So I wake up this morning at 5:30 to a call from the clinical officer. I feel good having gotten 7 hours of sleep. the patient I took out a GIGANTIC prostate from yesterday, was having abdominal pain. He had figured the catheter had plugged and his bladder was being filled with the irrigation solution to feel like bursting. He irrigated it and the pain subsided. I figured I was about to get up at six and knew I couldn’t sleep that quick so I got up. I made some toast and slathered it with peanut butter, then put on a thin layer of some fruit sauce. It tasted great. I drank extra water as I knew that since I came here I haven’t had time for lunch, thus meaning no water either (of course I don’t want to carry a water bottle all day!).
I headed in to the hospital at 7AM for the morning worship and sign out of admitted patients overnight. After that I went and started seeing patients till they had my first patient ready.
Manchiru had received spinal anesthesia and lay on the operating room table, her short thin frame exposed to all in the room. I placed a foley catheter as the circulating nurse is off on Fridays. I scrubbed and the scrub tech helped me don my cloth surgical gown and gloves. Fortunately before I came they discovered some size 8 gloves, so my fingers are not falling asleep by using small gloves! I then prepped her abdomen with betadine. I cut through her lower abdomen along the middle. Below black skin the white flesh and yellow fat opened behind the blade. Next fascia (gristle) and muscle, and lastly the peritoneum. There was yellow fluid in the abdomen. I swept the intestines towards the stomach to get them out of the way and took a look at her uterus. The ultrasound had demonstrated correctly that there were huge fibroids of the uterus. They introduced me yesterday to a uterine clamp. It looks like a giant, heavy duty, tongs with forked teeth that bend to curl towards each other. this is clamped onto the apex of the uterus in a savage way to use it as the force of retraction. The fibroid was so large it took two hands to force the handles together enough so it would lock into a closed position. The intestines were stuck to the back of the uterus, and a large fibroid protruded forwards toward the bladder. Everything was so stuck that the uterus could barely be moved with the medieval clamp I had placed on it. some intestines were stuck to each other as well. These adhesions could be spread easily and then cut with scissors. The ones behind the uterus, where the colon lay, were really difficult. Snip, feel, worry, snip, feel, worry…repeated again and again. I could free up one side but not the other. I started on the sides and when it became difficult I changed to another side. This cycle repeated over and over. Eventually the sides were freed down to near the cervix but the back of the uterus remained difficult. I decided to amputate the uterus midway so that I could have space to work easier behind in the area that was difficult. I started and got even more bleeding. We had lost 1.5 Liters of blood! The anesthetist left the room to call for blood from the lab. I decided the only way to get through this surgery was to cut through the thick adhesion between the colon and the uterus. I felt like I needed a machete as I hacked my way through the scar. This is likely the result of a pelvic infection in the past. I clamped either side where the uterine vessels lie. I had reached the bottom of the area that was accessible from any direction. I wasn’t really yet where I wanted to be, but decided that if I continued that disaster was sure to follow. I took the scalpel and amputated the uterus above the cervix. I quickly controlled the bleeding. I examined the colon and had not injured it in the process. I thanked God internally. I closed the opening and washed out the abdomen. I sutured the fascia and washed again. The skin was sutured closed and I went to the next OR.
I had a 50 year old guy that had dropped his hemoglobin to 7 (normal 14). So I did a scope to evaluate his stomach then his colon. The colon showed some polyps that they did not have any devices to biopsy them. But no obvious area of bleeding.
Then there was another 18 year old guy that had pain whenever he swallowed. So I did an upper scope to evaluate his stomach. He had ulcers and gastritis. So I started treatment.
Dr. Pierce, part of the group here with SIMS from Loma Linda Univ., asked me to see an old gentleman with COPD that had strider (an expiratory sound in the back of this throat. It had happened for few weeks and he wanted it evaluated. We put liquid lidocaine in the back of his throat and he gargled it. once his throat was numb the sound went away. I was very surprised. I look at his vocal cords with a laryngosope. Then one of the staff thought of looking with a gastroscope, so we looked with that. It gave a very good view and all appeared normal. Afterwards I realized he was probably “auto peeping”. Meaning that he had bad COPD/Emphysema and it was his natural way to pressurize his lungs to breath well.
There was another teenager that had a swollen hand for the past month. A few days before it had started draining pus. I helped the clinical officer numb up his finger. Once numb I directed her how to hold the knife and open his finger in a Z fashion. Pus poured out. We followed it and it went into his hand. So we opened on to the palm of his hand. We placed a dressing and hope the tendon that was at the bottom of the pocket of pus will heal over as well.
As I was finishing there was a woman who they were afraid of uterine rupture that had been given a local herb that makes extensive contractions happen during the labor. They started a C-section with a clinical officer. I have not helped with any C-sections because they apparently do them all here. Mid way through the anesthetist was available to do the second room at the same time. He left some random worker to watch the vitals and headed into my room. We had an older woman who had a femoral neck fracture. I prepped her leg for a traction pin to be put in her tibia. So I chose the pin site and made a nick in her skin. Then I got out the Dewalt drill and attached the pin. I drilled it through her leg from side to side, then we dressed the edges and sent her to the ward.
Then there was a couple patients for me to see. One had had upper abdominal pain for about a month who I scheduled for an EGD (upper scope) and the other was a 1.5 year old boy with a cleft lip. I scheduled him for next week.
The SIMS group was heading to a tea plantation for afternoon “high tea and croquet” and then a fancy dinner. It was an old huge home converted into a hotel by the family. We had missed high tea but headed out there for dinner. We drove out from the hospital compound and headed back towards town then veered off on another dirt road. Through field after field of tea. Eventually we went through the gate then for a couple miles further in the plantation. It was owned by an Italian family that had lived in Malawi for 4 generations. We arrived at the hotel that used to be the old house. It had huge rooms that were very ornately decorated and cost about $120/person per night. We met the grandfather that owned the plantation. He was a very energetic guy with white hair and a white goatee. We had a awesome meal at $20/person. It did NOT feel like I was in Africa. After much talk we headed home, checked on my patients and headed to bed, to sleep till 4AM. Then I received a call about someone who had been drunk and was gashed in the head with a broken bottle. I advised the clinical officer of how to close it over the phone. She felt comfortable with doing it so I went back to sleep until at 7AM when the children were outside playing.