Bere 2018 #18
It’s Sunday and we don’t do planned surgeries on Sundays, only urgent ones. So I’ve planned to do a gastrostomy tube on the old woman with a neck laceration from a cow horn that I did a tracheostomy on a few days ago. Also a debridement of necrotic tissue on the kid who may or may not have anthrax. Audrey is still having jet lag and I have to wait till afternoon to operate anyway to allow our anesthetist to go to church, so I tell her to sleep in and recover. Also Dr. Sarah has malaria so I ask her to stay home and get well. I go to the morning worship and then start rounds. The things I see on rounds that I can remember tonight are:
There is the 24 year old with urinary retention, that was told he had a bladder cancer. On my ultrasound I saw blood, not a tumor. I got about a liter of urine out of him. (by the way, I put a urine catheter in another young guy today and got out 3 liters. OUCH!! And he has been walking around with the urinary retention a few days). Back to rounds, this young guy is having pains going down both legs like sciatica. Then there is the old woman and guy who have had the amputations. The guy is healing well. The old woman is not! I think its malnutrition for her as the cause. There is the old woman with the tracheostomy who is gurgling in the tube, so I suction her out, provoking a LOT of coughing. The 14 year old boy with huge open area all over his lower leg I’m doing dressings on each day, he is slowly improving. The guy I did a prostate removal on, is doing well with minimal blood in his urine catheter. The guy with typhoid perforation- we are still waiting for his intestines to wake up after surgery (ileus). The lady with gastric ulcer perforation is improving and her drainage doesn’t appear to be gastric contents. Also the pH is much higher than if it were stomach acid. There is the nomadic lady that we took out an ovarian cancer with all the gelatinous stuff in her belly. She is improving and her intestines appear to be working again. And the old guy with a swollen foot. He is improving and wants to go home. I think it is still not that good, so I recommend he stay. He is insistent on leaving, so I discharge him. Again, I find it much easier to let men, choose poorly for themselves, than when they choose poorly for their wife or children.
On the adult ward, there is the lady who had a stroke who we are giving IV fluids to and asparine and she seems to slowly be improving. The next bed is a guy who has malaria and typhoid, and is improving and wants to go home. Another woman with a Hemoglobin of 3.3 received one unit of blood from her husband. She needs more and I tell the husband to get more family members to come to be tested to give. He says his family is to far away and he wants to leave. I get irritated, and feel the instinct to protect her from him, and I bristle. Fortunately I respond with kindness in my voice (a rarity in this situation). I tell him she needs more blood. He asks if he can give- well of course you can. The nurse tells me he already did the first unit of blood 3 days ago. OH! No you can’t give again, thank you for giving in the first place. He wants to take her to a hospital closer to his home for her to get blood, close enough that his family will go to that hospital. So I discharge her with iron and malaria treatment.
I do maternity rounds next. There is a woman in labor who the nurse says is progressing well, so I don’t bother checking. It seems the delivery nurses here are on top of things, having been trained well. I see a couple women on the ward who have delivered over the weekend and are ready to leave. Next is a Fulani woman (nomadic) who is here because she lives with someone here after she accepted Christ and was threatened by her family (who live far away) for forsaking Islam. She is pregnant and has malaria and giardia. The person with her speaks some English. So that’s slightly better, though not really easier. There is a baby who isn’t pooping and is two days old. Necrotizing enterocolitis? Obstruction? Malformation of anus or intestines? I hate operating on newborns- they seem to always die. I think malformations and other birth defects that I can’t diagnose are common on the ones I have tried. I continue antibiotics and later dilate his anus and some poo comes out. The girl who’s baby died shortly after birth, is ready to go home.
I head to the OR to debride dead black tissue off the 2 year old girl with suspected anthrax. She is given a shot of ketamine IV. I grab a scalpel and start carving off black dead stuff that doesn’t bleed. Eventually I’m down to her muscles on the whole right side of her abdomen and around to her buttocks. As I get to muscle I finally find tissue that bleeds. I pack all the open areas with Dakin’s solution (dilute bleach solution) and wrap her up with ace bandages. We take her to the postop area and bring in her mom to watch her as we prepare for the next one.
The next one is the woman with the tracheostomy tube and neck laceration from a cow horn who needs a feeding gastrostomy tube. She is very dehydrated. As I cut into her belly it barely bleeds. As she gets fluid throughout the surgery, she does start to bleed. I hope her kidneys survive. I cant check them so I have no idea it they are or aren’t. She does have urine in the bag, but I cant tell when it was last emptied. I found a tracheostomy tube and I’m able to change it out from the tube I put in the other day to this one with out bleeding or difficulty. I was quite worried about changing it out, and I’m grateful it went easily.
The maternity nurse stops by to say I need to see someone over there when I am done. So after finishing, I head over there. There are two women. One has a live baby with meconium (dark fluid that is baby poo, meaning fetal distress). The other has a dead baby and it isn’t coming out. She has a huge bruise (2x5inches) down there, where people at home had been working on her for hours. I take the one with the live baby to the OR and do a C-section. We get a floppy baby, but after working on it a few minutes, it starts to breath. I go back afterwards and use forceps to help extract the dead baby. She has a huge section of dead cervix hanging on by a thread (also dead “thread”) I cut off the dead tissue, which doesn’t bleed because it’s dead. She gets antibiotics and I hope she is able to heal. It’s one like this that seem likely to get a vessicovaginal fistulae. A connection between the bladder and vagina from the pressure of the babies head for hours that necroses the bladder. I’m now sweaty and tired and go home to drink some cold water and eat my first and last meal of the day.
As I go back in to check on people tonight, I find an old guy in the ER with a scrotum, literally the size of a basketball. Though that is not why he is here. He feels weak, has a headache, and the health center that referred him said he was pale. I look at his eyes and see NO blood vessels. He is pale! His hemoglobin is 3.3 and they have just drawn a unit of blood to transfuse him. I am sidelined by a couple people in the dark who say they have paid for the surgery for their family member, and can I do them tomorrow. I think I have a thyroidectomy, hernia, hysterectomy and a skin lesion removal tomorrow. So I told them we will figure it out in the morning.
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