Monday, December 31, 2018

Little Donkey

Clip clop. Clip clop. Clip clop. Clip.



I know the story. The little donkey caries the Savior of the world.




But my leg hurts so bad.


Man I wish I wouldn’t have made that snarky remark to Uncle. He bit me. I mean I’ve been bad, but did I deserve this?


Ouch. That hurts.

All donkeys wish to be like that story of old, carrying Mama Jesus. Or carrying King Jesus. With this hurt leg and all...

I would never even have the chance to be in a Christmas program. A few years ago some humans organized a Christmas play in Bere. That pregnant donkey delivered her BABY donkey DURING the play! Talk about a star! How am I supposed to do something memorable when I’m so lame?
I don’t even feel like walking on my hurt leg! Just a limp. Clip.


I’m getting a little woozy. I think I’ll lay down.

Wait, what is this? A big crowd? It must be those nasaras again. They are a pretty fun group, bringing songs and laughter to the village. Telling stories about the great donkey who carried mama Jesus.
I’m confused, they just came here yesterday. I was nuzzling up to the little one they call Addison. I just had no energy to run away. Stinking leg. They did say they were coming back with help.
There’s a few more of them today. The ones they call Andrew and Olen gave me a shot! Ouch! It hurt, but not as bad as my leg. I just have no energy to move. I can’t walk. I can’t move. What am I good for?

 Wait! What is this again? Andrew has picked me up! He’s carrying ME! In most stories of old with humans, it’s the DONKEY that’s supposed to carry the human! This human is carrying me! He said he wanted to bring me near the well to wash off my leg that was bitten.

I’m supposed to be the helper, but he is helping me. He must be a surgeon because he took one look at my abscess and cut it open. Right then and there!

The other nasaras said they needed a surgeon to help them with their work. Could this be him or her? My mama said it must be true because she read his shirt, “Bere or Bust.” Or maybe that means he was going to bust me up in Bere. I don’t know. But I somehow ended up in Bere, at the house of Olen. Andrew is not really busting me up yet, just changing my dressings where Uncle bit me. Now the woman is doing them.

Clip clop clip. Clip clop clip.

I’m getting better. I can actually walk on all four legs now. It’s been two weeks living and learning about the nasaras.

Clip clop. Clip clop.

But where is Andrew? I sure hope he comes back to help my humans when they need cut open too.

I think of the stories of old. Of the donkey who carried mama Jesus that starry night on the way to Bethlehem. Jesus came to help our world. And now I can be a helper too because I am no longer sick. Now maybe I can be in the Christmas program to help people know about Jesus’ birth. Now I can carry sick people to the hospital. Now I can......

Clip Clop. Clip clop. clip clop. clip clop...

Ps. Little Donkey has fully recovered. He plans to be in a nativity program that we are having mid January this year for our Happy New Year/we couldn’t do it earlier program. Stay tuned!! 
We love the animals in Bere too!! 

Pss. Drs Andrew and Megan were here visiting Béré for the first 2 weeks of December. We love and welcome visitors. Shoot us an email and ask how you can be helpful too! And pray for them and others who are planning on serving long term in the mission field.  Getting there is sometimes the hardest part. 

The New Hippo River

 The New Hippo River, a blog hand-written by Lyol Netteburg (age 9), typed by Mommy

One day we went to the river where we love to go swimming. When we got there I jumped out of the car and ran around the river with my brother. My Dad went a litter farther down stream. I had just stuck my foot in the water when my Dad said to my Mom, “Get the kids in the car!”
We all ran into the car. I saw little waves that got bigger and bigger. Then the hippo came up and was about 30 feet away from us. After it passed us I got out of the car and went to my Dad and Mom. My Dad showed me where he had seen the hippo before this. It had gone about 300 yards in 2 minutes.
My mom did not want to go swimming any more. My brother did not want to get out of the car. Zane did not let Addison get out of the car. Juniper was just relaxing in the back of the car.
So we had a looooong drive in the car instead of swimming that day.

