Third Shanksteps from Malawi
Today, Wednesday, is the day I go to Blantyre and have a surgical clinic in the morning. the hospital vehicle leaves at 7:30 so I was in the hospital making rounds at 6:30. I started in the male surgical room. Saw one patient then saw a commotion in the furthest bed near the wall. Siti and I walked over to the patient where two nursing students where holding the tip of the penis of the man I had done the elbow reduction on yesterday. Blood was pouring past their finger and there was a large pool between his legs and on either side of him. I grabbed some gloves and held pressure between his legs where the prostate is. With pressure the bleeding stopped. I held for five minutes as I figured out what had happened. One of the nursing students came to evaluate the patient this morning and the patient complained that he couldn’t urinate and his bladder was full. This student went and go the student that had placed the catheter yesterday. the two noticed there was no urine in the bag and decided to take it out. They deflated the balloon and pulled it out, with the ensuing fountain of blood that wouldn’t stop. A nurse had decided the man needed a urine catheter yesterday in preparation for his elbow reduction (which had not been ordered), and told the student to go do it without supervising it. The patient had “just urinated” so when he inserted the catheter and no urine came out, he inflated the balloon. The patient had much pain, but the student told him that that is the way it is! Thus the balloon was blown up in the urethra and not in the bladder like it should have been. So removing the pressure let loose all the vessels that had been damaged causing significant bleeding. The bladder was now full and I asked them to try and see if he could urinate while I visited with my other patients. At about 7:25 I got done and went back to check on him. NO URINE had come out, but the bleeding was fairly well controlled. I ran to tell Cristy what had happened and asked her to do a bladder puncture to let the urine out, so he could bide time till I came back in the afternoon after clinic.
It was a beautiful day to be driving through the tall slender stands of eucalyptus, little groves of pine, and huge fields of green tea plant. The road was mostly paved and had shallow pot holes all over. Most had been filled with dirt to make them smoother. Women were walking along the road with large loads wrapped in a cloth on their heads. Mini vans passed by constantly taking 18 people to and from town. A rare 125cc motorcycle whizzed by with a couple guys with helmets on. A few large trucks traveled this road, traveling slow to save gas and tires from the potholes. We passed small villages with a small market area. Houses are built of clay bricks and most are topped with a tin roof, some are thatched. There were 7 of us in the land rover, and we arrived to the clinic.
The midday was slow for me. I diagnosed a fluid collection around a man’s testicle, a woman who had colitis (inflammation of the colon), a man with a keloid in the central portion of his chest (this I injected with long acting steroids), a man with a peri-anal fistulae, a woman with severe reflux in spite of medication, and a late teen who was after surgery and had a ostomy and bowl leakage coming through his incision, and a woman with a urine infection after having a hysterectomy.
At noon the patients for me were done. The car would not come to get us till 4PM. So I sat in the office and waited for Dr. Chipolka to finish so we could go eat together. During my wait an Indian man named Adam, came into my office for a dressing change. We was a fourth generation Indian to live in Malawi. He said he new Cristy and invited me to his house to spend the afternoon with his family since he found out I had nothing really planned. I left with him and another gentleman in his Toyota Corolla. we wandered through various streets of town and ended up at his 15 year old daughters school, “where I used to go to school”. They both spoke perfect English and the local dialect, chechewa. We went to their house. He showed me their store and their house with a huge fence around it across the street. inside were tile floors, three fish aquariums, an african grey parrot. I met the rest of the family then we sat down and ate. There were about 10 different dishes of food in small quantities. We all took a small amount of each, filling our plates. then we dug in with our right hands! (the clean one, as the left is traditionally used for wiping yourself). It was very tasty. Afterwards we sat around and discussed fishing, family, work, and a little about the new female president of malawi. At 4PM he took me back to the clinic.
As I waited I read a book. Dr. Chipolka invited me to go get local transport and go into the market area as the car would not be ready for about 2 hours. They were trying to pick up blood from the blood bank. We walked around and saw the supermarket, the clothing stores, the random item shops, and a shop strictly for kids about 0-4 years. was very interesting to see the things that are available for the one who looks around.
