Im waking up shortly after dawn now which is my preference. So i guess my brain has finally changed time zones. I think it’s about a day per hour of time change to feel normal again. I feel cool- wow that’s awesome, it rained in the late evening and it doesn’t feel hot. i guess my body is changing temperatures too. I don’t know a time frame for my body to acclimatize. A couple weeks I think. I drink a lot of water in the morning preparing for the day of surgery. So I down about 1.5 liters. Then head to the hospital worship. though they speak french and I have difficulty understanding many times. If someone is speaking to me I can communicate and understand. After worship I make surgical rounds on my post operative patients. I see about 20 people in various stages of their convalescence. Some are there only for dressing changes as they heal their wounds from a wound infection. Ive seen all the wounds the first day so I let the nurses do the dressings the rest of the week and just tell me if their concerned about one. The prostatectomy guys all have bladder irrigation going and I decide who to stop and who to slow down.
Then on the the crowd outside the OR. People gather there that are family of those going to be operated on and also people who have paid the about $3 if they saw the nurse first and got whatever the nurse ordered in labs, or $12 if they only want to see the doctor. I greet the crowd and some thrust their little medical booklet towards me. I assure them that the nurses will get their “carnets” shortly.
in the OR things seem to be moving slowly and the patient is still getting IV fluids before their spinal anesthetic. The 22 year old that had agreed to a hysterectomy the other day after what appeared like a cancer in her uterus- has now refused because she wants to have more children. So as they get ready the old guy with a bladder tumor, I go and talk to her. I get my little ultrasound out and re-verify that I think it’s uterine cancer. I see what is in the form of a uterus and appears very irregular. So again I recommend a hysterectomy, for her health, and tell her she I doubt she could have a child with this uterus and that it will kill her with time and we should remove it. She and her husband hear me out and eventually decide to proceed with the hysterectomy.
An old guy with a tumor in his bladder that was seen on ultrasound is prepared and I operate on him. I ultrasound him a few days ago as well and saw what they had seen and so I chose to operate. I make a vertical incision because i may need more exposure to take out the tumor. It’s more anterior which should make it easier to get to than one posterior where the entry and exit is to the bladder. I open his belly and go into the bladder. Looking around inside- it looks very irritated but not anything that seems like a tumor, no stone, no thickening of the wall that is palpable. So after really opening it and really looking around I decide just to close him back up and treat him with antibiotic for cystitis (bladder infection). He was given blood at the beginning of the surgery because the anesthetist was worried about a lower hemoglobin of ?8. I thought we should wait and see if I got into bleeding, but he gave it anyway. I didn’t force the issue. At the end of surgery he started to ooze from it seemed everywhere. I thought of a reaction to the blood he received, causing his blood not to coagulate, so I texted the group of doctors here, and surprisingly it went through. (we’ve had very spotty cell service since being here this time). they said we had dexamethosone as the steroid and cimetadine as an antihistamine. So we gave him both. I check on him later in the evening and he appeared to be doing well.
The young woman with a uterine cancer I take next to the operating room. Her uterus is up to her umbilicus, that’s about the size of a 20 week pregnancy. She gets the spinal then is prepped and I open her abdomen. Upon entering the abdomen, I find a large mass. Then I see some dark blood in the abdomen. That’s not usual for a cancer. Omentum and small bowel are stuck to the mass. Slowly I free up the connections. I then realize there is a small uterus stuck to the front of it. So this is not the uterus, it must be a ectopic pregnancy. this make me very happy! An ectopic pregnancy (pregnancy outside the uterus) is only happy in this one instance, at least i can’t think of another time. Now I will be able to leave her other tube and ovary and her uterus and she will have a chance of getting pregnant again. Having children is the value of women here, so real important to them. So I take out the bleeding ectopic and then the oozing won’t seem to stop. I packed the pelvis and waited 5, then 10 minutes. Still oozing, so I ask if we happen to have surgicel, which looks like a gauze that stops bleeding. We do have ONE! (I will need to remember to try and ask and see if I can get any from my hospital at home if we can get any surgicel for here). I pack it into the pelvis and pack again, then when I check again it appears much better. So i recheck the other places I stripped off, wash out the belly one more time and close.
