Liberia #16

administrator Greg No Comments

Liberia #16

He lays on the operating room table moaning.  He’s about 60 and covered in a hospital gown.  Below his right knee a hole can be seen that is about an inch and a half wide and an inch deep and is a hole about the same depth.  The hole is in his tibia.  A terrible odor bathes the room as pus flows out of his bone.  The ankle below is swollen to three times the normal size and feels soft and fluctuant.  I put a needle in it last evening and got pus out.  He told me that his leg has had the hole in it 10 years, and drains small amounts only.  About a week ago his ankle became swollen and a couple days ago pus started draining from the hole. A septic ankle and chronic ostomyelitis are my diagnoses.  I decide to use cautrey on this case, even though I suspect sterility of the device is suspect.  Besides, how much more infected can I make a joint with pus in it?  A spinal is attempted by the anestatist student, I seriously question sterility in all places, her teacher doesn’t really use sterile technique!  I’ve seen him, dawn his sterile gloves then grab a bottle of rubbing alcohol to put on some gauze. (the outside of the bottle is NOT sterile).  Everyone will get a longer course of antibiotics.  After multiple bloody attempts, the anesthetist dawns  his gloves and helps, getting it in.  they patient lays back again.  I insert a foley, STERILLY!  Then I scrub, and dawn my apparel.  I use the cautrey to make a cut vertically over the lateral ankle.  Things look fine till I get down to the joint new level of stink, on the already pungent room.  I can pass my finger from front to back along the side of the joint.  So I open in the back as well.  I flush in a liter or two of saline until it is coming out clear.  We place a plastic flexible (penrose) drain and suture it in place.  In the hole, mid-leg, I see dead bone, and pull out chunks.  I bet there is more, but will stop at this for tonight.  I suspect a sequestrium (retained dead bone fragment) but would like an xray before progressing.  We don’t have one, so when he is a little better, will send him to another hospital for x-rays. (the referral hospital that is sending patients to us, JFK)  His leg is wrapped with lots of gauze and then an ace bandage.  He goes back to the floor when he is off oxygen and has stable vital signs.  He is the last surgery of my day.

I began with rounds, right after the morning devotion at the hospital.  I saw half of the 26 patients.  Then I had to wait a bit till the OR team was ready to start.  I did a small (by African standards) inguinal hernia with a bulge out all the time about 2 by 3 inches in size. I do a standard repair using mesh that has been sterilized in the autoclave.  Then next one is similar, with two hernias that are larger.

“Doc, cam see emergency!”  What’s wrong with them?  “Pane to much de belly”  As I follow Ruth downstairs to the cot in the room we call Emergency, I’m thinking of the different causes here.  Appendicitis, typhoid perforation, ulcer perf, cancer perf, the list is much longer.  A 14 year old boy is writhing around on the cot.  I put a glove on and touch is abdomen.  It’s rock hard and when I push down it causes pain, when I let up my hand quickly, he hollers in pain.  Peritonitis!  He will be the next surgery.  They place an IV there and start Ampicillin and Chloramphenacol.  I suspect appendicitis, but have been fooled by typhoid before, so I make a midline incision in the OR.  Before the incision, we pray for him as is customary.  Right under the skin is the fascia (the strength layer).  As I open the peritoneum, pus flows up and drains down either side of his still abdomen.  The amount we catch and goes to the suction canister is 250ml (half pint).  Eventually I discover a necrotic appendix.  I pull it up and tie off the base a couple times.  I wash out the abdomen with many liters of saline, till clear.  Then close up three layers.  He should do much better now!