Market Guy

During the first two weeks of the Smile Train team, we did three huge head tumor cases (along with many other head and neck masses, but not the HUGE ones like these). Two were big mandible tumors. Not little ones. BIG ones. They ended up with plates in place of a large portion of their mandibles that needed to be removed due to their tumors. Another was a man with a huge 3 kg bony tumor growing off of the side of his head.
None of this would have been possible without our amazing anesthesia team. And of course our visiting surgeon.
When you see one life changed from such an impossible surgery, you have to wonder who else is out there who hasn’t come in for a consultation. Olen and I were both in the OR when I wondered out loud, “Isn’t there a guy here in Bere with a big mass like this?”
Olen replies, “Ya, that guy in the market...Market Guy.”
We go on to explain that we have seen someone with a larger-than-life tumor on his face. It was so large that it has turned his mouth sideways. We go on to explain about Market Guy, and wouldn’t that be cool if we could find him?
Bill is only here for a limited time, but... he did decide to extend his stay by a week. And we will have an anesthesiologist here next week. I asked some of the nurses and they seemed to think that he still lives here in Bere.
I ask my guards the next day if there is someone in Bere fitting this description.
The next day, who shows up but Market Guy. Now market guy has a name, but we didn’t know his name before, so we called him that for short.
The tumor started to grow on Christophe’s face when he was ten years old. And for the past TWENTY years, it has continued to slowly grow. Disfiguring his face more and more. It was a large maxillary bony tumor, an amelioblastoma.
Christophe is a very open and likable guy. He’s not shy about his looks. He doesn’t cover up or hide. But this tumor has had a toll on him. He told me he wasn’t married because no girl would want to marry him. Not because of his looks only. But because they didn’t want to become a widow. The whole town knew that eventually the tumor would grow so big that it would kill him. And nobody wanted to become a widow knowingly. Nobody would let him marry their daughter. No one would give him a real job because everyone just gawked at him. No one took him seriously.
Several years before, he had a church family. He went to church. He believed in God. His church family saved up a bunch of money to send him to some specialists in NDJ. Everyone that he saw told him it was impossible. His tumor cold not be removed.
So he drowned his sorrows in alcohol. He didn’t drink a lot because he didn’t have a lot of money, but he drank as much as he could afford. The locals later told me that Christophe was the one in the market who could be found picking a fight (probably because he was drunk). He didn’t care. He quit going to church. His life was over already. He was doomed to die.
Until he wasn’t.

 That’s when the Smile Train team take two came along. Dr. Bill and Dr. Geech. Bill only had three more days left, so we reserved a whole day for Christophe’s case. We went in at 5am to prepare him. Get his IV, get him shaved and washed, etc. Jonathan did his amazing anesthesia (actually managed straight direct laryngoscopy). Bill did his wonders as God has blessed him to do.
No one could believe it! Everyone and their donkey stopped by to see the guy from the market who was said to be inoperable.
Now he has a second chance at life. Now he can get a real job. Now he can get a wife.
Christophe now wears a mask out and about. His mouth is still turned sideways because of the effect of the tumor growing for years, though he doesn’t have the tumor anymore. Prior to this surgery a mask would not in any way cover up his tumor. Bill plans to do more reconstruction on his face next year when he comes back.
Christophe went to church last week all dressed up in an old shirt of Olen’s. I don’t think that going to church alone can save a person’s soul, but now Christophe is searching for something to fill the void of emptiness that has filled his life for so many years. Please keep him in your prayers. I know Satan is unhappy about this change in Christophe’s life, but God is stronger and does the impossible so frequently.

