Sunday, May 22, 2011
Monday, May 16, 2011
One of my favorite attendings in residency used to always ask, ‘Well, what does your gut tell you?’
Tonight, the still small voice won out.
I admitted a boy last night with a distended abdomen, a fever of 40.4 (105 F), vomiting and no poop for two days. He didn’t seem peritoneal. His typhoid test was negative, as was his urine test. We couldn’t test his poop because he wasn’t pooping. I didn’t bother testing him for malaria. I just put him on fluids, quinine, metronidazole and ceftriaxone. And I told the parents not to let him eat.
This morning, his fever was down to 38 (100.4 F), but he was still distended. I put my finger in his bum, but couldn’t find any poop there to pull out. We stuck to the plan.
This afternoon, he wasn’t really much better. So we put in a nasogastric tube.
This evening, the nurse came to me and said that he wasn’t much better and the father wanted to go home and had already signed the Against Medical Advice form. I talked to Danae about it, and we felt strongly that the kid should stay. Lyol had just fallen asleep, and we felt strongly enough about it to leave Lyol in bed and go together to see the kid.
We explained at length that if the boy went home, he’d probably die. We explained that surgery was risky. We explained that even in the states, we try to treat obstructions medically, without surgery.
The father finally agreed to stay and continue NPO, IV fluids, antibiotics, NG tube and observation.
A still small voice spoke to Danae. Danae asked me to go home and get the keys so we could do an ultrasound.
The ultrasound just showed a lot of gas in the belly, which is pretty much what we expected. We were prepared to stick to our decision of medical therapy.
But even after the ultrasound, the still small voice was still speaking to Danae. ‘You know, I don’t know what’s going on, but we need to operate.’
I explained our sudden change of direction to the father, ‘Er... well... this still small voice thing is right 100% of the time, so I really think we should operate.’
We took the boy to the OR.
As soon as Danae cut into the peritoneum, pus started gushing from this small boy’s abdomen. A liter of it was sucked up, but even more spilled around and onto the ground. The smell of pus and poop hung in the air. Inside the abdomen, everything was stuck together and a thick layer of pus and poop was stuck to every foot of intestine.
Danae skillfully and patiently picked her way around the abdomen while offering her scrub assistant $10 if he could find the hole before her. Doing what she had never been trained to do, she was led by the still small voice to the hole. She closed it, something she had never done in residency.
The boy is still alive. We don’t know what the final outcome will be. But the guidance of the still small voice keeps us up at night when we don’t listen to it. Right now, it says that it’s 1AM and time to sleep.
Saturday, May 14, 2011
Warning: Rated PG-13, maybe 14 or 15.
As an ER doctor, I’m often on the brink of losing all faith in humanity. I’ve learned to distrust everybody.
Your chest doesn’t really hurt, you’re just a narcotic addict.
Your chest doesn’t really hurt, you just knew I’d see you faster if you said it did. You really came for your penile discharge.
Your chest doesn’t really hurt, you just wanted to come in out of the rain and get a warm, free meal.
The list goes on and on.
Today, Honore, one of my very best nurses, came and found me in my office. ‘We have a small emergency in the ER. Somebody got attacked by a bull.’ He swept his hand from his forehead up into the sky. Ok, the bull has horns. I like charades. Then he pointed to his tush. Aha, guy got gored in the bum. This should be interesting.
I pull back the curtain. There’s a woman lying on her side with her top leg pulled up to her chest. I see that the leg is wrapped around a belly. ‘Is she pregnant?’
‘Did you ask her? That looks like a pretty pregnant belly to me.’
They ask the patient. ‘Yes, she’s pregnant.’
‘How far along?’
There’s blood all over the bed, her clothes, her, the floor, my feet. I grab some gauze and start wiping. Where’s all this blood coming from? I’ve wiped it all off of her butt and I see no gaping bullhorn hole. Is this a joke?
‘Maybe from the anus,’ a nurse offers helpfully. No, it’s not the anus.
It’s the vagina. It’s inside the vagina. Not the outside. The inside. It’s torn horribly and bleeding heavily. I’ve seen enough.
