Monday, May 29, 2006

The things we see...

Hello,

I'm finally getting around to operating on the older lady with a smooth pelvic mass. I open the belly to find a round, smooth, grapefruit-sized mass sticking out with fingers of omentum and inflammation holding it to the pelvis like a mystic gazing searchingly into her crystal ball.

I slowly peel away the fingers until I find it firmly attached to the colon below. It is obviously filled with fluid; probably an abscess. I take a syringe and needle and aspirate. Yep, pus. Well, this should be easy. I get the suction ready and open up a small hole into the cavity and start slurping the thick, yellow gunk up. Then I start to feel some thicker stuff at the bottom. I pull the suction catheter out and see hair! The abscess is almost emptied now so I enlarge the incision to look inside. I see a golf ball-sized hair ball!

I pull it out and verify that there is no connection to the colon below. I cut off the walls of the abscess, just leaving that part that is attached to the colon and prepare to close.

But, then I remember I should run the small bowel and check the rest of the intra-abdominal contents. As I pull the small bowel out, I notice the proximal part is really distended while the distal part is tiny and shrunken. A bowel obstruction. I follow it along and find that near where the small bowel attaches to the colon it dives into the inflammatory mass in the pelvis where, suddenly, it becomes small. I try to dissect it out but it's a stuck mass. Then stool starts to come out of the sigmoid colon.

So much for nice and easy.

I suck out as much of the stool as I can and it seems to seal itself when retraction is released. I clamp and cut the small intestine on both sides where it enters the inflammation and leave that piece there. I close the part attached to the colon and bring the other side out through the skin on the left. We rinse out her abdomen, leave in two drains, and close up the laparotomy incision. I then suture the small intestine (that I've pulled through the skin to the fascia) and then evert the edges to sew them to the skin creating an ileostomy where the stool can come out so that the friable inflammatory sigmoid can hopefully heal.

Afterwards, Samedi asked me if he and Josue should bring in the next surgical patient. Josue piped up, "After all it's just a SIMPLE hernia."

I laughed. I've learned to never say something will be simple here. The things we see...

James

Spring up, oh blood...

Tout le monde,

As I walk into the wards I hope I won't throw up. I've been down with Typhoid Fever and just got up because I can't help worrying about this one patient and if I've made the right diagnosis. She'd come in with pelvic pain, no period for 2 1/2 months, and no bleeding. Since our ultrasound is down I just had my exam and intuition to go on. I decided it was an infection and started her on antibiotics while ordering tests for today.

But this morning, I was feeling nauseated and had diarrhea so I didn't to into work. However, I couldn't get out of my head I should go check on her.

I enter the female ward and turn to my right where I see the young woman sitting comfortably on the edge of her bed, smiling. I breathe a sigh of relief and walk up to her.

"Lapia"

"Lapia ei"

I reach for her carnet where I see a lab slip sticking out with red writing on it indicating results are in. I peruse quickly the tests... all negative for infection, but the pregnancy test is positive and her hemoglobin is 4.66 g/dL. My heart sinks. I ask her to like down and I palpate her abdomen. I think it's more swollen than yesterday and is tender in both lower quadrants but is still soft. I think about doing a culdocentesis to confirm that it's an ectopic pregnancy but deep down I won't feel at ease even if it's negative. She needs an operation.

She is soon prepared and lying on her side for the spinal anesthesia on the OR table. The Ampicilline has been given. The blood transfusion is running in. She has two good IVs. We can start. I easily find the spinal fluid and inject the lidocaine. Samedi, Josue, and I flip her over on her back and tilt her head down slightly. Josue attaches the pulse oximeter and automatic blood pressure cuff while Samedi and I prep the patient, then scrub, gown, and glove, and drape the patient. I grab the scalpel, Samedi says a prayer and I'm about to start when...

I turn my head and look at the pulse oximeter. It reads 85% oxygen saturation (normal is >92%). Her pulse is 65/min. I look across the drape at the patient and my eyes are drawn to the skin on her shoulders. She is covered with hives. Her eyes look blank and I'm not sure she's breathing.

