Not everyday breast cancer

She came with her husband and toddler. This husband showed tender concern for his wife, a beautiful sight in this culture where women are not personally valued. She estimated her age to be 28 years-old. Her birthdate was the typical January 1^st, that of most of our patients because they can only guess.  

She had a hard mass in her left breast. The tumor was big. Typical of the cancer we see here. There were also nodules under her left axilla (armpit) where cancer had spread to the lymph nodes from the breast. I have seen one single breast cancer patient here without obvious cancer in the axilla, only to find that the  tumor was invading directly into her chest. A different patient had cancer in the axilla that had formed an 8-inch wide fungating ulcer. The smell was so fowl she had to wear a mask for herself.  

 

This young woman was sad when I explained the prognosis. Chad has no chemotherapy or radiation. It is simply not an option. She and her loving husband decided to have surgery in an effort to prolong her life. Surgery also reduces the risk of horrible ulcerated tumors people live with here. We removed her left breast and lymph nodes. She stayed in the hospital until the incision was well-healed. I advised her small family that they must treasure every moment they have together now. They were grateful for the diagnosis and advice.

 

Breast cancer here is discouraging. It is one of the many unpleasant realities we face. I dream of screening programs. I have to remind myself that although a lot of things I do are palliative, we are still relieving suffering.  

 

 

 

Photos:

We see horribly advanced breast cancers. The woman in this young family photo had a mastectomy for breast cancer. Additional photos are of other cancers ranging from large tumors, to ulcerations and frank tissue necrosis.

 

Francais:

Patients viennent avec cancer du sein horrible. La femme ici avec sa jeune famille a subi une mastectomie pour un cancer du sein. Les autres photos sont des grands cancers, ulcérations, et nécroses. 

 

Español:

Pacientes vengan con cánceres terribles de la mama. La mujer aquí con su familia se sometió a una mastectomía para un cáncer de la mama. Las otras fotos son de canceres grandes, ulceraciones y necrosis. 

Chadian Massive Transfusion Protocol

At midnight the phone rang. “A woman who just gave birth is bleeding a lot.” 

In the OR Staci was performing a curettage to make sure no pieces of placenta were causing the problem. Medications oxytocin and methergine were in. Staci had also verified there were no major lacerations in the birth canal. We then quickly packed the uterus with gauze in an attempt to stop the hemorrhage. This woman had been laboring for days at home after her water broke. Her inflamed uterus was not clamping down like it should. Phillipe, our nurse who performs anesthesia, was infusing another bag of blood. 

Something drew my attention. It was the pulse on the oxygen sensor. Her heart rate was 170 beats per minute. My heart sank. Was that real? The last blood pressure (BP) reading was 80/50, was that heart rate true? It was ominous. The BP cuff finished cycling: 60/30. Her life at its end flashed before my eyes. Within minutes she would be dead. 

The blood was already pouring out in spite of the gauze packing. I asked Phillipe to run 2 bags of blood at the same time. “We’re doing a hysterectomy.” Opened the kit, threw betadine on her abdomen and began cutting. Her blood pressure was not measurable now. Quick clamp cut tie, clamp cut tie. “Please give more blood, yes, MORE blood!” Phillipe ran to the refrigerator again. Her blood pressure intermittently read at 50/30 when the machine would pick it up. Final clamp, cut, uterus out. Ahhhh, breathe…. bleeding stopped. 

The transfusion total was 9 units of blood.  

The husband was more educated than many of our patients. He was overjoyed when he heard his wife was alive. He understood we had to take out the uterus and said, “Whatever it took to save her, thank you.” 

Walking back to our house in the dark morning hours a flood of emotion overtook me. Her life, falling precipitously, was caught just in time. She is alive. People like the Netteburgs, by their sweat and tears, have developed the only blood bank in this part of the country. People hate donating blood here because it diminishes their “force” to work in the fields. However, every elective surgery patient must have a family member donate a unit of blood. We explain that if the patient needs it during surgery then we give it. If it is not needed during the surgery, we use it for emergencies.

