Bere 5/2025 #11

administrator Greg No Comments

Bere 5/2025 #11

Take back cow horn gored guy

Today was the whole day in the OR starting after worship and then another meeting the hospital workers have.  My first patient was a young boy of about 8 with a bladder stone.  He was rather stoic as we brought him into the or his dad at his side.  He lay on the OR table without a word.  He was put to sleep with Ketamine and valium and atropine.  I filled his bladder with water so that I could feel that first after I cut into his abdomen.  That way the intestines are out of the way.  So I cut down through the layers and into the bladder.  I sweep a finger around and find the stone.  I stick in some ring forceps and feel around with them till I feel the stone and grab it.  It looks about the size of a very large grape and is yellow with small bumps all over it.  We close up the layers as usual.

Next was an older guy with two bladder stones.  I could see them on ultrasound.  I did the same surgery but this time since he was an adult he got a spinal anesthetic. I pull out two stones that are smooth and dark green.  Im amazed at how many colors and shapes bladder stones are.  I wonder what makes the differences?

The next is a 10 year old boy with two areas of draining pus on his left arm for a few years since he broke his arm.  Pus drains out constantly.  The X-ray shows a healed fracture with a piece of bone poking out the side of the radius.  It is a sequestrum (dead piece of bone).  There looks like there could be another piece further up his arm where the other area of pus is draining.  After he’s asleep with ketamine I use the cautery to cut down to the bone in the distal arm.  I get to the moveable piece of bone and free up the end and pull out a 3 inch piece of dead bone.  I try to decide wether to go for the other area or not.  But he’s asleep so I proceed.  I decide to open up his old scar in this area figuring it’s unlikely to contain his radial artery or nerve.  I get about 1cm cut and blood quirts me in the face and down my front all over my scrubs.  I get a finger compressing it and try to decide what to do.  I can’t even get a look at it or it squirt me.  Finally I find a place off to the side a little where I ca put pressure and neither end will bleed.  I know with this such back pressure from the ulnar artery, even if I tied off the bleeding vessel, he would have enough collateral flow to not kill his hand.   Dr. Laurel came in the room and recommended I fix it so that’s what I did.  After suturing the artery back together, He had a good palpable radial pulse.  Fixed!

Dr. Andrew had done rounds today and said the guy that was injured with a cow horn needed to be explored.  He is getting sicker and has peritoneal signs.  So something changed in his abdomen.  I see him on the gurney and I know his intestines are leaking.  The drainage on his dressings has changed from a day ago.  Intestinal contents.  He’s perforated again.  It’s 4PM and I’m starting a potentially very Long surgery. I also have seen in the past few days a large are of skin necrosis lateral to where the cow horn went into his abdomen.  (For you medical folks maybe a Morel-Lavallee lesion).  So he’s in the pre-op area with his family around fanning him.  He’s grunting in pain.  I notice that the dressing on his side where the cow horn was, now is draining stuff that looks like pus with intestinal contents.  So the characteristic of the drainage has changed.  So I take him in and the anesthetist decides to give ketamine as well as intubate him.  As David goes to intubate I give the Ketamine and the Succinocholine.  He uses the one Glidesope we have here to intubate and does a fine job.  I’m at the ready to take over if he struggles.  We prep his abdomen and then reopen our incision that is about 7 days old.  I see the top has already dehisced.  Succus (intestinal contents) start welling up with every breath as I open. We suck it into the canister and more pours onto the drapes and down the sides of the bed.  I suction out everything I can and then look for the source.  I find my small intestine anastomosis is leaking on the antimesenteric side.  The possibilities are quite a few.  I didn’t do the first anastomosis correctly, he had low blood flow from his low blood pressure for a long time, he was on neosynephrine drip, his poor nutritional status, his very contaminated abdomen.  Or maybe all conspired against him.  I take out the stitches that hung to one side. And freshened the edge and reclosed this section.  I looked for my other anastomosis.  It also had a leak along one side wall.  It also was about 7mm in size.  The transverse colon seemed to be folded in this area, so in addition to the above factors effecting it, he also may have ended up with tension at the spot.  So I freshened and closed this too.  I washed out the whole abdomen removing all the fibrinous exudate I could easily remove.  I looked at the front and back wall of the stomach and then ran the bowel again.  Other than irritated, it all looked OK now.  No areas of necrosis. I closed his abdomen and included retention sutures.  I went to the side where his Morel-Lavallee necrosis was and started cutting off dead skin.  I ended up taking off a patch of about 6x10in about 3/4in deep.  Dead muscle too.  I put a large dakins soaked gauze dressing on it.  After extubation we wheel him back to the ward where the surgical ward.  Another nurse had set up a saturation machine and oxygen machine at his bedside.  I couldn’t order the meds for him as the electronic system was down.  But I told the nurse to take the family to the pharmacy and get him saline, Ceftriaxone and Flagyl right away.  He called me about an hour later saying the family didn’t go as they said they didn’t have money to pay for it.  It’s so frustrating when people say they have no money.  Do they really not, then I’ll pay for it.  Or are they just saying that in hopes that I will pay.  I decide to wait.  There are many family members around that patient so I think they will come up with the money.  In my American mindset, I just wish they were honest.  But honesty isn’t necessarily a value here.  Conserving relationship is more important than honesty I think, which is hard for my mind.  I’m beat so I head to bed.  In the morning I find they didn’t get the meds for a while but had gotten them eventually.  Someone took him off oxygen in the morning.  Just turned it from 5L O2 to nothing.  So I ask them to check the oxygen saturation.  A nurse shows up with the device and it reads 94%.  So we didn’t kill him.  He’s still very likely to die, but we haven’t caused it.  I keep praying for a miracle of healing for him.

God help this man to survive all the insults his body has gone through.  Please heal him!  We can’t do any thing more to help him.  Only You God can help.  Please intervene and heal him.  Amen 

Bere 5/2025 #10

administrator Greg No Comments

Bere 5/2025 #10

A MIRACLE! Thank you God!!!!  

I attend the morning worship and concentrate on listening to the one translating into French.  He reads a worship thought from a book called the Desire of Ages, a book about Jesus.  At least that’s I think what he’s reading from.  All the book covers here look different than ours so I’m not sure.  As I listen to the worship thought, daily life is going on past me on the other side of the fence that is around the hospital.  Horse and cow drawn single axle carts go by.  A small pack of dogs bicker with each other.  A young man appears to be harassing a woman who then picks up a small switch and goes after the young man.  Everyone is laughing except the woman who must at least be insulted.  A moto taxi pulls up with a couple people on it, bringing them to the hospital.  I find it hard to concentrate on the message as my brain is all over the place.  

After worship there isn’t any meeting so I go to the OR and tell them Im ready to work.  I do this to help them get going, otherwise they linger and do whatever else they do in the morning.  Like talk to a patient that is a friend and gab a while.  I also go by the surgical ward and tell them Im ready to round.  This gets both locations going.  But I just stand around waiting in the surgical ward.  So they get going.  The dressing cart is prepared faster and Emma changes from his street cloths into his scrubs and we start.  I see all the patients Ive already told you about.  The guy that was gored by a cow horn is better but is complaining of pain on his side where he was gored.  Some pus is coming out the drain I left.  But as I look with a flashlight at his dark skin, I realize he has some dead looking skin on his flank.  It looks like he was burned.  I asked the family and they decline knowing anything about it.  They’ve been very attentive to this man.  There are at least two people fanning him day and night.  It’s nice to see them so engaged.  I’m not sure what to make of it.  I wish I had a CT scan…… and so many other things to diagnose him further.  He’s still eating some boui (porridge) and pooped yesterday.  Great signs. I’ll keep an eye on that spot.  I leave most of the dressing changes for the nurse to do.  The next one is a woman who is a sister to Emma.  She had a thyroidectomy and we are certain the recurrent laryngeal nerve was cut which was repaired and would make a person hoarse.  She seemed hoarse the first day and now her is clear!   It’s a miracle!!!!  I’m excited to share this with the one who did the operation.  It has been many stress filled days of knowing this woman will be hoarse for months or permanently.  BUT SHE IS HEALED!!! We have been praying for that.  Thank  you God!!!!  We pray for so many people to be healed of physical or spiritual things and I don’t understand why it happens like this some times and other times it doesn’t.  But I’m so grateful to see healing when I do.  Later that day I share it with the surgeon and we just sit in the moment of relief and thanks to God!

Back to the OR and they aren’t ready yet.  Phillipe is concerned that we are starting a long difficult abdominal surgery and since the generators have been cutting in and out the last many days- is it safe to do this surgery.  He mentions that there is a generator specifically for the OR that hasn’t been started in about a year.  Could we make sure that one is functional first.  I think that’s a good idea.  So I ask Dr. Andrew how to arrange that, he makes a call then goes off to find out.  As always, missionaries, have so many different tasks to manage, and are pulled in so many ways.  It would be so much less stressful, if we were able to only stick to what we know- medicine….  So we prepare another patient in the second OR.  This one is a TURP (transurethral resection of the prostate).  We figure if the power goes out we can stop that surgery in the middle if we have to.  He is also known to have a large stone in his bladder too.  So the first patient waits all day and we never do get the go ahead from a generator standpoint.  So he is postponed till the next day.  The prostate is slowly shaved off using that same method I described in my last email.  Only this time each movement I make is bumping against a bladder stone.  If feels large, but then again, everything is magnified in this cystoscopic image.  It takes us a few hours to complete the resection of enough prostate so he should pee well.  We search many times for the ureters and never find them.  Thats a crucial part of the surgery.  So we are continuously bothered by that.  We need to see them and protect them.  But the stone has created so much inflammation we can’t identify them.  So we stay more in the middle where we know they aren’t.  After we decide we’ve done enough for the exposure we have. Then we transition to the surgery on the abdomen to remove the stone.  After going through all the layers of the abdomen and bladder, I try to grab and pull out the stone.  It is large and I have to enlarge my bladder incision twice before I can pull it out.  It is about 2.5inches wide and black with lumps all over it.  Each bladder stone is different and this is unique in it’s color and shape.  Wow, that must hurt being in there, and have been in there a long time.

The next patient needs a foot debridement.  No one in the room really understands her language.  So what I hear is she was normal 4 days ago then she an infection started.  I take off the cloth she has wrapped around her foot and the whole top of her foot is dead.  Dead skin and pus everywhere. (I’ll attach pictures).  Zach and I use scissors to cut away all the dead stuff till we get to bleeding, live tissue.  It smells awful!. We chip away at the dead stuff till it looks much cleaner but I’d be surprised if she doesn’t need a foot amputation.  I bathe the food in Dakins solution and then put wet dressing.  Ill check on her in the AM to make sure her infection isn’t getting worse or one of the rapidly progressing necrotizing infections.  Later in the night I’m in seeing another patient, and I see her leg is already less swollen than it was at the time of surgery…improvement.  I’m grateful!  Thank you God for the improvements I see in our patients.  The others are so hard to see and it’s great to see the good ones.  God give me strength for the bad outcomes too.   Amen

Bere 5/2025 #9

administrator Greg No Comments

Bere 5/2025 #9

Monday is usually a busy day.  I’m called to see a woman at 2AM who isn’t progressing in labor.  It’s the nurse I don’t have confidence  in so I’m not sure if I should start Oxytocin or not.  Unfortunately I awaken Dr. Staci and ask her.  She thinks it’s less risky to just wait till morning.    At 7AM I’m in worship when the nurse finds me again and says I need to see the same woman after worship.  I go there and nothing has changed.  Dr. Staci comes in and we decide after watching her contractions and how the babies heart slows down with each contraction and takes a little while to improve- that we should do a C-section.  So we find the husband who is avoiding us, because he doesn’t want to pay for anything, to go and get the lab work paid for and so we can proceed.  We keep telling the woman not to push because it hasn’t made a difference all night.  She can’t or won’t stop.  Looking between her legs suddenly the baby head has dropped down and is on its way out.  With another push the child is on the bed and crying.  Yay! She didn’t need a C-section after all.  Thank you God!

One of the first operations today is a TURP- transurethral resection of the prostate.  I’ve always done Friers prostatectomy.  Andrew was learned to do TURP and so I watched him set up the complicated thing then using the TURP wire, it it a loop of wire, it shaves off a little trench in the prostate and then the same loop cauterizes. Then another trench of tissue and cautery of the bleeding.  He showed me the landmarks to use and had me do quite a few.  It is a neat way to take care of excess prostate.  But I think I’ll need some more training on landmarks to be certain where to do it and where is deep enough.  We worked on shaving off pieces for a few hours.  When we were done it seemed like a bloodless field and we left a foley catheter in place.

There were many clinic patients to see so I headed over to the next building.  Now a day later, can I remember what I saw? Only some of them.  I saw the teen with drainage coming from a previous fracture site only in the rainy season- 8 months ago, maybe a sequestrum, but definitely not obvious.  I could see something on the X-ray.  Told him if it starts draining again, to come back then.  Rain started and it was a downpour.  Rained for a while and cooled everything off, even through the evening.  Another patient in clinic was an older woman with body aches, saw a few with bladder stones on ultrasound who couldn’t pee well and were set up with orders for a stone removal surgery and sent to the pharmacy to pay the equivalent of about $40 for the surgery.  By the way, some of you sent me with some money to use here.  They have an indigent care fund, and that is what the money went towards. Other patients I saw were a kid with a huge splenic cancer I could see on ultrasound.  Another was a pastors wife with one of the largest spleens I’ve ever seen.  Covered her whole abdomen, except for a small portion of the right lower quadrant.  Spent the whole afternoon in clinic.  When I was done and walked out of the building- what a refreshing feel.  It was a cool 75 and smelled like it had just rained.  Other than being awakened by a call at 3 AM, I slept quite well that night!

Bere 5/2025 # 8

administrator Greg No Comments

Bere 5/2025 #8

Sabbath was a peaceful day.  Dr. Andrew took his kids to the “monkey forest”  and they saw monkeys pretty close early in the morning.  I had a peaceful morning and then rode the big motorcycle to church with Zach on the back.  I went to the same church as last week.  It was unbearably hot with rain clouds all around but no rain at potluck.  Some people went to the river again and that was what I was hoping would happen.  I was cooler than the air and lovely to lay in the shallow brown cow poop shistosoma filled water.  In the evening I hung out with some missionaries and talked.

Sunday AM I am awakened about 5AM for a woman who has had 5 babies and all of them died during labor.  Her last one ruptured the uterus.  This one doesn’t seem to be progressing.  So I go in thinking she likely needs a C-section.  This nurse I remember I haven’t had much confidence in, in the past.  I see that the babies head doesn’t descend much during a contraction and I ultrasound the baby.  As I watch another contraction I see the heart rate slow down and it stays slow after the contraction.  Fetal distress.  I call in the team for an emergent C-section.  The maternity nurse brings the patient to the OR and we get her ready as Phillipe gets there.  It seems to move along faster than normal.  She has a previous scar on her lower abdomen from the uterus repair before.  It seems like a keloid (thick and large and hard), so I excise the previous scar.  Her scar tissue is pretty dense. After opening the muscles I find the bladder quite stuck and I can’t even drop it down out of the way.  I imagine this is because of the previous site of rupture and scaring.  So I have to make a higher transverse incision on the uterus than normal.  I reach into the uterus to grab babies head and it is wedged into the pelvis.  I work my fingers hard to try to get around the head to pull it back up.  It’s real hard to get my fingers around it then the suction of the pelvis holds my hand there, finally a bit of air goes around my hand and the suction is broken and Im able to pull up the head.  The baby is floppy.  And since I don’t trust the nurse I keep the baby on the wound in front of me for a little bit and get him breathing before handing him off to her.  The closure of the abdomen is uneventful and after about 5 minutes her and the anesthetist working on the baby, he’s breathing well.

The next patient we are suppose to do is a liver abscess but the power went out again.  This time I think they’re filling the generator.  They have two new generators that they say have oil cut off sensors that are bad?? Unlikely on a new generator.  More likely poor oil amount or quality.  So since I don’t have power I go to make rounds.  I take my headlamp and see all my patients in about an hour.

I go back to the OR and about then the power comes back on.  So they bring the patient in and I decide to ultrasound his liver to decide whether I’ll do it with a pigtail drain or open drainage.  There is no abscess.  I check the paperwork and it says a bladder stone on the ultrasound.  Is this the patient in bed 9 with the abscess?  Yes.  The anesthetist steps out to find out more.  They come back with the correct patient who’s been out under a tree so some other patient took that bed.  Ultrasounding the correct patient, I see there is a deep abscess in the posterior liver up near the diaphragm and heart.  OOOhhh.  If I miss the direction I could stab the heart and kill him.  I think about not draining it.  But it won’t get better without drainage and in the posterior liver, draining it with open surgery will be nearly impossible too.  So decide to put in a spinal needle in the direction I think I should go and watch on ultrasound.  I get right into it.  So I take the much larger pigtail catheter and feed it in till I see the tip in the middle of the abscess.  I withdraw about 80ml of pus.  I flush it with saline and attach a bulb for suction.  

The next woman is HIV positive and has had abscesses all over her chin and neck from tooth decay and infections.  She has a remaining hole just above her sternum that when she coughs or lifts something- pus drains down her chest from the hole.  I decided this must be a retrosternal collection.  So I numb her up and open the hole to probe it further.  I worry about wether the internal jugular vein has been pulled or displaced by scar tissue- will I get into significant bleeding that is difficult to manage.  I open a small amount at a time.  I probe the pocket with an instrument and feel that it’s not to big.  I had hoped to get my finger in, but I stop as Im not in bleeding and down want to cause it.  I put a piece of glove in as a drain and put a dressing.

There are not many cases scheduled on the weekend so we are done.  I head over to another missionaries house about 10 min drive away on a motorcycle. Unfortunately and fortunately they are just ready to have a late lunch.  So we are invited to eat.  We have a nice meal together and I spray the areas of their house they want sprayed with the insecticide I brought.

Back at the hospital I make it back in time to be a part of a party for one of the Cameroon missionaries here.  Two of the families here made cake- and they taste real good!  We take turns commenting on how we appreciate the person who’s birthday it is.  It think this is a nice way to party.

Just at the end of the party there is a call for a woman who isn’t progressing in labor and has a face presentation.  Normally the back of the head is the presentation part an this comes out easier.  The face is to broad and doesn’t deform like the rest of the head for a vaginal delivery.  We wait for the generator people to put in fuel as the power just went out.  Then she starts bleeding vaginally.  Now it’s an emergent C-section.  We pour in the fluids and get a spinal in the dark by headlamp.  We can’t wait for the power to come back on.  We must get the baby out as soon as possible.    She may have placental abruption (separation of placenta from uterus that will kill baby and make mom hemorrhage a lot).  As soon as the spinal has taken effect quickly cut into the abdomen, down to the fascia.  A quick cut and scissor of the fascia and separation from the rectus muscle.  Move the bladder down out of the way then open the uterus.  I immediately get some clots.  I reach in and fish the baby out.  He looks weak but starts little breaths.  The midwife is there to receive the baby and she takes her, and starts working to get the baby breathing well.  I close the uterus as fast as possible to help staunch the flow of blood mom is loosing.  Then tie off some other bleeders.  Mom is getting a transfusion at the same time.  God help this mom and baby!  I hear the baby start to cry- what a joyous sound!.  The power flickers back on for about 1 minute then fades out again.  Sweat is pouring in rivulets down my back and legs.  I slowly close up the different layers irrigating between each layer.  Mom has stabilized with more blood and all I feel now that my adrenaline is less- is HOT!!  After we are done and wheel the patient to maternity, the slight breeze outside is sooo refreshing.  The power takes a while to come back on.  More plastic bag in the generator fuel lines I hear.  Eventually the power comes back on and I’m able to sleep. Till 2AM when I’m called again.

Bere 5/2025 #7

administrator Greg No Comments

Bere 5/2025 #7

Always enjoy Friday evening worship to open the Sabbath.

Friday-  

This day went rather quickly as it was quite busy.  Andrew was doing a thyroid with a large goiter and I went to make rounds after morning worship.  I saw all the same types of patients I’ve mentioned these past few days.  The ones of interest were the man who was gored by a cow horn- he is doing better and is fully awake and communicating.  Is having a fever and is drinking some water OK.  Still waiting for his intestines to work.  The other is the child with a Tylenol overdose who had meningomyelocele back surgery.  Still having fevers and is being treated for meningitis.  Rounds took about 1.2 hours.  

I went into check how the thyroidectomy was doing and Andrew wanted me to scrub in with him.  There was some weird anatomy that had made it real challenging.  So I scrubbed and took over the place of his assistant.  It was a tough, long, tedious surgery and we got out a 2 x 4in goiter.

The next one I had was a lady who had had a mouth mass that was growing a couple years.  It grew off her gums and hung down in front of her teeth.  It had outgrown it’s own blood supply so it was necrotic and smelled awful!  I had asked Andrew to ask an ENT friend wether exposed maxilla would heal or not.  We never got an answer.  So I figured I’d take it off and hopefully I would be able to cover the bone with what was left.  It is so sad that people have to live with things to get to this point.  Terrible!!  I’ll attach a photo at the bottom.  I decided to start with a huge suture around the base because it seemed to have a smaller stalk at the teeth level then mushroomed from there.  So I looped the suture around the stalk and tightened real tight.  Then I cut off the majority of the tumor.  Then I could see to do something more.  She was already asleep with ketamine, but I injected some lidocaine for hemostasis.  I made an incision in her upper gums and dissected down to the bone.  Then I went across on top of the bone and beneath the vessels.  Then I created a space between the gums and the vessels.  Then I tied the vessels off higher and cut off more of the tumor.  I then used a rongour to bite off pieces of maxilla till I have the feeling of good hard bone.  My goal was to get all the cancer so it had a lesser chance of returning, though at this size I assume it has already gone into other lymph nodes.  After biting off all I thought would have tumor in it, I mobilized the upper gums and was able to get closure over the maxilla.  She went to the recovery room.

Then there was another miscarriage woman who was still bleeding and so I took her to remove the retained placental products.  This went well and took about 10 minutes once her spinal had been placed.  While I did that David took the burn girl in for debridement.  When I was done with the D/C I went to help him.  We each had scissors and were cutting off dead tissue of the woman who seized and fell in the fire.  Some had started to suppurate and separate from the underlying live tissue.  So we cut dead tissue away aggressively on all the spots that she had burns that were deep.

The last one I had of the day was an anal fistula.  These occur after a rectal abscess and have persistent purulent drainage from a little hole near the anus.  Annoying to always have some moist pus sitting there.  The solution is to cut the tract open.  So after a spinal, I stuck a metal probe into the tract.  I slowly felt around with the probe till I found the entry into the colon.  I flayed open the tract till where I could feel the anal muscle.  This I put a stitch through the trap and tied it on the outside.  It will slowly work it’s way through the muscle, healing the muscle behind itself.  This way there is minimal risk of incontinence.

I go home and get my laundry off the line that one of the ladies were paid to wash today.  Then on to eat supper at Megans house then to the Sabbath start worship.  We sand some English hymns a French hymn and some Childrens songs.  Then discussed a passage of scripture in 2Kings.  I’m enjoying the community of missionaries.  For the most part we are quite up front with each other, avoiding the superficialities.  And I like the honesty.

I check on a few patients tonight and start my cow horn trauma guy on malaria treatment because he still has a fever.

God guide us in our treatment of patients.  Most of all Lord, heal them with your power!  You are the healer and we want Your healing for missionaries that are sick and for all our patients.  Also use me in Your healing process if You want that.  Amen

Bere 5/2025 #6

administrator Greg No Comments

Bere 5/2025 #6

Long good day with a nurse induced overdose of a child

I  check on the guy who had been stabbed by a cow with it’s horn.  He is still alive.  Still in septic shock with a norepinephrine drip that no one is really monitoring.  I just ask the nurse to not touch anything.  I go to worship at the Hopital then back home to have my own time of reading and prayer asking God to heal my patients and to give me knowledge of what to do with the ones I will see today.  