I glance at the blood pressure and it's 84/36. I start to bark orders at Josue to start bagging her. He panics. He can't find the bag-valve-mask. Then he has no idea how to use it. I stand there helplessly scrubbed and sterile holding my impotent scalpel for a few frustrating moments before I give up, break scrub and grab the BVM from Josue, and start breathing for the patient as the pulse oximeter starts to beep slower and slower and the alarm sounds as the red numbers keep going down and down just to the 40s before my bagging starts to bring it back up.

Meanwhile, I'm ordering Josue to give Dexamethazone and Adrenaline. The IV fluids and blood are running full speed. I think we have some IV Benadryl somewhere. Fortunately, Anatole pokes his head in just then and I yell for him to go get Sarah. Anatole is by far the most nervous of nurses (since he's really a lab tech functioning as one) and so takes off like a scared rabbit.

The patient's pulse starts to pick up. Her O2 sat is still in the 80s but holding. Sarah comes in and then goes off in search of IV Benadryl. The blood is almost all in. She is fighting the bagging so I have Josue give her Diazepam and Ketamine to put her under. Sarah comes back. She can't find the Benadryl. I give the bagging over to her and go to look myself. I can't find it, either. I come back. The blood pressure has come up some as has the pulse (now 115/min) thanks to the Adrenaline. The O2 sat keeps going up and down. Samedi says he thinks the IV Benadryl might be in that little blue pouch down on the shelf behind the Anesthesia machine. Sure enough, I find it just in time to hear the patient start to retch. Foul, yellow-green, thick vomitus is coming out her nose and from in and around the oral airway.

I demand suction while Josue gives the Benadryl and her O2 sat starts to fall. She needs to be intubated. I grab the kit and a size 8 ET tube. I check the Laryngoscope and it works. I put a stylet down the ET tube, tilt her head back, insert the Laryngoscope and pull up. I suction out the airway and have a clear view of the vocal cords opening and closing. I position the ET tube and than quickly jam it through the cords as they open.

It slides in. I forgot to attach a syringe so Sarah quickly grabs one and blows up the cuff. I attach the bagging apparatus as her O2 sat has hit zero but her pulse is still strong at 136/min. Her O2 sat slowly climbs up to the high 80s but doesn't seem to want to get normal.

Sarah takes over bagging. Feeling like we need to get this surgery done as quickly as possible, I don't take the time to rescrub but just put on new sterile gloves. I grab the scalpel again and swiftly slice through skin, fat, fascia, and muscle to the peritoneum where I see the ominous dark look of intra-abdominal blood. I make a small nick in the peritoneum and dark purple blood shoots out. As I make the incision bigger Sarah gives her a deep breath and the blood literally wells out of her belly in a tidal wave crashing to the floor. I grab suction but it's like trying to drink from a fire hydrant.

I attach the autotransfuser and slowly suck up as much blood as I can to be regiven to the patient while the rest continues to surge every few seconds with each breath given and splash onto the floor which soon looks like a killing spree has just occurred as pools collect and seep into all corners of the room. Samedi takes over the suction as I start to insert lap pad after lap pad into the never ending reservoir of blood that is her abdomen.

The only bright spot is that with the release of abdominal tension, her breathing becomes easier and her O2 sat shoots up to 96%.

After taking off 1200cc into the autotransfuser, another 1-2 liters on the floor and another 1/2-1 L soaked up in a mound of lap sponges and gauze piled on her legs, we can start to make out the anatomy of the abdomen.

After handing off the autotransfuser to Jacob (who has just entered to see if we need help), I see the tell-tale smooth, purple mottled mass of placenta on the right side of her uterus where the ectopic pregnancy is. I reach in my hand to dissect it off the posterior peritoneum and a four-month-old, perfectly formed fetus shoots up and out. I grab him (as will be verified later with a close look between his legs) and toss him onto the mayo stand. The placenta part pulls up and out easily and I place one clamp across the tube where it is bleeding and the bleeding stops.