Consequently, every hernia we’ve worked hard to repair this month was another life-saving unit of blood. The cost of generators, fuel, and the mechanic to keep electricity working (most of the time) is beyond what most hospitals in Chad can afford. We have the luxury of keeping our blood bank refrigerator running. 

Our transfusion protocol includes a built-in 1:1:1 ratio of red blood cells, platelets, and plasma. This has been shown to reduce hemorrhage in numerous trauma studies. Even many rural trauma centers in the US have not yet achieved this goal. We don’t separate the components. Consequently, all of it is whole blood, and that’s what we give. 

This woman will raise her kids. People are not surprised when a mother dies in childbirth here. It is so common. Many children grow up without the mother they lost in childbirth. Not for this family though. She is alive! 

COVID hits Chad

Ricky was coughing and breathing hard. He was a small 12-year-old boy with grey fluid and pieces of necrotic tissue draining from holes on his leg. I took Ricky to the OR, explaining to the family that he may lose his leg. The infected tissue encased his tibia from just below the knee down to the mid shin. 

On the OR table his oxygen saturation was 60%.  He was coughing and taking each rapid breath with difficulty. We have no ventilators and not even oxygen. We performed the operation with only local anesthesia due to the risk that Ketamine would worsen his respiratory status. It was painful for both of us. I removed the infected tissue, and left the skin open to change the gauze dressings in the wound daily. He also developed other abscesses in other parts of his body the subsequent week. 

With antibiotics and excruciating dressing changes, the infections began to clear. We now had a segment of exposed bone needing tissue coverage. Dr. Bill Rhodes, a plastic surgeon with 25 years experience in Kenya, graciously mentored me via WhatsApp on performing a saphenous fasciocutaneous flap to cover the bone. He prayed for me too. I’m indebted to him.  Ricky’s leg is healing wonderfully now. 

We will likely never know if Ricky had COVID-19 and consequently became more susceptible to infections, or if his respiratory symptoms were simply from the bacterial infection with resultant sepsis. We have no tests for coronavirus in this part of the country. 

The capital has limited testing for COVID-19. Over 800 patients have tested positive so far. Close to 10% have died. Chad has 15 million people and only a handful of ventilators. There is no capacity to manage critically ill patients here, even if they were spread out over a 6-month period. In spite of this, the country has prohibited all transport and non-food commerce since March. For the many people who eat by what they have sold at the market that day, the economic consequences are devastating. Our patients tell us that in the nearby city of Kelo, there are children crying on the street in hunger. Hunger is a serious problem at baseline in Chad which shutting down the economy has only exacerbated. 

We have a nutrition center to help combat hunger. A potentially more challenging problem however, is how to treat the surgical diseases that cut short or handicap many people’s livelihoods.

The city of Kelo is the commerce center for our district. It is 2 hours away by motorcycle and located on the main route linking the capital from Moundou, second largest city. This whole district, including Kelo, at the moment has only 1 trained general surgeon. Our hospital serves a population of approximately 100,000 villagers in its local district which does not include Kelo. However, we are the primary surgical center for Kelo. In addition, patients regularly come to our hospital from all over the country and surrounding countries. 

A physician in the district hospital of Kelo sent a patient to me to re-open after he had performed a laparotomy that day. He did not feel comfortable managing an intestinal stricture. It was apparent that he had performed a lysis of adhesions and was concerned about a part of the bowel that had become narrow from the compression of an adhesive band. However, the band had been cut and the narrow area would now dilate to allow normal intestinal transit. I closed the patient, reassuring the family and the physician in Kelo that he should have normal intestinal function within a few days. The patient did great. 

