Comatose

 As I was rounding today, I experienced a miracle.

The young man arrived at my hospital sometime during the nights couple of days ago, not speaking and comatose. The nurse on duty prescribed the usual typhoid and malaria treatment, and I didn’t see or hear of him until the next morning.  

His father said he had fallen ill 3 days prior and had sat at a “Centre de santé” (local ill-equipped clinic) until comatose and then sent here.

During rounds, he was stiff and didn’t even flinch with my firmest sternal rub. But his eyes dilated very well with light—that’s “un bon signe” as I told his father. And when I pinched his thumb with my pen, he moved his hand away. There was hope, although not much. (I considered performing a lumbar puncture, but he had received IV antibiotics already and I wasn’t sure my management would change with positive or negative results.)

We don’t have an ICU. We don’t have fancy monitors in the medicine ward. But what we do have is IV access and a handful of medications. We have dexamethasone (our only injectable steroid), IV quinine, IV glucose, and IV ceftriaxone. That’s not much. I would have loved IV acyclovir and a million other medications, diagnostic tests (our chemistry machine is broken), and monitoring. As I sat there trying to communicate in French and bemoaning all I didn’t have, I remembered the one “thing”I always have with me. I have access through prayer to my Heavenly Father. The family and our rounding team surrounded his bed and I prayed in English.

The following day, the patient could open his eyes and became somewhat agitated. He wasn’t able to eat and I ordered a NG tube (feeding tube to his stomach). He hadn’t eaten or drank anything in 4 days and we don’t have TPN.

Then, this morning I walked up to his bed and was about to admonish the nurse for not placing the tube as instructed yesterday. I leaned over and greeted with a loud “bonjour! Comment ça va?” I was not expecting an answer. He opened his eyes and said “ça va un peu mieux.” He could speak! He had drunk some water and milk.

He still has a long road to recovery and is not yet out of the danger zone. But he is improving and I’m thanking God for this blessing.

~megan

A New Belly Button

 My name is Solomon. I am 18 years-old and have had liquid draining from my belly button since I was born. The liquid drained every day. I didn’t like it. 

For lack of means my parents brought me to the traditional healer. He gave me  herbal potions to drink. It did not change anything. My shirt was always wet from my draining belly button. The liquid had a bad odor. I avoided being near other people. 

Finally, my parents brought me to Bére Adventist Hospital. Thanks to God and the surgical team who helped me I have a brand new belly button! No smelly liquid drains from it now. My shirt is dry. 

Thank you, 

Solomon. 

This young man had a patent omphalomesenteric duct meaning the connection between his intestines and belly button did not go away like it should normally. Thanks to many kind people we were able to remove this abnormal connection in the operating room.

Nice rock

He made the 10 hour roller coaster ride over the potholes to come here from the capital. He had so much pelvic pain and difficulty urinating he couldn’t sleep at night. 

People ask why do patients come from so far away to Bere Adventist Hospital? One reason is that over 90% of the population has no access to safe and affordable surgical care. Most of the surgery performed here is by nurses or general practitioners with very little surgical training.

This man had to wait several days for his operation because we were so busy operating on people who would die if we didn’t treat them first. Today he was so happy to have his turn under the knife. His face lit up when we showed him this rock we took out of his bladder. He and his family were all admiring and photographing the stone. Of all the things we do, taking out a bladder stone seems to be one of the more impressive things in the eyes of people here. 

 

O Negative

 She was referred from the health center with profuse vaginal bleeding. On our ultrasound she was found to have a term pregnancy with placenta previa (thé placenta is over the cervix so it bleeds when the nurse performs an exam). 

The lab slip for her blood type had O- written on it. Our hearts sink when a patient has O negative blood. If the patient needs a blood transfusion to save her life we may not have enough of that precious limited resource. We performed a cesarean. When the baby came out we noticed the uterus had torn far laterally and posteriorly  into the blood vessels. The blood poured out within seconds.

The baby was alive and crying for which we were grateful. We were able to stop the bleeding with sutures, but she had already bled a lot at the health centers. She was pale and had low blood pressure. She was oozing from every surface. We gave her our last bag of O- blood. She wanted a tubal ligation which we performed. 

I scrubbed out to write the operative note. Stopping by the baby boy, he looked gray. I patted the baby. No cry like before. Only an agonal breath. Then no breathing. This mother had delivered 12 children. As is typical in Tchad however, many of them died before the age of 5. Children are critical here as they are one’s social security in old age. She has only one living child. This baby she hoped would be her second and her tubes were tied. 

We quickly started breathing for the baby. He was cold and gray. We placed her on our only rapidly available incubator, the mother’s chest under the drape while Staci was suturing the incision closed. With breathing and warmth the baby turned pink. Then he started breathing on his own and the mom is alive! 

The baby didn’t live a long time. One of our goals is to develop a NICU here to save more babies like these. Our current reality is that we struggle to have enough staff to save people like the mother. She did live for which we are very grateful. 

Hippo Attack

 He did not realize a hippopotamus was under the muddy water when he put out his canoe today. Without warning the giant beast was churning waves toward him. Within seconds the hippo had him in its jaws. 

