Money

I tell you, we will do anything to get money here.  Ha.  When the surgery is free...

I was walking by the bloc this morning when someone handed me their carnet (medical booklet).  I don’t like accepting carnets like this.  If I accept everyone’s carnet that I walk by, I end up running around like a headless chicken all day long.  

Patients are supposed to start out at urgence, then if the nurses there feel the patient needs to see the doctor, they give the carnet to us or put it in our office.  

But this guy had a cute little sick boy with him, so I took his carnet.  I flipped through the booklet.  

The patient was a 12-month-old baby boy who swallowed a little coin seven weeks earlier.  He was so cute and about the same age as Zane.  He had a fever and wasn’t breathing very well.  

I texted Olen, “A follow up kid for u who swallowed coin”

I explained that we should get an x-ray to know if the coin was still in the boy’s body.  (It obviously was since he was getting sicker).  I explained that we don’t have that here, and that we would have to send the boy to Moundou or NDJ to get an x-ray (in actuality, we have an x-ray machine, but the film is too old).  The family is from NDJ, but they didn’t look like they had any money.  

At this the mother pulled out an x-ray film that was dated from the end of April.  Wow!  That’s nice.  They already had an x-ray.  It was an OLD x-ray and the coin could have definitely moved since then, but at least it was a start.  You could clearly see a coin in the kid’s throat on the x-ray.

Olen’s note in the carnet mentioned that the child was breathing freely two weeks ago.  

Olen showed up and noticed the x-ray.  He never saw an x-ray two weeks ago when he first consulted the boy.  Who knows why they didn’t show Olen the x-ray two weeks ago.

Since we don’t have endoscopy/bronchoscopy machines here, I called James to see if he had any at his new center.  He said he did, but the light wasn’t working.  

There must be endoscopy in N’Djamena, but we’re not sure we can trust whoever that endoscopist is to be good with kids.  Nor did Olen want to send the kid on a twelve-hour bus trip.  Nor did he want to send the boy to Moundou for an x-ray.  He was pretty adamant about trying to get this thing out.

So back to square one.  

Sick kid.  Coin likely stuck in his throat.  

Being the gynecologist that I am, I don’t often read kid x-rays for stuck coins in their throats/lungs.  I’m pretty sure this would be a difficult vaginal approach under normal circumstances.  But seeing as how this is a pediatric case, and a male patient on top of that, I rule out the vaginal approach.  That’s about the end of my contribution.

Olen looked at the film.  He explained to me that if the coin is flat, it means it is in the esophagus.  If it is turned (looking at side), it means it is in the trachea (wind pipe).  Okay....lesson learned for the day.  This one was flat.

How do we get it out?  

We prepared several different sizes of laryngoscopes and some long tongs to grab the coin.  After going through an endless series of handles and blades and replacing burnt out light bulbs, we had a Miller 1 on the handle and a Miller 0, Miller 2, Macintosh 2 and Macintosh 1 at the ready. We inject ketamine IM for a dissociative agent.  We also give atropine IM to stop all the secretions we can expect as a ketamine side effect.

Olen stuck a laryngoscope in the kid’s throat.  Nothing.  There were a lot of secretions and it was difficult to see the vocal cords.  We tried several times.  Several different laryngoscope blades.  Nothing.  Olen visualizes the epiglottis easily each time, but never sees much else besides a ton of secretions.  No coin.  But we’re grateful that the kid maintains his own airway and keeps breathing without our assistance.  It’s never a guarantee when there’s a foreign body in the throat and anesthetic agents given.

We have got to get that money out!  This kid already is sick with an infection because the coin has been there so long.  We really need to get it out.  But messing around next to his wind pipe is also dangerous.  It could swell and then compress the trachea.  Already Olen has given 4mg of dexamethasone IM to prevent some of the edema expected after all the trauma of sticking laryngoscopes repeatedly into his airway.

Olen doesn’t think it’s in the trachea, because the kid is still alive two months after it happened.  And if it had passed from the esophagus into the stomach, he should be ok now and not breathing so poorly.  So it’s decided that the coin MUST be in the esophagus, eroding its way through and embedding its way into the esophageal wall.  It also must be causing a LOT of inflammation in the esophagus’ neighbor, the trachea.  If it perforates the esophageal wall, then stuff from the mouth and stomach can set up shop in the mediastinum and cause an infection in a place where antibiotics and antibodies can’t reach.  This is almost always lethal in the states and always lethal here.

Olen remembers seeing an endoscope of some sort laying around.  He takes Dad to see it.  Dad realizes that it’s a sigmoidoscope (meant to go up the bottom, not in the mouth) and they both quickly concur that it’s way too big to put down an adult’s throat, let alone that of a baby.  Being boys, they decide to play with it for a bit and find that we have a light source to fit the scope, which is great, but then they realize that it can only look up and right, not down and left, so that’s not so great.  But being only marginally functional is probably the reason it’s in Africa anyway.  Not broken enough to throw away without feeling wasteful...  So let’s send it to Africa where missionaries can use it to deliver high quality care!!!

The kid is starting to come out of his anesthesia and wake up and we’re all about to call it quits.  Then Olen suggests putting a Foley catheter (which is meant to go up the urethra into the bladder) through the nose and into the esophagus, then inflate the balloon on the end of the catheter, then pull the catheter back out through the nose, hopefully pulling the coin up from the esophagus into the throat, where he can pull it out with a surgical instrument.

Yeah, right.  I want nothing to do with this.  But Olen talks my Dad into giving it a shot.

Janna passes the Foley catheter through the nose and into the esophagus.  Olen puts three mL of water into the ballon and the catheter’s tip, somewhere in the esophagus.  Janna starts to pull the catheter slowly out of the nose until she meets very hard resistance.  We think the balloon is now in the back of the nose and are about to take the fluid out of the balloon to take the catheter all the way out and give up.

As a last-ditch effort, Olen inserts the laryngoscope into the posterior pharynx.  He says he sees the catheter still going into the esophagus.  He tells Janna to keep pulling harder and harder.

‘Stop!!! Hold it right there!!! Don’t move!!!’  Olen reaches for the surgical instrument, sticks it into the mouth and pulls out a 25 franc piece of money (about the size of a quarter).

We walk out of the operating room and stick the 25 franc piece in the father’s hand.

A smile of disbelief spreads slowly across his face.  ‘No!  That’s it?  That was in his throat?  For two months???  It’s out now?  It’s over?  Thank you!’

‘Al hamdullilah!’ (Glory to God)

You Might be in Tchad if...

Your patient explains how he has managed his urinary retention for the last two years with the same catheter. It’s, of course, due to impeccable hygiene. He demonstrates. He places the catheter, drains his urine into the collecting bag, then removes the catheter (which has built up a green funk over the years) and, after draining the urine from the collection bag onto the floor, places the business end of the catheter into his mouth and blows hard, inflating the urine collection bag like a kid’s party balloon. I could not make this up if I tried.

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.

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Danae Zain: +235 62 17 04 80

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