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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