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Disaster response B #8

            I am grateful, the next hurricane that is to come this way appears like it will be turning back out to sea before hitting the Bahamas.  These people sure don’t need any more trauma than they’ve been through.  

            I’ve done a few inguinal hernias today and assisted in a hysterectomy for someone who has had vaginal bleeding for many months.  It reminded me of the story in the Bible of a woman being healed because she had faith, and her bleeding stopped with touching Jesus cloths.  I wish Jesus power was in me to stop bleeding or healing at a touch!  That would be much better than the part I play now in the process.

            Tonight I’m asked to see a guy who has a dialysis catheter in his groin that is infected.  One was placed under his left clavicle before the storm but no one took out the infected one.  This is bad, because if there is infection in one part of the blood stream, it will often infect the new catheter as well.  I’m not sure why one wasn’t removed directly after the replacement was put in.  But here we are.  It seems a number of people we are seeing aren’t happy with the care they are getting on the island.  We could be seeing the slice of people unhappy, or the care could be poor.  Either way we are happy to take care of them and demonstrate Jesus love for them.  I decided to take it out.  I numbed up his skin and tried to dissect out the felt cuff along the catheter that holds it in.  I couldn’t seem to do it from the opening that I had, so I made an incision along the catheter.  I dissected it out and it still seemed stuck further on.  So I did the same thing closer to where I expected the entry into the vein.  Gradually it freed up and I pulled it out.  Then I held pressure for about 10 minutes.  He was supposedly on a blood thinner, but didn’t know which one.  He didn’t really seem to bleed a lot, but I wanted to be cautious.  The ER doc agreed to send him home a bit later on so I left to eat. (rice sprinkled with veggies)

            New day.  So a few days ago, after the operation of the person with extensor tendon injuries, I realized their thumb wasn’t working.  Had I missed a tendon repair, or was there a nerve injury that explained that finding.  So today the orthopedic surgeon and I explored the arm again.  I opened up the closed incision.  Next I dissected down to the tendon repairs.  I was able to find the missed tendon and when I pulled on it the thumb straightened out.  We extended our incision and couldn’t find the muscle belly that belonged to it.  We did find the other tendon that ran the thumb and it was intact, so it must be that that one is denervated (cut nerve so it doesn’t work any more)  So finally we attached the tendon end we found, to the extensor tendons that ran some fingers.  So when she opens her fingers her thumb will open as well.  At least this way she can open to grasp a cup or object.

            Next there was a lady that returned to have her abdominal hernia repaired.  She was done under spinal and did very well during surgery.  After that was a woman who had fallen and landed on her foot.  This fractured her medial ankle bone and her small leg bone (fibula), and ruptured some tendons.  So I helped the orthopedic surgeon do the operation.  She was put to sleep and then her leg was skin prepped all the way around up to the hip.  Then we put the drapes on.  We made incisions on either side of her leg, starting with the inside part.  Her medial maleolus was fractured and so we were eventually able to turn the foot out to the side and then back and get the bone fragments to line up.  Then we drilled, tapped and placed two screws to fix it.  On the outside, where the fibula was broken we cut down to the bone and found the fracture.  We bent a plate to match the bone and camped it to the bone (think something like a visegrip for the bone)  Then we drilled holes.  Measured each hole.  Tapped each, and then put the appropriate length screw in each one.  It’s like carpentry for the bones.  Then we closed each incision

In the evening I was asked to take fluid off a lady that had a near white out of her right lung field on xray.  So there was fluid around the lung.  She also had a large abdomen, and a thin body.  So she had ascites on exam.  We don’t have a thoracentesis  kit nor a paracentesis kit to drain these.  So I had to improvise.  The problem with that is, that the lung space has negative pressure.  So if there is a needle or a cut in the chest, it will suck air in around the lung and collapse the lung.  I had to place a needle, then remove the needle, leaving an angiocath, and then connect IV tubing, and then pull fluid from the lung space, push it down the tubing and start the gravity flow.  It took about 1:30 minutes to get it drained.  1800 from the lung space, and 300 from the abdomen. 

