Bere 2018 #5

Bere 2018 #5

It was Sabbath, the day I choose to go to church. At the hospital, it is a minimalist day. The doctors generally see the patients the nurses have questions about and other than that, the nurses do the rounds and change dressings. Dressing changes are at least half of what’s on the surgical ward. Some are infections after an operation, and some are accidents that are taking a while to heal. The dressings are usually done with a dilute bleach solution- which helps with the infection too. So I went in, to check on people before going to church. The surgical nurse had me see one old guy who couldn’t pee, even though he was here for a foot infection. He got a urine test and a catheter. Another lady was in labor, and was progressing well, so I didn’t need to be involved with her- the nurses deliver all the normal deliveries. After I finished with the ones they wanted me to see, I found Dr. Sarah and Gabriel and we headed off to a church about 30 min away. Dr. Sarah wanted some exercise so she rode a bike, and Gabriel and I rode motos. We wove though the village. Every 100ft or so there were a group of kids playing or working it the gardens by their houses. As we would pass they would sing out “Nassarra, Nassarra,….”(white person) smiling and waving. A few chanted, “Nassarra donne le cado” (white person give a gift). We wove through the village along the mud path with large potholes. We would go around the edge to stay out of the water when possible. A few times the puddle took up the whole road, to the trees on either side or someone’s field. Then we would have to go through the edge of the puddle (almost pond like). It’s the rainy season, so all the fields are green and beautiful. We pulled up into a small building with a tin roof. When I went inside I realized it was one of the “one day churches”. These are buildings that have been put up by donations, and are metal, so the termites cant eat them. I think the design and longevity of these buildings are amazing. The hospital is at least half made by them too. The Sabbath school was being given in French and translated into Nangere (the local language). Some were sticking to the lesson, but others had some questions that weren’t related. “If you become a Seventh Day Adventist- do you have to be re-baptized?” “Why is Sabbath on Saturday and not Sunday?” “Is Sabbath or Sunday the first day of the week?” (If you question these same things- ask me in an email, and I’d be happy to respond.) As we were finishing Sabbath school, a nurse called Dr. Sarah saying that a woman had arrived who she thought had and ectopic pregnancy. Her hemoglobin was 4.2 (normal is above 12). Dr. Sarah ordered some blood to start, and a pregnancy test. When asked what her vital signs were the response was her blood pressure is 12/7 (120/70). So at least I knew she didn’t have a low blood pressure at the moment. I hopped back on the moto and headed back to the hospital. I walked past the people around the wards that were sprawled out under the trees and on mats on the ground. The delivery room only had this patient in it. There are 6 beds with curtain partitions in between. This young woman had about 3 old women with her and a brother of the husband. Almost all the people here are thin, and usually when they’re lying on their backs there abdomen sinks in. Hers was distended up! I touched it and she winced in pain. I suspected she had a belly full of blood. The story I heard was that she had been up in the capital 3 weeks ago and saw a doctor for pain and they did something and said she had a pregnancy outside the uterus (ectopic pregnancy). They recommended surgery. She didn’t do it and a week ago came home to Bere. The last three days she’s had abdominal distention and increased pain. So they brought her in to be seen here. As I finished talking to her the first bag of blood arrived. They said other family members were on their way. I went to the ultrasound room and got the ultrasoud. I jelled up her belly and put the probe on. She had a lot of fluid in the belly- blood! The uterus appeared empty and above the uterus I could see something round with a baby inside it. There was no heartbeat, as expected. Likely a tubal pregnancy. This was her first baby! She needed a lot of blood and an operation to remove the ectopic pregnancy. I know that the anesthetist (trained on the job) prefers spinals, but this girl needed Ketamine, since she was already short on blood and giving a spinal in this situation can kill the patient with hypotension. Phillipe (anesthetist) arrived a short time after my call. The nurse brought the patient to the OR and we started preparing her. Getting an additional IV, putting in a urine catheter, getting the OR pack opened with gloves, scapel, and suture opened on the pack. Then when Samadi, my assistant arrived, we scrubbed an we started. I chose a low phanynsteal incision, and as soon as I got in the abdomen, dark blood came up like a fountain. We suctioned 4 liters of blood and more was on the table and floor around us. Eventually I could see to continue and I started to take off the fallopian tube that was a mess. The little 2month old fully formed baby popped out one side. Each time I see a small fetus; I am amazed at all the tiny features that can be seen. I completed moving the mess and started washing out the abdomen to try to remove as much blood as possible. Remaining blood can give the patient an ileus (the intestines don’t work well and are kind of paralyzed). I washed out with half liters of saline and used about 8 of them sequentially. Eventually it was mostly clear. I closed up the different layers and we were done.

