Liberia #17
Me an anesthetist or anesthesiologist? I can do it, if need be. I’ve decided after yesterday that I don’t like it! The other end of the patient is much more interesting and my preference.
It was Friday and I did part of the rounds as usual. Some getting better some staying the same, none died overnight. I’m am called to go outside to see a sick person in a car that they say has liver cirrhosis. I take about 30 minutes to finish what Im doing. Then head outside. The people milling about indicate the car. I peer into the back seat to see an old man laying still on the seat. He doesn’t breath. I think he is dead. I put a gloved hand on his neck, no pulse, he’s already dead. They said when they were coming in that he was breathing, very slowly. I call the burial team to do their assessment. They will come and do their assessment, then decide whether to take the body and cremate it due to Ebola risk or let the family take him to a funeral home.
A 40 year old woman has had a chest tube in for weeks, with pus draining out. The tube fell out a few days ago. There was remaining fluid and air in the chest outside the lung, and a trapped lung. Dr. Seton decided to open the chest to clean out what she can, and asks me do the anesthesia. I do not know the gas dosing of isoflurane that is available here or how to run the machine. She doesn’t think it will take but about an hour, so I decide to use Ketamine. An aid in the OR places a second IV line. I give the antibiotic, anti-nausea, and IV fluids. Then the Ketamine IM and some IV. The patient is asleep and breathing on their own. Dr. Seton preps and drapes the left back. She makes an incision and after some dissection, is into the lung space. Pus and rotten tissue is found. She plucks out chunks of rotten stuff and the stench in the room is significant. She decides to resect a rib and leave the space open so it will drain adequately. She does find a small area with lung, but most is just fibrous tissue and cannot be removed safely. From an anesthetic standpoint, the patient does great under Ketamine. There is no family around to watch the patient, so I keep her in the OR off to the side to watch her. Rather than delay further, early afternoon, I have them bring the next patient in. So I will keep an eyeball on one while giving anesthesia to the other.
The next on was in a motor vehicle accident more than a week ago and likely has an open fracture of her left elbow (humerus, radius and ulna). There are about three flexible areas in the arm where one should be. After Ketamine and other premedications, Dr. Seton explores the area and finds no discernable opening to the bones. So she does a dressing and the makes a splint out of plaster of paris. Then wait about 30 minutes for it to set up.
Eventually a family member arrives for surgery #1 and so we wheel her back to her room.
At about 4PM, the guy with the posterior dislocation of his knee for one month, and open fracture, refuses to come to the OR till his brother is there to sign. He initially went to the largest hospital in mid December, and was turned away, that they were only dealing with Ebola care at that time. So has been having he leg dressed at some clinic for the past month. He’s been to a number of other hospitals too, all of which are full or not doing non-ebola care. I wish he had been here at that time. Drs. Seton and Saunders could have delt with it much better at that time. Now there will be much scar tissue. So the second off the list. We’ve already cancelled a breast cancer today when it was so late. She will be done next week, and I guess this guy will be as well, continuing dressing changes as it has been done for the past month.
The woman to evaluate is about 40. She has had abdominal pain for about 3 weeks. Now on ultrasound by Dr Seton, it appears that she has a ruptured appendix with an abscess. She’s also had nausea, but denies vomiting, but hasn’t eaten much in many days. She’s a bit distended. Dr. Seton feels that she can stay low on the abdomen, so we decide on doing a spinal. I pre-treat the patient with about a liter of IV fluids, then prep the back after marking my injection site. Using a sterile technique, I insert the spinal needle low in the back at the appropriate angle. With a few inward adjustments, there is clear spinal fluid. I inject the long acting spinal anesthetic. She lays back. By the time Dr. Seton is ready to cut, she cannot feel anything below her upper abdomen and is breathing fine. As Dr. Seton enters the abdomen, the firm area is found and appears to be stuck to the colon on the right side and the left. She opens, the abscess and finds thick mucus. A mucocele of the appendix? After further investigation she palpates some enlarged nodes, so a mucinous cancer seems more likely. It is also attached to the abdominal wall. So resect or leave it and give her an ostomy. The decision is made to resect, giving her the longest chance of survival. Other than local nodes, no other signs of metatasis are seen or felt. Now we are in for the long haul. And now Dr. Seton needs to go higher. The patient starts feeling pain. Then retching. Liters of feculent smelling materials come out of her mouth, pooling around her neck and dripping off the table. The room wreaks. Im glad that she is fully awake, and she hasn’t aspirated, she doesn’t even cough once, vomiting laying on her back! I place an NGT and withdraw 2-3 more liters using a 60ml syringe. The suction they cannot seem to get connected to work properly at the moment, and when they do, it doesn’t draw out any, so I continue with the syringe. Since she is having pain, I start ketamine, and also want to protect her airway, so I intubate her. I breath a short prayer for guidance and insert it without difficulty, Praise GOD! Will Ketamine keep her going long enough? I believe so, I’ve done a number of hours in Cameroon under Ketamine. I give it to her in the muscle and in the IV. I also put her on the ventilator, once I figure out how to make it run. It is a strange combination, a ventilator and ketamine. But the dosing of isoflurane, or even if it is in the machine, I cannot tell. So I stick with what I know. Now that there is airway control and NGT evacuated her stomach. I wish I had the anesthetist I work with here! Dr. Seton also says it invades the abdominal wall. So after about 4 hours of working on the patient, the cancer is out. Two anastomosis need to be done. Each of these take about an hour, using the hand sewn technique. Not intestinal staplers here! At the end of the surgery, the patient is breathing on her own, and the stomach is empty. I take out the breathing tube and watch her for a half hour. She remains stable. I get to bed about 1AM. Long day! I do my bucket bath in the water we have, cold. And go to bed fairly wet. Hopefully to keep me cool enough to sleep quickly before I finish evaporating.
