Miscellaneous experiences...

Friends,

Random experiences:

1. The baby has one normal leg. He is two days old brought in by his arab nomad parents. The second leg is cut off halfway up the shin with something like a floppy foot with toes with no bones. Oh, he also doesn't have an anus which is why he was brought in. We take him to the OR, an IV started by Samedi sticking out from his good foot. Sarah administers the Ketamine anesthetic and the baby sleeps. I know I will have to do one of two things--one easy and the other hard. The most difficult will be to open his stomach, find his colon, cut a hole in it, attach it to his abdominal wall and let him poop out of there until his is old enough to try and create an anus for him. The easiest is what I try first. I heard about this a few weeks ago when I was with my surgeon friend, Greg Shank, at Koza Hospital in northern Cameroon. I grab a needle and a syringe and I poke it into his butt skin where his anus should be. I aspirate and fortunately, about 2cm in I hit meconium (baby's first poop). I leave the needle in to guide me and slice through his skin. I grab a clamp and dissect down until I pop into his rectum where black meconium and brown, stinky, regular poop pours out. I leave a piece of rubber catheter in and he wakes up to a new experience...defecation!

2. Angeline is well known at the hospital. She came in last year with osteomyelitis and ended up having to have the middle part of her left tibia taken out and her wound dressed with diluted Chlorox in order to get rid of the infection. Of course, that took months. We saw her grow up (and fatten up) before our eyes. She was always wary of us, though, and would often cry just seeing Sarah or I. Unfortunately, her bone never reformed and she was left with a floppy left lower leg that was left in a cast. When my orthopedic surgeon friend, Troy Dickson, was here we tried to contact her to come and have some sort of transplant procedure. We couldn't find her, however, so Troy told me what to do and left. Now she is before me.

Her leg is still floppy but the joints are also still moving normally and the fibula is intact. She is fat and healthy and yes looks at me with suspicion. I decide that her only chance of walking again is to do what Troy suggested and I've read about but never seen: a fibula transplant.

Sarah puts Angeline to sleep. Both legs have been scrubbed and now prepped with Betadine. My heart is in my throat. I know I'm in way over my head. I scrub and drape. I grab the scalpel and cut into the lateral side of her good leg and down to her fibula. I'd measured the defect on xray to be 7cm. I separated the middle part of the fibula from its attachments to the tibia and then with a tiny, Swiss Army Knike-like saw I cut out her tiny, chicken bone-like fibula. I put it in a dish of saline, close the defect in layers, staple her skin shut and cover it with a sterile dressing.

I go to the other side of the table and cut into her old scar and down to the two stubs of bone. I clean them up by munching on the ends of them with an instrument called a Rongeur, pull out some of the spongy bone from the knee end of the tibia, pull out the fibula and find it too short.

I split it in half and jam it into the two ends of tibia and surround the three fracture sites with pieces of spongy tibia. I close the fascia over the graft and staple the skin shut. I put on a dressing and a fiberglass cast with her leg in as close to normal position as I can guess without access to intraoperative x-ray.

I take off my gloves and gown, Angeline wakes up and my heart finally descends to its normal place in my chest. It was thanks to last year's SM, Jennie Norton, that her surgery is paid for but it will be only through supernatural intervention that it will actually heal and allow her to walk.

3. The baby has what sounds like asthma on listening with the stethescope, but as Dr. Ken points out, the baby's only one month old so it's probably bronchiolitis. In either case the only thing to do is treat with nebulized albuterol and oxygen. We have albuterol but no oxygen...wait, didn't we get one in the container? We search in our storehouse and find the oxygen extractor which we've never tried. Micky, the visiting ER nurse, is administering the neb. The lights are on because the sun has just gone down and our 2 hours of programmed electricity is just beginning so we find a transformer and plug in the O2 extractor. It works and the baby seems to be doing well on it as we watch its oxygen saturation rise (on the O2 sat machine given us 3 years ago by Erling Oksenholt the night I visited him in Oregon on the spur of the moment before going to Chad to visit for the second time on a trip that lasted only 2 days and didn't include a visit to B�r�). It started at 85% and is now up to 93-95%.

I'm called to see a 12-year-old boy with a swollen stomach and no stool or gas for a day. He needs a laparotomy. We go to the OR. His thin body is in contrast to his firm, bloated belly. Sarah finds an IV fast and gives him his Ketamine. I scrub and drape and quickly cut him open from sternum to pelvis around his belly button as his intestines pop out and spill across the abdomen. I don't see anything obvious at first but there are red patches all over the intestines with little darker areas. Something is weird. I think maybe Typhoid fever at first at the point of perforating.

Then, as I run the intestines I discover that part of it has twisted on itself. I untwist it and quickly the dark areas become normal covered except for those patches that look almost dead. I know I can't leave them.

I put on bowel clamps, clamp and cut through the mesentery on the bad looking section and once all the blood vessels are tied off I cut the dead intestine out and then suture the two cut ends back together in two layers of running sutures. I release the clamps, there is no leakage. I leave in a drain and close the fascia with sutures and the skin with staples.

I go back to check on the one month old. I see a dead bat in the trash can by the door. The nurses look up mischievously. The baby is stable but still wheezing. Apparently, a bat entered the room, hit the fan, and landed directly on the baby's face, dead as a doornail! The baby lives through the night and the next day and the next and goes home the third day.

The boy recovers normally and by the 5th day post op is eating, walking, pooping, and passing gas. He goes home, comes back 3 days later to have his staples out and looks fine.

4. The baby is one month old and has a circular wound around the back of its head. Over the course of the next few days of antibiotics and dressing changes the whole part of his scalp that is inside the circle comes off leaving his skull exposed in the center. We continue antibiotics, he nurses normally and to all other appearances is totally healthy. We do dressings with diluted Chlorox and his wound starts to turn beefy red. He is still hospitalized.

5. A 1 1/2-year-old comes in. She'd been seen by me in April 2004 when she was a few months old and had an abscess on her left arm incised. Apparently she did well and I never saw her again until today. Now she has a bone sticking out of her forearm. It is jagged and rotten. Her hand and arm move and function normally. A centimeter from the bone is another wound draining pus. The radius and ulna appear intact but there's this third bone sticking out. It seems her bone got infected last year but since she's so young and otherwise healthy a new bone formed pushing the infected part out until it came out the skin. Sarah gives her an IM shot of Ketamine and I grab the bone with a clamp and pull out a 3 cm long piece! That's it. She comes back two days later and the two wounds are all but closed and her hand and arm continue to function normally...

6. Today, a woman comes in with a change in bowel habits and a big hard mass right under her sternum that is pulsating. I can only think of very bad things that I couldn't do anything about like cancers and aneurysms and such. I say she should go to N'Djam�na. The husband says he doesn't have the money. I say maybe and x-ray would help, but our machine is down one week after our friends from Florida got it up and running. Finally, I say we can try and ultrasound but I don't think I'll be able to see much.

I pull out the portable, laptop-sized ultrasound just donated by GE and brought by the Florida team. It runs on batteries, so I can use it without the generator. I turn it on, put in her name and place the probe over the mass. To my pleasant surprise, it appears that it is in her liver and that it is either a cyst or an abscess. After looking in some books I am convinced that it is an amebic liver abscess so I hospitalize her and put her on Metronidazole. I will be able to check on her in a few days again and see if it's going down in size. If not I can use the ultrasound to help me put a needle in it! Technology comes to B�r�! Above all, I thank God that He made me think to use the ultrasound. Sometimes, I am so used to hopeless situations that it's hard to get used to having more options around now.

James