I have some bread and PB and head in to work.  Dr. Andrew is going to do surgery on a 4 day old with a meningomyelocele.  (Undeveloped lower back with nerve tissue exposed to the outside on lower back the looks like a healing wound about 1.5 inches across).  I go to make rounds.  The OR nurse will do a hernia repair in the second room in the OR..

I make rounds with Emma who is the long time day norse of the surgical ward and he is easy to round with as he knows all the patients.  The ones that stick in my mind now after a day of operating are:  Guy malled by a cow horn, teen girl burned all over body when she had a seizure and fell into a fire, teen boy with hippo bite, Old man with TURP, two old men with hydroceles, two old guys with inguinal hernia repairs, old man with arm with tumor removed and skin grafting, guy nurse with buttocks abscess after antibiotic injection at that site, boy with bladder stone removed.  Took me about an hour to see them all.  I left some of the dressing changes for Emma to do.  I notice a box of carnets (the little booklets that is the medical record that the patient keeps). I asked Emma what that was?  He said that those are all the patients he’s following for tuberculosis.  And there is a real problem with inconsistency of the supply of medicines.  He will get medicines for two months, then none for a month of two, then get them again.  I realize right away this is a terrible set up for medication resistance, which I had heard was already becoming an issue in this area.  A guy at that moment stopped us to ask Emma for his meds, and Emma was out of his meds and couldn’t get them.  I encouraged the man to go to Lai (Emma said they’d be out there too), or to go further away till he found them.  I hope he does find them- seems like an impossible task for a local person.

Back to the OR, and Dr. Andrew was just intubating his patient as Phillipe had been unsuccessful.  It looked like a hard intubation.  I asked if I could help him as I have tried to repair meningomyeloceles before in Cameroon, but hadn’t ever seen one done properly.  He agreed.  We lay the baby prone to expose the back and put the cautery grounding plate under him.  I prepped the kid with betadine and we dawned our cloth gowns after scrubbing our hands with brown colored bar soap.  Dr. Andrew cut around the skin beside the open raw looking area- the dura.  The anatomy was so hard to figure out.  Zach helped use Andrews phone to dial a neurosurgeon in Kenya for a video conference to ask his opinion.  The connection was terrible but with some creative hotspot thinking, a better connection was made.  The neurosurgeon said this was abnormal anatomy for this disease and gave some pointers on what to do.  It’s invaluable to have knowledgeable people, who understand the situation and limitations here, to give their opinions!  With a very tedious long dissection we removed the fascia off muscle, bone circumferentially. The power went out so we had to stop about 10 minutes, because we were using cautery and a bloodless field was crucial.  The fascia  was so thin over the bones the some holes were made which wasn’t good, because it needs to be water tight to hold in CSF (cerebrospinal fluid).  Next we undermined the skin all the way out to the sides of the abdomen.    We closed the dura in a running layer then the fascia was pulled over that and closed folding the dura in.  Then closed the skin in a running layer that was also to be water tight.

I went to the next OR to operate on a child that had a bladder stone.  The OR lights don’t work in this room and so I operated by my headlamp.  I had a hard time seeing and initially I thought it was my eyes are older and don’t want to focus close, especially after the last surgery that was all very close.  About midway through I realized my headlamp was very weak, so Zach turned on his and voila, I could see clearly… So other than the power going out some more the surgery went well.

Dr Staci had come from maternity and said that there was a C-section that needed to be done as the patient had come in labor and had a C-section before and was told to always have a C-section after that.  Phillipe had prepared her in the other room so I switched back to that OR.  This abdomen was quite scarred as I opened it through the previous incision. Muscles were stuck, bladder was stuck.  I opened the uterus to a gush of amniotic fluid.  I pulled the babies head out, and found a nuchal cord (cord wrapped around the neck) so I undid the wrap and delivered the rest of the baby.  He cried right away and I passed him off to the maternity nurse.  The closure of each layer went well and she didn’t have any vaginal bleeding from the uterus at the end of the surgery.  

The next young woman had had an early miscarriage and some retained  placental products in the uterus that could be suspected on ultrasound. So back in the other OR I did what is called a dilation and curettage.  Where we basically use some metal instruments to scrape the inside of the uterus clean of any retained pieces of placenta  so that the woman will stop bleeding and also diminish the risk of infection.

I found Dr. Staci on the maternity ward and looked at a patient in the delivery room.  Staci was getting ready to do rounds at 7PM as she had been busy all day with administrative stuff and still hadn’t had the time to make rounds. ( I’m convinced that she does a job that really should be three different people.  Director of hospital, only doctor on maternity, and director of AHI Chad. So if you are good at any of those jobs and want to live in Chad Africa, contact her or I).  Back to the work… I decided to offer to make rounds for her.  I’m not as competent as she is but figured that the nurse who was on was a good one and that she would know the patients well.  So I made rounds in stead of Staci.  Even my help is beneficial when it relieves the load some so that overworked doctors can have a little less.  I make rounds and discharge the patient I did a symphisiotomy on a couple days ago.  She is walking well, denies any pain.  Hasn’t washed the spot of the incision because her mom told her air would enter and she must keep it covered.  So I looked at it and it looked fine, and I encouraged her to wash it daily with soap.  I’m pleased that her next vaginal delivery should be easier for her.

I walk through the surgical ward on my way back to my room and to go get some supper- 8PM. I check on the cow horn injured man and his family is sitting him up and he’s requesting some water.  I tel them they can give him sips.  The nurse says the baby we did in the morning has a high fever of 40deg C, or about 104 F.  They gave Tylenol and it didn’t come down.  She says the Tylenol is nearly finished.  What?? The Tylenol bottle is 1000 mg and a baby takes about 30mg… So I have her show me the bottle.  It’s about 80% gone.  I asked her if the baby got all that in a dose.  She said yes.  So the meningomyelocele baby who we operated on for hours, was given about 800mg of Tylenol in stead of 35mg.  Thats about 20x a normal dose or 2000%.  A huge overdose!  I told her that this will kill the baby, not immediately, but in a few days or week.  She said, well what do we do about his fever?  I don’t think she grasped at all the critical error that was made.  Later I found out it was her who had started the drip and had overdosed the kid.  So if the kid survives his meningitis and fever, he won’t likely survive the liver failure that will result from that error.  How terrible…

God, only You can save this baby, only You can save this cow horn injured man.  LORD HELP THEM!  Save them from their injuries caused by disease, caused by us as we care for them.  HELP us!!!!

Bere 5/2025 #5

administrator Greg No Comments

Bere 5/2025 #5

Long night

I was told about 10 PM that the ambulance was gonna go out tonight to get a patient from Lai. At about 1130 I was called to see a patient that had intestines hanging out. I came into the ER and that’s exactly what I found. A 50-year-old guy with intestines hanging out his left side. Both large intestine and small intestine and a whole bunch of poop. He had been stabbed with a cow horn. There seemed to be no further history than that. He said that he did not hurt anywhere else.  So I called Phillipe the anesthetists and we went to the operating room. The ER Nurse had started two IVs, and then had put some Dakins solution over the exposed intestines that had poop all over them. After the patient was in the operating room, I tried to call my nephew Zack a number of times and he didn’t pick up. So I went to his house and beat on the door. Apparently he was fast asleep. So I shown my light in the window and beat on the window and eventually he woke up. He came to help me with the operation. In the operating room, the 50 year old man was intubated by Phillipe and then I prepped the abdomen and prepped all the intestines with Betadine and tried to wipe all the poop off of them. The size of the intestines and omentum that were out of the abdominal wall were approximately 8 x 10 inches in size.  He was hypotensive from the start. His heart rate was good, but his blood pressure was low and he’s been in septic shock ever since.

I take a scalpel and open the skin along the midline lower abdomen.  Through skin, fat to the fascia.  Then into the abdomen. I get a fair amount of blood and suction what I can and the rest spills from the patient down the sides of the table.  With in a short while I feel his blood has seeped through my cloth gown and through my scrubs to my skin. Yuck. The intestine has been stuck outside since this occurred at 5PM (I found out later) and I’m operating at midnight.  So the intestines that are stuck out are a bit purple and hard to get back inside.  After I work them back in through the hole they start to pink up and look as normal as the traumatized intestines can.  As I look around I find that there are two places the small intestine has been torn in two and there is a section of transverse colon that is devitalized (dead) because the mesentery was ripped off it.  So I take out the small part of intestine between the two torn pieces of small intestine and tie off the mesenteric vessels.  Then I do a single layer hand sewn anastomosis.  This is a series of small sutures about 1mm apart that reconnect the intestine back together all the way around the opening.  After about 45 minutes Im done with this one and work on the large piece of intestine that is devitalized.  I cut out the dead piece then re-anastomos it the same way.  There is still bleeding coming from somewhere.  So I feel up for the spleen- it’s lacerated too.  I open the skin all the way up to the sternum.  Now I can see the upper abdomen better and there is a cross shaped spleen laceration over the whole surface that is bleeding some.  As I inspect further, I see there are two holes in the diaphragm.  One laterally is about 10 cm and one right in the center of the left hemidiaphragm is about 2 cm.  I stick my finger through and feel lung.  So I get better exposure and suture up the diaphragm.  The patient keeps moving because he is only getting Ketamine as his anesthetic as the anesthetist didn’t think his BP was tolerating the isoflurane inhalation anesthetic.  So the patient would start tightening his abdomen like a sit-up and I’d have to ask him to give more.  This took a while.  After that I put a chest tube in to re-inflate the lung.  Surgery had been going on about 5 hours now and I verified there wasn’t any additional bleeding.  Again I washed out the whole abdomen with a lot of fluids. (The solution to pollution is dilution- so diluting out all the poop and bacteria in the abdomen ).  I closed the fascia and then skin loosely.  I went to the old OR to get one of the pleuravacs (container that attaches to chest tube) I just brought.  I plugged it up and then started my paperwork as he was extubated and taken to the recovery room.  About 5:30AM.  I did my paperwork and did one of the most lengthy notes here.  In case anyone else has to re-operate on him.  As I go out to the recovery room, I see Phillipe bagging the patient.  Oxygen saturation is in the 40%.  He hasn’t called me to tell me there was a problem.  How frustrating!!!  So I take over bagging and the patient is posturing decerebrate.  This is usually a sign of brain damage.  Finally I think the Holy Spirit prompted me to give Valium.  So we give that and the posturing stops and he relaxes.  Slowly the oxygen level rises.  If he wasn’t brain injured before I suspect he will be now.  I pray for him and ask for Gods healing and command the devil to leave him alone, this is Gods hospital and we are Gods people.  The devil has no right to harass him.

I stay for an hour, then decide to go back to the room while Phillipe stays at the bedside.  I eat some breakfast of toast with PB and mango sauce.  I shower then go back in.  Phillipe has started an Epinephrine drip.  As the day goes on I adjust that drip to try and keep his pressure up to the 80’s.  I go through my day of operations checking on him between cases.  I also see come of the consultations.  At about 4:30 Im crashing hard.  So I’ve finished the last surgery and go back to my room to drink a cold electrolyte drink and then go to Meghans house with Zach to eat.  I go home and lay on the floor in front of the fan- and I’m out.  I awake after 3 hours having missed calls from Dr. Andrew and texts.

I go in to check on the patient again and Dr. Andrew has been at the bedside for hours and they’ve set up and “ICU” with oxygen, a monitor and a norepinephrine drip.  I relieve him so he can go home and sit at the bedside till 9PM when the night nurse comes on.  I tell her about the drip (things they have never seen), and to leave the rate alone.  As well as all the nursing students.  Sure wish I had an expat ICU nurse with me tonight!  But I know I’ve done all I can do for this man.  And to be functional I need to sleep. I feel like I’m wound down enough to sleep again. 

I’m not called all night so I sleep fairly well.  I check on him at about 6AM when I awake and he has made it through the night.

God heal this man!  Show Your power and love to him.  Be glorified God by what you do in this hospital.  Help us to recognize all that You are doing here.  Give me wisdom and strength for today.  Amen.

Bere 5/2025. #4

administrator Greg No Comments

Bere 5/2025  #4

I slept through the night- yay!  The missionaries here are amazing!  So much to do, so often little sleep.  Dr. Andrew was up 5-6 hours last night with a child who was dying.  So sad and so many advanced diseases.  I think I say that every time I’m here.  It’s always very hard and very good to be back.  All the missionaries here are amazing and have such a heart for God.  They are wonderful people to hang out with.

I went to morning worship at 7 then found out there were no meetings after that.  So I thought of starting rounds or operations right away.  Well no nurse on surgical ward, and no one except patients sitting around with IVs in their arms in the OR.  So I go wandering around looking for workers.  I found the anesthetist chatting with a surgical patient.  I told him I was ready when he was, so he headed to the OR.  Since it is the hot season most of the patients and families spend their days outside.  They have to be collected from out under the trees, to come inside to round.  So after about 15 minutes I was able to go to the OR and start a surgery.  

The first guy had what was suppose to be a hernia and possibly a hydrocele.  After his spinal I thought it was likely a hydrocele.  But in palpation I got the sense of a hernia too.  So after we prepped him and put the cloth drapes on- I made an incision for a hernia figuring if it were a hydrocele (fluid around the testicle) that I would just extend down to it on the scrotum.  I did the usual exposure down to the fibrous layer and then opened it.  Still couldn’t reduce anything.  Eventually I got a little to go back in.  But the scrotum was still at least grapefruit sized on one side.  I finally opened the sack and found what appeared to be omentum (fat) as well as intestine.  The omentum was stuck to the sack.  So I tied and cut through the omentum.  Then the area I was unsure of, the area that could be intestine still wasn’t clear.  So I slowly dissected it.  After a bit of work it was more omentum that was encapsulated, weird.  So I took off the hernia sack and repaired the hernia with a mesh patch.  It’s the first mesh I’ve ever used here.  I’ve always been worried about infection.  But they have been using mesh lately and said they’ve not had many hernia wound infections.  At least there was an indicator in the pack that showed this pack was sterile!  The rest of that surgery went smoothly.

I saw a patient or two in the consultation room, which is now in a separate building, while I waited for the next patient to be made ready for the operation.  The next was a guy with two suspected liver abscesses.  As I ultrasound his scaphoid (concave) abdomen, I find a smaller superficial abscess and a larger deep abscess.  I numbed up his abdomen and put a needle catheter into the more shallow one and pulled out 30 ml of thick pus that slowly rolled into the syringe.  I couldn’t reach the deeper one and didn’t want to use a sharp spinal needle to do it.  Fortunately my hospital had a few pigtail catheters that were post dates that I brought.  So I stabbed one of those into his liver and into the second deeper one.  I drew about 50 ml pus out of that one and left this drain in that one.  Did the pigtail and also sutured it into place.  

The 60 year old man had bilateral hydroceles,  one medium hydrocele and a large hydrocele on the other side.  This fluid around the testicle I think is related to the shistosomiasis here.  A disease you can get from being in the rivers or a lake.  The solution is to dissect out the sack, resect the excess and evert it over the testicle and cord.  As I dissected out the side where Zach was standing it suddenly burst splashing testicular fluid all over his front and his shoe.  He was a trooper and took it and kept working.  The larger side had I bet about 800ml of fluid in it.  Quite large.  I resected both sacks and everted them and then sutured the testicle back to the base of the scrotum and closed the skin.

I saw a consult or two and then Dr Andrew said he had another surgery for me.  One I hadn’t seen before but they’ve done here a few times.  A hippo bite.  I understand that Hippos can be very territorial and you don’t want to get near one in the water nor on land.   They are large but can run almost twice as fast as a human (unless you’re Husain Bolt).  This teen boy was bitten in the leg.  He had a gash at his knee, a number of smaller punctures and a gash on his calf.  He got a spinal then we prepped his leg with betadine after washing it with soap and water.  So between the river water and the hippo mouth, I’m sure there are plenty of bacteria in the wound!  I loosely closed it, intentionally leaving space between each suture for pus to come out if it were to get overtly infected.

This evening I had a wonderful conversation with a missionary who has been helping people become free from devil harassment and oppression.

God please continue to guide them and Lord, use me in any way you want to, to advance Your kingdom!  I want Gods will do be done on this earth as it is in heaven.  (i.e.- Gods will isn’t being done on earth- His will, was the garden of eden…) See. Genesis Chapter 1 and 2.

Bere 5/2025 # 3

administrator Uncatergorized No Comments

Bere 5/2025 #3

Ohhh power just went out as I start to write and get ready for bed.  I certainly hope they figure it out or me sleeping without a fan will be very difficult!!  Today was my second day of operating.

I woke up early and did the things of the last post.  At 7AM I went to morning worship and then soon there after the power went out.  I knew there was suppose to be a woman with a large thyroid to operate on this morning and that would take a while.  There were some texts going back and forth about what was happening with the generator so I went to try and find out.  I found a number of guys I don’t know.  I guess they were newer than when I was here last year.  One was the mechanic, who can fix about anything.  At least he listed off a bunch of things.  He told me that the generator stopped because the voltage was zero in the battery.  He shows me a panel.  It has numbers and digital readouts.  So I know it wasn’t zero!  He showed me where the panel said 0V, but it was under the heading generator.  So the generator was off- thus zero volts.  I asked him for a electrical multimeter.  He said they were bringing it.  I was around there another 15 minutes with lots of discussion.  Finally they purged the diesel system of air and got a car battery and started the motor.  It ran fine .  Then they changed back to the “old” battery while it was running, putting the other battery back into the car.  

I was suppose to round and the other surgeons operate.  Then the first surgery, a large thyroid goiter was hypertensive.  So the other surgeons cancelled her.  So I was up for removing a young girls bladder stone.  Phillipe the anesthetist put the patient to sleep with propofol and some inhalation isoflurane and bagged her with a mask.  Her sat dropped temporarily then back up.  I scrubbed and we prepped the skin and put on the cloth drapes.  The nurse David had filled the bladder so it was near the umbilicus and then as I go in I will get into bladder and not intestines.  She’s about an 11 year old girl so she’s quite petite.  I cut through the skin low in the abdomen.  Split the muscles and identify the bladder.  She desaturates again, low this time, 40’s. Phillipe doesn’t have suction ready and he takes a bit to get it together.  Im trying to let the anesthetist do his job but Im about to scrub out to help him when it starts slowly improving.  I have a nursing student call in Dr. Andrew to assist.  He’s doing consultations.  The oxygen saturation is pretty good when he arrives.  So I continue the operation.  Andrew leaves and shortly thereafter the power goes out.  I always wear a headlamp so I’m the only one in the room with light.  I immediately worry will the patient desaturate and die for lack of the oxygen machine and anesthesia machine?  I try to hurry up as I just ready to retrieve the bladder stone.  I get it out and it’s about the size of filbert nut.  The patient slowly starts to desaturate.  I try to work as quick as possible.  About the time she’s in the 80’s for saturation the power comes back on and she slowly climbs back up to normal in the mid 90’s.  Wow that was stressful surgery.  So many things out of my control and many can kill or make a bad outcome.  

I go to see what’s happening in the other OR.  I find a nurse doing a hernia repair with a nursing student.  No one doing anesthesia.  I asked him where is his anesthetist?  Well he had done the spinal then started the operation.  I told him I thought that was very unsafe, decided not to make further comments and tell the missionaries that are here. That way they can address it if they wish.  It is quite different being in charge of a hospital like I was in Cameroon, vs visiting and trying to asses how to help without ruffling feathers.

The next one was a young girl of about 12 who had a broken leg about 3 years before and keeps getting infections in her skin.  She has some right hip pain as well.  So she had had an X-ray so I went to look at it.  It shows and involucrum (a thickened irregular bone associated with boney infection) and likely a sequestrum- a piece of dead bone that is an infection source.  The other doctors think this is the source of her various infections around her body.  I have no other explanation and this definitely looks like it’s a likely source.  In the operating room I open the outside of her hip bone and eat away at the soft bone down to the marrow.  But the infection seems to have been replaced with normal marrow and not full of pus like is usually the case.  So I wonder if I have missed the part with pus inside.  So I open the skin down to the bone quite a bit lower on the femur.  Here the bone is hard and normal and I can’t even make a window into it by trying to nibble away at it.  I ask for the nurse to search for another missionary to come in and help with their thoughts.  Two come and after discussion I decide to close up and they will send this info to the ortho friends they have to see who has better ideas.

When Im done with that David has done the other hernia case and there are no other planned cases today.  2PM- wow I don’t think Ive ever been done at that time.  So plenty of time for emergencies to be taken care of.  Zach and I head back to our rooms and get more water to drink.  When we’ve cooled off a bit in front of a fan, we go to the small market area just outside the hospital and I show him the types of things you can get.  We get some Gato (kind of like large donut holes) and sugar for them and for kool-aid I brought.  We also get toothpaste, and some little things that look like kit kat bars.  Back at my room we eat these and enjoy them.  

Im called to see a woman in labor who may need a C-section as the midwife says the baby is having some decelerations (heart slows down- a sign of fetal distress) with the moms contractions.  It’s this moms first child.  I go into the delivery room where there are rows of beds next to each other for delivering women.  There are two delivering women with many other women standing around.  The nurse tries to get the women to leave and some file out.  We ultrasound the one Im to look at.  The babies heart rate is good and its head down with the placenta not near the exit.  These are all good things.  But the baby isn’t coming out.  So I attach suction to the babies head which is right at the vaginal opening now.  With successive contractions I try and pull the baby with the suction attached to its head.  It doesn’t help much.  It seems the babies head is a little to large for the pelvis of the woman.  So the options are C-section or symphisiotomy (separating the pelvic bone symphysis to enlarge the pelvis).  I was taught symphisiotomy by an old OB/GYN while in Cameroon and this seems like an appropriate patient.  So I decide to do that.  Zach goes to the OR to collect a few things for me and the midwife gets some other things.  In between contractions, I place a foley (urine) catheter and then numb up the skin in front of the symphysis pubis (the connection of the front of the pelvic bone. I make a small incision in front of the bone and with the scalpel “feel” my way down to the ligament connection between the bone.  I put my finger in the vagina and push the foley catheter to one side so its not down the middle.  So with one finger inside the vagina and a scalpel cutting the ligaments I slowly divide the ligaments.  When it’s near the end I can feel the blade on the other side of the skin of my finger in the vagina.  If I go to deep I open the vagina and slice my own finger.  There is a pop and the bone opens about a fingers width.  The contractions keep coming and after the symphisiotomy the baby comes out in about two pushes.  Wonderful!  However the baby is floppy and there is meconium everywhere.  I pass the baby off to the midwife who takes him to the side table and starts suctioning his lungs and getting him breathing.  It takes about 10 minutes and more time on oxygen- but the baby appears to be doing well within about an hour with the midwife spending most of that hour with him.  While she helps the baby to live I sew up my small incision with a stitch and the nursing students clean up all the blood, placenta, meconium and mess.  I am always thankful to have a live baby – thank you Jesus!  Also thankful that this woman didn’t need a C-section- meaning a scar on her uterus, that gives her an increased risk of uterine rupture in the future.  Her pelvis will heal with a wider opening and her next delivery should be easier.

God help this baby to live and to grow to know You!  Give me strength for each day and wisdom for each patient I see.  Help me to support the missionaries here and help me to share Your love with all those around me.  Amen

Attached a picture of bladder stone.

