Shanksteps Bere 2017 #6

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Shanksteps Bere 2017 #6

It’s Sunday and Audrey just had to leave this morning. I’m missing her already. She, Deborah, Jent all left for home today. I wish Audrey could’ve had the time off to stay with me the whole time, but am also grateful that she was able to come at all. Olen dropped them at the bus station about an hour away this morning. I woke up early to see them off. It is to quiet now in the place I’m staying.

I head in to help with rounds after eating some pancakes with Dr. Rollin and Deloris. Pancakes with peanut butter and mango sauce. I’ve not even walked into the surgical ward with the stench hits me! Now I’m not one to be bothered by smells as my nose I inherited from my dad. That means it doesn’t work all that well, which in my line of work is usually a benefit. In the US, nurses may be retching around me and I’ll be doing just fine. But this one was strong! I walked in to see Christian changing a leg dressing. There lay an old woman on a bed, clouds of flies swarming around her, writhing in pain, as Christian loosened the bandage on her rotten leg. Pus flowed down her leg, across her bed and pooled on the floor. She had been admitted the night before and we were looking at it for the first time. We immediately felt like she would likely need an amputation, but could start with a operative debridement to evaluate it further. A new dressing was placed and we continued on rounds. There were many wounds to dress. Were they infectious tropical ulcers, burullies ulcers (from tuburculosis), a spider bite necrosis, a snake bite… So many options as to the causes of things that look similar. Most improve with dressings and proper care. The 23 year old woman without children that I took out two uterine fibroids, one the size of a large grapefruit the other an orange, was doing well. I doubt she will be able to have children even with them out, but at least she still has her uterus. A woman who cannot have children is not valued at all in this society. Their worth is their children. Usually when you ask a woman how many children she has, she will answer, “I’ve had 8 children and 2 are living.” This was the response yesterday when I asked a woman. So still having the chance to have children is very important to the 23 year old. We see the man we drained a psoas abscess on. He looked like death warmed over when we operated on him. He appears to be doing better and is in pain but better. His drains are working. Of course he is in pain! We only have ibuprofen and Tylenol to treat pain here. But every one of my patients here is up and walking the next day! It sure is nice not to have the negative side effects of narcotics though.

After rounds Christian and I head back to the OR to debrede the old womans leg. Now the OR smells like the surgical ward did. Somehow the masses of flies didn’t make it in there with her. [As a side thought: There are sterile flies and non-sterile flies. Non-sterile ones- are those that fly around the operating room landing in the open abdomen of the patient or on the sterile field. Sterile flies- are those that are cooked in the autoclave and found in the sterile pack when it is opened at the beginning of the operation.] It is useless to prep her leg with betadine to make it “sterile”, but I do it anyway. Pus drains onto the area I just prepped. I kick a trash can to the side of the OR bed just in time, the lake pus on the bed, drains into it. She has an open area about mid-calf that has granulation tissue but pus pooling around it. I probe with my finger and the skin is separated all around. My finger easily goes from the wound up to her knee and way beyond where I can reach going down her leg. We open the spaces. She ends up with open areas from her knee down to her ankle on two sides. Necrotic tissue and pus is removed. I know I will smell like pus, until I get a shower and change my cloths. Sometimes the smell clings to my nose even after that! I think she needs her leg removed, but will wait a few days before telling her that. It is easier for the patient to accept bad news when they have come to the same conclusion themselves. I see a few other consults and prepare them for surgery in the upcoming days.

I head home to shower and get the stentch off of myself. The cold shower feels wonderful!

