crepes, Guatemalan salad.  I didn’t bring anything and realize I should’ve come up with something even though I’m a poor cook.  I could’ve brought a dessert of granola bars or something.  We listen to worship music and eat brunch.  We then get a call from the hospital guard to come and see a patient that may have appendicitis.  After the meal Christian and I head over there.  A mid twenties, very muscular guy is laying stiff on the ER bed with sweat all over his forehead.  A grimace is on his face.  He is in obvious pain and he answers questions laying perfectly still.  He’s been sick for about a week, but yesterday the abdominal pain became much worse.  I touch his belly that is rigid and he grimaces each time I tap on his abdomen.  I guess he, like many others this week, needs a digital CT (cut and touch).  I learned this term from Christian and am enjoying it here more and more.  Mostly for the duplicity of it’s meaning.  I’m thinking it could be appendicitis, perforated typhoid, perforated ulcer, or bowel necrosis from an internal hernia.

In the OR I open the abdomen and immediately bile pours out.  This makes me think it is either stomach or small bowel.  As I look around the small bowel is very inflamed and red.  Looks like typhoid to me.  I come upon a spot where bile is pouring out of the distal jejunum (small bowel).  I freshen up the edges (make the hole larger excising the perforation), and close the hole.  We then look at all the small intestine from beginning to end.  There is one more area that is purple and very thin, nearly making another hole.  So I excise this area and close it the same way.  We wash out the abdominal cavity and close our laparotomy. He goes to the surgical ward.  Since he had spinal anesthesia, I am able to talk to him as we leave the operating room and tell him what we did.  He is thankful for our care for him.

I head over to the private ward as there was a father who asked me (in English) to see his son who hasn’t seen a doctor since he arrived yesterday evening.  I asked what was happening and the father said “his stomach worry him and it take 4 person to hold him down.”  I remember that a worrying stomach is a painful stomach as stated in Nigerian English.   And whatever he has he isn’t in his right mind- ?cerebral malaria, ?meningitis, ?advanced syphilis, ?hypoglycemia, ?stroke… the list is endless.  The physical exam is my only diagnostic. The treatments are limited, so I’ll call it something I can treat and treat it.

As Christian and I walk up to the ward, an overweight man greets us in French.  He is one we operated on recently and has a urine bag hanging out from under a wrap around is waist as a skirt.  So I assume we did a prostatic surgery on him.  He says he has some drainage that started today and opens his skirt.  I see a low midline incision an Christian remembers that he was a prostate resection.  He has pus coming out of his lower incision.  We tell him to go to the operating room  and we will be there in a few minutes to take care of it.  We walk into the other guys room and see a about 17 year old being held down by 4 others.  He is wide eyed and thrashes about.  He then relaxes for a minute or two then thrashes about again.  His malaria test is positive, so I suspect cerebral malaria.  He’s been treated in Moundou, the second largest city in Chad.  I’ve heard from people there that the medical care there is terrible, so I don’t assume that he’s been appropriately treated.  We order the things to treat him.  They thank us and we head back to do a dressing on the other guy in the OR prep room.  We open his lower incision and some pus comes out, he screams like we are killing him.  Very much unlike everyone else here.  He is apparently a chief of a part of a nearby town Kelo.  He is also heavier than most of the local people, which confirms his chiefdom in my mind.  Christian numbs him up before proceeding further.  He tolerates the rest better and is happy when he leaves the dressing change.  I head back to my room and write/read/rest.  It’s been a good Sabbath.  Jesus healed the lepers on Sabbath.  I closed the holes in some guys bowel, and Jesus will heal him too.

I’m at the morning worship and I’m told that all the foreigners that work or volunteer in the hospital are called to see the highest local government official, the prefet, this morning. We are also suppose to bring our passports. After living in Cameroon, this sounds fishy to me. No explanation is given, just the order to show up at 9. I’ve NEVER had to give my passport to any local officials while in a country, just at the entry to that country. So I know something is up, but don’t know what yet. We all gather and pile into the truck and head over there. After waiting outside about 5 minutes we are ushered into his presence. There are chairs around the room for all of us and he sits on a couch. He greets Olen as the head of the hospital and recognizes the rest of us. Small talk is then made about how each others families are doing. Coming down to business it is said that not all of us have been presented to him as the local authority, and that he needs to know who is in his domain so as to keep us safe. I don’t feel unsafe, and am still skeptical as to what this really means. He asks for each of our documents, and we present our passports. He hands them off to another in the room who starts to glance through them. They say they will need time to go through them and assure that all is in order, then they will call us to pick them up later. I feel uneasy about leaving my passport anywhere, much less here. But as there is no other option, we leave and get back to work at the hospital.

