Shanksteps Bere 2017 #8

admin Greg, Shanks No Comments

Shanksteps Bere 2017 #8

 

Olen and Denae’s kids are sick.  Fortunately it is with malaria!  You, reading that, are gasping!??!??  What? Fortunately malaria?  Yes it is true that malaria is responsible for 1.5-2.7 million deaths a year.  And death is more common in the young the elderly.   So why do I say fortunately? Because two of the kids were bitten by a rabid cat a few weeks back.  An rabies has a 100% mortality rate.   So we continue to ask God for protection from rabies in these kids. (If you want to read further on Olens blog- look up Olen Nettberg on blogspot).  The kids are getting better and are playing again.  So what do missionary kids do to play?  Run around in the yard, playing with sticks or toys.  Interact with other kids or adults.  Run around outside with a purple cape, being a superhero.  Ride a bike.  Visit their grandmother to see if there is different food at their house.  The thing they are not doing is surfing the internet as there isn’t any.  They also like to read and listen to books.  So they are on the mend.

I had a chance to look a the old lady’s leg that was rotten a couple days back.  It is looking cleaner, with only a small amount of pus.  We continue to do a dakins dressing (dilute bleach solution) and it is doing it’s work.  I continue to think she will need an amputation but is improving.  I send home one of the ladies that we took out a uterine fibroma and a number of the hernia patients.  I again appreciate the lack of paperwork here.  Only what is needed when someone sees them again.  Basically they are discharged with medicine and a little book.  In their little book we write what surgery they had and when they are to come back.  Their medicines are explained to them again as to how to take them and they’re off for home.  Discharge in 3 minutes!

I see Olen examining a little girl about 7 years old. She is crying and fell down a well today.  Her abdomen hurts.  Does she have a cracked liver, an injured intestine, a bruised muscle, something unrelated to the trauma- like typhoid or malaria causing abdominal pain?  So many questions and no answers.  He does an ultrasound on her and there doesn’t seem to be any fluid in the abdomen outside the intestines.  So a cracked liver is less likely.  I’d sure like to have a cat scanner!  There aren’t even any plain x-rays here.  Ultrasound only!  She is admitted to the pediatric ward to watching and treating her malaria that was positive on her test.

Amongst the many surgeries a few days ago was a 30 year old guy who had left flank pain.  In the US I’d think of diverticulitis as one of the first on my differential diagnoses.  Here Rollin thinks of a psoas abscess.  Christian and I opened his abdomen.  There was pus inside and a fullness in his flank under the colon, with the colon appearing normal.  We opened into the area and find that Rollin is right, a huge abscess.  We sucked out more than a liter of pus, then put a drain out to the outside and close the area we opened.  Over these past few days the two drains have plugged up with pus so thick it wouldn’t come out.  So we took him back and made a 4 inch opening in his flank to let it drain out.  Each day we flush it out with dakins solution and gobs of pus and debris come out.  He is looking better day by day but the quantity of pus continues.

I’m doing rounds and I see another man with pus draining from a small wound in his chin.  He is in obvious discomfort.  I push around on his neck and pus flows out of the hole.  I decide he needs better drainage.  I suspect this is from a rotten tooth, but he denies having any tooth pain in the past or now.  I take him to the prep room, of the operating room.  That is where we do quick procedures.  I numb him up as best I can with lidocaine.  Then I open a few inches under his chin.  He yells out in pain “my God, my God…”  I feel sad that I am causing him so much pain but know I have to break up the loculations in the abscess and it will take a few seconds more.  I get done and pack the area with gauze.  Now I expect it to heal faster.  He is already on the available antibiotics. (Available antibiotics are ceftriaxone, cipro, ampicillin, amoxicillin, metronidazole)  As I do round, at least half of the people are for dressing changes of infected leg, arm or other wounds, ulcers or abscesses.  Each of these patients tolerate significant pain every day during dressings to get better.  I wish I could give each a shot of ketamine before their dressings so that the changes could go easier for them, but there is no monitoring available if I were to do that, so I continue with doing it as quick as possible to get it over with and not draw out the time it takes.

