Shanksteps Bere April #5

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Shanksteps Bere April #5

In the late evening Im asked to see a guy with significant abdominal pain.  He says it started in the upper abdomen and then progressed to everywhere.  He’s quite tender in the upper abdomen and seems distended.  he has an inguinal hernia that is easily reducible.  He says he hasn’t passed gas but did have a liquid BM that day.  He’s had nausea but not vomited.  Then nurses had asked for an ultrasound and I think instead he needs a abdominal X-ray.  On the X-ray i don’t see any evidence of obstruction nor free air.  So I decide to treat his typhoid and see him in the morning.

In the morning he is still very tender and I think I should do a Bere “digital CT”.  Meaning digital (finger) cut and touch.  So i ask that he be the first one fo the day.  So they get him ready and I open his abdomen.  I get a bunch of fluid that i think looks like it may have come from the stomach.  So I go there first.  I look all over the stomach, front, open the back area, follow down the duodenum around the C curve of the duodenum. It’s difficult and it takes a while.  I find areas of inflammation and swelling in the tissue but no hole.  I run the small intestine from start to finish and see no problems.  I finally realize that everywhere Iv’e seen the inflammation has been most near the pancreas.  So that’s his diagnosis- pancreatitis!  I feel the gallbladder and don’t feel any stones.  It’s also small and not distended so I think i get a pretty good feel.  So i put drains in and close him up.  We don’t have any pancreas labs, so will have to rely on how he feels and when his intestines open up.  But there is nothing to do but watch and wait and hope that he heals.  Im praying for many of my patients.  God heal him!

The next patient Dr. Denae did I assisted her on.  It was a 30s year old woman with cervical cancer that was very hard and filling up the exit of the uterus.  She was bleeding and her baby was about 30 weeks along.  She had broken her water the day before and contractions had started.  So we needed to do a C-section because this baby had no way to be delivered vaginally.  The patient is having a lot of back pain and can’t sit.  So dong the spinal is very hard and we attempt to do it as she lays on her side.  The nurse tried, I tried, Olen tried- no go.  So we gave a bunch of local at the incision site and started.  We wanted to give the Ketamine at the last second so to have minimal effects on the baby.  We got our a crying normally formed baby.  In the lower uterus there was very soft tumor that was bleeding.  We closed her up and pray that she stops bleeding to have some time with her child before the cancer takes her.

The next one is a guy who had a bladder stone.  It was removed her about 2 weeks ago and then the urine catheter plugged up and overfilled the bladder.  Then the front repair fo the bladder ruptured.  So he was taken back and repaired again then developed a leak about a week ago. Now we took him back to repair that leak.  It was terribly stuck and difficult to create any planes of tissues that could be evaluated for closure.  Gradually we found layers to close.  We flushed the catheter with fluids and it didn’t seem to leak, so hopefully it will stay that way.

The next one was a woman who had an injury to her middle finger and the middle joint was stuck straight.   So when she made a fist it stuck out and was in the way.  So I offered to take it off completely or leave her with a small stub that may help some.  So she said a stub would be ok.  So i numbed up her finger at the base.  Once here finger was asleep, I cut through the tissues down to the bone.  then I nibbled away at the bone with rongours.  Made the end smooth then sewed the skin edges back together.

More happened than that, but that’s what comes to mind.  Pray for staff and patients here that they would really know God and follow His lead in their lives.

Shanksteps Bere April 2023 #4

Greg Greg No Comments

Shanksteps Bere April 2023 #4

Today is Sabbath, we go to church.  I woke at dawn about 5:30.  Fortunately they didn’t turn off the generator this morning, so I lay there in the fan for a little while.  I get up and drink a liter of water and shortly thereafter Im thirsty again.  I drink lots of water all day.

I go in to see the surgical ward before going to church.  I ask the on call nurse if there are any concerns and there aren’t.  So I go with the nurse and the students to the one patient I want to do the dressing on- the teen with the neck infection where I can see all the muscular neck anatomy I talked about last shanksteps.  He still says that when he swallows that fluid comes out his neck.  I change his dressing and see a fair amount of pus and saliva on it.  Though that is a little difficult to tell exactly.  But i have yesterdays experience to know that’s so.  I change the dressing and then talk with him and the guy with him that we need to place a feeding tube.  They seem to understand, but the ones that can make that decision- the older brothers- aren’t at the bedside.  So I will need to explain it again later to them.

It’s another sunny, hot day here.  At 8AM the temp on the little thermometer I brought reads 94.  I don’t feel sweaty as long as I’m not moving and sitting in front of a fan, but know Im evaporating constantly.  

