Chad #7 2019
Bon Soir (good evening), le Soir et bon (the evening is good). I greet and the return greeting is given. It’s about 9PM and I’m walking around the hospital letting all the nursing departments know that I’m the one on call. I start with the peds ward, and there are 3 nurses and students hanging around. Some of the nurses were on earlier, so they’re just hanging around talking. The nurse asks if I can see a workers children and treat them, as the nurses aren’t suppose to treat workers. (but everyone else they can prescribe for). There is a 10 year old boy and a 12 year old girl. Both have malaria on their tests, and the girl also has typhoid. I cant remember peds dosing, so it takes me a little while to look up the dosing and calculate what to give them based on their weighs. At the surgical ward the guy with a bunch of pus in his belly is having fevers to 40 deg. (about 104). He could have an abscess again in his belly or have malaria or both. He is still very distended and his drain is putting out some chunks of yellow stuff mixed with clear fluid. He’s passing gas today. His nasogastric tube, that’s attached to a urine bag sitting on the floor, has l lot of bile from today. I decide to treat him as if he has malaria and he may need a look and a washout. Wish I had a white cell count and a CT scan, though 3 days postop, a CT scan would be difficult to help know what to do as well. I tell the nursing students (that’s who covers the surgical wards here at night) to order IV quinine for him. The ER nurses are sitting outside chatting, so nothing going on there yet. The maternity nurse is making her rounds and giving medicines. One woman is in labor who had a baby in a cephalic presentation (that’s good). This will be her fourth delivery (also good, the road out has already been tested). As I walk back to the place I’m staying, large fruit bats are flying all over in the moonlight, eating from the large mango trees.
I made it out to that certain tree to send emails tonight. I did three hernias today and there was another guy with a bladder stone that said he couldn’t pee, but when we went looking for him he was no where to be found. Guess ill do him on Sunday or Monday. So I got done about 2 today, it was 102 by one thermometer in my room by one and 107 by the other. I brought thermometers with me because I was curious how warm it was. I knew it was hot and worse in the sunshine. This afternoon, Dr. Sarah, Gabriel, Diana, and Dr. Stacey and I, all went to that special tree to get 3G service and do stuff online. This was a different tree than I had been to before. I guess it works there sometimes, and at other times they have to go further to the other tree if it doesn’t. It worked well today and thus you see the emails I sent.
Throughout the night I wake up a number of times and feel hot. Then this morning after I’m up and drinking water. I start to hear thunder and it rains. Things are finally cooling off. Its 86 degrees inside and about 60% humidity. I think we’ve been running about 40% humidity.
I go in and see a few of the surgical patients. One lady I removed a breast cancer this week. It was in a difficult place in the upper breast near the clavicle. Removing it appropriately and then having enough skin for closure was challenging. The cancer was large, about 15x10cm and went down to the chest wall but didn’t appear to invade the pectoralis muscle. She also had a lymph node near by that was enlarged. I ended up closing her with a lot of tension at the incision, meaning I had to pull the remaining edges together with a lot of force on the sutures. She is doing well now but has a headache so I check her for malaria.
Another man I saw as a consultation between surgeries. He has diabeties. When I saw him, they said he had had a wound on his foot for a long time, and they mentioned something about a bone. The nursing student helping me translate took off the bandage around his whole foot. I could see his lower leg was swollen to above the ankle. I’m amazed by what I see. There is the bone of the big toe sticking out of the foot. Just the bone, not tissue around it. It almost appears like someone did a toe amputation but forgot to remove the bone. As I push on his midfoot, pus flows out around the open wound with the bone. Since he has diabetes he doesn’t feel his foot- which is why, I guess, this has gone this long without being addressed. I took him for the amputation the next day. They had an interesting way of preparing him. Abouna attached a rope to his ankle and strung up the let to an IV pole. Then they tied a foley catheter “real tight” around his thigh as a tourniquet. I thought that the leg should be put down for the amputation, but they said they always did it up like that. So I did it strung up like that. On this one I wanted to use the cautery. They have developed a method to keep the cautery probe sterile without putting it in a bleach bath. They made a long sleeve for it out of cloth and then they autoclave these cloths. So we stick it in the one end then slowly work it thought the cloth and then the tip is put in alcohol and then placed through the end into the cautery wand. So I used it. I cut thought the skin then controlled bleeding with the cautery. As I came to the different named vessels, I tied them off. The muscle I divided with cautery, and that diminishes the blood loss. We used a saw to saw through the tibia and fibula. As I divided the last of the tissue behind, the anesthetist, took the leg and placed it in the trashcan. I used a rasp to take off the sharp edges of the bones and we removed the foley “tourniquet” and no additional bleeding occurred. I realized that the incision was a little off and I had to take more on one side to make it look equal and for it to close well. He is not in much pain today. I am amazed at the difference in pain medication use in the US and the lack of pain medications here. Everyone here gets Ibuprofen and Tylenol. Yes they have pain, but they tolerate it well.
I finish looking at the patients I was interested in and see another that they wanted me to see. I found out Diana was going to a bush church and no one else seemed to today. So I asked if I could go with her and her translator. So today I went to church under some mango trees! I took Olen’s moto and followed them down the road towards Kelo. Once we crossed over the big river we took a left on the dirt path. (HaHaHa, all the paths are dirt here, as is the road we were on). We went for a fairly short distance then found about 8 people sitting under some trees on two benches. We pulled up and they made room for us on the benches and someone went to get another. The kids were a short distance away on a large mat. I found out they usually have a kids story during the adults lesson. I hadn’t planned on doing anything, but then offered to tell a bible story to the kids. The translator appeared pleased and so I went with him to do the kids story. He thought it good that we tell about Noah and the arc and the subsequent story about the tower of Babel. The kids seemed interested at first with the picture I was showing, then they got to squabbling amongst themselves and pushing and lost interest. I tried to redirect them but I couldn’t keep their interest so I cut my story short. We then joined the adult lesson. It didn’t rain enough to make it through the trees while we were there and only sprinkles on the way back.