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12 Bere 2024

It’s my last day in Bere and we have planned a long day, and it just gets LONGER!!  I start with a number of scheduled cases then have to cancel some scheduled to accommodate emergency after emergency.  I realize it’s Friday and there are no meetings so i go in earlier about 7:30.  I find Phillipe in the OR and ask him when i can start.  He said the kid with the cheek abscess is ready and we should do him early so that he can eat.  So I tell him to put him to sleep and Ill get ready.  he gives him a little Propofol and I lance his cheek and get nothing.  It felt fluctuant and  the dad said pus had been draining out of two small holes.  I go deep and get nothing.  So I probe the holes and they are real superficial.  So I biopsy a large lymph node near by and then close back up the hole I made, suturing it shut.

I run over to the surgical ward and tell the nurse, Emma, Ill try to round with him later, but to go ahead and do dressings… and let me know if there are problems.  He says the emaciated woman that Ive been watching and I wrote about in 11 Bere 2024, is nauseous, so I decide to give her metoclopramide to see if stimulating her bowels will resolve her issues.  Later she’s vomiting and then I chose to operate on her like i previously mentioned in the last Shanksteps..  So that was an emergency later in the day.  So after talking to him I continue operating.

A woman is brought from the emergency room who has an ectopic pregnancy- one that is outside the uterus.  She has the ultrasound report that says so. I ultrasound her and think I see a rib cage outside the uterus.  I don’t really see all the normal features of a fetus so I ask Audrey to come take a look.  So she comes over from maternity.  She looks around and doesn’t find anything but an irregular looking mass outside the uterus that has the appearance of a uterine fibroid.  We’ve heard of pedunculated fibroids that can hang off the uterus, so assume it may be that.  The patient has a negative pregnancy test which goes against an ectopic pregnancy.  She says she has been pregnant 14 months and the baby hasn’t moved the past 4 months.  I open up her abdomen and do not find a abdomen full of blood as is common with presentation of an ectopic.  I find the omentum stuck to a large mass.  slowly I free up the omentum from the mass.  Then as I free up more from behind the mass I see a hand.  Oh this IS a ectopic pregnancy.  As i identify more I find there is a fetus wrapped in omentum.  It’s head is not fully formed, I think if may be anencephalic.  So after getting it out there remained a mass further in the pelvis.  I free this up and it’s the placenta.  The baby was near term and was fed by blood from the omentum.  I’ve read about this being a possibility in the books, but I’ve never seen one.  Very strange!

The next two operations of the day were the two that I discussed in 11 Bere 2024.  One was the intestinal blockage after surgery somewhere else, and the second was a perforation of intestine of a boy after falling on the handlebar of his bicycle.

Next was a guy that the ER had sent over.  When you think of ER you think of a room glowing with light and different patient rooms and doctors and nurses running around taking care of emergencies left and right.  They’re calling other doctors to come and admit patients to different services in the hospital after getting lab work, CT scans, and X-rays.  Am i right?  The ER here is a nurse with two or three nursing students who jot down the patients complaints in the patient’s little medical booklet they keep with them, or they lose it and get a new one when they arrive.  Then the nurse decides what tests to get and what lab-work seems appropriate to them.  So this guy comes in with a huge scrotum that is painful and he has had a hernia a long time.  So the nurse orders a glucose test, malaria test, typhoid test, and sends him to the OR to be evaluated by us.  Well the last one was the appropriate one.  He has a large hernia that makes his scrotum look like a small watermelon.  I’m unable to reduce it (push it back inside).  So he’s next in the OR.  He gets a spinal anesthetic and then I open his groin. I start opening the different layers and it still doesn’t reduce.  Finally I open the hernia sac and see colon in it.  The colon is viable and so I slowly push it back inside.  Once the sac is empty, I separate it from the surrounding structures and then cut it off keeping clamps on the opening.  I then close the sac.  Then I do a tissue repair called a modified Bassini.  Closing the native tissues over the hole.  i don’t use mesh here for two reasons.  We don’t have much and secondly I still worry about wound infections and therefore mesh infections.  It doesn’t seem like there are many recurrences here, and I think part of the reason is that there are no narcotic pain medications, so people feel when they are pulling on the repair and don’t do things they shouldn’t.  We get done and I see that last of the consults that are waiting and then head back to our room.  It’s about 9 PM and I pray that we will have a calm night.  we plan to leave at 7 AM and I don’t want to do an emergency especially around 7AM when we need to leave and the other doctors aren’t quite back yet.  

