Chad #14 2019

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Chad #14 2019

            The X-ray machine I brought is working great.  The pictures are good quality.  I do worry about the cords that are attached and constantly being moved, as I expect them to break at some point and not work anymore.  A charging DR plate with wifi would be awesome but that is likely 40,000 to $60,000 and would require new software too.  So we will see how long this one lasts and get new cords when needed.  One is like a long USB printer cord, and the other is the Naomi power cord.  Today we did X-rays of a woman with 3 months treatment of TB looking for residual disease and she had some residual TB in an upper lobe.  Another was a woman who had been in a moto accident and was having some abdominal pain.  I told them an ultrasound was the answer we had, but they wanted an x-ray and as expected was normal.  Then there was a man who had been in an accident with finger pain, who had evidence of an old fracture.  Apparently one of the hospitals about an hour away in Lai doesn’t have X-ray either.  So now they will be sending all their patients to us to take them.  

            We put off some surgeries today as Olen, Denae, and I were all having diarrhea.  Sarah, Gabriel and Stacey had it the week before, so I’m not sure if we got it from them or from eating at the elders house after church the last week, as they didn’t eat there. 

            I find amusement out of peoples reactions on Ketamine.  Often there are different facial contortions people make and sometimes sounds too.  Often these sounds are yelling someone’s name repeatedly, or talking randomly.  We had a woman recently coming out of anesthesia from ketamine who started singing hymns. It was in Nangere so I didn’t know the words but some of the tunes I recognized.  I asked the nursing students if she was making sense.  They said she was singing perfectly.  Often we call in a family member into the preop/postop room, to watch the patient so they don’t sit up and fall off the stretcher.   So this woman’s husband was called in.  We explained that she didn’t know what was happening and that he needed to watch her.  A short time later as she sang with a loud voice he joined in and they sang hymns together.  They did this for many songs, until she was wheeled back to the surgical ward.  It was so joyful and pleasant, it made my day!  I’ve not seen anyone else that came out of ketamine singing.  

            Stacey asked if I had any vet friends.  I said Audrey does, what’s up?  She wanted to spay her cat and Sarah wants hers neutered.  So I offered my services.  I’ve done our cat in Cameroon with a vet, and I’ve spayed two dogs as well.  And neutering, I figured, I can definitely do that! I’ve done that for men, and well, I guess I’ve done the surgery for women as well- but a bit different in a cat.  So Stacey and Sarah purchased the supplies needed and we headed to their house to make their animals sterile.   I warned them that my concern was the sedation needed.  How much Ketamine is needed? I remembered that it was the same as humans and Stacey was able to figure it out.  We held the male cat and shot him in the muscle with ketamine- he made a horrible sound and then looked drunk shortly there after.  Not enough.  So we gave another half dose and waited another 15 min.  Still he just sat there with his head wagging back and forth as if he was a live bobblehead!  We gave another half dose and with each one he made a terrible meow!  After about 5 min, we put him on his back and put a clamp on the scrotum, the bad meow again.  So we gave him the “full” dose again.

            I want to give a brief background why I’m hesitant to sedate cats up till now.  When we were in Cameroon, Audrey was back in the US with her mom who was dying of cancer.  I was back in Cameroon and Audrey’s favorite cat became sick and was having diarrhea, and eventually got so dehydrated that he couldn’t walk.  I had one of the nurses come to our house and try to start an IV in the cat.  It worked for a second then with the cat thrashing about it came out.  I decided the only way I could hydrate the cat was to sedate it first.  I called the local vet, who only treated local cow diseases, I thought.  He said that he knew how to sedate a cat with Ketamine.  So he drew up what was much larger a dose than for a human.  I told him my surprise that it would take more than a human, and he said that’s the normal dose.  I didn’t know any better and I know that different sized creatures have different metabolisms, so a smaller animal has a faster heart rate… maybe they require more ketamine.  So he injected the cat into the muscle.  In about 2 minutes he was calm, then stopped breathing.   I was frantic, this was Audrey’s favorite cat, I didn’t want him to die.  I exclaimed that he gave to much, and he calmly says, oh it’s OK, they always do that then start breathing again.  Well, he didn’t, and I found myself giving mouth to nose respirations on Tiger for about 30 minutes before I finally gave up.  So my hesitation about sedating the cat and giving small doses repeatedly.