In between surgeries I go out and see some consults in the pre-op/post-op area. A guy is there with a tick in his ear. I say how do you know its a tick. He only answers that it is. So I go back into the OR and ask if we have an otoscope. I look in his ear and see half a tick and legs off that side, and it’s walking. I ask him if it hurts, and he says it’s not bad. I ask for some long sinus forceps. Im able to reach these in and touch it. This is a very sensitive area. I tell him not to move and he doesn’t. I can tell Im really hurting him but don’t know how to make it better but to get done. I try to grab a leg unsuccessfully. Finally Im able to pin it against the tympanic membrane and grab it and pull out the tiniest tick Ive seen. He was incredibly tolerant of my getting it. These people are amazing for their pain tolerance. We have NO narcotics here. So no matter what surgery I do- you get ibuprofen and tylenol, try that on your next surgery!
The last one I start at about 5 PM and it’s an ostomy reversal, so I know it will take a couple or more hours. Their belly is prepped, and I incise around the two lumened ostomy. I free up the tissues down to and through the fascia. As I pull it up to start to make the connection of the two ends, the appendix comes up too. Well I guess I’ll take that too. Then they won’t have appendicitis in the future. i make an anastomosis with multiple stitches, about ?50. Then I take off the appendix. I finish a bit late for the worship that is happening at one of the other missionaries houses. But I go check on a couple patients and go over there anyway. They hadn’t really started yet, so I get to attend all of it after all.
At home I have rice and beans that were prepared earlier that day and then shower and go to bed wet- hoping that I will be asleep before I evaporate. I do, and don’t get any calls and get a good nights sleep- thank you God!
Shanksteps 2022 #3
I lay awake last night. Is it still jet lag, or is it that I’m thinking about the 10 year old girl with the mouth mass, or am I still amped up after the difficult ostomy reversal I did till 9 last night with the hand sewn anastomosis? I don’t know but i was tired and couldn’t sleep. Sometime about 1AM I drifted off and didn’t want to wake when I when my alarm went off in the AM.
My first patient to operate on is the 10 year old with the mouth mass. It took a while for Phillip to put her to sleep and then when he intubated her, he got the tube in pretty quickly- that was great. Then she was prepped and drapped and I started. Just prepping it caused it to bleed. If her mouth had been open all the way it would have filled the opening, but it was a little off to the side. The mass was dark pink and her tongue light pink. It seems to be coming from the area of her teeth. So I attempted to put a suture around the base of it and amputate it so that I could see what to do next. The tie didn’t help much as it got stuck on her teeth and not really tight like I wanted. So I just held pressure on either side of the gums and cut it off. I cut away all the tumor down to the mandibular bone pulling the two involved teeth. Then I used a rongour to nibble away at the bone to get all of it off I could find. Then cautery and packing to get the bleeding to stop. There was a large lymph node under her mandible on the same side. I’m sure that was involved too. So I cut through the skin, fat, platysma, and then shelled out the node and stopped the oozing afterwards. After closing this one, the tooth area was relatively dry so I left the packing in place. She was extubated and seemed to be awake and doing well when they wheeled her back to her room.
Another one was the 14 year old girl who I had seen with the breast cancer and B cell lymphoma that I talked about in the last shank steps (of faith). Every time I see this girl she is only wearing a skirt and no top- which is usual here. However the unusual part is she always has one or two hands up cradling the breast and when I ask she says it hurts a lot. So she’s on the operating table and going to sleep. Philleep can’t seem to intubate her and as I look over his shoulder he is traumatizing the area and it’s bleeding a little. I ask if he wants me to try and he does. So, thank God, I was able to get the tube in an we started. Her breast was huge on the one side compared to the other. I slowly excised the whole breast taking the surface of the pectoral muscle with it and in some areas that were hard with tumor, went deep in to the muscle. I feel some enlarged lymph nodes in her axilla, so I take them out as well. One just falls apart into goo as I try to gently grab it. That one definitely had the cancer. Now I have a very large open chest wall where the breast used to be. So i had planned on doing a skin graft. they have a large blade with a guard on it and I try to use it on her leg for the graft and make a mess of a few inches of her upper leg. Then Daveed volunteers that they have a dermatome (cuts off half the layer of skin like the other was suppose to. This allows the skinned area to grow back and helps new skin to start on the recipient area.) This dermatome is put briefly into the autoclave to warm but not to sterilize like other instruments, as it would ruin it. I’m pretty sure warming didn’t help but that is what he does. There are blades with it and I pick one that both of us think is new. He says old (reused) and new are mixed together. I pick one I think is new and use it. The dermatome works great but the blade only half works, meaning it cuts on one side only. So I make a number of small strips of skin to use. Then there is suppose to be a machine that cuts small slits in to the graft to make a small piece of skin cover a larger area when it is stretched out. That isn’t available here so I just use a scalpel and make slits all over. it works pretty well and then the FP resident with me, Ted, does some and takes time and his looks much better. We then put all these pieces over where the breast used to be and with a lot of sutures, and time, they are sutured in place.
