The guy with three knees

I'm sure you think it's not possible to have 2 legs and 3 knees, but let me assure you: it is.

This guy comes to us with a 2-year old tib-fib fracture, not consolidated, and he's walking. He literally had an extra joint on one leg, the ends of the bone had somehow calcified and settled like a joint. It was incredible. (See pictures!!)

We could really make a difference in this guy's life. We could give him 2 straight legs and remove the 3rd knee!! 

So after spending a lot of time removing a lot of scar tissue and calcifications, we were finally able to put the two ends of the bone together, and Dr. Scott put an intra medullar rod for the Sign-nail repair.

It was a looong surgery, and there was a lot of pulling, pushing, hammering, etc. Bones are really freaking solid stuff!! It's not easy to break off the calcifications on the wrong parts. Again, Ortho is not my thing, but the fact that we could really reshape his leg was fascinating.

I'll stop talking and let the pictures tell the story. :)

Look at that articulation!

It was not easy to bring the ends of the bone together and straighten it

So much metal to choose from!! 

That's the intramedullary rod 

(Sign nail) going in

You can kinda see the rod 

going through

X-ray before operation

Like a kid in a candy store

Remember that episode of Grey's Anatomy when Christina enters the ER and says "it's like candy, but with blood, which is so much better!"?

Well, that's kinda what I felt today, but my specific kind of "candy" are sharp objects, like needles. I love drawing blood, injecting meds, putting in IVs, etc. I'm also really good at finding veins.

But today, I got to do something even cooler: I got to do 2 spinal taps! Seeing as I plan on doing neurosurgery, this is an important skill to acquire, and I did both perfectly. 2 Champagne taps!! It was awesome. Both were for hernia repairs.

What isn't my surprise when Dr. Scott hands me the needle driver and tells me to close this guy's skin! I thought he was joking, but since he was handing me the instruments, I realized he wasn't.

So I did my 1st suture on a live patient today. I had practiced doing knots and suturing on an amputated leg, but now I actually sutured someone's skin!!!!

This might be all silly to you, but I couldn't stop smiling afterwards. Remember that I only just finished 1st year of med school, nobody gets to do this stuff this early. I am so lucky!!!

To finish off my day, I changed the a supra-pubic catheter on another patient.

All in all, this was an awesome day!! :)

Pus

We had a couple of really long, full days. One of those days, Dr. Scott had to cancel consults because we had too many operations, a couple of which were urgent. As the name of this post suggests, there was a lot of pus involved.

We had one elderly man with an old femur fracture that had only a small hole on the skin. What was weird was that he was very skinny, and his other leg was very thin, but his broken leg had a huge thigh. Dr. Scott made an incision starting from the hole and as he widened it, pus just started pouring out. We suctioned about 2 LITERS of pus from this guy's thigh. As you can imagine, there was not much muscle or bone left, it was just mush. How in the world he wasn't septic and dead yet, I have no idea.

So we called the family and said there was no way to save the leg and asked if they were ok with an amputation. Well, the patient himself, who was semiconscious*, heard it and said he did NOT want an amputation. So we closed it back up and wheeled him out to get ready for the next patient.

But now the family talked to him, and explained that really, there was no leg to be saved, it would never be functional again, and on top of that, he was going to get septic and die. So he agreed to it, and we had to take him back to the OR.

Then, we had a guy come in with a huge dental abscess. His family almost took him home, but thank goodness, they didn't. The abscess was so big, once he was anesthetized, his muscles relaxed and it actually blocked his airway. He stopped breathing for a moment and I actually had to do CPR while they secured his airway with a nasal tube and administered O2.

Again, Dr. Scott made a small hole and pus just started pouring out. It's incredible!! I can't imagine how he could take days and days of pain before coming in!!!

So today I got to do 3 things I had never done before: made a skin incision and superficial suture on a leg (the amputated one), and did CPR on a real person (not the dummies we use in class).

What a day!!!

*our anesthesia is a combination of epidural, ketamine and diazepam. Sometimes the patients are knocked out, sometimes they're awake, talking, sometimes even moving. We have no respirator, so we cannot do full narcosis.