‘Who did this to her?’
‘No, didn’t you hear? It was a bull.’
‘Yes, it’s “bull” alright. But not a cow. She’s not telling the truth. Who did this to her?’
‘No, it was a bull. This happens here all the time. The bulls here gore people in the vagina.’
‘Seriously? You seriously believe this? Bulls here gore people in the vagina? Why don’t bulls in America gore people in the vagina? Have you seen a bull gore somebody in the vagina before?’
‘Have you ever seen a bull gore somebody before?’ By now, I’m interrogating five nurses who are all adamant that Tchadian bulls have a penchant for goring women in the vagina. Educated nurses who are telling me explicitly that bulls can’t resist a woman bending over and have a natural, unavoidable urge to gore women in the vagina.
One nurse finally works up the courage to say that he saw a bull gore a man in the anus once. ‘Did you actually see it?’
‘Was it actually in the anus or next to the anus?’
‘Well, next to the anus,’ he finally admits.
‘If a bull gores 100 women bending over, what are the odds that he actually gets his horn through her two layers of cloth and inside her vagina? One in 100? Five in 100?’
The biggest guess I get is five in 100. ‘Have you seen twenty women get gored by a bull? No, you’ve only seen one. What are the odds that this woman was gored inside the vagina? Not next to the vagina, not the outside of the vagina, but INSIDE the vagina? Was there anybody who witnessed her getting gored?’
‘Yes, her mother.’
‘Ask her mother if she saw it.’
‘The mother’s now saying that nobody was around to see it.’
‘So you want me to believe that a woman is more likely to get gored INSIDE the vagina, unwitnessed, through two layers of cloth without damaging the cloth, by a bull than she is to be sexually assaulted while pregnant?’
‘Of course. And why would she lie anyway?’
‘Because she’s trying to protect somebody or because she’s afraid of somebody.’
Kind of like a couple weeks ago when we had a girl with another cut in her vagina. She apparently had tripped and fallen on a stick. Somehow, this stick made it’s way through her two layers of cloth and into her vagina. Without damaging the cloth. Quite the stick.
Pregnant women are more likely to suffer violence than non-pregnant women. And pregnant women are more likely to suffer sexual violence. Yeah, this was (a) bull.
I’ve witnessed enough violence here already to make cable television blush. It’s so accepted that church members openly tell other church members about how they had to beat their wives the night before, you know, ‘Because she wasn’t respecting me.’ Well, I’m sure their wives ‘respect’ them now. So much for, ‘In perfect love there is no fear.’
I’ve heard the stories of men urinating on their wives, just because. It goes on and on and on. Problem with the kids, well then, you probably haven’t beaten them enough. Sometimes the children and the wives die as a result. More often, their souls are killed, but their bodies live on.
And men don’t masturbate here. I didn’t believe it when I first heard it. We do infertility counseling and treatment. As such, we do sperm studies. I figured the guys just hid in a corner of the hospital and... got their sperm samples. One day, a man told me he arrived for his sperm study. I gave him the lab slip. A couple minutes later, after the lab explained the test to him, he came right back to me. ‘I can’t do the spermogram because my wife isn’t here.’ Uh, excuse me. I asked a nurse to explain masturbation to the man. The nurse didn’t understand. I asked how we get our sperm samples. Apparently, couples are having sex somewhere at the hospital and collecting sperm that way. I asked several more of our nursing staff. They all claimed that men don’t masturbate. Why would they? I didn’t understand.
Now, I understand. Where violence is so accepted, even against women, a man is allowed to force himself on a woman at any time he desires. It’s not rape. Here, they call it ‘marriage.’
This is ridiculous. I have a life to save. More correctly, Danae has a life to save. I’ve now said ‘vagina’ in French more than I have in the previous... well, all my life... and it’s time to get the gynecologist involved. I tell the nurses to get the patient to the OR. They’re shocked. Why wouldn’t you just suture up her vagina here in the middle of the ER where all the world can watch? I just tell them to get her to the OR and storm off to find Danae.
