Shanksteps of Faith #8

Audrey Audrey No Comments


Audrey here. I don’t usually write much because Greg’s stories and pictures are so much more interesting.  I figured I should at least say a word before we leave on Tuesday so y’all wouldn’t think I did nothing. 🙂  I have been rounding every day on pediatrics and medicine wards.   Peds  can be extremely sad or very rewarding. The majority of the kids come in very sick, but after 2 days of treatment (usually for anemia and malaria) they are feeling better and running around. It is wonderful to see so many kids turn around so quickly and go home.  Of course there are some that come in very late, or very sick; often convulsing and sometimes with a hemaglobin less than 1g/dL. It is amazing how many of these kids do well with a transfusion of blood and a couple doses of quinine.  BUT there are the kiddos that succumb, and don’t make it home.  Those are the sad days.  The adults on the other hand seem to NEVER get better. This week I had a full ward of men and women, all with ascites from various different causes. Some had liver cancer, some cancer of the spleen. Others had nephrotic syndrome, or Congestive Heart Failure.  In others, the cause was a life of drinking way too much alcohol (usually rise or millet wine- bili bili). There are others with hepatitis, or HIV, or Schistosomiasis.  Almost all the adults I saw could have benefited from lasix to pull some of the fluid off. BUT… the hospital doesn’t have any. So… they were all sent to the market to find lasix. Some is probably legit, others may be blackmarket or not lasix at all. When I finished rounds Friday, I had 12 adults on the wards. This morning (Monday) there were only 2. The rest just disappeared. Discharged, or ran away without paying the bill. Two women last week had seizures and went into comas due to low blood sugars. I found one, Greg the other. Both came out of it with a bolus of dextrose and a bit of sugar under the tongue. Neither were there this morning.  I have heard that they both died when they arrived home. Some left to go to the witchdoctor? To try traditional treatment? I will never know.   Today I was called to peds to examine a 13 yr old girl who was “violated”. The story was a bit difficult to figure out. As well as I understand: The 13 yr old is brought by her father to find out if she is still a virgin. The father says this boy had sex with her. The girl says she had sex with the boy.  The boy denies everything. I am supposed to be the “tiebreaker”.  Is she still a virgin? Will she bring shame to the family?   I explain that even if her hymen is no longer intact, it is impossible to determine if it was from sexual relations, or riding a bike, or using a tampon, or, or, or… The father seems to understand but still wants her examined, and the results documented. Their plan was to take the boy to the police if the girl was no longer a virgin.  Can you imagine doing that in the US? One amazing story that I can tell you about my time here is about a little baby named Toungou. She is a twin, born 3 weeks before. I met her.  She was brought in to the hospital after being taken to 2 different health centers for 2 days of convulsions.  When I saw her, 2 of our volunteers here (an RT and a PA) had been trying to ressussitate her. She had stopped breathing twice already and had been bagged and given CPR.  We checked her sugar, which was normal. Hemaglobin was normal. Malaria smear was negative. No nuchal rigidity or bulging fontanelle. I helped bag her for several hours. We would stop, and she would breathe on her own. Then the breathing stopped. The heart slowed and stopped. She was pronounced dead. For 30 sec, 40sec…Then she would convulse and start breathing again. She did this 4 times and we decided that she really wanted to live.  Fortunately, the midwife here, who is also doing amazing things with preemies and very tiny babies, has a portable cpap machine. Little Toungou just needed to keep breathing to trigger the machine. She was given Rocephin, Dextrose, and put on cpap. Mom agreed to have us take care of her in our homes, so she spent every moment with one of us volunteers. Nights at one house to be watched carefully; days elsewhere.  I was fortunate to be able to hang out with her after rounding until she went home with someone else for the night. Within 3 days she started to look better. She was no longer seizing. She was being given mom’s milk by tiny NG tube. She was still receiving Rocephin for probable meningitis.  After 4 days with us night and day, she was given back to mom to take care of during day, and just spending nights with one of us.  After 6 days, she started breastfeeding on her own. The NG tube was removed and she went home yesterday. Glory Be To God!
I am now sending this from the capitol of Chad, N’Djamena. We are on our way to spend 3 days in Istanbul before flying back to Oregon. This has been a difficult trip for me (maybe more to follow), but baby Toungou and many of the other kiddos have made it beautiful as well.   