Shanksteps Bere 2017 #5

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Shanksteps Bere 2017 #5

I awake about 4AM.  The sound of bats outside in the trees is deafening.  The hospital has electricity 24/7 due to a generator running non stop (that must be a lot of diesel).  Since there is electricity, I have a fan on us at all times when we are in bed, that makes sleeping possible in the heat.  I lay there awake trying not to wake up Audrey, she is all covered up like it’s cold!  I lay there and read my devitional book (Jesus Calling) then continue where I’m reading in the New Testament in John 16.  This is always a peaceful time of morning.  About 6 AM the sun starts to rise and the room slowly gets lighter.  Olens mother-in-law Deloris had left us some granola to eat for breakfast.  She also made us some bread.  I discover during my time here that she is very giving of food, and I never have to go hungry.  It’s a Monday and the busiest day of the week in Bere.  Hospital work occurs all the days, minimal rounds are made on Sabbath, and emergencies attended to.  Sunday there are many consults and full hospital rounds to be made on the 80+ beds.  By Monday there are many people waiting for elective surgeries.  They run anywhere from 10-160 dollars.  The highest being for a prostatectomy, because old guys usually have the money and are definitely willing to spend it on themselves.

At 7:30 we head to the hospital for worship.  It is spoken in French and Nangere.  It takes place in the waiting area for the ER, which is a number of concrete benchs under an awning.  The ER is a room with about 3 beds.  It has no moniters or other signs that it is an ER other than the sign on the door that labels it the “Urgence”.  After the worship thought, the nurses give signout about what happened the day before to all the nurses and doctors.  This all wraps up about 8:30 or 9 and I head to the OR with Rollin and Christian and Audrey.  It appears that there are about 11 people on the waiting list.  It appears to be about 7 hernias, 2 incision and drainage of abscess, and a hysterectomy.  I asked Dr. Rollin and Christian what they wanted me to do and it was decided Id operate.  I like to do hernia repairs with mesh due to the fact that they are longer lasting and the risks are low.  Dr. Rollin doesn’t like using mesh because they’ve seen a number of infections after using them here.  So, since they will have to deal with whatever complications arise after I leave I choose to do the hernia repair with just suture in the method that they are used to using.

The first man is lying on the bed.  his scrotum is larger than a grapefruit with intestine in it and his legs splay far apart to accommodate it between them.  One of the nurses lifts it and puts the legs together and it then sits on top of them.  It’s been a while since I’ve seen one this big.  The patient is given fluids and then a spinal is placed with him in the sitting position.  I discover almost all cases are done with spinal and then some ketamine is given if the incision goes to the upper abdomen.  After the spinal the patient is laid flat and I scrub with Audrey.  It’s been a while since I’ve operated with her and we both enjoy it.  I make an incision in the groin and it barely scratches the skin.  I’d forgotten how hard I need to push with these blades to get through the skin.  After about 5 cuts, I’m finally through the skin.  The scalpels blades are new but not as sharp as I’m used to, and the skin is thicker too.  I slowly dissect through the usual layers to the hernia sac.  I dissect out the hernia sac from the scrotum and separate it from the testicle.  After opeing the sac, I discover that everything is stuck in it.  There is colon and small bowel.  I struggle for about a half hour to make heads or tails out of the mess.  The inside of the abdomen isn’t free either.  Eventually I make the opening in the abdomen larger and shove the whole thing in.  I do the suture repair.  This is about the longest hernia I’ve done in a long time.  I close the various layers and then skin.   I’m tired of my first case here.

Next is a woman with an inguinal hernia.  Less common and also much smaller.  She is about 45, 5’2” tall and weighs in the neighborhood of 100 lbs.  It’s nice to be operating on thin people.  After the spinal she lays there stark naked and is shaved and prepped for surgery.  She is shivering even though the room feels very warm to me.  Of course she is cold, the usual parts of her that are seen are her face, ankles and arms.  The head may or may not be covered.  Muslim women cover their heads and many other women do too.  After I scrub, I cover her body with surgical cloth drapes.  The has the tiniest of hernias and it takes me about 20 min to do the surgery.  So I have the most difficult first and the easiest hernia second.  The remainder of hernias this day were “usual large”.