            So this stripped yellow cat is finally asleep, tongue out a little, eyes wide open and fully dilated, and breathing.  I clamp his scrotum and no reaction.  I prep him with betadine, though I believe vets have told me that sterility is nearly impossible and really doesn’t matter (I hope to confirm that again when I get back).  I pull the testicle down and choose a place to cut.  We briefly considered shaving, and then realized that seemed impossible.  I cut down onto the testicle.   I expressed it through the incision and then, clamped, cut and tied off the vessels.  I got the other testicle to the same incision and did the same.  Then I sewed up the skin.  He was wrapped in a towel to stay put and we got the female cat.

            I recall that the female cat uterus seemed long as well as the fallopian tubes, compared to a human, so I planned a higher incision.  We went through the same halting, repeat injection of ketamine for this cat as well, and eventually were successful with a sleeping, breathing cat.  I shaved her belly in the lower area and made my incision.  WOW cat intestines are tiny compared to humans.  I searched and searched for the fallopian tubes.  Hmmmm, I must have forgotten the technique on grabbing them, I say.  Eventually I am able to sweep them up and take off the tubes and the ovaries.  The two cats didn’t eat or drink that evening.  The next day the male cat was back to normal, and the female was subdued and ate a little, so was on the mend.  A successful day in the home OR.

Chad #13 2019

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Chad #13 2019

            I feel terribly cold!!! It’s 88 degrees in my room.  I just woke up from sleep and I’m freezing.  After a day of operations there was a soccer match between the health workers (hospital employees) and the teachers.  Dr. Olen played with the hospital workers and the health workers won 4:2.  Yeah!  It was a good match and there were probably 100-200 people on the sidelines.   The referee was a teacher, and you could tell, from the way his called favored the teachers, especially with off sides calls.  It rained during the last half of the game.  So all that is the first time I’ve felt cold here.  Back in my room I warmed up and felt rather tired and went to sleep.   Around midnight I woke up feeling real cold.  I put scrubs on and wrapped myself in a sheet and lay on the futon for a little bit shivering.  I realize I’m getting nauseous too.  That’s strange, that rarely occurs.  I vomit a few times, and then I get diarrhea too.  Have you diagnosed me?  I had!  The only time I feel cold in hot places, is when it’s raining, or when I have malaria.   I also wonder if eating bule at the elders house may have given me dysentery, though the vomiting and diarrhea can be symptoms of malaria too.  I decide to go into the hospital and get a malaria test.  So bundled in my sheet I head in.  On my way I bump into Dr Stacey as she goes in to transfuse a little newborn with a hemoglobin of 3,  and ask her if I should start malaria treatment.  She asks whether I have a fever, and I don’t think so, but don’t have a thermometer.  She offers to lend me one when she gets done.  I go to the ER and have the nurse take my temperature 37.8C and start a little “carnet” medical record booklet.  Then I order myself a GE (gutepece) which is their malaria test.  As I go into the lab, I see the lab guy and a girl watching an English video of those competitions where contestants run up a wall, hang from bars, bar walk up the “salmon ladder”… on a laptop computer (I cant think of the name, but it’s real common).  It seems weird to see that here.  He pricks my finger for the GE and says it will take a half hour.  Stacey swings by so I go get a thermometer from her and she recommends if I go over 101.5 I should start treatment.  I head back to bed all wrapped up and with my scrubs on.  I turn OFF the fan for the first time while I’ve been here.  My temperature is now 100.9.  I vomit again and have some more diarrhea.  I sleep a few hours and wake up sweating.  I take off the sheet and am about the right temperature in my scrubs.  I drift back to sleep and awake sheep bleating and cats meowing.  This is a common way from me to wake up as Dr. Sarah and Gabriel have sheep that roam around and there are cats that used to be fed in my room, so they are constantly around begging.  I feel a little better but still wiped out.  I have a little more diarrhea but the vomiting has stopped.  After the morning worship I tell Olen, Stacey, and Sarah what’s gone on, and Olen looks up my GE and it’s positive, I do have malaria.  Sarah offers her own stash of Malerone from the US as treatment.  That is great, because it has less side effects than quinine, which is what I planned on taking.  I will try to get some in the US to replace it for her.

            On rounds I see my various wound patients, some are postop and some are ulcers that are being treated.  I feel rather worn out, so I sit down on patients beds often as I talk to them.  I try to keep hydrated, and so am drinking water and also Foster Clarks pineapple coconut drink, I got from the market.  I really want ORS oral rehydration solution, but there is none here at the hospital.  ORS is similar to pedialyte in the US and is used for rehydration from cholera and other diarrheas.  After rounds I head to the OR and will try to do a few cases.  They aren’t’ ready yet, so I see a few consults.  

