Monday, October 31, 2011

#65 Operative report #2 omphalocele

Omphalocele. Said like ohm-FALL-oh-seal.

An omphalocele is a malformation of a newborn baby. The cute little baby is born with some or all of it’s gut within a thin membrane on his or her abdomen. So if this thin little membrane gets infected or cut, all of the intestines spill out and the baby dies. The cure is to fix it with surgery.

Did I mention that these problems arise in NEWBORNS?! Very small, tiny, itty-bitty babies? Well, actually, they arise in utero while the baby is forming. But, most people here don’t get ultrasounds during their pregnancy.

These are pretty rare. I’ve never seen one here before. I’ve never seen one before here. Samedi and James saw and operated on ONE during all of their time here before.

God forsaw this and James just happened to make a last minute trip here yesterday to get some of his belongings to Moundou.

Then during rounds a lady came in with her baby girl. Malformation. Diagnosis. Omphalocele. At least I knew what it was.

“Hey, James, have you ever done one of these?”

“Yeah, one time with Samedi.”

“Do you mind staying a little longer to help us with this?”


The cute little girl was born the day before. She hadn’t eaten any breastmilk yet, but the family had already given her water. (This problem is SOOOOO getting old!)

We brushed up in the surgery book before starting.

Now comes for the interesting part.

Simeon gave her some IV Diazepam. Maybe the first problem. The O2 sat read 70%. Oh, wow! We haven’t even given ketamine yet. She is only 1 day old. This little girl was perfectly fine before we started. Well, minus the water, but at least breathing well.

We don’t have oxygen here, remember? The O2 sat improved and James, Samedi and I scrubbed.

If we don’t use a spinal, we do everything else here with ketamine. Not INTUBATED! It works surprisingly well actually. Except when they’re not breathing well!

We had barely started the surgery. I tied off the umbilical vessels, then made an incision about 4mm next to the edge of the omphalocele to undermine the skin all the way around. Then the same thing happened again.

James broke scrub and started doing CPR. I broke scrub and helped Simeon with respirations for the baby with the ambubag. I told someone to go get Olen to help with anesthesia. Olen came and helped out.

We re-gloved and continued with the operation. James cut off the small part of skin that was on the omphalocele. I undermined the skin that was left on the abdomen. Next, James pushed the herniated thin sac with intestines back into the abdomen and I closed the skin with mattress stitches. It was too tight to close the fascia. This will have to wait another 9 months or so for a second operation.

Then the baby would NOT wake up. The monitor wasn’t showing a good oxygen saturation. When we used the ambubag, it would improve, some of the time.

It was several hours after the operation was done. I had gone home to be with the kids and feed Zane. Olen called. He needed a break from baby that kept threatening to die. He couldn’t leave Janna and Adam alone with a sick baby. The oxygen saturation kept reading 60-70% for the longest time even with respirations. Should we cut all of the sutures? Maybe there was not enough space inside for the tiny lungs to expand.

So we switched out. I brought over a different oxygen monitor. The new monitor read 90%. Maybe the first two monitors just hadn’t been working. By now the baby looked okay. I put my finger in her mouth and she actually started to suck. I had the mom express some colostrum and used a syringe to put some in her mouth. She did well.

Janna volunteered to stay with the baby during the night to watch and observe. Usually we just leave the patient with the family to guard the patient, but we were sure the family would fall asleep and then the baby would just die if she needed to be stimulated to wake up.

By this time it was dark. I had a GYN patient to see in maternity, then a baby in urgence (the ER) with another malformation.

You will NOT believe this!

Another baby girl with an omphalocele! She had just been born that same day (at home of course, just like the one today). I could not believe it! TWO babies came on the same day with this rare problem.

So today I did the second operation. James wasn’t here. Samedi was out. So it was me and Abre. There were so many problems yesterday with anesthesia that I decided to do it with local anesthesia. I kept Olen in the room with me this time, just in case. It actually went much smoother not having to worry if the child was going to die or not. And no, the child was not suffering. The lidocaine actually worked well surprisingly.