Shanksteps of faith #7

Greg Greg No Comments

Horrible details follow, read only when you’re ready to be touched by someones hurt.

She is 18, she has pus coming out of her mouth.  She cant open her mouth because of a muscle spasm called trismus.  She is laying in the pre-op area and the whole place smells like horrible pus.  She appears to be in pain and has the very sick look to her.  Some of you will know what this looks like.  She has had dental abscesses for a week or two.  They brought her here on a two wheeled push cart.  They put the cart “en gaauge” to pay for her medications and treatment.  This means they have money coming but that the cart is the security that money is coming.  As she lays on her side I push around on her neck and she spits out some more thick pus.  She looks swollen like a chipmunk in her cheeks.  I feel they are both very soft around the mandible.  This pus near her mandible must communicate with her mouth.  She is the last surgery of the day and we take her back to the OR beating off the flys that accompany her.  Phillippe doesn’t want to give her any anesthetic as he thinks this will kill her.  I tend to agree that intubation is impossible, a tracheostomy has killed two patients here that I know of in the fact that they eventually mucus plug and the patient dies of asphyxiation.  Ketamine may be risky, I think a little would help.  He doesn’t want it and I don’t push. 

As I look over her face and neck, I push on the left chin and more thick pus flows out of her ear.  WOW!!! This is horrible.  I certainly do not think she will live through this.  I put in the local anesthetic after prepping her with betadine.  I cut in about a cm and don’t get pus like I expected by palpation.  So I use a syringue and needle and aspirate deeper.  I get air first, and this happens twice.  Oh even worse than I had thought.  She has gas, necrotizing bacteria.  God, I pray out loud, help this girl, heal her God, she will die unless you heal her!! If it is most merciful to let her go, then do it, otherwise heal her!!

I cut deeper and chunks of pus flow out.  I put my finger in and feel around the angle of the mandible, and then down her neck.  This is a big pocket.  I incise the lower part to of the pocket.  All of this is causing her pain, and she’s groaning with each push of my finger.  I irrigate out the hole with Dakins solution (a dilute bleach solution).  MORE pus and blood flows out.  I pack both holes and the bleeding subsides some.

The other side I decide to start lower at the angle of the mandible.  I inject lidocaine and incise.  Pus flows out of the hole Ive made and as I stick my finger in to feel the size and extent of the pus cavity, pus flows out her ear again.  So she has pus up the the base of her skull and it’s  coming from her inner ear out.  I flush and flush this one too.  Then I pack it.  Her heart rate stays about 140 and has a blood pressure in the 90’s.  She got Amp, Gent, and Flagyl.  Wish I had some clindamycin.

The nurses take her to the ward where she’ll sleep on the stretcher for the night because there are no beds on the surgical ward available.

GOD HEAL HER!  THAT’S  HER ONLY CHANCE!

Shanksteps of faith #6

administrator Greg No Comments

What an irregular day- it began normal and ended with me putting a chest tube in and taking a bullet out.  

The first surgery was a boy about 5 with a bladder stone.  Operating on the smaller ones isn’t fun for me as everything is small.  A small incision, a small bladder, a small opening- making it difficult to see and operate.  But I pulled a stone out of his bladder about 3/4in in size.