The first case is an ostomy reversal that Dr. Danae wants to do with me.  So we scrub and I assist her.  It appears to be a loop ileostomy.  She had called the previous surgeon to get information about what he did in Ndjamena, as nothing about the operation was written I the patients carnet.    Apparently he was not very helpful with saying what he did.  We cut around the ostomy and freed it up from the surrounding adhesions.  Then we created an anastomosis between two loops of bowel.  About this time I was feeling like diarrhea was going to hit me again.  So I asked Dr. Denae if I could leave and have Abouna scrub in.  She obliged.  I went back and after a couple more bouts, I lay on the futon to rest.  It was about 102 in the room and I lay there with the fan on me and sweat!  I slept a couple hours.  After dark I got a call from Dr. Stacey to help with a patient.  The lady was in labor and had a dead baby with an arm presentation.  This is a terrible presentation as it means the head and the butt of the baby are up higher in the uterus and the arm and shoulder are what is trying to come out.  The lady was given fluids and then Dr. Stacey and I each tried maneuvers to change the position of the baby in between contractions.  After 20 minutes of trying, we aborted that idea, and did a C-section.  Once we opened the uterus, it was still hard to get the baby out as we had to reach up from the lower uterus to get the head still.  Eventually we pulled out the dead, starting to decompose baby.  Inspecting the uterus, I discovered the right uterine artery had torn in two.  So the first thing I did was suture that artery to keep it from bleeding.  Next I controlled a few other bleeding spots that weren’t in the coming suture line.  After controlling the bleeding, I closed the lower uterus and sutured the bladder to it’s previous place.  When we came to skin I asked Dr. Stacey if I could leave as I was feeling weak again.  I went back to my room and had more diarrhea.  I showered and went immediately to bed.  in the morning, I felt better, but as soon as I started eating again, the diarrhea began.  I started Cipro and Flagyl right away, as I know in a couple days I will be on the all day bus without a bathroom and can’t afford to be having diarrhea, as they don’t stop except maybe twice all day.

Chad #12 2019

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Chad #12 2019

            Today was Saturday, the day I choose to go to church and worship God.  I woke up with the sun today as I have been for a while now.  I’ve been listening to The Jesus Dialogue by Herb Montgomery from Renewed Heart Ministries while I’ve been here.  It has really blessed me and given me a renewed view of Gods love for all humanity, including me.   So I listened to another part this morning.  I ate some ripe mangos- which are awesome this time of year!  Then I went in to see some patients that I was worried about.  Both guys with perforated appendicitis and pus everywhere are doing well.  The man with an ostomy and stool everywhere inside, from a sigmoid perforation, his ostomy is coming off and he has stool all over his dressing.  Lovely for the incision…  I found a couple more ostomy bags and gave them to the nurse so that he could change it.  The ER nurse asked me to see someone with typhoid, I immediately thought of perforation, but the was walking around and was an outpatient.  So I prescribed him treatment. 

I then made it back to where Jonathan was meeting a few of us to go to a bush church.   They’re all bush churches, but this one is further away from Bere.  I take Olen’s moto so that if I get called to the hospital, then I can leave and come back separately.  I prefer to ride the motorcycle anyway.  I enjoy the breeze in my face and the view.  They indicate the directions of how to start to get there, so I head off ahead, so I don’t have to eat the vehicles dust the whole way.  

I head out of Bere towards Lai.  It’s market day in Bere, so many people are walking along the road with things to sell or trade. Two wheeled carts with car tires are pulled along by either a small horse or a pair of cows.  They’re often hauling mud bricks, roofing reeds, or sacks of grain to sell.  Basically whatever is to heavy to carry on one’s head.  A few people are riding donkeys.  I drove ahead till I reached a town near by where they were going to turn off the main road.  I waited about 15 min till they caught up with me.  As I waited, I watched the variety of people going by towards Bere.  After Jonathan caught up with me, I followed him at a distance.  We took a winding path through the village that was really to small for his truck, as he often had dragging branches on both sides of his vehicle.  When there was a breezed from the side, I’d ride closer to him as the breeze took the dust away.  There were kids playing with sticks and rocks under the trees in little groups.  Women were out with wood mortar and pestle pounding rice and then pouring it in the breeze to get the chaff off.  Others were at their open wells, drawing water for the family or for animals.  After we left the village, we went through fields that were not yet planted.   There are many types of palm trees around this area.  There are a few coconut trees, and many of a smaller round looking fruit that’s hard too.  Apparently it takes about 20 years for these to grow big enough to produce the hard, small fruit.  There are little paths leading off everywhere and we pass other small villages.  A few times we take a wrong turn and backtrack a little.  It has been two years since Jonathan has visited this church.  Eventually we pulled into the village of Kalme.  