Bere 5/2025 #2

administrator Greg No Comments

Bere 5/2025 #2

Sunday- second day in Bere.  Sundays are usually slower because we have no planned operations and don’t see surgical consults like every weekday.  I did rounds with Dr. Laurel on both the surgical ward as well as the maternity wards.  We saw the usual variety of patients.  One thing new here is Dr. Andrew has learned to do TURPs.  So basically rather than taking out the prostate to help old men pee better, he is able to ream our the inside with a hot loop and get them to pee better.  That’s exciting.  So we saw a patient who had had a TURP, some burn patients, a child with hirshprungs (disease where the nerves of the large intestine are absent and it doesn’t contract well) who had a colostomy a few days ago, a broken arm, post surgical wound infection, diabetic ulcers, osteomyelitis of a hip that needs debridement, and more and more.  Then on the maternity ward, there were many women who had delivered a normal baby and ready to go home, others who had a baby with an unknown infection that were there for antibiotics for the baby, and others with C-section and one after hysterectomy.  Many were frustrating because they didn’t have paperwork or it couldn’t be found to easily see why they were there or what meds they were getting.  We ended up looking at medications paid for and asked a lot of questions to figure out why they were there.

After rounds I took the call phone to start taking call.  When Im here I often bring insecticide to spare in all their houses, to help kill mosquitos.  It’s suppose to last 4-6 months, so it should help each family especially as the wet season is coming up.  So I sprayed about 7 houses today to kill flies, mosquitos, cockroaches, ants…. About mid way through I got the message that lunch was ready so I detoured for lunch before going back to spraying.

When I was about done with spraying, I got the message that there was a woman who was to have her first baby who was footling breach (butt first).  So they recommended that I do a C-section.  She had had a previous C-section and wasn’t dilating with usual measures. (Usual measures like a foley catheter put through the cervix and balloon inflated to get the cervix to dilate).  So I took her to the OR for the C-section.  My nephew Zach would assist me.  She got about 1500ml of fluids than a spinal anesthetic by David.  I cut across the lower abdomen through the skin, fat, then to the fascia (like gristle).  Opened the fascia and separated it from the muscles.  Then opened down to the peritoneum exposing the uterus.  I incised the uterus and took the bladder out of the way.  Then I continued opening the uterus until I got a small about of amniotic fluid.  Sticking my hand in the uterus I felt around for a part of the baby to grab.  I found the butt.  I pulled on either hip and delivered the child out butt first.  The head stuck a little, as it’s the largest part of the baby.  But with a little twist and maneuvering the head came out.  The baby was floppy, but the new (she’s been here 2 weeks) midwife was at the OR bedside to take the baby so I clamped and cut the umbilical cord and passed off the little boy to her.  As I sewed up the bleeding uterus, I started to hear the baby cry with the midwifes help getting the baby going.  It is always a wonderful sound to hear the newborn cry!!  Happy Birthday!  Thank you Jesus for another live baby!  After closing the uterus and putting the bladder back into place, the rest of the layers were closed leaving a barely visible scar.

I head back to my room and get a text asking if I saw the kid with a facial laceration?  I heard they were at the pediatric department so I went there to look at him.  I called David to stay around till I found out wether it could be repaired under local or not, but he was already home.  The kid and family had gone to the lab to get bloodwork drawn.  I got out my headlamp and looked at him.  He was a boy of about 5 years old, with a gaping hole and cut on his upper left lip and cheek. I could see muscle and some loose teeth.  He had been kicked by a donkey in the face.  The blood work looked good and I took him to the OR.  Two of the pediatric nurses and Zach came with me.  I called David so he would come back in to do anesthesia.  The pediatric nurses rummaged around to find the supplies to get an IV.  Eventually one was in.  Then it blew the vein, so another one had to be placed.  Finally another was in and we started.  Under ketamine he did pretty well until he started vomiting food.  The fatter told us he had eaten 8 hours earlier but that didn’t appear to be the case.  Fortunately he didn’t appear to aspirate the food so he continued breathing well as I worked on his face.  I discovered that 4 teeth were loose.  Loose from the bone and also a maxillary fracture.  I asked for arch bars for the maxilla, and they didn’t have any.  But David could find wire.  So I wired a bad tooth on each Side to the good tooth next to it.  Not really stable but better than just leaving that peice move as it would.  Then for the laceration on his lip and face.  I took off the dead tissue and then brought the obicularis muscle back together.  Then I reapproximated the remaining muscles and tissue.  I closed the skin and the boy woke enough to go to the ward with his father.  I checked with the maternity and there were no concerns there.  I went by the surgical ward and they were concerned about the swelling of the abdomen on the kid with Hirshprungs disease.  His belly was distended but not very tender and his colostomy looked good.  So I reassured the family and headed home.  After writing to you, I showered and went to bed dripping wet, in hopes of falling asleep before I got too hot.  I dried out but was able  to sleep.

Somewhere around 4AM Im called to see two patients in maternity.  So I walk over there with my bag containing my ultrasound and other stuff.  It goes with me everywhere here.  The first patient the nurse shows me is a woman who has her 10th pregnancy and is at term and dilated cervix to 4cm.  The nurse can’t find the heart rate and the mother hasn’t felt the baby move since yesterday.  She’s having some contractions but hasn’t lost her amniotic fluid yet.  So I get out my ultrasound to see if the baby is still alive.  As I look around I can’t find any movement.  Then I see what looks like a still heart.  The baby is cephalic presentation (head first) which is good.  I tell the woman and the father my findings.  They remain stoic.  The nurse tells her to start walking around to help stimulate the cervix to dilate more and we will check her later to see how she is progressing.

The next woman she shows me is a young appearing woman who was in bed under her mosquito net.  She heard a commotion and when she opened her eyes a cobra was under her net in front of her and spit venom in her eyes.  Her husband killed the cobra and brought it in, in a sack.  They washed her eyes and face with water and came in here.  Apparently their cat had been stalking the cobra to kill it when it went into her mosquito net.  I haven’t encountered this before so I was able to have a good enough cell signal to look it up.  So I irrigated her eyes with Ringers Lactate solution until her eye no longer hurt much.  About 20 minutes.  Then I gave her antibiotic ointment and will check on her later today.  I asked the husband to show me the snake so he dumped out the pieces on the floor.  Im guessing if I put the pieces back together it would have been 3 feet long.

Now the sun is up and so am I.  I usually can’t fall asleep again when I go in, in the night anyway.  So I sit here in the cool of my fan, not sweating yet, to write you.

Please pray that God give me wisdom and strength for each patient I see while I’m here and that He give me the words to speak His love to each of them.  And that the devil is blocked from influencing or harassing me in this work.  Thank you!!!!

Bere 5/2025 #1

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Bere 5/2025 #1

I’m back in west Africa.  God and missionaries keep calling me back.  I came with my nephew Zach a nurse who is aiming for med school.  Audrey couldn’t come this time because she had  a recent knee replacement and is still recovering from that.  Not yet the time to run through airports to try and catch the next plane.  Also our dog, Tucker, is getting old and hobbling around and takes more care.  I have had a quite busy last month with Audreys surgery and a variety of things going on that I didn’t end up packing till the day before and day of my travel.  I signed out in the morning to my surgical partner and continued packing then left that evening for Portland to fly out that night.  All the flights were on time and I made all of them arriving in Ndjamena  mid day.  I stayed the night to meet Zach who came in on a flight later that evening.  We got the required police stamp with our taxi driver helping us.  We have used the same taxi guy since coming here at least 13 years ago.  He’s very dependable, drives a 1993 very beat up Corolla, and crams all our luggage under his hatchback that he has to tie down using the wiper blade as the attachment point up top.  I always find this humorous but it works.  We got on the bus to Kelo about 10:30 in the morning.  

Throughout the bus ride of 8 hours we watched the outside scenery go by and also watch the TV screen up front what showed African comedy, some Saudi music sung by very stoic women, and movies they showed like Delta Force. (Basically Americans killing muslims)  Still makes me feel a bit awkward as I don’t want to be associated with that.  I’m pretty sure Jesus came to save muslims too, and Buddhists, and Jews, agnostics, atheists, and you and me… I.e. everyone!! About 6 hours into the bus ride we stopped at the Bongor bus station.  Walked around about 15 minutes and looked at all the things the local vendors were selling.  To many things to mention, but ill list some: grilled chicken or beef, dates, apples, oranges, carrots, fried crickets, crackers, cookies, sodas, sandwiches, lettuce, onions, gum, sunglasses, belts, bananas, on and on…. The bus started honking it’s horn and we all got back on.  Traveled the last two hours then arrived in Kelo.  We pull off in Kelo and at the little bus station I point out the bags associated with Zach and I and also Dr. Eddie who’s bags hadn’t come a few days ago.  Then the taxi Moto guy finds me and we take all the bags to his motorcycle.  He negotiates the trip with two other motos and they load all our luggage onto two and Zach and I with the moto driver I knew.  It’s a two hour moto ride to get to Bere. About 40 minutes into the ride we realized one moto wasn’t with us.  So we stopped and waited, and waited.  Some passing motos said that he was back there fixing a flat.  Then others said he was going, then others say fixing a flat.  After about an hour of waiting our moto driver decided to go back and see what’s happening.  Apparently the roadside mechanic packed the tube.  He drove a short distance and a flat again.  Second time same thing happened.  The third time the mechanic removed the metal out of the tire when fixing the tube 🙂 then, surprise, it didn’t go flat again.  We made it to Bere about 8:30PM.  So traveling from my house Tuesday afternoon I arrive in Bere Friday night.  Long trip.  I ate supper at a missionaries house and we talked a while and I finally got to bed about 1AM.  I awoke at 5AM- jet lag…

Today was sabbath, the day I go to church (as Jesus did).  I wanted to go to the “mango tree church”  I like it because it’s under a mango tree and has lots of kids.  Well they have a new church building, so it wasn’t quite the same.  I got in the back of the truck with Zach and many others.  Held on to the roll bar and it took about 30 minutes to get there.  As we weave through the village we hear little groups of young children yelling “nasara” (white person) and waving.  I wave back.  Near our destination some run after us and jump on the back bumper to ride the last little bit to the church.  It’s a game to see if they can catch up and jump on- at least it appears like a game to them.

I joined the kids sabbath school singing songs under the mango tree and the adults were in the church.  We sang songs like, Father Abraham, God made the animals, and many more, most of which I knew.  After a talk about Jesus growing up and him being left accidentally in the temple by his parents.  We joined the adults for church.  I translated from French to English for Zach.  Church today was about Abraham and him being a man of faith in God.  And how he had lapses of faith when he went to Egypt calling his wife Sarah his sister and later on doing the same thing with the Philistines.  And how God made Sarah have a child even though she was in her 90’s.  And how God blessed Abraham when he chose to follow God even when God asked him to sacrifice the promised child Isaac.  Then God keeping him from doing that.  Summarized Genesis chapters ?8-15.  Was a thoughtful sermon.  This afternoon we had the potluck with all the missionaries and later spend some time at the river.  Had a great first day.  Tomorrow I plan on rounding with a surgeon and learning the patients, then likely start taking surgical and OB call.  Pray that I will do what each patient I see needs, and that God will show me what that is! 

Be’re’ Chad 2024 #12

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12 Bere 2024

It’s my last day in Bere and we have planned a long day, and it just gets LONGER!!  I start with a number of scheduled cases then have to cancel some scheduled to accommodate emergency after emergency.  I realize it’s Friday and there are no meetings so i go in earlier about 7:30.  I find Phillipe in the OR and ask him when i can start.  He said the kid with the cheek abscess is ready and we should do him early so that he can eat.  So I tell him to put him to sleep and Ill get ready.  he gives him a little Propofol and I lance his cheek and get nothing.  It felt fluctuant and  the dad said pus had been draining out of two small holes.  I go deep and get nothing.  So I probe the holes and they are real superficial.  So I biopsy a large lymph node near by and then close back up the hole I made, suturing it shut.

I run over to the surgical ward and tell the nurse, Emma, Ill try to round with him later, but to go ahead and do dressings… and let me know if there are problems.  He says the emaciated woman that Ive been watching and I wrote about in 11 Bere 2024, is nauseous, so I decide to give her metoclopramide to see if stimulating her bowels will resolve her issues.  Later she’s vomiting and then I chose to operate on her like i previously mentioned in the last Shanksteps..  So that was an emergency later in the day.  So after talking to him I continue operating.

A woman is brought from the emergency room who has an ectopic pregnancy- one that is outside the uterus.  She has the ultrasound report that says so. I ultrasound her and think I see a rib cage outside the uterus.  I don’t really see all the normal features of a fetus so I ask Audrey to come take a look.  So she comes over from maternity.  She looks around and doesn’t find anything but an irregular looking mass outside the uterus that has the appearance of a uterine fibroid.  We’ve heard of pedunculated fibroids that can hang off the uterus, so assume it may be that.  The patient has a negative pregnancy test which goes against an ectopic pregnancy.  She says she has been pregnant 14 months and the baby hasn’t moved the past 4 months.  I open up her abdomen and do not find a abdomen full of blood as is common with presentation of an ectopic.  I find the omentum stuck to a large mass.  slowly I free up the omentum from the mass.  Then as I free up more from behind the mass I see a hand.  Oh this IS a ectopic pregnancy.  As i identify more I find there is a fetus wrapped in omentum.  It’s head is not fully formed, I think if may be anencephalic.  So after getting it out there remained a mass further in the pelvis.  I free this up and it’s the placenta.  The baby was near term and was fed by blood from the omentum.  I’ve read about this being a possibility in the books, but I’ve never seen one.  Very strange!

The next two operations of the day were the two that I discussed in 11 Bere 2024.  One was the intestinal blockage after surgery somewhere else, and the second was a perforation of intestine of a boy after falling on the handlebar of his bicycle.

Next was a guy that the ER had sent over.  When you think of ER you think of a room glowing with light and different patient rooms and doctors and nurses running around taking care of emergencies left and right.  They’re calling other doctors to come and admit patients to different services in the hospital after getting lab work, CT scans, and X-rays.  Am i right?  The ER here is a nurse with two or three nursing students who jot down the patients complaints in the patient’s little medical booklet they keep with them, or they lose it and get a new one when they arrive.  Then the nurse decides what tests to get and what lab-work seems appropriate to them.  So this guy comes in with a huge scrotum that is painful and he has had a hernia a long time.  So the nurse orders a glucose test, malaria test, typhoid test, and sends him to the OR to be evaluated by us.  Well the last one was the appropriate one.  He has a large hernia that makes his scrotum look like a small watermelon.  I’m unable to reduce it (push it back inside).  So he’s next in the OR.  He gets a spinal anesthetic and then I open his groin. I start opening the different layers and it still doesn’t reduce.  Finally I open the hernia sac and see colon in it.  The colon is viable and so I slowly push it back inside.  Once the sac is empty, I separate it from the surrounding structures and then cut it off keeping clamps on the opening.  I then close the sac.  Then I do a tissue repair called a modified Bassini.  Closing the native tissues over the hole.  i don’t use mesh here for two reasons.  We don’t have much and secondly I still worry about wound infections and therefore mesh infections.  It doesn’t seem like there are many recurrences here, and I think part of the reason is that there are no narcotic pain medications, so people feel when they are pulling on the repair and don’t do things they shouldn’t.  We get done and I see that last of the consults that are waiting and then head back to our room.  It’s about 9 PM and I pray that we will have a calm night.  we plan to leave at 7 AM and I don’t want to do an emergency especially around 7AM when we need to leave and the other doctors aren’t quite back yet.  

We sleep for an hour or two and are called by the maternity nurse for a delivering mother who has vaginal bleeding.  Audrey heads in and I know we will have to operate on her so I head in shortly there after.  Audrey is already headed back to get me.  She says there is blood everywhere and the baby is still alive. I call Phillipe and David (anesthetist and circulator).  I see the patient in the bed of the delivery room.  (The delivery room is a room with 5 beds lined up against one wall.  If there are multiple women in labor they lie on the beds all lined up as they suffer.  The nurse may catch one after another like has happened many times.). So back to the woman at hand- she is absolutely covered in blood all over her cloths and there is a widening 4 foot pool of blood on the floor.  WOW!!!! That’s a lot of blood.  I run to the OR and get out two units of blood of her type and stick one under each armpit to start warming them.  I also grab a couple saline bags and run back to maternity.  I ask the nursing students to get the gurney from the OR and start wheeling her over there.  The nurse is getting in another IV line.  I also grabbed the transfusion tubing.  We start pouring in the fluids.  And we get her headed to the OR.  We get her laying on the OR table and stick in the second IV and get the anesthesia monitors connected.  Phillipe and David make it in and the blood is warmed up and Phillipe starts it as I get the OR kit for the C-section ready.  I get the gloves and suture and gauze…all opened on the scrub table.  Phillipe gives her a whiff of Ketamine and I open.  She groans a little but will have no recollection of it.  I go in all with a scalpel as fast as possible.  Through the abdomen and then into the uterus.  I pull out the baby and we hand it off to David.  I scoop out the placenta and start closing the uterus.  I didn’t take the time to find out why she was bleeding, just took care of the placenta so it would stop.  I ask David how it’s going as Im not hearing the baby cry.  I ask if he wants help and he does.  So Audrey scrubs out helps give the baby CPR.  Giving breaths and oxygen and chest compressions.  It takes a couple minutes before the baby’s heart started and started to breath.  She never really cried but moving extremities.  I close the uterus as best I can by myself and finally David scrubs in to help me.  Mom is doing well with three units of blood and baby is alive.  We leave as they start to mop up all the blood all around.  We are grateful to have a last live mom and baby for this trip!!  We sleep for a few hours then get up to start our three day trip home.

Be’re’ Chad 2024 #11

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11 Bere 2024

In the last day at Bere I did two intestinal repairs.  now that’s something often done by general surgeons.  One was a “usual” case and one “unusual”

First with the “usual”.  I was called to see a 10 year old boy who was on pediatrics after a fall on a bicycle.  At first I thought I understood he had fallen from a tree on a bicycle.  Then I saw the tell tale sign of a circle impression on his right abdomen.  A handlebar into the abdomen.  he had a rigid abdomen with peritoneal signs.  So I told them to take him over to the OR and start an IV on him.  He will need to be one of the next ones operated on.  I suspect that he may have pinched a piece of intestine between the handlebar and his spine.  This occurred a couple days ago.

As I open his abdomen i immediately get a lot of stool and pus and free air. I suck out all the stool i can and then wash out his abdomen with a lot of saline.  Once it’s coming out fairly clear, I start looking for the hole in the intestine.  I find it mid-jejunum (small intestine).  He has a hole one side of the piece of small bowel and a hole on the opposite side and a small hematoma in the mesentery to that area.  Definitely a pinched piece of intestine making the hole.  So i freshen up the edges of the holes and then suture them closed.  I do a single interrupted closure, meaning one layer of sutures to close the holes.  It takes about an hour.  Finally the holes are closed and we close up the abdomen.

The other one (unusual) was a woman who i had been watching over the week who presented to Bere about two months after a surgery at another place where she had some surgery where they did something and may had cut adhesions.  The patient and family doesn’t know and it’s not written in her book in a legible way.  They said shes been vomiting and cant keep food down two months.  Now that story makes me feel suspicious.  So i admit her and observe.  I give her nausea medicine and she seems to do better and eats some food.  Her stool is hard and she has firm areas in her abdomen that changes position- like intestine moving.  So I decide to stimulate her bowels with medicine to see if she can pass the stool and if thats causing the problem.  I had done an Xray of her abdomen that didn’t show obstruction but I was a little worried about a partial obstruction.  The surgical ward nurse came to tell me shes was vomiting a lot after this medicine.  It was my last day and I had watched her.  I didn’t wan to leave her for the other surgeon after I’d watched her so long- so I said to bring her to the OR and keep her NPO.  I was worried about operating on her because she was so thin she looked like a starvation person.  Meaning that I wondered if she had enough nutrition to heal a surgery!!  Or would she just leak with an enterocutaneous fistulae and die?  I felt forced to do something…. 

As I cut through her skin I immediately came to fascia.  No fat whatsoever.  She is starving to death!  I entered the abdomen and found dilated small bowel and decompressed small bowel.  Definitely an obstruction.  I started at the top where the dilated bowel was and followed it down.  I found an area of previous resection with that being the transition point between dilated and non-dilated bowel.  So to take out that section or just bypass it.  If I took it out I’d have a huge anastomosis to do and it would take a long time.  If i did a bypass, attaching the one piece to the other I could make it whatever size was needed and leave it at that.  So i did a side to side anastomosis. I cut each piece of intestine and started sewing them together with an opening in between.  This took about an hour.  The anastomosis looked good and as soon as I unclamped the intestine, fluid started going through.  Yay!  I closed her up and we went on to other surgeries.

Now a few days later she is post op day 4 and she is able to eat and shes moving her bowels.    And so is the boy of earlier in this message.  Im so grateful.  Always after an anastomosis of intestines Im not at peace till about a week later when everything is working well and there is no anastomotic leak or problems.  Im glad to hear they are doing well.  Thank you Dr. Jorla for letting me know.

Greg

Be’re’ Chad 2024 #10

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10 Bere 2024

At the end of another long day Audrey is called about 9PM for a mother at maternity what is at term and the nurse says the contractions are to hard and she thinks the belly has changed shape.  The patient is about mid twenties and has had 4 children and none of them living.  Audrey goes into evaluate.  She does an ultrasound and sees a baby with a very slow heart rate- fetal distress.  She needs an emergency C-section.  She calls me and I call the anesthetist and surgical assistant.  The abdomen is an unusual shape, signifying likely uterine rupture.  While Phillipe and David come in we get the patient to the OR and get some blood out of the fridge to start warming it up. We each stick a pack of blood under our armpits to start warming it as we race around the room preparing things.  We start pouring in the fluids as the nurse starts another IV.  A few student nurses from maternity are standing around not knowing what to do.  We have way to many nursing students in the OR each day.  Mostly in the way, however they do provide translation that is useful as someone usually can speak the language of the patient if we ask around to them.  I get the C-section OR pack.  All are wrapped in two layers of cloth and since we have the sterility indicators that I brought in them- I know this pack is sterile.  

Phillipe and David show up and I start scrubbing.  Phillipe is going to use Ketamine because she’s lost blood internally and because it’s faster.  After scrubbing and putting on my cloth gown and sterile gloves, I gown Audrey.  They’ve prepped the patient with betadine.  I go in quickly not taking time for cautery and stopping bleeding.  Its been about 45 minutes since we last ultrasounded the baby.  It’s as fast as it gets here.  I cut through the abdominal wall in a low transverse incision.  Go through the muscles vertically, then down to the uterus.  Release the bladder and push it down out of the way then cut into the uterus. I can tell it has a hematoma on the side and rupture there.  I pull the baby out and it’s floppy an no sign of life.  Audrey takes it off to the side and tries CPR for a while.  I put clamps on the uterus to stop the bleeding and then start closing it.  I can’t get the rupture closed by myself and after trying for a while to get the baby back to life, she gives up and joins me after scrubbing again.  The tear is down the side again and we are able to stop the bleeding and repair the side.  We saved moms life and are sad we didn’t make it to the baby in time, I think we went as fast as possible in this situation.

We go back home to the heat (97 deg) and decompress before getting tired enough to sleep.