I now remembered that the missionaries were getting together for a late lunch and I hoped they were still together. I headed over and we hung out for many hours. Hanging out with them affirmed to me that missionaries are very special people. They leave what is comfortable and known to go somewhere to do humanitarian work, be the love of Christ to others, accept hardship in many areas of life, put their family members at risk for diseases unknown to the western world, and so many more things. We had a nice evening together and great food too!

Bere 2018 #4

Bere 2018 #4

The sun set with a cloudy sky and then a downpour hit! I had just been out on the road leading to Lai out near that special tree where there is better cell service with 3G. It was a little hit and miss, as it dropped the call with my wife a number of times in a few minutes of talking. But I think I was able to send emails. So hopefully you received #1-3. I was out at that special place when Dr. Sarah got a call that a special delegation was at the hospital from Ndjamena, and wanted to talk to the head medical doctor to answer some questions and fill in some paperwork that they had. I had chosen to take all the hospital call tonight as she has not been off call for 3 months. So doing non surgical call I hope will not be to taxing for my brain. Anyway since I’m on call, I decided to go meet with the delegation. I hopped on the motorcycle and made a hasty retreat back the 10 miles or so to the hospital. Just as I got there the downpour started. There were 3 doctors here and a couple others. They were here in a program with an NGO that works through world health organization with regards to maternal and neonatal health. They wanted to do a short evaluation of the hospital and fill out some paperwork to turn in to the NGO. They said that the materials or education that is lacking would be funded through the NGO to improve maternal and children’s health. So the one I went with, wanted to see the OR and write down how many sterile packs we had for C-sections, hysterectomies, repairs of episiotomies, suction apparatus for retained placental products, oxygen machines, baby incubator… Then he asked what kind of doctors worked here and that there should be a OB/GYN, surgeon, pediatrician, anesthetist, general practitioner, midwife… Hmmmm. Currently there is only me and Dr. Sarah. Last week it was only Dr. Sarah for most of the last 3 months. For each of the OR packs they asked if all the instruments were inside, I said that we had 2 of each but that the normal number of clamps in each one is about half of the important ones. They asked if the scissors were sharp. Definitely NOT! So they registered 1 for each. Later on, we all got together and summarized their findings of the three partially filled booklets. Then they wanted the hospital stamp on a fourth empty one and my signature. So I signed a blank page that they will fill out later, another Hmmmm. I think I’m jaded from working in Cameroon. We had similar situations in Cameroon, and money was sent to our hospital in Cameroon but never made it to us. One of the times we were to get money, the medical director of the district took the money and bought himself a nice new 4×4 truck. So jaded, I am! After about 1.5 hours, they decided we were done and since it had rained they wanted a hotel or place to pass the night. There aren’t any in Bere nor rooms ready at the hospital that I’m aware of. So I sent them to ask a worker. They left and I did too.

While I’m here I’ve hired a guy to cook for me. He has cooked for other missionaries. I do not like cooking and here everything takes a long time to cook. Pluck the rocks our of the beans, pick the bugs out of the rice, go buy some vegetable so put in the beans and maybe some tomato paste, then its time to cook. This may take hours as the beans are super hard and dry. So between the time effort and my dislike for cooking I’ve hired Joshua. So I get “home” this evening and there is the local millet paste, a peanut sauce with green small leaves, and deep fried okra. Yum, I like all of it. Also a loaf of fresh bread. I put some peanut butter on that. Wish I had some butter, but the local margarine is awful tasting. So I had my fill then went back to the hospital to check in with each of the nurses to let them know that I was the one on call and to not bother Dr. Sarah. So I’m praying for rest tonight! As I write I can hear a sheep bleating directly behind my house, frogs croaking near by and crickets chirping. This is nature.

