Wednesday, June 27, 2012

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.

missionarydoctors.blogspot.com
 HYPERLINK "mailto:danae.netteburg@gmail.com" danae.netteburg@gmail.com.
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
Kelo, Tchad
Volunteers Welcome!!!










Saturday, June 23, 2012


Zane Update

We haven’t posted any updates on Zane for a while because, well, we don’t really know what to say. He’s certainly not any worse. And he just might be a little better. Maybe cured. Who knows.

So when we last talked... Zane had just gone three days without fever, starting day three of ceftriaxone. Then after EIGHT days of IV ceftriaxone at 100mg/kg/day (twice the dose than that for pneumonia), he had a fever of 100.5. Then 100.4 the next day. We completed ten days of IV ceftriaxone 100mg/kg/day on June 2.

He’s been anywhere between 99.3 and 100.3 since then. But no official fever. We had said that if he hit 100.5 after ceftriaxone, we’d draw a CBC with diff, malaria smear and stool study. If that was negative and our doctors in the US (whom we love!!!) told us to come home, we’d be on the next flight out, all of us together as a family this time. We figured we’d just make our family vacation Zane’s medical work-up. (As if there’s anything they haven’t already tested!)

But all-in-all, he’s less fussy and eating better. He’s even reaching his milestones. On Father’s Day, he took at least a half dozen baby steps in a row, covering at least six inches of horizontal distance in the process. Very impressive! And his vocabulary has stretched to things like Mama, Ball, Catch. But still no reliable Dada. How is it that my son can quite distinctly say Banana, but not Dada?

Anyway, we’re celebrating his first birthday on Monday. All are invited!!!

Thank you for prayers prayed. Please continue your prayers for him, as well as Lyol.

Because of his relatively stable health, we’re tentatively scheduling our annual leave for October 27 to December 26. We’d love to see you!

Incidentally, we’re putting up official calls on Adventist Volunteer Services for
1.  Anesthesiologist or Nurse Anesthetist
2.  Midwife
3.  Physical Therapist
4.  Dietician/Nutritionist
5.  Nursing Professor
6.  Pathologist
7.  Electrical Engineer

If you or somebody you know might be interested, email us!

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.

missionarydoctors.blogspot.com
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
Kelo, Tchad
Volunteers Welcome!!!

Monday, June 11, 2012

Miracles


 While we were home in the states last year, someone asked me if I saw miracles happen here.  

Well, the truth is, no, not everyday.  But I still know that God is working even when there are not out-right miracles.  I believe that in Heaven we will be amazed to know the amount of miracles that happened that we didn’t even notice. 

I have never walked on water.  I have never seen a withered hand instantly healed.  I have never seen a dead man walk out of his tomb after being dead for 3 days. 

I WILL say that when my miso stash was low, it somehow worked mysteriously more potent.  Really.  And then some wonderful person sent me more. 

I do believe that God works through modern medicine.  He also works through the archaic medicine that we try to practice here. 

Last night we witnessed a miracle. 

I suppose it could be explained away by the affects of modern drugs working on her system.  But it was still a miracle.  And everything good that happens comes from God.  And we praise Him. 

And I need to go check on her to see how she is doing. 

--------------------------------------------

She presented this morning at 2:30am.  Pregnant.  Term.  Vaginal hemorrhaging.  Been in labor since last night.  No wait, family changed the story.  Been in labor since the night before. 

Whichever the story, her vaginal exam told me that the baby was floating in her abdomen.  Normally, a woman in labor for a long time would have a baby fixed in the pelvis.  The contour of her abdomen was also not right.  It seemed exactly like Uterine Rupture.  I know this problem all too well here.  The uterus gets tired, like an old paper grocery sac, and breaks, expelling the baby and placenta into the abdomen.  The uterine arteries and veins get torn too and can continue to bleed until they are repaired or the patient dies.  It’s a lot of blood.  Like a battlefield on the losing side. 

Right away I called my OR team on the telephone (Simeon and Samedi) and told the family we were doing surgery.  The night nurse Josephine covering surgery and maternity helped me carry the patient, literally, to the gurney and roll her to the operating room. 

We started an IV and fluids and waited for Simeon and Samedi to arrive. 
While scrubbing, I started to doubt my quick decision.  Had I decided too hastily? 