Wednesday, December 26, 2018


Flaps. Where have you been my whole life?
I’ll tell you.
You’ve been hiding out with those plastic surgeons.
I mean, I’ve done a few for fistulas and a couple for exposed bone in an emergency, but now...
Now my eyes are open. Born as an ob/gyn and grown into a general surgeon of sorts by necessity, I feel like my hands have been freed, untied. Everyone needs a flap! You get a flap. You get a flap! YOU get a flap! Everybody gets a flap!!!
In the short time that Bill was here, I have learned so much from him. And the key is in the flaps! Now you can’t just start cutting into tissue and expect any old place to be a successful flap. You have to know your blood vessel anatomy! (And preferably nerve anatomy as well.) Or it dies.
One of the first cases that we did together was Charlot. Charlot became my patient postoperatively after he had had a repair from his antral gastric perforation. I re-repaired him quite nicely I thought. I took down the whole repair site that had broken down. I freed up the edges and closed him how I normally would. It was a large perforation, 2cm and along the superior border, so maybe that’s why it didn’t work in the first place. I didn’t let him eat for five days. Then I slowly advanced his diet. He was doing fine for a couple of days on liquids. Until he wasn’t. I planned to take him back that morning for a wash out. But when I removed the dressings, I found stomach contents. Then I realized that Dr. Bill had arrived in the night. He was a general surgeon, with a plastics speciality. Did he just want to do cleft lips and head tumors? Or would he help a girl out with this complicated case.
It turns out he was eager to help out in any way he could! And he did! Charlot became one of our complicated patients who, to this day, I have no idea how he survived without proper nutrition. We re-repaired him (#3). Tried a J tube via his nose, which Charlot ripped out some during the night, so it was no longer a J-tube. We put in a proper J-tube for a while, but it didn’t seem to be working properly. Finally on his 5th and final repair, Charlot was surely lacking nutrition, which makes healing anything a nightmare, Dr. Bill re-closed his perforation and made an abdominal wall flap to cover his stomach perforation. He made it 7 days after this 5th and final surgery NPO. There is no TPN here. We pulled his NG tube and advanced his diet VERY slowly. It worked! Abdominal wall flap to reinforce the gastric perforation’s 5th repair. All of this with the minimal supplies, labs (no chemistry here yet), and nursing care. Charlot is a walking miracle. The miracle is that he is walking and eating and very much alive.
Koumakang was also a case we did together early on. He is a young boy who developed a bad scalp infection. All of his scalp was dead from the infection. He underwent a debridement for dead skin and infection on this head. (Essentially, scrubbing his scalp with soap and water removed most of the skin.) After a few days, Bill and I grafted and flapped his head! His whole head, well, at least the part that grows hair. He had a large portion of his skull showing. Bill showed me that you can split the scalp into a few layers to make flaps. (I hadn’t heard the word ‘Galea’ since medical school.) This allows the skull to have a layer of tissue over it, onto which you can graft skin from other parts of the body. So we grafted his whole head.
So many cool flap cases. The list goes on.
