She had been 3 days in labor at home. Then she went to the clinic. They recognized that she needed to be at the hospital, so she was sent to us. As I walked into the room a putrid odor hit me in the nose. The smell of rotting flesh mixed with pus. So infection was clear. I did an exam and discovered a macerated head. The abdomen had a bizarre contour making me worry about uterine rupture. I attempted to pas a urinary catheter without success. It felt like it only went into the vagina. So I decided to place it as we performed a Caesarean section in the operating room.
Knowing the baby as dead I used Ketamine for anesthesia instead of a spinal, Ganava administered the anesthesia. Jacques and I performed the operation. Suspecting the uterine rupture, I made a vertical abdominal skin incision. The uterus was somewhat contracted and had a large hematoma all around the base where the bladder is. I opened the uterus in with a classical incision and pulled out a macerated child. As I inspected what was left, I could see that the uterus had ruptured completely at the base and was not attached to the cervix as usual. Also as I inspected why I had been unable to pass the urine catheter, I discovered that the bladder had necrosed the entire posterior wall. This occurs from pressure from the child’s head against the pelvis, where the bladder lies between them. This pressure of three days had caused her bladder wall to necrose entirely, leaving only part of the sidewalls and nothing down to the urethra (the normal area to urinate). We placed a catheter and attempted to reconstruct a bladder from the remaining tissue. I also removed the Uterus that was not attached any longer.
We are now three days after the surgery. I praise God! First, because she is overcoming the infection she has. Second, because her intestines are starting to function again. Third, as of yet she has had no urine leakage. May God be glorified in His healing of this woman and in all the patients we see.
Another I praise God for directly healing is a thirty-year-old man with tetanus. For about a week he appeared like it was likely he would die of spasms at any moment. Yesterday he was up and walking around, eating, and having almost no spasms. Glory be to God! Greg
Shanksteps #163
There are six weeks left of time here in Cameroon. Each day is filled with the usual complex patients at the hospital. Inpatient rounds, outpatients, surgeries, and periodic calls at night. The evenings are spent with Audrey and Sarah, often packing a few boxes, in preparation for shipping things back. Time seems to be passing quickly.
We are anxious about where we will work in the future. Anxious about who will come to cover the work here. Will the hospital fall again, as it had before we arrived? We have not yet heard of anyone willing or interested in coming! What lies ahead for us? What lies ahead for this hospital?
I spend periodic nights awake, mulling over things in my mind. I know we need to be back in the US, but there are so many uncertainties. We give the responsibility for the different things we have done to others as it is possible. I pray for Yves often (our administrator) who has been through many tough periods at the hospital. He is a missionary from the Southern part of Cameroon.
Life continues as it has for the past five years. But in the back of all our minds there are concerns for the future here and in the US. This is especially easy if we let ourselves focus on us! When we focus on God and His faithfulness, all worries diminish.
God has demonstrated He loves us. His ultimate sacrifice on the cross demonstrates that very clearly. If the God of our universe loves me, is interested in my life, is interested in this hospital and the lives of it’s workers; then I can sleep at night, knowing that He is in control if I allow Him to be in my life. He is in control of the hospital if He is allowed to be. And who better to be in control than our: all knowing, all understanding, all loving, compassionate God!
When I focus on Him, and not myself, I sleep, and am content in knowing that He is in charge, and despite of my inability to see my future or the future of the hospital, He IS love. And when I allow Him to take charge, He will do what is best for me, best for my future, best for my learning more about Him. Praise Him! Greg
Shanksteps #159
“Could one of you come and see this child?” Jacques asked Audrey and I. The child was breathing fast and was very pale. He is 7 months old, 6kg (about 13lbs), and has a huge anterior fontanelle which is very sunken in (a sign of severe dehydration). His hematocrit was 6% (normal 45%). He had just vomited blood-tinged fluid. As they placed an IV in his arm he did not move or cry. He had pneumonia from all the vomiting and aspiration of the stomach contents, giving him low oxygen. He needed oxygen!
Six days ago the workers emptied the water tank to patch and paint it. They scraped the insides, patched the holes with a tar compound, welded a few spots and then repainted it. This took about 4 days to complete. The fourth day the electricity went out. So we have been “functioning” without water in the hospital for many days now and with no electricity. Two days ago I wanted to do a hysterectomy on a woman that needed it and when we tried to start the large generator the batteries were dead. So without power I decided to put off the surgery till we have power again, and when my OR schedule is open, 3 weeks. So with all this we are out of power when this child is in need of oxygen.
