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#134 Shanksteps
I walk into the hospital not quite feeling all-right.  Audrey asks me to stay home, I won’t!  I have had a runny nose and feel achy all over for two days.  I did the malaria test and typhoid tests, both of which were negative this time.  The day before I did not have the stamina to last all day like usual.  So I decide at least I will go in and make rounds on maternity/surgical ward as I usually do.  I feel tired but know I can at least do this.  I woke up with a fever of 102*F.  Now it has come down after some Tylenol.  I make rounds, sitting down often on the patient’s beds to talk to and examine them.  After rounds the administrator asks me to do one administrative thing with him before I go.  He and Audrey are in cahoots to get me out of the hospital.  I’m not entirely full of “fight” anymore and decide to go home after helping him.  Then there is the all too frequent call to the urgence (ER).  Kalda has a patient who he thinks I need to operate on.  So I saunter over the
re.
The teenager is lying on his back with abdomen exposed.  He is a thin guy but has a very protuberant abdomen as I see him.  He has slightly sunken eyes.  I feel for his pulse and it is rapid, I count-128.  His father has brought him into the hospital after being berated by one of our nurses to come in.  He has been at home 4 days without any bowl function.  He is completely obstructed.   I find no hernias, no previous surgery, and no starting point for the pain.  The history taking is less than optimal, but as I re-ask he questions I’m getting no further.  I give up and examine him.  He is tender to palpation and as I thump on his abdomen he winces in pain.  At least it is clear what I need to do’ Operate!  I have them send him over to the OR and ask Jacques to get him ready.  He calls me a half hour later saying all is set to go.  So I meander to the OR, gulp down some water and scrub.
We pray for him, as we usually do before starting surgery.  I open his abdomen, skin, minute amount of fat, fascia, peritoneum.  Dark purulent fluid runs out.  I’m glad I didn’t let my own feelings keep me from doing what I needed to for him.  As I open further his intestines burst from the incision, being liberated from their confinement.   As I explore inside I find a black piece of tissue in his lower abdomen with stool coming out near by.  I realize that his ileum (last part of the small intestine) is necrotic and isn’t even visible as a structure any more, but on both ends of where it used to be there is open small bowel and the same where it used to be attached to the large bowel.  Everything else is dark and has the characteristic red rash appearance of typhoid.  Typhoid is likely the real culprit.  I bring out two ostomies because of all the fecal contamination inside.  We irrigate repeatedly, but then again, what can really get rid of this contamination?  After clos
ing and putting ostomy sacs on the ostomies he goes out to his room.  I sit to write the note and suddenly feel very tired.  I go home, have a fever of 101.5 and sleep covered with many blankets even though it is 90 in the house.
I am comforted by the fact that God gave me the strength to make it though the surgery even though I didn’t think I had it in me!

In His Service, Greg

Like most women here she started labor at home. It was her first. Her husband went away because it is shameful for the nomadic women if their husband hears them cry out in pain during delivery. She had contractions and around midnight two days ago she broke her water. Then her labor stopped. The following morning she went to a local health clinic and was watched there for some hours. In the afternoon they referred her to the hospital for better care. I evaluated her, felt she had sufficient room to deliver and decided to wait a few hours. I instructed the nurse to call me if the labor didn’t start again. She was more dilated than when they examined her at the health center, so I felt she was progressing even though she didn’t know it. We were called to see others during the evening and I forgot about her. The nurse never called and I slept fitfully. At 4 AM I awoke to banging and crashing sounds. There was a strong wind storm and thunder in the distance. Tree
branches rubbed and crashed on the tin roof making a terrible racquet. Dust was flying heavily in the air and I felt sand all over the bed and between my teeth. I closed up the windows to the house but it was a little late. Every step left a gritty feeling under my feet. I finally drifted off to sleep again.

At morning worship they talked about the woman who was not progressing in labor. She had now been more than 28 hours after breaking her water, too long! I asked Jacques to check her out, and if she was not close to delivering to take her to the OR and get her ready for a C-section. He called me a few minutes later and said she was in the OR, ready. The power was out since the windstorm and so we started the generator. It started and we began the surgery. Audrey and I pulled out a crying baby and were happy that we had done it early enough to save the baby.