Bere 2018 #3

Bere 2018 #3

As my father in law used to say “It’s a good tired”.  I’m tired at the end of a long day.  Here the day starts at 7:30 with a hospital worship.  I couldn’t fall asleep last night till about 2 so didn’t make it in on time.  But one of the nurses was having a teaching on tuberculosis.  It was quite informative about the countries methods of dealing with the disease and its treatment in different circumstances.  For example, a pregnant woman, a person who has had negative sputum’s then turns positive again, patients with HIV, children, those who get inpatient treatment and those outpatient…  After that we went and looked at the new OR that is being built.  They have a building structure that is metal (termites cant eat it), and are building block walls on the inside to create 2 operating rooms, preop, postop, instrument cleaning, and instrument storage areas.  Dr. Sarah Belinsky ( I guess she goes by Dr. Sarah so Ill call her that now) and I make some construction decisions, I head to the OR to verify whether they are preparing the first patient- and they aren’t.  So I try to hurry them along, it always seems like a slow start each morning as I recall. Dr. Sarah calls me into the ultrasound room to see a 20 year old girl.  She has a palpable abdominal mass.  It seems mid abdomen.  Oh NO!  It has to be cancer.  We look on the ultrasound.  I see ascites (abdominal fluid), which is a bad sign, and a large solid and cystic mass.   We look for the ovaries, and they seem normal as well as the uterus.  Liver doesn’t seem to have any metastases.  I feel terrible as I tell her and her older brother who brought her about our diagnosis.  We have no chemotherapy drugs nor pathology for a true diagnosis, so the only thing I can offer her is to explore her abdomen and take out the mass if I’m able to.  If she was an old woman, I wouldn’t offer as I don’t think it will be successful.  But a 20 year old, I’m going to try tomorrow.  I head back to the OR and they’re not ready.  So I head to make surgical rounds. I’m still completely stumped by a 15 year old kid who had 1-2 inch pitting edema all over.  I’ve thought and treated, congestive heart failure (heart seems a little big on ultrasound- not accurate in my hands), wet Beriberi (thiamine deficiency), treated his malaria and typhoid, nephritic syndrome as he is dumping protein in his urine.  Its these patients that I’m most frustrated by not having appropriate tests.  For surgical problems, if I open their abdomen, I can almost always diagnose and usually treat, even if I can’t figure it out ahead of time with the ultrasound.

Back to the OR and they are finally ready for a right leg amputation on a 60 year old lady that had been bitten by a snake a few weeks ago.  Most of the skin on her leg sloughed off and muscle died.  They have been doing dressing changes and now both her tibia and fibula in the lower leg are exposed for almost their whole length.  Pus continues to drain out of her foot.  It hurts her to have me touch it anywhere, except above the knee.  I decided to do an above knee amputation.  She hurts every time she moves and is lifted onto the OR table.  She is given a spinal anesthetic and I start my work.  The “tourniquet” that is on the leg is a normal blood pressure cuff that looses air constantly.  So one of the nursing students stands near by constantly pumping up the cuff.  I am very pleased that the cautery machine that I brought last year is still working.  Between the ‘tourniquet” and the cautery there is very little blood lost.  Once I’ve cut through all the muscles and tied off the arteries and veins, it’s only the bone that is left.  There is a little saw, that I use to cut thought the bone.  I’m tired after sawing a few minutes and hand it off to my assistant to continue.  Eventually we get through.  The saw is quite dull and likely has been used for a half century.  I close the muscle layers over the end of the bone then the skin and wrap it with an ace bandage.  Next was a inguinal hernia.

Then there is another inguinal hernia that is strangulated.  He’s had pain and not eaten for three days.  Says he’s vomited some.  I’m guessing he has dead intestine in it.  I open this area up and I see black tissue.  As I dissect around it, it seems to be coming through a small hole.  Eventually I open it once I’ve gotten to good tissue.  It is a necrotic hernia sac.  This usually means that there is dead bowl inside.  The fluid I get is clear and all the intestine I can find from this hole, looks normal. Disconcerting! It seems the same size as when I started, so I don’t think anything has reduced spontaneously.  I then have two options, open him up along the middle and look around or finish what I’m doing and see if he improves or worsens.  I decide to watch him after this operation.  (if you surgeons differ with me, let me know).  I’ll know tomorrow if I made a good choice or not.