We fixed the immediate problem of the exposed membranes, but the fascia (the thick stuff that causes hernias if it’s broken) was too tight to pull together. It will have to be done at a later time. If someone knows a pediatric surgeon who would like to come fix these two precious girls’ abdominal hernias, they are welcome here in 9 months or so. Otherwise it will be us.


Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!

Thursday, October 27, 2011

#64 Operative Reports #1

If I keep this up, I’ll never be able to take boards with these cases:

Cesarean Section, 10/25/11

The patient presented at “8 months” with vaginal hemorrhaging and the baby was determined to be alive with the fetal doppler. The patient verbally consented for a cesarean section for the indication of placental abruption. She was transferred from the delivery room to the operating room by having her hobble along with blood dripping down her leg.

Once on the table a spinal was attempted, but failed. I instructed anesthesia to please try again because lidocaine with ketamine makes it hard to separate the abdominal muscles. Anesthesia was indeed able to obtain spinal anesthesia. We prepped, scrubbed, and draped. (During scrubbing the water went off, so someone was sent to turn on the pump to fill up the tanks. We continued scrubbing).

Before incision, the patient’s heart stopped and she stopped breathing (yes, she died). (What? I didn’t even know there was a problem, Simeon. How long has the monitor not been picking up an O2 sat or heart rate. I did notice it was quiet, but I thought she just wasn’t hooked up yet.) Anesthesia started mask breathing for her. First assist and lead surgeon traded off chest compressions. Another nurse in the room ran to get Mr Dr Netteburg from rounds.

Her heart started up again. Anesthesia continued bagging. High spinal suspected.

Mr Dr Netteburg entered the room, but by this time things had somewhat normalized. Mr Dr Netteburg checked her pupils.

“Dear, her pupils are fixed and dilated.”

A Pfannensteil incision was made. This was sharply dissected down to the uterus. The baby was delivered in cephalic position. The cord was clamped and cut. The APGARs were...well, he was crying some, so that’s good, right? The baby boy was passed off to the awaiting NICU team (or, um, ER doctor) for possible resuscitative measures.

The uterus was closed in 2 layers with 0-chromic. Irrigation was done. Fascia was closed in continuous fashion with 0-vicryl. Skin was closed with 3-0 vicryl using interrupted suturing because EVERYTHING gets infected here it seems.

So, this was pretty much an uncomplicated surgery except that she died and came back to life.

Baby was sent outside to the awaiting family to wrap up in a non-sterile brightly colored African cloth.

Mother received artificial respirations long enough that the spinal wore off. As I was shining the bright lights in her eyes, she eventually started blinking and pushing me away with her hands. So, her fixed pupils improved, and I don’t even know what caused them.

Mother was transferred to maternity where the family was awaiting. Strict instructions were given to family members that if she stopped breathing, look for a nurse (which sometimes can be hard to find).

I learned I was supposed to give epinephrine for a high spinal apparently.

Mother and baby are doing very well now. The mother knows I will kill her if she gives her baby water. (And it’s not the first time she will have died, she does know that too.)

Yeah! I definitely can’t turn this operative report in. Although it IS the first one I’ve written in over a year. (At least one that’s been over 3 sentences long.)

olen and danae

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!

Saturday, October 22, 2011

#63 Girls Just Wanna Have Fun

Sweet 15. Oh, wait, 16 is another year away. But still, she’s growing up and it’s only fair for a girl to just wanna have fun on her birthday.

Brichelle is one of the most amazing teenage girls there is. We’ve written about her before because she’s Lyol’s babysitter. Everyone loves her. Especially Lyol.

Everyone pitched in to make her day. Marci and Mayline were in charge of recreating Australia inside the Parkers’ home. Marci had brought huge rolls of white paper with her, so they made several murals of the Great Barrier Reef, Sydney at Night, The Australian Outback, and Australian animals. That Marci... such a talented drawer! Since Brichelle is 15 (Tchadian marrying age), they even made a Crocodile Dundee to take pictures by.

Brichelle’s favorite food is Sushi, so Dani’s asian roots came together too for that.

One minor glitch. A positive malaria test the day before her birthday. Poor Brichelle. Luckily she wasn’t vomiting for her birthday and was able to continue her pills.