The spinal anesthesia had gone in and the patient was doing okay.  Simeon prepped her abdomen and Samedi and I put our sterile drapes over her, leaving her huge pregnant belly open to cut. 

But then her blood pressure started to tank.  She had been quite dehydrated from losing so much blood, so we were pouring fluids into her veins.  Josephine somehow started a second vein, and we gave even more fluids.  Nothing was helping.  50/20....40/20....Somehow she was still breathing. 

I had Josephine fish the phone out of my pocket and hit a few buttons to call Olen who was sleeping at home. 

“Dear, please come.  I have a lady trying to die on us.”

He started to explain to me how to mix up epinephrine, “Um...can you just come?” 

It’s hard to wait for the patient to stabilize her blood pressure before starting the surgery if she’s bleeding out in her abdomen.  So we say a quick prayer and I make a huge vertical incision in her abdomen. 

As we suspected there was a term dead baby floating in her abdomen just under the skin incision.  People here are skinny, there’s not much to cut.  I pull out the baby and placenta, and start to search for the bleeders. 

When a uterus ruptures, the normal anatomy is not so “normal” anymore.  Parts of blood vessels clot off.  Some of the blood congeals, mixing with normal tissue.  Some of the normal tissue dies...it’s one big mess.  The main goal is to stop the bleeding, and not get the ureters. 

Meanwhile her BP is still tanked.  It’s still 50/20.  Olen has arrived by now and has started giving her epinephrine. 

My patient’s uterus is so badly torn that I decide to do a hysterectomy.  I start on the left.  I’m trying to move quickly to stop the bleeding. 

I hear Olen tell me to feel for a pulse on her aorta. 

I feel. 

There’s nothing. 

Oh, great.  My patient has died. 

Wow, okay...I feel like a failure.  “So, that’s it, there’s nothing else we can do?”  I pound on her chest a few times, but it seemed hopeless. 

“Okay, there’s one more thing I’m gonna try, “ Olen says.

I get a little frantic and start suturing in big bites to just tie off things so we can close.  This is so sad.  I’ve never had a patient die on me while operating.  I’ve had several patients die here postoperatively, but not during the operation. 

It was at least one or 2 minutes.  Olen had started an epinephrine drip and had already given atropine IM while she was bradycardic (slow heart rate) and hypotensive, before her heart completely stopped.  Now he was kicking himself for not giving a little IV atropine earlier.  He opened the epinephrine drip to full-speed bolus and gave a gram of atropine IV push. 

Then, I heard it.  The pulse ox started recording a heart beat. 

Is that her?  I feel her aorta.  It was miraculously beating! 

Her BP improved, we finished up the c-hysterectomy, put in an NG tube to help evacuate the air that went into her stomach from bagging her (artificially breathing over her mouth), and watched her carefully for a while. 

I go home grateful that she is still alive. 

-----------------------------------

Okay, back from checking on her.   

She’s still comatose.  She remained that way all day. 

My thoughts went crazy.  How do you take care of a long-term comatose patient in a place like this?  How many of her brain cells were killed during all of that hypotension (low blood pressure), during the several minutes that she was literally dead?  Maybe we shouldn’t have tried so hard.  Maybe God shouldn’t have worked a miracle. 

God knows what He’s doing.  It doesn’t always turn out the way we think it should.

The patient’s parents are unhappy that her abdomen is so distended.  I don’t scold them for bringing her in so late in labor.  There must have been a reason.  I’ve gotten my self in trouble for scolding.  When I scold it seems like the patient dies and then I never see the family again.  And that does nothing for relations with people, which is why we are here. 

We continue to pray for her.   I told the family they had to donate blood to replenish the blood we already gave her. 

-----------------------------------

The next day.....she starts to wake up.  She’s REALLY agitated.  (some CNS abnormality I presume from lack of oxygen to the brain during the surgery).  She half wakes up and thrashes around a bit.  We give diazepam. 

I’m REALLY agitated.  (I don’t get diazepam).  I gave her 2 units of blood with the surgery.  The family promised to give blood yesterday.  They refuse now.  I need to give her another unit of blood. 

Well, actually I don’t really know if she needs it, but she probably does.  We have no functioning exam for hemoglobin or hematocrit (something broke), so I have seriously been going on clinical basis... color of conjunctiva and how much blood I think they lost. 