We suck and mop up the rest of the blood hiding out in the various pockets of the abdominal cavity, I tie off and remove the right tube and ovary, and we close her up.

Her hives have disappeared, her blood pressure is normal and, with bagging, her oxygen saturation remains normal. The auto transfused blood won't flow through the right IV so it's switched to the left where it runs for 5-10 minutes and then stops there too. Both Sarah and Josue are unable to find another IV so I grab a central line kit, betadine her groin, palpate her femoral artery, stick a large needle into her femoral vein, slide in a guide wire, pull out the needle, nick the skin with a scalpel, slide a dilator over the guide wire and slip the central line in before finally pulling out the guide wire and attaching the blood line.

After 800cc of the 1200cc of her own blood has run back into her there are two many small clots clogging up the filters and we have to give up on the blood. Sarah, Josue, and I have now been artificially breathing for her for almost over four hours. While Samedi, Jacob, and Josue clean up the substantial mess in the OR, the girl starts to wake up and I extubate her. We then bag her for a while more, and then wean her off oxygen. When she's breathing on her own, we wheel her out to the ward.

When I go home, I feel tired but energized. I drink some cold water, grab a bite to eat, and sit down with my guitar. The joy flows out of me as my heart and soul are poured out into the music and songs. I know I have just experienced a miracle. I know God has just used me and the chills run up my spine as the tears run down my face.

The next day, the girl is asking for something to eat. Three days later, she goes home.

James

Monday, May 22, 2006

How Not to Fall Off a Horse . . .

Howdy,

Koumakoi just cannot get on the horse. When it was Sarah and me, it was easy. I put my foot in the stirrup and swung up easily. Then, I put my weight on the opposite stirrup and she swung up behind me. Koumakoi can't seem to understand that. He comes straight at it, puts the foot in the stirrup and than grabs for me, almost pulling me off the horse. People run up to the fence from the TB ward offering all kinds of advice in Nangjere. Being an exceptional athlete, Koumakoi finally somehow manages to get up behind me without ripping me from the saddle...and we're off.

It's Saturday after church. The local churches have organized a yearly get together called L'Assemblée Regionale. Everyone has walked off to the river for a baptism but Koumakoi wants to talk to me about something pressing.

We start in a walk. I relish the distraction of Koumakoi's story as this is my first major solo horse ride and I'd rather not think about it so the horse won't sense my fear. Soon, the hospital fades into the background of the Tchadian bush as we take a small sandy path in the midst of the freshly plowed rice fields and the thin covering of green weeds. Huge, billowy cumulous clouds break up the monotony of the deep blue African sky. It is a pleasant 80 or 90 degrees and a cool breeze whips my hair back as I bounce up and down in a steady trot.

Koumakoi is relating the sad story of his best friend who promised not to get involved with his sister but just got her pregnant. He says he's already forgiven him but doesn't know what to do because now he can't trust him and doesn't know what is best for his sister as his friend wants to marry her but both parents are against it. I just let him talk as I try to concentrate on balancing on the horse and not getting bounced around too much.

All the paths look the same, but Koumakoi knows this bush like the back of his hand and continually tells me to turn here or cut across this field or go around that bush or whatever.

The smoke of fires announce the presence of the village of Kasserei, close to the river where we often swim and where today's baptisms will be held.

Soon, the crevasses and small mounds of hardened clay with the tops of a tree line just visible above broadcasts our arrival at the river. Koumakoi bounces off and I continue down the steep bank feeling like all I need is a Stetson and six-shooters to be right in a John Wayne movie or at least one of my childhood dreams. I tie the horse to a bush around a patch of grass, strip off my pants (revealing swimming trunks underneath) and join Pastor Job and Pastor Atchouma in the water.