 Suzanne. Suzanne was the victim of domestic violence. Her husband, who she’s been separated from for four years, used a machete to cut her left forearm almost entirely in two. He had been waiting for her and followed her home from the market one night and hacked hard at her as she was entering her compound. She went to the hospital in Lai, and we aren’t certain what they did there, but there isn’t really any evidence they did anything. Her family isn’t super supportive either. She ended up at home with an open fracture of her radius and ulna and all of her extensor tendons exposed to the world.
When she first arrived late one evening, Olen saw her at the door to the operating room and smelled something unpleasant. So he sat her down on the step outside the OR and took down the old, smelly, rudimentary bandage she had over her arm. She very literally had 2cm of radius and 2cm of ulna sticking out of her skin proximally and 2cm of radius and 2cm of ulna sticking out of her skin distally. I don’t know how that hand didn’t rot off on it’s own. Sometimes they do here. She was fortunate.
Bill wanted an X-ray of the arm before surgery, which is no small feat to accomplish, as it would involve traveling 25 miles by motorcycle over rutted dirt road, only to then have to take a Corolla filled with seven people for two hours to the next big town, then walk across town to the hospital, then repeat the trip in reverse. The family refused. Not because it would be too painful for the patient. Because they just wanted the arm chopped off. Olen tried to explain until he was blue in the face that we wanted to try to save this poor woman’s arm. They tried every excuse. Then they said they didn’t have money for the trip. So Bill and Laura actually gave them $50 so they didn’t have any more excuses and had to go get the X-ray.
Remember my hippo patient who I didn’t know how to do an ex-fix on? Well, now I do. We did an ex-fix on Suzanne’s radius. We tried to do one on her ulna, but it wouldn’t quite work, so we had to put a small rod in (to be removed later). After a few days... THE FLAP. This one is the ultimate flap. The one Olen’s wanted to do for years. The one where your mouth drops open in amazement that it can actually work. And not just work. Work in dusty, rural Africa. Because there certainly is a difference. But this surgeon has been in Africa for 20 years! He knows Africa and knows how to improvise! That is the key. We didn’t have the right parts for the ex-fix, so he used casting plaster to weave in between the pins and the rod to keep the radius fixed to the rod. Improvising. That’s the key. Along with flaps. The second key perhaps. To the same door.
Suzanne had a large open wound with exposed bone on her posterior forearm. So... flap from her abdomen of course. We created a flap (well, Bill really, but I assisted) from her inferior abdomen. Then sutured her arm to her abdomen! It’s still sutured to her abdomen by the way.
Ada is a little one-year-old who had a bad infection in her right groin. It was debrided and then developed into a hip contracture. She had a granulated (not skin-covered) area of about 8x8cm on her groin and abdomen. So... careful de-contracturing of her hip and then tensor fascia lata (TFL) flap! And graft her abdomen and leg, and voila. Another child saved from not being able to walk! And with a flap!
Odette had a large nose tumor. Take the tumor off and... you guessed it, flap! Pulled a flap from the side of her mouth! Leave for a month and then carefully cut if off. It’s still brewing!
Zachee, our ex-cook, had a tumor on the bottom of his heel. It was most likely a type of pre- melanoma or maybe even melanoma by now. He needed a wide excision of the tumor. So... you guessed it again! Flap for the win. This was so cool. A lollipop flap. A flap from his mid calf. He has an extra large skin pedicle for a month to bring blood supply to the flap.