We went through Kalme and had to get directions and redirections to make it to the church.  After we pulled up to the church, a horde of children crowded around us.  Olen and Denae ushered the kids into the children’s Sabbath school and we could hear the singing during the adult Sabbath school.  I went to the adult class.  It was in Nangere and wasn’t being translated, so I heard they were discussing Samuel and the way God called him, so I read that story in my bible again.  After Sabbath school, the kids joined us in the church and they lay a tarp on the ground for the kids to crowd on, the tarp covered the dirt floor and diminished the dust inside.  You know how kids fidget, and there was a constant cloud of dust as soon as they were in there.  

I always find it amusing and sad, the way people have been taught the western traditions of church.  The people that were participating up front, all went outside, and then at a certain song, walked single file, in and up to the front.  They prayed then sat down.  [In our church in Cameroon, everyone up front wore a tie, so they would go behind the pulpit and get a tie, then tie it on whatever they were wearing, and then file in with their ties in place.  I think a sad thing to have to do in this heat]  They sand some songs with clapping and homemade metal drum.  Jonathan gave a sermon in French that was translated into Nangere. We had a visitor Charles from Orlando Hospital, here to look at the OR design.  I translated from French to English for him.   

            After the church service the head elder invited all of us from Bere, to his house for lunch.  They put benches under the mango tree, shewed away the dogs and chickens and put a bowl of rice bule and a bowl of sauce to eat.  One of his teen sons, brought around a bucket of water to pour over our hands and wash them.  Then we dug in.  Take a small piece of bule in your hand, smash it into a spoon shape, dip it onto the green leaf sauce and put the whole thing in your mouth…repeat till your full.  Then we washed our hands again to get the bule and sauce off.  Charles and a couple others were worried about dysentery, so they didn’t partake.  The rest of us, polished it off.  After we ate, the elder wanted to show land that was given for a school, so Gabriel, Sarah and some others went to see it.  About 4 teen boys gathered around, so I asked them questions.

When do you start planting the fields?  They said when the rain has saturated at least 20cm down into the ground, then if you plant, things will grow.  So they are waiting for more rain.

What things will you plant?  Around Kalme- rice is the primary crop.  Though in places not far away they grow, peanuts, millet, watermelons, black eyed peas.

How long does it take for a planted mango tree to bear fruit?  About 4-5 years to bear it’s first fruit, and the one we were sitting under was likely 20-30 years old.

Do you till the field by hand or with cows?  Two cows are used with a plow for the initial turning.

We talked for a while and the ones that went to see the school property returned.  As we said our thank yous and good bys to the elder and his family, a guy wanted a ride back to Bere.  So he got on the moto with me.  He led us back a different way that was more direct.  A lot of it followed a very deep sandy path.  In some places I wondered if it was a dry stream bed.  It was a bit challenging driving on the sand with his added weight, as he was heavier than I.  We almost went over once.  Also the road was even tighter for the truck.  It was a fun ride anyway, and it was good to be out of the hospital compound.

Later on all the missionaries got together for a potluck lunch.  I brought koolaid drink.  They are a bunch of good cooks, so we all ate well.  It was umbearably hot, and when they asked what Charles and I wanted to do next, we decided a cooler river would be nice.  So we went for dip in the hippo river, in a shallow area that the hippos don’t go to.  It was so nice to just lounge in the water and be cool.  It’s also the area of the river that people bring their sheep and cows to cross to the other side.  So as we were there a few herds went through the water.  What a peaceful evening!

Chad #11 2019

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Chad #11 2019

            I did my first real X-ray today with the equipment I brought.  It was a lady who had an external fixture placed by Dr. Danae with the materials she has available.  Dr. Olen and Dr. Stacey were both there see how it’s done with the new machine, and two nurses as well.  I am real excited with how the picture turned out.  We took two views.  The healing callous was not what we had hoped at the fracture site but it showed that the bones were well lined up and the result should be good in the end.  The patient wasn’t to happy to hear she has to keep the Ex Fix in place for a while longer, but then who would be.

            Philbert and Lazar are in the process of building a radiology bed where the digital plate I brought can be set into the bed with the bed surface being flush afterwards.  We are also making a rope and pulley system that will take the plate up the wall for vertical films, like a chest xray.  and some shoulder films.

