Shanksteps #121
She sat down on the bench in my office and grinned, or at least did that motion with her lips. Something was in front of her teeth. She was three and her father had brought her in from a far village to be seen. About five months earlier she had developed a toothache and then a hole started under her right mandible and draining pus from the hole. The father was away for a few months with some work and her mother was afraid to come in without his permission. He returned from his 4 month trip and
after a few weeks brought her in.
I look into her mouth and see what appears to be bone in front of her front teeth. It appears to be coming from the left side and somewhat mobile. She is calm and so I decide to wait and evaluate it in the OR under anesthesia. I suspect it is osteomyelitis. She has a 0.5cm hole under her mandible with foul smelling saliva draining from it.
In the operating room I peer into her mouth and see her mandible exposed with one tooth remaining in the section from the angle of her mandible to nearly where the incisors would have been. She is asleep with Ketamine and I tug on the bone. It comes out easily and I have half her mandible in my gloved hand. God created our bodies incredibly! Her bone had become infected; her body had pushed up the necrotic bone through the gums and healed behind it. So she is still draining saliva from the
hole, but no more foul smell. What I think she needs is a free graft fibula implant to the area! This would give tissue and structure to her mandible and face. This is apparently done by transferring artery and vein to the carotid and jugular (sounds microscopic). I suppose this is usually done with anticoagulants that I do not have.
Again, as often, I do not have the expertise, materials, tests needed for this situation. God help me know what to do!
I was recently showing pictures to the visiting PA students from the south, that are doing a rotation with us. I am amazed again at the number of peculiar and advanced diseases that we treat here. We are usually beyond or way out on some tangent to what we were trained to do. We pray often for guidance when tests and our knowledge are lacking for the patient before us.
Please continue to pray for wisdom, perseverance, ingenuity, and more love for the people we serve. In His Service, Greg
Shanksteps #119
Shanksteps #119
WARNING: Not for young readers
He was in pain. He had had an infection of his scrotum for about 10 days that had been neglected. The smell in the ER was rank, with pus. His cloths were wet in the crotch and down his pants legs. He was dirty all over and his cloths were torn and ragged. His wife, daughter and a couple neighbors brought him in to the hospital after convincing him to let them bring him in. The nurse said that his testicles were free hanging without skin. So I decided to take a look in the OR where I could
actually debride what I needed to. They wheeled him to the OR and leaving a trail of foul smelling liquid along the way. I put on my mask and cap to help cut down the stench and removed his cloths on the OR table. Every day there are things unexpected or new. Today it was that the scrotum, or what was left of the infected skin, and the penile shaft were all averted and hanging but still attached to the glands of the penis. The testicles that had been denuded in the process and were free hanging,
held on by the spermatic cord and associated structures. I completed the debridement and dressing changes were done daily. This past week he decided to go ahead with the skin graft I have been wanting to do. He sold one of his goats and had enough money to do the surgery.
At this surgery I attempted to place a Foley urine catheter without success. He had a stricture forming mid penis. I used urethral dilators to dilate the urethra. During the process the scarring cracked and the foley exposed mid shaft. I took a skin graft from his right thigh, meshed it to increase it’s coverage and placed it over the denuded are of his pubis, scrotum, and penile shaft. He currently has about 90% take and I pray that he heals his urethral injury so that he is able to have
normal urine flow.