I go with the Netteburg to the church with the kids under the mango tree.  We drive there in the truck with me and the kids standing in the back, sun beating down on us.  It’s nicer in the breeze than the inside of the truck i imagine.  People walking along the road are enveloped in the dust cloud behind the truck.  Little groups of kids playing under trees near the road wave and yell “nasara”  their word for white person.  Nnaasssaaarrraaaaaaaa…..  It takes about 15 minutes to get there.  We pull up under some large mango trees and kids and adults flock around.  As we get out of the truck they ask if I’ll tell the kids a bible story.  I’d like a little more time than that to think, but agree to do it anyway.  Olen starts with singing with the kids songs that they have sung many times.  the kids join in exuberantly with singing and the motions.  When they are done singing, I tell the biblical story of Jonah and his hearing from God what God wanted him to do and Jonah choosing to do something else and run away.  And how God saved his life and brought him back to doing Gods will.  It took about 15 min with the translation and me speaking in French.  Denae repeated the story with questions along the way and the kids were very excited to respond with the answers.  Each kid who answered got a sticker. They were very excited.

We drove back home and hit a few dust clouds too as we passed some larger trucks taking the same road.  It appears they are doing some sort of road repairs.  It’s a weird time to do dirt road grading and repairs just before the rains start and they get destroyed again.  At home it’s 110 outside and 100 inside.

We gathered early afternoon for a potluck meal.  Food was excellent as I always find it at potlucks.  And as far as I could tell everyone had food.  We were thinking about walking around afterwards but there was a patient that needed to be watched as her labor progressed so we didn’t go out, had good conversations and played with balloons with the Netteburg boys that were left over from the wedding party.

Later on there is a patient who came in pregnant and wasn’t progressing and was found to have a dead fetus.  She was followed and given pitocin and still didn’t progress.  So when a C-section was needed, I offered to do it, so the other doctor could have some rest.  Olen did the anesthesia and Douri assisted me.  The baby’s head was high and not descending.  She had received enough fluids via IV so Olen placed the spinal anesthetic.  We prepped and dropped her abdomen and I did a phanynsteal incision (low transverse above pubic line).  I went in through the skin, fat (very thin), and split the rectus muscles opening into the peritoneum.  The uterus looked normal. I opened it in the lower section transversely. It was difficult to get the baby out.  I found the head was large and deformed.  So the head was likely to big for this woman’s pelvis.  I put clamps on the uterine edges to slow the bleeding.  Delivered the placenta, then started to close the uterus.  After controlling the bleeding spots, I saw a hematoma forming on the left side.  I opened the hematoma and put some sutures there.  The left uterine artery had torn when I pulled out the large head of the baby.  When there was no more bleeding then I closed the rest of the layers of the abdomen and she went to the maternity ward.

After a night surgery it takes me a while to wind down to be able to sleep.  Im able to text with my wife at home and finally when I feel tired I go to bed.   I got in bed around 1AM and lay there till about 3AM my brain going about random things- frustrating!  At 5:30 IM called about the patient with his neck open with infection.  He is bleeding from his neck again.  I race in and find he has about half a liter of blood clots in a basin in front of him.  It is coming from his mouth and doesn’t appear to be from his nose nor his outside neck wound.  Is he bleeding from his jugular vein?  I can’t see anything in his mouth bleeding and don’t think looking in his throat would help me even if I identified the spot on the inside.  I wouldn’t be able to stitch it… It appears to have stopped, so I order a hemoglobin and send the family to be tested for blood type in case we need to give him blood.  His previous hemoglobin was normal at 15.

I try to sleep again but it is impossible.  I am never able to sleep in the daytime.

God give me Your wisdom to know what to do with this boy. Help him to stop bleeding. Heal his terrible neck wound.  Help this boy to know Your love for him, and use me however you want to use me.

Shanksteps Bere April 2023 #3 with picture

administrator Greg, Uncatergorized No Comments

Shanksteps Bere April 2023 #3 with picture

Death- We all die.  Most of you reading this have hope of a life after death, one where we will live with God after all the pain of this world is gone and it is made new again like God designed it in the first place.  Since we are on this world we experience death, and in third world countries death is a daily experience.  Adults and children and especially young children.  If you ask a woman here how many children they have- the response is usually I’ve had (example) 6 children and 3 are living.  Since there is so much death it is an expected though mourned part of life.  I can accept it better when I know why someone dies than here where it’s sometimes diagnosed and sometimes i just suspect why someone I was caring for in the hospital dies.