Shanksteps Bere 2017 #7

admin Uncatergorized No Comments

Shanksteps Bere 2017 #7

I awaken before dawn again. I wasn’t woken up all night. I feel pretty good, but lay there awake anyway. Audrey has left back for the US, as she couldn’t get the same time off that I could. It is quiet and lonely in the place I’m staying. I’ve been told that since Chad has been taken off the list of places US citizens should go, a few years back, there haven’t been any more student missionaries. The birds are chirping, roosters are crowing, and Chad is coming to life. Days have passed since I arrived. Many hernia repairs, and a smattering of other interesting surgeries. Each day there is a list of 8-10 to be done. Most days we get the majority done and the rest wait till the next day. I’ve seen patients from Ndjamena, near the sudan border, near the border with CAR and from Nigeria. I was told today that if you want to be seen in a gov hospital, that you may wait weeks just to see the doctor. He/she may see a few each day then go off to their own clinic through a back door, leaving the rest just sitting there. Here they see a doctor, usually the day they arrive, are consulted for the surgery and can be done in a few days. Each day is filled with as many surgeries as the surgeon and staff can do- one after another.

An old woman is laying on her hospital bed in the corner of the room. Surgical patients line the walls on both sides. A few relatives stand around different patients fanning them with small woven grass fans. It is relatively quiet for the number of people in the small room. We start with the old woman. Her dressing is unwrapped and I see a large patch of black skin covering most of her forearm. This was apparently burned. Pus drains out from under the black skin. I expect to see maggots but none are present. We recommend taking her to the operating room for a surgical debridement.

Another in the room is the gentleman that we drained a psoas abscess on. His drainage tubes are full and haven’t been emptied overnight as they needed to be. Pus is draining around the tube that is full. I guess at least it is making it’s way out. I empty the bulb and thick pus with a bad odor is drained into the basin. Flies hover around the smell I’m sure they can sense a mile away. As the rounds continue, I head back to the OR to check if the first patient is ready. We find a child that has had a hernia stuck out for about 4 days. He is crying and looks sick. He needs a hernia repair right away. A different young man with an inguinal hernia is lying on the OR table, so he is done first.

The second is the young boy of about 10 years. I do his operation with the help of Christian. He is given some inhalational anesthetic (have no idea what was used) and ketamine. I’m glad to have brought a cautery machine that was donated by my hospital in the US. This helps a lot to minimize bleeding. The drape has much to large an opening and nearly exposes the boys whole abdomen. I put clips on the edges to make it a smaller circle. As his hernia is exposed I see dark necrotic (dead) tissue. I open the sac and find dead intestine. I have two options- open my incision into the abdomen to resect dead bowel or open a separate incision to do the same. We choose to extend our current incision. I open up the muscles into the abdomen and find an edge of a loop of intestine is the dead spot. I am able to cut off the dead piece and reconnect good intestine to itself. I re-close those layers and finish the operation.

The next is a gentleman who had difficulty urinating and a large prostate. On the ultrasound report, he was thought to have a large prostate as well, and maybe a bladder stone. He is a bit overweight- uncommon for here. He lays on the OR bed stark naked, is shaved and water is put in the urine catheter till his bladder is full and large. This moves the intestines out of the way so when we go into the abdomen we get directly into the bladder rather than intestines. I make an incision and have to cut down through the fatty layer then the abs. I’m then on top of the bladder. After opening the bladder I feel around inside. The prostate feels like a normal size inside, but there is a bladder stone about a centimeter in size. This can act as a ball valve, plugging off the ureter when it’s down at the bottom. I remove his stone and close him up.

Christian is out debreding the old woman’s arm. Pus and dead tissue are in a pile on the drapes next to where he is working. A lot of the skin of the arm has had to be removed. I’m glad we chose to debrede it today!

After a number of other surgeries I head back to the room where I stay. I’m grateful to eat food with Olen and his kids. Then back to my room to read, write, and eventually take a cold shower and fall asleep.

Shanksteps Bere 2017 #6

admin Shanks No Comments

Shanksteps Bere 2017 #6

It’s Sunday and Audrey just had to leave this morning. I’m missing her already. She, Deborah, Jent all left for home today. I wish Audrey could’ve had the time off to stay with me the whole time, but am also grateful that she was able to come at all. Olen dropped them at the bus station about an hour away this morning. I woke up early to see them off. It is to quiet now in the place I’m staying.