Next was a 65 year old woman with a uterine cancer as was seen on ultrasound.  I also did an ultrasound and just saw a lot of irregular tissue in the pelvis.  It seemed mobile so I decided to try and take it out.  Upon entering the abdomen, I find old blood and large old clots.  The bottom of the uterus seemed normal, but the top was very large.  I gradually worked around it and freed it up from the omentum and small intestine that were stuck to it.  Now it looks somewhat like the top blew out of the uterus.  We work down either side and eventually get to the end of the uterus and cervix.  I suture up the tissues and look for bleeding.  There is a little so I tie that too.  My resident, Anna, says there are studies now that say the fallopian tube can get ovarian cancer.  So we take the remaining fallopian tube, leaving the ovary.  I seem to remember that the ovary helps with osteopenia (weak bones) in post menopausal women.  

Audrey asks me to see a guy on the adult ward that has severe abdominal pain and has typhoid, and peritoneal signs (perforated intestine?).  I go to see him and he’s sitting up eating bouie (This is like a rice/flour/peanut porridge)  Hmm, If he’s really sick he shouldn’t want to eat.  He tells me his pain has been intense like this for two weeks.  He hasn’t been vomiting but once yesterday.  He has had some diarrhea, and also had some today.  He says he keeps down small amounts of food over these past two weeks.  His abdomen is quite tender with percussion tenderness, guarding and no rebound.  I’ve seen this before with someone here who just had very irritated intestine from their typhoid.  At the operation on that person they had red irritated bowel but no perforation.  I do a bedside ultrasound and see no fluid in the abdomen.  I order a upright abdominal X-ray and am told by one nurse we cant do those and only flat X-rays,  and by another we can.  I head back to the operating room where they are preparing my next patient.

I see a man in the pre-op area that has blood flowing out his foley catheter.  I ask the nurse who put in the foley if they blew up the balloon before or after getting urine/blood.  He says the guy has had frank hematuria for 4 days and worse the last two days.  There was straight blood coming out before he inflated the balloon.  I do a rectal exam and feel a very large prostate which is very soft.  Prostate cancer is my first suspicion and prostatitis my second.  I don’t know if prostatitis can cause frank hematuria.  I have the nurse put in a three way foley and start bladder irrigation.  Either way the type of prostatectomy I do, won’t help with a cancer as it leaves the capsule.  So I’ll treat him for prostatitis and hope that it stops.  I’ve had very poor internet while here, so I can’t look up things like I’d like to.

I walk back in to the OR and my next patient who has a pelvic fracture and a broken femur is sitting up because the anesthetist wants to put a spinal in.  I’m shocked that he sat up at the anesthetist’s insistence with a broken pelvis.  Since he’s already sitting up I tell Phillippe to go ahead with the spinal.  This guy was making mud bricks at the edge of a large termite mound.  They can get about 7-10 feet tall.  As he dug out dirt from it, it fell on him, breaking his femur and pelvis.  He came in with the traditional wood splinting.  I asked the nurses what the traditional healer would charge to do that and they guessed $40 equivalent.  We took off the splint and prepped his lower leg and I put a steinmen pin in the tibia for traction.  I’ll send a picture with either this email or the next with him in his bed.  It was quite a work of ingenuity, that involved a number of people.

Then there was a guy who had been about 10 hours north about a week ago.  There was conflict in the area and he was shot. Apparently he had a chest tube that was taken out and he made his way down here to be treated.  The nurse thought to get away from the area of conflict.  He has a whited out lung and a bullet in his back that’s palpable.  My student went away to the house of the guard to have some goat.  So I put in a chest tube in the OR and took out the bullet.  I got about 400ml of dark fluid (old blood) out.  I incised the area of his back with the bullet and pulled out what looked like a 223.  He was breathing better at the end of the procedure.  He walked to the surgical ward with his pleuravac canister in hand.

God, please give us wisdom to help these many different diseases and unknowns!

