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Chad #10 2019

            I’ve taken a shower with nice smelling soap, scrubbed everywhere, and my hands still smell like pus and stool.  I guess the gloves are thin enough that they must let fluid through or I got it in the sleeves.  It’s hard to say, because my hands are wet early on in the case from sweat.  The OR air conditioner didn’t work for a month apparently before I came but they’ve fixed it and it runs constantly during the day.

            I saw a guy yesterday that had what the carnet said was a strangulated hernia.  It was after I had finished my last case.  He was a little distended in his abdomen and had a right inguinal hernia.  I was able to reduce it, and gave him an order for surgery.  The total for the surgery and the meds after came to 58000CFA, that’s about $120.  I see that he’s paid and on the list this morning.  After a couple hernias, and a tubal ligation and a washout on the guy I did a few days ago with a perforated appendicitis and lots of pus, eventually we got to him.

            He was about 55 years old and walked into the OR with a stick as a cane.  I took a feel of the hernia which was visible and he got his spinal and we started.  Dr. Stacey wanted to do it with me as she is feeling a little better after dysentery.  We did the usual entry in the groin at an oblique angle and down through the layers to the inguinal structures.  We dissected out what looked like a hernia sac with stuff in it.  It seemed thick.  I squeezed it to empty it and if felt like I was just pushing out air. 

            No I believe the Holy Spirit prompts me to do things some times and if I follow it, things turn out better than when I don’t.  I felt a prompting to tap his abdomen.  I put one hand on the hernia sac and one on the abdomen and tapped the abdomen.  It seemed to pulse in the hernia sac.  I deduced that the hernia sac was full of air, meaning there was a hole in the intestines.  But the sac still felt thick like there was intestine in it.  And to thick to see through.  I decided I had to progress one way or another, so I cut it open.  Air and liquid stool flowed out!  OH NO! I must have just cut into the colon.  I put my finger in and felt the usual sac with an entrance into the abdomen and I could feel intestines in their normal position inside.  I was relieved that I hadn’t hurt the man and worried about what I was to find next.  I made an additional incision down the middle starting at his umbilicus and extending down to the pubis.  When I entered the abdomen, more air and stool came flowing out.  The room wreaked of stool.  Every area of the abdomen that I started separating the  stuck intestines, more pus and stool would flow out.  It saturated both sides of the bed and ran to a large puddle on the floor in spite of us sucking up liters of it with the suction.  My whole front felt wet through the cloth gowns, which is a disgusting feeling considering where it was coming from.  The whole small intestine appeared like it had typhoid and I expected to find a typhoid perforation and found none.  I identified the appendix and it didn’t appear inflamed.  Liquid was up around the liver and spleen after opening up higher in the abdomen.  On initial view the colon that I could see seemed fine.  I looked at the anterior stomach, no hole.  The posterior stomach was so stuck that I couldn’t see it nor seem to get to it.  Eventually I discovered a hole about an inch in diameter in the sigmoid colon.  There was some thickening there, so I assume it was a perforated colon cancer.  It could be a diverticular perforation, but I’ve not seen diverticula here before.  I assume I haven’t seen it because of their generally high fiber diet.  I resected the segment and decided to close the distal end and bring out the proximal end as an ostomy.  I hate giving people ostomies here, a there are no supplies for ostomy care.  But with all the contamination, he needed to be diverted, and not re-anastomosed.  About this time Dr. Stacey was didn’t look well.  She’s been suffering from dysentery so I asked how she was feeling.  “Not good”, so I asked her to scrub out and ask Abouna to come in to help me.  Once he scrubbed in, I sewed off the distal colon end in two layers, then I brought out an ostomy of the upper cut end of colon.  The intestines were to swollen to get back in the abdomen.  I had Phillipe put in a nasogastric (NG) tube to evacuate his stomach, and then milked all the fluid that I could, in the small intestines, back towards the stomach so it could be sucked out the NG tube.  Then I looked at the closed end again.  It was dusky and didn’t appear good.  So I cut off a couple more inches, and reclosed it again in two layers.  I brought out the proximal cut end through the rectus muscle as an ostomy.   There seemed to be insufficient length so I freed up a bit more of the descending colon to give more length to the ostomy and brought it back through the rectus and through the skin.  With quite a bit of effort the intestines were crammed back into the abdomen and the fascia was closed.  Before closing the abdomen I had to finish my inguinal hernia repair.  I resected the thick hernia sac and oversewed the end.  I did a suture repair, then felt it from the inside.  It seemed secure.  We closed the rest of the layers in the groin.  Then back to the open abdomen for closure there.  After getting the midline closed with loose sutures I “matured” the ostomy.  That is that I sutured it to the skin in a way that makes it stick out, kind of rolled out on itself making a somewhat mushroom appearance.  Dr. Stacey was back in the room and found an ostomy bag for us and we placed that as well as a bulb on the drain I had left in the pelvis.

