Chad #9 2019
It’s mid-day, and I’ve done a hernia and then an old guy with a large prostate.
I’m asked to see a patient in the adult ward that they cannot get a urine catheter into. The nurse says it only went in about 1cm then couldn’t go further. That’s a very unusual place for a stricture so I go, expecting to just be able to place the foley with out a problem. An old man is lying on a mat on the floor between the beds and appears to not be moving his right side. He must have had a stroke. He looks at me but cannot speak since he came in to the hospital. I try the 16F foley, no go. I try the pediatric 10F foley, and it wont go in either. I know I just used our urethral dilators so they are not clean. I ask the nurse to go to the OR and get a long Kelly clamp. After a lot of lubrication, I slide the Kelly clamp in and it dilates up the urethra, the mans good hand grabs mine as he has some pain. Eventually it’s large enough that I’m able to get the 16F foley in.
After the next hernia case Dr. Stacey asks me to see a patient on the adult ward with abdominal pain. She says he has typhoid and his abdominal exam has changed overnight and he seems much more tender. I go to the adult ward and find the nurse and ask him to translate. The beds are lined up against the two walls. I stand between two beds facing the patient that I’m to see. He is about 30 and lies there grunting softly. I tap on his belly with one finger on top of the other. He winces at every tap. I push in slowly, and let go quickly. He jumps in pain with obvious rebound tenderness. I think he must have perforated his typhoid. I make an order in the system and send his family to the pharmacy to pay for medicines. Later on, this order seems to have disappeared, as he has nothing written when I check it post-op. [I had an ER nurse change my orders on a patient today, to diminish the length of treatment and add in another two medicines that I did NOT order, in order to “make it cheaper for the patient”) VERY FRUSTRATING!!! I addressed that with that ER nurse] After I wrote for the medicines I informed Phillipe and Abouna about the new surgery. They send some student nurses to get the patient. After the spinal and our betadine prep and cloth drapes, we begin. I expect to find typhoid perforation so I cut in the lower abdomen. Upon entering the abdomen I get cloudy fluid. Since he required ketamine at the start too, he is now tensing his abdomen and the intestines are pushing out at me with every abdominal force the patient makes. So rather than trying to hold them in any longer, I let them pop out all over. I see some pretty inflamed intestine that is obviously effected by the typhoid. I don’t see any holes though. I follow the small intestine to the cecum and there is some pus there. I search around and start opening up a stuck area near the back side of the cecum and a fair amount of pus flows out. I find a retrocecal appendix. I do an appendectomy and then wash out the abdomen. It’s very easy to wash the intestines as most of them are pushed out onto the abdomen. Now the struggle to get them back inside. Abouna and I pull hard on the edges of the rectus muscles and try to stuff intestines back in. It feels like a loosing battle. Little by little, we are successful and he holds them back with one hand, once their inside. I slowly close the fascia from the top down. I wash the incision again and then close the skin loosely, leaving space for pus to escape if the incision gets infected.
I check on the consults that are waiting. The last two I see I worry about if they need operations too. One is an old man who has had urinary retention for 6 days and says they have been unsuccessful at getting a foley in and at a dispensary they’ve been putting a needle through is abdomen into his bladder to drain it, these past 6 days. Abouna tried to place a foley without getting any urine. So I try and slowly get it past the prostate, and about 500 cc of urine comes out. Next is a man with a strangulated hernia. He walks in fairly well, and I doubt he’s strangulated. I push on his inguinal hernia for a little bit and get it to reduce. I send both of these men to the pharmacy to pay for surgery and then we can do them in the next couple days.