Later in the day Olen is called back to the office and each passport was shown with it’s deficiencies, a lack of visa or lack of stamp… He had to find the recent visa or stamp for each one and that all was in order. Then the person said that the hospital needed to pay for the stamps and evaluation of the passports. They were declined. Then he was asked to give money for pens for the office, he offered the pen in his pocket. Eventually after a bit of back and forth, Olen was given all but 4 of the passports. Mine was in those that remained. (In a couple days I got mine back as well). So in the end it seemed to be a method to try to get some money from the hospital, frustrating!

Back at the hospital after leaving the above meeting, I change back into scrubs and head back to the OR. There are still about 8 people waiting for their surgery today. Each day we try to get through as many as we can and then quit about 5 or 6 and the rest are allowed to then eat and wait till tomorrow. We do two different guys with inguinal hernias and do a hydrocele. A hydrocele is when there is a lot of fluid around a testicle. One I did yesterday had a liter of fluid I drew off as I opened it. After these three there was a woman who was seen in the ultrasound room that Rollin had seen with a positive pregnancy test without any baby in the uterus. So it is likely this represented an ectopic pregnancy (pregnancy outside the uterus). This is important as usually they present to the hospital with bleeding inside their abdomen. So Rollin and I took her to the operating room. The spinal is placed, the patient prepped and draped. And the incision is made. Getting into the abdomen all is stuck in the pelvis. With a lot of difficult and uncertainty about identifying structures with all the inflammation, we eventually identify a teratoma. This is one of the strange things that occurs. It is a tumor with different tissue types inside of it. It often has hair, muscle, bone, or teeth inside. With a lot of effort we eventually got the teratoma out and closed up the abdomen.

Next we did a hysterectomy and then another hernia. And head out about 6 or 7 PM. About 5 in the morning I hear a voice outside my window. Christian is there to say he was called and would like my help. I get dressed in scrubs and head in to the OR. During the night he had gotten up to do a C- section and now there is another woman in the ER that was stabbed twice in the abdomen. The story I hear is that her father stabbed her. Apparently he has stabbed and killed her husband in the past and may have been in jail a short time frame. I pull the covering back and look at her abdomen. There is about a 1.5 inch wound on her right flank and also another in her right upper abdomen. Her abdomen is rigid and tender- peritonitis. For those who don’t know, a stab wound can hurt nearly anything in the chest or abdomen. It all depends on the direction and the length of the knife. This rule is confirmed again during this operation. She get’s a spinal like everyone else, a little strange to me as it doesn’t work in the upper abdomen, but it does provide some relaxation that wouldn’t be there otherwise. She gets some ketamine as well. She is prepped with betadine from chest to thighs, and a urine catheter placed. I pray out loud over her, as I do for all my patients I operate on. I ask for Gods guidance as I operate, for wisdom to make good decisions, for her not to have any complications afterwards, and most of all for her to know God in a meaningful way. I cut open along the upper midline. As soon as I enter the inside of the abdomen there is intestinal contents everywhere. The first thing I see is a small liver laceration, it’s not bleeding any more so I continue looking. I find a hole in the front of the stomach. I fix this, then we open up the space to the back of the stomach. As expected there is a hole back there too. We close that. Looking down and toward the middle there is a slice in the pancreas as well. Looking further, a hole is found in the duodenum (small intestine). After fixing that I dissect out the other side and find a hold in the other side at the mesentery (vessels of the intestine). We fix that and find four more holes in the intestine where the knife poked through two segments. Then on the left side where the kidney is there is a non-expanding hematoma. This means there was bleeding but didn’t appear to be bleeding any more. We look through the rest of the intestines and don’t see any more holes. Next I go back the the flank stab. I put a clamp into it and try to feel the area from the inside. I can’t so, I dissect and pull the right colon to the middle of the abdomen taking the duodenum with it. I can see them well and there is not holes. I probe the spot again and can now see it went to the right kidney and there is no expansion there either. We wash out the belly with a lot of fluid and then close the inside of the stab wound and close the midline incision. Most intestinal leaks occur within the first 5 days after a intestinal repair. So I will be worried about her for at least the next 5-7 days. I say another internal prayer, for God’s healing for her. No ICU and vitals wont be taken except once a day. Even the drain that I place near the pancreas, has no bulb as we used up the two we had, they were already reused on other patients and will be reused again once they’re available again. Again for most of you reading my letters, you are fortunate to have been born in a first world country and have good medical care. A place you could have ICU care if needed, get a full complement of medications and tests whenever was needed. You may not like your medical care system, but you can get care. People come here from literally ALL OVER Chad to be taken care of. Look at a map and see how large Chad is compared to your section of the US or Europe. No highways to travel 60mph on and they come. The medical system here may work some in the two large cities, but not in the whole rest of the country. Though I don’t like many things done in my own country, I am still grateful to have been born there.

