Chad #6 2019

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Chad #6 2019

            They are working on the air conditioners in the OR when I arrive- yeah!!!  I do rounds on the surgical ward.  It seems the guy with the pus in his abdomen is doing better and another with an appendectomy isn’t doing well.  I wish I had a CT scan for him.  He is distended, says he’s drank some bouille (rice milk and peanut butter porridge) and says he’s passed gas.  I’m concerned but decide to wait and not re-explore him today.  The lady that had an amputation for a leg cancer appears to be doing well but no one around can speak her language to really know.  She just smiles and points and rubs certain spots near the lower leg stump.  Another 14 year old kid with abscesses on his head- appear to be granulating well.  The perforated intestine man is doing well and starting to eat.

            While I wait for the OR to be ready, I’ve found out there is a cloths washer behind one of the other volunteers houses, so I go outside the hospital compound to get some laundry detergent.  There are small bags of three different types.  I choose from the biggest pile, assuming that that one is sold the most.  I give the guy 2000 CFA ($4) and see what he gives me back, rather than asking the cost.  He gives me back 1800.  So these small bags cost about 10 cents each.  I need to do laundry because all my scrubs are dirty now.  You remember that I had that guy with pus all over- I hope this soap is good and takes care of everything.  So I put in a load and go to the hospital.  Later I come back and hang my stuff on a line that’s hung under some huge mango trees.  The missionaries and volunteers are in a compound that’s behind and attached to the hospital and have large mango trees all around.  I asked other volunteers here if my cloths would be stolen and they said they hadn’t had any problem with people jumping the brick wall that’s about 7 ft tall.  I guess they wont see what’s in here unless they climb the wall

They first install a new air conditioner that was somewhere else in the hospital and it works.  We do our first hernia of the day.  Then they want a little to install the old air conditioner that has been repaired today.  We work with that one running the remainder of the day.  The OR starts out the morning at 95 degrees.  After running all day we end the day at 85 deg.  This feels so wonderful after being at 101!  At 85 I still sweat, but I can stand in front of the AC and cool off enough to not sweat for a little while.  I also feel like I’m not dehydrating nearly as much.

Around the OR anyone waiting for an operation is sitting on a bench or the ground.  Any time I walk out, there are questions as to when their patient will be done.  I explain again and again that we do it in the order they paid.

I do a couple of hernias then there is a combination hernia with a hydrocele.  His scrotum is about 13 inches long and about 7 inches in diameter.  As he lays on the operating table I pull it up and put his legs together and it sits high on top of his legs.  We prep and drape him as usual and now the room is cooler and I’m not dripping on the patient with my own sweat constantly.  I’m very grateful for the AC.  I work through the outer layers and get to the hernia.  It is inflamed and stuck to the surrounding tissues.  Slowly I separate out the hernia sack and am able to reduce the intestines back into the abdomen with a bit of difficulty.  I do a suture repair of the area after taking off the sac.  For the hydrocele I make a separate incision and go down to where the testicle is.  A large sac of fluid surrounds it normally in a hydrocele.  His sac appears dark.  I wonder if he has bled into his hydrocele.  Or is this a cancer.  After dissecting all around I pull the sac out of the scrotum with it still attached at the vessels and I open the sac.  Dark brown fluid with chunks comes rolling out.  This is disgusting!  I try to keep it away from my incision of the scrotum to not contaminate that area.  I decide this must be cancer, and decide to do an orchiectomy.  I tie off the vessels and spermatic structures and put that off to the side to open more later.  I close up the empty side of the scrotum and decide to leave a glove finger as a drain.  After I finish this operation I cut the “hydrocele” open further and find what appears to be a necrotic tumor.  It’s difficult to tell though, it doesn’t look like anything I’ve seen before.  I show pictures to Dr. Danae and she says she’s seen it a number of times.

After a few more cases I finish and I am walking out the OR door as I see a carnet (little booklet) of a consultation waiting.  I feel a little perturbed that no one told me there was still someone waiting. I have them call the patient in and my irritation disappears.  The patient is waiting with her mother to be seen.  Dad comes in too.  The child has an abscess on her neck.  This is no Dr. Pimple popper abscess (I’ve never seen her show), but a huge abscess that is so big on the right side of the neck that the head is tilted off to the left at a fairly sharp angle.  I’m surprised by how large and hard it is.  I hear from the father that the abscess started and later they took a knife that was heated in the fire and stabbed it, draining pus.  Then it re-accumulated.  It’s been going on 2 weeks now.  Abouna says they just lance these without anesthetic, but I feel sorry for the child and give local anesthetic.  It works somewhat and she screams before I touch her.  I sit down on the bed next to the child and immediately realize that was a bad idea.  My butt is very wet!  The child had urinated then when I sat down, I became the lowest place in the mattress, making all her urine flow to me.  AHHHH,  everyone else has a good laugh.  I incise the neck and very thick pus flows out.  I poke my finger in the hole to ensure I’ve opened it enough and to make sure there aren’t any loculations (compartments) that have to be opened.  My finger can go in the side of the neck and as I feel around, I feel the back side of the trachea (wind pipe).  This is horrible!!!  I don’t think there is a connection between this abscess and the trachea or the esophagus because she’s not coughing nor vomiting pus.  I flush this with Dakins (dilute bleach) solution and pack what I can with gauze.   After we finish and send her to the surgical ward, I and my wet butt head back to the place I’m staying for a change of cloths and some food that Zache has made.

