The boy is about 22 yo and I saw him yesterday afternoon and they were thinking of adding him on since we appeared to be done a little early. He had a hemangioma (mass of large blood vessels) on his inner thing that was about 4×10 inches. Some of the blood vessels were as large as my fingers. i said he should be the first case in the morning as it could be very hard to do. So this morning is the day. I ask him about how long this has been there as he lays on the OR table. It been present since birth and has slowly grown larger and larger. He says it hurts. I can imagine if it grew quickly it would hurt but not at a slow progression. That matter not- Im taking it off today. I scrub with one of the local docs who is doing surgery learning for 6 months. I start cutting around it and right away get into a few vessels. This gets my heart rate going. im trying to explain how he can help me and im finding it challenging. He isn’t really a good assistant. I need someone who knows what they’re doing. Dr. Steven comes in to check on me and I ask him to help. Then it goes much better. We are able to go back and forth whichever of us has an easier angle to dissect and the other of us cuts with cautery or ties a small vessel. We slowly peel it up including the underlying fascia or just above that. We finally define that it only had two small feeding veins. These were tied and it is off. Now how to close. I pull on the skin and realize I may be able to get it together with a lot of tension. So I start in the middle with a stitch, then in-between with more stitches. Until with about 30 stitches it all comes together. I’m glad to have gotten it together.
I do another surgery and then the third one is interesting too. This kid of about 8, had an infection going on in his leg for the past 8 months. It was painful and it had some draining pus that came out in different areas. The X-ray showed osteomyelitis (infected bone). This looked like a huge fat bone in the leg at least twice the size of a normal tibia bone. So i took him to the OR to drain it. I cut down to the involucrum (new bone growth around a dead piece of bone (sequestrum). I follow one of the holes that has pus coming out of it and find the hole in the involucrum. I use a rongur to eat the hole away till it’s very wide. I probe inside the bone in both directions. I get a lot of granulation tissue but not any dead bone. I follow another in the upper tibia and do the same thing. In that one I find a small piece of bone. It feels slightly mobile. I wiggle and try to pull on it. I think this is likely the sequestrum. I bite it in half with the rongur. Then one end I grab and am able to wiggle and twist it free. Yep it’s a sequestrum in the dead bone inside. The other end slides up into the top of the tibia. I use a curette and try to swipe it out. Finally i get a hold of it. It doesn’t want to come out, but with force it does. So at least two chunks of dead bone, the source of all this pus is out! i hope there isn’t more, but I can’f find more so i pack the holes down the center of the marrow after washing it with dilute bleach solution. He will likely be here months with packing his legs.
Today was a “normal” day. It rained heavily last night and it is finally cooler and I slept finally after about 3 days of minimal sleep. I get up about 7:30 and realize Ive already missed worship. I have my own usual morning worship- consisting of reading from the Bible, praying to God. I head in to see what’s happening and if any patients are ready to have their operation done. I know there are at least two hysterectomies on the schedule and the others on the list didn’t register so I guess they weren’t worrisome to me. The first lady is older and has a painful mass in her lower abdomen. I examine her belly as shes on the operating table, IV in place. Her head is covered over the top and her abdomen and chest are exposed and she has some shorts on. So she feels not well covered but acceptably covered considering shes here. Womens chest and abdomens aren’t usually terribly private. A child will pull a breast out of their moms shirt and start sucking. So i palpate and Im told shes here for a hysterectomy. She doesn’t want any more children. I look at her book and it says she would like to keep her uterus if possible but wants the mass gone. As it is almost up to her umbilicus I know Ill do a vertical incision.
At her operation in a few minutes after seeing some consults outside, I incise her abdomen up and down. Then into the abdomen we see the uterus is huge. I feel around and cant feel any uterine fibroids. So I guess I cant do a fibroidectomy, so a hysterectomy it is. Dr Steven and I are working together. So he works down one side and I work down the other. We get into some bleeding that we are able to control and we get down to the cervix and then take out the uterus. It looks about the size of a small bowling ball. Im sure she will feel better with this out. There is definitely more space in her abdomen!