So she DEFINITELY needs more blood and the family WILL donate! Seven family members crowd around the bed.  I make everyone leave for now unless someone will donate blood. 

We have given all of her meds and surgery for free up until now.  She now has a fever, so I had written for IV quinine and triple IV antibiotics.  This is very expensive for people who live here.  You can’t give free meds from the hospital forever, so I offer to pay with money that people give us only AFTER the family gives blood. 

I leave and come back.  Two guys have donated.  The women refuse to give.

I leave and come back in the afternoon.  After many long discussions, another lady finally decides to give blood.  I hang the third bag of blood. 

--------------------

She came around.  Slowly she woke up.  She had good days and bad days.    Yesterday I discharged her on postoperative day 9 in pretty good health, though a little weak walking around still. 

The best part for me.....her name. 

Danayo Blandine.  I kid you not!  Spelled just like that on the carnet (her medical booklet). 

(For those of you who don’t know...my maiden name was Bland....so her name is basically a french version of my old name.) 

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.

missionarydoctors.blogspot.com
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
Kelo, Tchad
Volunteers Welcome!!!

Sunday, June 10, 2012

Don't get a big head.

At least, not like this girl. She's two years old and seems to be well fed. And her head is bigger than mine. Literally.

Her dad brought her to me, desperate. He visited all the hospitals in N'Djamena. Nobody there could help him. There is no neurosurgeon in Tchad. So he came here.

And I can't help him either. I told him that his daughter has hydrocephalus. I told him that the liquid in her head keeps getting made, but can't get out. I told him that it's smushed his daughter's brain into a thin rim near the skull bones and now almost all of her head is consumed with liquid. It even pushed so hard to make the head and skull bones get to the size they're at.

He understood.

I told him that in America, there's a surgery that they would have performed months before to put one end of a tube into these large collections of fluid, that they would have buried the tube under the skin and put the other end in her belly, where the draining fluid could be reabsorbed.

He asked me to do the surgery.

I told him I couldn't. I don't have the proper drain/shunt. I've never done one before. I've never seen one done. I just know how it's done. I told him that if I tried it, I would probably end up killing his child during the surgery and that, even if she did survive, her brain was probably not elastic enough to recover and she would have a great risk of infection or her shunt blocking.

He told me that she couldn't walk, talk, see, feed herself. Nothing. That she wasn't living anyway. He told me that it's ok if she dies in surgery, maybe it will help me learn and do a better job with the next patient.

It was painfully clear that he cared for his daughter, had taken good care of her, and that his heart was not just breaking, but broken. He knew his daughter would die.

That night, just because, I tried to look up in all our books how the surgery is done. None of my books will even discuss it. They don't want to condone trying if you don't already know.

Today he was back: My daughter will die anyway, that's a 100% certainty. There is a great chance she dies during the surgery, I understand. There is a great chance that she dies after the surgery, I understand. There is a great chance that she never gets better, I understand. There is a great chance she will have an infection after the surgery, I understand. But I understand that there is an chance, perhaps an infinitely small chance, perhaps less than a 1% chance that she will do better. And there is a chance that you can learn and do better with the next patient. That is enough for me. I want you to do the surgery.

What do I do? What would you do? I'm not in the Kevorkian business. I don't kill people. But I know that, even if his daughter dies, this father will be able to rest knowing that he did all he could for her. He spends all day and night feeding her and tending to her, since she can't feed herself or toilet properly or express her needs and wants.

What do I do? If I send her away, she will die a miserable death at home, having had her last option exhausted.

What do I do? If I operate, she will almost certainly die before she leaves the operating room, if not, shortly thereafter.

What do I do? If I try to send her overseas, the organizations who do these surgeries will refuse. I've met this problem before. They only accept patients when they're certain they'll have a good outcome. If they accept a difficult patient, and the patient dies, it doesn't look good for their donors and publicity.

What do I do? I can't pay to send her overseas myself. Rumor has it there's a neurosurgeon there who can do the surgery for $2,000, plus cost of transport, expenses, etc.

What do I do? Any neurosurgeon want to send me the textbook chapter on shunts for dummies? When you don't have a proper shunt?

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
Kelo, Tchad
Volunteers Welcome!!!