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Chad #4 2019

The last two nights we’ve been awoken in the night for a C-section.   Both for failure to progress and fetal distress.  One got a living baby the other a dead baby.  The one that died was bagged for 30 minutes then lost its heart beat.  Then we decided to stop.

            Last night I’m awoken by a knock on the door, to see a 18 year old guy who was in a fight and stabbed twice.  Once in the neck and once in the right lower back.  The nurse wants me to evaluate the back wound.  He says the neck one is superficial.  The back is deeper and he indicates about 1 inch on his own finger.  He says that that wound bled a lot.  I walk in to the “ER” which has been renovated since I was last here.  It has a main entrance area that has a desk and three rooms with a couple beds in each.  This guy is laying on his left side with a bandage on his back.  I take off the bandage and put on some gloves.  I tell him it will hurt, then probe his stab wound with my finger.  I can get my smallest finger to go all the way in, angling down towards his pelvis.  This could have entered his abdomen and hit intestine.   So after probing the stab wound I feel his abdomen.  He has no pain in his belly.  They give me a suture and I put one suture in to re-approximate the edges leaving space for blood to come out.  I kept him overnight to see how he did, and if he declines will operate on him.  We have six cases already planned for today and already 3 for tomorrow.  I have been busy each day from morning till 5-8pm with surgeries all day. 

            It is still unbearably hot in the OR.  Yesterday it started at 95 degrees then went up to 101deg for the rest of the day.  I got my hopes up as they found another air conditioner to put in the OR, but it felt cool for about 5 minutes after installation, then was warm all the rest of the day.  I feel bad for Dr. Denae and Dr. Sarah who have been dealing with this heat in the OR for weeks.  I am drenched constantly with my own sweat.  I’m drinking a lot and don’t pee at all, all day.  In the evening after drinking a few more liters of water, I finally pee some rose colored fluid.  I wonder if I’m getting myoglobinurea from kidney damage.  Now way to know, just drink more.  The repair man has arrived this morning, so they will hopefully be able to get something working today.  I don’t like wet cloths as, it contaminates the sterility of my cloth OR gown.  But yesterday I decided it was getting wet either way.  So before each case, I would remove my shirt and cap, rinse them, wring them out, and put them back on.  This seemed to help a little.  I’ve been making a little stink about the AC to the administration, in hopes that it will spur them on to have it fixed.  I even told them I would stop doing elective cases unless it’s fixed soon.  I don’t intend on following through with that at all, but they haven’t fixed it for Dr. Danae and Dr. Sarah, so why not push them more?

            The last surgery of the day is most memorable.  A thirty year old guy had been sick for about a week.  Then about three days ago he stopped passing gas and stool.  He looks very sick to me.  Everyone here is thin, and when they lay down their abdomens are concave with ribs showing.  His don’t show at all and his abdomen stands up taught.  I take a finger and tap on his belly.  With every percussion he jumps and grunts in pain.  I check rebound by pushing in on his belly slowly, then letting go quickly.  He jumps in pain when I let go.  He has peritonitis so he needs to be operated on.  Since I’m seeing him in the preop area as a consult, the OR crew which includes 2 nurses and 4 students, prepare him to be the next operation.  He gets the usual fluid load before a spinal.  I know he will need Ketamine instead because a spinal only covers the lower abdomen.  I’ve given up on that fight with the anesthetist.  He gives a spinal to everyone, and I’ve come to terms with that.  After the spinal is in, Phillip preps his abdomen with betadine, while the other nurse and I scrub.  We put on our cloth gowns and  our cloth drapes and start in. I enter the upper abdomen after he has pain and is given ketamine.  The upper abdomen is hard to get in to and everything is stuck.  I cant seem to get very far and worry about cutting into a piece of intestine.  Then I do something I’ve not done before, made a second incision in the lower abdomen.  This got in directly and pus flowed out all over the bed, me, my assistant, and pooled on the floor.  I’d guess about three liters.  Now I’m not only drenched in sweat with all this stuff on and 101 degrees, but now I have pus on me and it smells awful.  Even my terribly functioning nose cannot mistake it.  This has been there many days, the intestines are stuck together making pockets of pus in various places.  I eventually free up all the small intestine.  I look it over and cant find anything wrong, I look over the large intestine- nothing.  I dissect to behind the stomach- nothing.  Front of the stomach- nothing.  I feel the surface of the liver and spleen- nothing.  I irrigate every thing out with a lot of saline.  I’m quite frustrated as I’ve seen his whole abdomen and didn’t find the source of the pus.  I close him up with another prayer that whatever caused this has sealed itself and will not leak any more.  Disconcerting!