Next is a younger woman in her 30s who has an ovarian tumor. She definitely wants more children. She has had 4 and and only 2 are living, and hasn’t had any for the last 4 years. Womens value in the local cultures are very tied to how many children they have. So i want to take the ovary, both to help her live longer and so that she still has a chance to have children like she wants. I palpate her abdomen and then get my butterfly to see it for myself. Apparently there was some confusion wether the mass was in the ovary or uterus. I see a large mass and then a small uterus behind. I open her thin abdomen and start exploring with my fingers. It seems the intestines are stuck to the mass all over. This is a bad sign, more likely to be cancerous. I slowly dissect some off an Dr Steven dissects other parts off. Then we get into a cystic area somewhere deep inside. A dark bloody fluid comes out. We dissect more and find that we end up getting two large cysts. Then there is a large mass below that is really stuck to the rectum and bladder and i feel we cannot get down to the uterus. We are bleeding and leaving cyst wall stuck to intestine. So if this is cancer, there is definitely not a cure here. And with us dissecting the bladder and rectum the chance of injuring these and blood vessels is very high. So i tell Dr Steven i think its time to stop and get out, that we are not helping any more. After assessing it again he agrees and we drain and start closing. We are both bummed that we couldn’t get it out safely. But Im also glad to not be threatening her lift TODAY.
I go out and see some more surgical consults as they get the next US proportioned guy ready. Everyone here is very thin, and this guy isn’t. He has a mass on the back of his leg, and it is likely a sarcoma. These need to be removed with a good margin of normal tissue around them. The anesthetist Phillipe, puts in the spinal and after a number of minutes have past we get 8 people around him to turn him on his side. His big belly starts to drape off the side of the narrow OR table, so we reposition and prop him so that he is safely on his side and then we are able to work on the back of his lower leg. I want a centimeter of normal tissue around the tumor. Now this sounds easy, just measure and cut 1cm further. Yes that is easy at the skin, once you are deeper it’s harder to be certain that your are one cm away. To be certain you’d have to cut down to it and then go back a cm to make sure you have it. But that violates the purpose of staying away that far in being beyond tumor that is microscopic spread. So it ends up being a feel of how much tissue is between my finger and the cancer. So i end up cutting a large hole out of the back of his leg down into the muscle. So after removing it, the spot is about the size of half an orange. There is not near enough laxity of the surrounding skin to get it any where near back together. So I can skin graft it or leave it open. Skin grafting covers this large divot with skin and it will forever look like a large divot. Or I can leave it open and in about 3 months it will be flat and covered with skin. So I leave a large hole in the back of his leg for Gods design to take over and heal it.
The next guy I operate on is the guy I referenced a couple days ago that has epilepsy and fell in the fire and burned his toes on his left foot, well the three middle ones, and also burned the top/side of his head. He has exposed skull that will not heal and cannot be skin grafted, and three toes that are floppy and have bone sticking out of one. So in the operating room I slowly remove the three toes that need to come off and then I get to the interesting part, the skull. There is a patch of about 3x5inches that is exposed. Since this won’t heal the solution is to remove the outer table of the skull and leave the marrow to granulate. So after prepping the head I get the drill and drill multiple small holes in the outer skull. Then I use a rongour to nibble off the bone between the holes. One hole drills quickly and a get a constant squirt of dark blood coming out about 5 inches. Oh no, did I hit the cavernous sinus, a large vein just above the brain? I hold pressure for a few minutes and every time i let go the same stream is there. Dr. Steven has the idea of taking the bone shavings and shove them into the hole, so I do that and we hold pressure and continue work. This eventually works and we finish up removing the outer skull. Later that night I check on him before going to bed and and he is not bleeding and he is laying flat and i get him with head up like I want and head to bed.
Ohhh, Noooo! I walk into the preop/recovery room and Dr. Steven is looking at a guy laying on his stomach. It appears like the mans anus exploded! what happpenneddd? He was riding a bike yesterday when he fell of and the pedal went into his anus. It looks aweful with loose tissue hanging all over. he has a urine catheter that has blood in it. I see Dr. Stevens examination and its clear there are more than one hole and its kind of difficult to see what is actually the anus into the rectum. So we decide to do the hystorectomy case that is already in the OR ready then we will do this guy.
The hystorectomy is the third case of the day. We did a mastecomy first on a lady with inflammatory breast cancer which is considered pallatative- not for cure but to give her a better life for a little while. I was able to remove the breast and get some enlarged lymph nodes out of her axilla (arm pit). It was a bit snug getting her skin back together, but was able to do it. And i left a piece of glove at the bottom to come out as a drain.