Greg

Be’re’ Chad 2024 #9

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9 Bere 2024

I did a prostatectomy yesterday and as I usually do, I put the foley catheter on traction, with the foley bag always being half full and laying over the end of the bed.  So i was called in at 8:30 pm because the guy was crying in pain.  I know that none of the prostatectomy guys like traction, it always hurts.  And of course they are getting the only medications we have for pain here which are Ibuprofen and Tylenol.  So I go in to see him.   They have it off traction and are trying to flush the catheter.  I take over and get red blood with clots out of the foley.  Im really frustrated as it’s not on traction and so it’s bleeding more.  I know if it bleeds to much and isn’t flushed out- then the clots collect in the bladder and then Id have to reoperate and clean out the bladder again. I decide that the next nurse is coming on shift in about 15 minutes.  Im so tired, so rather than hanging around I go home and lay on the concrete floor.  I wake up 3 hours later in a pool of sweat.  I remember that I needed to see the patient so I go back in.  He’s writhing around in pain. His foley is plugged! I unplug it and am glad I went in to see him.  I discuss with this nurse what to do if it plugs and she seems much more attentive than the last nurse.  So I head back and shower and get in bed dripping wet,  It’s still 98 deg in the house when I go to bed.  But I fall right to sleep.

Im awakened at 5 AM with the maternity nurse who says there is a new patient who has a dead baby and has hard contractions and isn’t progressing.  Audrey went in to see that patient and was back soon saying that the patient had a dead baby and had a ruptured uterus.  So I called in Phillipe and David and about an hour or more later we were beginning the surgery.  As I cut into the abdomen with a phanynsteal incision, as soon as I enter the peritoneum- lots of blood.  I feel around and find the dead baby floating around in the abdomen with the placenta.  Again the uterus is torn up the side, just like the one yesterday.  I find the deep spot and put ring clamps all along.  Then I start closing.  I get the uterus closed and then oversew a few bleeding spots.  Audrey is assisting me and we close up the abdomen.  She goes off to check on another patient that has had her first 4 children die during child birth.  I see some consults and she comes back and tells me she wants to do another C-section on this one so she will have a live baby.  They are just ready to put in the spinal of my next patient- so we get that one off the table and get the next C-section going.  

We know the baby is not in distress so we take our time getting into the uterus.  We see a little meconium (baby poop) on the kids face- so there was fetal distress!  He has a nucal cord (umbilical cord around his neck) so I reduce that and pull him out.  He cries immediately- yay! A live baby!  Audrey and I close back up.  It’s about noon when I start my first case that was planned that day.

this woman has had a large abdomen for quite some time.  Ultrasound says it’s a large cyst.  Must be ovarian!  I open her thin protuberant abdomen.  Immediately there is a huge cyst in my view.  I open nearly from the pubis to the xyphoid.  Then im able to pull it up.  It’s about the size of a basketball.  I release omentum from it and then find it’s attached in two places.  I tie off these areas and get to lift it out of the abdomen.  Im guessing about 15lbs.  Her abdomen went from looking pregnant to looking scaphoid.

I go out to do some more consults and I find a guy sent over by the ER because he has a leg infection.  It appears he has drop foot and hasn’t walked for a while.  he says his legs have been infected 2 months and he hasn’t walked for a month because of pain.  I try to figure out where his pain started, what part of his leg.  It takes a lot of questioning as the nursing student translating for me I think is asking something different than what I said.  After about 4 minutes of talking I think it started at his knee then later he had pus coming out in different areas of his leg.  I ask to have him taken into the OR.  I see another couple of the consults as they get him ready with fluid and a spinal anesthetic.  They call me once the spinal has been placed.  The anesthetist walks out of the room shortly there after and is going about 10 minutes.  Where did he go?  He went out.. is the answer.  Out where?  We don’t know.  Rather than getting upset like is my instinct when this happens- i keep my cool and just watch the BP when it cycles and listen to the SAT monitor.  The guy remains stable as he had been given enough preload of fluids.  I start with the knee joint.  I try to pike a needle attached to a syringe in to get a sample of the knee fluid to see if it is obvious pus.  His leg is so swollen I cant seem to get it in the joint, or at least I cant pull anything into the syringe when i think Im in the joint.  But I decide it is suspicious enough that I open the side of the joint beside the patella anyway.  I do get some pus.  So I wash it out with dakins and put in a piece of sterile glove as a drain.   The remainder of the leg is swollen.  So I aim for the draining holes.  I probe each one with a forcep and then open along the direction of the largest part that avoids important structures like names nerves, names arteries, or named veins.  Of course there is bleeding from smaller vessels but packing the abscess sites helps stop that.  After I follow about 7 draining sites and open them, I cant feel or tell of any other place that needs to be opened.  So Ive packed them all then I wrap with elastic bandages.  It’s about 6 PM and I’ve gotten through the consults and surgeries so I head home to eat whatever Longue has made and am content to have a seat and some rest.

Be’re’ Chad 2024 #8

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8 Bere 2024

It’s sabbath and we woke up before dawn to go on a moto hippo run.  Gary was here and had large motorcycles and he wanted to go out early to see if we could see the hippos.  That sounded like a great idea to us.  So Gary, Cherise, Audrey and i went out on motos at 5 AM.  We drove in the dark as the sky started to lighten.  We went in the direction of Kelo to the area of the lake.  After about ?20 minutes of riding we arrived at the lake.  They weren’t visible so we rode along the side of the lake through dry grass and over animal paths to the water.  The grass was about 2 feet tall.  After about 5 minutes by the lake we stopped to stand at the edge and see the sun come up.  It was a pretty sunrise, not the bright orange ball that sometimes comes up but was beautiful anyway.  Various birds were flying by in formation.  Others as individuals.  Swallows swooped down skimming along the surface and drinking the water as they flew.   A king fisher dove in and came up with a fish.  After watching the sun come up and seeing the reflection on the water we continued on further along the lake.  Finally we came to an area that couldn’t be crossed easily.  So we decided to turn around.  We notice that the moto that Gary is driving has a flat tire.  So he limps home and Cherise gets on with us.  We make it back and have some breakfast.  Then we go and join Gary and other at church in Bendele.  We sit through a hot sabbath school and then just as church is starting Im called to the hospital for a C-section.  

This lady presented this morning with a few contractions.  She was given Cytotec by the nurse and then her contractions started in earnest.   About mid morning she was fully dilated and she continued with hard contractions.  Then she had more abdominal pain and the uterus changed and became disfigured.  The nurse was worried about uterine rupture and so called us.  Audrey agreed and we took her to the OR.  She was in a fair amount of pain.  Phillipe the anesthetist got blood warming to give her.  He preloaded her with IV fluids and we started.  On ruptured uteruses I make a vertical incision.  As i got into the abdomen there was a lot of blood.  I saw a large hematoma on the left of the uterus.  As I felt higher I felt an arm or leg.  I pulled on the appendage and found it to be a leg.  The whole baby and placenta were outside the uterus, obviously dead.  I took them out as one unit and then pulled up the uterus to explore where the rupture was.  It was all along the left side of the uterus.  This was an odd location, as usually I see it low and in front.  I put clamps along the opening and reached for the bottom and started suturing.  I found a couple different areas where the uterine artery or its branches were bleeding.  After tying off a number of areas, the bleeding finally stopped.  Phillipe had kept up with the blood loss and she received a total of 4 units blood.  So the patient did well in the end and will need to have a planned C-section at each subsequent delivery.                                                                             

It’s about 111 deg today and i finally get to demonstrate the misting system to the missionaries in the public area where we eat lunch.  It works quite well.  The pump gets real hot so I only run it in about 1/2 hour segments.  But it works and I’m glad to have brought all the stuff for it.  Later in the evening we have everyone over to our place and we have a game night.  It is fun and we learn a new game as well.  it’s 97 in our house as we go to sleep- tough to sleep…

Be’re’ Chad 2024 #7

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7 bere 2024

When is it unwise to do an operation.  If I do a challenging one and succeed am I good, or lucky, or blessed by God.   If I do a challenging operation and hurt someone am I bad, unlucky, cursed, negligent…

I saw a woman in the last few days that was having a lot of abdominal pain.  She had some varices (enlarged serpigenous veins) on her abdomen from an inch above her umbilicus up to nearly her zyphoid.  She said these were very painful.  In the bottom area I had the feel that there may be a small hernia and she definitely was more tender there.  I got a small fluid wave on tapping so I think she has ascites too.  So by deduction she also has cirrhosis.  This can cause a back up of the usual venous drainage and make other veins, like the abdominal wall, dilate and take up extra flow.  So this becomes a high risk person to operate on and a risk of getting into bleeding that is difficult to stop and ultimately could kill her.  I’m hesitant.  But if she is having pain primarily at a small hernia I can fix that and try to take out these veins too.  So through translation of a student nurse I tell her about all this and that she could die from the operation.  She wants to proceed, that’s why she came to the hospital.  I think i can safely take it out so I book her.  

So today Im looking at her on the OR table and thinking, what was I thinking the other day.  My courage is smaller today.  I tell Phillipe the anesthetist to warm up blood to give her if we get into a lot of bleeding.  I choose an assistant who is very good at assisting and will be a great help if I get into lots of bleeding.  I scrub at the OR sink with the bar of soap on the side counter and then put on my sterile cloth gown and sterile gloves.  I incise lower than all this mess and come up slowly underneath where I can see different structures bettter.  I slowly dissect around one side and see large vein after another.  There is slight bleeding but it is a small vein outside the vericosities.  As I slowly go up and peel this mass of veins up towards me, I find a small perforating vein from the inside.  I tie it three times and then divide it.  The whole rest of the veins go flat.  Wow, that was all fed by one smaller vessel!  Now I have more courage, I work faster now and find a second perforator near the top, likely the outfllow vessel.  I’m able to take off the whole thing and loose less than 1ml blood.  What do I feel- relief, gratitude to God for helping me not cause bleeding, and more relief!  Should I have done the surgery, I don’t know.  One day I had the courage, today i didn’t but did it anyway.  Thank you Lord God for helping me do it well without harming her.

This was Auds birthday too and she adds the following.

Thanks everyone for the wonderful birthday wishes. It was awesome to get them over here in hot, dusty Chad. 

My day ended up to be fantastic. I started off the day feeling just a tad sorry for myself but decided to have a good day anyway. People started wishing me a “Happy Birthday” right off. I rounded on the maternity ward and it went smoothly. I’m really enjoying the nurses that I’m working with which makes the mornings more fun. 

I came back to my place and had a bite to eat which was delicious local food. Several people stopped by to eat and chat. 

Be’re’ Chad 2024 #6

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6 bere 2024

It’s my least favorite thing here in Bere, neck abscesses from dental cavity infections.  I am sitting in the worship area which is a metal awning outside the ER.  Someone is giving a worship thought to the hospital workers in French and its translated into Nangere, the local language.  Im distracted by chickens walking by and pecking at something on the ground next to me.  There is a muslim man sitting in the front row waiting for the ER to open and just stayed there when worship started.  Another younger muslim guy walked up and starts talking to him, someone asks him to be quiet as we are having a meeting.  Then one of the nurses that asked me to help him with his schooling last week, walks up to me and says his uncle isn’t doing well and would i come see him.  I had admitted the uncle the day before.  He had swelling of his chin and neck and I did an ultrasound and didn’t see anything to be drained. It had be the rotten tooth cause.  He couldn’t open his mouth for me to see anything in it (trismus).  So I treated him with IV antibiotics.  I go over to where he is and his family is carrying him from under the tree to his bed.  He is sitting rocking back and forth and looking weaker and weaker.  They get a sat monitor and his sat is 47.  He is dying… I tell them to carry him to the OR NOW.  they grab him and I run for the OR.  I get the stuff and as soon as he’s on the table I try to intubate him.  I don’t expect to be able to open his mouth at all and also think of an emergency trach.  But I try, and it opens some.  My mac intubation blade is to small.  I find another and try again.  I intubate him and we start CPR.  The nursing student stays in the room and the other family members leave.  I pray for God to save him as I do chest compressions once the anesthetist is there to bag him.  I switch off with Audrey and a couple of OR guys.  We do chest compressions and bag him for more than 30minutes.  His pupils are fixed and dilated.  We stop.  He is still dead..

Another of my least favorite is a similar issue of a woman who was admitted over the weekend.  I found her on rounds Sunday morning.  She had an ace bandage around her neck that was wet with pus and her whole upper chest area was red and was like a big fluid pocket- pus!  So I told her to not eat or drink anything and she needed to go to the OR.  I wanted to sedate her but when in the OR i realized she couldn’t open her mouth but about a quarter of an inch.  So I cant sedate her and she will have to be done with local anesthetic.   This never works well, but is what is necessary.  The OR staff doesn’t want her in the OR because she smells awful, like dead flesh. (Think decaying animal).  So we do it on a bed in the consultation room.  She is sitting leaning against another woman.  I put betadine on, I know is useless, and then inject lidocaine in a few areas.  This is painful and she pushes me away.  She says she is going to die.  I think to myself that she probably will.  I incise the different areas that I injected and cups of pus flow out.  There is a dead patch of skin on her neck and I cut that off with scissors.  I realize that when she coughs a well of pus flows up from behind her sternum.  I see dark black tissue bubble up too.  I grab it with a forcep and pull up a huge piece of dead tissue from behind the sternum.  I grab the Dakins bottle (dilute bleach) and drown the area with it.  More pus flows up and out from behind the sternum.  The guy standing by helping hold her and the woman holding her, both nearly pass out.  The stench is awful.  im glad we are not in the confined room of the OR.  After there is pus everywhere and I cant smell anything but dead smell, im done.  I’ve pack everything I can and I go to wash off all my exposed skin I can.  I don’t think i got it on my skin, but I feel very dirty…

So i hate that the people here have no available dental care or way of getting to it.  And even when they have rotten teeth they often want to keep them because they’re the only teeth they will ever have.  We, in the first world countries, are very blessed to have access to care many other people in the world have no access to at all.

God help me to demonstrate Your love to these suffering people!

Bere Chad. Miah Davis

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Dear reader,

My name is Miah Davis. I am 17 years old, and am graduating high school in June of 2024. I shall be attending Walla Walla University to take either medical or nursing prerequisites, and aspire to be either a CRNA or anesthesiologist someday. 

I was granted an opportunity to go to Bèrè, Chad as part of a medical mission trip team. I embarked on the journey with no expectations really, but I gradually became astonished by the rusticity of Bèrè Adventist Hospital. When I first walked into the various wards—maternity, pediatrics, adult, surgical—the simple spaces were not a surprise. It was not until I went on rounds and spent many hours in the operating room (OR) over the next few days that I realized two things: 1) how lucky I, as an American, am to live in a country with such advanced health care and 2) how great of a God I believe in. 

I have heard many people in the US complain about the cost of healthcare, whether that be the cost of birthing in a hospital, attaining cancer treatment, or getting insulin needed to survive with diabetes. I do agree that such things are dreadfully overpriced in the US, but I have now seen a place without them. In the US, there is consistent pre-natal care and multiple options for a safe birth, In Bèrè, birthing mothers can only be monitored, given epidurals, and taken in for c-sections. Sometimes the beds the women give birth on break during labor. Cancer treatment is surgery, and if surgery cannot get rid of it, there is nothing more the doctors can do. Diabetics are given a syringe and enough insulin to last a month. At the end of the month, the individual comes for a refill and a replacement of the now very dull syringe needle. Therefore, despite the hardships, I think that US residents should be more grateful for the medical technology it has. 

In the US, sanitation and privacy are highly valued. The Bèrè wards, excluding the OR, contain beds lining the walls, no privacy anywhere. There are curtains for doors, and concrete floors. Doctors and nurses do most of the physical exams without gloves to preserve the limited supply of gloves for the cases that truly require them. 

The Bèrè OR is the most basic an OR can be. Patients have consults in the OR waiting area, and do post-surgery stuff in a partially partitioned off space behind the waiting area. The two operating rooms are the two rooms in the entire hospital compound to have air conditioning despite the extreme heat (at least to us Americans). Unlike the US OR’s and their seamless floors and positive pressure, the OR floor not only has atmospheric pressure and seams, but there are also holes and bloodstains on the floor. The anesthesia machine only relays blood pressure and heart rate. It does not show the telemetry or the information from the cardiac monitor. There are often up to 10 aspiring nurses crowded into the room during an operation trying to learn. IV’s and syringes are reused, and fluid is often transferred from non-sanitary to sanitary syringes. Glove fingers are used as drainage capsules. Surgeons from the US will often ask for a certain tool only to be told that the hospital does not have one. Scrubbing down for surgeries is taken very seriously, but I am sure many US doctors would still gasp in horror. 

I have seen many patients here in Bèrè with afflictions—typhoid, abscesses from dental infections, malaria, etc—that are virtually non existent in the US. I have been able to observe, and assist in surgeries that teach me so much about the human anatomy. I have experienced what it is like to not have advanced medicine like the US does. Most of all, I have seen the human body and its interworking parts in ways that only further solidify my belief in God Our Creator. The body heals wounds, protects against internal foreign objects, and recovers from surgical procedures. In my mind, this can not be in accident. It is a beautiful masterpiece of God’s craftsmanship. 

This trip has been life changing. The people here—locals, missionaries, and OR staff—have found their way into my heart, and I am so grateful that I have the chance to spend two weeks in Bèrè, Chad. 

Sincerely,

Miah Davis

Bere Chad 2024 #5

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The boy is about 22 yo and I saw him yesterday afternoon and they were thinking of adding him on since we appeared to be done a little early.  He had a hemangioma (mass of large blood vessels) on his inner thing that was about 4×10 inches.  Some of the blood vessels were as large as my fingers.  i said he should be the first case in the morning as it could be very hard to do.  So this morning is the day.  I ask him about how long this has been there as he lays on the OR table.  It been present since birth and has slowly grown larger and larger.  He says it hurts.  I can imagine if it grew quickly it would hurt but not at a slow progression.  That matter not- Im taking it off today.  I scrub with one of the local docs who is doing surgery learning for 6 months.  I start cutting around it and right away get into a few vessels.  This gets my heart rate going.  im trying to explain how he can help me and im finding it challenging.  He isn’t really a good assistant.  I need someone who knows what they’re doing.  Dr. Steven comes in to check on me and I ask him to help.  Then it goes much better.  We are able to go back and forth whichever of us has an easier angle to dissect and the other of us cuts with cautery or ties a small vessel.  We slowly peel it up including the underlying fascia or just above that.  We finally define that it only had two small feeding veins.  These were tied and it is off.  Now how to close.  I pull on the skin and realize I may be able to get it together with a lot of tension.  So I start in the middle with a stitch, then in-between with more stitches.  Until with about 30 stitches it all comes together.  I’m glad to have gotten it together.

I do another surgery and then the third one is interesting too.  This kid of about 8, had an infection going on in his leg for the past 8 months.  It was painful and it had some draining pus that came out in different areas.  The X-ray showed osteomyelitis (infected bone).  This looked like a huge fat bone in the leg at least twice the size of a normal tibia bone.  So i took him to the OR to drain it.  I cut down to the involucrum (new bone growth around a dead piece of bone (sequestrum).  I follow one of the holes that has pus coming out of it and find the hole in the involucrum.  I use a rongur to eat the hole away till it’s very wide.  I probe inside the bone in both directions.  I get a lot of granulation tissue but not any dead bone.  I follow another in the upper tibia and do the same thing.  In that one I find a small piece of bone.  It feels slightly mobile.  I wiggle and try to pull on it.  I think this is likely the sequestrum.  I bite it in half with the rongur.  Then one end I grab and am able to wiggle and twist it free.  Yep it’s a sequestrum in the dead bone inside.  The other end slides up into the top of the tibia.  I use a curette and try to swipe it out.  Finally i get a hold of it.  It doesn’t want to come out, but with force it does.  So at least two chunks of dead bone, the source of all this pus is out!  i hope there isn’t more, but I can’f find more so i pack the holes down the center of the marrow after washing it with dilute bleach solution.  He will likely be here months with packing his legs.

Bere Chad 2024 #4

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Today was a “normal” day.  It rained heavily last night and it is finally cooler and I slept finally after about 3 days of minimal sleep.  I get up about 7:30 and realize Ive already missed worship.  I have my own usual morning worship- consisting of reading from the Bible, praying to God.  I head in to see what’s happening and if any patients are ready to have their operation done.  I know there are at least two hysterectomies on the schedule and the others on the list didn’t register so I guess they weren’t worrisome to me.  The first lady is older and has a painful mass in her lower abdomen.  I examine her belly as shes on the operating table, IV in place.  Her head is covered over the top and her abdomen and chest are exposed and she has some shorts on.  So she feels not well covered but acceptably covered considering shes here.  Womens chest and abdomens aren’t usually terribly private.  A child will pull a breast out of their moms shirt and start sucking.  So i palpate and Im told shes here for a hysterectomy.  She doesn’t want any more children.  I look at her book and it says she would like to keep her uterus if possible but wants the mass gone.  As it is almost up to her umbilicus I know Ill do a vertical incision.

At her operation in a few minutes after seeing some consults outside, I incise her abdomen up and down.   Then into the abdomen we see the uterus is huge.  I feel around and cant feel any uterine fibroids.  So I guess I cant do a fibroidectomy, so a hysterectomy it is.  Dr Steven and I are working together.  So he works down one side and I work down the other.  We get into some bleeding that we are able to control and we get down to the cervix and then take out the uterus.   It looks about the size of a small bowling ball.  Im sure she will feel better with this out.  There is definitely more space in her abdomen!

Next is a younger woman in her 30s who has an ovarian tumor.  She definitely wants more children.  She has had 4 and and only 2 are living, and hasn’t had any for the last 4 years.  Womens value in the local cultures are very tied to how many children they have.  So i want to take the ovary, both to help her live longer and so that she still has a chance to have children like she wants.  I palpate her abdomen and then get my butterfly to see it for myself.  Apparently there was some confusion wether the mass was in the ovary or uterus.  I see a large mass and then a small uterus behind.  I open her thin abdomen and start exploring with my fingers.  It seems the intestines are stuck to the mass all over.  This is a bad sign, more likely to be cancerous.   I slowly dissect some off an Dr Steven dissects other parts off.  Then we get into a cystic area somewhere deep inside.  A dark bloody fluid comes out. We dissect more and find that we end up getting two large cysts.  Then there is a large mass below that is really stuck to the rectum and bladder and i feel we cannot get down to the uterus.  We are bleeding and leaving cyst wall stuck to intestine.  So if this is cancer, there is definitely not a cure here.  And with us dissecting the bladder and rectum the chance of injuring these and blood vessels is very high.  So i tell Dr Steven i think its time to stop and get out, that we are not helping any more.  After assessing it again he agrees and we drain and start closing.  We are both bummed that we couldn’t get it out safely.  But Im also glad to not be threatening her lift TODAY.

I go out and see some more surgical consults as they get the next US proportioned guy ready.  Everyone here is very thin, and this guy isn’t.  He has a mass on the back of his leg, and it is likely a sarcoma.  These need to be removed with a good margin of normal tissue around them.  The anesthetist Phillipe, puts in the spinal and after a number of minutes have past we get 8 people around him to turn him on his side.  His big belly starts to drape off the side of the narrow OR table, so we reposition and prop him so that he is safely on his side and then we are able to work on the back of his lower leg.  I want a centimeter of normal tissue around the tumor.  Now this sounds easy, just measure and cut 1cm further.  Yes that is easy at the skin, once you are deeper it’s harder to be certain that your are one cm away.  To be certain you’d have to cut down to it and then go back a cm to make sure you have it.  But that violates the purpose of staying away that far in being beyond tumor that is microscopic spread.  So it ends up being a feel of how much tissue is between my finger and the cancer.  So i end up cutting a large hole out of the back of his leg down into the muscle.  So after removing it, the spot is about the size of half an orange.  There is not near enough laxity of the surrounding skin to get it any where near back together.  So I can skin graft it or leave it open.  Skin grafting covers this large divot with skin and it will forever look like a large divot.  Or I can leave it open and in about 3 months it will be flat and covered with skin.  So I leave a large hole in the back of his leg for Gods design to take over and heal it.

