Bere 2018 #9

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Bere 2018 #9

***READER BEWARE: very descriptive anatomy below, read as adults, not with children. ***

The list has a mastectomy, two hydroceles and a tubal ligation. That’s the operations that were to happen today. We did the middle two today. After worship and a lengthy meeting afterwards we finally started rounds at 8:30. Did the usual dressing changes and of interest to me was the guy with the intestinal volvulus from the other day. He has started passing gas and his belly is softer, a good sign. Things are working. Also the other guy with a strangulated necrotic hernia sac is doing great and is eating and pooping without any abdominal pain. I’m grateful. There are a number of them I pray for daily, which I’m concerned about. I pray for all the patients in the hospital globally but specifically for some.

A woman is lying in the preop area with a IV running and under the sheet I can see one breast standing up. For those of you who may not have done breast reconstructive surgery, it’s not good when a breast stands straight up. Normal breasts fall to the side and flatten some when lying on the back. So I suspected this was the lady for the mastectomy. I hadn’t seen her before. She saw a nurse who set her up for surgery after her husband paid and someone of the family gave a pint of blood (as in all elective surgeries). They got her back to the OR and I had a look at what we were doing. She is about 28 and had noticed a lump about 3 months ago. When I look at the breast the skin looks like an orange with little dimples in it. It stands straight up and very firm. There are two open draining areas on the skin. In her armpit there is a large- 5cm lymph node. As I move it up and down it does move some but I can tell it’s attached to the underlying pectoralis muscles. I also do not think there will be enough skin left to close the hole if I took it off her chest. Through the anesthetist translating I tell her I think I could take it off. I don’t think I will be able to get the skin closed, that she will loose some function of her arm, and that I don’t think it will really help her live longer as it has already spread. I use round about language to get to each of these points, making sure she understands each. I recommend that we not do the surgery, that even if we were successful at removing and closing the skin, that the cancer would come right back. I ask if there is family here. She says we should call her husband. He isn’t out there, but her older sister and mother are. They are brought into the OR and I tell them all the same things. I tell them that I expect it to get larger, the openings in the skin to get large and start to stink, and that she is unlikely to live a year longer. This is a really difficult discussion all the way through. I keep thinking of the gravity of what I’m telling her and trying not to tear. I ask who or what she believes in. She says she is and evangelical Christian. I try to encourage her that God loves her, even though she is going through something terrible. And that one day we will be in Heaven, where there will be no more cancer, nor more pain, sadness, and we will have healthy bodies forever after. I encouraged her to keep her faith in God and Him only. They say the husband needs to know all I’ve said and make a decision. This is a patriarchal society and women have no say in decisions even that concern her health.

I started the hydrocele surgery and midway through, I heard that the husband wanted to cancel surgery and go do traditional healing. He didn’t believe in cancer and that a traditional healer (witch doctor would get rid of it). When I was done with the surgery I called the family into the preop/postop area to talk about it again. I covered all the same stuff again. There was no crying, no visible responses, any of the times I discussed it. All were very stoic. Eventually the husband decided not to try with surgery. I encouraged him strongly that since he believed in Jesus that he should keep all his hope in Christ alone and not in any time of other healing or traditional things. That those things are not God’s things and that they should not attempt anything else. If and when there was pain, that she should see us again to get some pain medicine. They affirmed they believed in God and had no more questions. I felt very sad as I started my second hydrocele repair.

After that hydrocele repair was complete there was an old woman with a uterine prolapse for repair. As I saw here a few days ago, her whole uterus (about 5 inches) was prolapsed out between her legs all the time. I decided to do her operation abdominally as I feel I can get better suspension of what’s left from that approach. She is given fluid and then a spinal anesthetic. Dr. Sarah wants to do the surgery so we do it together. We choose a low incision along the ‘bikini’ line. I expect her uterus will easily come up and out of that incision as it has plenty of movement already. After we are inside, it seems more stuck down that I expected. There is some small intestine stuck to it and some loops stuck behind it. Slowly I’m able to free them up. As I free up these loops, I get into some small pockets of puss. So apparently when she had abdominal pain that I treated with Cipro for her typhoid, had apparently caused these pus pockets. She was better the following day but I was getting into them now 5 days later. One side of the uterus seemed to come up better now, so we started working on that side. Next to the other side. Clamping the vessels and tying them as we moved down each side. Eventually we get down to the bottom of it and finish taking it out and then suspend what’s left so there shouldn’t be any prolapse any longer. I decide to leave a drain, down to where the pus was. She definitely will stay on antibiotics. Of course every surgery is to help to minimize post op infections.

