Jared’s Blog

Last Day at the BMC

Today is my last day to work in the hospital in Nalerigu.  I come to this day with mixed emotions ….. perhaps happy that today is the last day but thinking that the experience has definitely been one of the best during my residency. 

Last night after a few hours sleep I was called to the hospital for ‘a lot of vaginal bleeding’ by the Canadian Endocrinologist volunteering here.  He knows as much about this as I know about Hashimoto’s thyroiditis, so I was very happy to lend a hand. 

Interestingly, as I was leaving the hospital after performing the D&C I was stopped by a nurse who said “Dr., we have a new patient.”  It was 11:30 and I didn’t want to stay any longer but a brief look at the chart revealed a second scenario of ‘Lots of vaginal bleeding’.  The story for this second patient was identical to the first: An incomplete miscarriage with retained products found on a brief ultrasound scan.  Both required a D&C.  In medicine diseases and pathologies ALWAYS come in sets of two’s or three’s.

 Yesterday I walked into Maternity where the nurse said “Doctor we have four c/sections today”  To my amazement they were right about three, a high amount of surgical deliveries in one day at a place where the midwives can handle breech twin deliveries.  I was able to perform two of the deliveries, the surgeon completed the third.  Again, in medicine diseases and pathologies ALWAYS come in sets of two’s or three’s.

The fourth case they presented to me was a lady with 2 prior vaginal deliveries and a C/S on her third pregnancy who was making steady progress through labor.  Each time I evaluated the patient her cervix continued to dilate appropriately, her pains increased, and she began demanding another C/S to stop her pain.  At my last evaluation before going home she told me “If you FEAR GOD you will give me a C/S”.  I can’t remember what I told her except that it was safer for her baby to come through her vagina than by the knife, even if it hurt alot.  How’s that for being a compassionate male?  (The surgeon was called by maternity to evaluate her for surgery after I refused …. He said “It’s labor!, woman was made to suffer” How’s that for a compassionate surgeon?)

My month here has been amazing for a few reasons, chiefly that Dr. Faile arrived during my second week.  He is the son of the surgeon who started the hospital, he served here for twenty years and returns now on a yearly basis to ‘help out’.  I am glad his month coincided with mine. 

I call him the ‘Godfather’ of Nalerigu.  After the word got out that he was here many people came everyday from miles around to say hello and ‘pay their respects.’

He has taught me how to sew up bowel on a typhoid perforation, shown me hydrocele and hernia repairs, let me saw bone during a leg amputation, yesterday we did a skin graft.  I want to be like this guy some day.

Funny stuff for medical folks

A few remarks on Obstetrics and Surgery in Africa:

On the subject of incisions: A vertical skin incision is perhaps more accepted than the Pfannensteil.  Luckily the current surgeon performs Pfannensteil’s which makes it acceptable that I do the same.

4) If a Baby seems hesitant to come out vaginally:

I’ve learned that a 1/4 tablet of 200 mcg cytotec placed in a vagina can equal 40mU/min of Oxytocin through the IV. A vaginal birth WILL occur.

When it rains it pours.

I had a late night over the weekend in a rather difficult c-section, the case went poorly from the start and I was thankful that momma and baby did OK. 

 The next morning on walking to the hospital I received a call from the ER doctor working here that there was a women in labor in urgent need of an evaluation due to bleeding.  I walked into L&D and found a lady with a rather protuberant and double-humped abdomen.  Ultrasound confirmed my suspicion, twins! After a late night and not much sleep due to the concern over the previous case I was in no frame of mind to perform another surgical delivery, but the surgeon’s phone was off, the ER doctor couldn’t operate, so it was left up to me.  I spent the next few minutes pouring over a few books (I have only delivered twins once before) and PRAYING.

 The case went well, above are the twins … one boy and one girl!

The next morning I performed C-delivery #7 here and was greeted with a surprise … an extra amniotic sac and another baby!  Below are the twins …. one boy and one girl!

Days gone by

We have settled into life here in the BMC in Nalerigu but the situation is unsettling.  The hospital is wonderfully equipped but overly full at all times.

 It’s past midnight in the BMC and Dr. Etu and I lean in over the body of an 11 year old Female recently discharge from a hospital in WaleWale down south.  They discharged her after nine days because ‘her condition wasn’t getting any better’ according to her mother.

As I listened to the story and looked at the girl I get a feeling in my stomach - she is sick in a way that makes Doctors nervous.  Her exam was difficult, I suspect she had been given medicine at the previous hospital; she slipped in and out of wakefulness and listlessness. Her abdomen was taut and felt like fire to the touch.  I called the Nigerian surgeon Dr. Etuh to evaluate her condition and the decision was made to take her to the OR.

 The case began with a mini-laparotomy - a short incision made below the umbilicus to get a glance at what’s inside.  If things look allright then the abdomen is closed, if not the incision can be extended higher up to the breast bone.