I had the easy role to play. After work I went with Tammy, Brichelle and Naomi (Tchadian who knows a million languages) to the local “foot spa.” We went to an arabic lady’s house for the afternoon to get henna done on our feet. It was scorching hot inside her hut. But hey, a girl’s gotta feel pampered somehow here in Tchad.

After we were done, Cory arrived with the motorcycle to escort Brichelle back to her birthday party. After a big “surprise!” 18 party-goers were off to start a picture treasure hunt. Even though it was already dark, four groups set off to find various things to take pictures of. The person with the most points after an hour would be the winner. There were things like ......

A picture with a baby goat.
The picture with the most dogs in it.
The picture with the most cows in it.
A picture of a Tchadian couple holding hands.
A picture of the best Crocodile Dundee impersonator. (Lyol won easily.)
A picture of blueberries.
A picture of fish and chips.
A picture of the tiniest Tchadian money and the oldest Tchadian money.
A picture of a bouquet of pictures.
A picture of a Tchadian kid with an English-writing T-shirt.

Afterwards we ate and watched the picture show to determine the winner. Of course Brichelle’s team won! She’s so good!

It was quite a fun night. Even though 15 is marrying age, we hope Brichelle waits a little longer at least.

olen and danae

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!

Wednesday, October 12, 2011

#62 Triple Trouble

‘Say what?’ ‘Come again?’ ‘Watchu talkin’ ‘bout, Willis?’

These were all things I tried to say, but it kinda came out like, ‘Uuuoooooaaaaapppttthhh.’ I think I picked it up as one of the local tribal languages for the above sayings.

Mom was just explaining that there’s no dating here. Apparently, it’s a rule. It was originally meant just for the student missionaries here. (Which, by the way, are multiplying like rabbits around here!!! We’ve got thirteen right now!)

Normally, I wouldn’t be upset about this. But you gotta pull this out on me in public? Right now? Right in front of my girl? Seriously? But, Mooooooooommmm! It’s not fair!

Friday, I was just minding my own business, doing my thing. You know how it is. Coo for a little bit. Look real cute like. Pretend like you’re gonna cry, but then break a smile at the last second. (That one busts people up, man. Works every time.) Breastfeed a bit. Turd in your pants. Make ugly faces at your brother when Mom’s not watching. Read A
Tale of Two Cities when Mom’s not watching. You know how it goes. I don’t need to tell you. You’ve all been there. Anyways, this total hottie rolls up, right. Looking all sassy in her onesie. Sporting these hot pink cloth diapers. You feel me? So of course, I’m all like, ‘Hey, what’s up, baby? You new around here? Cool, cool. No worries. Don’t be scared. I know it’s like, Africa and all, but no stress, baby. I’ll show you around a bit. Just stay close, you know, cuz this is like all real up in here. We’re talking Africa-style. There could be like vicious tigers and bears and woodpeckers and penguins and dolphins and stuff around. So stay real close in case I need to fend ‘em off for you.’

She totally fell for it and was diggin’ on me. She let me slip my arm around her. Everything was going great.

Of course, then her big brother came barging in. Dude can’t respect privacy, man. This cat was on my shoulder all day like bird dookie. Anyway, he got all scared by the talk of lizards, so he started crying. The crying was killing the mood, man. So I stuck my thumb in his mouth since I couldn’t find a pacifier. Then while he was distracted, I totally slid my hand down his sister’s back to her derriere. You can see in the picture what I mean.

Anyway, that’s when Mom caught us and busted out the whole ‘No Dating’ speech, right in front of everyone. It was no secret that it was aimed at hottie and me. Anyway, baby, while we’re apart, you know I’ll be thinking about you and waiting for you.

Oh, I should explain. Hottie is Miriam. Her big brother is Adam. They’re the Appels. They were actually born within 24 hours of me. What are the odds? Three Americans in Tchad born within 24 hours! That’s a first, I guarantee. They’ll be moving to Moundou, a couple hours away while their parents open a surgery center there. But you know we’ll be in touch.

Friday, October 7, 2011

# 61 Return

I started writing this blog 5 months ago. But there was a change in the outcome that was difficult for me, so I did not finish it. Plus our blogs can be depressing enough.