I head in to help with rounds after eating some pancakes with Dr. Rollin and Deloris. Pancakes with peanut butter and mango sauce. I’ve not even walked into the surgical ward with the stench hits me! Now I’m not one to be bothered by smells as my nose I inherited from my dad. That means it doesn’t work all that well, which in my line of work is usually a benefit. In the US, nurses may be retching around me and I’ll be doing just fine. But this one was strong! I walked in to see Christian changing a leg dressing. There lay an old woman on a bed, clouds of flies swarming around her, writhing in pain, as Christian loosened the bandage on her rotten leg. Pus flowed down her leg, across her bed and pooled on the floor. She had been admitted the night before and we were looking at it for the first time. We immediately felt like she would likely need an amputation, but could start with a operative debridement to evaluate it further. A new dressing was placed and we continued on rounds. There were many wounds to dress. Were they infectious tropical ulcers, burullies ulcers (from tuburculosis), a spider bite necrosis, a snake bite… So many options as to the causes of things that look similar. Most improve with dressings and proper care. The 23 year old woman without children that I took out two uterine fibroids, one the size of a large grapefruit the other an orange, was doing well. I doubt she will be able to have children even with them out, but at least she still has her uterus. A woman who cannot have children is not valued at all in this society. Their worth is their children. Usually when you ask a woman how many children she has, she will answer, “I’ve had 8 children and 2 are living.” This was the response yesterday when I asked a woman. So still having the chance to have children is very important to the 23 year old. We see the man we drained a psoas abscess on. He looked like death warmed over when we operated on him. He appears to be doing better and is in pain but better. His drains are working. Of course he is in pain! We only have ibuprofen and Tylenol to treat pain here. But every one of my patients here is up and walking the next day! It sure is nice not to have the negative side effects of narcotics though.

After rounds Christian and I head back to the OR to debrede the old womans leg. Now the OR smells like the surgical ward did. Somehow the masses of flies didn’t make it in there with her. [As a side thought: There are sterile flies and non-sterile flies. Non-sterile ones- are those that fly around the operating room landing in the open abdomen of the patient or on the sterile field. Sterile flies- are those that are cooked in the autoclave and found in the sterile pack when it is opened at the beginning of the operation.] It is useless to prep her leg with betadine to make it “sterile”, but I do it anyway. Pus drains onto the area I just prepped. I kick a trash can to the side of the OR bed just in time, the lake pus on the bed, drains into it. She has an open area about mid-calf that has granulation tissue but pus pooling around it. I probe with my finger and the skin is separated all around. My finger easily goes from the wound up to her knee and way beyond where I can reach going down her leg. We open the spaces. She ends up with open areas from her knee down to her ankle on two sides. Necrotic tissue and pus is removed. I know I will smell like pus, until I get a shower and change my cloths. Sometimes the smell clings to my nose even after that! I think she needs her leg removed, but will wait a few days before telling her that. It is easier for the patient to accept bad news when they have come to the same conclusion themselves. I see a few other consults and prepare them for surgery in the upcoming days.

I head home to shower and get the stentch off of myself. The cold shower feels wonderful!

Shanksteps Bere 2017 #5

admin Shanks No Comments

Shanksteps Bere 2017 #5

I awake about 4AM.  The sound of bats outside in the trees is deafening.  The hospital has electricity 24/7 due to a generator running non stop (that must be a lot of diesel).  Since there is electricity, I have a fan on us at all times when we are in bed, that makes sleeping possible in the heat.  I lay there awake trying not to wake up Audrey, she is all covered up like it’s cold!  I lay there and read my devitional book (Jesus Calling) then continue where I’m reading in the New Testament in John 16.  This is always a peaceful time of morning.  About 6 AM the sun starts to rise and the room slowly gets lighter.  Olens mother-in-law Deloris had left us some granola to eat for breakfast.  She also made us some bread.  I discover during my time here that she is very giving of food, and I never have to go hungry.  It’s a Monday and the busiest day of the week in Bere.  Hospital work occurs all the days, minimal rounds are made on Sabbath, and emergencies attended to.  Sunday there are many consults and full hospital rounds to be made on the 80+ beds.  By Monday there are many people waiting for elective surgeries.  They run anywhere from 10-160 dollars.  The highest being for a prostatectomy, because old guys usually have the money and are definitely willing to spend it on themselves.

