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.