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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
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

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 #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

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

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

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

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

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 #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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