At 7:30 we head to the hospital for worship.  It is spoken in French and Nangere.  It takes place in the waiting area for the ER, which is a number of concrete benchs under an awning.  The ER is a room with about 3 beds.  It has no moniters or other signs that it is an ER other than the sign on the door that labels it the “Urgence”.  After the worship thought, the nurses give signout about what happened the day before to all the nurses and doctors.  This all wraps up about 8:30 or 9 and I head to the OR with Rollin and Christian and Audrey.  It appears that there are about 11 people on the waiting list.  It appears to be about 7 hernias, 2 incision and drainage of abscess, and a hysterectomy.  I asked Dr. Rollin and Christian what they wanted me to do and it was decided Id operate.  I like to do hernia repairs with mesh due to the fact that they are longer lasting and the risks are low.  Dr. Rollin doesn’t like using mesh because they’ve seen a number of infections after using them here.  So, since they will have to deal with whatever complications arise after I leave I choose to do the hernia repair with just suture in the method that they are used to using.

The first man is lying on the bed.  his scrotum is larger than a grapefruit with intestine in it and his legs splay far apart to accommodate it between them.  One of the nurses lifts it and puts the legs together and it then sits on top of them.  It’s been a while since I’ve seen one this big.  The patient is given fluids and then a spinal is placed with him in the sitting position.  I discover almost all cases are done with spinal and then some ketamine is given if the incision goes to the upper abdomen.  After the spinal the patient is laid flat and I scrub with Audrey.  It’s been a while since I’ve operated with her and we both enjoy it.  I make an incision in the groin and it barely scratches the skin.  I’d forgotten how hard I need to push with these blades to get through the skin.  After about 5 cuts, I’m finally through the skin.  The scalpels blades are new but not as sharp as I’m used to, and the skin is thicker too.  I slowly dissect through the usual layers to the hernia sac.  I dissect out the hernia sac from the scrotum and separate it from the testicle.  After opeing the sac, I discover that everything is stuck in it.  There is colon and small bowel.  I struggle for about a half hour to make heads or tails out of the mess.  The inside of the abdomen isn’t free either.  Eventually I make the opening in the abdomen larger and shove the whole thing in.  I do the suture repair.  This is about the longest hernia I’ve done in a long time.  I close the various layers and then skin.   I’m tired of my first case here.

Next is a woman with an inguinal hernia.  Less common and also much smaller.  She is about 45, 5’2” tall and weighs in the neighborhood of 100 lbs.  It’s nice to be operating on thin people.  After the spinal she lays there stark naked and is shaved and prepped for surgery.  She is shivering even though the room feels very warm to me.  Of course she is cold, the usual parts of her that are seen are her face, ankles and arms.  The head may or may not be covered.  Muslim women cover their heads and many other women do too.  After I scrub, I cover her body with surgical cloth drapes.  The has the tiniest of hernias and it takes me about 20 min to do the surgery.  So I have the most difficult first and the easiest hernia second.  The remainder of hernias this day were “usual large”.

Rollin and Christian finish rounds and come back to the OR.  Next is a uterine fibroid that the two of them do.  I hang out in the entry room seeing surgical consults and being called to help do an ultrasound to check out something the nurse couldn’t figure out on it.  One ultrasound, the nurse cannot figure out whether the woman’s mass is in the uterus or ovary.  I walk past the hoards of people milling round under the trees to the ultrasound room.  I’m thinking to myself, how can he not tell if it’s in the uterus or not?  Unfortunately I find the same thing.  I cannot tell either and am frustrated.  I guess we will need to do a digital CT to figure it out and take out whatever we find.  Here, digital CT means- cut and touch with our digits! Either she has a uterine tumor or an ovarian tumor.  Whichever it is, she doesn’t want any more children and we will take out either one.  Each elective surgery is required to pay and someone of the family to donate a bag of blood before they will be on the surgical waitlist.

About dark we choose to make the others wait till another day.  I head home to a meal that Audrey and Deborah and Jent have made.  I’m tired, jetlagged and happy to get some rest.