Shanksteps Bere 2017 #8

Olen and Denae’s kids are sick.  Fortunately it is with malaria!  You, reading that, are gasping!??!??  What? Fortunately malaria?  Yes it is true that malaria is responsible for 1.5-2.7 million deaths a year.  And death is more common in the young the elderly.   So why do I say fortunately? Because two of the kids were bitten by a rabid cat a few weeks back.  An rabies has a 100% mortality rate.   So we continue to ask God for protection from rabies in these kids. (If you want to read further on Olens blog- look up Olen Nettberg on blogspot).  The kids are getting better and are playing again.  So what do missionary kids do to play?  Run around in the yard, playing with sticks or toys.  Interact with other kids or adults.  Run around outside with a purple cape, being a superhero.  Ride a bike.  Visit their grandmother to see if there is different food at their house.  The thing they are not doing is surfing the internet as there isn’t any.  They also like to read and listen to books.  So they are on the mend.

I had a chance to look a the old lady’s leg that was rotten a couple days back.  It is looking cleaner, with only a small amount of pus.  We continue to do a dakins dressing (dilute bleach solution) and it is doing it’s work.  I continue to think she will need an amputation but is improving.  I send home one of the ladies that we took out a uterine fibroma and a number of the hernia patients.  I again appreciate the lack of paperwork here.  Only what is needed when someone sees them again.  Basically they are discharged with medicine and a little book.  In their little book we write what surgery they had and when they are to come back.  Their medicines are explained to them again as to how to take them and they’re off for home.  Discharge in 3 minutes!

I see Olen examining a little girl about 7 years old. She is crying and fell down a well today.  Her abdomen hurts.  Does she have a cracked liver, an injured intestine, a bruised muscle, something unrelated to the trauma- like typhoid or malaria causing abdominal pain?  So many questions and no answers.  He does an ultrasound on her and there doesn’t seem to be any fluid in the abdomen outside the intestines.  So a cracked liver is less likely.  I’d sure like to have a cat scanner!  There aren’t even any plain x-rays here.  Ultrasound only!  She is admitted to the pediatric ward to watching and treating her malaria that was positive on her test.

Amongst the many surgeries a few days ago was a 30 year old guy who had left flank pain.  In the US I’d think of diverticulitis as one of the first on my differential diagnoses.  Here Rollin thinks of a psoas abscess.  Christian and I opened his abdomen.  There was pus inside and a fullness in his flank under the colon, with the colon appearing normal.  We opened into the area and find that Rollin is right, a huge abscess.  We sucked out more than a liter of pus, then put a drain out to the outside and close the area we opened.  Over these past few days the two drains have plugged up with pus so thick it wouldn’t come out.  So we took him back and made a 4 inch opening in his flank to let it drain out.  Each day we flush it out with dakins solution and gobs of pus and debris come out.  He is looking better day by day but the quantity of pus continues.

I’m doing rounds and I see another man with pus draining from a small wound in his chin.  He is in obvious discomfort.  I push around on his neck and pus flows out of the hole.  I decide he needs better drainage.  I suspect this is from a rotten tooth, but he denies having any tooth pain in the past or now.  I take him to the prep room, of the operating room.  That is where we do quick procedures.  I numb him up as best I can with lidocaine.  Then I open a few inches under his chin.  He yells out in pain “my God, my God…”  I feel sad that I am causing him so much pain but know I have to break up the loculations in the abscess and it will take a few seconds more.  I get done and pack the area with gauze.  Now I expect it to heal faster.  He is already on the available antibiotics. (Available antibiotics are ceftriaxone, cipro, ampicillin, amoxicillin, metronidazole)  As I do round, at least half of the people are for dressing changes of infected leg, arm or other wounds, ulcers or abscesses.  Each of these patients tolerate significant pain every day during dressings to get better.  I wish I could give each a shot of ketamine before their dressings so that the changes could go easier for them, but there is no monitoring available if I were to do that, so I continue with doing it as quick as possible to get it over with and not draw out the time it takes.