 

DSC_5764

DSC_5787

 

 

Liberia #14

administrator Shanks No Comments

Liberia #14

“Docta, ……… ca”  Im sorry, repeat that again. “De… bleed…ca”.  Slowly the cobwebs of my mind clear and Im able to make out a little more.  I understood, bleeding and car.  Ill come.  I get out from under my mosquito net and head in to the hospital.  At the car out front I hear a woman hasn’t had a period for two months and is now bleeding profusely.  I put some protective gear on and then peer into the back of the car with my headlamp.  A 20 year old girl looks back at me from the lap of another girl.  Im praying internally, Jesus, please help me know if this is Ebola.  Ive not seen any, and at 2AM I hope this isn’t my first.   Does she throw out? (vomit) “Ya, she trow out.”  How many times today? “won taim”.  How many times did she toilet yesterday, or today?  “She no toilet!”  Seriously?  How long since she had a bowl movement? “She no toilet!”  No diarrhea?  “Ya”  But BM? “Ya, Yestaday” After a long drawn out conversation, they deny headaches, feeling sick in the past few weeks, weakness, being near anyone who died…  I have an uneasy feeling.  I look at her eyes, they are very pale.  I again ask for heavenly help in deciding what to do.  No discernable answer.   By bringing here in, if she doesn’t have ebola- I can likely save her life, with a curettage and some blood.  If I’m wrong she will die, and potentially infect workers and potentially myself.  I decide to curretage.   Everyone is gowned up to the hilt, to bring her in the hospital and up the couple flights of stairs to the delivery room where I will do the procedure.  I go and get on all my gear too.  The gown is to short and I have difficulty zipping it up completely in the front.  I need the extra length on my arms, so I don’t get a space between my gloves and the sleeves.  So I leave it unzipped a little, at least it is really tyvec, the correct material!  I place an apron in front and we give ketamine.  In seconds she is out.  I examine the area of bleeding.  There is a placenta partially out the cervix.  I remove the rest and use special instruments to scrape any that remains out.  I have nothing on me and she is no longer bleeding much.  I again pray that I have done what is the right thing to do.  I go back to bed, and toss and turn for a while.  I wake up early to talk to Audrey, and the signal is good so we skype, that’s always great!

I find out after worship that the vomiting has stopped, the bleeding has stopped, and I am grateful to have done the right thing.  I  am more comfortable now, and can focus on other things more clearly, even though a bit tired.  There are 18 patients in the hospital.  So we divide and conquer.  Then to the operating room.

Fully gowned and sterile, we pray, then I place the blade on the abdomen, and with a swift stroke, the edges pull apart and the usual bleeding starts.  I’ve chosen not to use cautery on this surgery, because I have a suspicion that the cautery cord isn’t really sterilized well.  We dab, and put little clamps on vessels that bleed more quickly.  There is almost no fat, so right after the skin is fascia.  I slowly enter the inner layers, exposing a smooth broad surface.  I put my fingers in, and then use scissors to open the rest of the abdomen.  It is a huge cyst.  It displaces all the intestines up to near the sternum.  She hasn’t been able to eat much for a while, as there is no space in her abdomen.  I remove the ovarian cyst, about the size of a womens volleyball.  Later we weigh it, 2.7kg (6lbs).  I think a gallon of milk is 8lbs.  She has an umbilical hernia that I repair that in the closure.

The remainder of the afternoon is filled with >15 outpatients.  And the occasional “emergency” sick person in the back of a car, 2 of which I admit, one I turn away with horrible edema and liver failure.  I have nothing I can do for him.  Surprising enough, he had had most of the labs I would be interested in at another place in town.  So the labs and the yellow eyes, confirmed that I couldn’t offer much.

Liberia #13

administrator Greg No Comments

Liberia#13

“Doc, kom up ward. M fowa B five gaspin” I’m coming. I hung up the cell phone. I know this patient well. I admitted him. I diagnosed him with HIV, what I think is encephalitis, and abdominal pains ? He has been doing poorly, so it doesn’t surprise me. I’ve heard Dr. Seton say that when they call for gasping, it is usually to pronounce death. I got up there and that was the case. So I did some of the paperwork on that patient. Then went for my breakfast. Today, since it was early enough, and the power hadn’t been cut off yet, I made some oatmeal, and cut up bananas into it. That and about a liter of water started my day.

Will the pain ever end? I did another full day of medicine. I again have respect for my wife and all you other docs who see medical issues every day. Some want to tell me their own diagnosis, or tell me what tests they want. After a particularly demanding woman, I asked her, “if you have your diagnosis and your treatment, why did you come to see me?” you can go to any pharmacy here, with any slip of paper and pick up whatever medicine is available.