Another woman awaits a curettage after not getting all of the placenta out after a delivery.  She is very nervous about it.  We bring her family in and explain everything again.  She agrees and we walk her into the OR.  She starts crying and says she doesn’t want to do this.  So we take her outside to her family.  We all gather our stuff and I go to check things on the surgical ward- about 5PM.  WE are called back to the OR for a C-section.  A lady has not been progressing all day and apparently has been in labor a number of days at a dispensary before coming here this afternoon.  She arrives and sits on the OR table for her spinal.  After the spinal is in, she is laid back and we prep her for surgery.  The cloth covered C-section pack is laid on a nearby table and opened.  A fly is flying around the room and lands on the open pack.  We wave it away and as it is the only C-section pack “sterile”, we use it anyway.  I am totally convinced that God protects our patients, as infections for clean surgeries are very rare in spite of the conditions.  Dr. Sarah does the surgery and I assist.  The baby comes out with meconium everywhere.  But breaths and cries- Yeah the sounds of a live baby!  The area is closed up and she heads back to her maternity bed.

I’m asked to see an old man who had a prostatectomy before I came, and has urinary retention now 7 days after surgery.  This morning when I saw him he was still with dark bladder irrigation.  Likely meaning he is breaking down blood clots that remain in his bladder.  He is eating and in pain from a bladder that is visible when I look at his abdomen.  I flush his urine catheter and try repeatedly to clear the blockage.  Finally I just remove it.  He is able to urinate.  I hope that he continues to urinate or I may need to re-explore his bladder again.

I head back to the place I’m staying and eat the food that was prepared by a guy I’ve hired to make my food while I’m here.  He’s prepared and left me some millet paste with an eggplant/tomato sauce!  Not exactly my favorite, because we had something similar so often in Cameroon.  But I’m hungry and so I eat till I’m full.  I realize that the phone credit that I purchased yesterday evening is nearly gone.  I haven’t used much that I can think of today so I go through my phone again and try to turn off everything I can find that is sucking up my phone credit CFAs (Central African Francs).  I head out to the market to get some more.  It’s all dark but a few cell phone lights can be seen.  I find the guy selling the Tigo credit and tell him I want 5000CFA ($10).  He punches in a certain number on his phone and I get a text message that that much has been added.  He also sells brown soap, tomato paste, some soda drinks, Chinese batteries, pens, paper, a few types of shower soaps, flour, rice, different types of small cookies and crackers, powdered milk, garlic, small onions, maggii flavor cubes and many other small things.  I head back to my place.  In the dark on the walkway I feel like I stepped on something.  I flip on my headlamp and see that hundreds of termites are building a mud mountain that is half way covering the concrete walk.  They start scattering and kind of raising up toward the light.  It’s a strange site.  In the day, these always look like nothing is happening, but it’s slightly taller.  They are very busy tonight.  Guess Ill be looking at them every evening when I come back, for interest sake.  I hope you all are enjoying these stories.  If you’d like to hear about something specific, then email me back.  I’ll respond, even if I’m back home wh

Bere 2018 #2

Bere 2018 #2

Got to Bere Hospital last night. Had a few hours sleep and was awakened to help with a C-section. I told them to call me if anything happened or they wanted help. So I get myself together, find my scrubs, cap, mask, headlamp, keys, and OR shoes and stethoscope and head in. When I arrive Dr. Belinsky is already scrubbed and the patient has a spinal in place and they’re waiting for me. This young woman has been pregnant 6 times and all the babies have died. This time, she is at term, and is in a transverse position with a hand and umbilical cord coming out. For those of you who don’t know, babies can some out head first (preferable), feet first. Transverse doesn’t come out! So either the position needs to be changed or a C-section. I scrub and assist. Once the baby comes out, he is a little floppy, but with some drying and rubbing, he starts crying. This is a wonderful sound in any C-section- live babies cry!!! She gets closed and wheeled out the the preop/postop area. There are a couple patients needing to be seen by me that have been saved for when I arrived. One is a lady with recurrent breast cancer with large, hard lymph nodes in her arm pit, and metastases in the liver. I share the sad news with her that I cannot do anything to help her. We have no chemotherapy drugs here, especially the specific ones that can sometimes help. She starts to cry and lift her hands towards heaven. The nurse says I should encourage her. I think he means that I should gloss over what I’ve said and make it more palatable or less direct. In my western mindset, I think everyone should know exactly what the doctor thinks, and he’s asking me to not tell the whole truth. I tell him that I wont. Then he tells me, no maybe share something spiritual. I finally get it! I ask her what her beliefs are, and she is evangelical. I encourage her to focus on God and His love for her and that He doesn’t want this situation for her either. I share that we don’t have to fear the future or death, because we will be with Him. I pray for her, asking for Gods healing. And asking if God doesn’t heal her that he give her strength and peace for the coming months. She seems more at peace and leaves the room.