 Upon entering the peritoneal cavity copious amounts of rank-smelling green fluid pour from the abdomen.  After the waterfall subsided our incision was lengthened above the navel up to the sternum. Intestines spilled out covered in filmy bacterial exudate and black spicules colored the bowels from local ‘herbs’ that had been given to the child.  The typhoid (Salmonella typhi or paratyphi) had chewed two smalls holes in the final section of the ileum about 5 inches from its connection with the colon. 

This condition happens to be one of the most common surgical needs here in Ghana.  Because of the late presentation and neglect the child was in full-blown sepsis and her chance for survival seemed especially dim.

 On finishing the case the surgeon noted that a portion of his work looked unacceptable - one end of the intestine looked ‘dusky’ and no longer fresh. He tediously spent an additional hour removing his suturing to free up a section of bowel and make a further resection to healthy viable tissue.  Dr. Etuh remarked that if the child lived he did not think she would survive an additional operation if needed.

The child made it out of surgery after copious irrigation to decrease bacterial load and with a freshly made ileostomy draining onto her abdominal wall. 

The next morning I was called at 11:00 to sign a death certificate.  I approached the bed and saw our child lying with one arm draped lifelessly accross her abdomen, I stared waiting to see her chest rise and fall, rise and fall …. but nothing.  No sounds through the stethoscope. 

I looked down at the ileostomy and noted the perfect sutures placed specifically to cause a stomal stump of the correct height and width.  Both holes were patent and draining well. 

No matter what you do sometimes a person can’t be saved, but I admire Etuh for trying.

A story from Africa

The sun has set and the guinea fowl are making noise and music with a background of crickets chirping amongst other bush critters outside.  The noises work as a harmony coming through the screen door to the operating suite and are in stark contrast to the events insides.  I am transfixed over a patient in a scenario that only seems to occur in Africa, or so the stories from other travelers and medical journeymen out in the international scene come to tell.

My journey to Africa was set long before I came to be a physician, it came from years of my Grandfather’s stories of traveling as a hunter on Safari for big-game animal.  I would listen as a child to his tales about piloting a B-26 Martin Marauder during the War, and then later to his quests for the next trophy on Safari.  All told he traveled to Africa 7 ot 8 times before age and dementia caught up with him but his pictures and stories have lived on in my memory.  He never came home without bringing me some trinkets like a miniature zulu shield or a ziploc bag full of foreign demonination to go along with his stories and images that were always a little other-worldy and left much to think about.

Although I never much understood hunting and the quest to bag the next trophy I know that my Grandfather donated the meat from his kills to local villages and was very generous with his tourism dollar.  I feel in a way that I am relating to a man I miss dearly in coming on my second trip to Africa to learn tropical medicine and provide care for a continent that my Grandfather felt so dearly about.

As I sit on the stool air brushes across my moist face from the AC unit stuck in the wall and I try not to become overly cognizent about what I’m doing or the fact that I’ve never performed this procedure before.  My residency at a high-volume county hospital in Texas has left me with the most procedural training amongst the current doctors available in the little hospital this evening, so I go about the work knowing that I’m helping the mother.

 The patient before me is pregnant, or had been for about twenty weeks until she went into spontaneous labor with a breech baby.  She came to the hospital for the delivery of a baby that had surely passed away prematurely, perhaps days to weeks ago, and was now ready to leave her body and make way for new life.  The medical term is IUFD, which stands for intrauterine fetal demise. 

 The midwives had cared for the breech as they do here until the body descended and stopped, the head wedged in the uterus and pelvis.  They applied traction gently and then with some force but found the body to be unwilling to come so more traction was applied.  After some time of this they panicked and called for help.  After examing the mother it became clear that the damage was done and the body was no longer attached; only a head and placenta remained.  This would need to be removed quickly before infection set in.

After the patient arrived to the procedure room she was placed in lithotomy and I had the nurse administer Ketamine, a dissociative amnestic to help the Mom relax.  I was given a fresh surgical kit full of instruments that I recognized and a few that I didn’t. Fortunately one of those instruments I didn’t recognize nor know the name of turned out to be very important and well-designed, like a pair of miniature forceps, for the head delivered easily and correctly with their application.  Afterwords the bleeding was well controlled with cytotec and a gentle curretage of the uterus. 

I’m confused about why I share this particular event today.  I could have reflected about all the fascinating Malaria I saw or the skin tumor the size of a brick or any of the other incredible pathologies I came in contact with today. 

Maybe I share the story because something went horribly wrong and I helped prevent a further bad outcome.  Maybe it’s the concept of growing up a little, flying by the seat of your pants and figuring out a new skill in the process.  Maybe it’s just that the images of what I’ll remember today are a little overwhelming and other-wordly and I need to start the process of thinking about it. 

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