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I’m spent mentally but am happy too.  I asked special prayer from some of you that i had whatsapp contact with and God answers prayers.  He doesn’t always answer the way I want but today WAS the way I wanted.  The boy woke up after the surgery and could move his legs.  I intubated him at 9:30 AM and we extubated him at 4:30 PM.  Phillipe and Ndilbe couldn’t figure out the new anesthesia machine for the vent so they bagged the patient on isoflurane for the entire time.

Andrew (the missionary surgeon here) and I have been planning this surgery for a few days now that we were able to see the CT scan.  I saw the kid in the outpatient area a couple weeks ago and Andrew sent the boy to Ndjamena to the government hospital for a CT scan.  The boy had a huge mass on his back.  its been growing since he was 5.  He and his father went to Ndjamena and spent a week trying to get a CT scan done and apparently did other tests that whomever they saw ordered but the CT was never completed.  So last weekend the local chaddian doctor took them back to Ndjamena and took them to the hospital and with his contacts there, got the CT done and onto a USB drive so we could see the images.

We saw what looked like a mass coming from the spinal canal about L1,2,3 as the spinous processes in that area were deformed.  We decided to try to take off this mass and so that was the only surgery we planned today.

In the pre-op area i talked to the boy and his family about the complications that were possible.  I spoke to the chaddian doc, who talked to the boys uncle, who translated again to the boy and his mother.  I mostly wanted them to know that he could bleed to death or be paraplegic afterwards.  They understood and wanted to proceed.

After he was asleep, we turned him prone, which seemed to make me more nervous than the two doing anesthesia.  I marked the large vessels in the mass with a sharpie so i would know where they were after prepping.  We washed his back and the mass with soap and water then prepped it with betadine.  Then I put on the sterile drapes.  I cut first with a blade, to see how much bleeding would occur (a way to check where there is no bleeding times or INR…, then I used cautery.  As we came to large veins Andrew and I would ligate each of them.  Small ones we cauterized (electrically burned).  We created a flap above and a flap below to allow enough skin to cover the hole that would be left after we removed the mass.  We then gradually cut down on either side till we reached the back muscles and then cut towards the center.  We intentionally left a bit more tumor in the center of the back were we suspected the nerves of the spinal cord could be present.  After the tumor was removed it weighed in at 37lbs.  I gradually got the skin edges together for closure.  It wasn’t pretty as the line made kind of an “S”.  I guess I cant cut on two sides of a LARGE thing and get it to look as good afterwards.  for a breast tumor I do much better.  We kept him deep on anesthesia till we could flip him back over.  Then he took a while to wake up.  Eventually he was able to be extubated. He moved his legs!! Yea!! Thank you Jesus!

Chad 2022 #10

Days are long and it’s impossible for one surgeon to keep up, it’s likely two cannot keep up.  when i came there were 70 people waiting for surgeries and there are still 66 on the list.  People are coming from Garoua Cameroun and even further west near the Nigerian boarder in Cameroon.  Ive

I’ve seen people from all over chad, even from the capital.

Yesterday my day started with a patient with a large uterine fibroid.  It appeared she was about 24 weeks pregnant with a bulge in her lower abdomen that went above the umbilicus.  I did a quick ultrasound with my butterfly ultrasound and saw what I thought was cystic, but was read as solid by the previous ultrasonographer. Either way I couldn’t find a uterus so assumed it was all uterus.  She had been prepared for the possibility of a hysterectomy and I confirmed that with her.  She wanted more children but for her health she wanted it out whatever it was.  As I opened her abdomen the mass seemed to be cystic and stuck to surrounding things like intestines and ureter (tube from kidney to bladder).  It took some time to free it up and eventually I found it was attached to a small uterus in the pelvis.  After we removed the cystic ovary I closed up the top of the uterus.  I looked that the other remaining falopian tube appeared scared down and closed.  So i opened it and sutured it open.  That way she’ll at least have a chance to get pregnant, like she wants.

Next was a guy who was about 40 years old.  He had a inguinal hernia.  As i dissected it out it communicated all the way down to his testicle as a hydrocele (sac of fluid around the testicle) too.  I’ve not seen that combination before.  Usually they are separate.  Hernia sac and hydrocele separately.

A 3yo girl was standing next to a fire when her polyester skirt caught fire.  Polyester melts as it burns and sticks to the skin.  So she has burns all over her lower abdomen, genitals, and down both legs.  When she came to the hospital about a week ago she had been burned 5-7 days before hand.  They had put rabbits fur on the burn areas to help it.  It seems like when I operate on those burns quickly they bleed a lot.  So I decided to wait till the burn area starts to lift off the underlying tissue.  This had occurred so I had the nursing students bring her next.  I realized that there were maggots coming out from under the abdominal burn area.  Fortunately maggots only eat dead tissue, they don’t hurt live tissue.  But they are still disgusting!  She got Ketamine to put her to sleep while David and I debreded off the dead tissue with scissors.  We washed her with Dakins solution (a dilute bleach) and placed dressings.  She will need some skin grafting in the near future.

Earlier that day I had been asked by Dr. Megan to see a patient on the adult ward who had a firm abdomen.  After examining her i agreed that the patient had peritonitis and needed to be operated on right away.

As i opened her belly she had nearly a liter of pus come out.  As i looked around for the cause, nothing was initially obvious.  The appendix was normal, the intestines were irritated but not perforated with typhoid.  Eventually i found the most inflammation in the pelvis and found some abscesses there and what appeared to be perforated diverticulitis.  This was really stuck and a mess.  After about 4 hours working on her I had cleaned out the pelvis, washed her abdomen out, taken our the rotten piece of sigmoid, and brought out an end colostomy.  Tired, but two more emergencies to go.

Next was a kid who had ascites (fluid in his abdomen, most often from cirrhosis), and had an umbilical hernia that started leaking the ascites.  It appears like he was peeing from his umbilicus.  This fluid coming out can be a way for the bacteria to go in.  So i repaired his umbilicus and tried to make a water tight closure.

My last guy was about 24 with a rigid abdomen.  Rock hard, and peritonitis.  So I operated the same way on his as the old woman.  Looked around and bile everywhere.  Didn’t find a hole in the small intestine nor large intestine.  I found it on the front surface of the distal stomach.  A perforated stomach ulcer!  I made the edges new and then sutured the hole shut.  Then I reinforced the repair with a piece of omentum (fatty layer in the abdomen).  I put a drain (a cut Nasogastric tube) near by so that if the hole leaked, hopefully the drain would pick up the fluid that leaked.

There were a few surgical consults that had waited all day so I saw those next.  Later we went to Megan and Andrews house to eat supper!  Thank you Megan!  It’s always wonderful to eat after a long day working.