The next guy I operate on is the guy I referenced a couple days ago that has epilepsy and fell in the fire and burned his toes on his left foot, well the three middle ones, and also burned the top/side of his head.  He has exposed skull that will not heal and cannot be skin grafted, and three toes that are floppy and have bone sticking out of one.  So in the operating room I slowly remove the three toes that need to come off and then I get to the interesting part, the skull.  There is a patch of about 3x5inches that is exposed.  Since this won’t heal the solution is to remove the outer table of the skull and leave the marrow to granulate.  So after prepping the head I get the drill and drill multiple small holes in the outer skull.  Then I use a rongour to nibble off the bone between the holes.  One hole drills quickly and a get a constant squirt of dark blood coming out about 5 inches.  Oh no, did I hit the cavernous sinus, a large vein just above the brain?  I hold pressure for a few minutes and every time i let go the same stream is there.  Dr. Steven has the idea of taking the bone shavings and shove them into the hole, so I do that and we hold pressure and continue work.  This eventually works and we finish up removing the outer skull.  Later that night I check on him before going to bed and and he is not bleeding and he is laying flat and i get him with head up like I want and head to bed.

It’s been a good interesting day.

Bere Chad #3

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Bere 2024 #3

Warning graphic!!

Ohhh, Noooo!  I walk into the preop/recovery room and Dr. Steven is looking at a guy laying on his stomach.  It appears like the mans anus exploded!  what happpenneddd?  He was riding a bike yesterday when he fell of and the pedal went into his anus.  It looks aweful with loose tissue hanging all over.  he has a urine catheter that has blood in it.  I see Dr. Stevens examination and its clear there are more than one hole and its kind of difficult to see what is actually the anus into the rectum.  So we decide to do the hystorectomy case that is already in the OR ready then we will do this guy.

The hystorectomy is the third case of the day.  We did a mastecomy first on a lady with inflammatory breast cancer which is considered pallatative- not for cure but to give her a better life for a little while.  I was able to remove the breast and get some enlarged lymph nodes out of her axilla (arm pit).  It was a bit snug getting her skin back together, but was able to do it.  And i left a piece of glove at the bottom to come out as a drain.  

The next lady had a mass in the pelvis that a previous doctor had thought was uterine in nature.  So we took her to the operating room to attempt to remove it.  As I palpated her abdomen it seemed to be about 10 by 12 inches in size and didn’t want to move around when i pushed on it.  So i imagined it was fixed to surrounding structures.  After she has her spinal anesthetic placed by the anesthetist she is laid down and her abdomen is prepped.  Next I get scrubbed and put on the cloth gown and my sterile gloves.  I put the cloth drapes on the patient and we begin.  After we pray for our patient I make a vertical abdominal incision.  I go through the skin, then a tiny layer of fat, then fascia, then into the peritoneum (inner layer of abdomen).   Next i see intestines and after sweeping them to the side with my fingers, I feel the mass. It appears cystic and it is stuck all along the right side.  i can feel around the back side and it seems there is space behind near the rectum.  Slowly I make an incision along the right side and slowly make it down to where the iliac artery and vein are.  I find there seems to be two main cysts.  Im able to slowly go inferior to the cyst and the later and find the two main cysts off in my hands.  Below that is the uterus that looks fine and the left ovary is normal.  So I close up the fascia, and skin and she goes out to the recovery room.

Next is the guy with the bike pedal to the rear end.  He gets a spinal anesthetic after enough IV fluids were given.  Then he’s put up in stirupps flexing at the hip so we have a good view of the anus.  It really does look like an M80 went off inside.  I swipe poop out of the way and spray down the hole with Dakins (dilute bleach) solution. As I look around the anus, I realize there’s a hole anterior to the anus and then realize that the hole is between the prostate and the rectum. The prostate normally is directly next to the rectum. How did he get a hole between two small structures the don’t come apart easily.  As I evaluate the rectum it appears intact.  I think a diverting ostomy would be best, but after discussion with the doc that’s always here, decide to not do that yet.  An ostomy is hard to have here as there are minimal ostomy supplies available so no real seal on the abdomen.  I have patients at home that will give me supplies, but it always seems there are more important things to take in my ?6 pieces of luggage.  I decide to leave a large drain deep in the hole and suture it out to the skin.  Then I excise the dead tissue and suture skin back to the anus- or whats left of it.  I sincerely doubt he will have any continence, but then again, there did seem to be a little anal tone left.  I had warned the patient before the surgery that I thought he may be incontinent after this accident, forever.  

i go out to the preop/postop room and start seeing the different surgical and medical consults that are there.  A young kid with a vascular mass on his inner thigh, a kid with enlarged cervical nodes, an old woman with abdominal pain going on 3 years, a 30yo man with an abdominal mass that fluctuates in size and i think i see a mass on ultrasound, an old guy with eye itchiness and a cornea that is completely whited out…. After about 10-15 pateints i head towards home and make it about 20 feet.

The nurse from maternity sees me walk by and says “doc I was just going to look for you” Well it was said in French…. So there is a woman who has just arrive with her 4th pregnancy at about 8 months and shes having vaginal bleeding.  The babies heart rate is normal, but blood and clots continue to come out.  She’s not in labor and is at one centimeter cervix dilation.  They just are drawing a hemoglobin level and getting an IV going.  I do a bedside ultrasound with my Butterfly (small ultrasound that i attach to my iphone).  I find the placenta appears intact and not covering the cervix and babies heart rate is good.  I decide to go get some advise from my wife and another nurse here.  I find them painting a house in preparation for a doctor that is moving here soon.  After their advise I go get some supper of rice and beans and then go back to see what the hemoglobin and results are.  She continues to have bleeding.  So i decide to do a C-section.  I try to call the two guys back to the OR.  I cant get either one.  So the nurse goes to use the  “hospital phone”.  It has no cell credit so they cant make calls either…. I ask the maternity nurse to do something or send someone.  Normally I’d be quite mad by now, but I made an internal pact to push gently when encountering problems here this time and let people make poor choices if they make them.  So i sit for about 45 minutes before the scrub tech shows up.  Then he tells me he also does anesthesia now if I can find someone else to assist me.  So I go find Audrey and ask her to assist.  She is willing and eventually we start. I make a low pfannenstiel incision (bikini) and go down to the muscles.  I divide them along the middle and open to the uterus.  I make a low across incision on the uterus and get immediately quite a bit of blood.  OHhh, placenta abruption (the placenta separating from the uterus and it bleeds in between).  I find the bulging sac of amniotic fluid and open it.  Gush, I feel the blood and amniotic fluid run over the front of me and I feel the wetness through my gown from my belly button to about mid thigh.  I don’t like that feeling!  That’s the side effects of cloth gowns- not impervious at all!  I pull out the babies head and suck out the nose and mouth.  Then pull the rest of the kid out.  She starts to cry as we cut the umbilical cord.  Yay!! A live baby!  So many come so late that we doctors usually see the worse cases and baby deaths.  The normal deliveries are done by the oncall nurse.  I pass off the baby to the nurse near by.  Audrey and I then close the uterus and then the abdomen.  Mom and baby are doing well.  I head home to slow down and shower and get to bed late.  It was a long but good day

.

Shanksteps Bere 2024 #2

Greg Greg No Comments

We

We are back in Bere, Chad. It is the HOT season. Our room is about 95 to 97deg F in the
evening. Im able to fall asleep for about 2 hours then Im awake again, hot and jetlagged. I lay
there till morning. I get up and all I want is cold water. It’s a choice. We have a refridgerator in
the place we’re staying, but the more water or things we put in it the hotter the room it’s in
gets, as expected. So its a tradeoff. Denae and Steven are doing a very difficult surgery in the
morning before she leaves. It’s a enterocutaneous fistulae (connection of the intestine to the
abdominal wall that makes stool to leak out a hole onto the belly). As they work on that I go
and make rounds. Emma, the surgical ward nurse, is knowledgeable about their different
reasons for surgery and rounds go fairly quickly. I look at all the wounds that are granulating
and change the dressings. One dressing stands out: This guy of about thirty has seizures and
during a seizure fell in the fire and burned his foot and head. I have yet to ask him what
contortion allowed this to occur! But he came in a couple weeks ago with three toes burned
and his head charred. After taking off his dressings i see that the three toes are super floppy,
almost like they don’t have any bones in them?? One has a bone because it is sticking out the
end of his toe. As I take off his scalp dressing I see that he has good granulation around the
outside and a patch of about 2x4inches of exposed skull. I know that skin grafting doesn’t
work on a bone, so this will need special attention. I see the patients with vessicovaginal
fistulaes that Dr. Denae has operated on and they are in various stages of their 4 weeks with a
urine catheter. Some have been “discharged” to the outside to save bed space for other
patients, and they come in to be seen while rounds are made. others have had hystorectomy,
hernia repair, hydrocele- that ended up being a hernia stuck to a testicle and they had to take
the testicle (orchiectomy). I see a boy with a humerus fracture that he got climbing in a tree
and falling out of it. Thats how most of the children break bones, climbing in a mango tree to
get mangos and falling to the ground.
I head back to “my” house, which by the way is the place I’ve stayed in before. I think it’s the
place James and Sarah Appel first built when they started building stuff in Bere. I unpack
some things and then go and check how things are going in the OR. i do some other surgery –
which i don’t remember now. Then we get done earlier since its a Friday and we like to be out
for Sabbath if possible. We really value Sabbath rest as Jesus observed it. Im able to visit with
old friends (missionaries) and it’s a nice evening.
Im called in to see 4 accident patients. The nurse says one has an open knee and the others
with broken arms, but not open. They were on motorcycles that hit one another. I remember
that most patients once they’ve been diagnosed with a fracture, want to be treated by the
traditional bone healer. So i tell him, whoever wants me to treat them, have them stay. if they
want the bone healer they can go. So when i get in there to see them, only the guy with the
open knee fracture is left. So I look and all is see is pieces of his patella (knee cap) sticking out
at odd angles. As i touch it pieces come off in my hand. Dirt and sand is everywhere. I ask for
an X-ray, but the nurse tells me the person lives to far away and phones are not working. So i
tell them to send someone to get him and someone to get the OR crew of Philipe and David.
Only David comes in. But the guy who does the sterilization of instruments says he can help.
So I go to the OR after waiting about .1.5 hours to get ahold of the right people without
success. In the OR i help the assistant gown up as I don’t think he really knows about sterility.
Not that this knee is sterile- it has dirt and sand in it. I find there is no identifiable knee cap. i
see a piece of the end of the femur chipped off and no other identifiable structures. I open it
up more and more and still cant identify any remaining structures. So i wash it out and close
the skin and plan on an Xray tomorrow. To see if that gives me any more clarity as to what can
be done. I head home.
i shower and get into bed dripping wet. I sleep for maybe an hour then lay awake most of the
night tossing and turning. it’s still hot!!(In the next day or so, i am informed in the operating room that this guy wants to go home. And
he signs out against medical advise)

#1 Bere 2024

Greg Greg No Comments

Shanksteps Bere 2024

We are back in Bere, Chad. It is the HOT season. Our room is about 95 to 97deg F in the

evening. Im able to fall asleep for about 2 hours then Im awake again, hot and jetlagged. I lay

there till morning. I get up and all I want is cold water. It’s a choice. We have a refridgerator in

the place we’re staying, but the more water or things we put in it the hotter the room it’s in

gets, as expected. So its a tradeoff. Denae and Steven are doing a very difficult surgery in the

morning before she leaves. It’s a enterocutaneous fistulae (connection of the intestine to the

abdominal wall that makes stool to leak out a hole onto the belly). As they work on that I go

and make rounds. Emma, the surgical ward nurse, is knowledgeable about their different

reasons for surgery and rounds go fairly quickly. I look at all the wounds that are granulating

and change the dressings. One dressing stands out: This guy of about thirty has seizures and

during a seizure fell in the fire and burned his foot and head. I have yet to ask him what

contortion allowed this to occur! But he came in a couple weeks ago with three toes burned

and his head charred. After taking off his dressings i see that the three toes are super floppy,

almost like they don’t have any bones in them?? One has a bone because it is sticking out the

end of his toe. As I take off his scalp dressing I see that he has good granulation around the

outside and a patch of about 2x4inches of exposed skull. I know that skin grafting doesn’t

work on a bone, so this will need special attention. I see the patients with vessicovaginal

fistulaes that Dr. Denae has operated on and they are in various stages of their 4 weeks with a

urine catheter. Some have been “discharged” to the outside to save bed space for other

patients, and they come in to be seen while rounds are made. others have had hystorectomy,

hernia repair, hydrocele- that ended up being a hernia stuck to a testicle and they had to take

the testicle (orchiectomy). I see a boy with a humerus fracture that he got climbing in a tree

and falling out of it. Thats how most of the children break bones, climbing in a mango tree to

get mangos and falling to the ground.

I head back to “my” house, which by the way is the place I’ve stayed in before. I think it’s the

place James and Sarah Appel first built when they started building stuff in Bere. I unpack

some things and then go and check how things are going in the OR. i do some other surgery –

which i don’t remember now. Then we get done earlier since its a Friday and we like to be out

for Sabbath if possible. We really value Sabbath rest as Jesus observed it. Im able to visit with

old friends (missionaries) and it’s a nice evening.

Im called in to see 4 accident patients. The nurse says one has an open knee and the others

with broken arms, but not open. They were on motorcycles that hit one another. I remember

that most patients once they’ve been diagnosed with a fracture, want to be treated by the

traditional bone healer. So i tell him, whoever wants me to treat them, have them stay. if they

want the bone healer they can go. So when i get in there to see them, only the guy with the

open knee fracture is left. So I look and all is see is pieces of his patella (knee cap) sticking out

at odd angles. As i touch it pieces come off in my hand. Dirt and sand is everywhere. I ask for

an X-ray, but the nurse tells me the person lives to far away and phones are not working. So i

tell them to send someone to get him and someone to get the OR crew of Philipe and David.

Only David comes in. But the guy who does the sterilization of instruments says he can help.

So I go to the OR after waiting about .1.5 hours to get ahold of the right people without

success. In the OR i help the assistant gown up as I don’t think he really knows about sterility.

Not that this knee is sterile- it has dirt and sand in it. I find there is no identifiable knee cap. i

see a piece of the end of the femur chipped off and no other identifiable structures. I open it

up more and more and still cant identify any remaining structures. So i wash it out and close

the skin and plan on an Xray tomorrow. To see if that gives me any more clarity as to what can

be done. I head home.

i shower and get into bed dripping wet. I sleep for maybe an hour then lay awake most of the

night tossing and turning. it’s still hot!!(In the next day or so, i am informed in the operating room that this guy wants to go home. And

he signs out against medical advise)

Shanksteps Bere April #12 with pictures

Greg Greg No Comments

Shanksteps Bere April #12 with pictures
I go in for the last day at Bere Hospital before I leave.  Went to morning worship then back to my room to prepare stuff while they have another meeting.  When I go back in I do rounds with Abouna, a nurse who does quite a number of surgeries as he’s been trained.  He’s quite intelligent.  I do rounds with him so that he knows what I plan for each of my patients and can tell the next surgeon when he comes next week.
The first patient is ready, he’s an old tall Arab guy with a large prostate on ultrasound and can’t pee.  I start to cut his abdomen and though the nurse said he was ready he feels it!  So I wait till he gets some ketamine before I continue. I make a phanynsteal incision, cutting down through the skin and fascia, split muscles along the midline and then spread above the bladder sweeping the peritoneum and intestines up and away from the bladder.  I open the bladder and suck out all the liquid we’ve put in the bladder to distend it.  I feel inside and feel a huge prostate.  Hmmm, is this cancerous?  I don’t feel nodules, but it is large.  Slowly I break the anterior prostate and gradually shell it out with different fingers.  As each one gets tired, I use a different finger.  Usually my right index and middle fingers. I have to make my incision in the bladder a little larger as it won’t come out of my original size incision.  After removing it, I sew up the back wall down low where most of the bleeding occurs.  Blood is constantly welling up and it’s hard to see.  Eventually with the stitching it slows down.  I put a new foley in and inflate the balloon.  I check to find that both ureters are still putting out urine and I hadn’t caught either one in my stitching.  They are working well, so I close the bladder in two layers like usual.  I leave a piece of sterile glove as a drain and close up the rest of the layers, irrigating at each layer.  We take him out to the “recovery room” and bring the family in to show them how to take care of the bladder irrigation.  It’s sad that I feel more confidence in the family doing well with the irrigation than the nurses.  But the families here are used to caring for their patient and they’re invested.  Once they understand what I want them to do they usually do it.  It just takes repeated translations to tell them.  And I do it differently than Dr. Denae, leaving the foley on tension, so it’s a learning curve for the nurses too.  Once I think the family understands, I see some consults about a leg mass, neck mass, infertility, a hernia, Then go into the next surgery that’s ready.
The next was an old lady with a black dead foot.  Yesterday when I saw it, it was dry gangrene, dead and shriveled black without an odor.  Today the whole pre-op area smells like dead with pus! Wet gangrene.  She is taken back and a spinal anesthetic done.  Her below knee amputation goes well.  There isn’t as much blood flow as normal so I wonder if she will heal this amputation site.  I do it with a nursing student as Abouna had to go to the government office because he’s involved in some sort of land dispute.  They call him and say come now, so he leaves work and goes and deals with it.  A few hours later he’s back at work.  The student helping me is helpful, but I have to direct him quite a bit on what to do.
I see some more consults, and then there is a older woman with a hernia in her central abdomen about the size of a foot ball.  Initially when I saw her I wasn’t sure wether this represented a hernia or a mass, but I suspected hernia.  After her spinal we are able to reduce it, hernia!  I cut down into the large fat layer and gradually around the hernia sac.  I open and resect the large sac.  I then close the fascia with a large suture.  I suspect she may have a large seroma (fluid collection) in the fatty layer, so I leave a piece of sterile glove as a drain.
One of the consults I see next is an old guy who can’t pee.  He says he had a foley catheter in that didn’t work but when they pulled it he had a lot of blood in his penis.  Once again I be the foley was placed and the balloon blown up below the prostate and not in the bladder.  Then  suprapubic foley was placed.  He hasn’t been able to urinate with his penis since.  The foley in the lower abdomen fell out a week ago.  He went to the hospital in Kouseri (Cameroon) and they wanted 200,000- 300,000 CFA ($400-500) for the surgery to fix him.  He decided to come to us about 12 hours away.  But it took him about a week to find money and get here.  He says that he can’t pee and small amounts of urine come out his abdomen.  I do an ultrasound with my Butterfly and see a very full bladder up to his naval.  He pays at the pharmacy for a foley and bag and I take him into the operating room as I know this will be difficult as the tract has closed up.  I anesthetize his skin and cut back open the skin.  I know Im going to do this blind along a tract that has closed, but I hope I can re-open it and get a foley in the same place.  So I probe the tract with a sterile heavy blunt probe that usually used for vaginal stuff.  Im gradually able to shove it down the tract into the bladder.  I feel a pop then pull it back out.  No urine.  I know I was in deep enough it was easy after the pop.  And I know I have a huge target of urine to hit.  So I put the heavy probe down a foley catheter and push it down.  It’s tight but I think I get it in.  The probe is difficult to pull out.  After getting it out- only a small amount of urine in the foley.  I use a force to cram more foley in the hole.  Urine comes welling up in the foley.  I very grateful.  I blow up the balloon, which doesn’t cause any pain, so the balloon is in the right place.  He drains about 2 liters of urine and feels much better.  
I look at the registry of surgeries since Ive been here.  35 surgeries in 2.5 weeks.  That’s a good number.  I’m looking forward to being home with my wife and in cooler weather.
Pic of large prostate and a prostate patient.

Shanksteps Bere April #11

administrator Greg No Comments

Shanksteps Bere April #11

I started an audio book in the evenings called Cross and the Switchblade- about ministering to NY gang kids.  Im finding it hard to put down to write you all 🙂  I want God to use me like he did David Wilkerson.  Not for kids in NY but however He sees fit.

Today God is using me to help individuals here with their diseases that I can help with surgically.  I make rounds while I wait for the OR crew to get the patients ready.  I start at 8:30 after they’ve had their morning meetings.  At 7AM I went to the Hosptial worship.  It is singing a song in Nangere and then a worship thought that someone has prepared which is translated from French into Nangere.  Or vis versa if the speaker is Nangere.  During rounds I see the guy with the open below knee amputation that I amuptated for wet gangrene of his diabetic foot.  Now he’s granulated and free of infection so it’s time to close it.  I send him to the OR for preparation.  I check on the guy who had pancreatitis and had a lot of pus out his abdomen yesterday.  I see intestine at the wound site- oh no a dehiscence and eviceration.  I tape a dressing on him tightly and send him to the OR so he can be operated on today as well.  He just ate bouii, so he’ll have to wait till later.  The teen with the open neck wound and a feeding gastrostomy tube is doing well so far just very weak from lying around.  The kid with the leg burn that I did the release on is doing well but not walking yet because of pain. I encourage him to walk.  The old guy with head trauma still hasn’t woken up yet, so we continue IV fluids.  The family wants to give him water orally, I strongly discourage this as he will aspirate and then die, which he may anyway!  I see the kid that I opened the femur on for osteomyelitis drainage and do his dressing.  He tolerated it really well but screams at one point.  The people here are so tough!!  His mom cradles his head as I change his dressing.  There are so many painful dressings here, and we can’t take all of them back to the OR for changing as there is to much to do and I don’t want to give sedation I their hospital bed for fear they won’t be watched and could die.  They are used to doing dressings on the ward, and I do it in spite of the pain I’m causing him.  Of course him living with osteo that is draining at different points on his leg is also painful.  So he has dealt with pain a long time. 

 The first surgery is that of the below knee amputation.  He is given a spinal by David and then his leg is prepped and draped.  Then I cut off excess muscle and bring up the flap.  It has shortened some with time so it’s a little tight to bring up to cover the opening.  With a bit of effort and suturing, I bring the edges together leaving a drain going along the base  inside.

Next is a woman with osteomyelitis of her mandible with draining sinuses.  I explore this and nibble away at rotten bone.  Its is somewhat helpful I think but it’s really when there is a sequestrum (dead bone that has separated) that I feel like Ive really done something useful for them.  She also needs her teeth pulled that are the rotten source, I leave this to the nurse who does that.  Though the OR isn’t a bad place to do this!  I pack and put tape on the dressing.

Next is the older guy with dehiscence and pancreatitis.  I had pulled his pancreas drains a few days ago as they weren’t functional any more.  After his spinal, we prep his belly and opening with betadine. Then as I look in is see my suture intact all along with a rim of fascia just ripped off one side.  Did he do a sit-up and just rip it off, or did the pancreatic juice make the fascia weak, or was it the subcutaneous abscess that did it?  Likely a combination of all of this I guess.  Either way I debrede off the edges and take out the previous suture.  I re-close his abdomen with retention sutures and a fascial closure and leave the skin open for packing between them.  I hope this one doesn’t fall apart.  If it does he may need to be dressed open and I guess that will be the next surgeons problem as I leave soon.

Then there is a patient that hasn’t progressed as needed in her labor for a child.  So she is brought to the OR by Dr. Staci for a C-section.  As she does the C-section I see outpatients that have waited all day since morning.  In between seeing the patients with STD’s, infertility, neck mass, goiter, kid who can’t pee (stone), large inguinal hernia…

I go and check on how the C-section is going.  I see the local doc giving a mask to the baby who is blue and not breathing.  He is shoving the mask onto the face of the baby tilting the head forward and trying to mask him.  I ask that the oxygen be brought, and I take control of bagging the baby.  I tilt the head back to open he airway and mask effectively.  Pulse ox that I have put on shows oxygen saturation of 72 (normal above 92).  A nasal cannula is put under the mask and I bag for for a while till the saturation is normal and the kid appears to be breathing on his own without masking.  I explain to the students how to position the head for masking, and hope the doctor is listening.  I leave to go back to the consultations.  I see a older woman with a huge abdominal mass sticking out how her fat abdomen.  It’s likely a huge hernia that won’t reduce.  Another 27 year old woman has uterine prolapse after a delivery of a dead baby.  Another has vague abdominal pain that “starts in my legs, goes up my abdomen to my chest then back to my central abdomen”  I treat him for typhoid and worms. I often find descriptions of symptoms amusing and also difficult to figure out what to do.  But with limited meds, I choose what’s available and likely to help.  