Chad #3 2019

            It’s outrageously HOT!!!  As I’ve mentioned the AC in the operating room isn’t working.  I drip constantly with sweat.  Sometimes it drips on the patient I’m operating on, contaminating everything.  A fly persistently landed on a patient mid-surgery.  The coolest it got was this morning about 7 AM when it was 86 degrees.  Mid-day it was 95 outside, hot compared to my 65 on the US west coast, but it got up to 101 IN THE OPERATING ROOM today and stayed there for the remainder of the day.  They have put in a fan that was blowing on me or my assistant, whomever was on that side of the room.  I never imagined an OR could be sooo hot.  In the US most OR’s are mid sixties.   With all the mask, hat, gown, and gloves, even in the US I get hot sometimes, here…  

            I type as I sit here at 10 PM waiting for the OR crew to come in for a strangulated inguinal hernia in a man that’s had pain since mid afternoon.  I have a fan on me and my apartment is 90 degrees.  I’ve stopped sweating,   I hope that Ive hydrated enough that that may not be the cause.

            My first case this morning was one that came in a little bit ago.  The 8 year old boy was apparently clawed by a crocodile.  He had puncture wounds on his abdomen and in a semicircle on his back.  To me it sure looked like a bite mark, but the father insisted it wasn’t a bite, but the croc clawed at him.  He had omentum sticking out an abdominal puncture site.  I put in local anesthetic after prepping him and we put the cloth drapes on him.  Phillipe the anesthetist didn’t want the patient to watch so he taped his eyes shut.  That bothered me, and I asked him to either remove the tape or to give him some ketamine so he wouldn’t remember it.  I cleaned up each wound and was able to get the omentum back in the abdomen and close the fascia.

            Second was a back wound that had been cleaned up with dressings and another doc wanted it to be closed somewhat so that it would heal faster.  It was a difficult thing to do.  I imagine it will get infected and likely drain for a while anyway.

            Third, was a C-section for triplets.  They were doing well, and it was time.  So Dr. Sarah and I took her to the OR.  The incision was the usual phanynsteal (low transverse) incision.  As we used the scalpel to enter the uterus the amniotic sac bulged out.  We poked the sac and amniotic fluid poured out.  The baby was in a breach position.  The second sac, had a baby with a head first position.  Feeling around inside, there weren’t any other babies.  Guess we should have had a look with the ultrasound ourselves.

            Fourth was a C-section for a woman who had been in labor a long time and wasn’t progressing.  It was her first child.  We pulled out a limp baby.  Dr. Sarah came in the OR to help revive the baby.  The baby was bagged for more than 30 minutes, the heart stopped and they stopped trying.

            I ate supper then later on was called to see the ER patient.  He was about 50 years old and cried out in pain every 5 minutes or so.  Apparently he had a strangulated  inguinal hernia.  I followed the nurse who called me to the ER.  He lay there calmly on his side.  His pain had gone on a few hours and I decided to try to reduce the hernia. I looked at a scrotum that was at least 12 inches long and about 6 inches in diameter.  The firm large part was off to the left side.  The right side was shorter and smaller.  I cupped the hernia and tried to massage it back in.  Circle motions, change in position and there was no success.  The family of the bed next to his wanted me to see their patient.  He was about a 60 year old guy that couldn’t pee.  Someone had attempted to place a urine catheter at another hospital in Kelo and then when they were unsuccessful, they put a needle through his low abdomen into his bladder and drained off 500ml of urine.  Then they sent him our way.  The nurse had attempted to place a catheter here, but was unsuccessful.  So I took a catheter and slowly pushed it in.  There was a lot of resistance, but eventually with steady pressure it gave way and entered the bladder.  I imagine he either has an enlarged prostate or a bladder stone.  Will get an ultrasound tomorrow to evaluate it.