We have started the small generator of the lab and decide to transport the patient into the lab waiting room so that we can use the electricity there to run an oxygen concentrator (there is no bottled oxygen here). After placing a bed in the waiting room and hooking him up he breaths slightly better but needs blood. The mother is the same blood group so she gives to her child. The day passes and it is time to turn off the generator for the lab. The child has received the blood but is still very hypoxic (low oxygen) without the oxygen. Should I run the generator over the weekend for him? How long will he need oxygen? Will the oxygen actually help him survive, or will he die anyway? Should I tell the family that since the generator is running only for their child they would have to pay for gas? If I say this will they refuse treatment? I ask Aud what she thinks. We decide to keep the generator going and not talk to the family about gas for fear that they will refuse treatment.
At midnight I am called because the generator is stopping every 45 minutes. Apparently it is plugging up with gunk in the lines and for air vacuum in the tank. Baya, the nurse who is in the ER, is somewhat mechanical. So I offer tools and ask him to try to fix it. I don’t get called for the rest of the night.
It is Sabbath (Saturday), I plan on sleeping in. I wake up at 7AM to the sound of chickens and immediately think of the child. I can’t sleep any longer because I continue to think of him. I get up and head into the hospital. He is still alive! I have prayed for him a number of times through the evening and night. I am thankful God has spared his life. The generator worked all night after Baya tried a few things. I take him off oxygen and his oxygen stays above 92%. I transfer him to the ward. Our chaplain, papa Sidi, has just prayed for him again.
I see another girl that is 16 with severe headache and neck pain overnight. I do a lumbar tap (take spinal fluid) to evaluate for meningitis; I also treat her for cerebral malaria.
I leave the hospital hopeful for the child who has survived the night. Greg
My frustration know no end as I write this addendum. It is Saturday evening. The nurse on today did not observe my patient well. He calls me when the child is really dypnec (short of breath). They put him back on oxygen to late. He died.
Shanksteps #158
Diagnostic dilemmas are constant here. This comes from the fact that to diagnose different diseases there are a limited number of tests available, and even those are made more limited by patients refusing to do the ones we desire. Most often they want tablets but not tests. The Nigerian patients that come here want both. They are a select few who have some money, are unsatisfied with their own medical system and come here because there is a foreign doctor. They frequently request ultrasound and x-rays because they feel that that is where their pain (“worry” as they describe it in Pidgin English) will be diagnosed. They often want to see where the wound is that hurts them inside.
So an old, very thin (likely between 80 and 90 lbs) sees me in the office. She is deaf and mute. Her son talks to her with gestures, which make no sense to me at all. He somehow has deduced that she has pain in her chest. He says that she has had this for about three months. She has not had a cough but just pain. I listen to her chest and hear breath sounds on the left but very muffled ones on the right. I tap and hear a dull sound, she is full of fluid. I request an x-ray, and they agree and go to pay the $7 to get it. She is lucky because this day we happen to have electricity. It has been out every day for 1-10 hours for the past 5 days. The chest shows a complete white out on one side. I do a tap with a needle and find dark yellow fluid that the lab says has some gram + cocci in it. Infection? Contamination of specimen? It is unclear. But the fluid needs to be drained.
When I first arrived at Koza there were no chest tubes here and I used a urine catheter for my first one. Today we have two sizes so the student missionary and I select the smaller size and numb up the area of insertion. We prep her side and hold her hands out of the way as she is contaminating the field demonstrating where her pain is again. Her son and another nurse hold her arms. We put the tube into her chest and get 1300ml of fluid. She coughs and appears worse for a little while. Maybe I should have let off the fluid a little more slowly.
Over the next few days she drains about 800ml a day. She is getting thinner by loosing all the protein every day in the fluid. Or I assume that’s what’s happening. So if I take out the tube all the fluid will reaccumulate and I don’t have anything for plurodesis (making the lung inflamed and stick to the chest wall, effectively stopping the fluid collection). So eventually I talk out the tube. She reaccumulates the fluid and I let her go home. I’ve treated her with broad spectrum of antibiotics; we are currently out of TB medications. The government supplies these for free but when we ordered them they said they had run out in the far north. So free TB meds doesn’t help when there are none. And since they are free none can be bought either, because there is no black market desire for them. So she reaccumulates her fluid and goes home in a day or two. Another dilemma unsolved.
The same thing happens in the room next to hers. There is a man with huge ascites. I drained off about 15 liters the other day. He had a tense belly for a month. I drained a lot off and he lost 9kg with the fluid extraction. His abdomen was large but then not tense. The peritoneal tap showed no bacteria. I treated him for schistosomiasis, TB, abd peritonitis, other worms, and a loop diuretic (water pill). He does not appear to be improving either. Is it cirrhosis from his long time millet wine usage? Possibly, but I can’t treat that other than, encouraging him not to drink. So another dilemma unsolved. I know these same dilemmas can happen in the US, but it is so much more frequent here. This is the frustrating reality of third world medicine. Greg