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Chad #5 2019

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Chad #5 2019

            In between surgeries I try to see consults that are waiting outside the OR for a doctor to see.  Whoever is seeing consults usually does it in the “preop/postop” room.  So the room is kind of a zoo.  Usually one or two preop patients area there with IVs running, and a postop patient.  The room is about 18×15 ft.  Then to them we add in the consultations.  Most people don’t seem to care about privacy, but sometimes an many may turn away from the others to show me his hernia.  Occasionally there is a vaginal exam, and for those we usually send everyone else in the room out.  So I’m in-between cases and seeing a few consults as they get the spinal anesthetic for the next hernia patient ready.  There is a 14 year old girl that I’m asked if Id do a breast reduction.  I say sure, but why would someone need that here?  This is often cosmetic in the US but can be for very large breasts that give someone back pain.  I look at this girl and she is about 4ft 8 inches tall.  As she sits in the chair her breasts are the largest I’ve ever seen under her shirt.  I’ve not even seen any that had huge implants be this large.  As she lifts her shirt I see that they are sitting on her legs.  They are HUGE, I estimated about 15 lbs each.  WOW, no, I really don’t want to do this.  Especially in someone who hasn’t had children and will need to breast feed in the future.  There must be a hormonal problem to cause this!  I hear there is a plastic surgeon coming with an anesthetist and a team in November, so I decide she would be better served by waiting till that team arrives.  They are a little unhappy at the wait but accept it anyway.  Apparently her breasts have been getting bigger over that past 1.5 years.  I encourage them to fabricate or find a large bra to help, I seriously doubt anything that size is available anywhere!

            Between other cases I see a kid with a tumor growing on his mandible.  The teeth there are splayed out and feel loose.  His upper lip protrudes forward and I think this may be Burkett’s Lymphoma.  Whatever his diagnosis, we have no medicines for it and say there may be something in Ndjamena.  They look at us blankly, knowing they have no ability to go to Ndjamena and get treatment.

            I remove a large prostate and then am asked to see a guy in ultrasound.  Now he has a BIG prostate!  It fills nearly his whole bladder with about 10x10x10cm of prostatic cancer.  He came to be evaluated because of hematuria (bloody urine).  The only thing I can offer his is an orchiectomy (remove both testicles) as testosterone stimulates prostate cancer growth.  I leave to go back to the OR before he has come to a decision.

            I do another large hernia that makes the scrotum look to be about a liter and a half in size, then I see a boy that has a lump on his right mandible and a mass in his mouth.  As I peak inside I see some teeth going different directions and a hard pointy lump underneath.  I suspect this is rotten mandible that is pushing up.  I have he and his dad go to the pharmacy and pay for a sequestrectomy, and I think that comes to about 25,000 CFA ($50).  Later on I see them after a couple more surgeries.  We bring into the OR, give him a shot of Ketamine, and I probe around with my finger.  It feels mobile but I can’t quite grab it.  I get a Kelly clamp and grab it, rock it back and forth and out I pull a piece of rotten mandible with a tooth in it.  I see another tooth heading towards the back of his mouth with it’s full roots exposed, so I grab that and rock it back and forth then yank it too.  I shove some gauze in the hole and we take him back to the room I originally saw him in- preop/postop/consultation room.

            I see a guy in-between cases that can’t pee well.  His ultrasound says he has a small stone in his bladder.  He says he hasn’t peed for 2 days.  His bladder is full but not up to his umbilicus like I’ve seen before.  I get a foley out of the OR and try to put in his penis.  It gets about half way down the shaft then is blocked.  I ask him how he pees, and he conveys what sounds to me like drops coming out.  I think he must have a stricture. I get the smallest child’s foley, and it wont go I either.  I tell the OR crew that we need to operate on him.  In a few minutes they tell me he is peeing a little and is not blocked.  I decide to wait till morning, as it’s already late and I’m hoping he will make it till then.  The next morning, he sees me on rounds and wants reimbursed for what he paid to have the surgery.  Apparently he peed some blood then he had normal flow after that.  He must have passed the stone. 