The next lady had a mass in the pelvis that a previous doctor had thought was uterine in nature. So we took her to the operating room to attempt to remove it. As I palpated her abdomen it seemed to be about 10 by 12 inches in size and didn’t want to move around when i pushed on it. So i imagined it was fixed to surrounding structures. After she has her spinal anesthetic placed by the anesthetist she is laid down and her abdomen is prepped. Next I get scrubbed and put on the cloth gown and my sterile gloves. I put the cloth drapes on the patient and we begin. After we pray for our patient I make a vertical abdominal incision. I go through the skin, then a tiny layer of fat, then fascia, then into the peritoneum (inner layer of abdomen). Next i see intestines and after sweeping them to the side with my fingers, I feel the mass. It appears cystic and it is stuck all along the right side. i can feel around the back side and it seems there is space behind near the rectum. Slowly I make an incision along the right side and slowly make it down to where the iliac artery and vein are. I find there seems to be two main cysts. Im able to slowly go inferior to the cyst and the later and find the two main cysts off in my hands. Below that is the uterus that looks fine and the left ovary is normal. So I close up the fascia, and skin and she goes out to the recovery room.
Next is the guy with the bike pedal to the rear end. He gets a spinal anesthetic after enough IV fluids were given. Then he’s put up in stirupps flexing at the hip so we have a good view of the anus. It really does look like an M80 went off inside. I swipe poop out of the way and spray down the hole with Dakins (dilute bleach) solution. As I look around the anus, I realize there’s a hole anterior to the anus and then realize that the hole is between the prostate and the rectum. The prostate normally is directly next to the rectum. How did he get a hole between two small structures the don’t come apart easily. As I evaluate the rectum it appears intact. I think a diverting ostomy would be best, but after discussion with the doc that’s always here, decide to not do that yet. An ostomy is hard to have here as there are minimal ostomy supplies available so no real seal on the abdomen. I have patients at home that will give me supplies, but it always seems there are more important things to take in my ?6 pieces of luggage. I decide to leave a large drain deep in the hole and suture it out to the skin. Then I excise the dead tissue and suture skin back to the anus- or whats left of it. I sincerely doubt he will have any continence, but then again, there did seem to be a little anal tone left. I had warned the patient before the surgery that I thought he may be incontinent after this accident, forever.
i go out to the preop/postop room and start seeing the different surgical and medical consults that are there. A young kid with a vascular mass on his inner thigh, a kid with enlarged cervical nodes, an old woman with abdominal pain going on 3 years, a 30yo man with an abdominal mass that fluctuates in size and i think i see a mass on ultrasound, an old guy with eye itchiness and a cornea that is completely whited out…. After about 10-15 pateints i head towards home and make it about 20 feet.
The nurse from maternity sees me walk by and says “doc I was just going to look for you” Well it was said in French…. So there is a woman who has just arrive with her 4th pregnancy at about 8 months and shes having vaginal bleeding. The babies heart rate is normal, but blood and clots continue to come out. She’s not in labor and is at one centimeter cervix dilation. They just are drawing a hemoglobin level and getting an IV going. I do a bedside ultrasound with my Butterfly (small ultrasound that i attach to my iphone). I find the placenta appears intact and not covering the cervix and babies heart rate is good. I decide to go get some advise from my wife and another nurse here. I find them painting a house in preparation for a doctor that is moving here soon. After their advise I go get some supper of rice and beans and then go back to see what the hemoglobin and results are. She continues to have bleeding. So i decide to do a C-section. I try to call the two guys back to the OR. I cant get either one. So the nurse goes to use the “hospital phone”. It has no cell credit so they cant make calls either…. I ask the maternity nurse to do something or send someone. Normally I’d be quite mad by now, but I made an internal pact to push gently when encountering problems here this time and let people make poor choices if they make them. So i sit for about 45 minutes before the scrub tech shows up. Then he tells me he also does anesthesia now if I can find someone else to assist me. So I go find Audrey and ask her to assist. She is willing and eventually we start. I make a low pfannenstiel incision (bikini) and go down to the muscles. I divide them along the middle and open to the uterus. I make a low across incision on the uterus and get immediately quite a bit of blood. OHhh, placenta abruption (the placenta separating from the uterus and it bleeds in between). I find the bulging sac of amniotic fluid and open it. Gush, I feel the blood and amniotic fluid run over the front of me and I feel the wetness through my gown from my belly button to about mid thigh. I don’t like that feeling! That’s the side effects of cloth gowns- not impervious at all! I pull out the babies head and suck out the nose and mouth. Then pull the rest of the kid out. She starts to cry as we cut the umbilical cord. Yay!! A live baby! So many come so late that we doctors usually see the worse cases and baby deaths. The normal deliveries are done by the oncall nurse. I pass off the baby to the nurse near by. Audrey and I then close the uterus and then the abdomen. Mom and baby are doing well. I head home to slow down and shower and get to bed late. It was a long but good day