            I’m called in the night because the family is refusing to get meds for him.  I tell the nurse he needs meds as he has a huge infection and will die without them.  He goes back and apparently the family came up with a little money to buy meds for the night.  A nock at the door again at 4 AM, and the nurse says that the patient is demanding water and pulled out his NG tube.  I’m sure he needs more IV fluid and is dry. I don’t think it will make any difference for me to go talk to the patient and think that administration should consider whether he needs meds for free?  So I tell the nurse the complications again and ask them to address it with administration- which I’m sure won’t happen till morning.

            During rounds this morning I discuss how crucial the antibiotics are for the man to the 4 younger men with him- likely his sons.  I get on their case about not doing what is necessary for him.  At the end of rounds they have gone and bought his medicines, so after 12 hours without antibiotics in a perf sigmoid, finally he has antibiotics.  Unfortunately, I am still jaded from my time in Cameroon, where everyone claims to have no money.  Even the Koza chief who drove an old mersades, and had 4 wives and numerous children, claimed to not have money.  Obviously I could help financially, and it is hard to know when to and when to push the family to fork it over.  So is still struggle with it.  I think hospitals should have a good Samaritan fund that is run by an honest local who can differentiate who really needs the help and who is not wanting to contribute to their care.

Chad #9 2019

            It’s mid-day, and I’ve done a hernia and then an old guy with a large prostate. 

I’m asked to see a patient in the adult ward that they cannot get a urine catheter into.  The nurse says it only went in about 1cm then couldn’t go further.   That’s a very unusual place for a stricture so I go, expecting to just be able to place the foley with out a problem.   An old man is lying on a mat on the floor between the beds and appears to not be moving his right side.  He must have had a stroke.  He looks at me but cannot speak since he came in to the hospital.  I try the 16F foley, no go.  I try the pediatric 10F foley, and it wont go in either.  I know I just used our urethral dilators so they are not clean.  I ask the nurse to go to the OR and get a long Kelly clamp.  After a lot of lubrication,  I slide the Kelly clamp in and it dilates up the urethra, the mans good hand grabs mine as he has some pain.  Eventually it’s large enough that I’m able to get the 16F foley in.

After the next hernia case Dr. Stacey asks me to see a patient on the adult ward with abdominal pain.  She says he has typhoid and his abdominal exam has changed overnight and he seems much more tender.  I go to the adult ward and find the nurse and ask him to translate.  The beds are lined up against the two walls.  I stand between two beds facing the patient that I’m to see.  He is about 30 and lies there grunting softly.  I tap on his belly with one finger on top of the other.  He winces at every tap.  I push in slowly, and let go quickly.  He jumps in pain with obvious rebound tenderness.  I think he must have perforated his typhoid.  I make an order in the system and send his family to the pharmacy to pay for medicines.  Later on, this order seems to have disappeared, as he has nothing written when I check it post-op.  [I had an ER nurse change my orders on a patient today, to diminish the length of treatment and add in another two medicines that I did NOT order, in order to “make it cheaper for the patient”)  VERY FRUSTRATING!!!  I addressed that with that ER nurse]  After I wrote for the medicines I informed Phillipe and Abouna about the new surgery.  They send some student nurses to get the patient.  After the spinal and our betadine prep and cloth drapes, we begin.  I expect to find typhoid perforation so I cut in the lower abdomen.  Upon entering the abdomen I get cloudy fluid.  Since he required ketamine at the start too, he is now tensing his abdomen and the intestines are pushing out at me with every abdominal force the patient makes.  So rather than trying to hold them in any longer, I let them pop out all over.  I see some pretty inflamed intestine that is obviously effected by the typhoid.  I don’t see any holes though.  I follow the small intestine to the cecum and there is some pus there.  I search around and start opening up a stuck area near the back side of the cecum and a fair amount of pus flows out.  I find a retrocecal appendix.  I do an appendectomy and then wash out the abdomen.  It’s very easy to wash the intestines as most of them are pushed out onto the abdomen.  Now the struggle to get them back inside.  Abouna and I pull hard on the edges of the rectus muscles and try to stuff intestines back in.  It feels like a loosing battle.  Little by little, we are successful and he holds them back with one hand, once their inside.  I slowly close the fascia from the top down.  I wash the incision again and then close the skin loosely, leaving space for pus to escape if the incision gets infected. 