We sleep for an hour or two and are called by the maternity nurse for a delivering mother who has vaginal bleeding.  Audrey heads in and I know we will have to operate on her so I head in shortly there after.  Audrey is already headed back to get me.  She says there is blood everywhere and the baby is still alive. I call Phillipe and David (anesthetist and circulator).  I see the patient in the bed of the delivery room.  (The delivery room is a room with 5 beds lined up against one wall.  If there are multiple women in labor they lie on the beds all lined up as they suffer.  The nurse may catch one after another like has happened many times.). So back to the woman at hand- she is absolutely covered in blood all over her cloths and there is a widening 4 foot pool of blood on the floor.  WOW!!!! That’s a lot of blood.  I run to the OR and get out two units of blood of her type and stick one under each armpit to start warming them.  I also grab a couple saline bags and run back to maternity.  I ask the nursing students to get the gurney from the OR and start wheeling her over there.  The nurse is getting in another IV line.  I also grabbed the transfusion tubing.  We start pouring in the fluids.  And we get her headed to the OR.  We get her laying on the OR table and stick in the second IV and get the anesthesia monitors connected.  Phillipe and David make it in and the blood is warmed up and Phillipe starts it as I get the OR kit for the C-section ready.  I get the gloves and suture and gauze…all opened on the scrub table.  Phillipe gives her a whiff of Ketamine and I open.  She groans a little but will have no recollection of it.  I go in all with a scalpel as fast as possible.  Through the abdomen and then into the uterus.  I pull out the baby and we hand it off to David.  I scoop out the placenta and start closing the uterus.  I didn’t take the time to find out why she was bleeding, just took care of the placenta so it would stop.  I ask David how it’s going as Im not hearing the baby cry.  I ask if he wants help and he does.  So Audrey scrubs out helps give the baby CPR.  Giving breaths and oxygen and chest compressions.  It takes a couple minutes before the baby’s heart started and started to breath.  She never really cried but moving extremities.  I close the uterus as best I can by myself and finally David scrubs in to help me.  Mom is doing well with three units of blood and baby is alive.  We leave as they start to mop up all the blood all around.  We are grateful to have a last live mom and baby for this trip!!  We sleep for a few hours then get up to start our three day trip home.

11 Bere 2024

In the last day at Bere I did two intestinal repairs.  now that’s something often done by general surgeons.  One was a “usual” case and one “unusual”

First with the “usual”.  I was called to see a 10 year old boy who was on pediatrics after a fall on a bicycle.  At first I thought I understood he had fallen from a tree on a bicycle.  Then I saw the tell tale sign of a circle impression on his right abdomen.  A handlebar into the abdomen.  he had a rigid abdomen with peritoneal signs.  So I told them to take him over to the OR and start an IV on him.  He will need to be one of the next ones operated on.  I suspect that he may have pinched a piece of intestine between the handlebar and his spine.  This occurred a couple days ago.

As I open his abdomen i immediately get a lot of stool and pus and free air. I suck out all the stool i can and then wash out his abdomen with a lot of saline.  Once it’s coming out fairly clear, I start looking for the hole in the intestine.  I find it mid-jejunum (small intestine).  He has a hole one side of the piece of small bowel and a hole on the opposite side and a small hematoma in the mesentery to that area.  Definitely a pinched piece of intestine making the hole.  So i freshen up the edges of the holes and then suture them closed.  I do a single interrupted closure, meaning one layer of sutures to close the holes.  It takes about an hour.  Finally the holes are closed and we close up the abdomen.

The other one (unusual) was a woman who i had been watching over the week who presented to Bere about two months after a surgery at another place where she had some surgery where they did something and may had cut adhesions.  The patient and family doesn’t know and it’s not written in her book in a legible way.  They said shes been vomiting and cant keep food down two months.  Now that story makes me feel suspicious.  So i admit her and observe.  I give her nausea medicine and she seems to do better and eats some food.  Her stool is hard and she has firm areas in her abdomen that changes position- like intestine moving.  So I decide to stimulate her bowels with medicine to see if she can pass the stool and if thats causing the problem.  I had done an Xray of her abdomen that didn’t show obstruction but I was a little worried about a partial obstruction.  The surgical ward nurse came to tell me shes was vomiting a lot after this medicine.  It was my last day and I had watched her.  I didn’t wan to leave her for the other surgeon after I’d watched her so long- so I said to bring her to the OR and keep her NPO.  I was worried about operating on her because she was so thin she looked like a starvation person.  Meaning that I wondered if she had enough nutrition to heal a surgery!!  Or would she just leak with an enterocutaneous fistulae and die?  I felt forced to do something…. 

As I cut through her skin I immediately came to fascia.  No fat whatsoever.  She is starving to death!  I entered the abdomen and found dilated small bowel and decompressed small bowel.  Definitely an obstruction.  I started at the top where the dilated bowel was and followed it down.  I found an area of previous resection with that being the transition point between dilated and non-dilated bowel.  So to take out that section or just bypass it.  If I took it out I’d have a huge anastomosis to do and it would take a long time.  If i did a bypass, attaching the one piece to the other I could make it whatever size was needed and leave it at that.  So i did a side to side anastomosis. I cut each piece of intestine and started sewing them together with an opening in between.  This took about an hour.  The anastomosis looked good and as soon as I unclamped the intestine, fluid started going through.  Yay!  I closed her up and we went on to other surgeries.

Now a few days later she is post op day 4 and she is able to eat and shes moving her bowels.    And so is the boy of earlier in this message.  Im so grateful.  Always after an anastomosis of intestines Im not at peace till about a week later when everything is working well and there is no anastomotic leak or problems.  Im glad to hear they are doing well.  Thank you Dr. Jorla for letting me know.