Im called in last night to see a lady that I had performed a procedure on earlier that afternoon.  She had been admitted a few days ago and had malaria and seemed short of breath yesterday.  So Olen did an ultrasound and found what seemed to be a prominent amount of fluid on one side.  He sent her over to the OR to have me drain it.  The lady was tachypnec (breathing at a rate about 30) after being moved around.  No one spoke her language so we made signs as to what we were doing and she also seemed not all there.  i did an ultrasound with my Butterfly and saw fluid on the right.  So I didn’t know wether to draw it off with a small needle or a chest tube.  so I put a needle into her chest and drew off fluid that looked like pus.  So I decided the chest tube is what she needed.  I put lidocaine in her chest wall about the level of the mid breast and made an incision and spread slowly down between the ribs.  as soon as i entered the chest cavity pus came spewing out with each breath.  I put a chest tube in and attached it to the one pleuravac (canister) that has been washed out and reused for many years.  (They aren’t available here.)  after finishing the procedure I hook the pleuravac to suction and more fluid pours out.  I get a total of 1700 of pus, after whatever drained all over the OR bed and the floor.  she is coughing and that gradually calms down.  I call her family, three guys, into the OR so they can see the amount drained off before I dump it as it nearly fills it and I want more space in it for the weekend.  It’s made to be used one time so it is difficult to dump out as it doesn’t have a drain place.  eventually i get it emptied and reattach it.  Her saturation is good and she’s a little low on blood pressure and as we give her IV fluids it improves.  She is taken to the surgical ward.  I check on her shortly there after and verify that the tubing isn’t kinked and that the family knows how to push on the foot pump every so often to create suction for the system.

So Im called in at night to see her because she isn’t doing well. I go in right away to see her and she is dead.  Not just dead but cool and dead.  The nurses have a list of hourly blood pressures which I asked them to do- and amazingly enough they did.  Usually it’s a fight to get daily blood pressures.  Anyway the blood pressures have been good.  They said a bit earlier she drank water and didn’t choke and that from the nurses (don’t know wether they were students or nurses) point of view she was doing well.  When they came to get her blood pressure it was zero so they called me.  No CPR.  I don’t do it either, as i find in this rural place when we are treating suspicion rather than diagnoses it’s futile.  No ekg machine, and Im not sure it would help anyway here.  I tell the men she is dead.  This usually causes an uproar by women of the family who start mourning.  However there are no women of that family around so they are silent and sad.

Another patient that has cheated death so far, but may die in the near future is about 18.  He came in a couple days ago with a severe neck infection after having a tooth abscess that continued down into his neck and necroses the skin on the front of his neck.  The dead tissue was debriefed in the OR and when I came the first day he was in the recovery room he was being suctioned frequently because he was bleeding from somewhere in his mouth.  No spot could be identified but clots kept coming out.  he wasn’t conscious enough to protect his own airway.  I didn’t expect him to survive the night.  A visiting ER doc got up every hour or two and suctioned out his airway in his room with a foot operated little pump.  It worked and when I rounded the next day he was still alive and more conscious.  Yesterday when I rounded I take off the neck dressing and I see all the muscles and thyroid of the anterior neck.  From side to side and up onto the left jaw muscles too.  It’s a gruesome site that reminds me of the “bodies” display I saw at the museum once on the human body.  Or anatomy class in medical school.  I flushed out the pus in his neck and realize that he seems to be choking.  So I sit him up and have him drink some water.  a fair amount comes out his neck wound.  So there is communication with his throat and this open neck wound.  Im not sure what to do about that.  I will tell the family that he needs a feeding tube.  I think he has survived the infection and will die of starvation if I don’t feed him someway.  We also still need to pull the rotten teeth that were the source of the infection.

So death is ever present.  It is always hard to deal with and each patient I get attached to and think they are doing well and that what we did made a difference- if they die it is hard to deal with.  Other patients I expect to die it seems less painful.  Then there are the ones like this last one I expect to die and didn’t (yet).

God, help me to know what to do with each patient I see and guide us to help as many as possible and know when it’s not possible.

Shanksteps Bere April 2023 #2 with pictures

administrator Greg No Comments

Shanksteps Bere April 2023 #2 with pictures

Today I awoke before dawn when the generator went off at 5AM and the fan quit.  Instant heat.  It was down to 86 by the morning.  So at least not 95 like i anticipated.  But I normally sleep in a room that’s 60 deg.  So it was toasty.