There is an old guy with a penile stricture that wants a repair. It’s been a few years since I did one of these so I look up the post operative care and find that they need repeat urethral dilations every few weeks for life. He lives a few hours away and though he says he will do it, I decide that it’s not best for him and that he should keep his suprapubic catheter. He accepts this and I tell him there will be a Kenyan surgeon here in about a month if he wanted to talk to someone else about it and get another opinion. He says he’ll come back in a month to find out.
As I’m about ready to leave the OR one of the other doctors says there’s a guy who she thinks needs a chest tube. We look at him together and do a bedside ultrasound with my pocket ultrasound. Its not as good as a larger model, but it’s portable! I can see that there is fluid about half way up the lung. This ?20 year old guy was stabbed by a cow horn about a month ago and has gotten gradually a bit of pain and a little shortness of breath when he walks. We put a needle into his chest and get out pus. So I take him back to the operating room and walk Ted through the technique of putting in a chest tube. After the tube is put in, there is no pleuravac, so we connect it to a urine bag which immediately fills to 1500ml of pus then some blood at the end. WOW, that’s a lot of pus in the chest. No wonder he was a bit short of breath!
Each day is a variety that is interesting. Many advanced stages of diseases are seen here! God help us help these people, give us wisdom to know what to do and how to do it! Guide our minds and hands!
Shanksteps #2
Am I too jaded, calloused from being overseas and seeing too much death and terrible diseases? I think I want to feel what Jesus feels when He looks at our pitiful state here on earth. I want to have His compassion and love for those around me. And partially I do, but I also have gotten more calloused, maybe a protective barrier to patients plights in Africa.
Yesterday I evaluate a girl who is 14. she is a thin girl with a gigantic breast mass that is painful. She has a history of some kind of cancer that was diagnosed during an abdominal surgery. A piece was taken to Poland and pathology from them just came back with B-cell lymphoma. she came in this time because she heard on the radio that I was here. She wants the painful breast removed. As i see her, I note a huge breast on one side and a tiny one on the other. I feel her abdomen and she has masses in there too. I’m sad as I evaluate her. I don’t know if a mastectomy will help or hurt her. No chemotherapy is available here. It may help her pain for a while but will it heal? It does seem a little mobile from the chest wall, and that may be a good finding. Or it could be attached to the muscle and the muscle moving. I tell them I’m willing to do the surgery and give them the most likely postoperative events. Today she is laying in her bed just holding her hurting breast, stone faced without a sound. When I ask she says it hurts. The dad is in Ndjamena and they are waiting for him to send the $80.
Another one came in because they heard I was here, and she has a mouth tumor that has been present for 2 months. She appears about 10 and the tumor is on her lower teeth and is about the size of a medium sized lemon. I run my finger around it and it starts to bleed. I give her a gauze and she spits blood for a while, while they hold pressure. She also has a few enlarged submandibular lymph nodes. So likely spread to those as well. I don’t know what this would be but would be awful to have that in the front of your mouth bleeding and making it difficult to eat. I plan on taking this out tomorrow, and Im worried about blood loss, and how soon it may come back. God help me do what’s best for her!
