(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.
