Bere 2018 #17

admin Greg No Comments

Bere 2018 #17

MEDICALLY GRAPHIC- READ BEFORE SHARING WITH CHILDREN!

 

It is Sabbath. I went in this morning to see patients. In peds, I found the child I had seen yesterday with the black dead patches all over the place. I think it is cutaneous anthrax. My wife had seen it yesterday, she has a very good memory for things, and she came up with the diagnosis. It is rarely seen in the US. It is gotten by contact with animals and animal products. Of course we could be wrong, we have to go on hunches, as diagnosing isn’t possible for many diseases. I check on the surgical ward, the maternity ward, ER, and private rooms. A few patients stop me along the way to ask questions. There was an old man last night who wasn’t breathing well after the family force fed him some bouille (rice, flour drink), and Im sure he aspirated it. He died overnight.

Audrey and I get on Olen’s moto and head out to a church about 20-30 min away. It ends up being about 6 miles. We both chuckle at the masses of kids that see us and yell and wave with smiles, saying “Naaasssaaarrraaa” (white person). At church there are 5 benches for seats and we sit on the front one of the left two benches. Kids gradually show up and sit along the edges and slowly inch forward to look at us. Near the end of Sabbath school, I get a call from the maternity ward. “Docteur nous beswoun de vous vite, Il y a une femme avec une enfant avec le bra dehor.” (if you speak French, please excuse my terrible spelling and grammar). Doctor we need you quickly. There is a pregnant woman with a arm out. If just an arm is out then often the baby is trying to be delivered sideways, rather than head or butt first. Transverse babies don’t come out. They die and sometimes rupture the uterus. So we hop on the moto and head back. Audrey goes to change into scrubs and I go to see the patient.

I see a 18 year old girl with two old women standing by. The girl has one leg draped of the side of the delivery bed and the other knee up in the air. A babies body and legs and one arm are hanging out of the vagina. Apparently she has been like this since she was at home. No contractions. Babies dead (often will die in a couple minutes in this position, because the head compresses the umbilical cord, and then the baby has no more oxygen coming to it). The uterus still seems larger than just a head, so I wonder out loud whether there is a second baby in there. The nurse checked and didn’t hear another heart beat. I’m in my church cloths (nice shirt and slacks), and I wish I had scrubs on. I put on gloves and start to feel the position of the baby. I find there is few things more gross than having gloves on, reaching in to help deliver a baby, and getting half your arm inside. Being covered beyond the limit of my gloves with meconium, vernix, blood, urine, amniotic fluid- I just want to have a shower!! And of course I’m sweating profusely! It seems the chin of the baby is stuck up above the front of the pelvic bone of the mom. There seems to be quite a bit of space towards moms, back but baby is not coming down into that space. I pull and push and twist. How much force does it take to decapitate the head of a baby that is stuck, I think. I don’t every want to find out! I get the babies head turned and it still wont come down. Mom has no contractions. I ask the nurse to start an oxytocin drip. Then mom starts to have contractions. I’m worried that with the contractions and a stuck head, the combination could rupture her uterus. As she starts to get contractions she starts pushing. I had asked the staff to find me forceps, and they arrive. I’m able to get the forceps on the babies head and with mom pushing, me pulling with forceps, finally the head starts to move down. As it starts to move, I stop pulling. If it comes out to fast and doesn’t have time to stretch the vagina, then you get tears that need to be repaired. The babies head is out and the placenta follows shortly as I massage the uterus. I do an ultrasound and don’t see anything abnormal and no second baby. The size of the uterus is also as expected. I take off my gloves. Did they protect either me or her? Unlikely. I go to the sink, and wash my arms up to where my short sleeves begin. It’s good to get all those fluids off me. I am glad for intact skin, without cuts or injuries, as this would make me contracting something more likely. I leave the nurse to check for tears, and call me if she needs me. They will usually repair the tears themselves. I go back to the house, get cold water, and sit in front of the fan.