Olen has been gone for 9 days taking oral ER boards in the states. (He’s coming back today by the way). It’s 4:30 in the morning, the 2 boys are asleep, and I was just awakened to check on an OB patient.

In Olen’s absence I’ve been rounding on the whole hospital. Our census is not as high as it could be, but it still takes up a good chunk of the day. Thankfully Scott (surgeon uncle) and Bekki (nurse aunt) are here to help. The last few days Scott has been practicing his French and taking over surgery rounds.

Yesterday I started in pediatrics. We have about 16 or 17 patients on pediatrics right now. Most of them have malaria and severe anemia. One has Burkitt’s that is amazingly improving, but it was my first patient of the day that caught me with my guard down.

The nurse started presenting to me: “5 months old, vomiting, fever, pale.” More of the same things I usually see on pediatrics. But I could not get over the father’s face. He looked so familiar.

The nurse explained more of the history. This baby is an orphan.

“What?” I usually only understand about 1/2 of what they explain to me in French, so I have them repeat it again and again. But I’m getting better.

“Okay, okay, sounds like the baby has malaria, but why do I know him?” I would remember that face anywhere. If you’ve been through something traumatic with someone, it’s hard to forget them.

Then it came out. “The baby’s mother died here.”

Here at this hospital. Here under my care. Here at this Christian hospital where miracles happen.

Then I instantly remembered him. His puffy eyes. His wailing when he received the news.

His pregnant wife had come in initially after having broken her water at 8 months. The problem was that she had 2 c-sections already. I struggled over her plan of care, but decided to hospitalize her and sit on her (no, not literally). I gave her antibiotics. The baby was doing well. I explained to her and her husband that I planned to do a third c-section, but was waiting for the baby to get bigger (We have no Nicu). If the baby came quickly and easily, then maybe a vaginal delivery. Very unlikely.

She was hospitalized a couple of weeks. Things settled down. She did not get infected or have labor.

The family demanded to leave. I urged them not to. I was angry at this man, her husband. He did not understand. I tried to explain. I was probably too harsh. But in the end, they left. I knew she would come back with a dead baby, or hemorrhaging, or with her uterus ruptured.

She came back. With labor. I don’t remember the time line now, but she came back. I ended up doing a c-section, one of the hardest of my life. There was so much bleeding and scar tissue. We had no cautery (it intermittently works). It took me a very long time just to get to the baby. I had to cut and tie off muscle and thick pieces of scar tissue that were attached to the uterus.

The baby boy came out small but alive. I remember searching for her tubes so that I could prevent another c-section like this and maybe prevent her from dying with another pregnancy. I couldn’t even get her uterus out. It was stuck in her abdomen. I couldn’t find her tubes. I irrigated her several times. Her muscles were a little oozy after being cut. I carefully searched out any source of future bleeding. I did not want to go back in this abdomen again.

I planned to write a blog of this great story of both mom and baby returning to the hospital and living.

But the next day she died. She may have bled into her belly from the sounds of things. I was at the river when it happened. I went directly to the morgue where all of her family had gathered. There were gobs of people, but her husband did not arrive until after I did. He had gone to the village.

The family was getting ready to take my patient home to begin the funeral services. But the baby. The baby was still living. Who was going to care for the baby? We unfortunately had gone through this scenario before.

Everything was happening so fast. I ran back home to prepare a quick bottle of formula. I don’t usually like to give away whole cans of formula because babies die so easily here and then it gets wasted. Or they just sell it for money. But I felt compelled to give a bottle and can of formula to this precious little boy.

The father was understandably too upset to listen to how to mix up the formula, so I found a teenage guy who spoke decent French. I explained that the water needed to be boiled, don’t dilute it, and never give plain water to this small of a child. I begged them to return if they needed any help.

And with that they were off.

I didn’t hear from them. I assumed the baby died. Then we went on annual leave.

I still remember the deaths I feel like I maybe could have changed. I think of them often here. Today God allowed me to see the beauty of this little child He is watching over and allowed me to bring into this world. Please pray that this baby continue to thrive.

olen and danae

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!