Can you guess what the next operation was?

Did you guess C-section? No. How about hernia? No. Well if you guessed ectopic pregnancy- than you were correct. Our 4th one this week. There are a host of reasons that women can get a tubal pregnancy. Most of them have to do with anatomical problems with the tube for one reason or another. So another belly full of blood in an anemic woman who was pregnant. And another small 2 month (2 inch) formed baby with arms and legs, that has lost it’s life and the mothers too, if she hadn’t come for surgery and received blood too. It’s been a productive day. We had water all day and electricity for almost all of it.

I convinced David to try and run the autoclave 2 hours instead of 1.5 from start to finish. I think it needs about 1 hour at temperature. But since the pressure gauge and thermometer don’t work any more, well, I just want longer. With this time frame it did get the indicator tape black finally. So I feel that these at least might be more sterile. I found some of the small indicator strips I brought last year, so I may try putting one of those in a pack to see what happens. I’m not really sure I want to know, but I do. There are so many possibilities for postop infection. Many in the USA, and even more possibilities here.

For those of you who have been in Africa- do you remember flying termite night? Well this is it. Hundreds of flying termites are buzzing around each light that is lit tonight. It only happens about one night a year. People in Koza would put buckets of water out and slap the termites into it. This catches their wings. Then the wings can be plucked off; they’re fried, and eaten. “Very tasty”, but I haven’t had the courage to try it.