Rollin and Christian finish rounds and come back to the OR.  Next is a uterine fibroid that the two of them do.  I hang out in the entry room seeing surgical consults and being called to help do an ultrasound to check out something the nurse couldn’t figure out on it.  One ultrasound, the nurse cannot figure out whether the woman’s mass is in the uterus or ovary.  I walk past the hoards of people milling round under the trees to the ultrasound room.  I’m thinking to myself, how can he not tell if it’s in the uterus or not?  Unfortunately I find the same thing.  I cannot tell either and am frustrated.  I guess we will need to do a digital CT to figure it out and take out whatever we find.  Here, digital CT means- cut and touch with our digits! Either she has a uterine tumor or an ovarian tumor.  Whichever it is, she doesn’t want any more children and we will take out either one.  Each elective surgery is required to pay and someone of the family to donate a bag of blood before they will be on the surgical waitlist.

About dark we choose to make the others wait till another day.  I head home to a meal that Audrey and Deborah and Jent have made.  I’m tired, jetlagged and happy to get some rest.

Shanksteps Bere 2017 #4

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Shanksteps Bere 2017 #4

Today we wake up early and our plan is to head to Bere.  James and Sarah get up early and feed us breakfast (Thank you!)  We then head to the bus station with all our plastic boxes of medical luggage in the back of the RAV4.  It’s dark and we are turning on one path then another, and if James weren’t driving, I’d be totally lost.  But I do see a little glow on the horizon so that can give some orientation.  We arrive at the bus station while it’s still dark.  James gets our tickets and then we realize the bus is on the other side of the road and there’s a concrete barrier between sides. So we go down about a half mile and turn around.  Arriving at the bus, there are crowds of people milling about.  There is a large bus that is air-conditioned, YEAH!  We get our things put underneath and then board.  The pungent smell of urine greets us.  There are decorative drapes on the windows and all around.  Reminds me of what I’ve seen in pictures of busses in India.  We find seats free near the back door and Allah sits behind us.  About a half hour later the horn is blowing and we are moving forward slowly, kind of waiting for the last people to get on.  We take off with a few empty seats.  These are gradually filled along the way by people standing on the sides of the road waiving us down.  As we leave town we are stopped at a number of police barriers.   We stop at some and others drive right through.  It’s getting a little lighter, and I can see temporary shelters and a section with many camels.  I guess this is the area where the nomads are.  They are often the ones with camels and herds of goats, sheep and cows.  A few horses may be seen too.  All the animals are very thin with all their ribs showing.  We also pass a few heavily laden two wheeled trailers that are being pulled by a long horned cow.  About an hour out of Ndjamena we are stopped at a police barrier.  A policeman gets on at the front and slowly asks people for their identity cards or me for my passport.  He is asking men, the women and young he doesn’t ask.  He asks for my identity card and I give him my passport, he asks for Audreys too.  He looks behind us and then gets off the bus with my documents and others cards.  Allah tells me I need to get off and talk to him.  I think that if I wait he will bring it back.  Allah says that the bus will leave either way.  So I get off with him to go talk to the policeman.  He says something to Allah who translates to me that he “wants a drink”.  I understand this immediately to mean he wants some money.  Rather than striking up a conversation like I should, I get angry.  I raise my voice and say I’ve come to help the Chadian people and all my documents are in order.  I demand my passport to show him, and surprisingly he gives me one.  I show him my visa…  I put out my hand for the other, and again, surprisingly he gives it to me.  I walk back to the bus.  As we leave, Audrey reminds me that I need to talk with the policeman on the bus before he takes my documents.  I had forgotten that this helps a lot!  One thing about the culture here is that relationships are very important.   And so if you are friendly and make conversation, this avoids many troubles.  I think they are spot on here, and I (and many in the US) could learn a lot from 3rd world countries in this regard.

We continue down the road.  There are little villages here and there, and many miles of open areas with few trees, shrubs, and dried grasses.  It’s the dry season and things are dying.  The hamartan winds are blowing so there is a lot of dust in the air, as it comes off the Sahara.  Northern Chad is in the Sahara, and so we are still very sandy and dry here as well.

