MissionDocs.org

Greg

Have you ever had to really pee? No REALLY urinate!!!? A thin old man came back to see me today after being treated for prostatitis. He had taken all of his medicines and is having urinary incontinence at night. He feels OK but at times has lower abdominal pain. A lay him back on the examining room table and he looks about 25 weeks pregnant. A mass in his lower abdomen reaches to above his umbilicus. I know immediately what the problem is. He is having overflow incontinence at night. His bladder is so full that it leaks. Though is prostate is so large that he cannot empty his bladder. He needs his prostate removed (as we don’t have prostate medications here, and no one could afford to take them indefinitely, even if they were available). I decide to put in the foley myself, as I have seen a couple nurses or students put in foleys and they are usually not done sterilely. I also suspect this will be in a while till he gets his prostatectomy, so I don’t want his bladder more infected than it already is. I demonstrate to the nursing students how to put one in sterilely and I immediately get 2.4 Liters of urine! As it flows out the abdomen becomes concave again. He develops pain as the bladder contracts down, and in a few minutes this subsides. He leaves the hospital content, and will come back next week if he is ready for surgery. I want there to be even a few more weeks before doing the prostatectomy since I think he had prostatitis about a week ago and this makes the surgery difficult.

I had planned to operate on Gift Edson today. He is a 2yo boy that has a cleft lip. Unfortunately he ate a full breakfast this morning. So we had to postpone his surgery. I don’t want him vomiting and aspirating during surgery.

This afternoon I was asked to see a woman who was in labor and they were unsure of the gestational age and whether there were one or two fetuses. The clinical officer feels that she may need a C-section as she has a small pelvis. I went to the maternity ward and saw a young woman who had had 4 previous children. One normal delivery and 3 C-sections. Now she is on her fifth. She lays on the delivery room table on her side intermittently grimacing in pain but not uttering a peep. She is covered from the waste down with a thin cloth that was her wrap around skirt. As in most of the developing world, breasts are not a sexual organ so they are not necessarily covered. I get the ultrasound machine and take a look. She has twins with one in the head down position and one in a transverse position. She has been draining amniotic fluid since today at 11AM when she came back from working in the fields. I discuss with the nurse that a C-section is NOT needed, but that we DO need to try to stop her contractions. I give her salbutamol and nifedipine, both of which have been shown to not really work for stopping contractions but that is what’s available. Gave her IV fluids and started antibiotics. I checked on her a half hour later and it appeared that her contractions had stopped. I head home to write all of you!

As a reminder, anyone interested in helping financially to Koza Hospital in Cameroon or to Malamulo Hospital in Malawi, where I am currently, may send donations to:
Summersville SDA Church
Box 2128 Hwy 41
Summersville, WV 26651
And you may receive a tax receipt for your donation. Please specify clearly where you would like your money used, and if you have a specific project or interest in the use of your money, please make that known. Also prayers and your personal help at either of these institutions are greatly appreciated. If you desire to travel to them and lend a hand, please contact me.

I start this morning a little anxious. I believe this is about a 200 bed hospital and I am the only physician. Dr. Chipoka is gone, Cristy (my sister) is doing an interview then all day clinic in Blantyre, and I am left. Dr. Pierce a visiting doc with SIMS from Loma Linda is doing physical exams most of the day and is aslo not available. I have scheduled 5 cases today and I have a lot of rounds to make.

I start in the “ICU” where my gentleman after the prostatectomy is staying. They feel it is easier to do the bladder irrigation in the ICU than the floor, so he will stay till the irrigation has finished. He is doing well but still needs a little irrigation. I am called by Kachawala that the 2 month old for a circumcision is ready. He gives a little sedation and I inject the penis with lidocaine. The boy screams. I wait and then start. He screams again. I wait some more for more Ketamine to take effect. Finally he is adequately sedated and I put his foreskin into the Gomco clamp and clamp it down. I wait a few minutes and then excise the foreskin. It seems to have controlled the bleeding so I place a dressing. I leave him with Kachawala to let him wake up while I go and see more patients.

In the female surgical ward are my two old women with femur fractures that are in traction. I wish I had the SIGN equipment here for femur fractures. I guess they can fix fractures at the government hospital with orthopedic nails… But if a patient goes there, they often wait for months before a procedure is done. Apparently the care there is free, but with so many people they are just full all the time and others wait weeks or months. So I offered to send them there but they both chose to stay here as they have had bad experiences there before. They are both doing well and we will begin physical therapy when Giani is back tomorrow. Limbaghani asks me to see a patient in the outpatient area. A boy with a cough. I ask him to evaluate then let me know what he things. I get a call from the OR that the lady with epigastric pain and vomiting is ready for her EGD (upper scope to look in stomach). I leave rounds and head for the OR. She is tachycardia (fast heart rate) because she is very nervous about the procedure. I reassure her and Clara (anesthetist assistant) gives her Ketamine to sedate her. I have a little difficulty getting past the tongue into the esophagus, but finally it slides behind her vocal cords and into the esophagus. It looks normal until the stomach where it is reddened and there are a few ulcers. The first part of the small intestine appears fine. I deflate her stomach and hand the scope to the assistant to clean it. Then back to rounds.