Another patient arrived from Kelo because there was no one perform his surgery there that week. He had a distended, hard, abdomen. He had suffered from abdominal pain for 5 days. He took his last agonal breath as I entered the emergency room to see him. I screamed with emotion asking why he had not come earlier. They said, “It’s God’s will that he died.” From a throat tight from crying I said, “NO! It’s God’s will that he could receive life-saving surgery earlier.” 

Then there is Ricky, and many others like him who are alive and walking because they came to our hospital. We do not lack patients. They crowd outside the OR. When I leave to see patients on the ward, or to try to go home they call out to me. It is exhausting. In a couple years we will have enough surgeons to start a top knife surgical training program. This will begin to beat back the onslaught of suffering we face daily. There will be so many more boys like Ricky, smiling as they walk. 

(Written in May 2020)

Morning Run

Andrew went for a run this morning and was surprised to see his patient also out for a morning walk. This patient came in about 6 weeks ago with a dental abscess with necrotizing infection of the neck extending to the mediastinum and chest wall. His prognosis was very grim. Thanks to God and to debridement, wound care, and antibiotics, this patient is still alive and doing very well.

Here are some pictures of how his treatment progressed:

This was at his original debridement. 

The debridement went all the way to the trachea. We don’t have ventilators here, so we were concerned that if the infection spread further it could be disastrous.  Here is two weeks later—after more debridement and aggressive dressing changes.

Two weeks later, after more wound care and smaller debridements, the wound was ready to close. 

Pregnant and Trapped

She came from a health center after 2 days of malaria treatment. She was six months pregnant. On arrival at our facility she rapidly delivered a dead fetus. Then she began to hemorrhage. Her eyes were yellow from jaundice and she was anemic from malaria. We rushed her to the OR and examined to verify there were no lacerations requiring repair. We packed her uterus with compresses to tamponade the bleeding and gave medications to contract the uterus. No success. The bleeding soaked through the compresses. Her heart rate was high and blood pressure too low to measure with the machine. We did not have enough of her blood type in our refrigerator. I decided to do a hysterectomy to stop the bleeding. 

She was oozing blood from every surface upon entering the abdomen. The blood was not clotting. An ominous sign indicating a person has lost the ability to form blood clots and stop bleeding from even small abrasions. Took the uterus out. Her blood pressure did not rise over 60/30, causing dreaded acidosis. We did not have any more blood to give her. Her heart stopped, restarted with epinephrine, stopped again and did not restart. 

Megan was also six months pregnant at that time. I spray our house with insecticide almost weekly and Megan only leaves the house in daylight. One evening at dusk a lady came wanting to sell bananas. Megan stepped out for 2 minutes and when she came back in she had a mosquito bite. Eleven days later she developed fevers, chills, fatigue, and headaches. At the same time she began having painful, frequent contractions. Malaria parasites concentrate in the placenta and can instigate preterm labor. My mind sees the jaundiced lady dying in front of me in spite of my best efforts. 

Megan started Malarone for malaria. She continued having painful contractions. Then after 3 days the contractions began to improve. The fevers and chills resolved and she began to feel better. Yay, we can hang in there until we leave to give birth in the US. She still has contractions at times. They improve when she lays down or rests. Frustrating for a type A personality.  

I finish a case and sit down to write my operative report. A text from Megan reads, “Our flight on June 24 was cancelled.” COVID 19 has kept the airport in Chad closed, but certainly it will open some flights soon? The flight was rescheduled for July 6. 

We search for other backup options. What other countries surround Chad? The part of Nigeria bordering Chad is home of the Boko Haram and even most Nigerians won’t go there. Niger is not friendly. The part of Libya bordering Chad is hostile. It would be unwise to cross the border to Sudan as a white person. Central African Republic is unstable. Cameroon is the best option for a land escape from Chad in spite of being in a civil war between the English-speaking and French-speaking people of Cameroon. However, the border is closed with military guards due to coronavirus. The Cameroonian embassy refuses to give visas until Chad officially opens its borders.  I have patients who can sneak across the border on motorcycles via back roads, however me trying to do that with Megan and Adelie might get us shot or in jail. 