The next surgery, is a 20 year old guy with “appendicitis”, who has had pain for 9 days. So here’s a short surgical lesson- appendicitis is short term, day or so and it bursts or gets better with surgery or sometimes antibiotics. The ultrasound saw a mass and an inflamed appendix. I have little faith in the ultrasound interpretations and consider doing one myself. I figure it won’t change the fact that I need to operate on this guy, so I head in to explore him. He has a fullness on his right abdomen and it’s quite tender. The rest of his abdomen doesn’t hurt at all. Samadi, the old nurse who has done operations for years here, assists me. He’s been doing them the past months here as the surgeon was gone, but when we talk about who will do the surgery, he says that I’m the surgeon and I should go ahead. I, of course, agree with him and we move on. I’ve forgotten how difficult it is to open a persons abdomen here. The skin is tough and the scalpels aren’t real sharp. I slowly go through the skin, small layer by layer. After about three slices, I’m finally through his skin. There is a thin fatty layer and I’m at the fascia. I open the fascia and spread into the peritoneum. No puss or air or stool in the abdomen- good. I feel for the mass. It seems that the omentum (fatty layer in our abdomens that helps sequester infection) is stuck up to the abdominal wall. I slowly push my finger in that area separating the omentum from the abdominal wall. Puss rolls out, my nose, immediately catches the whiff too. I eventually figure that the guy had perforated typhoid that his body walled off. I put a drain in and washed him out. I also decided to remove his appendix, so that it wouldn’t be the cause next time either. I close him up and he is off to the surgical ward.

Next is an older man with a broken ankle that has been here about a month. He has a huge open wound and an ankle that rotates 90 degrees out, making the sole of his foot point off to is right. This occurred because of an accident on a moto. I agree with the others assessments that he needs an amputation, for the infection and because this is a non-functional foot and likely osteomyelitis (bone infection). In the operating room he gets a spinal anesthetic, then I go about removing his leg below the knee. I have to leave the amputation site open because of the infection and hope he is able to get some sort of wood prosthesis in the future. Ive heard they can be made about 4 hours away.

Then there is the mid 20’s guy with a small left inguinal hernia. We bring him into the operating room after the staff has cleaned it and Ive seen a couple more consults. I consider using mesh again and realize that most of the “sterile” packs have not changed color of the marking tape. I ask the guy who sterilizes stuff in the autoclave to put these packs back inside as they aren’t sterile. I again decide that I won’t use mesh during this visit. I’d prefer to have a chance at leaving the missionaries here a hernia recurrence in the future than a mesh infection. So I resect the hernia sac and use suture to reinforce the area.

A woman comes in from an outside hospital a few days ago. She had a very foul vaginal discharge and had apparently had a delivery that some repair had been done afterward. Her uterus looked very irregular on ultrasound and the nurse who does ultrasound thought that there was a perforation of the uterus. Samadi took her to the OR and opened her up and didn’t find any perforation. She continues to have a foul odor and so we took her for a uterine curettage. We were able to get small amounts out retained placenta out of the uterus, but just as Dr. Belinsky and I were finishing up, we see that there are large areas of necrotic tissue on either side of her upper vagina, near the cervix. The baby’s head usually causes pressure necrosis against the bone in front, so I’m not sure what caused this problem. I’m surprised that she is not deathly ill. So we debrided off whatever dead tissue we could and packed some gauze into both sides. I imagine that she will heal this, but it will take a while and she will smell bad until it heals. I warn her of these things and we wrap up the day.

Tomorrow holds a hernia and amputation of a lady’s leg that was bitten by a snake, and both bones in the lower leg are exposed for the majority of their lengths. I try to sleep tonight, but sleep is not coming, likely jet lag. So here I type. I hope to get out the forked tree about 10 minutes up the road to send these in the next couple days (yes that’s real). Apparently if I go 20 minutes away the cell signal is even better. Guess I’ll see what I can do.