Todays surgeries were a prostatectomy, an abdominal hysterectomy on a old lady with uterine prolapse, an involcrum window and trying to drain pus of chronic osteomyelitis going on 10 years, and exploration of a guy who presented with peritonitis. He had 3 days of pain and yesterday intense pain everywhere. The ultrasonographer thought of appendicitis. I’m thinking , it could be: appendicitis, typhoid perforation, gastric perforation, perforation colon…. So which incision to make. We need a CT abdomen. Instead i’ll do the Chadian Digital CT. Digital (finger) Cut and Touch! So we fit him in between the other surgeries. In the OR Phillip puts in a spinal and David puts in a urine catheter and preps the abdomen with butadiene. I wash my hands with the bar of soap that is available. No other hand scrub is available now. I make a midline incision in the center of the abdomen as I don’t know wether I will need to go higher or lower as i don’t know what’s really happening inside. I get a little bit of pus when Im in the abdomen. I feel around and feel an enlarged appendix so I extend down the abdomen. I can see that the side wall of the appendix is blown out. So after freeing it up, I tie it twice and take it off. then I make a purse string around it with suture and duck the stump in. Then we (Ted an family practice resident and I) irrigate the abdomen a lot with saline. Once the fluid we are sucking out of the abdomen is clear we close.
I go home an find a number of people in our home. There are many short term volunteers here at the moment. a couple are physical therapist, a PT, a couple family medicine residents, and then the missionaries that are here. We have hired a guy to cook a meal in the evenings for us so that when Audrey and I get home from the hospital there is food to eat. So we asked this guy to make more for about 10 people. So we are eating in the evenings with a number of people. It makes for better community and a meal is sure nice when we are done with work.
Shanksteps 2022 #1
Shanksteps 2022 #1
Here we are again on another trip to volunteer in Africa. We are going to the same hospital in Chad we’ve been to a number of times. Currently there is no general surgeon there, and hasn’t been for a few months. If you know of any general surgeons who want to go and live in Chad, one or two are very needed. (They could contact me for starters).
We leave home Tuesday and stay in Eugene to catch the 5AM flight. Then to Seattle for a long 12 layover. Then a 9 hour flight to Istanbul. We are there a couple hours then on to Ndjamena, Chad on a 8 hour flight with a stop in Niger along the way. Each flight is progressively more “african” in nature. By the last flight there is no calling of sections to load the plane. Everyone just forms into a mass of people jockeying for a position at the area where you go past the attendants taking our boarding passes, and we know this so we stand near the front and end up in the first quarter of people loading. this is advantageous because then there is still luggage space above to put our carry on luggage rather than it taking up floor space near our feet.
We land in Ndjamena on Friday at 2AM and go through immigration and customs after collecting our baggage- which all made it! then on to find our driver L. He has picked us up many years of going there and is always punctual and has also arranged for us to be able to change money at this hour of 2AM. L is definitely more expensive ($40) than he used to be, but still worth it to have someone we know waiting for us. We ask him what bus we should catch from Ndjamena to Kelo- and he recommends the 5AM bus. We like this bus because its a large one with a defined seat and has airconditioning that helps some. so we could go to the mission we were to stay at for an hour or just go to the bus station. So we decide to head to the bus. the streets are empty but at the bus station there is plenty of people getting ready to travel and others trying to sell their wares to them. L gets me a guy to sell me sim card for my phone and credit for it. The sim doesn’t seem to work and then it does after all. L gets us our tickets and we load the bus with our luggage stored beneath. We choose a seat nearer the front as this is usually less bumpy than near the back. We start out before completely full so we stop at various spots along the way to pick up other people. At one area we stop at a military checkpoint and all the men have to get out and get patted down and show what’s in our bags. This goes off relatively well and we all board again. A bit later there is a little commotion as water starts running down below the seats on the other side and down the isle. Someone thinks its water, and then another says someone peed in the back. I don’t smell anything like pee so Im grateful and also grateful it didn’t get on the bag i have at my feet. We arrive at Bongor the bus stop for changing some passangers. we wait here for about 15 minutes and mill about the small area. there are many vendors there selling things like- potatoes, taro, other roots I don’t know, roasted beef, lamb, goat. My favorite to see is the huge pile of fried grasshoppers. I don’t have the courage to try them, though Audrey has and didn’t get any. We all load back on the bus when they start honking and we head on to Kelo.