Bere 2018 #8

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Bere 2018 #8

It seems unusually quite as I wake up. All I hear is the chirping of crickets and bird songs. Then I realize, it’s because my fan is off. I guess the power went out again. I was told yesterday we have 4 generators. 2 are old and don’t work anymore. The one we are using is only made to work 10 hours out of the day, so it gets to hot. And I’ve not heard anything about the 4th one. I consider laying in bed as there will be no elective operations today with out water and power.(water is still out today). I’ve not been told of any emergencies yet, so Ill rest. Then I realize there is morning worship and maybe another meeting too. So I get up and find a bottle of water that the accountant got for me last night and drank a liter. I read my own customary worship and head to the hospital. After worship at the hospital, I make rounds on surgical ward, then medical ward, and start doing ultrasounds, as the ultrasound nurse is gone this week. I am pulled aside to see a surgical consult in the OR preop area. It is a 7 day old boy that has hypospadius (opening of the penis is not the end but half way down the shaft of the penis). This malformation is somewhat difficult to manage and could be worse, if it was at the base of penis or scrotum. I recommend that the parents get it repaired at 1 year of age. He is continent, but the opening is in the wrong place. A little older he will have had time to grow and make it a little easier. I encourage the parents not to circumcise the child as a little extra skin there may make the reconstruction a little easier. Some of you are thinking- why would you do that surgery??? Well, there is no urologist any where near here, maybe in the capital, and no pediatric urologist at all. So, It’s whomever is here in a year. I go back and do a few more ultrasounds. They are done on almost everyone. The local population has grown accustomed to it and always want it, whether it will be diagnostic or not! So after a reprimand by the nurses, I’m doing them on whomever wants them and not objecting. I guess if the patient wants to spend 4500CFA ($9) to have a look, that’s fine with me. All the rounds are now finished and I head back to the house to rest and wait an hour before going back to see more ultrasounds I expect will be waiting. I’ve hired a cook while here, and he is getting 2000CFA ($4) day to make a meal for me in the evening. He also does some housework and works about 4 hours a day. That is decent pay for a day here. [By the way, I went in the village and ate the other day with Sarah and Gabriel for 300CFA ($0.65) for a plate of rice with beans and green leaf and peanut sauce and sweet potatoes. Way more than I could eat. So he is doing well with that amount.] I relax and read an interesting book called “The Insanity of God”. The electricity is back on but no water. I ask in the OR if they have any urgent cases and there aren’t so I go back to doing ultrasounds. I’m doing one ultrasound when I get an impression to ask further questions. This one is for abdominal pain. I see ascites, but she doesn’t seem to be in much pain. I push around and she doesn’t make any faces or grimace nor try to stop my hand. I look at the uterus and it looks empty and normal. She says she has irregular periods when I ask. My impression is to get a pregnancy test. She’s had a number of children. (one today was on her 11th child). After a number of other patients she comes back to the waiting area and is pregnant. Well, that must mean she has an extrauterine pregnancy (ectopic pregnancy). I re-examine her abdomen and she still doesn’t seem in pain. If she has an ectopic and this is blood she should be VERY tender. She doesn’t appear to be. I set her up for an exploratory laparotomy and find out her Hemoglobin is 4.7 (normal >12) So it must be blood. Later on, in the OR, I put a needle in to the abdomen with the ultrasound, and get dark blood, my diagnosis must be correct. We still have no water. A new pump was purchased and brought in, a price of 800,000CFA about $1600. Ouch!!! That’s a financial hit to the hospital! They are still installing it. The OR staff dump diluted bleach water over our arms as we scrub with soap and the brush. Dr. Sarah takes the lead and does the surgery. As soon as she enters the abdomen, a fountain of black blood erupts forth! Our cloth gowns are covered. Blood is running off all sides of the bed and there is a huge puddle of blood on the floor. We find a 3cm bulge in the left fallopian tube and remove it. After irrigating out the abdomen as much as possible, we close her up. At the end of this operation, my cloths are dry (I don’t know how) and Dr. Sarah is covered from mid abdomen to her knees in blood. Again I hope we get water tonight! This lady has had pain for a week. And apparently is very stoic! It is hard to read stoic people and the opposite as well, people who cant tolerate a small thing either. Both are exaggerated in opposite directions with reality somewhere in the middle. My guess is that those that seem exaggerated in either direction, more things are missed; because either every little thing is a disaster or nothing is ever a problem worth looking at. Two extremes. Fortunately, today, I listened to that Holy Spirit voice that told me to get a pregnancy test.

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Bere 2018 #7

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Bere 2018 #7

Fatigue, a back ache, a runny nose, blood all over the front of my scrubs, that’s how I walk back to my place tonight at about 8PM. Went in at about 7 this morning and expected a slow day because there was only two planned surgeries today. But as always happens, what’s expected doesn’t happen. The staff is in mid-sign-out when I arrive. I stand in the back and listen to who came in overnight. Then there is a time where the staff can bring up issues they need to mention or complaints they have. There is a need of blood pressure cuffs, a computer that works in the surgical ward and someone is unhappy about the number of mosquitoes in the ER. Everyone else is laughing at him, because mosquitoes are everywhere. But he feels his workspace is inundated with them. I head to the OR to see who’s ready, and of course no one is. Then I find out the water is off, so we have to wait for water. Apparently there is one faucet designated for people of the village to come and fill up their containers. Someone broke this overnight, and it drained the elevated tank of all its water. So headed to the surgical ward for rounds. As I’ve mentioned, this is a lot of dressing changes. Some are accidents that are healing, others are post-surgical infections. I also have the old man that I put a small IV catheter through his abdomen yesterday, to buy me some time to operate on his urethral stricture today. He hasn’t eaten and I re-explain the different possibilities of the operation to him. Dilation of the stricture in the penis, or opening his penis and his bladder to fix the stricture, and the need for likely a lifetime of urethral dilations either way. And if the stricture couldn’t be repaired (to long a narrow area), then he may need a catheter in his abdomen for the rest of his life to drain the urine. He doesn’t like this possibility but says to do what I can for him. “Doc je une malade au uregence pour vous a regarde’.” (There is an ER patient to see). I head over there with the nurse. This 30-year-old guy has had abdominal pain for three days and it’s been intense. I touch his abdomen and its tense and very tender. He has what surgeons call a surgical abdomen- peritonitis. I write the orders and head to the OR. They have a patient in there, and the water has returned.