I check on the consults that are waiting.  The last two I see I worry about if they need operations too.  One is an old man who has had urinary retention for 6 days and says they have been unsuccessful at getting a foley in and at a dispensary they’ve been putting a needle through is abdomen into his bladder to drain it, these past 6 days.  Abouna tried to place a foley without getting any urine.  So I try and slowly get it past the prostate, and about 500 cc of urine comes out.  Next is a man with a strangulated hernia.  He walks in fairly well, and I doubt he’s strangulated.  I push on his inguinal hernia for a little bit and get it to reduce.  I send both of these men to the pharmacy to pay for surgery and then we can do them in the next couple days.  

Chad #8 2019

            There is fluid between the liver and the kidney, Dr. Sarah told me this afternoon after I had completed a hernia, prostate, and hernia.  (By the way, the prostate was the largest I have removed, about an orange in size).  There seems to be sediment in the fluid.  It may be an abscess.  The guy is sitting stone-faced, on the chair in front of me.  He shows me his belly, which is distended.  I have him lie down on a stretcher.  He doesn’t seem to have percussion tenderness nor rebound, but definitely doesn’t like me pushing on his abdomen.  He is the usual thin Chadian guy about 5ft, 8in tall.  He probably has a BMI (Body mass index) of about 15.  I don’t know what he has but I think we should operate on him.  So I do a digital CT. (that is cut and touch with a finger).  That’s the best diagnostic tool we have!  As I examined him lying down, I did have the sense that as I tapped on his belly, there was a slap against the organs- making me feel like there must be free air in the abdomen, even though the rest of the exam didn’t seem like that.  We had the nurse start an IV and I operated on a guy with difficulty urinating.

            This guy had had a prostatectomy here before and apparently had a small 0.6 cm bladder stone.  I had tried to pass a foley a day or two ago and there was a urethral stricture about mid-penis.  So I couldn’t even get in  the smallest.   I had planned on operating on him that day, then after he paid and before I got to him, he urinated “well”.  He wanted reimbursed, so I wrote for that.  Next I see him the following afternoon, and he’s saying he’s not urinating well, and wants the operation.  I send him again to pay for the operation, and I see in the computer Friday afternoon that he’s paid.  At the end of our other surgeries Friday, we call his name and he’s no where to be found.  So we left.  They thought he may be at the mosque for Friday prayers.  Finally I see him Sunday and he says its’ still hard to urinate.  So we schedule him for today guessing that he must be getting some urine out, as he wasn’t in the “ER” for it.

            His bladder was distended, which makes the operation easier, as it pushes the intestines up and out of the way to cut down to the bladder.  As I cut down to the bladder through his previous scar, I had barely gotten through the muscles when I entered the bladder in the scar tissue.  Urine flowed out.  I enlarged the opening.  I felt around in the bladder and didn’t find a stone.  Since I hadn’t been able to pass a foley from the outside I  passed one from the inside.  It seemed to get hung up in the same place about mid-shaft on the penis.  So I used metal dilators and dilated up the urethra.  After getting up to a 22F size, I still couldn’t get a 20F foley in(smaller).  An 18 wouldn’t go in.  so I put a dilator backwards from the bladder out, attached a suture, then pulled the suture through.  Then I tied the 18F foley to the suture and pulled from the bladder side, to pull the foley in.  This worked. I closed the bladder in two layers and then the fascia then the skin.

            Next I thought would be the guy with a broken nose to elevate the pieces, but they had told him to go home and come back tomorrow.  So next was the guy with a distended abdomen.  He got the usual spinal, then I prayed for his as I do with all my surgeries.  Since we thought the fluid was more in the upper abdomen by the ultrasound report I started up there.  I asked Phillipe to give ketamine, and after he had I cut along the middle from top down to the umbilicus.  As I got in the abdomen there was a rush of air coming out.  I didn’t find much else initially, but as I searched around, I got LOTS of pus flowing up.  2 liters of pus came out.  As I finished one pocket of foul smelling stuff, I’d find another.  I had everyone in the room give their guess as to the source.  Abouna- infected ascites, Phillipe- infected ascites, Diana-wouldn’t commit, and I chose a perforated stomach ulcer.  I should’ve known better just by the smell.  But I figured upper abdomen, either that or perf typhoid.  I kept getting more pus the more I searched.  I kept on opening down, further and further, till eventually he was open from xyphoid to pubis.  There seemed to be a little fullness in the right lower quadrant.  I looked for the appendix and then felt like I got a different smell, and worried that I had pushed a finger into the colon.  As I explored the spot more, and gradually identified structures from all the inflamed tissues, I eventually realized that this was below the cecum and not the small intestine.  I identified the ureter and then followed it down, protecting it.  Then I discovered it was a rotten appendix that had perforated.  I did and appendectomy and we washed and washed the abdomen.  I decided that I would plan on another washout in about 24-48 hours.  I closed the fascia and left the skin open. My cloths smelled like the other day- stink!  I have blood and pus on me! I wish there were impervious gowns here!  After surgical cases like these- my soap and shampoo always smell especially wonderful!

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.