117 Shanksteps
It is feast or famine, as far as surgery goes. I may go days or even a week and not do a surgery, then there may be so much I cannot do it all. That is what Monday was for us. Sunday we saw about 34 in clinic and made rounds in the hospital on about another 40. Some are on “autopilot” with healing wounds or other static things. Others very complex, like patients in diabetic ketoacidosis and recurrent ascites with no known cause. I started the day knowing that I was going to do a real long surgery. There is a woman who had urinary obstruction after surgery for which I was going to do a definitive operation. I was either doing an ileoconduit or a bladder suspension with extension to adapt the ureter to it.
Before we made rounds I met with Audrey to pray that the day would go according to Gods plan. As I went to leave my office a man who I had seen the day before, came running in dripping. I have been seeing him nearly every two weeks and draining 15 liters (4 gallons) of ascites off him. The day before as I was seeing 34 clinic patients I told him to come back tomorrow to do the drainage that I was too busy that day. I also reiterated again that if at any time his umbilical hernia started leaking that he should come back immediately. So in he comes with his umbilicus (belly button) spouting like a fountain. His umbilicus had indeed ruptured. I sent him on to the operating room and followed the trail after him. I put a clamp on his umbilicus to stop the flow so to not get the entry to the OR all wet… We opened him up to fix his hernia. There was a fleshy mass on his gallbladder and a small one on the left lobe of his liver. I couldn’t find anything else so I suspect this is the cause of his ascites. (still undiagnosed) He needs a biopsy, but then he didn’t even want to do the surgery for fear of the cost. I just told him there was no other option! During the surgery, Djoudge, the cleaner, came in to tell us that a woman was in labor. I asked him to call Audrey to check her out, since there was no nurse free to see her. Audrey came in a few minutes later saying that she was concerned about uterine rupture and that she needed a caesarean section. I the man’s abdomen in the most water-tight fashion possible.
Immediately we were called to see a woman who was having difficulty with labor and had a possible uterine rupture. After checking her out, Audrey and I decided it was best to do a caesarean section for fetal distress and imminent rupture. So Aud joined me for her c-section for speeds sake. We delivered a crying baby boy of about 9 lbs. We decided to do the long surgery directly after. I went to finish rounds, Audrey to see some patients in the clinic before starting. The nurses would have to take care of the rest.
Nguizaye had been operated on before for extensive uterine bleeding and had been transfused a number of times. At the time of her hysterectomy everything was stuck to the back of the uterus which was much enlarged. After extensive adhesiolysis and much difficulty in the pelvis from all the adhesions, a total hysterectomy was performed. She came out of the surgery well but with bloody urine. Over the next 24 hours she made essentially no urine in spite of being rapidly replaced with fluids. The day after the first surgery, I reoperated on her and was unable to identify the area of ureter entrapment. I put in some makeshift stents as a temporizing measure while I decided what to do definitively. The stents became infected and she was not doing well. So this was the day for a definitive repair. Having asked many colleagues their opinions (and only one responding) we started.
Entering the abdomen, was already difficult. Adhesions everywhere. Then omentum stuck down to the previous operation site and the area of previous adhesions. With much difficulty and tedious work we dissected out the ureters. This took about four hours. I decided we did not have the room sufficient to use a bladder mobilization to reinstitute urine flow. So it would be an ileoconduit. About this time another woman was having difficulty with labor so Audrey set up for a C-section in the other operating room. We changed around nurses to cover both rooms well. Fortunately the student missionaries are up to speed and a real help in the OR now. Soon I hear yelling and movement in the other room. Audrey comes back in a few minutes with a crying baby in hand. She delivered without the C-section. So she would rejoin me again. I resected a piece of ileum to make the conduit between the ureters and the ostomy. Reconnected the intestine and then started the anastomosis. Baya (the ER nurse on call) came panting into the room. “A man has been stabbed and is bleeding profusely from his abdomen. “ As I have one patient open on the table with no one else who can do this I tell him to have them hold pressure and that they MUST go on to Mokolo. People do not want to go to Mokolo but it was necessary. So I continued my surgery. It was tedious and deep. The woman had lost much weight, but unlike most here, she still had a bit of fat, making the surgery deeper and more difficult. We finished the surgery at 10PM, ten hours after the start. Back cramps, headaches, and extreme tiredness made it difficult to write all the notes of what had taken place. We made it home after seeing some in the ER, about 11:30PM, massaged each other’s back knots and went to bed. She is still very sick, electrolyte abnormalities, delirium, malnutrition, and three anastomosis; enough to make any surgeon worried. Then put on top of that the absence of an ICU and monitoring. If she makes it, it is only because of Gods direct intervention. I pray for her before going to bed, as I wake up and many times throughout the day. Please keep her in your prayers also. In His Service, Greg