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Shanksteps Bere April #12 with pictures
I go in for the last day at Bere Hospital before I leave.  Went to morning worship then back to my room to prepare stuff while they have another meeting.  When I go back in I do rounds with Abouna, a nurse who does quite a number of surgeries as he’s been trained.  He’s quite intelligent.  I do rounds with him so that he knows what I plan for each of my patients and can tell the next surgeon when he comes next week.
The first patient is ready, he’s an old tall Arab guy with a large prostate on ultrasound and can’t pee.  I start to cut his abdomen and though the nurse said he was ready he feels it!  So I wait till he gets some ketamine before I continue. I make a phanynsteal incision, cutting down through the skin and fascia, split muscles along the midline and then spread above the bladder sweeping the peritoneum and intestines up and away from the bladder.  I open the bladder and suck out all the liquid we’ve put in the bladder to distend it.  I feel inside and feel a huge prostate.  Hmmm, is this cancerous?  I don’t feel nodules, but it is large.  Slowly I break the anterior prostate and gradually shell it out with different fingers.  As each one gets tired, I use a different finger.  Usually my right index and middle fingers. I have to make my incision in the bladder a little larger as it won’t come out of my original size incision.  After removing it, I sew up the back wall down low where most of the bleeding occurs.  Blood is constantly welling up and it’s hard to see.  Eventually with the stitching it slows down.  I put a new foley in and inflate the balloon.  I check to find that both ureters are still putting out urine and I hadn’t caught either one in my stitching.  They are working well, so I close the bladder in two layers like usual.  I leave a piece of sterile glove as a drain and close up the rest of the layers, irrigating at each layer.  We take him out to the “recovery room” and bring the family in to show them how to take care of the bladder irrigation.  It’s sad that I feel more confidence in the family doing well with the irrigation than the nurses.  But the families here are used to caring for their patient and they’re invested.  Once they understand what I want them to do they usually do it.  It just takes repeated translations to tell them.  And I do it differently than Dr. Denae, leaving the foley on tension, so it’s a learning curve for the nurses too.  Once I think the family understands, I see some consults about a leg mass, neck mass, infertility, a hernia, Then go into the next surgery that’s ready.
The next was an old lady with a black dead foot.  Yesterday when I saw it, it was dry gangrene, dead and shriveled black without an odor.  Today the whole pre-op area smells like dead with pus! Wet gangrene.  She is taken back and a spinal anesthetic done.  Her below knee amputation goes well.  There isn’t as much blood flow as normal so I wonder if she will heal this amputation site.  I do it with a nursing student as Abouna had to go to the government office because he’s involved in some sort of land dispute.  They call him and say come now, so he leaves work and goes and deals with it.  A few hours later he’s back at work.  The student helping me is helpful, but I have to direct him quite a bit on what to do.
I see some more consults, and then there is a older woman with a hernia in her central abdomen about the size of a foot ball.  Initially when I saw her I wasn’t sure wether this represented a hernia or a mass, but I suspected hernia.  After her spinal we are able to reduce it, hernia!  I cut down into the large fat layer and gradually around the hernia sac.  I open and resect the large sac.  I then close the fascia with a large suture.  I suspect she may have a large seroma (fluid collection) in the fatty layer, so I leave a piece of sterile glove as a drain.
One of the consults I see next is an old guy who can’t pee.  He says he had a foley catheter in that didn’t work but when they pulled it he had a lot of blood in his penis.  Once again I be the foley was placed and the balloon blown up below the prostate and not in the bladder.  Then  suprapubic foley was placed.  He hasn’t been able to urinate with his penis since.  The foley in the lower abdomen fell out a week ago.  He went to the hospital in Kouseri (Cameroon) and they wanted 200,000- 300,000 CFA ($400-500) for the surgery to fix him.  He decided to come to us about 12 hours away.  But it took him about a week to find money and get here.  He says that he can’t pee and small amounts of urine come out his abdomen.  I do an ultrasound with my Butterfly and see a very full bladder up to his naval.  He pays at the pharmacy for a foley and bag and I take him into the operating room as I know this will be difficult as the tract has closed up.  I anesthetize his skin and cut back open the skin.  I know Im going to do this blind along a tract that has closed, but I hope I can re-open it and get a foley in the same place.  So I probe the tract with a sterile heavy blunt probe that usually used for vaginal stuff.  Im gradually able to shove it down the tract into the bladder.  I feel a pop then pull it back out.  No urine.  I know I was in deep enough it was easy after the pop.  And I know I have a huge target of urine to hit.  So I put the heavy probe down a foley catheter and push it down.  It’s tight but I think I get it in.  The probe is difficult to pull out.  After getting it out- only a small amount of urine in the foley.  I use a force to cram more foley in the hole.  Urine comes welling up in the foley.  I very grateful.  I blow up the balloon, which doesn’t cause any pain, so the balloon is in the right place.  He drains about 2 liters of urine and feels much better.  
I look at the registry of surgeries since Ive been here.  35 surgeries in 2.5 weeks.  That’s a good number.  I’m looking forward to being home with my wife and in cooler weather.
Pic of large prostate and a prostate patient.