To shorten up the story, Danae cut off the woman’s labia and sutured up a huge wound inside the vagina, consistent with what a stick or some other instrument could do. The woman required a blood transfusion and the baby was dead when she arrived. She delivered the stillborn shortly thereafter.
We’ll never know the true story. It’s known between the woman and God only. Well, and I suppose either a man or a bull is in on the secret too.
Tuesday, May 10, 2011
Guy comes in with a rash progressive for a year. RPR negative (which is rare here, since malaria can make it positive too). Not better with doxy, erythro, griseo, ceftriaxone, mebendazole, praziquantal, ivermectin and diethylcarbamazepine. Been here for over a week. Any ideas?
Monday, May 9, 2011
It’s me, Lyol, again.
I am now 2 years and 3 months old. It’s growing up time. Time to get my own room say Mommy and Daddy. I thought maybe they were going to kick me out into the village to get my own hut. But, instead they are having a bedroom built INSIDE our own house. I am so lucky.
But there are TWO rooms under construction right now. Do I get TWO rooms? One to play in and one to sleep in? Brilliant!!!
Mommy has set aside all of my old baby stuff to go in the other room. How very exciting. I get to play with my old baby stuff in one room and my more grown up stuff in the other room.
The builders came on Thursday. They have put up 2 walls already. Mommy was very excited at the progress, which she says happens very slowly here sometimes.
All that’s left is to finish the walls, cut out the windows, replace the windows, put in doors, stucco the walls, paint the walls, paint the walls again, put in electricity and lights and switches and... well, there’s still a little left to do. They said they might finish it this week. So, if you factor in African time, it might be done by... carry the one... divide by pi... square root... n!... f(x) d/dx... take the hypotenuse... (this is too much math for a two-year-old) probably around April. 2013.
I’m getting kinda tired of my crib. I let my parents know. Every morning. About 4AM. Usually, I start out with a plaintive cry for ‘Dink.’ They eventually caught on to the fact that I was just trying an excuse to get them to come to my crib, where I can always woo Mommy (and sometimes woo Daddy) into taking me back to their bed. So now they leave a bottle of water in my crib every night and when I wake up and cry ‘Dink,’ they just tell me to get the drink that’s already beside me.
Well, believe you me, I got more in my repertoire than just ‘Dink.’ At that point, I give ‘Eet’ a shot. That rarely gets me anywhere near getting to eat. I’ve also tried ‘By-dah-meen,’ ‘Kan-nee,’ ‘Schlee-bah,’ ‘Meen-aight,’ ‘Buhk,’ ‘Tshim-eeng,’ ‘Jooosse,’ ‘Tub,’ but those have never gotten me vitamins, candy, Sheba, Midnight, books, swimming or juice while I was still in bed.
Finally, I figured out the fool-proof. All I need to say is ‘Pee-pee’ or ‘Ca-ca’ and Viola! I get a free ride out of bed. Mommy will let me take a quick sit on the toilet, then takes me back to her bed. Daddy will let me sit on the toilet forever, then puts me back into my own crib. That fool just doesn’t get it. I don’t want back in my own bed. If it’s Daddy, I know I’m going back to my own bed, so I drag out the toilet thing. I’ll sit there for hours. He and I will have poop-offs. Sometimes, I’ll sit there so long I fall asleep on the toilet. But it’s better than the crib! That thing is like a prison! It’s got bars and everything!
Anyway, Mommy and Daddy have promised me the queen-size bed. Not bad for a two-year-old! But there are a couple stipulations. #1 I need to be able to get into bed by myself. #2 I need to stay there and not get into Mommy’s bed. (Everybody knows it’s her bed. Daddy just rents his side.) #3 I need to give up my room whenever we have company. I’m cool with those rules.
Bring on the progress!!!
Sunday, May 8, 2011
One Month Out
The lady that had the curettage after having a retained placenta for one month recovered. She was on IV antibiotics for several days. She was discharged home a couple days later with a shot for birth control. She went home with her father’s family. Her husband abandoned her because she hasn’t given him a child. All of her pregnancies have ended in loss.