            I made it to the food tent to find all the food was gone.  Then I heard there were some people at Wendy’s.  So they brought me a salad to eat.  Now Ive showered, eaten, and going to hit the sack. 

Disaster Response B #7

            The patient load is changing.  Over the weekend we had 140 ER visits one day and 130 the next.  Today is less.  It seems that there is a whole lot of congestive heart failure now.  People lost their meds in the storm and can’t see their own doc so they’ve been without meds and now are coming in very short of breath.  Last night someone about 30 was at home and had worsening breathing for a  few days.  Everyone was living in their upstairs rooms because the bottom of the houses had been flooded.  The car had been ruined with the flood, so they went to find a neighbor with a car in the middle of the night.  They tried a number of times to call 911 and couldn’t get out.  The cell phone system was down.   Once they found a neighbor with a car, they had to carry her down 13 stairs to the car.  They piled her five sleepy, young children in the car and headed in to our hospital.  They raced into the parking lot with the horn blaring.  Our nurses ran out to see what was going on, and found a woman barely breathing.  She was brought in and intubated.  She was given medicine to make her urinate off the extra fluid and the staff arranged transfer to the referral town on another island.  A helicopter landed in the parking lot to pick her up.

            One of the people I saw for a surgical consult was a woman with a fungating breast cancer.  She had had it for a long time and when it was small back in 2012 had seen her doctor who had said it was nothing and they didn’t do anything about it.  Later it became huge and ulcerated, necrotic and smelled horrible.  She saw a doctor and was referred to an oncologist.  The oncologist flies in from another island and charges $600 to be seen.  Then chemo the patient said costs $3000 for the first round.  They heard things were cheaper in Cuba, so flew there to be evaluated.  So they’ve been going to Cuba for every round of chemo.  She wanted to be seen to see if we could do anything else.  I looked at her breast and it was all raw, red tissue all over and firm and dimpled out into the armpit (peau d orange).  She was improving some with the chemo.  The local surgeons said that chemo was free by the government, but she said it’s not what she found out.  I advised her to continue the chemo, and referred her to the local surgeons to be seen again here.

            I did a right inguinal hernia repair in the OR and then removed a toenail on an older man with an ingrown toenail.  Then there was a older man with a left inguinal hernia that I repaired.  I saw another man with an inguinal hernia in the ER and set him up to do his tomorrow.

            I was asked to see a 98 year old woman in the ER who’s son was with her.  She had a large pendulous breast with cancer on one side maybe about 8 inches in size and another breast cancer on the other side about 2 inches in size.  Both appeared mobile and I could likely get them off.  At least it would take away the smell of the one breast that was necrotic (dead tissue).  She had been loosing a lot of weight and her son was very attentive and concerned about her weight loss and some pressure ulcers that had developed on her spine in the low back.  She wasn’t eating much for a few weeks because she didn’t want to and it appeared like she couldn’t stay awake to talk to us.  I decided that in her wasting condition that it wouldn’t be wise to do a surgery on her- that it would speed up her demise and she wouldn’t heal in her malnourished state.  The son was fine with that as he was afraid of her having surgery too.

            Tonight’s meal was pasta with veggies.  Different than the other nights- somewhat tasty.

            As I sat there and talked to a few of the other doctors and staff, the ER doc asked me to see a patient in the ER.  This man had had a mass on his tongue a long time.  He is a smoker.  The mass had gotten larger and eventually filled up his whole tongue.  Tonight as I looked at him he appears about 40 with a large mass under his left mandible (jaw bone).  It was about 2 inches long and stuck out about 1 inch from the surface.   This appeared to be one of many metastasis that I could feel in his neck.  There is nothing we could do for him and recommended that he see an oncologist and wrote a referral for him.  The suffering of people is incredible, both from disease and from the hurricane.  God give me continued compassion for each person I see, and give me wisdom to treat each ones physical and spiritual needs. 