The first one is a 20-year-old girl with an abdominal mass with ascites. Dr. Sarah wants to do it with me, as she wants to broaden her experience in surgery. I lead her through the operation. She makes an incision in the skin, and we get to fascia right away, almost no fatty layer. Once we get into the peritoneum, we get some cloudy fluid. Feeling around, I do not feel metastasis everywhere like I suspected. Instead I feel large lumps in the mesentery, and a large lump in the retro peritoneum. I decide this must be abdominal tuberculosis. This is a great finding for her! This is treatable! When would you ever be happy about a diagnosis of tuberculosis? I take some fluid and send it to be evaluated for evidence of TB bacilli. I’m happy to give her a possibility of something treatable. As we finish up with her- I remind the staff that the guy in the ER should be next. They say they have a hernia next as the guy in the ER ate this morning. I’m not pleased about waiting, but think that is reasonable. I think nothing will move out of his stomach anyway, but decide not to say much more.

The next guy isn’t just a hernia, he has 3 hernias! One in both groin and one in his upper abdomen. There is a new doctor that showed up yesterday unannounced. So it is he that helps me with this one. It’s a slow process as we fix one hernia after the other. Eventually they are all fixed and he heads to the postop/preop area. They have the old man with the IV catheter in his abdomen and a urethral stricture there in the preop area. He is refusing to have the surgery as his family hasn’t arrived yet and he is adamant about having the IV catheter out of his abdomen saying he can pee just fine now. I don’t believe his AT ALL, but as I don’t feel like fighting in an old man who can make his own decisions, I pull it out. Had it been a woman or a child, I would have fought the husband or father for the good of the underdog. But this guy- no. They take him back to the surgical ward. It’s mid afternoon and the water is gone again. This time it’s the well pump. They have to take it to a town 3-4 hours away to try to get fixed. So now I have this emergent surgery and another one that just arrived with an ectopic pregnancy. Both HAVE to be done today. I ask the staff to get some water from a hand drawn well in the village, add bleach to it and use it to wash our hands and postop instruments. They put it in a bottle and dump it over our hands and arms as Dr. Sarah and I scrub for this guy. She opens up his abdomen along the middle from top to bottom. Im initially suspecting a gastric perforation as he has upper abdominal pain to begin with. But his intestine is really distended. As soon as we open the abdomen the intestines “jump” out, released from the confines of the abdominal wall. I see some of them in the lower abdomen are purple. (not great blood supply). I look around and realize that there is a volvulus. The intestines have twisted on themselves, blocking off their own blood supply. I untwist it and they look better within a few minutes. The large intestine fills with fluid as it continues on as well. At the end of surgery there is poop all over the operating room table as it was released. What a mess without much water. They have brought in more water and they clean up well.