The 5 weeks postpartum patient with a ruptured appendix is recovering as well. She is ready to go home now. She lives very far away, so is waiting to go until her stitches come out on Monday. Her malnourished baby though is far from “healthy.” He is now nursing quite well directly from her, but it’s hard to change the culture. DON’T give WATER to your little baby! He is 6 weeks old and less than 2 KG. His birth weight was probably the same by the looks of his body. He had a fever the other day and so is now on antibiotics.
She ended up being my 6th mother who died as a result of pregnancy. I had originally thought her drastic hypoglycemia was a result of quinine, which was weird because she had been eating and drinking and only on oral quinine.
The same thing happened 3 or 4 times over the next 2 days. She was given IV dextrose each time and recovered. We started her on an IV sugar water drip. We wondered if her liver was shot.
Then she didn’t recover. She stayed unconscious. We were able to get a glucose level at that point which was normal. She started having a high and frequently recurrent fevers.
The family demanded to take her home. They said they didn’t have any money. We explained that we were ALREADY giving her free care. We reasoned with them that the funeral costs would be more expensive. (People here are never ready to pay for hospital costs, but it is expected to use every last dime they have for funeral costs to feed the visiting family). They agreed to stay a little longer.
We started her on Ceftriaxone, an IV antibiotic. Maybe she had meningitis now. Maybe it was cerebral malaria. Maybe I had no idea what it was (yes, this is true).
The family kept insisting to take her home. We explained she would for sure die at home. She may live if she stayed in the hospital, but we could not guarantee it. They stayed.
Then Friday night at midnight (of all hours) the nurse came to the door saying the family insisted that they leave with her. They filled out a paper saying it was against medical advice and left with her and the small baby.
This last week the family came back. They wanted help with milk for the baby. The mother had lived until the following Monday and then died. This small baby actually looked healthy. He had been nursing from a family member (I thought the sister-in-law, but now I think the grandmother???).
For those who haven’t lived in a place like this, the following may be hard to understand. But... if I gave the family formula, they would just run out. It is 3,000 F (about 8 dollars) per can, which may last 1 week for the first little while. They would thin out the formula or give it with non-boiled water. It just doesn’t work well here. The baby would become malnourished and die. If there is any possibility for breast milk here, it is the best solution. I explained that they must continue with the same family member who is willing to donate breast milk at least for 1 more month. They will come back in 1 month to discuss the milk situation further. They live over 20 km away. In a car, it can take over an hour on these roads just to go 10 km. People don’t have cars here either.
I still don’t know what the mother’s diagnosis was. If I had liver function tests, I might have known if her liver had been failing. It wouldn’t have changed the outcome though. Maybe it was acute fatty liver of pregnancy, but it doesn’t quite fit. Maybe she had multiple diagnoses. Maybe it was malaria and then changed to cerebral malaria. Maybe she was just too anemic to fight off the malaria, even with the quinine. We never did get more O negative blood.
Josephine is still here. She is the lady who had the ruptured uterus and cesarean-hysterectomy. Three weeks postoperatively I discovered I had cut her right ureter. This gave her a huge infection, which I believe was the cause for her vesico-vaginal fistula also.
She is 5 weeks out from the repair of her ureter. The right ureteral stent is still in place. I had to leave the foley in to keep the stent in place because the stent didn’t have a loop at the end.
Several weeks ago she developed a postoperative ileus (when the bowel goes to sleep). She recovered from this with bowel rest and an NG tube (an awful tube that goes from your nose to your stomach to keep the stomach empty). Afterwards she was doing great. Just malnourished. I started giving her a yummy protein supplementation drink that someone had left with us.
Then she developed a wound infection. Her skin had to be opened and is now being packed with dilute bleach water compresses. It’s looking better.
This last week she got malaria again. She has been vomiting and now looks awful. She is too skinny. I asked her what she missed from N’DJamena. She said milk. So we brought her some powdered milk. She needs nutrition! I just want her to get better!
I plan to take her stent out next week. She will eventually need a repair of her fistula, but that will have to wait until she is healthy again. For now she is still recovering. Please keep her in your daily prayers.
