Bere 2018 #3
As my father in law used to say “It’s a good tired”. I’m tired at the end of a long day. Here the day starts at 7:30 with a hospital worship. I couldn’t fall asleep last night till about 2 so didn’t make it in on time. But one of the nurses was having a teaching on tuberculosis. It was quite informative about the countries methods of dealing with the disease and its treatment in different circumstances. For example, a pregnant woman, a person who has had negative sputum’s then turns positive again, patients with HIV, children, those who get inpatient treatment and those outpatient… After that we went and looked at the new OR that is being built. They have a building structure that is metal (termites cant eat it), and are building block walls on the inside to create 2 operating rooms, preop, postop, instrument cleaning, and instrument storage areas. Dr. Sarah Belinsky ( I guess she goes by Dr. Sarah so Ill call her that now) and I make some construction decisions, I head to the OR to verify whether they are preparing the first patient- and they aren’t. So I try to hurry them along, it always seems like a slow start each morning as I recall. Dr. Sarah calls me into the ultrasound room to see a 20 year old girl. She has a palpable abdominal mass. It seems mid abdomen. Oh NO! It has to be cancer. We look on the ultrasound. I see ascites (abdominal fluid), which is a bad sign, and a large solid and cystic mass. We look for the ovaries, and they seem normal as well as the uterus. Liver doesn’t seem to have any metastases. I feel terrible as I tell her and her older brother who brought her about our diagnosis. We have no chemotherapy drugs nor pathology for a true diagnosis, so the only thing I can offer her is to explore her abdomen and take out the mass if I’m able to. If she was an old woman, I wouldn’t offer as I don’t think it will be successful. But a 20 year old, I’m going to try tomorrow. I head back to the OR and they’re not ready. So I head to make surgical rounds. I’m still completely stumped by a 15 year old kid who had 1-2 inch pitting edema all over. I’ve thought and treated, congestive heart failure (heart seems a little big on ultrasound- not accurate in my hands), wet Beriberi (thiamine deficiency), treated his malaria and typhoid, nephritic syndrome as he is dumping protein in his urine. Its these patients that I’m most frustrated by not having appropriate tests. For surgical problems, if I open their abdomen, I can almost always diagnose and usually treat, even if I can’t figure it out ahead of time with the ultrasound.
Back to the OR and they are finally ready for a right leg amputation on a 60 year old lady that had been bitten by a snake a few weeks ago. Most of the skin on her leg sloughed off and muscle died. They have been doing dressing changes and now both her tibia and fibula in the lower leg are exposed for almost their whole length. Pus continues to drain out of her foot. It hurts her to have me touch it anywhere, except above the knee. I decided to do an above knee amputation. She hurts every time she moves and is lifted onto the OR table. She is given a spinal anesthetic and I start my work. The “tourniquet” that is on the leg is a normal blood pressure cuff that looses air constantly. So one of the nursing students stands near by constantly pumping up the cuff. I am very pleased that the cautery machine that I brought last year is still working. Between the ‘tourniquet” and the cautery there is very little blood lost. Once I’ve cut through all the muscles and tied off the arteries and veins, it’s only the bone that is left. There is a little saw, that I use to cut thought the bone. I’m tired after sawing a few minutes and hand it off to my assistant to continue. Eventually we get through. The saw is quite dull and likely has been used for a half century. I close the muscle layers over the end of the bone then the skin and wrap it with an ace bandage. Next was a inguinal hernia.
Then there is another inguinal hernia that is strangulated. He’s had pain and not eaten for three days. Says he’s vomited some. I’m guessing he has dead intestine in it. I open this area up and I see black tissue. As I dissect around it, it seems to be coming through a small hole. Eventually I open it once I’ve gotten to good tissue. It is a necrotic hernia sac. This usually means that there is dead bowl inside. The fluid I get is clear and all the intestine I can find from this hole, looks normal. Disconcerting! It seems the same size as when I started, so I don’t think anything has reduced spontaneously. I then have two options, open him up along the middle and look around or finish what I’m doing and see if he improves or worsens. I decide to watch him after this operation. (if you surgeons differ with me, let me know). I’ll know tomorrow if I made a good choice or not.
Another woman awaits a curettage after not getting all of the placenta out after a delivery. She is very nervous about it. We bring her family in and explain everything again. She agrees and we walk her into the OR. She starts crying and says she doesn’t want to do this. So we take her outside to her family. We all gather our stuff and I go to check things on the surgical ward- about 5PM. WE are called back to the OR for a C-section. A lady has not been progressing all day and apparently has been in labor a number of days at a dispensary before coming here this afternoon. She arrives and sits on the OR table for her spinal. After the spinal is in, she is laid back and we prep her for surgery. The cloth covered C-section pack is laid on a nearby table and opened. A fly is flying around the room and lands on the open pack. We wave it away and as it is the only C-section pack “sterile”, we use it anyway. I am totally convinced that God protects our patients, as infections for clean surgeries are very rare in spite of the conditions. Dr. Sarah does the surgery and I assist. The baby comes out with meconium everywhere. But breaths and cries- Yeah the sounds of a live baby! The area is closed up and she heads back to her maternity bed.
I’m asked to see an old man who had a prostatectomy before I came, and has urinary retention now 7 days after surgery. This morning when I saw him he was still with dark bladder irrigation. Likely meaning he is breaking down blood clots that remain in his bladder. He is eating and in pain from a bladder that is visible when I look at his abdomen. I flush his urine catheter and try repeatedly to clear the blockage. Finally I just remove it. He is able to urinate. I hope that he continues to urinate or I may need to re-explore his bladder again.
I head back to the place I’m staying and eat the food that was prepared by a guy I’ve hired to make my food while I’m here. He’s prepared and left me some millet paste with an eggplant/tomato sauce! Not exactly my favorite, because we had something similar so often in Cameroon. But I’m hungry and so I eat till I’m full. I realize that the phone credit that I purchased yesterday evening is nearly gone. I haven’t used much that I can think of today so I go through my phone again and try to turn off everything I can find that is sucking up my phone credit CFAs (Central African Francs). I head out to the market to get some more. It’s all dark but a few cell phone lights can be seen. I find the guy selling the Tigo credit and tell him I want 5000CFA ($10). He punches in a certain number on his phone and I get a text message that that much has been added. He also sells brown soap, tomato paste, some soda drinks, Chinese batteries, pens, paper, a few types of shower soaps, flour, rice, different types of small cookies and crackers, powdered milk, garlic, small onions, maggii flavor cubes and many other small things. I head back to my place. In the dark on the walkway I feel like I stepped on something. I flip on my headlamp and see that hundreds of termites are building a mud mountain that is half way covering the concrete walk. They start scattering and kind of raising up toward the light. It’s a strange site. In the day, these always look like nothing is happening, but it’s slightly taller. They are very busy tonight. Guess Ill be looking at them every evening when I come back, for interest sake. I hope you all are enjoying these stories. If you’d like to hear about something specific, then email me back. I’ll respond, even if I’m back home wh