In past emails we discussed an gentleman with the name of Gudaidai. He was the man here at the hospital for about 2 months that all our treatments did not take away his abdominal pain. It was so intense that he stopped eating and went from about 120 lbs to about 85 lbs. He wanted to die and asked everyone to leave him at the hospital to die. His wife left him out of discouragement. We had been praying for him individually. We got a group of the hospital workers together and prayed earnestly
for his healing. God healed him over the next three days and he went home with almost no abdominal pain. He came back to see us again today. He is a new man. He has regained weight and walks with a lively step. He know God has healed him and he is attending a Christian church in his home village. We thank God for his miraculous works amongst us. We are very blessed to see His working every now and then in a very direct way, often when all hope is nearly lost, including for us! We praise Him
for His leading. Please pray that He continue to guide us in very clear ways as it is very hard to live here and continue the constant daily battle with patients, with people, and ultimately with the devil! Thanks for those of you who pray for us daily, we really need it. Greg
Shanksteps #118
We decided to “take a day off” and go to Maroua to look for some personal things. As with most trips to Maroua we decided to check what things the hospital REALLY needed and maybe we would pick that up too. We, of course, came up with a huge list of medications we still have not been able to get and would look for in a few places, also : brooms, squeegee brushes for the floor, rakes for leaves, detergent for the laundry, and try to “repair” a few batteries that were shorted out, fill up a few
gas tanks, buy cloth for sterilizing OR supplies in, and other odds and ends. So off to Maroua we went early in the morning. As you have probably read the road is not the best for the first 1.5 hours. (12 miles). It’s like driving up stairs in places. Slow going and beats up the truck. Since the hospital does not have a vehicle we use our own to pick up medication shipments and carry most things to the hospital. It works well but only the front brakes work for now till I find someone who can
fix a US trucks rear oil seals.
We went the 1.5 hours to Mokolo then hit the good road to Maroua. In Maroua Audrey and Elisa (a good friend and nurse) headed for the market and I went to look for meds. Yves went to look for a solution for visas with immigration and Pierre to find his son to drop off some millet and peanuts for him.
While looking for meds Ganava (maternity nurse) beeped me. I called him back to find out that there was a patient that was 9 months pregnant and was bleeding profusely vaginally, and the baby was dead. As I was three hours away I asked him to send the patient to Mokolo (the road like stairs) as that is the nearest hospital from us.
Of the 35 types of medication we were looking for, 6 were available for us to buy. We were able to purchase all the other things we needed and headed for Koza around 5PM for the three hour drive home. On the way home another nurse (Kalda) called to see where we were. He said the woman’s husband had finally showed up and they were deciding whether or not to go to Mokolo. At that point I was an hour away, she had survived all day, so I told them to wait, and get her ready in the OR. We got home
and changed and went to the OR. The patient was still in the delivery room. A dried pool of blood lay at least a yard wide in all directions. A slower drip had dried about a foot wide and had gradually mounded up with dried blood during the day. She was very pale. We called the lab tech to check the other members that were then present to give blood to her again. (Ganava had given a pint of blood earlier that day when only her husband would get tested and he was not a match)
We started the surgery, pulling out a white, stiff baby, liters of blood and probably 2 liters of blood clots. Blood was everywhere! That was the 4th one in the last two weeks that had abrupt-placenta. And the fifth dead baby removed by caesarean section in that time frame. (the fifth was placenta previa) At the end of surgery I found out that the approximatively 8 women outside had refused to be tested to give blood. One had and didn’t match. So I called Kanas into the OR and gave her 500ml
of my blood.
God had kept here alive till we got back, and while her husband was not there to make a decision to take her to another hospital. We praise God for His goodness to His children, even when they do NOT know Him.
#117 Shanksteps
117 Shanksteps
It is feast or famine, as far as surgery goes. I may go days or even a week and not do a surgery, then there may be so much I cannot do it all. That is what Monday was for us. Sunday we saw about 34 in clinic and made rounds in the hospital on about another 40. Some are on “autopilot” with healing wounds or other static things. Others very complex, like patients in diabetic ketoacidosis and recurrent ascites with no known cause. I started the day knowing that I was going to do a real long surgery. There is a woman who had urinary obstruction after surgery for which I was going to do a definitive operation. I was either doing an ileoconduit or a bladder suspension with extension to adapt the ureter to it.