We are back in Bere, Chad. It is the HOT season. Our room is about 95 to 97deg F in the evening. Im able to fall asleep for about 2 hours then Im awake again, hot and jetlagged. I lay there till morning. I get up and all I want is cold water. It’s a choice. We have a refridgerator in the place we’re staying, but the more water or things we put in it the hotter the room it’s in gets, as expected. So its a tradeoff. Denae and Steven are doing a very difficult surgery in the morning before she leaves. It’s a enterocutaneous fistulae (connection of the intestine to the abdominal wall that makes stool to leak out a hole onto the belly). As they work on that I go and make rounds. Emma, the surgical ward nurse, is knowledgeable about their different reasons for surgery and rounds go fairly quickly. I look at all the wounds that are granulating and change the dressings. One dressing stands out: This guy of about thirty has seizures and during a seizure fell in the fire and burned his foot and head. I have yet to ask him what contortion allowed this to occur! But he came in a couple weeks ago with three toes burned and his head charred. After taking off his dressings i see that the three toes are super floppy, almost like they don’t have any bones in them?? One has a bone because it is sticking out the end of his toe. As I take off his scalp dressing I see that he has good granulation around the outside and a patch of about 2x4inches of exposed skull. I know that skin grafting doesn’t work on a bone, so this will need special attention. I see the patients with vessicovaginal fistulaes that Dr. Denae has operated on and they are in various stages of their 4 weeks with a urine catheter. Some have been “discharged” to the outside to save bed space for other patients, and they come in to be seen while rounds are made. others have had hystorectomy, hernia repair, hydrocele- that ended up being a hernia stuck to a testicle and they had to take the testicle (orchiectomy). I see a boy with a humerus fracture that he got climbing in a tree and falling out of it. Thats how most of the children break bones, climbing in a mango tree to get mangos and falling to the ground. I head back to “my” house, which by the way is the place I’ve stayed in before. I think it’s the place James and Sarah Appel first built when they started building stuff in Bere. I unpack some things and then go and check how things are going in the OR. i do some other surgery – which i don’t remember now. Then we get done earlier since its a Friday and we like to be out for Sabbath if possible. We really value Sabbath rest as Jesus observed it. Im able to visit with old friends (missionaries) and it’s a nice evening. Im called in to see 4 accident patients. The nurse says one has an open knee and the others with broken arms, but not open. They were on motorcycles that hit one another. I remember that most patients once they’ve been diagnosed with a fracture, want to be treated by the traditional bone healer. So i tell him, whoever wants me to treat them, have them stay. if they want the bone healer they can go. So when i get in there to see them, only the guy with the open knee fracture is left. So I look and all is see is pieces of his patella (knee cap) sticking out at odd angles. As i touch it pieces come off in my hand. Dirt and sand is everywhere. I ask for an X-ray, but the nurse tells me the person lives to far away and phones are not working. So i tell them to send someone to get him and someone to get the OR crew of Philipe and David. Only David comes in. But the guy who does the sterilization of instruments says he can help. So I go to the OR after waiting about .1.5 hours to get ahold of the right people without success. In the OR i help the assistant gown up as I don’t think he really knows about sterility. Not that this knee is sterile- it has dirt and sand in it. I find there is no identifiable knee cap. i see a piece of the end of the femur chipped off and no other identifiable structures. I open it up more and more and still cant identify any remaining structures. So i wash it out and close the skin and plan on an Xray tomorrow. To see if that gives me any more clarity as to what can be done. I head home. i shower and get into bed dripping wet. I sleep for maybe an hour then lay awake most of the night tossing and turning. it’s still hot!!(In the next day or so, i am informed in the operating room that this guy wants to go home. And he signs out against medical advise)