A while later we get stopped at another barrier and a military guy gets on in the front and another at the back door near me.  He walks straight up to me and with a stern face asks for my documents.  I start talking as Audrey takes her time rummaging around in the backpack for the passports.  I say hello and that we are doctors traveling to help the people of Bere.  That we will be there about a month and that we have just arrived.  I tell him we have brought medical supplies to bring to the hospital as well and that we are tired from our long trip that had started 2 days before.  He then says he just saw Olen from Bere come by there the day before.  I tell him that I was suppose to be with Olen but that my travels had been delayed.  He notes that he is coming to Bere next week, and I volunteer that he should say hello when he comes.  He smiles, and I show him the covers of the passports, he waves them away and continues down the line.  Others behind me are not as fortunate and as I see others get off after him when he descends down the stairs.  Eventually they get back on and we continue on our journey.  About 3 hours into our voyage we stop for a 15 min stop in a little town and back into a bus station.  We all pile out and they lock the doors so our things don’t disappear.  We go and pay the guy at the toilet the 50CFA (about $0.15) and walk in to the pit toilet.  It is full and the stench is overwhelming.  I am very happy to just need to pee.  I then walk around and look at the people selling various foods.  The one that catches my eye most are the fried grasshoppers.  There is large pile of them and a person is buying a small bag full.  I ask if they are good and I am assured they are and am offered one to try.  I can’t do it- so thank them and decline.  There are also piles of fried doe like donut holes.  Meat grilling on a fire, lemons, oranges, a few apples, peanuts, watermelon, papayas, taro, and a few other vegetables I don’t recognize.  I guess as we are after the rainy season, there is still a variety available.  They honk the horn and we all load again for the 4 hours that remain.  We continued on the paved road all the way.  There were many many large holes in the pavement all the way down.  So there was a lot of slowing down and swerving to hit a shallower area of holes.  If the road were good, we could’ve made it in half the time.  We don’t get stopped anymore and arrive in Kilo that afternoon.  We unload our boxes and luggage and wait for Dr. Bland.  We load up our stuff and head to Bere with him.  Before we leave town we look for gasoline.  Both stations in “town” are out of gas, and we have enough to make it to Bere so we head out.  We pass some girls selling bottles of roasted peanuts, so stop to get some.  As soon as I roll my window down and call them over, there is a mass of people wanting to sell theirs.  About 10 bottles are shoved through the window and dropped in my lap.  I try and tell them to stop and it’s mass confusion.  I finally roll up my window, I try to stop with it a little down- but it is automatic and continues all the way up.  Fortunately no ones fingers were in it when it closed.  I eventually get it a little down and get the excess bottles out.  I then pass out he money and wait for change.  About 3 minutes later the one woman I gave it to, gave me the change back.  Everyone else was unhappy that I didn’t take their nuts and waved them at me to take more.  We drove down the dirt road and into Bere Hospital.  It was dark when we arrived and we were happy to be off the road and take cold showers and get to bed.  Mrs. Bland had made some food and left it in our kitchen.  How nice to have that when we arrived!  It felt very good to get the dust off our bodies and as I usually do in sub-Saharan Africa- I went to bed dripping wet.  I hoped to fall to sleep before I evaporated.  And sleep I did- till the bat noises woke me up at 3 AM as my jet lag kicked in.  9 hours different is difficult for a number of days.

Shanksteps Bere 2017-3

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Shanksteps Bere 2017-3

I awake from a relative unrestful sleep- because of jet lag. It is 3:45 in the morning. There are dog barking, insects chirping. I lay there in the heat and toss and turn. I went to bed wet last night, and hoped to sleep before I evaporated. The desert cooled off and I felt cold in the middle of the night. At about 4:20 I hear the familiar Allahu akbar (God is greatest)x4

Ashhadu anna l ila ill Allah (I testify that there is no God but Allah)x2

Ashhadu anna Muhammadan rasul Allah (I testify that Mohammed is God’s Prophet)x2

Hayya alas salah (Come to prayer)x2

Hayya alai falah (Come to security/salvation)x2

Allahu akbar (God is greatest)x2

La ilah ill Allah (there is no God but Allah)

Assalatu khayrum minan naum (Prayer is better than sleep)

This intonation goes on for about 3 minutes (can be heard online if your interested). I feel at home in West Africa again. I lay awake unable to sleep and have my special time with God. I am also reading a book called “The Bondage Breaker”. Within an hour the sun is coming up and the sound of chickens and dogs increase. It is Friday. We have decided to halt our progress to Bere to stay with some friends in Ndjamena (the Appels).