Before amputation

After amputation

Correction

A lot of people who read my blog say things like "you're a hero", "you're a saint", and somebody lately said I was the closest person to Mother Theresa they've ever met.

Well, let me tell you something: I am none of those things. Yes, I am helping people, and yes, I love knowing that my work makes a difference in people's lives. But I am *not* sacrificing myself by being here. I like it. I learn SO MUCH, and I get to see incredible conditions that I would never have the opportunity to see elsewhere.

Plus, I am one of those crazy, insane people, who finds the inside of the human body fascinating. Think about it: you have a body for 50, 60, 70 years, but you only get to see the inside of your mouth, nothing else. To be able to see inside the body, you have to be a serial killer (which I'm not, rest assured), or a surgeon. I am on my way to becoming a surgeon, but I still have many years ahead before I can call myself that. And as a lowly medical student, even if you are lucky enough to get into the OR, you usually don't scrub in, which means you're at least 3 feet away from the table and can't really see much.

Here, I get to scrub in to 3-4 surgeries **every day**!!! I have had my hands inside the abdominal cavities of several people. My index finger has found a hole in someone's small intestine. I have touched several femurs, tibias, humerus, and held them in place while the surgeon drilled through them. I get to see and touch everything, and it is *awesome*!

So basically, I'm here because I love medicine, I am curious about the human body, and I want to learn everything as fast as possible. I've wasted too much time already, and being here gives me a huge advantage.

Please don't confuse my excitement and curiosity for sainthood. I'm just a sinner like everyone else.

Cancer

I mentioned on the last post that I was overwhelmed and tired because Tchad is hard and sometimes it gets to you.

Adorable 9-year old girl, Caroline, cones in carried by her dad. Skinny kid, but not malnourished, just normal skinny. Then she lifts up her skirt, and her thigh, just one of them, is larger than mine. It's a hard mass and it hurts when we move/touch it.

The only thing to do is to amputate her leg. So we schedule surgery for the next day.

We get into the OR and I'm already sad enough as it is, but this thing was scary. We only had one unit of blood available for her, and there were massive veins you could see through the skin. Crazy.

Upon further inspection, her lymph nodes were swollen in the arms, neck and groin, which is a good sign the cancer had already spread. We have no image studies (except x-rays and even that has to be done at the public hospital) and no pathology. No way to know for sure.

Dr. Scott makes a superficial skin incision, just a couple of inches long. And it bleeds, it bleeds, it bleeds. He tamponades it with a wad of gauze, and it immediately soaks up through the gauze. He presses it for a while and it just keeps bleeding. Eventually, the bleeding slows down enough, that he can suture it shut. It was only a skin incision!!!!!!

There was no way to go deeper. She would have bled out in minutes. There was no way to amputate. Even then, the cancer has probably metastasized to several places. We had to send her home. There are no treatment options in Tchad.  

We also had an elderly man with a giant mass in his prostate, also inoperable. And a young woman, with a baby actually breastfeeding while she was examined, with a giant mass on her face, probably a tumor of the nasal passages, which will erode her sphenoidal bone straight into her brain.

And there was a middle-aged woman with a lump on her neck. Lymph nodes swollen all over. Checked her abdomen, and she had palpable masses throughout.

Basically, cancer sucks. And there's a lot of it here, I don't know why. Little kids, adults, elderly people. And they *always* come when it's giant and you just can't do anything anymore.

The pictures below are of Caroline's leg.

Compare the diameter of her two legs

Notice the size of the veins

Tired...

Feeling overwhelmed and tired. It's been a tough couple of days here. Lots of emotions, and it's not likely to get better in the next couple of days. I'll write a proper post later, but to make a long story short, we had a 6-year old girl with inoperable cancer and had to send her home to die. In pain.

Then, the hospital administrator was robbed after leaving the bank with a substantial amount of cash.

Life is just complicated in Tchad. Sometimes more than I can handle...

Pray for us.

Miracles (photos)

Photos from the burn patient. It doesn't show her back and buttocks, but it gives you an idea.