Tuesday, October 4, 2011

#60 - Scary

It’s been a really long day, but I would like to ask you for your prayers for our health.

Last night we had dinner with Tammy and Jamie to discuss some plans for our student missionaries. Tammy made some yummy fajitas with some real burrito shells that someone had sent her in a care package. The first clue that Olen was sick was that he didn’t eat any. He said he wasn’t hungry. Probably jet lag he thought.

We got home later. He was exhausted. We got ready to go to bed. He felt hot to me, so I took his temperature. 100.7.

“Oh great, Dear. You probably have Malaria. Do you want to start quinine tonight?”

We said we’d get him a test in the morning and wait to start quinine till the morning.

I got woken up at 4am to go deliver a baby. Same old story. Labor for a long time. Baby delivered with meconium. I couldn’t find the deLee suction. Nurse ran to the OR to get me another one. Baby ambubag wasn’t working well. I did mouth to mouth. Grandma actually came over to me after a couple of minutes to say it’s okay to stop. I said no. Cute baby girl is still living now. And actually doing well. Praise God.

I came home around 5am. I felt impressed that I needed to really pray extra hard today. I felt God’s peace before starting the day.

7am came and Olen still felt bad. He barely woke up. He wasn’t vomiting, but said he felt nauseated. I was the good missionary wife and let him stay in bed. I was pretty sure he had malaria. Zane stayed in bed with Olen, while I brought Lyol over to the Parkers.

After morning worship and the staff meeting, I went home to feed Zane. Anatole came over as promised to get Olen’s malaria test. Olen was very exhausted and stayed in bed, but said he would try to come round on medicine and pediatrics later.

I rounded on maternity. Thankfully the cute baby girl who delivered today was still living. I tried to get her to eat. She had the energy, but the mom had “agitation” (whatever that is), so didn’t really have any interest in feeding her child. I can’t figure out if she’s mentally ill or not yet.

On to surgery rounds.

It was getting late. I already didn’t scrub with Samedi for an interesting case of perforated intestine/infected abdomen because there were so many patients to round on.

I got Olen’s positive malaria test and bought him some quinine pills. I ran home. Gave him the meds and made him eat a banana. He looked really tired, but said he’d come in a few minutes to do pediatric rounds.

I started medicine rounds and by the time I finished, Olen had finished pediatric rounds and came over to Urgence with me. I noticed his scrub top was drenched in sweat. It was hot out but not that hot.

“I guess the tylenol helped your fever break.”

By this time it was around noon already. Juliette kept presenting patient after patient to us in Urgence. Where did she find so many patients? Olen sat at the desk in urgence, he started to doze off. He’s probably just tired I thought.

I had 3 new volunteers with me (2 premedical students and 1 nurse). I had Amanda, Anna, and Janna take turns interviewing the patients. We saw several, about 5 or 6. I would interrupt Olen’s dozing to ask him questions from time to time.

Then a guy came in with elephantiasis of his leg I think. “Olen, this is up your alley, not mine.”

“Olen, here drink some water.”

Nothing. He just spurted air out of the side of his mouth.

What? Olen is REALLY sick. He’s not really conscious. He is drifting.

The girls helped me bring him over to the examining table and I kicked the patient out. Stuff usually happens slow here. You usually have to write for meds in someone’s patient book, then the family member brings it over to the cashier. You pay, then bring it to the pharmacy, then the family members bring it to the nurses.....all before giving it to the patient.

But somehow, people just went to the pharmacy and got stuff for me thank goodness!

Nurses came from all places. One got an IV. I called for dextrose. Olen hadn’t eaten anything except a banana, so he was probably hypoglycemic. After one ampule of dextrose, we got a sugar which was normal by now if he had been low.

He looked white. Very white. Juliette took his BP. 70/40. By now he had IV fluids running.

“Please someone squeeze that bag to get it in faster. And get another IV line.”

Janna retook the BP. “It really is 70/40 Danae. And his pulse is thready.”

I start to freak out a little. Olen wakes up a little, but falls back asleep. He’s eyelids are very heavy. He just looks like he doesn’t have a care in the world.

Another nurse gets another IV started. We give a second dextrose. This is NOT my field. I’m NOT an ER doctor.