            One of the operations during the day is a guy who has had some blood in his urine.  An ultrasound shows a bladder stone.  He has paid the 90,000cfa ($150) to have the operation.  The nurses get an IV in him and preload him with saline.  He gets his spinal and his abdomen is prepped with betadine and a urine catheter put in and water I put in to distend his bladder.  Once he looks slightly pregnant, with a bulge in his lower abdomen, then he’s ready for surgery.  We pray, then I open his lower abdominal skin with a few slices of our poor quality scalpel.  I divide the fascia and then use my fingers to spread around the bladder and push the peritoneum with the intestines, up and out of the way.  I open into the bladder and feel around with my finger.  Sure enough, there is a large stone.  I try to get my fingers behind it to bring it up to the incision and there isn’t enough room with the incision I made in the bladder.   I put a clamp into the hole, and the stone is to big to get with the clamp.  I have to extend the bladder incision about 3 inches to get large enough to get the stone out.  The stone ends up looking like sandstone that is about 2x2x1inches in size.  I wish I could keep it but the family wanted to take it home.  I close up the bladder, in two layers leaving the foley catheter in place.  After leaving a piece of glove as a drain, I close the rest of the layers.  We put on a dressing, and he’s out of the OR for the next patient.

            Mid-day, I’m asked to see a pediatric patient that came in.  Her parents tell me that she was sick with a cough and they determined it was the common problem with the uvula and it needed to be cut off.  So they had the local guy who does that, cut it off.  I imagine it is done like it was in Koza, with a U shaped piece of wood shoved in the back of the throat and then a razor blade is used to trap and cut off the uvula against the piece of wood.   All of this was done the previous day around noon.  After the uvula was cut, the child started having dark bloody bowel movements.  Then overnight they became red blood.  I took a tongue depressor and gagged the little girl, and sure enough she had evidence of bleeding and an absent uvula.  There was no active bleeding by the time I saw her.  She was pale, especially in the whites of her eyes.  Her hemoglobin was somewhere around 9.5, but I didn’t believe it.  With her being pale and lethargic, I decided to transfuse her anyway.  So the nurse ordered blood.

            Last night, the nurse came to the door about 9pm.  “There is a guy in the ER that was in an accident with his moto going off a bridge near Lai.  He is not talking.”  I follow him back to the ER room.  The guy is laying on the stretcher with no one around.  This is odd, usually there is a crowd with an accident.  I ask where the family is, the nurse says an ambulance, came and dropped him off.  An ambulance???  Apparently he is someone from the local health department and so someone went and brought him in, in a “ambulance”- because it has those words on the side!  No first aid or ACLS equipment.  I looked him over.  His forehead had a burned oval area on it, and this whole forehead was soft with a hematoma.  I couldn’t feel any step-off, like a skull fracture.  He had a laceration on his upper lip with dirt in it.  His mandible and maxilla seemed stable as well as his facial bones- no palpable fractures.  He had another oval burn on one of his arms.  His heart, lungs, chest, back, pelvis, legs- were all-normal.  His pupils reacted normally.  Someone came in the room- mid evaluation.  I hate it when people are gawking at whatever is going on, so I shine my headlamp in his eyes to make him back out of the room.  He puts his hand over his eyes and asks me to stop.  I tell him only family is permitted.  He says that this guy is one of his workers, so I stop.  This guy ends up being very helpful and I apologize later, for being rude to him.  Then other people from the health department start showing up.  I decide to go get Olen, as these may be local bigwigs that he may need to be a part of.  So Olen comes in with me and we decide it is a good time to take an X-ray.  Not so much because of it’s medical usefulness, but more because it will make everyone feel we are taking good care of him and also be an advertisement of the X-ray machine the hospital just got.  I go in the room I set it up in and turn it all on.  About 6 guys carry him in and lay him on the table.  He immediately lays on his side.  We try to turn him on his back and he starts talking a lot and won’t.  He reeks of alcohol.  Eventually I think he is still enough for a second, that we shoot one with us still in the room.  He moves mid picture.  But everyone gets to see his skull and that we have an X-ray machine.   As he is very uncooperative, we abandon the films and he’s carried back to the other room and watched overnight.  We ask the nurse to wash out and bandage his wounds, give him tetanus vaccine and an IV antibiotic Ceftriaxone.  The next morning when I see him, I open the bandages and realize they had sutured the lip shut.  I push around on it, and pus comes out one end.  I reopen and pack the wound.  He is conscious and responds appropriately.