Good Friday. I had much better plans for the day. Proof that things never go how you intend in Africa. I really wanted to have a nice normal day in the hospital, do the scheduled surgeries, and then "celebrate" Good Friday. They showed the Jesus film in Lingala around 6 or 7pm and I was hoping to do a worship time in the evening after that with the group. Well, none of that quite happened, so I guess I should back up and give you the scoop of the day....
Morning report was bit more filled with case reports of stuff going on around the hospital, which just means the night team had a busy one. All things they were able to handle, and at least there was a baby born that made it, so that was nice to hear. We had a meeting afterwards and discussed some other hospital logistics, then we headed off for rounds. So far so good. We saw a couple patients in the Salles de Urgences, one of whom I'll come back to and give you her full story, but she was a bit sick, but looked like at the moment she was under control. The scheduled surgeries for the were with Boni (probably spelling his name wrong, sorry), who is I believe an NP of sorts who was trained in specific surgeries and thus qualified to do those specific procedures. Anyway, Dr. Wegner was off the hook for the most part, though he popped in a couple times hear and there. They asked if any of us would be willing to help, and the others seemed a bit hesitant because Boni doesn't speak any English really, and I think the last time they worked with him they weren't sure what was going on. Anyway, I like awkward situations remember, and the worst that can happen is I stare blankly through my mask and say I don't speak French. It was better than that thankfully. Sephora (the French medical student) came with to help translate during the first case and let Boni know I would be assisting him.
First up was a young boy, 5-6 maybe, who had a congenital inguinal hernia/hydrocele. His case went pretty smoothly actually. I first assisted during the case, and I've seen enough hernia repairs in my time so I didn't really need to communicate in the same language to get the gist of what was going on and help him. The poor little guy was sobbing before we started, and it is annoying to not really be able to say anything. But once we gave him the ketamine that settled him down. Anyway, at the end of the procedure Boni tried to ask Sephora to ask me if I could do the closing stitch, and I was like oh sure, I can do a running subcutaneous stitch? I don't think it was translating easily for Sephora what I was saying so he just handed me the suture and said go for it. I stared closing with the running subcutaneous (which is the stitch I've always done in the past) and was what he was hoping for. Sephora said afterwards he said that he was happy and she said "I made him like me." Which is good. Always good to get the local health care people to like you. If I wasn't sure, when Dr. Wegner came in Boni said to tell me he thought I made a very good assistant. So, positive thing for the day anyway. When we went around the room stating our names and position I said, "Aaron, assistant." Andreas, one of the nurses/assistants for the surgical block asked me to say it louder and repeat. I did, and he asked again. Then Sephora said that they couldn't really understand the "Air" (aa) - "ron" for my name. So I said it more French sounding and they got it.
Next up we had a D&C for retained placenta from a woman who had recently delivered. Dr. Wegner came in to do an ultrasound during the procedure, and it was overall a pretty quick one. Didn't smell so great, but when did retained placenta ever smell good? By this point in the day it was about 1:30-2pm and I ran off to grab a quick bite to eat. I will tell you a bit about this meal since it finally had.....CROCODILE. Yep, awesomeness. Did you eat crocodile today? Probably not. This wasn't like the ground crocodile meat in spaghetti either, this was chunks of crocodile meat. He must have been snapping not too much earlier. I guess it's kind of a mixture of chicken, pork, and steak. It kind of tastes like chicken and pork, but is chewier like steak meat, and has kind of a pork look to it. I have some pictures of the raw meat from the market I'll show you later. Anyway, fully refreshed by my crocodile lunch I headed back to the surgical block.
I walked in, changed back into my scrubs, and Boni saw me and pointed for me to grab an apron and scrub in. Good, I thought, he wants me to keep working with him. I scrubbed in and went in to the OR, not really sure what the case was. I knew there was a potential abscess drainage (you know, the whole pus thing), but found out that it was actually an ectopic pregnancy that we hoped hadn't ruptured at this point. I guess he gave me the apron because he thought it would get messy. Once you've cut into a few abdomens you get the hang of the operation, and I've done hysterectomies and ex laps, so since we are going to the same area, it was easy to follow and figure out what he needed to operate easily. We got in and found the ectopic pregnancy in the fallopian tube, and were able to make an incision along the tube and remove the fetal products without really damaging the tube. The surgery also went pretty well. Afterwards, Boni asked me to close again, this time with simple interrupted stitches as you would normally do for an abdominal incision like this. She had a cesarean section about 10 months prior, and we went in through the old scar, which made the repair....fun (difficult to stitch together old scarred tissue really nicely). That about did it for the surgical cases. I'm sure at this point you're thinking, so what was so bad about today? Everything went well. It's not that it was bad to this point, I actually figured the day had gone well and I guess was feeling to relaxed for a moment. I stopped by the ER and found Amanda, still working with this poor little two and a half year old girl. I'll tell you her story now.