Chad #4 2019

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Chad #4 2019

The last two nights we’ve been awoken in the night for a C-section.   Both for failure to progress and fetal distress.  One got a living baby the other a dead baby.  The one that died was bagged for 30 minutes then lost its heart beat.  Then we decided to stop.

            Last night I’m awoken by a knock on the door, to see a 18 year old guy who was in a fight and stabbed twice.  Once in the neck and once in the right lower back.  The nurse wants me to evaluate the back wound.  He says the neck one is superficial.  The back is deeper and he indicates about 1 inch on his own finger.  He says that that wound bled a lot.  I walk in to the “ER” which has been renovated since I was last here.  It has a main entrance area that has a desk and three rooms with a couple beds in each.  This guy is laying on his left side with a bandage on his back.  I take off the bandage and put on some gloves.  I tell him it will hurt, then probe his stab wound with my finger.  I can get my smallest finger to go all the way in, angling down towards his pelvis.  This could have entered his abdomen and hit intestine.   So after probing the stab wound I feel his abdomen.  He has no pain in his belly.  They give me a suture and I put one suture in to re-approximate the edges leaving space for blood to come out.  I kept him overnight to see how he did, and if he declines will operate on him.  We have six cases already planned for today and already 3 for tomorrow.  I have been busy each day from morning till 5-8pm with surgeries all day. 

            It is still unbearably hot in the OR.  Yesterday it started at 95 degrees then went up to 101deg for the rest of the day.  I got my hopes up as they found another air conditioner to put in the OR, but it felt cool for about 5 minutes after installation, then was warm all the rest of the day.  I feel bad for Dr. Denae and Dr. Sarah who have been dealing with this heat in the OR for weeks.  I am drenched constantly with my own sweat.  I’m drinking a lot and don’t pee at all, all day.  In the evening after drinking a few more liters of water, I finally pee some rose colored fluid.  I wonder if I’m getting myoglobinurea from kidney damage.  Now way to know, just drink more.  The repair man has arrived this morning, so they will hopefully be able to get something working today.  I don’t like wet cloths as, it contaminates the sterility of my cloth OR gown.  But yesterday I decided it was getting wet either way.  So before each case, I would remove my shirt and cap, rinse them, wring them out, and put them back on.  This seemed to help a little.  I’ve been making a little stink about the AC to the administration, in hopes that it will spur them on to have it fixed.  I even told them I would stop doing elective cases unless it’s fixed soon.  I don’t intend on following through with that at all, but they haven’t fixed it for Dr. Danae and Dr. Sarah, so why not push them more?

            The last surgery of the day is most memorable.  A thirty year old guy had been sick for about a week.  Then about three days ago he stopped passing gas and stool.  He looks very sick to me.  Everyone here is thin, and when they lay down their abdomens are concave with ribs showing.  His don’t show at all and his abdomen stands up taught.  I take a finger and tap on his belly.  With every percussion he jumps and grunts in pain.  I check rebound by pushing in on his belly slowly, then letting go quickly.  He jumps in pain when I let go.  He has peritonitis so he needs to be operated on.  Since I’m seeing him in the preop area as a consult, the OR crew which includes 2 nurses and 4 students, prepare him to be the next operation.  He gets the usual fluid load before a spinal.  I know he will need Ketamine instead because a spinal only covers the lower abdomen.  I’ve given up on that fight with the anesthetist.  He gives a spinal to everyone, and I’ve come to terms with that.  After the spinal is in, Phillip preps his abdomen with betadine, while the other nurse and I scrub.  We put on our cloth gowns and  our cloth drapes and start in. I enter the upper abdomen after he has pain and is given ketamine.  The upper abdomen is hard to get in to and everything is stuck.  I cant seem to get very far and worry about cutting into a piece of intestine.  Then I do something I’ve not done before, made a second incision in the lower abdomen.  This got in directly and pus flowed out all over the bed, me, my assistant, and pooled on the floor.  I’d guess about three liters.  Now I’m not only drenched in sweat with all this stuff on and 101 degrees, but now I have pus on me and it smells awful.  Even my terribly functioning nose cannot mistake it.  This has been there many days, the intestines are stuck together making pockets of pus in various places.  I eventually free up all the small intestine.  I look it over and cant find anything wrong, I look over the large intestine- nothing.  I dissect to behind the stomach- nothing.  Front of the stomach- nothing.  I feel the surface of the liver and spleen- nothing.  I irrigate every thing out with a lot of saline.  I’m quite frustrated as I’ve seen his whole abdomen and didn’t find the source of the pus.  I close him up with another prayer that whatever caused this has sealed itself and will not leak any more.  Disconcerting!

