Thursday, October 23, 2008

A Horse is a Horse... of Course, of Course & Things That Go Bump in the Night.

A Horse is a Horse... of Course, of Course.

I had not come to the other side of the planet expecting to do veterinary medicine. But, you come expecting the unexpected.

Sarah, Jame's Danish wife and lead RN for the hospital, happens to love horses, and owns 2 of them here in Bere. One of them developed some kind of abcess just above the knee on the inside of his right rear leg, just above the knee. For whatever reason, the royal "we" decided I was the one who was going to lance the thing. I was assured that this was a "good horse," that would never kick me in the face as I stooped over with a sharp object to inflict pain without anesthesia during this medical endeavor. So, I found a #11 blade in the OR and off I went to meet Sarah and Suzanne in the brick stable where they were tying the front and rear left legs together. After saying a brief prayer and strategically placing my right shoulder against his flank, and my neck pushing against his hip, I felt down the leg with my hands until I found the abcess. The horse keeps trying to push his legs together, just like a 3 year old trying not to use the bathroom before making it inside the house before loosing control. Well, after jockying for position a minute or so, I was able to sink the blade to the hilt in the pocket of pus that popped out as soon as I stepped away from the danger zone. Hmph. That was easy.

Sarah was so grateful, that the next day, when the horse came back with a HUGE, gaping, bleeding wound on the extreme upper inner left rear leg... who did she turn to? Exactly. Me. Fortunately, I was given the anesthesia duty while her husband James was cajoled into doing the sewing. Once again, we raided the OR for some equipment, paid the pharmacy for 4 grams of ketamine, 40 mg of Valium (in retrospect, perhaps a bit much, but hey... it NEEDED to be enough to anesthetize a HORSE) and about 12 million units of penicillin. I've never started an IV on a horse, and I wasn't about to learn. I made Sarah give the shots IM (in the neck muscles). It took a while, but the horse did get drunk-ish, and 6 of us combined were able to tip the horse over onto the ground. Unfortunately, it fell operative side down, making James' job all the harder. We poured some dilute bleach over the wound to wash it out, still requiring 6 people to hold the horse down and tie the legs so James didn't suffer from 4 or 5 different kinds of facial fractures while sewing up the horse's ass. I got to irrigate and cut the sutures with the kitchen scissors (finally, a pair that actually cut!).

Now if you think people come out of ketamine anesthesia badly, you should see a horse do it. This thing wigged out! it was running in circles on it's side, scrapping off it's skin around the face/eye and knees on the one side. We stuffed a towel as best we could under the head to keep the damage to minimum, but he fought SO hard, it was nearly impossible to do a good job of it. Of course of course the horse the horse couldn't feel a things he was doing to himself, and wouldn't stop either. Eventually, enough of the meds wore off (after about 25 minutes of this fiasco) and the horse could actually stand up... sort of. Sheeze. I thought people were hard to deal with. Anyway, best we could guess, either a bull gored the thing from behind (unlikely, it's a fast running horse. I should know, I rode it.), a person threw a spear/knife while chasing it out of their garden/property, or it got spooked and back into an old, stiff, cut-off palm frond (those things are like gladiator weapons around here!).