The US embassy had a repatriation flight in early April, and has communicated that no further flights are being planned.  We suspect that the embassy staff have also left, since we have been told the embassy is essentially closed. If the baby was born here, we would be unable to leave for a while since it would require a consular record of birth abroad and a new passport, which according to the website, are unavailable at this time.

Work has been busy here. A man came with a necrotizing infection of his neck and chest that turned his tissue into pieces of grey dead matter that would almost knock you over from the smell. My assistant had to take frequent breaks to keep from fainting while I performed the debridement. I thought the patient would die. The infection tracked under the sternum toward the mediastinum on the right. I placed a chest tube on the right, but no pus came out. I told him to prepare to die and pray to live. He lived. He required several debridements as new pockets of infection turned up further lateral on his neck and inferior on his chest. His dressing changes take a long time, but today there is no longer any infection!

Another man presented with an abdomen full of stool from an intestinal perforation after he fell from a mango tree. He was also near death, but pulled through. I closed his ileostomy today. I was going on to another case when a boy came with low blood pressure, tachycardia, fever and severe abdominal pain after having fallen from a camel a couple days ago. He is one of the nomadic Fulani who roam far from civilization.

I perform a laparotomy and evacuate lots of blood. He has a hematoma in the back of his upper left abdomen (zone II). It does not seem to be actively expanding. Not too much blood oozing from around it. Hopefully it does not re-bleed. His 3 family members tried to give blood for him, but they all tested positive for Hepatitis C. They somehow found one unit for him and we gave him an additional one unit from our precious stash. He’s improving. 

I’m sitting down to write my operative note and see this text from Megan: “Our July 6 flight was cancelled and Air France plans to not schedule any flights the rest of the summer.”  

We strive to provide the best care possible with our limited resources here and continue to improve. Patients travel hundreds of miles and bypass numerous other hospitals to receive higher quality care here at Bere Adventist Hospital. However, this is still not where I want to risk my wife giving birth. Things could go great and it would be no problem. Things could be complicated. When will this COVID-19 insanity end for Africa? 

The baby inside of Megan is happily trying to do triathlons already. The baby kicks, runs, and swims. The fetus is now at the gestational age where it could likely survive if born here in Chad where there is no NICU. 

Adelie is healthy. She is finishing a course of quinine for a bout of malaria she got in spite of Malarone prophylaxis. We’re grateful she has taken her horribly bitter pills like a champion. She likes to go running with me in the morning. She points out cows and says, “Moo.” She chases goats. We are grateful for health ourselves and the ability to help many people here attain it.    

What were we thinking coming here?

(Written on January 1, 2020)

He came with severe abdominal pain for 5 days. He was distended, tender, and covered with numerous sets of cuts—neat little rows of three parallel skin cuts in each set—marking the efforts of an enthusiastic witchdoctor. We opened the abdomen and found black bowel. A congenital hole in his small bowel mesentery had allowed both a section of his sigmoid colon and terminal ileum to become strangulated. We excised the putrid-smelling bowel. I experienced the joy of beautiful hand-sewn bowel anastomoses. 

Two weeks ago we flew to N’Djamena, Chad’s capital, loaded our 7 suitcases onto a bus, and rode 12 bumpy hours to our new home in Bere, Chad. Our kind friends in the dental clinic there had purchased food for us. They also arranged our taxi who brought us to get SIM cards, use the restrooms in their house, and helped us get loaded onto the bus. We felt spoiled. It was an incessantly bumpy ride as the government is bankrupt, corrupt, doesn’t fix the road, and rainy season doesn’t help much either. Adélie had more than enough traveling that day, but she got out at a bus stop and enjoyed making friends with the local kids who were eating dried grasshoppers. 