I ran to the office to find the pulse ox, but couldn’t find it. So I ran into the OR where they were doing a case to ask Simeon for one. I didn’t even put a mask/hat on.

Back at Urgence Olen started to improve. I asked him how he is. “I’m fine,” he would say sounding very slow and drunk. By now his BP had improved to 90/50.

I send Tammy a text to feed Zane formula if he was hungry because I was very late getting home now. He hasn’t needed to get formula yet, but I can’t store breast milk reliably here, so I had some formula saved for emergencies. But, the phone services aren’t working right now. I send Anna over to her house to relay the message.

After the 2nd 1/2 liter of IVF’s, he remained conscious. Tammy came over to tell me that Zane was asleep and fine. No need to worry.

Olen continued to say that he was ‘fine.’ At least his color was mostly back by now. We started him on the third bag.

It had been quite crowded outside of the ER consultation office. It’s not too often patients come to Bere Hospital and their doctor crashes on them.

The nurses said they heard people saying that they might as well leave. If their doctor got this sick, what hope was there for them? But somehow they stayed.

Janna and I walked Olen home. I’m greatful that we had been in the hospital where I could easily ask for help even though the phone services were down.

After a short break at home and making sure Olen was okay, I went back to see more patients. I saw maybe 10 or so more patients in our office. Then I found someone who needed a D&C for an incomplete miscarriage. Since the phones were down I did my own anesthesia without Simeon. I asked one nurse to help me who was already here. I gave her a shot of ketamine and then did the D&C.

By the time I got home again it was almost 6 pm.

Olen’s feeling better now. He ate a little rice and sauce for supper. He’s also forcing himself to drink some lemonade I mixed up for him.

God still has a plan for us. Please continue to pray for our health. Especially Olen having malaria right now. This was one scary day for me!

Monday, October 3, 2011

#59 Zain or Tigo

This is my first attempt at writing a blog. Anything is probably better than nothing for a kid who is only 3 months old.

I’ve only been back in Africa for a little over a month, but already I’m a celebrity. When my mommy goes to the market, she hears people calling from all directions, “Mamma Zane, Mamma Zane.”

Mommy and Daddy tell me they just liked my name, and that’s why they gave it to me. But I think maybe they are just using me as a conversation starter. The two main cell phone companies here in Tchad are Zain and Tigo. But mommy swears I’m not named after a phone company! When we got back from the states Daddy introduced me in church. He said my name was Zane...and the next one will be Tigo. I think you have to live here to get the joke. So now everybody knows my name and REMEMBERS it!

Mommy even texted Daddy one time and spelled my name wrong. She spelled it Zain instead of Zane. How bad is it when your own mommy can’t spell your name?

We are running into a bit of a problem though. The company Zain has changed their name to Airtel. I’m glad Mom and Dad didn’t name me that!

We’ve been having lots of fun in my first 5 weeks in Africa. Mommy has been on a sort of maternity leave for the first month, but goes in and helps Daddy when he needs it.

Apparently it’s been cooler with the rainy season. Even down to the high 70’s in the mornings sometimes. Mommy tries to appease all of the old village ladies and puts a hat on me to keep me “warm.” We wouldn’t want me getting cold in humid 80 degree weather! Do they not see the sweat dripping off my face?

Mommy, Lyol, and I went to the market several times this month. We now have a rolls royce buggy that we use when I’m not riding in mommy’s sling. Both Lyol and I sit in it. All of the kids in the village are so interested in it and want to push it. I think it’s fun to listen to them speak in Nangerie. I hope I can speak Nangerie soon, but for now all I can say is “Oh, ooooo, Oh, oooo.”

Last week was really fun for me. I got to go on another airplane ride to pick up my great Uncle Scott and Aunt Bekki. I pretended to be a pilot, but that didn’t last too long. People don’t trust kids my age to fly yet. Maybe someday I’ll be as cool as Gary is. Daddy left to go take a big exam, so we’ve been really missing him. We are praying for him. Please pray for him too. Mommy won’t let me do any new tricks like rolling over until Daddy gets back. I tell you, these parents, holding me back from my true potential!