God help the people I’ve seen today to heal and gain their health back.  Help them to know how much You love them!  Give me Your words to speak to them!

Shanksteps Bere April #10 with pictures

Greg Greg, Uncatergorized No Comments

Shanksteps Bere April #10 with pictures

As you read in my last Shanksteps Ive fretted a lot about wether I should take this old guys nose off for a squamous cell carcinoma, leaving him looking very deformed with a large hole in the middle of his face.  I thought a lot about it last night as I was trying to go to sleep and also this morning as soon as I woke up.  I do that when I have sick or difficult patients.  When I got in there this morning to the OR, the crew told me he had decided against surgery and had gone home.  So I was at peace then.  I was looking through an Indian textbook of surgery and realize  again, that we are not the only ones who see advanced cases of cancer and other diseases.  It’s probably indicative of being in a third world country where there is very low income, minimal health care, and inability to get to where there is healthcare.

I examined another woman today between surgeries.  She was one of the many medical consults I saw today.  She could speak in French quite well.  So as I talked to her I got the story that she is about 5 years after her period ended and she noticed about 2 months ago she was having vaginal bleeding.  She also has some hematuria (visible blood in her urine).  I suspect cervical cancer.  So I do a vaginal exam and find that she has a large hard cervix that is attached anteriorly to the bladder.  So it must be invading the bladder causing her to bleed with urination.  I have to tell her that she has cervical cancer and it is already to advanced to take it out.  If she has means, she can go to Cameroon and see if she can find chemotherapy that may help.  I think that is only in the capital.  I have to give information often to people- and I don’t like having to do it.  It makes me sad and uncomfortable and it certainly does for the person who hears it.

First surgery is a prostatectomy on an old guy who can’t pee.  The second is on a young boy ?8, who can’t pee either.  But his problem is a bladder stone.  David wants to intubate with ketamine.  I question wether this will work, but figure he must have learned this with Dr. Olen recently so I question him about the dosing.  He tells me how many mg he wants to give and it sound correct to me.  So he gives some and goes to intubate with me looking over his shoulder.  The kid clamps down hard on the laryngoscope and I worry about him breaking his teeth.  He gives him more ketamine.  Then again, Finally I ask him how much is he planning to give? 7ml.  For his weight Im guessing less than two would be way more than enough.  He tells me how he calculated it and how many cc’s that is.  He calculated correctly but thought there were 50mg/10ml.  In reality its 50mg/ml.  So he has way overdosed.  The kid keeps on breathing and so I decide Ill proceed and Ill ask him for more if the kid really starts moving.  We fill his bladder with water and start the surgery.  After opening the bladder we find a stone about the size of a pencil eraser- large enough to plug the exit of the bladder.  I closed him up and checking on him later he seems to be doing well.

On rounds, I ask the kid with the open neck to try a swig of water.  It pours out his neck in a different place.  So we will just keep with G-tube feeds for a while before trying again.  He is starting to heal, and I’m hopeful that he will survive.

I was called in tonight to see a guy who had had an accident on a motorcycle yesterday in a town about 2 hours away.  They left the other hospital to come here.  He has been unconscious since the accident.  He has a cut on his head that they repaired.  As I examine him I find he had normal pupils, hardly reacts to painful stimulus and has a broken clavicle and loose ligaments in his left knee which is also swollen.  I don’t find any other abnormalities.  His glucose is normal, and his blood count a little low but reasonable.  He has a urine catheter in place, but it’s in the wrong place because the bladder is full without it coming out.  So the nurse will replace the urine catheter and start IV fluids and we will watch and see if he recovers from his traumatic brain injury.  Im called back in because the foley catheter can’t be re-inserted.  And he’s bleeding after the last one was removed.  Yep, the balloon must have been blown up below the prostate.  I hate it when people do that- it makes for a lifetime of urethral strictures- if he survives his brain injury.  I go in and there is blood all over  coming from his penis.  Sure enough, I can’t get a foley in because the urethra was burst with a blood inflation.  I try a number of times.  Finally I give up and put in a suprapubic IV catheter.  This will get him through the night so I can deal with it tomorrow.

PICS- Below are the burn kid post-op leg contracture release, and the old man with squamous cell eaten the inside of his nose.

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Shanksteps Bere April #9

administrator Greg No Comments

Shanksteps Bere April #9

It rains near by in the early evening and the air cools from 95 to about 86.  I sleep well.  I am called at 5:30 to see a woman who is 26 years old with RLQ pain since last night.  She says the pain is constant and strong.  She points to her Right flank.  She’s vomited a couple times.  Her tests show she has malaria and doesn’t have typhoid.  Though I know the type of typhoid test we have here is very inaccurate.  She also is not pregnant.  She denies any vagnial discharge and hasn’t had any problems with BMs or urination.  I ultrasound her and see a normal appearing kidney on that side.  I can’t see an appendix.  But based on her symptoms I think this likely represents appendicitis.  So I ask them to keep her NPO (nothing per Os.  Nothing by mouth).  Get an extra IV going and we will plan on operating on her this morning.

Later on Im told she is feeling better and doesn’t want surgery.  I think good, maybe I was wrong.  Then I see a text from Dr. Staci, appy lady, have I seen her.  She sends her over to the OR where I’ve been all day.  As I examine her she says she feels somewhat better and doesn’t want an operation.  I take this as a good sign, and decide Ill examine her again in the morning.

My first surgery this morning was an old guy with prostatic hypertrophy for a prostatectomy.  I wish I new how to do a TURP and had the equipment.  That would be best, but I do what I know how to do and it does help them.  I do tow old guys today in the same manner as Ill describe now.  They get a spinal anesthetic.  Then fluid is put into and distends their bladder displacing the intestines up and so when I cut down in the lower abdomen, I get to bladder rather than intestines.  His abdomen is prepped then I cut through the various layers to the bladder.  I sweep the peritoneum (covering of intestines) up and out of the way.  Then I open the bladder, sucking all the fluid that we had just put in there.  I stick my finger in the bladder and feel a large prostate.  Slowly I shell it out.  There are two large pieces.  My fingers and ligaments ache a bit as they really get taxed when I do this.  I close the bladder in two layers and then leave a sterile piece of glove as a drain, and close the rest of the layers.

The next is a woman who has cervical cancer and vaginal bleeding and keeps on dropping her hematocrit as we give her blood.  So I decide waiting isn’t helping her so I decide to proceed.  We give her two bags of blood then start the surgery.   As the foley is inserted it drains blood.  I re-look at her carnet (medical booklet) and it definitely says vaginal bleeding with mobile cervical cancer.  So I open her abdomen and find a small uterus.  And something hard in her omentum.  I take the hard part out of the omentum and don’t find any evidence of metastasis on liver or peritoneum.  I clamp, cut, tie down the sides of the uterus and each tie really stresses my fingers again.  These also stress my finger ligaments as it takes a lot of force to tie these tight so the vessels won’t bleed afterwards.  Finally I come across below the uterus, cervix across the vagina.  I look at the cervix on the specimen and it looks normal.  Hmmm, well sure doesn’t look like cervical cancer to me.  Back to ? Bladder cancer.  I can’t feel anything abnormal in the bladder.  But Ive decided even if I see a bladder cancer again I will likely not do any surgeries for it.  It is many hours of surgery and I don’t want to do anymore ileoconduits and don’t think it really prolonged their lives in the past.  So I close.  Even tonight as I type I can feel my index finger is tired.

I do the other prostate guy in the same way as above.

Then the last one of the day is a 20 something woman with huge swelling of her face she says has gone on 3 years.  And worse these past 4 days.  So does she have a cancer that now has become necrotic??  So many unknowns here!  I did an ultrasound yesterday and think there may be an abscess underneath.  With the most being right where the facial nerve lays in front of her ear.  Her eye is puffy and I think it must be pus.

While Im waiting for her to be ready I see many consults.  One sticks out in my mind.  It is a guy who has a cancer on his nose.  Dr. Denae biopsied and sent to Ndjamena and apparently it is a squamous cell carcinoma.  He smells awful!  His septum has been eaten away.  I think that if I do an aggressive resection I may be able to get it all but he will have a horrendous looking face afterwards.  Maybe if he survives, someone could do  a plastic reconstruction afterwards.    So I offer a very disfiguring surgery to them and the want it!  I have a difficult time explaining what he will look like afterwards, but they want to proceed.  I take about 45 minutes to explain.  They go to pay for the surgery.  God help me to get it all out and for it to be worthwhile for him to be disfigured like this!

The girl is ready and so she is given propofol and ketamine.  I cut into the side of her face in a way that I think won’t hit the facial nerve.  I stuck a needle in and so I know there is pus down there.  I go deeper and deeper and eventually hit pus.  It flows out. It was a significant pocket.  As I flush it out, the nurse thinks the fluid is going into her mouth.  Wow, these neck infections and dental abscesses are awful!  Ive seen so many this time.  I pack the hole and she goes out when she’s awake.  

Another dental abscess is draining on another patient’s mandible and we pull out a piece of dead bone out of her upper neck.  These people desperately need dental care!

I think there are only a handful of dentists in the whole country and likely most are in Ndjamena.

I will do the nasal cancer guy tomorrow.  God help me!! I need your knowledge! I’m so inadequate to deal with so many things here.  HELP ME!

Shanksteps Bere April #8 with pictures

administrator Greg No Comments

Shanksteps Bere April #8 with pictures

Yesterday was different at the hospital.  There were a few surgeries scheduled and one lady for a hysterectomy had a low hemoglobin and needed transfused first, the other two or three ate that morning, so I suddenly had no surgeries to do.  I did rounds with the nurse and about 6 nursing students.  I looked at everyones incisions, opened all the dressings on those with chronically healing wounds, and it took about 2 hours to round this way on about 28 people.  The ward is full and I even saw a few that are living under the trees, discharged but Dr. Denae still wanted to check on periodically.  I got done early afternoon.

So I went and ate some lunch at Netteburg’s and then decided to go out to Bendele where a missionary friend of ours just flew in with his plane a few days ago.  He has a plane that can carry a number of people and still take off and land in a short runway.  I think i mentioned that i often come here with a perimeter spray to help with mosquitos and other insects that infest or eat a house.  So I wanted to offer to spray the missionaries house down there too.  So I rode a motorcycle down there.  It was hot but nice to be outside.  Im on Doxycycline for my malaria prophylaxis so the sun feels especially hot and I burn easier with it.  So by the end of the day Im a little sun burned.  I spray Deietrichts house.  Then I help in the hanger.  He wants to pull a large motorcycle down to the hanger from the hospital.  It’s not been used for years and he wants to get it going.  So we go back to the hospital on one other large motorcycle with a rope.  The one that’s been sitting has flat tires, and eventually we find a pump that works and then he pulls me motorcycle to motorcycle back to Bendele.  We don’t have a key for it so can’t do much.  We move planes around and get one that’s been sitting started and it needs a lot of work.  So i help with a few things till dark then head back to the hospital.  It’s nice to see long time friends again.

Today I did rounds and I had the patient with an open neck drink water while I watched his neck.  It poured out his neck.  His neck is finally starting to granulate as he is getting some nutrition.  So he has survived the infection, will I be able to convince the family not to get him enough food for him not to starve to death.  It’s hard for people to give adequately when it’s not going in their mouths.  They showed me the bouii (porridge) that they were about to give and it was scalding hot.  I told them it would burn his stomach and only give him cold bouii.  Since it’s Friday we only schedule a few cases as we expect other hospitals to refer patients in to us on the weekends when their doctors don’t want to work.  I guess there are 1-2 distant hospitals that do this at times.  So the first person I operate on is an older woman with a large lipoma (fatty tumor) on her back.  It is lobular and takes a while to get it all out.  She tolerates it well, and I though she would need sedation, but they said do it under local, and she did well.

The next was a a boy about 10 with osteomyelitis (bone infection) of his left femur (upper leg bone).  I looked at his X-ray and it appeared to be the whole bone.  He has had osteo of his fibula on the other leg and Dr. Denae had removed that a number of months ago.  Now he has pus coming out the side of his upper leg near his knee.  So the treatment of this in these rural locations is not months of antibiotics but open drainage.  So in the operating room he is given a spinal.  Then I make a long incision down his later upper leg and slowly go down through the muscles with cautery.  I get into a few pockets of pus.  To open the bone is challenging with the tools we have here.  I have a drill in a sterile pouch and a chisel. So I drill numerous holes in two lines down his femur and then use the chisel to get the bone in-between out.  This opens up the medulla and allows for drainage of the internal pus.  I worry about my chisel action cracking the bone across, creating an open bone fracture than he cannot walk on- likely ever again.  I’m grateful that didn’t happen.  Cleaned out all the medulla and packed a dressing into it.  He will be here for months of dressing changes now.

In the evening we all get together for Sabbath vespers at Netteburg’s house.  Vespers here is one of the highlights of my week.  We worship God with songs and words and say what we are thankful for this week.

  

 

Shanksteps Bere April 2023

Greg Greg No Comments

Shanksteps Bere April 2023

I go in this morning to see who is on the list for surgeries today.  There is a girl with an abdominal mass, a old woman with an abdominal mass, an old man for a prostatectomy.

The girl is about 8 years old with a abdominal mass that feels quite a bit larger than a soft ball.  She is on the OR table after her spinal anesthetic has been placed.  The mass feels mobile but attached.  I ultrasound it and find a solid tumor.  Is it a mesenteric  mass like Dr. Denae thought, intestinal mass, ovary.  More importantly will I be able to get it out or will it be stuck to everything and be unresectable?  I open her abdomen and am staring at a large mass.   It seems more mobile than I thought.  I open from pubis to above the umbilicus before I have enough length to get around this.  It’s huge for her little abdomen.  i get around it and pull up, it pops up through the incision.  YAY!  It isn’t stuck everywhere.  I soon figure out it is an ovary and the pedicle seems long and it has momentum (fatty layer in abdomen) stuck to it.  I clamp, cut and tie, the portions of the a omentum off and then do the same for the vessels leading to it, which are huge.  I take it out and then inspect the rest of the abdomen.  She has a few larger lymph nodes in the omentum.  These are probably metastasis.  So I take them out too.  I look at her liver, and peritoneum (covering of the abdomen) and don’t find any more evidence of tumor.  Her other ovary looks small and normal.  So we close her up.

The next older woman has more body fat than most here so I know she will be more challenging to operate on. I ultrasound her abdomen and find what I think is a large uterus and a huge fibroid in it.  I ask for them to interpret for me and find out if she wants more children.  She says she’s had 9 and doesn’t want anymore.  Plus she’s past the time of her period anyway.  So I plan on a hysterectomy or mass excision if Im wrong about its source.  As I go to see consults, Olen says.  Oh look at that, her blood pressure is 210/114.  She doesn’t know that she’s hypertensive and so we cancel her surgery and tell her to come back in a few weeks once her blood pressure is better controlled.  The staff look at me like Im crazy.  So I tell them the possible problems with it in the OR and they translate for her.

Next is an old guy who who can’t pee and has a large prostate on ultrasound done here and has a urine catheter in.  We put water into his bladder to distend it and clamp the foley catheter.  Then prep and drape him.  It’s been since I was here last, since i took out a prostate.  I make a low phanynsteal incision and go down to the distended bladder.  I open it and find a large prostate.  slowly I shell it out with my finger.  It’s always kind of difficult and taxing on the ligaments of my finger.  I change fingers a number of times as one starts to hurt.  I get out two large lobes and a smaller one.  The bleeding is constant as it usually is.  So I suture up the posterior area.  i put in a large 3 way foley for continual irrigation and close the bladder.  I start the irrigation as soon as i close the bladder in the first layer.  This irrigation will continue for days until it is clear enough to stop.  It is the only thing that keeps blood from making clots in the bladder and a need for reoperating.  

I walk through the surgical ward because I’m done earlier than expected.  I see the guy with the chest tube and people are propping him up and he’s breathing fast.  I check his chest tube and all appears normal.  there is fluid where there’s suppose to be and everything connected correctly.  There is about 1.7 liters of pus in the container.  His heart is racing.  I don’t see neck venous distention.  He’s sweating because it’s real hot today.  I want a chest Xray to make sure the chest tube is keeping the lung expanded.  I go and tell the chief nurse who is also the person who takes X-rays and does ultrasouds.  They run to get me and say that he’s not doing well.  There is a crowd of people out around him.  He is sitting on the ground and apparently passed out as they tried to walk him to the Xray.  He’s conscious, but real tachycardic.  There are a million things that could be going on.  Of them, what are some that I can diagnose or suspect to treat here?  I ask if he’s eating and they say no, and not taking much water either.  So maybe he’s dehydrated, I ask for IV fluids to be run in quickly.  He’s peed twice today and it was dark tea color.  His blood pressure is low about 90/60 sitting on the ground, and HR 120.  we carry him back to his bed and give him fluids.  I guess he can’t make it to the Xray.  No bedside Xrays here.  I check on him later with Olen.  We ultrasound his chest and Olen sees normal lung on the other side and consolidated lung on the affected side.  No pneumothroax (air around lung) and no hydrothorax (fluid around lung), and pus continues to drain out the tube.  As I feel his pulse again it’s less but now seems irregular.  slow then fast alternating.  Maybe he’s in atrial fibrillation.  We consider our only anticoagulant aspirin.  And decide to see if he is still irregular tomorrow.  This is the first time I wish we had ECG here. (no machine and those little pads- we use those up like crazy at home.  they don’t stick well at home, i can’t imagine they’d work at all here.)  

Shanksteps Bere April #6 with pictures

Greg Greg No Comments

Shanksteps Bere April #6 with pictures

BEWARE_ The attached picture some may consider gruesome.  That is the reality here!

I’m adjusting a little to the heat but sleeping is still the hard part.  I go in and see my surgical patients while I wait for the first surgery to be ready.  I round on the ward that has about 20 people.  Here is a brief summary: There is the teen girl with bladder extrophy, multiple vessico-vaginal fistulae repairs, guy with a hippo bite to his arm with tendon repair, bladder stone boys, Achilles tendon repair boy after bicycle accident, osteomyelitis on the foot boy which is granulating. repeat repeat bladder repair after stone extraction. above knee amputation infection, and open neck teen.  Im called back to the OR as Olen has intubated my first baby.

The baby is about 1 year old and has a retinoblastoma.  That is cancer of his eye.  His eye looks very abnormal and appears to be growing out of his face.  I can’t remember if Ive taken out a retinoblastoma before in Cameroon or not.  I know Ive seen them before.  Either way I think of the possibility of a lot of bleeding deep in a hole I have difficulty of controlling.  I pray over each patient before operating and do the same for this baby. (I don’t like operating on babies!!  here they die to often of unknown problems)  After prayer I start by prepping the face and I scrub my hands with the bar soap that is available.  No normal surgical soaps available here.  I probe around the eye and realize the lower lid is invaded by the cancer but the upper lid isn’t.  So I save as much of each eyelid as possible to be able to put those into the cavity that’s left so that less granulation will be needed. to close up the space.  I gradually cut and dissect around the eye, initially its fairly easy but as it gets further deep in the hole of the eye socket it becomes more challenging.  Finally I’m back to where I imagine the optic nerve and vessels to be.  I place a right angle clamp and work it around the eyeball down to the base and clamp.  I hope I have whatever bleeder is there as I have to now cut off the eyeball to seee what I’m doing behind it.  I cut and there is no bleeding.  I realize as far back as I can go there is cancer or at least it looks like that to me.  I reclamp as deep as I can and take off a little extra cancer.  I see it also appears to have invaded towards the nose side.  I knew this was palliative not curative- but it’s still sad!  i suture in the eyelids as much as I can and pack the rest of the space.

Next one is a 7 year old boy who was burned down the back of his leg a couple years ago and has a large contracture from his buttocks down to his ankle.  It creates a large web of tissue going down that pulled his heal towards his buttocks.  His knee he cannot straighten beyond 90deg because of it.  So he stands perched on one leg like a flamingo.  I plan on a Z-plasty,  which takes the forces of contraction and changes their direction so as to not make the same contracture again.  I finish my rounds on the surgical ward as Olen intubates him teaching David while he does it.  Since it is hard to find surgeons and anesthetists to come here they are teaching local nurses to do anesthesia and surgery.  If you want to help in this way please contact me and I’ll put you in contact with Dr. Davenport.  I’m called after he’s intubated.  We turn him mostly prone and prep his legs.  I prep the second for a skin graft if I need it.

First I cut the cord on the back of his leg the part that is really contracted up and firm.  Then I gradually mobilize a flap of skin on each side.  I start making my cuts in these flaps and then have a hard time figuring out how to create the Z-plasty with them.  I ask Olen to open a book for me and my incisions are correct but I still can’t figure out how to make it look good.  Eventually i find an acceptable way but  it seems to have areas of tension and areas of laxity.  So I have probably chosen a poor location to do a Z-plasty.  I free up everything that feels tight and still the knee doesn’t go straight, even with a lot of pressure there is still about a 20deg bend.  I guess it must be his knee then.  so I continue closing, which takes me a long time and a bunch of suturing to get this closed. There is a small open area left at the top so I fashion a piece of skin I cut off into a skin graft and suture it in place.  I put his leg in a splint after placing a large dressing.

There is a guy waiting in the consultation area that Olen says needs a chest tube.  While my next patient is being gotten ready I take this guy into the other OR and place a chest tube.  As soon as I get it in he takes a huge breath and coughs.  Pus from his lung space spews out the hole and all over me and shoots out the chest tube hitting boxes and the floor about 10 feet away.  This is disgusting!!!  I suture it in place and he continues to cough but now I’m ready.  I’ve had coughing later as the lung expands but not at the beginning like this.  I put a dressing and hook up the reused reused pleuravac.  I put him to suction and it appears to be working.  I attack the little foot pump suction I brought here last time and show the family how to pump it to create suction.  Later that evening he has put out 1500ml of pus into the pleuravac.

The last guy of the evening is the teen with the open neck that I wrote about a few shanksteps back.  The one who necroses the front of his neck with infection from a tooth abscess and when he eats it comes out his neck.  He his for a feeding gastrostomy tube.  He is given spinal anesthesia and sedated a little unintentionally.  The nurse didn’t realize that one of the IV bottles had Ketamine- even thought it was written on it, and gave it quickly.  So he was out of it too.  Fortunately he didn’t stop breathing and didn’t need to be intubated as that would be disastrous, as he can barely open his mouth.  And a tracheostomy in the open pus field would be awful.  The G-tube part of it went well and he went back to his room.

It was a long day.  A cool shower was awesome!

Shanksteps Bere April #5

Greg Greg No Comments

Shanksteps Bere April #5

In the late evening Im asked to see a guy with significant abdominal pain.  He says it started in the upper abdomen and then progressed to everywhere.  He’s quite tender in the upper abdomen and seems distended.  he has an inguinal hernia that is easily reducible.  He says he hasn’t passed gas but did have a liquid BM that day.  He’s had nausea but not vomited.  Then nurses had asked for an ultrasound and I think instead he needs a abdominal X-ray.  On the X-ray i don’t see any evidence of obstruction nor free air.  So I decide to treat his typhoid and see him in the morning.