We could see it and then hear it after that. A huge thunder storm. A number of the volunteers are going to Kelo tomorrow along with AHI lab people. About 8 all together. Now it is raining so hard I have to yell to Audrey who is sitting right next to me. Rain on a tin roof, I love this sound. I still hear the thunder but the rain is the loudest sound. It is finally cooling off after a VERY HOT day. I pray that my patients will do well tonight, as I always pray, and that I will be able to sleep well with the cool evening.

 

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for information on our missionary and pastors oasis visit www.lifeimpactministries.netand click on Safe Haven Oasis

Bere 2018 # 16

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Aud’s day.
Friday morning I actually woke up on time to make it to morning worship. The day before I slept til noon after being up til 1am with the surgeries, and suffering from jetlag. After worship I did rounds on pediatrics and adult ward. Of course all the kids I saw had malaria. Fortunately none were terribly sick, and there weren’t even many kids on the ward. It took me a little time to familiarize myself with the way things are done here. They do have an electronic medical record that is fairly simple, but I am just not very computer savvy. After rounds I went to the OR to see what was going on. This is probably the most interesting site in the hospital. It is where we see most of the strange medical presentations. Greg and Dr Sarah were just about to start a surgery on a young woman they expected had ovarian cancer. Ultrasound showed a mass in the pelvis and a lot of fluid in the belly (assumed to be ascites). Having finished the work I had planned to do, I decided to stay, watch and take pictures. Greg has been teaching/guiding Dr Sarah in surgeries so that she has more training when we leave. So, Sarah started the surgery, opening the belly to be able to remove the mass. They realized that with a lot of fluid present that they would need suction, so someone ran to the surgical ward to retrieve the only suction machine in the hospital, that was with the old lady who had gotten the tracheostomy the night before. They opened the belly, and NO FLUID CAME OUT. Instead, here was a copious amount of clear/yellow gelatinous material. So the first thing they had to do was scoop out, handful by handful this jelly-like stuff. (When we return there will be several videos posted so you can experience it too). They found the mass which appeared to be an ovary, and removed it along with the fallopian tube. Diagnosis: probable ovarian mucinous cystadenoma. Of course we would never get a true diagnosis as there is no pathology available. There are also no chemo agents available. Or specialists. Or specialty hospitals…
The next surgery I did with Greg so that Dr Sarah could finally have a break. She has been here as the only doctor for the past 3 months. I assisted Greg with an inguinal hernia operation. We see a significant number of hernias here as the people do so much heavy lifting. The surgery went without any problems, so we started to prepare for the next operation which was a prostatectomy. The next patient was in the operating room and we were about to scrub for surgery when a midwife comes running into the room, sweating, carrying a limp newborn. The baby was born at 33 weeks gestation and was delivered in the maternity ward just moments before. She didn’t cry immediately and was now limp and turning blue. The midwife placed her on the newborn incubator table (which doesn’t work). Greg grabbed a small mask and ambu bag and started bagging air into her lungs and giving chest compressions on her tiny chest. I listened to her hear beat and lung sounds. She did have a heartbeat but it was much too slow for her age. She did not however take any breaths on her own. He continued to bag, I continuted to dry her and try to stimulate her to breathe. When Greg was bagging, it sounded like air was entering her lung through thick mud. Yes, lung-singular as there was absolutely no air going into her left lung. At one point she started to breathe on her own and I was ecstatic, but this was very short lived and soon her breathing stopped and heart beat slowed. We tried for almost 45 minutes to convince her to live, but we were never able to get her oxygen saturation above 48% (normal 98-100). I also never heard breath sounds on the left. Greg had left to scrub for the next surgery and I finally realized that nothing I could do would help this little one. I had wanted to intubate her, but no such luck to have anything to intubate with- tube, or lighted laryngoscope. Finally I stopped bagging and watched her oxygen saturation and heartbeat go to zero. I don’t know exactly why we couldn’t bring her back; too young, undeveloped lungs, something critically wrong with left lung, perhaps other malformations (she didn’t look quite normal). There is so much death here in Africa. Some unavoidable like this kiddo, some frustratingly avoidable like that which Greg has written about in the little boy with rectal prolapse.
We just do our best and pray, pray, pray for God’s guidance and mercy. Til next time, Aud