I baptize five young Nangere Tchadians but feel uncomfortable with the
pressure being put on some on the bank who remain un-baptized, using mass appeal. Last year we did the same thing and already 5 of the young people have been sleeping around with each other and getting themselves pregnant and almost none of them come to church at all.

After everyone leaves I take a short relaxing swim, pull my pants on and quickly mount the horse and ride him up the bank to the waiting Koumakoi. I was kind of hoping Koumakoi would return with the rest so I could have a few moments to myself for a leisurely ride back on the horse. But since he's still hanging around I let him try to get up...and that's where the trouble starts.

Using the same technique as before but with better success this time, he
manages to pull me straight off sideways to the ground. I whip my foot out of the stirrup and manage to keep from hurting myself but the saddle is now underneath the horse. I heave and tug until it is back right side up and then remount telling Koumakoi he better just walk.

After about 15 minutes I start to feel bad so I dismount and let Koumakoi ride. As the cell phone tower of Béré comes into view I want to ride again...second mistake.

I easily mount the horse and am maybe feeling a little too overconfident. I have the single rein in my right hand and the rest of the "rein" (a mere rope) in my left. As Sarah taught me, I make a puckering "pop" with my mouth and at the same time dig my sandaled heels into the horse's flank. On the way out, that was sufficient to start a trot. Now, just as in the movie "A Christmas Story" where the normally obligatory "I triple dare you" is unceremoniously skipped, the horse jumps straight into a full gallop.

Now, for those of you accustomed to horses, that would be no problem. For me, however, I couldn't get into the rhythm. No matter how I tried I was opposite of the horse, meaning my butt was getting pounded with each bounce and I was hanging on for dear life. Amazingly, I still hadn't lost my confidence and was actually rather enjoying the speed of racing across the African plain with the wind in my face and the mud huts of Béré rapidly approaching. In fact, I was cocky enough to think that I'd just slow the horse down and restart the gallop, hopefully this time in sync.

As I'm bouncing along, I start to lean back and pull back on the
single rope tied around the horse's muzzle. At the same time, still at full gallop, the horse moves up to go over a small earthen dike in the local rice field. These two movements combined with my lack of experience leads quickly to a sudden sinking realization that I am totally out of control and off balance. I feel myself rapidly falling backwards and to the right as I let go of the rope.

Then things move to slow motion: The horse is moving his front legs up and over, followed by a lifting of his hind parts up and over. The rope is flying out of my hand and off with the horse. My left foot is swinging out and up while my body is leaning back and right. I somehow find the time to think that I shouldn't get caught in the stirrups so I instinctively kick my right leg back, up and out to sling off the stirrup. My right arm reaches out behind me and finds sand at about the same time as my right hip and lower back and then things rapidly speed up as I roll, jump to my feet and watch the horse high-tail it for home. I gather my flip-flops, and not yet feeling any pain take off after the horse.

As I watch the horse trotting merrily away with the saddle hanging off the side and one stirrup dragging the ground under his belly, my only thought is "please let me catch him before he shows up at home with all the people there who'll instantly know what happened." I doggedly walk after the horse who happily runs off every time I get close.

I soon start to feel a burning in my arm and notice that I have road rash all over my right forearm. I can start to tell, too, that once the adrenaline wears off my back and butt is going to be super sore. Koumakoi comes running up and I tell him I’m OK. I finally get a break when the horse follows the trail around a plowed field allowing me to cut across at an angle and get in front of him.

Then, not really looking back I start walking casually towards home. Occasionally, I'll stop, then restart walking until the horse starts to follow my lead...that's what he really wants, is to follow. At last, he gets close enough that I grab the rope, reposition the saddle and mount back up only to discover that the right stirrup is missing.

Koumakoi and I start to retrace our steps until we see two kids walking up holding the missing stirrup which is soon put back on the saddle.

Needless to say, there was no galloping the rest of the way...but, I can't wait to get back on...the challenge has been set, and I want to meet it...

James

Sunday, May 21, 2006

Lightning

Salut!

