Shanksteps #1 Malawi 2013

Audrey and I arrived yesterday to Malawi. It started as an eventful trip. We arrived at the airport in Portland. As we were getting up to check in at 4:45PM we checked our passports. Wouldn?t you know it?my passport had expired three months ago, and I have to have it to travel to Malawi. I was stumped. What to do? I called an online passport agency and they said turn around was three days at the soonest. But they said if I was able to go to the passport agency that they can sometimes turn it around in a day. So at 4:55 I was able to get a person in the one in Seattle. They said it was possible if I had proof of a flight, and was there at 08:00am. So we rented a car and started driving. The next morning I arrived at their office when they opened and ended up 10th in line. But with lots of prayer and redoing passport photos, I was able to get a new passport that afternoon. That evening we took the 4 and 1/2 hr flight from Seattle to Washington DC. After a couple hour layover, flew 14 hours from DC to Addis Ababa, Ethiopia, and ate injgera and Chiru (tasted great). Then from there to Blantyre Malawi, about 4 hours. Audrey and I hit the sack early at 7PM and slept the whole night through.
Today I had 5 surgeries scheduled for me and ended up doing 8. The first was unable to urinate and had a bladder catheter through his abdominal wall the past month so that urine could pass that way. I talked to him with one of the nurses translating, answered his questions. He lay on the operating table, exposed to the world. Nurses, nursing students, anesthetist and scrub tech, milled around the room making preparations. After the spinal anesthetic was in, his abdomen was prepped. I placed the blue towels in place and the drape. With one cut of the knife, I was through the skin and non-existent fatty layers. Following the catheter into the bladder, I cut through the scar tissue by the catheter. Finally identifying the bladder. I opened the bladder and then stopped the bleeding. The prostate was huge. I shelled out the prostate from its place. The urethra (bladder emptying tube) was narrowed and I couldn?t get the next catheter in. So I put a small catheter from the bladder out the urethra then attached the other one to the end and pulled it in. Closed the bladder, put a drain in place and then closed the skin. Later I was told his catheter wasn?t working. Nursing students were all over the place but a nurse was nowhere to be found. After two episodes of this I finally told the clinical officer and he will watch him this night.
Next was a young woman with HIV that had an empyema (infected fluid around the lung). I placed a chest tube and got milky yellow fluid.
Back in the operating room, an older man lay on the table. He had a swelling in his scrotum for a long time. It was about 11 inches long and 4 inches wide. A hydrocele, a collection of fluid around the testicle, was what I would take care of next. After spinal anesthetic he was numb below his umbilicus (belly button). I opened the scrotum and released the tissues around the sack of fluid. I opened the sac and resected most of it, everting what was left. Placing the testicle back in the scrotum I closed the layers, leaving a drain in place if any blood collected in the area.
I did 4 EGDs (esophagogastroduodenoscopy- that?s a mouth full). Scoping the esophagus and stomach is rather simple, but requires sedation for most people to tolerate the gagging sensation. I think it ended up being a combination of sedation and gagging today. The anesthetist gave less than I preferred, but all tolerated it quite well in spite of it. I diagnosed esophageal cancer, gastritis, gastric ulcers, esophageal Candida- in these patients.
Last was an older man with an infected gall bladder. The infection had resolved on his lab work, so I wondered if the diagnosis was correct. I repeated an ultrasound. I could see the gallbladder wall was thin, I couldn?t see any stones, but there was sludge (like sand inside). I saw a collection of fluid I couldn?t explain. So I decided to take out the gallbladder anyway. Since laparoscopy isn?t really feasible, I did it open. (thus large incision verses small incisions with a camera). I opened the skin, fat, muscle, into the abdomen. Upon entering the abdomen, I got dark bloody fluid. After freeing up adhesions to the gallbladder(gb), I saw a black necrotic gb. So the difficulty of taking out the gb started. It was falling apart as I retracted it. I soon realized I couldn?t get off the liver. So I took off the front wall of the gb. Down at the base I was able to find the duct draining the gb and tie it off with a stitch. I irrigated the whole area and then closed.
After that I went and checked on my post-op patients again. Walking ?home? about dusk, I heard the college students having evening songs at their worship, and observed a beautiful sunset.
The first day of surgery at a rural mission hospital, it was a good day!