            The ER nurse called the two OR guys and their phones were turned off.  So he had to get on his motorcycle  (moto) and go to their houses and get them.  I went back to my apartment and waited there.  Once they arrived they came to get me.  In the OR it had cooled off to 98 degrees.  After the spinal and prepping the scrotum and everything else, I started my incision.  I am continually amazed at how the local scalpels cannot cut the skin here.  In the US one swipe with the scalpel and your through the skin and into the fat area.  Here, I have to cut about 3 times just to get through the skin, and that’s pushing real hard.  Granted, their skin is tougher, but still its ridiculous.  As I went through the different layers I eventually found and dissected out the hernia.  Opening the sac, I found intestine that looked dark.  After I pulled it out, I realized it was going to make it.  I had difficulty putting it back inside and had to make the hernia site even larger, to be able to shove it back in.  Then I went through repairing the different layers then about midnight, back to bed.

Chad #2 2019

            It’s 92 degrees as I drip from my shower to my bed.  The fan is just outside the mosquito net pointed at me.  Totally wet, and the fan on me, I don’t feel hot for the first time! 

            At midnight I get a call from Dr. Sarah from the maternity ward that there is  a patient with a uterine rupture.  Apparently this patient is in her 3^rd pregnancy and has been at a district health center clinic and has been in labor 5 days (way to loonnngggg)!  She had had a previous C-section so this was especially to long.  This mother was sent here after developing more intense abdominal pain.  There is no baby heart beat.  They are putting in the spinal.  As we start the surgery her blood pressure was 7/4.  Which in our usual terms is 70/40, low.  She’s lost a lot of blood and I hope that she got enough fluids before hand to not go lower.  People can die from a spinal that have lost to much blood or they haven’t gotten enough fluids before it’s placed.  As we get into the abdomen we get a lot of blood as expected and immediately see the back of the baby.  I see the umbilical cord and there is no normal blood flow palpable in the cord confirming that the baby is dead.  The baby, cord, and placenta are all free floating in the abdomen.  We pass all of this off to the nurse in the room and continue on to the uterus.  The mother wants more babies so we try our best to save the uterus.  It is torn across the front where she had a previous C-section and then down the front of the uterus towards the vagina.  The part down there was very thin and difficult to separate from the bladder.  Suturing the bladder into the uterine repair is a bad thing!  We put clamps on each side laterally on the uterus where the uterine arteries are bleeding.  We suture the large hole shut and reinforce it with more stitches.  Dabbing and looking, dabbing and looking…there is no more bleeding.  I massage the uterus to help it contract.  About this time we hear of another mom in labor that isn’t progressing, and we ask that she be given a good IV with IV fluids running.  We close the fascia and then as I close the skin, Sarah takes off to check out this other woman.  Within about 5 minutes Sarah is back and confirms that we need to do a C-section on her.  As we take off the drapes we see a “code brown”, with the relaxation of the spinal there is a huge pile of poo between the legs.  It takes a little while for the nurse and anesthetist to clean it up, before we can start the next case.  By now I am sweating more than ever.  The air conditioner in the OR, is the only one in the hospital, and it’s not working for 3-4 weeks now.  It was “fixed” last week only to fail after 30 min of use.  It is now 94 deg in the OR, as it appears to be warming up with the lights and machines on.

            The next girl is lying on her stretcher and is moaning and rocking back and forth saying, “I can’t do it”, in French!  She is taller than average and muscular and lays there naked with an IV and urinary catheter in place.  She holds out her hand in a pleading gesture of requesting help, reaching towards me.  I find out this is her first delivery and she’s not pushing any more even when contractions are coming.  She gets her IV fluids and spinal and she doesn’t drop her blood pressure to much.  Her baby had a good heartbeat on the maternity ward.   We do an incision across the lower abdomen in the “bikini” line.  Skin, tiny bit of fat, fascia, muscles are all opened to see the uterus.  We make an incision above the bladder and push it down with repeated motions to separate it off the front of the uterus.  Then we make an incision in the uterus and see a baby.  The head is really stuck in the pelvis.  Sarah asks the anesthetist to push up in the vagina to push on the baby’s head to dislodge it.  I’ve not ever done that before.  This help is successful and she pulls out a living, crying baby.  This is the only time I really appreciate a crying baby!  I really dislike pulling out a limp, non-breathing, baby in a C-section when we had thought the baby as alive at the start of the surgery.  This baby is crying and we pass him off to the nurse to dry him and tie his umbilical cord.  We close up the uterus and the subsequent layers as we work our way out.  It’s now 3 AM, I’ve lost a lot of sweat in the OR, and so I drink a lot when I get back to the room I’m staying in.  Next is the shower again, and off to bed dripping wet!