He was struggling to breath in the stretcher there in front of me. His t-shirt was dripping in blood. The left chest was sunken, flailing as he inhaled. 

I placed a chest tube and packed the wound. Air expelled from his chest cavity bubbled in our make-shift water seal. He breathed a bit more easily and his oxygen saturation’s improved. His low blood pressure resolved with the additional assistance of blood transfusions. He will have a rough road to recovery but should make it. 

Thumbs Up

This 4-year-old boy came after vomiting everything he ate for a month. In the previous week he had not even been able to keep down any water. He finished treatment for malaria and typhoid without improvement. He had a huge scar on his abdomen from an umbilical hernia repair in the capitol a year before so I suspected an adhesive bowel obstruction. Strangely he was not very distended or in much pain. He simply threw up every single ounce of what he put in his mouth. Ultrasound showed nothing notable. We offered the family an operation. We explained we may not find something we can fix with surgery.  

Our super smart nurse assistant predicted it would be a negative laparotomy. When we opened the abdomen there were no adhesions or small bowel dilation. There was nothing abnormal about the intestines. I told our nurse he won. Nothing we could help with. Disappointing!

I kept looking and praying we could find something. The stomach seemed really big. The anesthetic we often start with for children is ketamine alone. This kid was requiring some gentle bag masking with anesthesia. They tried, but couldn’t pass a tube in the nose to decompress the stomach. I kept examining the stomach. The pylorus, where the stomach meets the beginning of the small bowel, was hard. It seemed extremely narrow. We could not seem to force any air from the now giant stomach past this point into the small bowel. This was hard and fibrotic, unlike the common pyloric stenosis seen in babies. 

I decided to open the connection that seemed blocked with scar tissue (Heineke-Mikulicz Pyloroplasty). This is a delicate procedure in a 4 year-old. I was sweating not only because it was 80 degrees F. If what I was doing to him did not heal adequately, within a couple days the stomach juices would leak outside the intestine. If that happened in our circumstances here in Chad, the child would die. 

We watched pensively over the next several days. He was doing well and we let him drink liquids. He would cry whenever he saw me, but enjoyed drinking with no vomiting. He’s eating liquid cereal now without vomiting for the first time in over a month. He’s going home a week after his operation. I’m ecstatic. 

He and his family allowed us to take photos. Then his family talked to him and he did something I have never seen someone do here. Picture below.

War Breaks Out

 “Doctor, we have trauma patients for you to see.” I run to Urgence. 

What happened? “The nomadic cattle herders are fighting against the crop farmers. This man was shot in the neck with an arrow. He pulled the arrow out. He says it hurts to breath and swallow.” 

I feel his neck. Crépitus like rice crispies popping is under my fingertips. Great. I should explore this zone II neck injury in the OR.

Oh there is another patient, an arrow penetrated his left chest...and oh, another patient is on the way. 

More of the story comes out. A wonderful man named Solomon cooks lunch for us during the week. His nephew went to visit family out in a village. Suddenly, the sesame stalks they had harvested were on fire. The nephew ran out to see what was happening. He was unarmed. The nomadic cattle herders were waiting for him and after nailing him with an arrow they ran to him and broke his neck. Villagers are fighting back at the Fulani cattle herders and more people have joined the violence on both sides. 

This man with the arrow in his left chest has developed a pneumothorax. 

We place a chest tube. It has been fun to help the local Chadian docs learn procedures and in this case one did it without my help for the first time. We have no chest tube atriums so I jerry rig a foley bag tube into a container of water to act as a one-way valve water seal. 

The military is out in the bush now. I have to be careful what I write. (If you know, you know.) I’ll just say that they used weapons not available to others. They  protected the Fulani. I will admit the Fulani are a beautiful Muslim people. My friends and I here love them. 

Now for the neck injury. I intubated him in the OR to secure the airway while attempting endoscopy. Too much edema and blood to see well. I opened the neck with the incision I’m most comfortable with for carotid artery surgery. The arrow had penetrated the thyroid cartilage right into the posterior larynx.

No problem right. Just like every other penetrating laryngeal injury I have seen... Just kidding. In 8 years of taking call in busy trauma centers I’ve never dealt with this. Even if I had, an ENT specialist would have been responsible. Here there is no ENT specialist available to the common villager. 

(Figure shows instrument pointing to the hole in the thyroid cartilage of the larynx)

We repair the injury in 3 layers and place a drain. I pray that the repair will heal. If not, he will have saliva pouring out his neck for a long time. 

While in the OR more victims are arriving. These are no longer arrows, but rather targets of the military. Our guard’s brother finished bleeding to death from a thigh bullet wound while they carried him through the hospital gate. Another shot in the right shoulder was successfully treated with a compression dressing one of the local docs placed. 

Now I’m placing combat gauze in a bullet wound to the head with gray matter and blood coming out. His mental status is surprisingly good. 

We pray that people will forgive. Human retaliation will only bring more pain. Thankfully, our patients in the hospital are doing very well.