We arrived in Bere to find a welcome sign drawn on our wall, a cozy-looking fireplace fashioned with construction paper, and stockings with our names on them. Olen and Danae Netteburg have really gone out of their way to help make this transition easier for us. Also, Staci cleaned our house, Keith and Tammy cleaned and cut our yard for us. The student volunteers made the artwork for the sign and cinnamon rolls for us. We feel so welcomed.

The last 2 weeks have been a blur. There is a list of patients waiting for surgery. To accommodate them we work often into the night and never stop for lunch. There are rounds with the one nurse in charge of all 20-40 surgical patients. Communicating with the patients typically involves communicating in French to someone who then translates to whatever other language the patient speaks. Then there is the stream of patients filing into the pre-op area for consultation. 

I am adjusting to the system here. There is a single OR. The team of OR staff consists 2 people--a local nurse that has learned to perform spinal anesthesia, give Ketamine, and rarely halothane/isoflurane with a bag mask. The second OR staff member is a local nurse who washes and autoclaves instruments, preps patients for surgery, and assists when needed. There is no scrub tech and I dream of having one as soon as I can make it happen. We put the sharps on one corner of the instrument stand and grab all the instruments ourselves. Often the spinal either doesn’t work, or wears off quickly. The patient starts straining and pushing all the intestines in our way during a critical part of the operation such as closing the peritoneum on a giant sliding inguinal hernia. It is quite frustrating and I hope to never complain about anesthesia in the US as we are so spoiled there. 

One notable case was when we were securing a prolapsing uterus to the sacrum with rectus fascia. Exposing the sacrum without good retractors is enough of a challenge, but then the patient started pushing all her viscera out at us making it impossible to safely place sutures without risking damage to the unforgiving iliac veins. In spite of the inadequate anesthesia, the patient’s blood pressure was intermittently 60/30 mmHg due to the anesthesia. We stopped and called our ER doc who can do anything. Olen came and further titrated the bag-mask halothane. The patient stopped expelling her abdominal contents at us and her blood pressure normalized. Olen has countless responsibilities, so it is not feasible to tie him up on the OR routinely. Olen and Danae have sent nurses to nurse-anesthesia school so if they come back we may have better anesthesia in a couple years. 

I use electrocautery when operating by myself, but Danae uses only a scalpel blade. Most of the instrument trays don’t even have a scalpel handle so we just grab scalpel blade with 2 fingers and cut. 

Danae is an OB-GYN who has been the only surgeon here for much of the last 9 years. She has tremendous experience and I’m grateful for the chance to learn from her. She has handled the volume of patients--1400 operations/year—primarily single handedly. I estimate she has performed about 3,000 inguinal hernia repairs, more than many general surgeons. She is teaching me OB-GYN and everything else that is so different here. 

I’m learning to perform prostatectomies. They involve opening the bladder followed by distasteful blunt finger dissection. It’s bloody. Not my style. An elderly man had a prostatectomy shortly before we arrived. He had the bladder fall apart because the family unthinkingly occluded the urinary catheter while tying it to the bed. It was like that all night. No nurse noticed. He had a string of complications related to that and eventually died.  

Nurses are supposed to take q4 hrs vitals for the first day post-op, but it is often a struggle to make that happen. There are many discouraging things. Nurses are supposed to arrive fresh for their 8 hour shifts, but at times they have been working in the rice fields to make more money and then sleep on their shift. They are also stretched quite thin with all their patients. Families feed the patients, purchase the meds and IV fluids in the pharmacy, and do most of the basic care. Last week we found that medications were not given even though a nurse signed stating that they were administered. We made an announcement and this week it seems medications are actually being given. I am working to get them to record urine output. There are so many challenges it can be quite discouraging, but we have a nursing school and are helping to raise the quality of care through education. 

Then there is my friend with the big smile. His bowel anastomoses obviously healed well. He is eating and walking around. I broke into tears today when I explained to him how much he encouraged me. He is a human being snatched from imminent death. That makes it all worth it.