Disaster response B #6

            Today started out slow, and ended with a 4 hour operation.  Ended meaning I haven’t been called again yet.

            I did rounds with the local surgeons on my patients.  We also rounded on the ortho patients who had wounds.  

            We brought back the first wound change patient to the OR.  The first was the leg wound on a woman that weighs two of me, and is 4ft 9in.  Her leg wounds are slowly improving.  I talked to her about her experience during the past few weeks of the hurricane.  She said she lives on Abaco- the island that was nearly flattened, but had moved here for work.  She is a chef and couldn’t find work there.  She was at her rental apartment when the storm started.  The water started coming in under the door.  The landlord ran around telling people to leave to get to higher ground.  She went out and started walking down the street.  She said the water was flowing deeper and deeper.  People were walking everywhere.  She said the water flowed down the street, may take a left or right around a house and keep going.  She said the water was up to her waist and brown with sewer.  A truck was going by and she hailed it down, and climbed on.  She said she would go where ever it was going.  It went to the Seventh-Day Adventist church.  She stayed there for two days.  She said that in the storm part of the roof of the building was torn off and they got rained on, and some debris fell down, but no one was hurt.  She doesn’t yet know what happened to her house in Abaco.

            After that there was a person with a buttock abscess with a WBC count of 1.8 and HIV.  That abscess was much cleaner than yesterday when I opened it.  

            I then helped out in the ER to see patients with abdominal pain, foot ulcers with osteomyelitis (bone infection) and small lacerations.

            I was in the ER when the triage people rushed in a lady who was holding her head and bleeding all over from her head.  She had two large wounds open on each arm.  We rushed to take care of her.  She was placed on a bed and I started to evaluate her.  Nurses put in IV lines in her legs.  The story she told was that she told her son to mow the yard today, and she went out of the house.  She came home and he hadn’t done it.  She asked him why not and he got angry.  She said that he uses marijuana laced with other things.  He grabbed a machete and attacked her, slicing into one arm, then the other, then her head.  She was able to get away and to the hospital.  The cut on her head was about 3 inches long.  On the left arm there was a large flap of skin with a laceration (cut) about 8 inches, on the right arm a laceration about 6 inches.  Another doctor and I took her to the operating room.

            After putting her to sleep about 2:30 PM we got to work on the right arm.  We washed it out and explored it.  She had 4 extensor tendons cut in her right arm and some muscles too.  I took off the dead tissue and slowly repaired each of the tendons.  I closed up the outer sheath of the muscles and then skin, and placed her in a arm splint to relieve the tension on the repairs.  That took about 1 hour.  The other side had 7 cut tendons and the ulna bone had been sliced in half as well.  I debreeded the dead tissue and started to repair the tendons.  The orthopedic surgeon decided to put a plate on the bone so I undid the tendon repair, and the three of us doctors plated the ulna.  First clean off the bone, next put the titanium plate in place.  Then with the row of holes, drill a hole through the bone, then measure the thickness.  Tap the hole, then choose a screw that is the right length for that hole and screw it in.  Next do that repeatedly till it has about 2-3 screws on each side.  We fit the bone fragments back in the hole behind it and then started the tendon repairs.  Each tendon was a bit tedious to repair as they were about 1-2mm in size and I had a larger suture than I wanted- so added to the challenge.  Eventually we were successful and closed up the other layers and put that arm in a splint.  Next I cleaned off the head laceration and closed it with staples.

            She was extubated (breathing tube taken out) and we went to the recovery bed.  I explained to her family her injuries and what repairs I had done and the likely recovery course.  It was 7:30PM.  It was an interesting surgery.  I went to get my rice and vegetable supper.  They got a fridge today with cold drinks and some candy bars.  That’s where I got dessert!  Now off to bed after checking on her one more time.