In the morning he is still very tender and I think I should do a Bere “digital CT”.  Meaning digital (finger) cut and touch.  So i ask that he be the first one fo the day.  So they get him ready and I open his abdomen.  I get a bunch of fluid that i think looks like it may have come from the stomach.  So I go there first.  I look all over the stomach, front, open the back area, follow down the duodenum around the C curve of the duodenum. It’s difficult and it takes a while.  I find areas of inflammation and swelling in the tissue but no hole.  I run the small intestine from start to finish and see no problems.  I finally realize that everywhere Iv’e seen the inflammation has been most near the pancreas.  So that’s his diagnosis- pancreatitis!  I feel the gallbladder and don’t feel any stones.  It’s also small and not distended so I think i get a pretty good feel.  So i put drains in and close him up.  We don’t have any pancreas labs, so will have to rely on how he feels and when his intestines open up.  But there is nothing to do but watch and wait and hope that he heals.  Im praying for many of my patients.  God heal him!

The next patient Dr. Denae did I assisted her on.  It was a 30s year old woman with cervical cancer that was very hard and filling up the exit of the uterus.  She was bleeding and her baby was about 30 weeks along.  She had broken her water the day before and contractions had started.  So we needed to do a C-section because this baby had no way to be delivered vaginally.  The patient is having a lot of back pain and can’t sit.  So dong the spinal is very hard and we attempt to do it as she lays on her side.  The nurse tried, I tried, Olen tried- no go.  So we gave a bunch of local at the incision site and started.  We wanted to give the Ketamine at the last second so to have minimal effects on the baby.  We got our a crying normally formed baby.  In the lower uterus there was very soft tumor that was bleeding.  We closed her up and pray that she stops bleeding to have some time with her child before the cancer takes her.

The next one is a guy who had a bladder stone.  It was removed her about 2 weeks ago and then the urine catheter plugged up and overfilled the bladder.  Then the front repair fo the bladder ruptured.  So he was taken back and repaired again then developed a leak about a week ago. Now we took him back to repair that leak.  It was terribly stuck and difficult to create any planes of tissues that could be evaluated for closure.  Gradually we found layers to close.  We flushed the catheter with fluids and it didn’t seem to leak, so hopefully it will stay that way.

The next one was a woman who had an injury to her middle finger and the middle joint was stuck straight.   So when she made a fist it stuck out and was in the way.  So I offered to take it off completely or leave her with a small stub that may help some.  So she said a stub would be ok.  So i numbed up her finger at the base.  Once here finger was asleep, I cut through the tissues down to the bone.  then I nibbled away at the bone with rongours.  Made the end smooth then sewed the skin edges back together.

More happened than that, but that’s what comes to mind.  Pray for staff and patients here that they would really know God and follow His lead in their lives.

Shanksteps Bere April 2023 #4

Greg Greg No Comments

Shanksteps Bere April 2023 #4

Today is Sabbath, we go to church.  I woke at dawn about 5:30.  Fortunately they didn’t turn off the generator this morning, so I lay there in the fan for a little while.  I get up and drink a liter of water and shortly thereafter Im thirsty again.  I drink lots of water all day.

I go in to see the surgical ward before going to church.  I ask the on call nurse if there are any concerns and there aren’t.  So I go with the nurse and the students to the one patient I want to do the dressing on- the teen with the neck infection where I can see all the muscular neck anatomy I talked about last shanksteps.  He still says that when he swallows that fluid comes out his neck.  I change his dressing and see a fair amount of pus and saliva on it.  Though that is a little difficult to tell exactly.  But i have yesterdays experience to know that’s so.  I change the dressing and then talk with him and the guy with him that we need to place a feeding tube.  They seem to understand, but the ones that can make that decision- the older brothers- aren’t at the bedside.  So I will need to explain it again later to them.

It’s another sunny, hot day here.  At 8AM the temp on the little thermometer I brought reads 94.  I don’t feel sweaty as long as I’m not moving and sitting in front of a fan, but know Im evaporating constantly.  

I go with the Netteburg to the church with the kids under the mango tree.  We drive there in the truck with me and the kids standing in the back, sun beating down on us.  It’s nicer in the breeze than the inside of the truck i imagine.  People walking along the road are enveloped in the dust cloud behind the truck.  Little groups of kids playing under trees near the road wave and yell “nasara”  their word for white person.  Nnaasssaaarrraaaaaaaa…..  It takes about 15 minutes to get there.  We pull up under some large mango trees and kids and adults flock around.  As we get out of the truck they ask if I’ll tell the kids a bible story.  I’d like a little more time than that to think, but agree to do it anyway.  Olen starts with singing with the kids songs that they have sung many times.  the kids join in exuberantly with singing and the motions.  When they are done singing, I tell the biblical story of Jonah and his hearing from God what God wanted him to do and Jonah choosing to do something else and run away.  And how God saved his life and brought him back to doing Gods will.  It took about 15 min with the translation and me speaking in French.  Denae repeated the story with questions along the way and the kids were very excited to respond with the answers.  Each kid who answered got a sticker. They were very excited.

We drove back home and hit a few dust clouds too as we passed some larger trucks taking the same road.  It appears they are doing some sort of road repairs.  It’s a weird time to do dirt road grading and repairs just before the rains start and they get destroyed again.  At home it’s 110 outside and 100 inside.

We gathered early afternoon for a potluck meal.  Food was excellent as I always find it at potlucks.  And as far as I could tell everyone had food.  We were thinking about walking around afterwards but there was a patient that needed to be watched as her labor progressed so we didn’t go out, had good conversations and played with balloons with the Netteburg boys that were left over from the wedding party.

Later on there is a patient who came in pregnant and wasn’t progressing and was found to have a dead fetus.  She was followed and given pitocin and still didn’t progress.  So when a C-section was needed, I offered to do it, so the other doctor could have some rest.  Olen did the anesthesia and Douri assisted me.  The baby’s head was high and not descending.  She had received enough fluids via IV so Olen placed the spinal anesthetic.  We prepped and dropped her abdomen and I did a phanynsteal incision (low transverse above pubic line).  I went in through the skin, fat (very thin), and split the rectus muscles opening into the peritoneum.  The uterus looked normal. I opened it in the lower section transversely. It was difficult to get the baby out.  I found the head was large and deformed.  So the head was likely to big for this woman’s pelvis.  I put clamps on the uterine edges to slow the bleeding.  Delivered the placenta, then started to close the uterus.  After controlling the bleeding spots, I saw a hematoma forming on the left side.  I opened the hematoma and put some sutures there.  The left uterine artery had torn when I pulled out the large head of the baby.  When there was no more bleeding then I closed the rest of the layers of the abdomen and she went to the maternity ward.

After a night surgery it takes me a while to wind down to be able to sleep.  Im able to text with my wife at home and finally when I feel tired I go to bed.   I got in bed around 1AM and lay there till about 3AM my brain going about random things- frustrating!  At 5:30 IM called about the patient with his neck open with infection.  He is bleeding from his neck again.  I race in and find he has about half a liter of blood clots in a basin in front of him.  It is coming from his mouth and doesn’t appear to be from his nose nor his outside neck wound.  Is he bleeding from his jugular vein?  I can’t see anything in his mouth bleeding and don’t think looking in his throat would help me even if I identified the spot on the inside.  I wouldn’t be able to stitch it… It appears to have stopped, so I order a hemoglobin and send the family to be tested for blood type in case we need to give him blood.  His previous hemoglobin was normal at 15.

I try to sleep again but it is impossible.  I am never able to sleep in the daytime.

God give me Your wisdom to know what to do with this boy. Help him to stop bleeding. Heal his terrible neck wound.  Help this boy to know Your love for him, and use me however you want to use me.

Shanksteps Bere April 2023 #3 with picture

administrator Greg, Uncatergorized No Comments

Shanksteps Bere April 2023 #3 with picture

Death- We all die.  Most of you reading this have hope of a life after death, one where we will live with God after all the pain of this world is gone and it is made new again like God designed it in the first place.  Since we are on this world we experience death, and in third world countries death is a daily experience.  Adults and children and especially young children.  If you ask a woman here how many children they have- the response is usually I’ve had (example) 6 children and 3 are living.  Since there is so much death it is an expected though mourned part of life.  I can accept it better when I know why someone dies than here where it’s sometimes diagnosed and sometimes i just suspect why someone I was caring for in the hospital dies.

Im called in last night to see a lady that I had performed a procedure on earlier that afternoon.  She had been admitted a few days ago and had malaria and seemed short of breath yesterday.  So Olen did an ultrasound and found what seemed to be a prominent amount of fluid on one side.  He sent her over to the OR to have me drain it.  The lady was tachypnec (breathing at a rate about 30) after being moved around.  No one spoke her language so we made signs as to what we were doing and she also seemed not all there.  i did an ultrasound with my Butterfly and saw fluid on the right.  So I didn’t know wether to draw it off with a small needle or a chest tube.  so I put a needle into her chest and drew off fluid that looked like pus.  So I decided the chest tube is what she needed.  I put lidocaine in her chest wall about the level of the mid breast and made an incision and spread slowly down between the ribs.  as soon as i entered the chest cavity pus came spewing out with each breath.  I put a chest tube in and attached it to the one pleuravac (canister) that has been washed out and reused for many years.  (They aren’t available here.)  after finishing the procedure I hook the pleuravac to suction and more fluid pours out.  I get a total of 1700 of pus, after whatever drained all over the OR bed and the floor.  she is coughing and that gradually calms down.  I call her family, three guys, into the OR so they can see the amount drained off before I dump it as it nearly fills it and I want more space in it for the weekend.  It’s made to be used one time so it is difficult to dump out as it doesn’t have a drain place.  eventually i get it emptied and reattach it.  Her saturation is good and she’s a little low on blood pressure and as we give her IV fluids it improves.  She is taken to the surgical ward.  I check on her shortly there after and verify that the tubing isn’t kinked and that the family knows how to push on the foot pump every so often to create suction for the system.

So Im called in at night to see her because she isn’t doing well. I go in right away to see her and she is dead.  Not just dead but cool and dead.  The nurses have a list of hourly blood pressures which I asked them to do- and amazingly enough they did.  Usually it’s a fight to get daily blood pressures.  Anyway the blood pressures have been good.  They said a bit earlier she drank water and didn’t choke and that from the nurses (don’t know wether they were students or nurses) point of view she was doing well.  When they came to get her blood pressure it was zero so they called me.  No CPR.  I don’t do it either, as i find in this rural place when we are treating suspicion rather than diagnoses it’s futile.  No ekg machine, and Im not sure it would help anyway here.  I tell the men she is dead.  This usually causes an uproar by women of the family who start mourning.  However there are no women of that family around so they are silent and sad.

Another patient that has cheated death so far, but may die in the near future is about 18.  He came in a couple days ago with a severe neck infection after having a tooth abscess that continued down into his neck and necroses the skin on the front of his neck.  The dead tissue was debriefed in the OR and when I came the first day he was in the recovery room he was being suctioned frequently because he was bleeding from somewhere in his mouth.  No spot could be identified but clots kept coming out.  he wasn’t conscious enough to protect his own airway.  I didn’t expect him to survive the night.  A visiting ER doc got up every hour or two and suctioned out his airway in his room with a foot operated little pump.  It worked and when I rounded the next day he was still alive and more conscious.  Yesterday when I rounded I take off the neck dressing and I see all the muscles and thyroid of the anterior neck.  From side to side and up onto the left jaw muscles too.  It’s a gruesome site that reminds me of the “bodies” display I saw at the museum once on the human body.  Or anatomy class in medical school.  I flushed out the pus in his neck and realize that he seems to be choking.  So I sit him up and have him drink some water.  a fair amount comes out his neck wound.  So there is communication with his throat and this open neck wound.  Im not sure what to do about that.  I will tell the family that he needs a feeding tube.  I think he has survived the infection and will die of starvation if I don’t feed him someway.  We also still need to pull the rotten teeth that were the source of the infection.

So death is ever present.  It is always hard to deal with and each patient I get attached to and think they are doing well and that what we did made a difference- if they die it is hard to deal with.  Other patients I expect to die it seems less painful.  Then there are the ones like this last one I expect to die and didn’t (yet).

God, help me to know what to do with each patient I see and guide us to help as many as possible and know when it’s not possible.

Shanksteps Bere April 2023 #2 with pictures

administrator Greg No Comments

Shanksteps Bere April 2023 #2 with pictures

Today I awoke before dawn when the generator went off at 5AM and the fan quit.  Instant heat.  It was down to 86 by the morning.  So at least not 95 like i anticipated.  But I normally sleep in a room that’s 60 deg.  So it was toasty.

Went in and rounded with Denae to learn the patients on the surgical ward.  Many chronic wounds or infections that are being dressed.  Some in diabetics and others not.  A lady that had mastitis that sloughed all the skin of the breast.  Older guy with osteomyelitis (bone infection) Bladder stone removals that got infected.  Patients she’s repaired vessicovaginal fistulae (connection between bladder and vagina from prolonged labor and necrosis of the tissue between the two.

They worked on the generator today and then about 10 AM said one was fixed enough that we could do surgeries.  The other was hopelessly ruined by the piston going through the side of the block.  i think these two generators have been running 24/7 alternately for 10-15 years so not surprising that a major problem has happened.

I went to the OR and found out my two first surgeries were to remove bladder stones from a 7 year old and a 14 year old, both boys.  The first one the two visiting ER docs did the anesthesia.  I told them Ketamine should be fine, so it was given and I started. The boy was quite fearful, which is unusual here but quite understandable, but after Ketamine he was calm.   I made an incision in the low abdomen across the belly in a gentle curve down low.  Went through the different layers and exposed the bladder we had distended with water and betadine.  The cautery was being used in the other OR by the nurse doing a hernia surgery(he has been being trained by the other surgeons so there can be some coverage when there are no surgeons here;  If you are a surgeon and want to volunteer in Bere it’s very needed the rest of this year).   so without cautery I got more bleeding than I like.  I used to use Ketamine a lot in Cameroon I have opinions about how much and IM / IV to give, and what meds to associate with it.  They did a different way which is fine but at least on that patient seemed less effective.  Every-time I touched him in his lower abdomen he would push back, obliterating my view.  They gave more and more and gave ativan…  He still pushed back at every touch.  Finally they intubated him and with isoflurane he stopped pushing back.  After opening the bladder, I fish around with my finger and pull out two smooth oddly shaped stones, each about a quarter in size.  i feel around and don’t find anything else abnormal.  i close up the various layers and leave a piece of glove as a drain to the space outside the bladder.  This is in case the urine catheter gets plugged and the nurse doesn’t alert me or unclog it that there is a way for fluid to drain out if it ruptures through my bladder repair.

In between cases I go and see a girl who is about 5 months old and has a huge nose mass.  it was small at birth and now is very large.  Is it a tumor from a sinus, brain coming forward, a mass of blood vessels?  So many options I know very little about.  i get an ultrasound and see some solid material in it and also fluid.  She starts to cry as I am running my ultrasound over it and i see that with each force of her crying, the fluid areas expand.  This make me think of it being brain and cerebral spinal fluid coming out. (I will attempt to attach pictures of her at the bottom).  I decide if I try to resect this it will likely kill her.  At first the family is forceful that they want me to do surgery to take it off, then as we discuss it they decide if she will die either way, that they prefer to take her home and let whatever happens happen.  I wish I could do something useful for the child, but I don’t think Id help and would hasten her demise.

The next 14 year old boy with another bladder stone is brought to the OR after cleaning it.  The nurse doing anesthesia tries a number of times for the spinal without success.  I offer to try.  the boy is very stoic and not moving much with each poke in his back, which is hard to sit still for as it’s painful.  I give it a few tries, then get the right space and inject the medication.  He lays back and it works and he feels nothing from mid abdomen down.  His surgery goes much easier as I have cautery now, a good assistant (the previous assistant was a student nurse, not as helpful), and a patient that is still and not reacting to what Im doing.  I get into his bladder and I can feel the stone down low.  Instead of floating around in the bladder like the last kid, this one is stuck down in the outlet of the bladder.  Im amazed he could get any urine past it.  It seems to have grown in place and is extremely hard to dislodge from its pocket.  I try a variety of things.  Finally I have to use some sharply toothed clamp to get a hold of it and slowly yank it from its place.  This one is the size of a small chicken egg a little more than an 1 inch in length and oval with a nodular surface.  I close up his bladder and abdomen and see some consults in the OR entry room.

In the afternoon there is a wedding of a missionary and her fiancé from the same country she’s from.  i don’t make it to the wedding, which is OK with me.  I do make it to the reception and enjoy food and seeing other missionary friends that aren’t at the hospital but live in a town a little ways away.  It gets dark as we are out and Im being bitten by mosquitos.  i hope I don’t get malaria again.  Ive avoided it that last few times Ive been here but many of the missionary kids have malaria right now because of an evening event recently they tell me.  I make sure and take my prophylaxis tonight.  It’s cooled off to 92 and I shower and go dripping to bed.

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Shanksteps Bere April 2023 #1

administrator Greg No Comments

Shanksteps Bere April 2023 #1

As you know, When Im on a mission trip, I like to share with you my experiences in these Shanksteps.  They are shank steps of faith.  So we have chosen to try and follow wherever God leads us and right now that’s Bere Chad.  We had been scheduled to help out medically in the aftermath of the earthquake in Turkey.  When that was no longer needed and we were cancelled from going, we offered our time to Bere Adventist Hospital so I came here.  Audrey didn’t join me this time so you’ll here things from my perspective only this time.

Getting here is always a bit of an adventure.  It went like this.  Fly from OR to Seattle, Seattle to Istanbul Turkey, Istanbul to Ndjamena arriving around 10PM.  Passing through immigration, and health screening, and then picked up my baggage.  Through customs where they requested to open my boxs, then after a bit of a discussion and showing my donations that I was bringing in and scanning my cases, they let me through.  Changed some money to Central African Franks and picked up by the taxi guy who has picked us up for years.  Slept in a mission guesthouse for a few hours, then the same taxi guy picked me up at 5am to catch the “first bus” south.  About 5:45 the bus is full and we head out.  Its a big air-conditioned bus that’s worn but still cooler than what’s 100deg plus outside.  Each of us has a seat that isn’t shared with anyone else- so that’s my preferred way to get here.

As we leave Ndjamena, I listen to my audio book and watch the scenery go by in the window.  First its the city with all its little shops and motorcycles and people milling about.  Whenever the bus stops people are just outside the window trying to get the passengers to buy whatever they are selling.  Peanuts in 1 liter bottles, shoes perched on their heads and others in their hands, mangos on a platter on their head, bags of sugary sesame seeds baked into little flat cakes, and a number other nuts or grains I don’t recognize.  

As we get out of the city, there are the nomadic camps of people with camels and others with cows.  They are traveling through seeming to follow wherever the sale of the animals occurs and where food for the animals is available.  We pass other little villages of more people, motos, shops.  woven mats can be seen for sale outside some little building.  Most buildings as you get more rural are mud walls and a thatched roof.  There is a business selling mattresses and so mattresses are piled high in a stack outside it.  Women are out in the morning sweeping off the dirt in front of their business, to make it clean and get the days trash away.

We pass a number of communal wells that have a hand operated pump.  Lines of little girls or boys with their buckets are outside these.  we pass on with a boy pumping that is completely naked.  He’s about 7, and is a face on profile, legs spread as he pulls down on the pump lever repeatedly.  water flows out the other side into his bucket.

I get to Kelo and the missionaries have arranged for two motorcycles to get me.  So I get out of the bus and indicate my luggage to the bus guy who takes my things out from under the bus.  a crowd of moto taxi guys want to take me wherever I want to go.  Finally one comes up to me and says he’s Christoph, he makes a call and gives it to me, It’s one of the missionaries.  I realize he’s confirming with me who he says he is.  My plastic boxes are tied with rubber cords to the back of one motorcycle and I get on the back of the other.  Then it’s about a two hour ride to Bere.  It’s the dry hot season here.  It is about 105 degrees and the hamartans are occurring.  These are winds coming off the sahara going south that bring in dust.  So the air smells dusty and the sky looks sunny with what appears like smog but is dust.  There is no water on the roads as it’s dry but there are big “potholes” that we weave around as we go along.  We go through barren fields, little villages, and open areas where there is a lake in the rainy season.

After arriving at the hospital I bump into a number of my friends who are missionaries here.  The missionary kids are first to see me and they say hello then the others.  Im tired and hot.  But I came here to help so I hear there are some operations going on because the generator is running so I offer to help.  I guess one fo the two generators blew up yesterday, so only one is working and it’s leaking oil enough that someone has to stand near by and put in oil frequently so it doesn’t burn up.  We hear that a mechanic is coming today to fix it.  The other one apparently had something go wrong inside and a piston came out the side of the case- sound like that one is a goner.  

I get to my place to stay- which is a hours I’ve stayed in before and now is a missionaries house but they are gone and have agreed to let me stay in their place- THANK YOU!  I go though my stuff and find my scrubs… OR gear.

In the OR there is a diabetic with a very infected leg up to the knee.  He’s been told he needs an amputation, I agree, and take him into the OR.  We have visiting ER docs who do the spinal anesthesia and I take of the leg below the knee with the help of the other ER doc.  Part way through the leg I get a lot of pus out.  I think it needs to be a higher amputation but since he was told he’d loose it to this level I stay there below the knee and leave it open.  There is good blood flow so it may heal.  The saw to go through the bone is missing a pin so the blade keeps on falling off the handle.  I put some suture where the pin used to be and that helps.  the saw is old and not very sharp so I get a workout cutting through the bones.  I clean out the pocket of pus that was between the soleus and gastrocnemeous (between calf muscles).  I wash it with dakins solution (diluted bleach) and wrap the stump after controlling all the bleeding spots.  

Next is a 14 year old that had a bicycle accident that put a cut in the back of his leg just above the heal and he has a hole and a gap in his achilles tendon.  He can still flex his ankle so the tendon isn’t cut all the way but there is definitely a gap.  So after he has his spinal anesthetic, I open vertically next to the tendon.  I find it is all cut except for about 2 mm left on one side.  I clean it out and go higher till I find the other end of the retracted tendon.  (as the muscles contract the tendon disappears up the leg)  I grab it and pull it back down.  I debreed off the dead edges and suture it back together.  Then I fashion a cast to hold his ankle still so that it can heal over the next 8 weeks.  He will need another cast in a couple weeks that likely won’t happen, as he won’t come back to the hospital, I just hope I can impress on him the importance of not walking on it and rupturing the repair.

The last one is a woman with a sever neck infection.  I feel there is pus in her mouth and feel a fluctuant area on her neck.  She also has gas in the tissues of her lower neck and upper chest.  This is a bad sign.  She is to sick to intubate and cannot open her mouth hardly at all,  so we give her local.  Denae (missionary surgeon) and I open it up and get a lot of pus.  We open her chest and don’t find much there.  No tracks along her muscles or fascia.  WE pack the open areas with dakins solution and wonder if she will survive.

I go to Netteburg house and eat supper about 8:30PM.  Im grateful for food.  We talk for a while and I head back to take a “cold” shower which is more of a trickle coming out of the tube from the shower.  If I squat down I can get enough pressure to get wet.  It feels real good!  I go to bed completely wet and am able to fall asleep before I evaporate.  If not then Id do it again.  It’s the only way I can fall asleep in the heat.  its about 95 deg when I go to bed.  I wake up this morning at 5am when the power goes off and the fan stops.  Another hot dusty day.