Bere 2018 #15

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Bere 2018 #15

The first thing I do when I get into the hospital this morning is to check on the woman with the tracheostomy tube. The student missionary, Diana, has taken good care of her throughout the night. She has suctioned the tracheostomy a number of times and the woman is awake and not pulling on it. She is motioning that her stomach hurts. I try to have her sit up and swallow some water. It obviously doesn’t go down well. She is struggling to swallow. I’m glad I put a trach in her and wish I had a bronchoscope and EGD to look at the internal parts of the repair. I wish I had a tracheostomy with a number of inner cannulas. These are the parts that are changed out when they get plugged with secretions. Do I need to make a big hole in her neck so that it cant close up for months? The family didn’t even want to get her antibiotics. They said that the person with the money was coming. But when they arrived they didn’t go to the pharmacy. Eventually after they talked to her she grabbed the roll in her skirt and gave them a key. I assume that is to wherever she keeps her money. I told the men around that they should be ashamed of themselves. That their momma has to pay for her own care when it is the mans job to do so! (at least that’s culturally appropriate for men to do here, they are the ones with money). I discuss with them many times during the day to go and purchase the medications. I still don’t know if they actually did it like they said they were going to.

I do dressing change rounds (surgical rounds) on the surgical ward then do rounds on the medicine ward. Then I go to the “ER”, a room with 6 beds in it lining the walls. There are no diagnostic machines, no monitors, nothing that demonstrates this is an ER other than it says “Urgence” on the wall outside. I’m asked to see a guy who came in last night with a tender abdomen. It’s been tender for 3 days. As I talk to them I lay my hand on his belly. He winces. I give a slight tap with a finger, he grimaces. I do a normal exam, and he has a rigid abdomen. All signs that he has perforated intestine. I need to do a digital CT. here this does NOT refer to a CAT scan like in the US. It refers to cut and touch with fingers. So I put in all the orders into the ipad (they have a simple system called Open Kims, that was donated and is very useful.) So I put the orders in and the family goes to the pharmacy to purchase the medicines. When he has paid and gotten the medicines- His bill comes to about $150, they get him ready with a spinal and urine catheter. Dr. Sarah is done with rounds and so she joins me. She does the majority of the surgery. As we get through the skin, non-existant fatty layer, fascia, and peritoneum we then get pus. As we look around feeling for something that might be suspicious we don’t find anything by feeling. So we start pulling out the intestine out of the incision and look for holes. In the distal small bowel, we find a small hole in the intestine. I freshen up the edges, excising the hole and making it a little larger with good edges to close it. Then I close it with interrupted silk sutures. As we look around we find two other spots that are soft and necrotic and nearly holes. So we excise these two spots and Dr. Sarah and I close them. WE wash out all the pus we can and clean the intestines. We put them back inside with difficulty as he also has had ketamine from the start as the spinal didn’t cover that high on his abdomen. It’s kind of like the patient is doing a sittup, his muscles are real hard. Eventually I shove them all in and we are able to close the abdomen.