Shanksteps of Faith #5

Greg Greg No Comments

I walk into the OR (operating room) and they tell me that my patient isn’t ready.  It’s 10:30, and they’ve had plenty of time (since 8AM) to get them ready.  Im frustrated but hold my tongue.  They don’t llke to work late but also don’t start at any reasonable time either.  I go back out to the pre-op area to see some consults that are waiting while I wait for them.  I see a 8 year old girl with a huge cystic mass under her armpit.  It’s not painful and has been there about 8 months.  The cyst is getting larger and they want it taken care of.  What is it?  I don’t feel any nodes anywhere.  I ultrasound it and it seems like simple fluid with a couple small solid areas in it.  Is it a cystic tumor?  She has not been injured there nor any infection there.  So i offer to take it off, not knowing wether I will be helping her or not.  I don’t think Ill be hurting her.

I go back into the OR and Philippe has my patient intubated and asleep.  The patient has a transverse colostomy.  About 8 months ago he was in a town on the border of Sudan and was stabbed and had the ostomy placed at that time.  His records don’t show how much intestine is left nor where along the intestine the ostomy is so that I can plan what to do.  So blindly I start the surgery.  I go through the previous scar and get into the abdomen.  I’m into  a lot of adhesions.  All of the scissors in this package are horrible.  none of them can cut the tissue Im trying to cut.  I ask if they have any scissors that work and they only find one pair of eye scissors.  they were very small, but they cut.  After a while of cutting scar tissue, I found they had brought up the side of the transverse colon as the ostomy.  Likely the area that was stabbed.  I was able to take this down and make a repair.

Another consultation conundrum was a 22 year old guy with a huge neck cyst that was very soft.  It started at his jaw angle and went down to his clavicle.  I ultrasounded his neck and just fluid.  What is it?  I have no idea.  So I take his number and will see if we can come up with something and then decide whether to take it out or drain it.

The next patient has lost their records from before and also has an ostomy.  WOW, Im seeing so many ostomies here this time!  I operate on her and cut the many adhesions to try to find out where the part of the colon is to attach this part to.  After about an hour of searching I find what I think is the piece way down in the pelvis.  I have one of the nurses in the room do a rectal exam and sure enough it is WAY DOWN THERE.  There are no rectal dilators and no EEA staplers, and it is to low for me to make an anastomosis without this, so I have to abandon my efforts to try to reverse her.  When I tell the family postoperatively, they seem unaffected.  They ask if the smile train doctor coming in a month can fix it?  I tell them he won’t have the equipment either.

It is now 5PM and there is a 40 year old diabetic with a gangrenous foot.  I had seen him yesterday and asked the family to give blood and we would operate.  One person tried but was Hepatitis B positive so I asked them to get other family members to give.  We are still low on blood so we are trying to push all the operative patients families to give, this helps their loved one and also if we don’t use it- it helps the rest of the hospital for emergency needs.  Abouna gets the patient ready and as he has been doing surgery before I came thought about debriding it.  But he felt crepitance (gas in the tissues).  This is a horrible sign of gas forming bacteria and can kill someone quickly.  So I tell him a simple debridement of tissue won’t work and he needs his leg amputated below the knee.  I also call in his brother and explain it to him.  They say do whatever is needed.  In the operating room we don’t have a tourniquet, so the nurse wraps two urine catheters tightly around his leg.  He still bleeds a lot and I wonder if the tourniquet is just stopping the venous return but not the arterial flow- actually making it bleed more.  I get down through the muscles on either side of the bone and then get the bone saw to cut the bone.  This is a well used saw and isn’t sharp.  Anna, a FP resident here for a few weeks, tries to cut and then I take over and with a lot of effort, I saw through the bone.  I take a blade and cut off the rest of the muscles quickly and then control the bleeding.  I leave the area mostly open as I want to treat infection and evaluate for crepitance in the morning.

Tonights meal is rice with a peanut vegetable sauce.  I’m very hungry and it is delicious.  Audrey and I sit in front of the fan for the evening and catch up on our day.  We try to catch up each evening as this is one of the things that help us feel closer to each other.  Then it’s a cold shower (that’s all there is, and also all I want) then off to bed dripping wet.  Hoping I fall asleep before I finish evaporating. I awake this morning to some birds singing loudly outside my open windows before the sun has risen.