Shanksteps Bere April #11

I started an audio book in the evenings called Cross and the Switchblade- about ministering to NY gang kids.  Im finding it hard to put down to write you all 🙂  I want God to use me like he did David Wilkerson.  Not for kids in NY but however He sees fit.

Today God is using me to help individuals here with their diseases that I can help with surgically.  I make rounds while I wait for the OR crew to get the patients ready.  I start at 8:30 after they’ve had their morning meetings.  At 7AM I went to the Hosptial worship.  It is singing a song in Nangere and then a worship thought that someone has prepared which is translated from French into Nangere.  Or vis versa if the speaker is Nangere.  During rounds I see the guy with the open below knee amputation that I amuptated for wet gangrene of his diabetic foot.  Now he’s granulated and free of infection so it’s time to close it.  I send him to the OR for preparation.  I check on the guy who had pancreatitis and had a lot of pus out his abdomen yesterday.  I see intestine at the wound site- oh no a dehiscence and eviceration.  I tape a dressing on him tightly and send him to the OR so he can be operated on today as well.  He just ate bouii, so he’ll have to wait till later.  The teen with the open neck wound and a feeding gastrostomy tube is doing well so far just very weak from lying around.  The kid with the leg burn that I did the release on is doing well but not walking yet because of pain. I encourage him to walk.  The old guy with head trauma still hasn’t woken up yet, so we continue IV fluids.  The family wants to give him water orally, I strongly discourage this as he will aspirate and then die, which he may anyway!  I see the kid that I opened the femur on for osteomyelitis drainage and do his dressing.  He tolerated it really well but screams at one point.  The people here are so tough!!  His mom cradles his head as I change his dressing.  There are so many painful dressings here, and we can’t take all of them back to the OR for changing as there is to much to do and I don’t want to give sedation I their hospital bed for fear they won’t be watched and could die.  They are used to doing dressings on the ward, and I do it in spite of the pain I’m causing him.  Of course him living with osteo that is draining at different points on his leg is also painful.  So he has dealt with pain a long time. 

 The first surgery is that of the below knee amputation.  He is given a spinal by David and then his leg is prepped and draped.  Then I cut off excess muscle and bring up the flap.  It has shortened some with time so it’s a little tight to bring up to cover the opening.  With a bit of effort and suturing, I bring the edges together leaving a drain going along the base  inside.

Next is a woman with osteomyelitis of her mandible with draining sinuses.  I explore this and nibble away at rotten bone.  Its is somewhat helpful I think but it’s really when there is a sequestrum (dead bone that has separated) that I feel like Ive really done something useful for them.  She also needs her teeth pulled that are the rotten source, I leave this to the nurse who does that.  Though the OR isn’t a bad place to do this!  I pack and put tape on the dressing.

Next is the older guy with dehiscence and pancreatitis.  I had pulled his pancreas drains a few days ago as they weren’t functional any more.  After his spinal, we prep his belly and opening with betadine. Then as I look in is see my suture intact all along with a rim of fascia just ripped off one side.  Did he do a sit-up and just rip it off, or did the pancreatic juice make the fascia weak, or was it the subcutaneous abscess that did it?  Likely a combination of all of this I guess.  Either way I debrede off the edges and take out the previous suture.  I re-close his abdomen with retention sutures and a fascial closure and leave the skin open for packing between them.  I hope this one doesn’t fall apart.  If it does he may need to be dressed open and I guess that will be the next surgeons problem as I leave soon.

Then there is a patient that hasn’t progressed as needed in her labor for a child.  So she is brought to the OR by Dr. Staci for a C-section.  As she does the C-section I see outpatients that have waited all day since morning.  In between seeing the patients with STD’s, infertility, neck mass, goiter, kid who can’t pee (stone), large inguinal hernia…

I go and check on how the C-section is going.  I see the local doc giving a mask to the baby who is blue and not breathing.  He is shoving the mask onto the face of the baby tilting the head forward and trying to mask him.  I ask that the oxygen be brought, and I take control of bagging the baby.  I tilt the head back to open he airway and mask effectively.  Pulse ox that I have put on shows oxygen saturation of 72 (normal above 92).  A nasal cannula is put under the mask and I bag for for a while till the saturation is normal and the kid appears to be breathing on his own without masking.  I explain to the students how to position the head for masking, and hope the doctor is listening.  I leave to go back to the consultations.  I see a older woman with a huge abdominal mass sticking out how her fat abdomen.  It’s likely a huge hernia that won’t reduce.  Another 27 year old woman has uterine prolapse after a delivery of a dead baby.  Another has vague abdominal pain that “starts in my legs, goes up my abdomen to my chest then back to my central abdomen”  I treat him for typhoid and worms. I often find descriptions of symptoms amusing and also difficult to figure out what to do.  But with limited meds, I choose what’s available and likely to help.  

God help the people I’ve seen today to heal and gain their health back.  Help them to know how much You love them!  Give me Your words to speak to them!