You will notice on our blog, missionarydoctors.blogspot.com, that we have a link for donations. This is through Adventist Health International’s website. We believe strongly in the mission of AHI. We feel that AHI is an organization worth supporting. By donating through AHI, you can be reassured that there is a strong measure of accountability following your donation. Just mark the donation for ‘Bere.’ And remember that your gift is 100% tax-deductible.
Olen Zain: +235 62 16 04 93
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Sunday, May 1, 2011
It’s interesting and scary the things you see one month after a delivery here in Tchad.
I had 2 such interesting cases 2 days apart.
Two days ago I had a patient who came in one month after her delivery. She had delivered an 8 month old at home and the baby died. The placenta never delivered. She wasn’t hemorrhaging, but complained of leaking pus for 2 weeks. You think???
Her hemoglobin was 5.8. She was also the rare O negative blood type, of which we had none of in our blood bank (I already have plans underway to start a blood drive here and give away free t-shirts that someone donated). None of the family was a match either. So I was out of luck for a reserve of blood.
My ultrasound confirmed retained placenta, a bad thing. Also bad were air bubbles visible on the ultrasound within the placenta. I don’t know if anyone in first world countries ever finds retained placentas a month out, but I’m pretty sure air bubbles mean the infection is really, really bad.
I brought her to the OR and did a sharp curettage (we don’t have suction curettage). Pus and dead tissue were extruding from the cervix. One has to be careful with putting instruments into a pregnant or postpartum uterus because they are easy to perforate, especially one that is infected. I pulled all I could out with a ring forceps, then finished with multiple passes of the sharp curettage. Everything was infected and adherent. I don’t know if her uterus will ever be normal again with such a large infection.
After the operation I looked in her carnet (health booklet). Two years ago she hemorrhaged after a 4 month miscarriage and had to have 2 curettages. Her hemoglobin was down to 2.7 at that time!
We need some serious community education: Come to the hospital if your placenta doesn’t deliver and...bring your friend/family member with you who is the same blood type when you go to the hospital.
She’s on triple antibiotics and 2 days out. She’s still anemic.
Today another patient came. The story started with Olen understanding the patient was 1 week out from delivering at home. Maybe the placenta didn’t deliver. Who knows. History is often irrelevant here. He told me the baby was really skinny too and not eating from her breast.
When I asked with the same nurse to help interpret, the story changed. The patient delivered at a hospital 5 weeks ago!!! Still sketchy, who knows what happened at this other hospital. Apparently she received blood a week out or something. Her abdomen has been hurting for a month!
Her abdomen was quite rigid and you could tell she needed an operation.
I repeated the ultrasound. Is that blood in her uterus or in the abdomen? It’s hard to see the uterus. I do an pelvic exam while Olen helps with the abdominal ultrasound. The mass is not moving in her abdomen.
To the OR again. Normally not a problem. Today is day 2 for me of beaucoup de diarrhea. Two days ago I ate a mango after just rinsing it, not really washing it. I suspected that was the source of my problems. Yesterday was back and forth between bed and the toilet. Everything I drank came straight out the other end. Also vomited about 4 times yesterday with much force.
I was better today, but only planned on coming in to do a quick curettage. I had no strength. It’s already 2pm!
Once in the OR I decided to start with an ultrasound guided curettage just in case it’s in the uterus. I start. I put a small dilator in and quite a bit of blood comes out. Maybe all that blood is in the uterus and I just can’t see the wall around it? I’m able to put an instrument in, but with the ultrasound am able to find the other end of the uterus. The uterus is small, and has nothing stuck inside. That means all that blood has to be extrauterine (outside the uterus in the abdomen)!!! Where is it coming from? It doesn’t make any sense.
I ask someone to call for Samedi (who is on vacation). He’s not anywhere close, 7 km away visiting some family.
Okay fine. I get a little grumpy.
Olen and I scrub, and I open her abdomen.
That’s not blood it’s pus! We evacuate 3 liters of liquid pus from her abdomen!!! That’s a lot.
