Bere 5/2025 #14
How do I tell the guy who was stabbed with a cow horn that I think another operation isn’t useful. That a proximal ostomy isn’t survivable here. It would require taking the contents of the ostomy and putting it back into the mucus fistula (the other part of intestine coming out too) and re-feeding the other end, so it can continue on down the intestines. That them doing that if they did it well, he would still very likely die. Die with renal failure, with persistent malnutrition, with infection. These are the thoughts Im having as I’ve seen him and start my first surgery of the day. The dressing was done in the morning and intestinal contents poured out of the glove drain I left in him. I hear this from Dr Andrew who was doing rounds. The older brother isn’t there so the conversation can’t happen yet.
My morning started at 4 AM with a call that the knee cap accident guy wasn’t doing well. And as I change into cloths they call me back saying he’s dead. I had gone in to see him last night and no body in ER or surgical ward knew of the guy I had been called about. I try to go back to sleep unsuccessfully. In the morning I find out he had been in the ER but the nurse didn’t get sign out about him at shift change so she didn’t know about him at all. I start my first surgery with the previous thoughts of the cow horn guy going through my mind. It’s hard to be focusing on one thing and mulling over another. So I focus not the patient in front of me as best I can.
My first surgery is a TURP (transurethral resection of the prostate). I’ve done many open prostate surgeries and now I’ve seen a TURP, done one with supervision and now this one is for me to do. I get all the tools set up which are quite extensive. The patients spinal has taken effect so I stick in the cystoscope. I look down the tube of the penis as I insert it through the penis into the bladder. I see a ureter on either side of a huge prostate. I realize this will be a difficult long surgery. I use a loop wire I can see out the end of the scope to burn off a first groove of prostate. It bleeds and I cauterize the bleeding. Another pass makes another trench and I continue to control bleeding. After about an hour I get into some bleeding I can’t see where it is. The blood is swirling around the camera. I push the camera real close to the surface to try to see. I search and cauterize. It takes another half hour before I have really controlled it so I can see again adequately to continue on. It takes me about 3.5 hours to do this prostatectomy. The patient won’t have an incision and will heal quickly but it is now about 2PM and there are many other operations to do.
My next one is a guy who calm in last night and has an open femur fracture making his knee and foot point off at a bizarre angle. He stinks so bad that the nurses didn’t give him a bed in the ward but just put him on the veranda of the OR. There are always people sleeping there so it’s not a bad place, they just want the stench out of an enclosed space. He was in a motorcycle accident 10 days ago. The family carries him into the OR and he drips pus the whole way and a swarm of flies follow him as they carry him in to the OR. By the time he is laying on the OR table there are only a few flies that made it that far. No one does anything about it and I can’t seem to kill them so I carry on. (In the US, a fly anywhere in the area of the OR causes an uproar. Rooms are closed until the fly is isolated and killed. Then work can go on). We go on anyway. His leg is tied up to an IV pole to raise it off the bed so we can prep it all around, more pus runs out of little holes along the side of his thigh. I do an open above knee amputation about mid upper leg. As I cut through the muscles of the leg I get into two huge pockets of pus that drain all over my surgical field. I tie off the large vessels and cut off the bone with a dull stainless steel hand saw. There is a tiny file inside I use to round off the sharp edges of the bone. Then I put a dressing over the open end. We will change the dressing daily till it looks clean enough to close.
My perforated appendix guy is looking bad with a high heart rate and a breathing rate about 45/min. His belly is all distended. I had evacuated 2L pus in the original operation. There was also some necrotic retroperitoneum at that time. So I take him back again for a washout. I find the same nasty looking area in his retroperitoneum and try to take off more tissue along the ureter and close to the vena cava. The bowel doesn’t look happy in a few areas because of what to me appears like typhoid effects. Beefy red intestines. There are no palpable thin spots so I decide not to take any intestine out but decide to take another look in two days. I recluse him. No open abdomens here, no vac dressings…
It has been a long day so I head back to eat some supper at a missionaries house. I have some beans and rice and a great mango. I am spent, and head back to get some rest