It all starts with a clear, still night. Nothing moves for fear of creating even more heat, more sweat, and less sleep. The stars are such as can be appreciated only by one who lives with no electricity in a likewise unlit village on the African plain. The only things daring to break the stillness and silence are the ever-present, malaria carrying Anopheles mosquitoes...they never sleep, nor slumber.

I feel something crawling down the back of my leg. I slap at it only to discover a rivulet of sweat. I drift in and out of a feverish dream. Then, it starts.

A gust, a flutter of the curtains, a rustle of leaves. A flickering on the horizon like a fluorescent light bulb on its last legs. A muffled roar growing louder by the second leading to an explosion of curtains shooting out like billowing robes of an Arab fleeing on his camel. Somewhere in the dark a rooster scurries off with a squawk half caught in his throat.

I turn on my sweat soaked pillow; my body begging to be touched by even a wisp of that cooling breeze. A pitter-patter starts on the tin roof. The sent of a moss-filled rainforest drifts in on winds dropping sharply in temperature. The pitch black night continues to be broken by nature's strobe light.

Suddenly, all silence is drowned in thunderous applause as a million shimmering liquid bullets pound out their cadence overhead and all around.

The stars are gone in a billowy mass of tumbling clouds with now a constant flickering of lightning illuminating the shadows of the naked limbs of the trees performing their yoga at breakneck speed as they are thrashed about in the torrent. An occasional flash blinds the eyes followed by the sharp crack and rumble of a bolt hitting close to home. The inside of the mosquito net becomes a spider's web filled with shadowy forms flitting back and forth across the walls and ceilings of this bomb shelter as the "rockets red glare, the bombs bursting in air" make sleep neither possible nor desired.

The next few days bring a flood of change across the landscape of Bere as people melt away from the hospital and stream to the fields. Horses and cows appear out of nowhere attached to locally fashioned plows. Rows upon rows of freshly turned soil mark out their measured lines in between, around, and almost in the mud huts. Pigs grunt in contentment contributing to the tilling of the soil in their ceaseless search for earthworms. Other porkers lounge lazily in the mud puddles newly formed in the middle of the main road. Soon, the roads will be a thing of the past...

The rainy season has started...

James

Wednesday, May 17, 2006

Twin eclampsie, twin ectopic

Hello all,

The young woman's eyes are swollen almost completely shut. Her face is puffy and deformed. Her pregnant belly bulges out as if it wants to explode. She is unconscious. I turn to the family standing by to learn more. She has been having seizures since the morning. I check her blood pressure. It's 176/132...unbelievably high. The diagnosis is sure: eclampsia. I check the fetus' heartbeat. It's normal. David goes to call Samedi. Hortance has already given Diazepam. She finds the vein while I run to the pharmacy to bring back an old bag of Magnesium.

As Hortance inserts a urinary catheter I watch the Magnesium drip in drop by drop. She's still having occasional seizures. Samedi arrives, we transfer her to a gurney and we wheel her towards the Bloc Operatoire. I fumble with the code on the lock in the dark and finally yank it open. We creak open the doors, flip on the lights and pull the patient into the OR. A quick scrub and drape and the patient is ready, the knife is in my hand.

We pause, Samedi prays and I quickly slash down to fascia, dissect up, and cut, pull apart the muscles and peritoneum to reveal the glistening lower uterine segment. A small incision, a push with a clamp and the amniotic fluid sprays up into the wound. Fingers in to guide the scissors, cut, cut, and a shock of wet, black hair is revealed. Hand reach in, bend the head forward, Samedi pushes on the uterus from the belly side and the baby pops out and starts to gasp for air as its arms and legs jerk upward. Clamp, clamp, and cut between and the baby is in Sarah's hands to be dried, stimulated, and revived. A cry soon pierces the air and I clamp the bleeding edges of the uterus and start suturing in close. There are no complications and the skin is soon sewed shut with a subcuticular suture, a dressing placed, and we unscrub to go back and sleep.