Went in and rounded with Denae to learn the patients on the surgical ward.  Many chronic wounds or infections that are being dressed.  Some in diabetics and others not.  A lady that had mastitis that sloughed all the skin of the breast.  Older guy with osteomyelitis (bone infection) Bladder stone removals that got infected.  Patients she’s repaired vessicovaginal fistulae (connection between bladder and vagina from prolonged labor and necrosis of the tissue between the two.

They worked on the generator today and then about 10 AM said one was fixed enough that we could do surgeries.  The other was hopelessly ruined by the piston going through the side of the block.  i think these two generators have been running 24/7 alternately for 10-15 years so not surprising that a major problem has happened.

I went to the OR and found out my two first surgeries were to remove bladder stones from a 7 year old and a 14 year old, both boys.  The first one the two visiting ER docs did the anesthesia.  I told them Ketamine should be fine, so it was given and I started. The boy was quite fearful, which is unusual here but quite understandable, but after Ketamine he was calm.   I made an incision in the low abdomen across the belly in a gentle curve down low.  Went through the different layers and exposed the bladder we had distended with water and betadine.  The cautery was being used in the other OR by the nurse doing a hernia surgery(he has been being trained by the other surgeons so there can be some coverage when there are no surgeons here;  If you are a surgeon and want to volunteer in Bere it’s very needed the rest of this year).   so without cautery I got more bleeding than I like.  I used to use Ketamine a lot in Cameroon I have opinions about how much and IM / IV to give, and what meds to associate with it.  They did a different way which is fine but at least on that patient seemed less effective.  Every-time I touched him in his lower abdomen he would push back, obliterating my view.  They gave more and more and gave ativan…  He still pushed back at every touch.  Finally they intubated him and with isoflurane he stopped pushing back.  After opening the bladder, I fish around with my finger and pull out two smooth oddly shaped stones, each about a quarter in size.  i feel around and don’t find anything else abnormal.  i close up the various layers and leave a piece of glove as a drain to the space outside the bladder.  This is in case the urine catheter gets plugged and the nurse doesn’t alert me or unclog it that there is a way for fluid to drain out if it ruptures through my bladder repair.

In between cases I go and see a girl who is about 5 months old and has a huge nose mass.  it was small at birth and now is very large.  Is it a tumor from a sinus, brain coming forward, a mass of blood vessels?  So many options I know very little about.  i get an ultrasound and see some solid material in it and also fluid.  She starts to cry as I am running my ultrasound over it and i see that with each force of her crying, the fluid areas expand.  This make me think of it being brain and cerebral spinal fluid coming out. (I will attempt to attach pictures of her at the bottom).  I decide if I try to resect this it will likely kill her.  At first the family is forceful that they want me to do surgery to take it off, then as we discuss it they decide if she will die either way, that they prefer to take her home and let whatever happens happen.  I wish I could do something useful for the child, but I don’t think Id help and would hasten her demise.

The next 14 year old boy with another bladder stone is brought to the OR after cleaning it.  The nurse doing anesthesia tries a number of times for the spinal without success.  I offer to try.  the boy is very stoic and not moving much with each poke in his back, which is hard to sit still for as it’s painful.  I give it a few tries, then get the right space and inject the medication.  He lays back and it works and he feels nothing from mid abdomen down.  His surgery goes much easier as I have cautery now, a good assistant (the previous assistant was a student nurse, not as helpful), and a patient that is still and not reacting to what Im doing.  I get into his bladder and I can feel the stone down low.  Instead of floating around in the bladder like the last kid, this one is stuck down in the outlet of the bladder.  Im amazed he could get any urine past it.  It seems to have grown in place and is extremely hard to dislodge from its pocket.  I try a variety of things.  Finally I have to use some sharply toothed clamp to get a hold of it and slowly yank it from its place.  This one is the size of a small chicken egg a little more than an 1 inch in length and oval with a nodular surface.  I close up his bladder and abdomen and see some consults in the OR entry room.

In the afternoon there is a wedding of a missionary and her fiancé from the same country she’s from.  i don’t make it to the wedding, which is OK with me.  I do make it to the reception and enjoy food and seeing other missionary friends that aren’t at the hospital but live in a town a little ways away.  It gets dark as we are out and Im being bitten by mosquitos.  i hope I don’t get malaria again.  Ive avoided it that last few times Ive been here but many of the missionary kids have malaria right now because of an evening event recently they tell me.  I make sure and take my prophylaxis tonight.  It’s cooled off to 92 and I shower and go dripping to bed.

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