A little after noon we arrive in Kelo. We anticipate someone from the hospital picking us up in a vehicle but they are not there. We get out our luggage and pay a guy with a cart to move everything off to one side where our thing can sit without worrying too much about them. We sit down on a bench that is near by to wait. After about 30 min we get a hold of the guy who was to get us and his car got full of water crossing a large water area on the road that was deeper than expected, and died and was being towed back to Bere by a tractor. He then tried to arrange another vehicle. After about an hour we hear that it would be best to go by motorcycle taxi the last ?2 hours. He wants to arrange the motor taxi for guys from Bere as they don’t charge double like the other moto taxi guys may require. We wait another hour and a half. People are coming, but they don’t show up.
During this trip I realized my Keen sandals soles are falling off. I only brought them and OR shoes. So i ask around and find a guy sitting under an umbrella who is fixing shoes. He says he can fix them for 2000CFA ($4). So I sit near him on a bench and another guy starts talking to me. Id guess he’s about 20 and seems drunk. As I sit there I realize the guy who fixs shoes is next to a woman who is selling vodka, wine, and other spirits in little plastic bags. So this guy is drunk. He asks lots of questions and talks about how hard english is to learn, and why I won’t drink with him, or buy him another bag of drink. The guy fixing my shoes warns me to watch my phone as the kid next to me may steel it (thank you). He glues the sole on with some contact cement used on a bicycle repair kit after cleaning off all surfaces. It seems like a weak repair. So he then sews across the front and back of the sole to secure it better. This seems to work well. And later on I am very grateful to have them fixed as you will read.
Then about 4pm Im starting to worry, if we get started too late it will be dark and more difficult to travel., and darkness also increases the price and chance of a fall. I know the road is muddy and apparently had large amounts of water in some places. He calls a guy at the bus station and this guy helps us get some motorcycles from another town beyond Bere. But they seem only partially interested and also charge a lot. WE want three motorcycles and there are only two of them. Then finally two from Bere show up and say they are here to take us to Bere and load our gear on their motorcycles. They strap our four plastic luggage boxes on one motorcycle with the driver sitting on the gas tank, and put Audrey and I on the other. So both are very loaded.
Then the fun begins. We travel through Kelo then head off the main road. Ive not been this way before and know it must be to avoid water on the main road as it gets huge deep mud puddles. We wind through many small villages with stretches of farm land in between. Here a left there a right. Nothing distinguishes it from any other trail to follow. Most of it just wide enough for the motorcycle, so only foot paths we are following. We go through patches of puddles and our feet are wet. The motorcycle is making a strong clicking sound with each rotation of its tire and I wonder if we are going to break down on the way- but our driver Sebastian says its not a problem and will get us there fine. about an hour into the trip its getting dark and we are going through some deeper water and getting stuck in the mud. I have to get off in the mud to push. I have mud up to mid pant leg now. We nearly fall over a number of times in the mud and in other sections in deep sand. Then when its fully dark we hit the big sections of water. We go about 100 feet into the water and we hit a rock or log that stops us abruptly. i have to get off and push and water is up to my knee. He continues on with Audrey and I walk for a way till he stops and lets me get back on. Then there is a section that he says we have to walk through and they will push the motorcycles and meet us on the far side. We meet up with the missionary Charles who had planned on getting us in his car that died with water in its engine. He had come to help us in this section. So we walk with him. Carry on back pack on our back and walking through the water. We walk through a section of water that was about 100m and about thigh deep. Charles says the day before this was passable with a car and that it had risen to this. We walk on and get to another large area of water. There are no motor or people. just a tractor pulling a large trailer loaded with grain, through the water. Audrey, Charles and I walk for probably a mile through water that varies from ankle deep to Audreys waist. I am very thankful my shoes were fixed and are working well. After about 45-60 minutes of walking in water we arrive at dry ground again. the same motorcycle have gone some other way and meet us walking on the dry road again. It’s only a few miles left to get to Bere. We are glad to be there and meet some other missionaries. We are taken to the house we will stay in for the month and shower and sleeeeep! We left home Tuesday evening and arrived in Bere Friday night. Thank you God for helping us get here safely and giving us rest.