Early the next morning I'm in morning worship and a commotion starts up outside the door. Sarah goes out and soon comes back to whisper in my ear that I should go see this patient. I quietly get up and go to the exam room. An young Arab women wrapped in brightly colored clothes and vail is lying unconscious on the bed having seizures. She is obviously pregnant.

D�j� vu? You bet. Her blood pressure is also elevated at 162/130 but this time the baby's heart beat is absent. She has been like this since yesterday. The same process is repeated until I get my hand in the uterus to bring out the dead baby. Samedi pushes and a limp fetus plops out. I start to clamp, clamp and cut between and he gives a faint gasp! I quickly cut and hand the baby to Sarah who begins to breathe for her with a bag-valve-mask as she checks and finds a faint heartbeat. Samedi and I continue our work on the mother and we soon are rewarded with a small cry followed by a hearty yelp from the now vigorous little girl!

A woman comes to see me that morning after the surgery. She has had abdominal pain for a month now and was seen at our hospital in April for the same pain plus some vaginal bleeding. She was treated, the bleeding and pain stopped and she was sent home. Now she is referred from the Hospital in Lai for an ultrasound. Unfortunately, the ultrasound is temporarily out of order. On exam the only thing remarkable is tenderness in her lower abdomen. I suspect pelvic inflammatory disease and hospitalize her. The next day she is no better and her pregnancy test comes back positive. I decide to operate.

She is prepped and draped and the anesthesia is given. I hold the scalpel again as I pray for God's help during this surgery. I slice open the abdomen from belly button to pelvis and dark blood surges out of the wound.

Samedi quickly starts suctioning as I jam lap sponges into the four quadrants of the abdomen. We finally get enough of the blood sopped up to see that there is a large ectopic pregnancy in the pelvis but it is so advanced that everything is inflamed and stuck together so that I can't even identify the uterus much less the other anatomy. I start at the left abdominal wall and incise through the peritoneum. Blood continues to ooze as Samedi suctions and blots and I try to be methodical while at the same time hurried as I want to stop the bleeding. Finally I identify some of the blood vessels feeding the ectopic pregnancy from the side and am able to tie them off. After what seems like another eternity of mopping and aspirating up blood I finally have a breakthrough as suddenly the ectopic pops out of the pelvis and I can know identify the uterus and where the mass is attached. I clamp and tie off the blood vessels and suddenly the whole thing is out. I rinse out the belly and dap carefully all around. There is no bleeding anywhere. I close up and breath a prayer of relief.

Four days later, the woman is doing well when another woman comes in with almost the exact same problem. This time I don't waste a day but operate immediately and there is less blood and less inflammation. It's always scary though when that surge of blood rises towards you as you open up the abdomen. There's that brief moment of panic when you wonder if you'll be able to stop it. Then, somehow you find, or God finds for you, the courage to calm yourself and proceed with persistence until it is finished, one way or another.

James

Tuesday, May 9, 2006

Back in Chad!

Everyone,

After a rebel attack on Chad's capital, N'Djaména forced us to reroute our return through Cameroon we arrived in Yaounde, took an 18-hour train trip up to Ngaounderé followed by a 9-hour bus ride to Maroua and a 2-hour pickup truck ride up to the Koza Adventist Hospital where we spent a week working with Drs. Greg & Audrey Shank before going back to Maroua and taking a 3-hour bus ride to Yagoua, a 20-minute motorcycle ride to the border, a 5-minute canoe ride across the river and a 3-hour ride in our truck back to Béré where the rains have already started, the desert is starting to turn green again and our staff has heroically been holding down the fort amidst strikes and local hospital closures forcing our uneducated nurse/surgeon, Samedi, to perform almost 80 surgeries during our absence (no doctor at the hospital for over 2 months) saving countless lives with 100% post-op recovery. If that doesn't convince anyone there is a God, than nothing will!

More stories soon I'm sure!

James