Dr. Seton and I decided to split the work as usual. Today I made rounds on all the inpatient and she worked the outpatient department. The two burn patients are slowly doing better. More bleeding tissue at each dressing change, means that things are starting to heal and new vessels are growing. The patient I explored and reclosed her abdomen, is doing wonderfully. I’ve forgotten how fast intestines start working after a large surgery without any narcotics. Hers started the day after surgery, most in us seem to take 5-7 days. The 18yo girl with a symphisiotomy, is up and walking down the halls. Her baby, who got a neonatal infection and malaria in utero, is doing well, and breastfeeding now. 60 year old guy we did a prostatectomy on is doing great and I send him home with his urinary catheter. The HIV woman with the lung infection, I though had been getting steroids for the past 4 days, had not. I ordered them and the mini pharmacy on the floor didn’t have it so they said it was out. When I asked if the main pharmacy downstairs or stock had it, I found out they did. Just didn’t ask for it. So it will be interesting to see if she starts improving now that she will really be getting treatment. The pediatric room is always bothersome to me. They are either bouncing back and eating and playing, or getting worse and dying. They go rapidly one way or the other. Had both sides today. A convulsing little girl of 2 years, got medicine, and stopped convulsing, then 30 later went from normal respiratory rate to zero. Nurses called me about 8 minutes later. The delay didn’t help, but made the inevitable, final.

“De boy kip falling daun. In de mornin he fine. Afta servic he wak wif me. Den he fall daun. Now he wik an very tird” I look at him last night, he looks drugged. Mom says he had a runny nose, so she gave him erythromycin and Tylenol. Then within a half hour he was falling over. I admitted him with supportive IV fluids. This morning he is the opposite of the last child. This boy did gorge himself on breakfast, and throw up, but is playing, whacking the wall with his feet, and asking to go home. Much better!

After seeing about 25 inpatients, I eat PB and jelly for lunch, and of course much cold water. Then I go replace Dr. Seton outside. Each patient has waited for 4-5 hours to be seen. Some are unhappy, most are just happy to be called and progress in the process. I deal with back pains, numbness and tingling, coughs, malaria, typhoid, sexually transmitted diseases, inability to conceive. I get called to see someone in a car.

“Yestaday, he swel up.” Has her leg done that before? Is it both legs? “He swell up yestaday! Yestaday!” Both legs? (Im trying not to get in and touch her till I get more of the story) “Bof leg swel up.” Has it happened before? “Yeh, one tim de say he hav hart probem. Dis tim much pain.” Any other symptoms? “Hed pain him, n he wik over body” Weak? The whole body or the leg only? “He wik! Wik! I determine there are not really any other symptoms. The legs are both swollen, but the left much more. And it’s quite tender with cellulitis. I do the paperwork to get her in and give her antibiotics IV. They wheel her in and then carry the wheelchair up the two flights of stairs to the ward.

At about 5PM I am finally done with all the patients, and I head back to the ward. Dr. Seton is taking care of some patient issues, and said a foley needed to be palaced in a man in a private room. I go to each of the pharmacies, one on the patient floor and the one downstairs and eventually collect all the necessities. They had attempted to place it, I found out with catheter and non-sterile gloves and KY jelly. Not even an attempt to prep the skin and do it sterile. I guess Foleys aren’t done sterilely buy nurses here, or that’s the feeling I’m getting. (number two patient). So it took a little while to find betadine to clean the skin with. Plenty was in storage, just not on the floor.

I walk with the tray of supplies into the room. An old man sits on his bed leaning against the wall. Legs wide apart, with a small towel between them. I ask him to remove the towel. He has a scrotum the size of a womens volleyball with genital to match. I clean and insert the catheter in a short distance. He must have a stricture. I was trying with the smallest size we have. He says he can urinate. I cancel the urine sample, as it will just leak all over his skin and be a useless sample. He is treated for a urinary infection, without the test.