I’m very frustrated tonight. I got called into the hospital to see a 2 year old boy who has a rectal prolapse. This is when the rectum turns inside out and sticks out the anus. I also have seen an intussusception present this way. This is where the intestine invaginates on itself and sucks one piece of intestine into another. So I suspect this is more likely. I walk in by the light of the moon with my headlamp off. I go to the peds area where they receive kids. There is a mother with two guys and a child with lying on his belly, with a wet cloth covering a bulge at the anus. I lift the cloth off and see a looped piece of intestine sticking out the anus. As I feel around it at the anus, I’m convinced that this in an intussesception. He needs surgery to remove dead intestine and to reduce whatever intestine is still living. I do the usual things of asking the family to go to the pharmacy to buy medicine and pay for surgery. The total comes to an equivalent of $120. They say they have no money, as everyone says, and I say they should go to the pharmacy or send a guy home to get it. As I go to the maternity ward, there is a pregnant woman there that the nurse is not sure if it is a head presentation for a delivery. I take her to the ultrasound room and confirm that she is a cephalic presentation. Then I check on the woman with a tracheostomy that is now on the surgical ward and has a suction sitting on the floor next to her. She is breathing fine for now. I head back to peds. The family has left with the child to see what his uncle can do to help them pay the bill. I am very frustrated. I want to operate on the child. I also want to respect that the hospital needs to pay its bills and workers, and therefore needs paying patients. I feel like I have failed to show Christ’s love to this patient tonight. Would Christ pay the bill for them? Would He help create the feelings of things being done for free at this hospital? No he would put a hand on them and it would be healed. I guess I didn’t think of asking Him to heal the child in that moment. I am praying that they will return soon to allow me to operate on them. I am praying for healing now- though that feels woefully late. Again, I look forward to the day when the pain, sorrow, and sickness of this world are gone, and you and I can live forever in peace and health and joy with God for all eternity.

for more mission stories visit our mission website www.missiondocs.org

for information on our missionary and pastors oasis visit www.lifeimpactministries.net and click on Safe Haven Oasis

Bere 2018 #14

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Aud’s in Bere, Chad

So, I am writing my first note from Bere at 1am on Wednesday night/Thursday morning. Why at 1am you might ask. Well, this is the first time I have had to sit and reflect on my journey here.
I left my house in OR around 2pm on Sunday afternoon after my sweet kiddo made me an awesome lunch. I drove to Eugene to hit Costco for some last minute goodies to bring to our friends here in Africa. I suppose it was a funny site in the parking lot of Costco as people drove by watching me weigh and re-weigh my trunks so they wouldn’t exceed the 50lb weight limit. 2 people offered to help me get them in the car, not realizing that I had picked those trunks up dozens of times already to max out the space. Finally happy with the weights, I started driving to Portland. I got to the parking area and again had to lug the trunks from he car, to the shuttle, to the checkin. I was so happy when they finally disappeared with tags for N’Djamena, Chad.

My flights were uneventful. Ovenight from Portland to Chicago; 15 hrs Chicago to Ethiopea; then on to NDJ Chad. I was able to get through customs with no hassel at all- a first for me coming into a West African airport. The only glitch in my travel was the miscommunication of landing time, so I had to wait at the airport for awhile. It was extremely hot, especially after coming from 50 degree Oregon, and I didn’t have a phone to call, or a contact number for my ride. I finally borrowed a phone to call Greg, who called our friends that were to give me a ride. I met up with Gabriel, Dr Sarah’s fiancé and Sarah Appel and went on to Sarah A’s house on the farm.
I spent a nice afternoon at her place, walking around and taking the best cold shower I’ve ever experienced. We ate at 6pm and by the end of dinner I was almost falling asleep on my plate, so went right to bed, sleeping deeply until I had to wake at 5:40 to eat and get to the bus terminal.

I got on the bus around 8am. Now, I wish I could show you pictures of this bus. Imagine a grayhound bus, with curtains, and window decorations, and tassels, and streamers. (Last year’s bus even had beachballs hanging from the ceiling). Now add lots of people and kids in all shapes and sizes, with all of their individual smells- some amazingly sweet, others not as pleasant. Plus the luggage. There were largs sacks of onions blocking the aisle of the bus, and everone was required to step over and around, no matter what kind of skirt or wrap you might be wearing. Fortunately on this trip we were not stopped by police or army to inspect, and re-inspect our travel documents. In the past we have had 3-7 stops just for police to try to extort money. Not so this time, a very pleasant surprise. The bus made numerous stops to pick up and let off passengers. We stopped in the middle of nowhere and everyone started getting off. I soon realized it was a potty break-just stand next to the bus and do your business… The next stop was Bangor. This was the only major “city” on the route. It was also a good place to get crackers, soda, water etc. So, I got some “roadside meat” which was delicious, and yes, I tried fried crickets. Pretty good mixed with hot pepper spice. Finally off we went to my final stop of Kelo where Greg was there to meet me.