Shanksteps #11 2022

administrator Greg, Shanks No Comments


We are back stateside.  We spent a couple days in Istanbul on our way back, since our flights took us through there.   That was a new and good experience.  Going to the spice market, large mosques, the grand bazaar and encountering many different people and a city of 16million.  Ill include a few pictures.
As I reflect on Bere, There are so many needs both of the people and of the hospital.One thing Bere Hospital needs is some NICU nurse volunteers.  There are some really small babies that are making it, if they get good care.  I heard that the smallest that has survived here is about 0.9Kg.  That’s about 1.8Lbs.  The small ones survive when missionaries take the kids at night and warm them and give their meds at the appropriate times and feed and give IVs to them.  Otherwise they miss doses of antibiotics, don’t get their IV’s or fed via their nasogastric tube frequently enough… and they die.  Of course some would die with neonatal infections too.  But with good care the chances of survival increase significantly.  The doctors have tried to impress upon the nurses the importance of all of this, but it seems very difficult to change the hours meds are given and the intense care the small ones need.  It just doesn’t happen.
What the people of Chad need most is a correct view of God and His love for them.  Of course isn’t that what we all need? A correct view of God.  I’ve read a very good book called the Beautiful Outlaw by John Edredge.   This gives me great understanding of Jesus and his personality.  Excellent.  Another real good one is The Insanity of God by Nik Ripkin.  About his missionary experience and how God sustains those christians in persecution and different circumstances.  Also excellent.
Thanks for traveling with us on this adventure with God, trying to take care of His kids around the world.  We hope you’ve been inspired to follow wherever God leads you.  He does provide!!
While in Bere we were in contact with some workers from our previous hospital in Koza Cameroon.  We have been told that Boko Haram is still in the area and it is NOT safe to visit there.  If any of you are still interested in supporting the ongoing work in Koza, tax deductible donations can be sent to:
Summersville SDA Church70 Friends R Fun DrSummersville, WV 26651
Phone number 3048726958
With a separate note that it is for Koza Adventist HospitalThank you!  We will make sure it gets there when there is enough to send 
If you want to provide assistance either financial or by volunteering to Bere Hospital please contact stacild@gmail.com Also https://ahiglobal.org/donate and you can specify Bere Hospital
I pray you will be open to whatever God has planned for you and that you’d follow His will in your life.  God bless you, Greg and Audrey

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Shanksteps #10

administrator Greg, Shanks No Comments

It’s Monday and my last day.  I’m doing a hysterectomy and I hear there is a woman who is out there that has a neck infection.  Oh no, another one?  Most commonly from a dental abscess that’s untreated a long time.  Its near the end of the day, and in between cases I go out to look at her in the pre-op area.  The whole area smells aweful!!!  She is laying on the one bed in the area alone and semi conscious.  I call the family in and tell them to stay at her bedside so she doesn’t fall off the bed.  I look over her and they say she has been sick about 2 weeks and in an altered mental state for three days.

So I ask myself why bring her in now?  Because they have had pressure by family or friends to bring her in.  They have already tried the traditional healer (witch doctor) and not gotten better.  And now that she is ready to die, they bring her in so that she can die at the hospital and they will be able to say they’ve done everything they could.  So that the neighbors and distant family will not criticize them.

Well at this hospital we operate on emergency cases without requiring money first.  That sure is a great thing, because they would never give money for her in her condition- they know she will die.  I KNOW SHE WILL DIE.  But it is God who can do something about her situation that we have no control over.  I pray for her and send the family to the pharmacy to buy medications…  I ask the “nurses” to start an IV and get fluids going.

I do my last surgery that was scheduled that day and come out to check and see if she is ready.  The family didn’t go to the pharmacy, as I anticipated they wouldn’t.  She does have and IV and we take her to the operating room.

I will not attach pictures, but if you’re interested you can email me at my usual email directly and I can send some.  They are graphic and disturbing of the reality of her surgery.

What follows is graphically descriptive- if you do not want to hear it- then skip the next paragraph.

GRAPHIC paragraph- I want Phillippe to give some ketamine, but he is concerned about her airway as she can’t open her mouth because of trismus.  If I push on her neck she will slowly grab my hand a push away, but definitely altered consciousness.  Im going to be debreding her neck so I think a trach is a bad idea.  He doesn’t think a nasal intubation is a good idea.  So to say there are no good options.  He finally gives a whiff of Ketamine and we start.  She groans at each cut but is less conscious and will not remember this.  The resident, Anna, who is with me does a lot of the debreding.  It is a horrible process. We open where there is a open area of her neck with pus and grey tissue.  At each movement more of the dead smell wafts out.  We start cutting off dead tissue and go from her left ear, down her neck to her upper chest.  We can put our finger undreneath all along this area easily.  Underneath this flap of semi-dead skin, there is a grey layer of fat, then under that some black muscle and some live muscle.  The platysmus muscle is partially alive a and partially dead.  We end up taking off all her skin in an area of about a 10 x 10 inches of chest in the center and then back up the other side of her neck to her other ear and a little on the side of her forehead, then around the base of her chin to complete the area.  We then take off all the grey and dead tissue we can get off.  All while she is groaning at times and Im asking Phillippe to give a little more- which he doesn’t want to do.  As he is conservative with it, she does breath fine and keeps her saturation up during the entire thing.  We take off a little more skin in some areas and the area is looking and smelling better.  (Im grateful in cases like this, that my nose doesn’t work as well as some peoples)  So she survives the surgery and as we bring her out to her family with all the dressings covering everything.  I tell them it is their turn.  They brought her here to die, but I have asked God to heal her and help her live.  They need to go to the pharmacy and get the IV and medicines that she needs now!

We leave the next morning.  I hear that she survived. Then a couple days later I hear that a NG tube was put in for feeding and later that day she died.

The other girl with pus coming out her mouth and ear is doing well and has minimal pus on the dressings now.

Shanksteps of faith #9

administrator Greg No Comments

The 18 year old girl with pus coming out of her mouth and ear- from her jaw; is still alive!  Praise God!  She still has trismus and can’t open her mouth far, but seems like she’s a little better.  I saw her on rounds today.  There is still pus on her dressings but seems better.  

Have I mentioned that I have to operate often on suspicion rather than a diagnosis?  Have I also mentioned that I find it hard to operate on missionaries without all the information I’d have in the USA?


Friday afternoon I hear that D (a missionary here) has abdominal pain and has just returned from a trip for supplies in Moundou.  Should we treat him for travelers diarrhea?  Well I need more information, so I have some time and so I go to talk to him in his house.  He is in pain and moving around a bit.  He hasn’t eaten anything on the trip and only drank bottled water.  But he does have significant abdominal pain.  He says his pain started early that morning, and started all over the abdomen, and is still all over.  I examine his abdomen and find it’s definitely more tender in the right lower quadrant.  It could be: appendicitis, a tumor, a blockage, typhoid, kidney infection…  We start an IV and get him some IV diclofenac.  I also start empiric antibiotics.  Later I go to evaluate him again and his pain is much better, but now in the right lower quadrant.  I then think it’s appendicitis.  We talk about operative and non-operative management.  He wants to accept the risk of recurrent appendicitis and have non-operative management if it will work. He’s quite tender all over but I don’t think he has generalized peritonitis.  I pray for him, for healing and for wisdom as to whats best to do with him. One of the nurses takes care of him all night.

Sabbath morning I go to check on him again.  He is much better and pain remains now only in the right lower quadrant.  I’m content he is improving.  I check on him a number of times that day and he seems relatively the same but maybe more distended.  I wonder if he is really getting better with antibiotics or now not?  His typhoid test is normal (about a 50% accurate test, so NOT accurate), and his white count as read by counting cells is 5.  Various missionaries hang out with him all day, and another nurse continues to give him his meds.

Sunday morning  I go to see him and he seems a little worse with pain in both sides of lower abdomen.  I consider this a failure of non-operative management.  He also just vomited before I arrived, about 500 mls of bile.  He wants to talk to the other missionary docs before doing anything else. I go outside and am able to get a signal and talk to his wife and tell her I think he should be operated on right away.  I go into the hospital to make rounds and inform the others.  After rounds I go back to see what the discussion has been.  He’s been walking around trying to see if that would help. It hasn’t.  One of the other docs did an ultrasound looking for the appendix and found fluid on the right side.  Then all three of us docs go and talk to him together.

We discuss that MAF has the ability to fly him to Ndjamena, there is a Air France flight that night and he could be in France by the following morning.  The other option is for me to operate.  I try to make it real by telling him, with these circumstances, I’d be operated on here.  The other two docs are divided as to whether they’d stay or try to get to France.  He contemplates it for a while and decides to accept the risks here rather than the risks of travel (someone would have gone with him).

We are all suppose to go to one of the Chaddian workers houses to eat lunch, because she invited all the missionaries to come.  We have to cancel this just as we were suppose to be there- what a bummer!  We head to the OR ahead of him to clean it real well and get it ready.

After cleaning I head back to his house and he decides to walk to the OR.  We have a wheelchair at the ready in case he changes his mind.  About half way there he uses it.  He’s a tough one.  

We prep him and I make the incision.  He is getting Ketamine and Valium as some of the missionaries were concerned about Phillipp’s general anesthetic, and I know Ketamine will work if he gives enough- he’s a bit conservative with it.  D is light with it and I keep asking Phillippe to give more.  We have some propofol so eventually he gives that.  The other doctors are at the head of the bed too, monitoring vital signs…

As I open his abdomen I find dark serosanganous fluid. I feel around the cecum and can’t feel an appendix.  Then I fell a little release and a loop of maroon bowel comes up.  I can tell a band of tissue had been across it cutting it off and leaving a line on it. So it’s either a band partially blocking his intestine or could be a bad patch of typhoid.   I feel around and can’t feel anything left that’s unusual.  I realize his appendix is tucked behind the cecum.  So I free it up and do an appendectomy.  At least that won’t be a confusing factor in the future.  I look around and find nothing else abnormal.  Now I’m worried if he will heal his typhoid or perforate in a few days.  I close him up and we take him back to his house where one of the missionaries will be with him constantly for many days.

UPDATE:  At the time of sending his bowels are opening up and he is starting to drink and advance his diet.  I thank God for his healing.

Shanksteps of Faith #8

Audrey Audrey No Comments


Audrey here. I don’t usually write much because Greg’s stories and pictures are so much more interesting.  I figured I should at least say a word before we leave on Tuesday so y’all wouldn’t think I did nothing. 🙂  I have been rounding every day on pediatrics and medicine wards.   Peds  can be extremely sad or very rewarding. The majority of the kids come in very sick, but after 2 days of treatment (usually for anemia and malaria) they are feeling better and running around. It is wonderful to see so many kids turn around so quickly and go home.  Of course there are some that come in very late, or very sick; often convulsing and sometimes with a hemaglobin less than 1g/dL. It is amazing how many of these kids do well with a transfusion of blood and a couple doses of quinine.  BUT there are the kiddos that succumb, and don’t make it home.  Those are the sad days.  The adults on the other hand seem to NEVER get better. This week I had a full ward of men and women, all with ascites from various different causes. Some had liver cancer, some cancer of the spleen. Others had nephrotic syndrome, or Congestive Heart Failure.  In others, the cause was a life of drinking way too much alcohol (usually rise or millet wine- bili bili). There are others with hepatitis, or HIV, or Schistosomiasis.  Almost all the adults I saw could have benefited from lasix to pull some of the fluid off. BUT… the hospital doesn’t have any. So… they were all sent to the market to find lasix. Some is probably legit, others may be blackmarket or not lasix at all. When I finished rounds Friday, I had 12 adults on the wards. This morning (Monday) there were only 2. The rest just disappeared. Discharged, or ran away without paying the bill. Two women last week had seizures and went into comas due to low blood sugars. I found one, Greg the other. Both came out of it with a bolus of dextrose and a bit of sugar under the tongue. Neither were there this morning.  I have heard that they both died when they arrived home. Some left to go to the witchdoctor? To try traditional treatment? I will never know.   Today I was called to peds to examine a 13 yr old girl who was “violated”. The story was a bit difficult to figure out. As well as I understand: The 13 yr old is brought by her father to find out if she is still a virgin. The father says this boy had sex with her. The girl says she had sex with the boy.  The boy denies everything. I am supposed to be the “tiebreaker”.  Is she still a virgin? Will she bring shame to the family?   I explain that even if her hymen is no longer intact, it is impossible to determine if it was from sexual relations, or riding a bike, or using a tampon, or, or, or… The father seems to understand but still wants her examined, and the results documented. Their plan was to take the boy to the police if the girl was no longer a virgin.  Can you imagine doing that in the US? One amazing story that I can tell you about my time here is about a little baby named Toungou. She is a twin, born 3 weeks before. I met her.  She was brought in to the hospital after being taken to 2 different health centers for 2 days of convulsions.  When I saw her, 2 of our volunteers here (an RT and a PA) had been trying to ressussitate her. She had stopped breathing twice already and had been bagged and given CPR.  We checked her sugar, which was normal. Hemaglobin was normal. Malaria smear was negative. No nuchal rigidity or bulging fontanelle. I helped bag her for several hours. We would stop, and she would breathe on her own. Then the breathing stopped. The heart slowed and stopped. She was pronounced dead. For 30 sec, 40sec…Then she would convulse and start breathing again. She did this 4 times and we decided that she really wanted to live.  Fortunately, the midwife here, who is also doing amazing things with preemies and very tiny babies, has a portable cpap machine. Little Toungou just needed to keep breathing to trigger the machine. She was given Rocephin, Dextrose, and put on cpap. Mom agreed to have us take care of her in our homes, so she spent every moment with one of us volunteers. Nights at one house to be watched carefully; days elsewhere.  I was fortunate to be able to hang out with her after rounding until she went home with someone else for the night. Within 3 days she started to look better. She was no longer seizing. She was being given mom’s milk by tiny NG tube. She was still receiving Rocephin for probable meningitis.  After 4 days with us night and day, she was given back to mom to take care of during day, and just spending nights with one of us.  After 6 days, she started breastfeeding on her own. The NG tube was removed and she went home yesterday. Glory Be To God!
I am now sending this from the capitol of Chad, N’Djamena. We are on our way to spend 3 days in Istanbul before flying back to Oregon. This has been a difficult trip for me (maybe more to follow), but baby Toungou and many of the other kiddos have made it beautiful as well.   

Shanksteps of faith #7

Greg Greg No Comments

Horrible details follow, read only when you’re ready to be touched by someones hurt.

She is 18, she has pus coming out of her mouth.  She cant open her mouth because of a muscle spasm called trismus.  She is laying in the pre-op area and the whole place smells like horrible pus.  She appears to be in pain and has the very sick look to her.  Some of you will know what this looks like.  She has had dental abscesses for a week or two.  They brought her here on a two wheeled push cart.  They put the cart “en gaauge” to pay for her medications and treatment.  This means they have money coming but that the cart is the security that money is coming.  As she lays on her side I push around on her neck and she spits out some more thick pus.  She looks swollen like a chipmunk in her cheeks.  I feel they are both very soft around the mandible.  This pus near her mandible must communicate with her mouth.  She is the last surgery of the day and we take her back to the OR beating off the flys that accompany her.  Phillippe doesn’t want to give her any anesthetic as he thinks this will kill her.  I tend to agree that intubation is impossible, a tracheostomy has killed two patients here that I know of in the fact that they eventually mucus plug and the patient dies of asphyxiation.  Ketamine may be risky, I think a little would help.  He doesn’t want it and I don’t push. 

As I look over her face and neck, I push on the left chin and more thick pus flows out of her ear.  WOW!!! This is horrible.  I certainly do not think she will live through this.  I put in the local anesthetic after prepping her with betadine.  I cut in about a cm and don’t get pus like I expected by palpation.  So I use a syringue and needle and aspirate deeper.  I get air first, and this happens twice.  Oh even worse than I had thought.  She has gas, necrotizing bacteria.  God, I pray out loud, help this girl, heal her God, she will die unless you heal her!! If it is most merciful to let her go, then do it, otherwise heal her!!

I cut deeper and chunks of pus flow out.  I put my finger in and feel around the angle of the mandible, and then down her neck.  This is a big pocket.  I incise the lower part to of the pocket.  All of this is causing her pain, and she’s groaning with each push of my finger.  I irrigate out the hole with Dakins solution (a dilute bleach solution).  MORE pus and blood flows out.  I pack both holes and the bleeding subsides some.

The other side I decide to start lower at the angle of the mandible.  I inject lidocaine and incise.  Pus flows out of the hole Ive made and as I stick my finger in to feel the size and extent of the pus cavity, pus flows out her ear again.  So she has pus up the the base of her skull and it’s  coming from her inner ear out.  I flush and flush this one too.  Then I pack it.  Her heart rate stays about 140 and has a blood pressure in the 90’s.  She got Amp, Gent, and Flagyl.  Wish I had some clindamycin.

The nurses take her to the ward where she’ll sleep on the stretcher for the night because there are no beds on the surgical ward available.

GOD HEAL HER!  THAT’S  HER ONLY CHANCE!

Shanksteps 2022 #1

Greg Audrey, Greg No Comments

Shanksteps 2022 #1
Here we are again on another trip to volunteer in Africa.  We are going to the same hospital in Chad we’ve been to a number of times.  Currently there is no general surgeon there, and hasn’t been for a few months.  If you know of any general surgeons who want to go and live in Chad, one or two are very needed.  (They could contact me for starters).  
We leave home Tuesday and stay in Eugene to catch the 5AM flight.  Then to Seattle for a long 12 layover.  Then a 9 hour flight to Istanbul.  We are there a couple hours then on to Ndjamena, Chad on a 8 hour flight with a stop in Niger along the way.  Each flight is progressively more “african” in nature.  By the last flight there is no calling of sections to load the plane.  Everyone just forms into a mass of people jockeying for a position at the area where you go past the attendants taking our boarding passes, and we know this so we stand near the front and end up in the first quarter of people loading.  this is advantageous because then there is still luggage space above to put our carry on luggage rather than it taking up floor space near our feet.  
We land in Ndjamena on Friday at 2AM and go through immigration and customs after collecting our baggage- which all made it! then on to find our driver L.  He has picked us up many years of going there and is always punctual and has also arranged for us to be able to change money at this hour of 2AM.  L is definitely more expensive ($40) than he used to be, but still worth it to have someone we know waiting for us.  We ask him what bus we should catch from Ndjamena to Kelo- and he recommends the 5AM bus.  We like this bus because its a large one with a defined seat and has airconditioning that helps some.  so we could go to the mission we were to stay at for an hour or just go to the bus station.  So we decide to head to the bus.  the streets are empty but at the bus station there is plenty of people getting ready to travel and others trying to sell their wares to them.  L gets me a guy to sell me sim card for my phone and credit for it.  The sim doesn’t seem to work and then it does after all.  L gets us our tickets and we load the bus with our luggage stored beneath.  We choose a seat nearer the front as this is usually less bumpy than near the back.  We start out before completely full so we stop at various spots along the way to pick up other people.  At one area we stop at a military checkpoint and all the men have to get out and get patted down and show what’s in our bags.  This goes off relatively well and we all board again.  A bit later there is a little commotion as water starts running down below the seats on the other side and down the isle.  Someone thinks its water, and then another says someone peed in the back.  I don’t smell anything like pee so Im grateful and also grateful it didn’t get on the bag i have at my feet.  We arrive at Bongor the bus stop for changing some passangers.  we wait here for about 15 minutes and mill about the small area.  there are many vendors there selling things like- potatoes, taro, other roots I don’t know, roasted beef, lamb, goat.  My favorite to see is the huge pile of fried grasshoppers.  I don’t have the courage to try them, though Audrey has and didn’t get any.  We all load back on the bus when they start honking and we head on to Kelo.  
A little after noon we arrive in Kelo.  We anticipate someone from the hospital picking us up in a vehicle but they are not there.  We get out our luggage and pay a guy with a cart to move everything off to one side where our thing can sit without worrying too much about them.  We sit down on a bench that is near by to wait.  After about 30 min we get a hold of the guy who was to get us and his car got full of water crossing a large water area on the road that was deeper than expected,  and died and was being towed back to Bere by a tractor.  He then tried to arrange another vehicle.  After about an hour we hear that it would be best to go by motorcycle  taxi the last ?2 hours.  He wants to arrange the motor taxi for guys from Bere as they don’t charge double like the other moto taxi guys may require.  We wait another hour and  a half.  People are coming, but they don’t show up.  
During this trip I realized my Keen sandals soles are falling off.  I only brought them and OR shoes.  So i ask around and find a guy sitting under an umbrella who is fixing shoes.  He says he can fix them for 2000CFA ($4).  So I sit near him on a bench and another guy starts talking to me.  Id guess he’s about 20 and seems drunk.  As I sit there I realize the guy who fixs shoes is next to a woman who is selling vodka, wine, and other spirits in little plastic bags.  So this guy is drunk.  He asks lots of questions and talks about how hard english is to learn, and why I won’t drink with him, or buy him another bag of drink.  The guy fixing my shoes warns me to watch my phone as the kid next to me may steel it (thank you).  He glues the sole on with some contact cement used on a bicycle repair kit after cleaning off all surfaces.  It seems like a weak repair.  So he then sews across the front and back of the sole to secure it better.  This seems to work well.  And later on I am very grateful to have them fixed as you will read.

Then about 4pm Im starting to worry, if we get started too late it will be dark and more difficult to travel., and darkness also increases the price and chance of a fall.  I know the road is muddy and apparently had large amounts of water in some places.  He calls a guy at the bus station and this guy helps us get some motorcycles from another town beyond Bere.  But they seem only partially interested and also charge a lot.  WE want three motorcycles and there are only two of them.  Then finally two from Bere show up and say they are here to take us to Bere and load our gear on their motorcycles.  They strap our four plastic luggage boxes on one motorcycle with the driver sitting on the gas tank, and put Audrey and I on the other.  So both are very loaded.
Then the fun begins.  We travel through Kelo then head off the main road.  Ive not been this way before and know it must be to avoid water on the main road as it gets huge deep mud puddles.  We wind through many small villages with stretches of farm land in between.  Here a left there a right.  Nothing distinguishes it from any other trail to follow.  Most of it just wide enough for the motorcycle, so only foot paths we are following.  We go through patches of puddles and our feet are wet.  The motorcycle is making a strong clicking sound with each rotation of its tire and I wonder if we are going to break down on the way- but our driver Sebastian says its not a problem and will get us there fine.  about an hour into the trip its getting dark and we are going through some deeper water and getting stuck in the mud.  I have to get off in the mud to push.  I have mud up to mid pant leg now.  We nearly fall over a number of times in the mud and in other sections in deep sand.  Then when its fully dark we hit the big sections of water.  We go about 100 feet into the water and we hit a rock or log that stops us abruptly.  i have to get off and push and water is up to my knee.  He continues on with Audrey and I walk for a way till he stops and lets me get back on.  Then there is a section that he says we have to walk through and they will push the motorcycles and meet us on the far side.  We meet up with the missionary Charles who had planned on getting us in his car that died with water in its engine.  He had come to help us in this section.  So we walk with him.  Carry on back pack on our back and walking through the water.  We walk through a section of water that was about 100m and about thigh deep.  Charles says the day before this was passable with a car and that it had risen to this.  We walk on and get to another large area of water.  There are no motor or people.  just a tractor pulling a large trailer loaded with grain, through the water.  Audrey, Charles and I walk for probably a mile through water that varies from ankle deep to Audreys waist.  I am very thankful my shoes were fixed and are working well.  After about 45-60 minutes of walking in water we arrive at dry ground again.  the same motorcycle have gone some other way and meet us walking on the dry road again.  It’s only a few miles left to get to Bere.  We are glad to be there and meet some other missionaries.  We are taken to the house we will stay in for the month and shower and sleeeeep!  We left home Tuesday evening and arrived in Bere Friday night. Thank you God for helping us get here safely and giving us rest.