I made rounds on the maternity ward. The boy with the puncture wound to his head is doing well. I tell the family that it is God healing him that is keeping him alive, they smile and nod even though I think they do not believe in God. I am thankful I do, and the He is healing this boy! I see the others and then go to the office. In the office I see about 12 patients. Then the next surgery is finally ready. Three hour turn over! I’m frustrated, but go back to the OR. Frustrated mostly because I expect that it will take about 4 hours to take out a pelvic tumor on this next patient, and it is early afternoon.

Audrey and I start the surgery and we find a lot of small intestine stuck into the pelvis to the top of the mass. After much dissection we determine that it is a huge hematoma, likely an ectopic pregnancy. I guess her having a period a few weeks ago was not correct. We evacuate the hematoma and remove what was left of her blown out uterus. She didn’t want any more children so it made it an easy choice.

Audrey, Jacques and I clean the OR as the cleaner has already left. Then off to the ER to see what patients were waiting for us. We see a large row of people still there. It is about four patients with many family members. We see them in each of our offices. Yaouke, the nurse from maternity comes to my office. He asks me what I want to do with the man that came over with the infection near his scrotum, it smells so bad that the patients are leaving his area because of the odor. I had not heard about him. Someone thought that I had. I went and looked at him. The odor hit me about 100 ft before I arrived at the building. I put on a mask to not show my facial expressions. Lifting up the cloth over him, I see a black area on his perineum. I touch it and feel bubbles under my gloved finger, gas gangrene (Forniers Gangrene). He needs to be operated on right away. He has about a 40% mortality if he were in the US and getting good ICU care. I believe his chances are m
uch better here as we will be praying for him. I take him in the OR. As we go through the doors I fight off the mass of flies trailing him. Only a few make it in the OR with him.

Dr. Okudire and I start the debridement behind his scrotum. Brown, foul smelling fluid runs out. We take off a huge chunk of skin all the way down to muscle and down to anus. There seems to be an area tracking up in his inguinal region. We follow it up. We are now on his lower abdomen. The skin looks normal but the infection runs along his fascia (necrotizing fasciitis). We resect more and more. Off come layers of muscle, fascia and more muscle. The infection is deeply seated. We end up debriding off all the skin on the right half of his abdomen up to the right nipple. The infection skims along on his ribs up to here than back to his right back. Finally we get it all open and removed. Raw muscle and peritoneum are showing everywhere. It looks like an anatomy lesson on a live patient. I put dressings on it and we clean the OR thoroughly. I wish I had done it somewhere else. Will I have wound infections with my other cases now? I say a prayer for him again and
give instructions to Ganava. He will be taking care of him tonight. “God, please send your angles to keep him safe and please heal him of all this infection and the insult I have just created.”

I head home to a loving wife and rice and white beans. The salad is wonderful, fresh vegetables!!! I eat my first meal of the day at 7:30 PM. I guess all those pounds I made in the US are keeping me going. I think I gained about 15 and have now lost about 5 already. It is amazing to me how resilient we are. I can gain and loose weight, and this man can live in spite of the odds. Pray for his recovery.