We all eat an oatmeal breakfast and James and I head to the hospital. It is a mission hospital that James volunteers at here in Ndjamena. We go to see an old man who needs a debridement of his foot. It’s a holiday and the hospital has two nurses on and we can’t find either one. Finally we find one in the “ER” (two bed small room with a curtain in between them). We go to see the man with the foot that’s been infected and draining for many months. He is eating bouii (pourage), meat, and other things for breakfast while he was ordered NPO (nothing by mouth). So it is unsafe to give him sedation and do the debridement. So we tell him not to eat anymore and we will work on him in the afternoon.

We go and find the covering Chadian doctor and do rounds with him. During rounds we see a 10 year old girl that has been treated for myositis (muscle infection) of her upper leg. She lays on the bed very stoic. The antibiotics seem to not be working as her upper leg remains swollen and very tender to touch. There are little healed cut marks on the thigh, which I interpret as the place of most pain. (In Cameroon these cuts were made to let out he bad blood or pus by someone at home with a razor blade). She had an ultrasound 4 days ago and no abscess was seen. Her leg had been wrapped in a gauze and the nurses put alcohol on the gauze. The patient thinks that it may be a little better. We talk to her and her mom and grandma who are at the bedside. I wonder if there isn’t an abscess now, as it isn’t better. So we tell the family we will be doing another ultrasound. The mother wants to wait for the father to make the decision, and we convince them not to wait. She is taken to the ultrasound room. She is lifted onto the exam table with eyes ready to pour forth tears. She doesn’t know what we are doing. Her grandma is there encouraging her. As James looks around her thigh- we find what appears to be a pocket of fluid that seems to be lateral on the leg. After explaining to the mother and grandmother what we’ve found we convince them to let us take her to the operating room for sedation and to open her leg.

In the operating room she is given a shot of ketamine and we wait. She is eventually staring off into space with unconscious eyes. I incise the side of her leg and spread into the muscles. Spreading around I start to wonder if we really saw an abscess. James spreads around to and pus flows out. We put a finger in and break up the loculations all around the femur. We get about 300ml of pus, and the space is about half of her lower thigh. We wash it out with dakins solution and pack it with gauze. I am now content that she will get better.

We are called to the ER again to see a guy with a strangulated inguinal hernia. An old man lies on the bed. His hernia has hurt for 4 days. And yesterday he started to vomit and has been unable to pass stool since yesterday. His abdomen is very bloated. We ask for the operating room crew to be called in for an emergency hernia repair. In about an hour we are in the operating room.

He is given a spinal anesthetic and we start. I incise the skin and I think, either this skin is tough or this blade is dull. I make a number of passes with the knife and am finally through the skin. The hernia is large and firm all the way down to the bottom of the scrotum. Slowly we dissect out the hernia sac. We open the sac and find his colon and omentum(a fat layer it the abdomen) in it. The colon does not look good. I open the hernia site larger and with more space, blood starts to change the color of the colon back towards normal. I’m able then to reduce the colon and omentum back into the abdomen. Within minutes we hear diarrhea coming between his legs. The blockage has been relieved and the odor of success is permeating the room. We close up the hernia site and close the skin.

Later we debrede the infection off the foot of the old man.

After each operation the staff take whatever has been removed out to show the family and they nod and make comments about whatever they see. I’m often curious what they are saying. Especially about the pus from the girl, because there were a lot of facial expressions and talking.

We went back home and ate some rice and beans. It is 95 and dry. We spend the afternoon talking and swinging in hammocks. Night falls and it finally starts to cool off. I’m am very grateful for cooler nights. I’m also grateful for the ability to serve others with trips like this. Seeing other cultures always reminds me of the blessings I have that many others do not have, purely because I was born in a 1st world country.