Of all these medical issues! And not many hospitals are treating anything. Part is they don’t have many workers just like us. With the non-governmental organizations paying 10 times higher than the previous prevailing wage. Workers are going to them and the ebola treatment units in droves. Very few remain to provide other types of care. The NGO’s help but at a significant loss in the system. How will the country recover. Likely when the NGO’s pull out. Then who will work for 1/10th the salary again at their previous hospital? Only very discontented workers that have no other options.

Please pray that the workers here will stay and provide the care that is desperately needed here.
for more mission stories visit our mission website www.missiondocs.org

for information on our missionary and christian workers oasis visit www.lifeimpactministries.net Safe Haven Oasis

Liberia #12

administrator Greg No Comments

Liberia #12

“I wa ultrasnd!”  But you don’t need an ultrasound. She looks around at her two fiends, “ba I wa ultrasnd”  I finally give up discussing why I think it isn’t needed and tell her to go pay, and I will do it.  This 25 year old says she had a miscarriage 3 months ago.  “Den dae klin me aut” I think this meant that she had a curettage to remove anything that remained and stop bleeding.  Den dae … injection da last 3 momph.  I assume Depoprovera, but she cannot confirm the medication.  It was done somewhere else so I cannot look it up.  She goes inside to pay for the ultrasound.

The physicians assistant, who decided to work today, but won’t be here the rest of the week,  asked me to see another guy.  He said the man had an infection starting with a sore on the top of the foot, then the foot fall off. I was skeptical, as you are right now.  He heard from a neighbor that sorcery was the cause, so he came to me for confirmation, whether a medical issue caused it or a spiritual issue.  The man walked in with crutches.  He sat down and I asked him to take the sock off the stump so I could see his leg.  There was a healed stump over what appeared to be the upper portion of the ankle joint.  A small sinus below, appeared to be draining fluid.  He said he had no drainage.  He didn’t ask me the same question that the PA had.  We discussed what happened and he confirmed the same story of his foot falling off.  We discussed that if someone could make a prosthesis, that a below knee amputation would usually fit a prosthesis better than what he had, it also supports the weight differently so it would not have the same pressure points that his current condition would develop if he tried to put something to walk on down there.  He decided to try the JFK hospital for a prosthesis possibility.

The previous patient was waiting outside the tent, when I came out, to go inside the hospital again.  “No money da ultrasnd! Injection!” You want an injection? She nods her head.  They say we have Vit K and ergometrine.  Neither of which I will expect to help in this situation.  I tell her that, and she goes off to get them anyway, with my order.

I go home to eat lunch at 2PM.  Just as I finish a liter of water, the nurse is there, she wants and ultrasound and now has paid the money.  How frustrating people can be!  I figure if adults want to pay for a useless test, after Ive explained it’s futility, I will do it, unless it will harm them.  An ultrasound wont harm her, it just is now annoying me.  It shows blood in the uterus as expected.  So I still prescribe her meds, including contraceptives in high doses, that actually may help her, and tell her to come back in a day or two if it doesn’t stop, and I would “kleen her aut!”

Another old woman complains of generalized weakness.  She had been seen here 4 days ago, and the labs we have were negative.  I recommend drinking a lot of water- thinking of dehydration, and eating food- nutrients and vitamins.  The son asks for something to help her eat.  I give her a multivitamin, which everyone here believes will help your appetite (it doesn’t medically, but might psychologically when then think it will).   After a bit more discussion they are content and leave.

I’m done with rounds and one of the burn patients dressings, and now done with the above two patients, so am eating lentils and typing.  The more medical issues I see, the more grateful I am not to be an internist / family practitioner / pediatrician…  you all are amazing to deal with this stuff every day!  But I do think that the generalized weakness and numbness that so many describe annoys me the most.  I still haven’t figured out yet whether they mean the same to the patient as those words do to me. (When we were in Cameroon, Nigerians would talk about fever- and to them that was the word for pain.  Fever in head, fever in abdomen…)  So some of it may be word choice, another is I can do nothing about it- neither diagnosing nor treating.  I need patience.