Shanksteps Bere April 2023
I go in this morning to see who is on the list for surgeries today. There is a girl with an abdominal mass, a old woman with an abdominal mass, an old man for a prostatectomy.
The girl is about 8 years old with a abdominal mass that feels quite a bit larger than a soft ball. She is on the OR table after her spinal anesthetic has been placed. The mass feels mobile but attached. I ultrasound it and find a solid tumor. Is it a mesenteric mass like Dr. Denae thought, intestinal mass, ovary. More importantly will I be able to get it out or will it be stuck to everything and be unresectable? I open her abdomen and am staring at a large mass. It seems more mobile than I thought. I open from pubis to above the umbilicus before I have enough length to get around this. It’s huge for her little abdomen. i get around it and pull up, it pops up through the incision. YAY! It isn’t stuck everywhere. I soon figure out it is an ovary and the pedicle seems long and it has momentum (fatty layer in abdomen) stuck to it. I clamp, cut and tie, the portions of the a omentum off and then do the same for the vessels leading to it, which are huge. I take it out and then inspect the rest of the abdomen. She has a few larger lymph nodes in the omentum. These are probably metastasis. So I take them out too. I look at her liver, and peritoneum (covering of the abdomen) and don’t find any more evidence of tumor. Her other ovary looks small and normal. So we close her up.
The next older woman has more body fat than most here so I know she will be more challenging to operate on. I ultrasound her abdomen and find what I think is a large uterus and a huge fibroid in it. I ask for them to interpret for me and find out if she wants more children. She says she’s had 9 and doesn’t want anymore. Plus she’s past the time of her period anyway. So I plan on a hysterectomy or mass excision if Im wrong about its source. As I go to see consults, Olen says. Oh look at that, her blood pressure is 210/114. She doesn’t know that she’s hypertensive and so we cancel her surgery and tell her to come back in a few weeks once her blood pressure is better controlled. The staff look at me like Im crazy. So I tell them the possible problems with it in the OR and they translate for her.
Next is an old guy who who can’t pee and has a large prostate on ultrasound done here and has a urine catheter in. We put water into his bladder to distend it and clamp the foley catheter. Then prep and drape him. It’s been since I was here last, since i took out a prostate. I make a low phanynsteal incision and go down to the distended bladder. I open it and find a large prostate. slowly I shell it out with my finger. It’s always kind of difficult and taxing on the ligaments of my finger. I change fingers a number of times as one starts to hurt. I get out two large lobes and a smaller one. The bleeding is constant as it usually is. So I suture up the posterior area. i put in a large 3 way foley for continual irrigation and close the bladder. I start the irrigation as soon as i close the bladder in the first layer. This irrigation will continue for days until it is clear enough to stop. It is the only thing that keeps blood from making clots in the bladder and a need for reoperating.
I walk through the surgical ward because I’m done earlier than expected. I see the guy with the chest tube and people are propping him up and he’s breathing fast. I check his chest tube and all appears normal. there is fluid where there’s suppose to be and everything connected correctly. There is about 1.7 liters of pus in the container. His heart is racing. I don’t see neck venous distention. He’s sweating because it’s real hot today. I want a chest Xray to make sure the chest tube is keeping the lung expanded. I go and tell the chief nurse who is also the person who takes X-rays and does ultrasouds. They run to get me and say that he’s not doing well. There is a crowd of people out around him. He is sitting on the ground and apparently passed out as they tried to walk him to the Xray. He’s conscious, but real tachycardic. There are a million things that could be going on. Of them, what are some that I can diagnose or suspect to treat here? I ask if he’s eating and they say no, and not taking much water either. So maybe he’s dehydrated, I ask for IV fluids to be run in quickly. He’s peed twice today and it was dark tea color. His blood pressure is low about 90/60 sitting on the ground, and HR 120. we carry him back to his bed and give him fluids. I guess he can’t make it to the Xray. No bedside Xrays here. I check on him later with Olen. We ultrasound his chest and Olen sees normal lung on the other side and consolidated lung on the affected side. No pneumothroax (air around lung) and no hydrothorax (fluid around lung), and pus continues to drain out the tube. As I feel his pulse again it’s less but now seems irregular. slow then fast alternating. Maybe he’s in atrial fibrillation. We consider our only anticoagulant aspirin. And decide to see if he is still irregular tomorrow. This is the first time I wish we had ECG here. (no machine and those little pads- we use those up like crazy at home. they don’t stick well at home, i can’t imagine they’d work at all here.)