All of the pus must have been walled off after such a long time. I can’t find any of her intestines. I can see her uterus. Everything is inflamed. I discover that all of her intestines have a thick layer over them, making them walled off.
Maybe this is a TB abscess that she had before she delivered. I still need to find her appendix. I guess I have to cut into that mass somehow. It’s too thick to feel where each part of intestine is. I grab the mass and make a cut with the scalpel.
I cut into the small intestine. Yes, INTO. However, I entered the space where all the intestines were, which is where I needed to be. Poop comes out. After separating some of the intestines from the thick wall of the abscess, I repaired the small intestinal hole I made.
I am NOT a general surgeon!
If I can just find the appendix to know if it’s okay, I will close her. The intestines look better than I thought they would look. They are adherent to each other, but peel away from each other also. Maybe this abscess was just incidental. We do find lots of those here.
After quite a while of searching for the appendix, I get more frustrated. Where is it? I know where it should be, but still can’t find it. I don’t want to close her just to open her again after a few days. Second operations never go well.
This is not supposed to be happening. I didn’t come here to be the only surgeon. What am I even doing here? I haven’t had enough experience in operating yet! How am I supposed to find this appendix? I get pretty negative in my head, which I’m sure shows on the outside too. Let alone the electricity keep going on and off because there’s a problem with the generator. The air conditioner in the OR is also not working well (won’t work without electricity), and it’s the hottest month of the year.
Someone please call Samedi to see if he can come.
Samedi finally made it. He opens my incision another 5 inches above the umbilicus. We search and search for the appendix. Finally against the sidewall in the right lower abdomen Samedi says he found the necrotic remains of the ruptured appendix. He clamped off the base and tie it off. The bowel remained adherent to the sidewall.
Lots of irrigation, a drain that doesn’t work well in her abdomen, and we closed her.
I am thankful Samedi was able to come and help. After the operation we had several more patients to see in the office. The electricity wasn’t working well, so the ultrasound machine wasn’t either. We finally got it working and made it home by 6 pm.
I found myself still grumpy from working so hard when I was sick. Then I had to think. Many of these patients who were waiting to see us had waited hours and hours. I asked one patient how far away they lived. 7 Km. They probably will be walking home or staying out under a tree here until the morning.
Please pray for the baby of the woman with the ruptured appendix. They are feeding it some formula, but I’m sure they don’t haven’t had enough money to feed it well. It needs to breast feed. She has milk in her breasts too. It is one of the skinniest babies I have seen here. Five weeks old and so malnourished.
Seeing as how April is winding down and May is soon approaching, we are beginning to feel the oncoming rainy season. We’ve had two rains so far. Nothing that’s flooded, mind you, but just enough to cool down the temperature to nearly tolerable. Of course, the next day it’s 118 again. You can imagine the humidity.
So to wrap up what’s rumored to be the hottest month, here’s a special edition of ‘You Might be in Tchad if...’
You Might be in Tchad if...
You find yourself putting on a fleece in 90-degree weather. It’s normal.
Your thermometer says 117. In the shade. In your house. And 94 at 6am.
You’re writing this at 3am because it’s still too hot to fall asleep.
Watching a thrilling DVD on the computer while in bed has you glued to your sheets. As in, it’s so hot that you’re sweating while doing nothing, so the sheets stick to you. What? Come on! You’ve honestly never heard the phrase, ‘Glued to your seats.’ It’s a pun. It’s punny. Get it? Like funny. See, I just made another pun just right there. And you missed it.
You fight with your spouse in the middle of the night to see who gets the sweatiest part of the bed. No no, it’s not what you think. You actually both WANT it. The evaporation makes it the coolest part of the bed too. You shamelessly bury your face in it to make it feel a little less like 100 degrees in your bedroom.
You know the importance of pre-hydrating before going to bed. You can lose pounds of sweat while you sleep. Or poop. Or eat. Or exist.
You find your thermometer inadequate. It only goes to 120.
You know that romance dwindles at 91 degrees Fahrenheit. It stops completely at 114.
You have come to accept it as completely normal that you are sweating in your house while doing nothing.