This was the skin graft 

done on January 13th. 

This was taken on February 5th, about 3 weeks after the skin graft. You can see a small layer of fat starting to form, but there's the pressure sore in the middle...

This gives you a better idea of the extent of her burns... 

Miracles

Most of our patients get post-op infections. It's a fact of life. In Tchad, if you get a paper cut and don't soak it in alcohol several times a day, it will get infected.

We have a patient who was in a house fire. Her buttocks, lower back and thighs suffered 3rd degree burns. She came to us 6 weeks after the fire, clearly in a lot of pain, but somehow not infected. Not septic. Not dying.

We did 2 small skin grafts on her, and they took beautifully. It covers only a tiny portion of her burns, but it's progress. Her back has some granulating tissue. Incredibly and against all odds, she is healing.

If that's not a miracle, I don't know what is.

Male Anatomy - part 2

Apparently there have been a few cases of flesh-eating bacteria, with very particular tastes. They don't eat everything, just skin. 

If you're a boy and/or a little squeamish, I suggest you stop reading now. Continue at your own peril. 

It so happens that this very unfortunate guy had flesh-eating bacteria eat away at the skin of his scrotum. Not his penis, not his legs, just his scrotum. He showed up with completely necrotic skin (1st photo). 

So Dr. Scott debrided it, put him on massive doses of antibiotics, and left the wound open, with his testicles free. Luckily for him, the bacteria were not interested in his testes. 

But now comes the question of what to do with his testes! There's no way to grow that much new skin, and the tiny amount of skin not eaten by the bacteria was not enough to cover the testes. So Dr. Scott went back in, separated the two, made a little pocket under the skin of each thigh and inserted them. 

This ensures their safety from the elements, but has a particular side-effect. You see, the reason why the testicles hang in a pouch outside the body, is because sperm need a cool environment. The 37C of normal body temperature is too hot for them. So this guy has not lost the ability to produce sperm, and all his hormones will still work properly. But his sperm will likely die of heat, from being confined inside his thigh. 

The lesson of the day is: when you scratch your balls, make sure your hand is clean and don't break the skin!!! 

Necrotic skin

After debriding

The next day

Separating and inserting into thigh

Male Anatomy -part 1

I actually wrote a post about this last time I was here, but for the new comers, I'll explain it again. 

When a baby boy is born, the testicles descend into the scrotum and the little orifice which allowed them to pass down from the abdomen closes naturally. Most of the time. 

However, sometimes the hole remains open and allows fluid to trickle down and accumulate in the scrotum. This is called a Hydrocele, for those of you who want to read up. In the western world, mom realizes something weird is going on and takes the baby to the doctor. The liquid is drained, the hole is closed, and the problem is over. 

In Tchad, they don't come in until they can't walk anymore, and that usually takes years. So we get a lot of grown, sometimes elderly men, with giant scrotums full of fluid. In other words, giant balls. 

We drain it, sew it up and they can go home. With normal sized parts...

Children

(Surgical pictures at the end of the post, scroll slowly if you don't want to see them.) 

It's a recurring theme in Tchad that nobody seeks medical attention until they're about to die, or whatever ails them becomes unbearable. And since they are extremely resilient, sometimes that means years.

Today we had 3 surgeries, the first of which was a 4 year old with an exposed femur fracture for 1 year. The exposed bone was dead, of course, but surprisingly, he had no infection.

So Dr. Scott cut off the dead bone and put the 2 ends together, put them on an external fixator and closed. The hope is that the bone will actually grow enough to compensate for the loss and he will have legs of equal length. In any case, he will definitely get to walk. Again, something that isn't possible with an exposed femur fracture...

Then another little kid, from yet another motorcycle accident. That one was 10 days ago, but the arm had gotten stuck on something and almost completely ripped from the torso. Almost, but not completely. Except the nerves, ligaments and blood supply was part of what got ripped... and the result is a child attached to a completely dead, cold, putrefying arm. I'll let you imagine the smell. So it was an amputation, leaving the wound open because of the infection.