By then Sitihana has seen all the surgical patients, and informs me of how each is doing. I write a not on the ones I think it may be helpful but skip writing on the ones (like the two in traction) that are stable and it wouldn’t help. Cristy has asked me to write more here, as students sometimes look at our notes. The OR is getting ready George (pseudonym) for his anal fistula and hemorrhoid. They guy with the stab to his inner arm seems to be doing well and I am continually happy about that. Then they call to the OR.

I head back and lay George on his side and prepare for surgery. He has two anal fistulas and a large external hemorrhoid. I put a probe into the fistula and follow it to the anus. I open the tract then probe the other. It goes deep to the musculature into the rectum. I choose to put a suture through the tract. I do not want to divide the musculature and make him incontinent. It will take a couple months, but the suture will slowly cut through the muscle healing behind it, and he will not have incontinence. I remove the hemorrhoid and suture the opening. We lay him on his back and tell him about the surgery. He had had a spinal anesthetic so is fully awake for the whole thing.

Libingahni asks me to see a patient that is waiting outside the OR with a mass on the bottom of her great toe. He feels that we should do a biopsy to look for cancer. I walk out to see a woman about 22 years old with pyogenic granuloma on the bottom of her toe. It appears like flesh growing out of her toe. It is quite tender. I explain that cancer is not my concern but that we can excise it and it is unlikely to recur. She agrees and so we take her into the side procedure room to remove it. I inject her to to make it go numb after disinfecting it. I then excise the area. I had discussed with her that at that location it may not be able to be closed. This turns out to be the case. So I stop the bleeding with cautery and put a dressing. She will come back daily for dressings and I’ll see her in a week.

The OR staff informs me that the other woman I had planned for an EGD did not arrive and that the man for prostatectomy did not arrive either. I decide to get lunch for the first time since being here. I finish rounds and then head home. At home, Rebecca is preparing the local food semma. It is a paste made of field corn flour. She also prepared a greens dish and eggs to eat with it. I stuff myself and feel satisfied. It’s very similar to the food in Cameroon but there it was with millet which I think had more nutrients. Now she is shelling beans one by one. Her help is invaluable. I miss Isiah who used to be a joyous help in Cameroon. I miss his constantly whistling and commentary about the latest soccer match or political situation or how now that Obama was president he would be coming to America because his “brother” would invite him. We would all laugh as he would explain himself wearing a black suit for the first time “black on black, it’s very handsome!!!” It was good to see him last time we were there and I miss him now.

This afternoon I was called to see the pathology results of the 13 year old that had a mid transverse colon obstruction. The pathology returned invasive adenocarcinoma. This makes me very sad. She was just telling me that she wanted to go home today because she has exams starting tomorrow and didn’t want to miss them. Now I have to tell them that she has cancer, and at a high grade. I will refer her to the oncologist at the government hospital, but I am quite skeptical that they will have the appropriate chemotherapy and that it will have much effect because she had ascites from the cancer. These are things that it is very painful to have to tell my patients, and even worse when they are at the beginning of life.

Then there was a patient on the medical ward that had come in after a fall a few days ago. An X-ray was done today that showed a radial head fracture. I asked the nurse to collect the material to place a cast. After getting the materials I went to the room and found Amie attempting to do a lumbar puncture. Her “sterile” technique with sterile gloves was anything but sterile. She failed to get into the spinal canal. I re-prepped and got a new spinal needle. After two attempts I got clear fluid. The samples were taken then I addressed the arm. I wrapped his arm with gauze and then placed plaster on it, holding it in position to have the angulations I wanted.

Then I started seeing all the patients with Siti. It was a short visit with each just to see how they were doing and to make sure there were no real problems. On each ward I’d ask the nurse if there were any problem patients. They would answer no. When I did it on peds I found two patients I was very worried about. One has malaria and a fever of 104deg F. I added a second medication to help with their malaria treatment. Another 2 month old baby had been admitted today. I have been on call today and I wasn’t called. Now I know why Cristy lays eyes on each patient at night to see if there are any problems. The baby’s heart rate was 180, and breathing at 120 A MINUTE!!!! Rubs and wheezes and crackles could be heard all over the lung fields. He was getting Ampicillin and Gentamycin. I found out we could do nebulizer treatments. Then called Cristy to see if she was close and could see him. She was and so we gave him epinephrine and salbutamol treatments. The oxygen concentrator could not pump enough oxygen through the small tubing to the nose. There are no masks and the nasal canula is tiny. It pushed 1L/min through (very low).

I leave the ward tonight worrying about that baby and knowing I can do nothing more. Lord keep the devil and his minions away from this baby. Help him to live, help him to heal. We know sickness and pain was not your design and we long for the day when we will be in the New Earth (heaven) and be away from all this pain. Lord come quickly!