The 22 year old woman is there in the preop area, lying under a sheet and with her head scarf on. She is obviously uncomfortable. I touch her abdomen and she winces in pain. Dr. Sarah does an ultrasound and confirms what appears to be a pregnancy outside the uterus with fluid (blood) in the abdomen. The generator has now quit as we take her into the operating room. They restart it and it runs for 10 seconds and shuts off. I hear that it is to “hot”. To me that means out of water for the radiator or out of oil. It runs in the hot season when it is 125 deg, so now when it’s 90, it should run just fine! Eventually the anesthetist comes in and says that we should proceed, as it won’t get fixed. So I run back home to get extra batteries for my headlamp and other lights that I happened to bring with me. I see Gabriel and he rounds up some more headlamps for us to use. It is very hot and still in the OR now. I figure it will be my sweat that will cool me now. We use cloth gowns here as they are reusable. As I open one of the gowns, I get a little odor of rotten flesh. OH NO, I hope these were cleaned and sterilized well after the leg amputation the other day. I ask if anyone else can smell something. They can’t, and my nose doesn’t work well anyway. So I hope I’m imagining things. I don’t see anything unusual, and the marking tape on this pack seems to have reached the temperature needed. Or at least black marks on the tape. I sure wish I KNEW that these were sterile. I wish we had a real, functional, electric autoclave!!! As we open this woman’s abdomen dark blood comes flowing out all over me. It quickly saturates through to my skin! And no water for a shower tonight. I wish I had thought to fill some buckets with water earlier in the day or when I arrived here! We find a small tubal pregnancy that has ruptured. We remove it and as we’re mid-surgery the electricity comes back on. Guess the generator is working again. The generator runs this hospital 24/7/365 days a year. It is one of the major expenses of running this hospital. More than all the salaries of the staff. In the end, I head home and find a washcloth that I saturate with water left in a cup that I had sitting out, and wipe the dried blood off me. I feel better, but not clean. I guess 9pm isn’t a time to try to find water in the village, it’s nice to sit under a fan though. I head back into the hospital to tell them I’m on call again and see a young student that is jaundiced and vomiting in the ER. I order some things and hope we can figure out something for him.

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Bere 2018 #6

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Bere 2018 #6

It’s nearing sundown, about a half hour left and I want to get out and call my wife from that special tree on the road! We got done with rounds in the hospital by about noon, I rounded on surgical ward, and saw consults in the ER, and rounded the medical ward. In the ER there was a guy who had had a prostatectomy 2 months ago and was having urinary incontinence. As I looked at his abdomen, I could see his bladder poking up from below and went all the way to above his belly button. WOW that is a full bladder. I ordered a urine catheter and urine bag. They went of to the pharmacy to get them and came back with them. The nurse called me that she couldn’t get it in. I looked and she had only gotten in about 3 inches. It was sticking mid-penis. So I had them get a child’s sized one- also wouldn’t pass. I started talking to the nurse and I look over and the guy has the small catheter in his hand feeding it into his penis to try and get it through. I scold him- but also understand his desperation to have it in. Then the decision was- call in the OR crew for a stricturoplasty of the urethra now or get him by till tomorrow. I chose to get him by till tomorrow, review stricturoplasties (if I have anything that covers that)?! So I took a 16G iv catheter and poked it (sterilely) through his belly. We taped it in place and put and IV tubing to it with an empty IV bag and lay it on the ground. Urine was flowing freely out. Now I have bought myself some time to decide what’s best to do. He said the original catheter before surgery was a very small one so I suspect he had a stricture (narrowing) of the urethra back then. This can happen when the urine catheter balloon is not inflated in the correct spot, or other reasons too.

After getting him “tucked in”, I went to Dr. Olen’s motorcycle and jumpstarted it with a truck that had just come back from Lai. I ran it out to the airstrip about 15 min away to charge up the battery. On the way back, I ran out of gas. Gas is sold in the market in various sized glass bottles, but none out where I was. So I pushed the moto to the market and got a couple liters. Then it started right up again. Now I’m about an hour from sundown. I text Audrey to see if she can talk if I went to that special tree. She responds and I have about a half hour of sunlight left to run out the 20 min drive. Many people are walking along the road, motos are kicking up dust. Donkey pulled carts are carrying supplies. A bull cart is carrying a bunch of people. Kids are fishing in the rice swamps for catfish. Eventually I arrive at about the spot and I have 3G. I try for 5-10 minutes to get an internet signal- eventually it works and I’m able to connect. We have a good conversation, I’m blessed to have a wonderful wife and daughter!

I drive back in the dark, being pelted by bugs in my face and chest, but moving at least keeps the mosquitoes from having a festival on me like when I was talking on the phone. I sure hope I avoid malaria this time! I get back to the hospital and a nurse wants me to see a patient so I do. It’s that same guy. I reassure them a little blood in the tubing is expected and tell everyone I’m on call. Now I sit here in my room, with a ceiling fan running above me. Finally cooler that the whole rest of the day.