Basically, she came in with cerebral malaria. It's a pretty bad form of malaria, and I recommend using wikipedia if you want to understand details. Anyway, they usually get really hypoglycemic and they have seizures, on top of having the fevers and such already. The possibility for seizures and hypoglycemia is multifactorial, but the glucose can drop because the infected cells are already using more glucose than normal, and there isn't enough going to the brain. Her case was bad, she had 4+ malaria (scaled 1-4). On top of that, the Quinidines, the drugs sometimes used to treat malaria, can also cause hypoglycemia. I guess her family at home accidentally overdosed her on the quinine drugs too. So that added to the mess. Then, well we were in surgery, she vomited and aspirated it into her lugs and was having great difficulty breathing. So I walked in and saw Amanda dealing with this sick little girl and jumped in to help. We were trying to get the pulse-ox to work so we could get her O2 sats, which took like 2 hours I think to finally find one that worked. We had to suction her lungs out as best we could, suction through her NG tube too cause I think she was still aspirating, and try to give her diazepam as she was seizing consistently. Main thing at that moment was trying to get her to breathe. We don't really intubate here cause we have no way to keep them ventilated. We had oxygen running on her and that seemed to be helping a bit. Her lungs were really congested though and just sounded awful. Dr. Kiong was sitting there and asked if I knew how to do chest physiotherapy like they do in cystic fibrosis patients. I was like, well we don't have a vibrating vest to put on her, but I can percuss around on her lungs and see if it helps. So we held her up and started drumming on her back and chest trying to break up some of the junk. Between that and Amanda suctioning out her lungs as we did it, she actually started satting higher and her lungs started to sound clearer. I dunno if it's paper worthy, but hey it worked for her so I'll take it. We kept suctioning her, percussing the back, checking blood sugars (really low, like below 20 and probably lower....it just says "low" when that low) and giving dextrose, deciding to give blood because her hemoglobin had dropped a lot (hemolysing from all the malaria), and trying to keep her seizures under control.
At this point I realized about 4 hours had gone by when Dr. Wegner, Kara, Stephanie and Jason showed up. Amanda and I had been so busy with her the time pretty much flew by.....and yet dragged on. I spent another several hours with her just trying to keep her stable and praying that she kept breathing. We tried to get some phenobarbital, but couldn't find any in the pharmacy and I don't think they could find any in the town either. We finally were able to get some blood and started that. She's B+, just like me, so I was about to hook myself up and give her my blood when they came in with the bag. So we kept going back and forth - blood running.....then check glucose and give dextrose.....oh, she's seizing again, let's give diazepam.....ok blood hooked back up.....suction her out.....give diazepam....check glucose again.....you get the idea. With how many kids die from things this, it's hard to watch when you think to yourself "ALL I WANT IS SOME PHENOBARBITAL TO HELP STOP THE SEIZURES!" But alas, there's none. Things like that, or even trying to find a pulse-ox that works, or a glucometer that works, and you can't, and you don't know what her oxygen percentage is....it's what makes it difficult. Really start to appreciate the ease of the medicine we have in America. I was trying to get this glucometer to work and I joked to Amanda that I usually just put an order in the computer for accuchecks and it magically shows up in Epic saying what the glucose was. Here I push the meds, check the sugars, give dextrose, set up IVs, etc. on top of whatever else. Really just the bread and butter medicine that maybe you see more on TV typically.
By this point we really realized how much time and passed, and found out that one of our doctors had a temp of 40 degrees Celsius (like 104 Fahrenheit), so we sent him to bed and realized he might have malaria. Jason was feeling a bit tired as well, and hopefully he's not getting sick. He's only here through Tuesday, so we want to keep him as healthy as possible for his last few days. The little girl's uncle is one of the nurses, so we showed him how to check and administer everything, and left her in capable hands. I was just packing up to leave when a motorcycle accident rolled in. I ran out and the guy was on a wheelchair moaning loudly. Unable to ask him really anything other than "Wapi?" (pain?), to which he didn't respond anyway, I took a blood pressure and got a pulse ox set up. Basically all his vitals were stable, his heart and lungs sounded good, and he didn't have any abdominal pain or pain when I palpated the rest of his body....so I'm not sure of what was going on. Amanda came over and asked him where the pain was and he said everywhere. I think he was a bit hysterical maybe from being freaked out he got thrown from his motorcycle, but overall he seemed okay. He said something about maybe losing consciousness, but I'm not sure as it didn't look like he hit his head.....I can't really understand what they're saying anyway. We started an IV and left as he was clearly stable and not in any threat of dying right then and there.
So that's my day. At this point it was about 10pm and too late to really do any worship time. I know they usually do movie night on Fridays, and tonight was Star Wars Episode 1 as well. I think Jason stopped by and grabbed a bite to eat over there during movie time, so at least he was able to eat something. I headed back to the house and snacked on some beef jerky and gatorade (dinner of champions). Really the day was pretty good as everyone survived to this point, all the surgeries went well, and the little girl is doing a bit better. It's just the frustration of not having basic medical equipment that is maybe wearing on me a bit.....and it's so hard to get some stuff into the country as well. I guess most of the trips I've done in the past we've come fairly prepared with things we needed and I never felt like my hands were entirely tied. Sure, things are never ideal, but usually we can figure something out. I guess it was the moments that I sat with Dr. Kiong today and we said, "Well, what do you think we should try next?" So just a long day, but nobody died, so I'm thanking God. And praying that during the night the little girl survives. It'll hit me a bit harder if I wake up tomorrow and hear she didn't make it through the night. I'm tempted to run back over there now, but really we've showed the nurse what to do and we don't have the equipment or facilities to do much beyond that if she stops breathing and such. All I can do is hope and pray.
Anyway, thanks for reading. Sorry if I come across overly frustrated. I am very thankful for the people I get to work with and what we do have here, which is more than what they would have if not for the hospital here. So, there's a plus side. I won't post this until tomorrow (Saturday) because I don't have internet at this point. I think we are rounding with Dr. Wegner in the morning and we'll see what unfolds for the day. Sounds like he's on call, so we just wait to see what comes in over the weekend. I know we are planning some stuff with Sarah that is upcoming, such as a jungle walk, and not sure if we will arrange any of that over the weekend or not. Going to be awesome though. Keep praying for all our patients, especially the sick little ones who really need an American pediatric hospital with equipment....but thankfully Dr. Wegner is ER/peds so we are pretty set. Have a blessed evening.
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