Before we made rounds I met with Audrey to pray that the day would go according to Gods plan. As I went to leave my office a man who I had seen the day before, came running in dripping. I have been seeing him nearly every two weeks and draining 15 liters (4 gallons) of ascites off him. The day before as I was seeing 34 clinic patients I told him to come back tomorrow to do the drainage that I was too busy that day. I also reiterated again that if at any time his umbilical hernia started leaking that he should come back immediately. So in he comes with his umbilicus (belly button) spouting like a fountain. His umbilicus had indeed ruptured. I sent him on to the operating room and followed the trail after him. I put a clamp on his umbilicus to stop the flow so to not get the entry to the OR all wet… We opened him up to fix his hernia. There was a fleshy mass on his gallbladder and a small one on the left lobe of his liver. I couldn’t find anything else so I suspect this is the cause of his ascites. (still undiagnosed) He needs a biopsy, but then he didn’t even want to do the surgery for fear of the cost. I just told him there was no other option! During the surgery, Djoudge, the cleaner, came in to tell us that a woman was in labor. I asked him to call Audrey to check her out, since there was no nurse free to see her. Audrey came in a few minutes later saying that she was concerned about uterine rupture and that she needed a caesarean section. I the man’s abdomen in the most water-tight fashion possible.
Immediately we were called to see a woman who was having difficulty with labor and had a possible uterine rupture. After checking her out, Audrey and I decided it was best to do a caesarean section for fetal distress and imminent rupture. So Aud joined me for her c-section for speeds sake. We delivered a crying baby boy of about 9 lbs. We decided to do the long surgery directly after. I went to finish rounds, Audrey to see some patients in the clinic before starting. The nurses would have to take care of the rest.
Nguizaye had been operated on before for extensive uterine bleeding and had been transfused a number of times. At the time of her hysterectomy everything was stuck to the back of the uterus which was much enlarged. After extensive adhesiolysis and much difficulty in the pelvis from all the adhesions, a total hysterectomy was performed. She came out of the surgery well but with bloody urine. Over the next 24 hours she made essentially no urine in spite of being rapidly replaced with fluids. The day after the first surgery, I reoperated on her and was unable to identify the area of ureter entrapment. I put in some makeshift stents as a temporizing measure while I decided what to do definitively. The stents became infected and she was not doing well. So this was the day for a definitive repair. Having asked many colleagues their opinions (and only one responding) we started.
Entering the abdomen, was already difficult. Adhesions everywhere. Then omentum stuck down to the previous operation site and the area of previous adhesions. With much difficulty and tedious work we dissected out the ureters. This took about four hours. I decided we did not have the room sufficient to use a bladder mobilization to reinstitute urine flow. So it would be an ileoconduit. About this time another woman was having difficulty with labor so Audrey set up for a C-section in the other operating room. We changed around nurses to cover both rooms well. Fortunately the student missionaries are up to speed and a real help in the OR now. Soon I hear yelling and movement in the other room. Audrey comes back in a few minutes with a crying baby in hand. She delivered without the C-section. So she would rejoin me again. I resected a piece of ileum to make the conduit between the ureters and the ostomy. Reconnected the intestine and then started the anastomosis. Baya (the ER nurse on call) came panting into the room. “A man has been stabbed and is bleeding profusely from his abdomen. “ As I have one patient open on the table with no one else who can do this I tell him to have them hold pressure and that they MUST go on to Mokolo. People do not want to go to Mokolo but it was necessary. So I continued my surgery. It was tedious and deep. The woman had lost much weight, but unlike most here, she still had a bit of fat, making the surgery deeper and more difficult. We finished the surgery at 10PM, ten hours after the start. Back cramps, headaches, and extreme tiredness made it difficult to write all the notes of what had taken place. We made it home after seeing some in the ER, about 11:30PM, massaged each other’s back knots and went to bed. She is still very sick, electrolyte abnormalities, delirium, malnutrition, and three anastomosis; enough to make any surgeon worried. Then put on top of that the absence of an ICU and monitoring. If she makes it, it is only because of Gods direct intervention. I pray for her before going to bed, as I wake up and many times throughout the day. Please keep her in your prayers also. In His Service, Greg
