He lay crying on the emergency room table, grabbing his lower abdomen. He got up and slowly walked outside, all bent over. Nearing a tree he lifted his gandara and tried to pee. Nothing! With a grimace on his face he walked back in. He had come to the hospital a couple weeks ago. He had taken the antibiotics and felt better for a little while. Yesterday he couldn’t pee, so he went to a hospital in Mokolo and they put in a urine catheter. After his bladder was empty he felt pain and the need to pee but nothing was coming out the tube so he asked for it to be removed. He went home that evening and couldn’t pee all night. Then he came to “our” hospital.
The nurse tried to place a urine catheter, but it wouldn’t go in. I walked back into the room as the old man is yelling, grunting and deep breathing, trying to tolerate the placement of a catheter that was trying to enter the prostate that is to tight to even let urine through.
So I get on sterile gloves and give him a hand. More yelling ensues. I get it partially in, but not enough to get urine. As I pull it out it tugs significantly and he jumps and yells some more. The curtains the we put up have been removed between patient beds in the emergency room, so the 13 year old girl who has pneumonia and is breathing at a rate of 50/min, looks on at the commotion. Neither he nor she seems to be bothered by the indecency of the situation. I call for the nurse to bring me a smaller catheter. The pharmacy doesn’t have one. Dr. Roger, a Congolese doc that is covering for a while, walks in and says he thinks there are smaller ones. No one can seem to find them. I take off my gloves and check out the stock. Fortunately for the patient, we find some and it goes in much easier with only short yelling and grunting. We send his family off to the pharmacy to purchase all the materials for a prostatectomy.
I take a look at the 13-year-old girl. She came in that morning after 4 days of not breathing well. She is thin, in the first stages of puberty, and breathing fast and deep with a LOT of effort. She had been started on penicillin. Her bed is in a sitting position, and she was leaning forward to try to get in more air. The oxygen concentrator was giving her 2L of oxygen. I ask for the oxygen saturation monitor, and they tell me both have been broken. I ask for one of the nurse’s motos and go home and get a finger monitor that my anesthetist in OR, gave me to come over with. I head back and check her oxygen, its 77%. I listen to her lungs and there are crackles all over, with quite a bit of wheezing. Let’s see, what antibiotics do we have right now? Amoxicillin, Ampiciillin, Chloramphenacol, Cipro oral, and metronidazole, penicillin. What bacteria are possible here? What’s common here? I’ve forgotten what I used to think when here! I start her on Ampi and Chloramphenacol, thinking it will cover Strep, Staph, and H. flu. (common bacteria in the US). In the US I would intubate her, here I just hope she keeps breathing.
The family returns, having paid the materials for the prostatectomy. I’m surprised, but then remember that they had been home preparing to come back for surgery, when they heard that I was coming. I head off with Audrey to go home and change cloths to attend the wedding of Avava and Valantine that we came for.
After the wedding I head to the operating room with Dr. Solomon (The other Congolese doc that’s covering here). They have done one prostatectomy and the patient didn’t do well, so they have been telling the old men with urininary problems to come back in Dec, when I arrived.
Ketamine, Valium and Atropine are given and the old man is off to sleep, making the funny faces people make when hallucinating on Ketamine. We open the pack of sterile equipment and find they are out of gowns and have put yellow, infectious gowns in the packs. These are a thin, see-through, material that is NOT sterile. We open other packs till we find the one with cloth gowns. We put these on and I have to say something to the other Doctor about sterility as he grabs his gloves with his bare hands and pulls them onto his gown. We change the gloves and continue.
I press the blade against the dark skin, and it fillets open showing the white and yellow inner layers. It’s been a while since I’ve operated on dark thick skin. Essentially no fat is there. I divide the fascia and open the space above the bladder. I fill the bladder with saline, and then open it. My finger examines a huge nodular prostate at the apex. Cancer? I crack the prostate anteriorly with finger pressure. The other doc feels the same area. I realize that my thin gloves must have a microscopic hole, as my index finger is wet under the glove. I double glove. I attempt to shell out the prostate unsuccessfully. I think about a different approach, and decide that it’s not wise under my current circumstances. I have opened the prostate enough that he should be able to pee again, but the prostate will stay. We close the bladder, fascia, and skin, leaving a glove piece as a drain. Wish I had brought in the drains someone gave me before coming! I always worry about part of the glove tearing off inside as I try to pull it out a few days later. As we are closing the irrigation starts filling in the wound. The catheter must be blocked. I irrigate it and a large clot comes out. I reinforce with the assisting nurse that is giving Ketamine that this is the reason we need to be vigilant of the irrigation. He assures me that they are. (even though it is truly the family that does the irrigation and empties the urine sac).
I return to see the 13-year-old girl in the emergency room. She says she’s breathing better, but looks about the same. Her oxygen saturation is better after increasing the amount, but she is still breathing very fast.
I head home to prepare for the evening party of the married couple for close friends and family. That night I pray for all our patients, but specifically the old man and the young girl. “God protect them from poor care, dirty surroundings, and their disease. Thanks.” G