In His Service, Greg and Audrey

Shanksteps # 132

I knew it was going to be a tough day.   We had just finished a C-section at 2:30AM.  Took a shower and headed to bed.  I drug myself out of bed at 6AM.  I made hot chocolate and had my own worship, arriving at the hospital at 7:30.  I had a colon cancer to resect today and was worried about it.  I had diagnosed it on colonoscopy back in February.  He was the head nurse of a health center and had decided to try traditional therapies.  Now after many months he came back to have it removed.  In Maroua (three hours away) they had asked him $400 to remove it.  Here I expected it would end up being about $200.  Money isn’t really an issue for him, but he chose to have it here anyway.
After morning worship and sign-out I headed to the office to see a few patients that were waiting there.  There was the follow-up for typhoid treatment, a bad pneumonia with significant shortness of breath, a child with a cough for months and weight loss- possibly TB.  There was a woman coming to follow up her hypertension, a teenager with a right inguinal hernia, and an old man with prostatitis.  Finally there were no more for the moment so I “ran away” from the office.  The office is kind of like the ER, if you are around their will always be one more question or one more patient to see.  Audrey was making rounds on the pediatric ward with 28 patients (24 beds, some two to a bed).  I made rounds on the maternity/surgical ward as usual.  There were three recovering from prostatectomies this past week, three who delivered a newborn over last night, the girl that we did the c-section on in the morning.  Others were wounds that were healing, a child with chronic constipation r
equiring rectal lavages, and the girl healing from her skin graft following a burn of 2 months ago.    There was the boy who caught his fingers in the grinding mill, taking care of half of three of them, requiring a revision of the damage.  There were two with endometritis after delivery at home and two with threatened abortions after working all day in the fields; another with gonorrhea PID who is pregnant.  Finally we were ready to start the colon resection.
He was a large, short man.  Unusual for most surgeries here, he had a number of inches of fat to go through before reaching the inside of the abdomen.  Intestines and omentum spilled out as he tensed his abdomen.  Ketamine (anesthetic), love it and hate it!  It was taking a lot to keep him from moving.  He did tell me ahead of time that he drank SOME!  After exploring all over I did not see evidence of any metastasis. The tumor was low in his pelvis.  I identified the path of each ureter.  Mobilizing the descending colon, we ensured that there was adequate length to reach the lower portion once we had resected the tumor.  After removing it, how would we put it back together?  Normally I do a hand-sewn anastomosis between the two pieces of bowel.  This was really to low.  I thought we had one circular 29cm rectal stapler.  So it was found. I hadn’t used that style before but was able to create a good anastomosis.  Filling the abdomen with saline (to look for air bubbles – l
ike looking for leaks in a tire tube) the anastomosis proved airtight.  Four hours later we were done.  (seems so easy here, one paragraph!)
I dropped my operating stuff off in my office.  Saw a few patients that were waiting for me.  Amadou called me to see a patient in the ER.  It was the son of the Sous-Prefets assistant.  He had been by the road and hit by a passing motorcycle.  He was conscious and had a wound on his right head behind his ear.  Grey tissue was in the wound.  Oh this looked reminiscent of a few months ago.  I put on gloves and examined him.  Some scrapes and bruises were found on his legs.  His head had a depression that my finger could sink into.  Pupils were reactive.  He needed to have his open skull fracture debrided and closed.  I called Jacques to come give anesthesia and ran home for my first meal of the day, it was 6:30 PM.  I inhaled some potato fries and salad and went back.
After putting him to sleep, I opened up the area on his head.  The skull had been punctured and many fragments bent into the center of the hole, grey and white brain tissue pooled in the area.  With difficulty I removed or elevated 7 pieces of bone.  During the process one artery was uncovered that bled profusely.  After a struggle I was able to tie it off adequately.   I could not find enough dura to close.  I created a patch out of temporalis fascia and sewed it in place.  Placing a drain, I closed the hole.  His pupils were reactive and we sent him back to his room to wake up.
“Doc, can you see this woman in maternity?”  It was Amadou again.  A woman was in labor at home since early this morning.  She had been “worked on” and had a very edematous perineum.  The baby had sounded good to him.  Oxytocin had been started to restart labor.  Now she was having abdominal pain.  Examining her, there seemed to be enough space for the baby to come out, but I found no baby heart beat.   I ran to get the ultrasound.  Baby was head down and the heart was not moving.  I thought I could see the placenta laterally but wasn’t sure.   I attached forceps and tried to help the fetus come down.  It seemed unsuccessful.  Then I realized that she had ruptured her uterus.  So back to the OR we went.  After 30 minutes we were deciding whether to repair the uterus or was it too damaged.  She had told me she didn’t want more children.  It was fortunate because it was very damaged and we needed to remove it.
Yaouke came in and mentioned that we needed to see another kid when we were done. She had eaten a meat sauce with a bone in it and felt it get stuck in her throat.  She had a lot of salivation and couldn’t swallow.   We finished up the operation.  It was 2AM.  We pulled in the girl to the other OR.  After writing my operation note, I went and did a laryngoscopy.  I could not see anything unusual.  I prayed that she would not have any real problems.
I arrived home, showered and fell into bed.  It had been a long two days.  God give me the strength to continue.  Give me patience even though I feel very short tempered.

Counting on HIM, Greg