The third was a woman with a large, hard mass on her thigh. It looked like a giant mole. It was deep into her sub-cutaneous fat, but had not reached her muscles. Besides a little bleeding, it was removed without complications. Of course, we have no way of knowing if it spread somewhere else, and that thing was massive. 7cm by 5cm at least.

Anyway, I had been craving surgeries, and it felt great to scrub in again, but that little kid who lost his arm made me really sad.

Things that happen in Tchad that you have to get used to but probably never will...

Living arrangements

A lot of people have asked me how the living conditions in Tchad are, so I thought I'd make a post with some pictures to give you guys a better idea.

The first time I came to Tchad, I didn't know what to expect when it came to my living arrangements. The hospital and the living quarters are located in the same walled complex, and separated from each other by a brick wall. The house is pretty modern, with everything you would expect in a normal house, normal bathroom with shower (cold water but you don't really need it to be hot) and flushing toilet. The only exception is wifi which doesn't exist. Electricity is provided by a generator and internet from mobile phones. I got a little bedroom with a lockable door, a nice bed with mosquito net and a dresser. I was beyond happy, as I had expected a lot worse.

This year, when Bekki wrote me to say they were excited for me to arrive and my room was ready, I had expected the same room. What isn't my surprise when Bekki takes me to my own little apartment!! When I was here last, it had been a shipping container used for storage. They converted it into a full apartment, with full kitchen and bathroom! And it was just for me!!

Here are some pictures:

That's the door on the wall that separates the hospital from the residencial area

That's the outside of the house I live in

My very own kitchen!! 

Bedroom

Bathroom

Garden at sunset 

So there you have it. I really had not expected to have all the comforts we expect in other countries. Coming to Tchad is hard in many ways, but the living conditions are not one of them. Of course, this is not how the general population lives... but I'll have to write another post about that. :) 

Tchad- round two

I am sitting on a bus, crossing Tchad from the capital, N'Djamena, to Moundou in the south. I'm really excited, and can't wait to get there and see Dr. Scott and Bekki (his wife) again.

The first time I was here, it was the unknown. Arriving in the middle of the ebola epidemic, there was fear it would come to Tchad (it didn't). And like this time, I was arriving at 11pm in N'Djamena and leaving at 6am on a bus to Moundou. It was certainly an adventure and I won't deny, there was a little bit of fear mixed in with excitement. I knew that trip would change me. I was afraid I wasn't up for the challenge.

I hadn't even started med school yet, and my only training was what I had learned in a nursing's assistant course and the basics of giving shots, drawing blood and putting in IVs, that I learned during my internships in hospitals in Germany.

Now, after a year of med school, my practical knowledge hasn't changed much, except for all the things I learned my first time in Tchad. This is such an incredible opportunity, I am very lucky and blessed to be able to do it. I hope to learn a lot more, maybe even suture and catch a baby or two! (The hospital where I will spend most of my time does not have maternity/gynecology, but I will spend 2 weeks at a different hospital, where they have it!)

It's funny how the unknown has become familiar, and I can feel like I am going back home, in the heart of Africa.

I'll leave you with a picture of the sunrise. It's bad quality, but it will give you a small idea of the beauty I am lucky enough to see. Enjoy!

Irony in the New Year

Right before New Year's 2014/2015 I wrote a post about losing my phone and feeling guilty and stupid when I thought about buying a new one and how many people that money could help. But I found the phone and everything was ok.

This time, the phone was actually stolen from my bag, so I obviously didn't get it back. My mom offered to buy me a new one, but I declined. As much as it sucks to not have my awesome iPhone, I borrowed and old Samsung from a friend and it will have to do. 

I guess I learned something. 

So for this new year 2016, as I prepare to go back to Tchad and deal with real poverty, hunger, need, I hope to keep my priorities in order and remember that there are many things more important and necessary than a phone. 

And I wish for all of us, whether you have something to do with medicine or not, that we strive to make the world a better place. Even a little bit. We really *can* make a difference, and if we all do just a little, it all adds up to something great. 

Happy New Year from Berlin!!!!