Greg

9 Bere 2024

I did a prostatectomy yesterday and as I usually do, I put the foley catheter on traction, with the foley bag always being half full and laying over the end of the bed.  So i was called in at 8:30 pm because the guy was crying in pain.  I know that none of the prostatectomy guys like traction, it always hurts.  And of course they are getting the only medications we have for pain here which are Ibuprofen and Tylenol.  So I go in to see him.   They have it off traction and are trying to flush the catheter.  I take over and get red blood with clots out of the foley.  Im really frustrated as it’s not on traction and so it’s bleeding more.  I know if it bleeds to much and isn’t flushed out- then the clots collect in the bladder and then Id have to reoperate and clean out the bladder again. I decide that the next nurse is coming on shift in about 15 minutes.  Im so tired, so rather than hanging around I go home and lay on the concrete floor.  I wake up 3 hours later in a pool of sweat.  I remember that I needed to see the patient so I go back in.  He’s writhing around in pain. His foley is plugged! I unplug it and am glad I went in to see him.  I discuss with this nurse what to do if it plugs and she seems much more attentive than the last nurse.  So I head back and shower and get in bed dripping wet,  It’s still 98 deg in the house when I go to bed.  But I fall right to sleep.

Im awakened at 5 AM with the maternity nurse who says there is a new patient who has a dead baby and has hard contractions and isn’t progressing.  Audrey went in to see that patient and was back soon saying that the patient had a dead baby and had a ruptured uterus.  So I called in Phillipe and David and about an hour or more later we were beginning the surgery.  As I cut into the abdomen with a phanynsteal incision, as soon as I enter the peritoneum- lots of blood.  I feel around and find the dead baby floating around in the abdomen with the placenta.  Again the uterus is torn up the side, just like the one yesterday.  I find the deep spot and put ring clamps all along.  Then I start closing.  I get the uterus closed and then oversew a few bleeding spots.  Audrey is assisting me and we close up the abdomen.  She goes off to check on another patient that has had her first 4 children die during child birth.  I see some consults and she comes back and tells me she wants to do another C-section on this one so she will have a live baby.  They are just ready to put in the spinal of my next patient- so we get that one off the table and get the next C-section going.  

We know the baby is not in distress so we take our time getting into the uterus.  We see a little meconium (baby poop) on the kids face- so there was fetal distress!  He has a nucal cord (umbilical cord around his neck) so I reduce that and pull him out.  He cries immediately- yay! A live baby!  Audrey and I close back up.  It’s about noon when I start my first case that was planned that day.

this woman has had a large abdomen for quite some time.  Ultrasound says it’s a large cyst.  Must be ovarian!  I open her thin protuberant abdomen.  Immediately there is a huge cyst in my view.  I open nearly from the pubis to the xyphoid.  Then im able to pull it up.  It’s about the size of a basketball.  I release omentum from it and then find it’s attached in two places.  I tie off these areas and get to lift it out of the abdomen.  Im guessing about 15lbs.  Her abdomen went from looking pregnant to looking scaphoid.

I go out to do some more consults and I find a guy sent over by the ER because he has a leg infection.  It appears he has drop foot and hasn’t walked for a while.  he says his legs have been infected 2 months and he hasn’t walked for a month because of pain.  I try to figure out where his pain started, what part of his leg.  It takes a lot of questioning as the nursing student translating for me I think is asking something different than what I said.  After about 4 minutes of talking I think it started at his knee then later he had pus coming out in different areas of his leg.  I ask to have him taken into the OR.  I see another couple of the consults as they get him ready with fluid and a spinal anesthetic.  They call me once the spinal has been placed.  The anesthetist walks out of the room shortly there after and is going about 10 minutes.  Where did he go?  He went out.. is the answer.  Out where?  We don’t know.  Rather than getting upset like is my instinct when this happens- i keep my cool and just watch the BP when it cycles and listen to the SAT monitor.  The guy remains stable as he had been given enough preload of fluids.  I start with the knee joint.  I try to pike a needle attached to a syringe in to get a sample of the knee fluid to see if it is obvious pus.  His leg is so swollen I cant seem to get it in the joint, or at least I cant pull anything into the syringe when i think Im in the joint.  But I decide it is suspicious enough that I open the side of the joint beside the patella anyway.  I do get some pus.  So I wash it out with dakins and put in a piece of sterile glove as a drain.   The remainder of the leg is swollen.  So I aim for the draining holes.  I probe each one with a forcep and then open along the direction of the largest part that avoids important structures like names nerves, names arteries, or named veins.  Of course there is bleeding from smaller vessels but packing the abscess sites helps stop that.  After I follow about 7 draining sites and open them, I cant feel or tell of any other place that needs to be opened.  So Ive packed them all then I wrap with elastic bandages.  It’s about 6 PM and I’ve gotten through the consults and surgeries so I head home to eat whatever Longue has made and am content to have a seat and some rest.