At 6;30 the land cruiser picked us up. We drove back just after the sun had set. Arriving back at the hospital. I found Cristy and asked how the guy had done that couldn’t urinate in the morning. She and then a clinical officer had put a needle into his bladder from his belly whenever he was in pain from to much urine. I decided that I needed to take him to the operating room. I planned on opening his bladder, placing a foley catheter backwards through the penis then connect another catheter to it and pull it in the correct direction.
We took him to the OR, he got a spinal, then I attempted placement of a large catheter before performing the surgery. Thank God, it went right in. We were all happy to go home around 9PM.
At 10:30PM I got a call from the clinical officer on duty and the covering general doctor. There was a 22 year old guy who had been in the market in the afternoon, had a problem with someone over 100Kwacha ($0.45) owed to someone that had escalated when the guy tried to collect his money and was stabbed in the inner bicep. They had put a bunch of clamps into the wound and the bleeding had slowed. They wanted help taking care of it. I threw on some shoes and headed in. The wind was blowing, everything was black except for the brilliant milky way and the southern cross. The guy, Precious, is laying on the exam room bed with blood all over him. Blood is covering the sheets that on him. A random appearance of surgical towels around his right upper arm identify the area of bleeding. Clamp handles are sticking out of an open wound on the inner side of his bicep. Precious seems to be going in and out of consciousness. and IV is running in his left arm. Female family members wait in the waiting room just outside and there are two young men in the room with him. Dr. Chipoka and Amie show me the area. The bleeding is currently stopped but nothing had been used to clean the skin in all the commotion.
I grabbed some betadine and swab everything on the arm including the instruments. I don sterile gloves that are quite small and check out the area. It appears to me that one of the clamps is on the median nerve. The brachial artery is clamped as well. Before donning gloves the entire arm and hand were very cold, so this confirms my findings. Apparently when he arrived from a nearby clinic, he had had a tourniquet placed about 5 hours before. I unclamped the one on the nerve and immediate bleeding ensued. Then I was attempting to stop it just as they had. I realized this was not something that would be able to be fixed easily so asked them to call the operating team. I probe the depth of the wound and my whole finger disappears to where I suspect skin is on the opposite side. He has received multiple bags of IV fluid and I ask them to find the lab tech and order blood. Fortunately when I was in clinic in town yesterday they had picked up blood from the blood bank. they never have much but had some. They attempted to call the lab techs, then the other ones not on call. None answered for the subsequent two hours! Finally a hand carried note to their door produced one unit of blood, in stead of three, right at the end of surgery.
We lay Precious on the operating room table, and stripped all the bloody cloths off him. His arm was prepped while I scrubbed my hands and arms with the local liquid soap that’s available. The scrub brush is the same I’ve used ever since I got here. I extended the stab wound in each direction. This helped to show the vessels and nerve better. The vein was a labyrinth around the artery. It was cut in numerous areas and the artery was severed in a strange shape. It was quite tedious trying to figure out the anatomy. I eventually deciphered what everything was and anastomosed the artery back together. I questioned the arms viability as I did not have any catheters that are used to pull the clot out of the artery the had been held shut with a tourniquet then a clamp. The vein was irreparable and I tied it off. The nerve I sutured back together in hopes that it will grow and he would have function again. At the end of the surgery just as the anesthetist was going to remove the breathing tube he started vomiting. A thick paste of whatever he had eaten flowed out of his nose and mouth. he was not yet conscious and thrashed back and forth on the bed. It took 4 of us to hold him on the OR table while he vomited repeatedly. We wiped vigorously each time as the suction was to small for the size of the things coming up. After about 15 minutes of retching there appeared to be no more to come up so we were able to extubate (remove the breathing tube) and take him to the ward. His arm remained very cold and had no palpable pulses. I made my way past the numerous hospital buildings, through the trees to Cristy’s house. I took a warm shower but still was to wound to sleep so I wrote part of this that night. “God, please help Precious arm to live and be functional” I prayed as I drifted off to sleep for 2.5 hours before they called at 5:30AM for anther patient.