Of course, nothing here is without challenges and complications. At some point during the three weeks of cleft lips and cleft palates and insane tumor resections and flaps and... our dermatome went for a swim. And dermatomes are not meant to swim. (A dermatome is a machine, ours is run on compressed gas, that vibrates a blade to take a thin slice of skin from one place in the body and put it onto another place that needs skin. The host site loses such a thin layer, that it heals quite quickly with minimal intervention. Without a dermatome, one must take a ‘full-thickness’ skin graft from a donor site, which means the original host site needs extra work to heal, and the graft itself is a much more painful process for both surgeon and patient, not to mention drastically more time-consuming.) Some exceedingly helpful and overworked nurse in the operating room was trying to do a great job and clean our instruments really well... and didn’t speak English... so didn’t read the ‘Do Not Submerge’ warning on the dermatome. So bleach water got into all manner of places where it shouldn’t have. And now we don’t have a working dermatome, which is a losing situation for Danae, who now has to spend copious time carefully removing full-thickness grafts and then treating the place she took the graft from, and a losing situation for the patient, who now has to heal up where they lost a thick hunk of skin.
So... if anybody has a spare dermatome lying around and collecting dust...

Saturday, December 22, 2018

The Béré Train

The  Bere Train
Chug-a chug-a. Chug-a chug-a. Chug-a chug-a. Chug-a chug-a. Choo-choo! What train is that?
Oh it’s the smile train.
What? Wait, there’s no train in Bere. There’s not even a paved road!
We had a lot of reasons to smile in the month of November. We were also very busy. Hence the delay in writing many of the following blogs. A big part of both being busy and having reason to smile was our SMILE TRAIN!
Was that start too cheesy?
SMILE TRAIN is an organization that helps fund repairs of cleft lips and palates all over the world. We were lucky enough to be a recipient of their special generosity this year.
Probably one of the biggest hurdles (well, we had bigger hurdles, believe me) was figuring out what to write on the welcome sign that translates Smile Train into french. THERE ARE NO TRAINS IN CHAD! So we went with ‘station’ instead, kind of like a bus stop. The sign read, “Bienvenu à la gare de sourire.”
Introductions to our Smile Train team.
Aubrey, an ED doctor from Arizona here to help with the flow of patients just prior to the Smile Train’s arrival. She helped with rounds, delivered babies, and assisted in surgery also. She took the initial pre-op history and physical on many of the patients. Thus, she knew the patients’ names and histories better than most of us.
The anesthesia team. Dr. Ian from North Carolina, a professor in CRNA school with his two anesthesia students, Jenny and Ben. Ian is a friend of our old BFF, Mason. They work together in America, and Ian is one of the few people in the world who can put up with him. We are the other two people in the world (well, Kim... and Grace and Emmie... and everybody else who’s ever met him, everybody loves Mason McD). Ian gained notoriety when he calmly slipped in a completely blind nasotracheal tube after an old lady’s airway filled with blood from a bleeding oral mass during attempt McGrath intubation.
Bill and Laura Rhodes. Missionaries in Kenya for over 20 years. Laura is the surgical assistant and organizer of many of their Smile Trains. Bill is just the guy that does all of the surgeries. No big deal. You have a 3 kg bony tumor on the side of your head. Sure, let’s take it out. Piece of cake. He’s a plastic surgeon with a love for head and neck tumors. Or pretty much anything that anyone else can’t do, send it to Bill.
Together, this visiting team made miracles happen in Bere.
It’s impossible to tell all of the stories of patients that were helped. It was sure something special to be a part of the SMILE TRAIN this year in Bere. The first annual SMILE TRAIN! We were able to see the twinkle in the eyes of the healed cleft lips. (They weren’t able to smile well yet because they were post-op and not supposed to be moving their sutured and derma- bonded lip).
Cleft lips and palates are a malformation that these patients are born with. It’s no one’s fault. Yet the whole world looks at them as if they are a freak. In America, these patients would have undergone surgery early on. But two of our patients this year were adults, having lived their whole life being gawked and stared at.
The sparkle in their eyes when they looked into the iPhone on selfie mode and no longer saw a deformed lip. They saw a normal boy or girl. Just like everyone else. Priceless.
The first group was here for almost two weeks. There was so much work for a specialist such as Dr. Bill that we asked him to stay for another week. He said he would if we could find another anesthesia team as the first group already had tickets back to America.
Wait. What? Serious? You’ll seriously stay? I don’t think Bill thought we could pull it off. He thought that was a safe bet for sure. This is the morning of November 13.
Olen was on the phone immediately. ‘Hey, so I know it’s November 13 and all, but can you fly out in four days to come to Chad on your vacation time over Thanksgiving and work like a dog for free?’
We found a guy in TN who had done anesthesia school (just for you Geach). I went to Southern with Jonathan and Belen way back when. Then I followed them out to medical school at Loma Linda. Dr. Geach agreed to come with the other Dr Geach for the week of Thanksgiving at the drop of a pilgrim’s hat. And faster than you can baste a turkey, we were into our 3rd week of speciality surgeries. More head and neck tumors. Thyroids, masses, and more clefts. And everything else under the sun.
Three weeks of starts anywhere between 5am and 6am every morning and going as late as 7pm to 10pm every. single. night. We worked HARD. God was good to us, however, and blessed us with miraculously few emergency cases to do during those three weeks, although there were some.
Here are some before and after pictures. There were 13 cleft lips and 2 cleft palates. And so many other crazy surgeries from the brain and hands of Dr Bill.
(At some point, and we will make it at this point, we should mention what amazing people Bill and Laura are. They are the most encouraging and positive and uplifting people we have ever met. And low-maintenance! We spoiled them with electricity and running water! They have raised four children in Africa, all of whom have grown up to be wonderful family-oriented Christians contributing to society. They take probably close to a dozen trips to various mission hospitals every year, which must be exhausting, but they still seem so energetic! The night before they left, they invited us in and talked to us for a very long time, encouraging us, hearing our visions, making us dream even bigger and possibly convincing us to commit to Bere even longer than we had previously imagined. You never know...)