Chad #3 2019

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Chad #3 2019

            It’s outrageously HOT!!!  As I’ve mentioned the AC in the operating room isn’t working.  I drip constantly with sweat.  Sometimes it drips on the patient I’m operating on, contaminating everything.  A fly persistently landed on a patient mid-surgery.  The coolest it got was this morning about 7 AM when it was 86 degrees.  Mid-day it was 95 outside, hot compared to my 65 on the US west coast, but it got up to 101 IN THE OPERATING ROOM today and stayed there for the remainder of the day.  They have put in a fan that was blowing on me or my assistant, whomever was on that side of the room.  I never imagined an OR could be sooo hot.  In the US most OR’s are mid sixties.   With all the mask, hat, gown, and gloves, even in the US I get hot sometimes, here…  

            I type as I sit here at 10 PM waiting for the OR crew to come in for a strangulated inguinal hernia in a man that’s had pain since mid afternoon.  I have a fan on me and my apartment is 90 degrees.  I’ve stopped sweating,   I hope that Ive hydrated enough that that may not be the cause.

            My first case this morning was one that came in a little bit ago.  The 8 year old boy was apparently clawed by a crocodile.  He had puncture wounds on his abdomen and in a semicircle on his back.  To me it sure looked like a bite mark, but the father insisted it wasn’t a bite, but the croc clawed at him.  He had omentum sticking out an abdominal puncture site.  I put in local anesthetic after prepping him and we put the cloth drapes on him.  Phillipe the anesthetist didn’t want the patient to watch so he taped his eyes shut.  That bothered me, and I asked him to either remove the tape or to give him some ketamine so he wouldn’t remember it.  I cleaned up each wound and was able to get the omentum back in the abdomen and close the fascia.

            Second was a back wound that had been cleaned up with dressings and another doc wanted it to be closed somewhat so that it would heal faster.  It was a difficult thing to do.  I imagine it will get infected and likely drain for a while anyway.

            Third, was a C-section for triplets.  They were doing well, and it was time.  So Dr. Sarah and I took her to the OR.  The incision was the usual phanynsteal (low transverse) incision.  As we used the scalpel to enter the uterus the amniotic sac bulged out.  We poked the sac and amniotic fluid poured out.  The baby was in a breach position.  The second sac, had a baby with a head first position.  Feeling around inside, there weren’t any other babies.  Guess we should have had a look with the ultrasound ourselves.

            Fourth was a C-section for a woman who had been in labor a long time and wasn’t progressing.  It was her first child.  We pulled out a limp baby.  Dr. Sarah came in the OR to help revive the baby.  The baby was bagged for more than 30 minutes, the heart stopped and they stopped trying.

            I ate supper then later on was called to see the ER patient.  He was about 50 years old and cried out in pain every 5 minutes or so.  Apparently he had a strangulated  inguinal hernia.  I followed the nurse who called me to the ER.  He lay there calmly on his side.  His pain had gone on a few hours and I decided to try to reduce the hernia. I looked at a scrotum that was at least 12 inches long and about 6 inches in diameter.  The firm large part was off to the left side.  The right side was shorter and smaller.  I cupped the hernia and tried to massage it back in.  Circle motions, change in position and there was no success.  The family of the bed next to his wanted me to see their patient.  He was about a 60 year old guy that couldn’t pee.  Someone had attempted to place a urine catheter at another hospital in Kelo and then when they were unsuccessful, they put a needle through his low abdomen into his bladder and drained off 500ml of urine.  Then they sent him our way.  The nurse had attempted to place a catheter here, but was unsuccessful.  So I took a catheter and slowly pushed it in.  There was a lot of resistance, but eventually with steady pressure it gave way and entered the bladder.  I imagine he either has an enlarged prostate or a bladder stone.  Will get an ultrasound tomorrow to evaluate it.

            The ER nurse called the two OR guys and their phones were turned off.  So he had to get on his motorcycle  (moto) and go to their houses and get them.  I went back to my apartment and waited there.  Once they arrived they came to get me.  In the OR it had cooled off to 98 degrees.  After the spinal and prepping the scrotum and everything else, I started my incision.  I am continually amazed at how the local scalpels cannot cut the skin here.  In the US one swipe with the scalpel and your through the skin and into the fat area.  Here, I have to cut about 3 times just to get through the skin, and that’s pushing real hard.  Granted, their skin is tougher, but still its ridiculous.  As I went through the different layers I eventually found and dissected out the hernia.  Opening the sac, I found intestine that looked dark.  After I pulled it out, I realized it was going to make it.  I had difficulty putting it back inside and had to make the hernia site even larger, to be able to shove it back in.  Then I went through repairing the different layers then about midnight, back to bed.