Greg had decided to not repeat his trip into Bere with getting the truck stuck, so he came to get me on a motorcycle. We hired a 2nd “clandoman” (moto driver) to bring my two 50lb trunks and off we went. Fortunately it hadn’t rained for 2 days so the dirt roads weren’t slick mud, but were still covered wih huge puddles. I knew this would be an adventure when Greg said, “ok, with this puddle, you need to lift up your feet or you’ll get wet.” Sure enough, the water came up over the tires but we made it through. All in all, the 2 1/2 hr ride was very pleasant, getting in just 30 min after sundown (with a crummy headlight).

As soon as we arrived, Greg went in the hospital to see a woman who had been injured by a bull. For you squeamish types, this might be where you should stop reading. The old woman had been charged by a bull, slicing her throat with its horn. She was still alive and breathing when Greg got there. Dr Sarah thought it had gone through a small bit of her trachea and possibly esaphagus. He was then notified of a 2 yr old with a strangulated inguinal hernia. Greg called for me to come and do the surgery with him to repair the neck and then repair the hernia on the kid. When I saw the woman, I could feel air escaping her neck with every breath. Already a miracle that she was alive. We prepared for surgery. It should be known now, that there are no ventillators, no gasses to put people to sleep, no pain medicine stronger than Ibuprofen. She was put to “sleep” with Ketamine and then Greg started to explore the injury. The injury was just above the trachea in the soft tissues. Not great, because this area will swell up terribly if injured and will become easily infected. All this to say that soon she would not be able to breathe through her windpipe. We decided to do a tracheostomy below the injury so she would have a secure airway. “Do they have tracheostomy set up here?”, Greg asked. No! So he started to do a trach, inserting a endotrachael tube, getting it set, then cutting it shorter so it would‘t stick out so far. By the time we were doing this, she had stopped breathing so it became emergent. We had a very hard time keeping her oxygen normal. The nurse doing anesthesia was bagging her in attempt to bring up her saturations. Greg, meanwhile was trying to repair the bull induced injury of her neck. I finally broke scrub to listen to breath sounds finding them only on the right. When we pulled the tube back a bit, she was then able to breathe using both lungs. She was still only taking a breath irratically so Phillipe continued to bag her. With the neck repaired as well as could be expected, we now had the challenge of managing a tracheostomy in an old woman, with none of the nurses trained to do so, no respiratory therapy, no ICU. I stayed by the old woman trying to keep her oxygen level as close to normal as I could. Greg did the next surgery on the 2 year old boy with inguinal hernia with a sweet nurse from South America who has been working here for several years. Fortunately for the kid, his bowels were still healthy and so it was a quick surgery. Meanwhile, I was suctioning, intermittently bagging, and manually giving oxygen to the woman. Her breath sounds were becoming very wheezy and diminished so we gave her IM Salmeterol (like Albuterol), IV Dexamethasone, Epi down the trach, then injected. She finally started really breathing on ther own, but was still fairly unstable. After doing as much as we could, we left her with Dianna, the nurse who had done the hernia operation with Greg, and decided to come back to the house to have dinner. It was now midnight. We ate rice and beanballs (like meatballs but bean based) in a tomato sauce. Greg went back in to check on the old woman, and I took the second best cold shower of my life. So here I am, writing while Greg showers. An exciting first day in Bere.
Total travel: Sunday at 2pm to leave the house- arrive Bere Wednesday night around 7pm.

Update: Afte sleeping until almost noon today, I went in to find the old woman doing well, considering… She has not pulled out her trach. She is breathing comfortably. Her lungs finally sound good. If only her family would actually pay for the antibiotics she needs, she might just make it. She will probably need the tracheostomy for some time to allow her neck to heal. She is having a hard time understanding why she is breathing through a tube in her neck, but has finally accepted it and is not fighting it. With patients and cases like this, I have to give all the credit to an awesome God who loves us and her, as she really should not still be alive.