Other than that, I did actually anesthetize a human today... an 11 year old girl while James fixed her cleft lip. She really needed it, and it was her best chance at a normal life and possible marriage. My problem... I couldn't intubate this kid. The mouth just wouldn't open after we gave her valium and ketamine (no inhaled anesthesia or muscle relaxants available here). I considered injecting epinephrine around the surgical site to decrease the bleeding I knew would run down into her airway, but James and I feared the tissue deformation would alter the appearance too much. So, I shot her IV bottle full of ketamine, set the drip rate by hand, put on sterile gloves and suctioned as much blood as I could to keep it from running down into her lungs during the case. All she had to breath was room air. Running to many things in the OR on the generator power has been known to blow the generator, so the O2 concentrator wasn't a reliable option when suction, overhead lights, pulse oximeter, blood pressure cuff, and (excuse for) air conditioner was running. So, it was a new kind of airway "management" for me. Before it was all said and done, she'd lost about 200 ml of blood in the suction canister and we'd pulled out 2 very large, long clots from her posterior nasopharynx. Fortunately, she coughed up some blood a few times, and that cleared out her airway almost as good as the suction. I dripped some dilute epinephrine into the wound from time to time, and we held pressure on occasion, and learned it's true... all bleeding stops. I left her laying on her side after surgery, after briefly considering holding her upside down by the ankles to see if I could drain out any extra blood. But, since her O2 saturation hadn't ever been less than 94% on room air, I didn't think it would matter much. So I let her alone to wake up later in the day.

We were supposed to operate on a 9 month old... but the parents refused to pay (James requires payment PRIOR to operating on ANYONE. It's a policy that works well).

I spent some time trying to repair a Welch Alyn ProPaq monitor today... to no avail. Maybe tomorrow. The new power supply I brought does take the local 220V, but the plug is US style. The OR has US style plugs, but they are all on a 110v circuit. So, that'll take some work. I think it's the old lead acid battery that's gone back and has broken the flow of electricity, even when it's plugged in with a good power source. I will attempt to re-wire it tomorrow. And, if it goes "kablooey" when I turn it on... oh well. It wasn't able to be used before I got my hands on it anyway :)

Suzanne gets her local garb tomorrow (she met the taylor for measurements 2 days ago) and will shop for my cloth as well. I'm going Ossama style... turban and all. Suzanne insists she's getting me a pair of gold aviator sunglasses to wear with the outfit. Oh, and get this. She's going to throw in a pair of all leather, Ali-Habbiib sandals with the thick strap that goes all the way around the big toe (this facilitates running from the local authorities). This could be fun. Imagine me landing in Omaha Nebraska all decked out like this and walking past security. HAA!

Things you don't want to hear in the mission field: "No way, it's WAY to long to be one of my hairs."



Things That Go Bump in the Night

As you might suspect, one of the reasons they call in the jungles of Africa is because of all the animals that live and move out, about and around here. Our encounters thus far have provided various levels of entertainment for me, and sheer terror for Suzanne. The first time was when a praying mantis landed on the broken screen between us. I made an offhand comment about it, knowing Suzanne wanted to avoid ALL contact with creeping insects. She surprised me by grabbing her camera and started snapping picts! Then, as she zoomed in on it, the thing turns it's head and looks right at her with it's alien head and googly eyes. It was THEN that she freaked out. If that wasn't enough to get her paranoid... the big bats that whooshed by us the next evening were just what the doctor ordered. I hadn't seen her stop cold in her tracks like that since we first arrived in N'Djamena and saw these 10 inch lizards scurrying up and down the outside walls of the room we stayed in before coming to Bere. Then, after we got to Bere and got settled into our new rooms, she was woken up by a scratching sensation under her bed. That would've been the mice or rats. She told me the next morning she was ALMOST came and woke me up at 3:30 AM to come into her room to kill whatever was living under the bed. And let's not forget the two large spiders that live under the pictures hanging over the dinner table and come out like clock work when we sit down to eat. She's gotten used to those. It's the wasp that she wigged out over this evening, flailing her arms wildly around her head, tripping and nearly collapsing on top of me and my laptop while I was studying French using Rosetta Stone. She really hates the insects here. In fact, nothing gives her more joy than to hear the bug zapper *snap* in the evening as we sit around using iTunes to play Name That 80's Tune after dinner.

Things you don't want to hear in the mission field over dinner: "You could think of them as large pieces of sand. But I wouldn't go so far as to say there are rocks in the rice. Beans though... those have rocks."


Things you don't want to hear in the mission field: "No, I'm not kidding. We're about out of charcoal."

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