Bere 2018 #7
Fatigue, a back ache, a runny nose, blood all over the front of my scrubs, that’s how I walk back to my place tonight at about 8PM. Went in at about 7 this morning and expected a slow day because there was only two planned surgeries today. But as always happens, what’s expected doesn’t happen. The staff is in mid-sign-out when I arrive. I stand in the back and listen to who came in overnight. Then there is a time where the staff can bring up issues they need to mention or complaints they have. There is a need of blood pressure cuffs, a computer that works in the surgical ward and someone is unhappy about the number of mosquitoes in the ER. Everyone else is laughing at him, because mosquitoes are everywhere. But he feels his workspace is inundated with them. I head to the OR to see who’s ready, and of course no one is. Then I find out the water is off, so we have to wait for water. Apparently there is one faucet designated for people of the village to come and fill up their containers. Someone broke this overnight, and it drained the elevated tank of all its water. So headed to the surgical ward for rounds. As I’ve mentioned, this is a lot of dressing changes. Some are accidents that are healing, others are post-surgical infections. I also have the old man that I put a small IV catheter through his abdomen yesterday, to buy me some time to operate on his urethral stricture today. He hasn’t eaten and I re-explain the different possibilities of the operation to him. Dilation of the stricture in the penis, or opening his penis and his bladder to fix the stricture, and the need for likely a lifetime of urethral dilations either way. And if the stricture couldn’t be repaired (to long a narrow area), then he may need a catheter in his abdomen for the rest of his life to drain the urine. He doesn’t like this possibility but says to do what I can for him. “Doc je une malade au uregence pour vous a regarde’.” (There is an ER patient to see). I head over there with the nurse. This 30-year-old guy has had abdominal pain for three days and it’s been intense. I touch his abdomen and its tense and very tender. He has what surgeons call a surgical abdomen- peritonitis. I write the orders and head to the OR. They have a patient in there, and the water has returned.
The first one is a 20-year-old girl with an abdominal mass with ascites. Dr. Sarah wants to do it with me, as she wants to broaden her experience in surgery. I lead her through the operation. She makes an incision in the skin, and we get to fascia right away, almost no fatty layer. Once we get into the peritoneum, we get some cloudy fluid. Feeling around, I do not feel metastasis everywhere like I suspected. Instead I feel large lumps in the mesentery, and a large lump in the retro peritoneum. I decide this must be abdominal tuberculosis. This is a great finding for her! This is treatable! When would you ever be happy about a diagnosis of tuberculosis? I take some fluid and send it to be evaluated for evidence of TB bacilli. I’m happy to give her a possibility of something treatable. As we finish up with her- I remind the staff that the guy in the ER should be next. They say they have a hernia next as the guy in the ER ate this morning. I’m not pleased about waiting, but think that is reasonable. I think nothing will move out of his stomach anyway, but decide not to say much more.
The next guy isn’t just a hernia, he has 3 hernias! One in both groin and one in his upper abdomen. There is a new doctor that showed up yesterday unannounced. So it is he that helps me with this one. It’s a slow process as we fix one hernia after the other. Eventually they are all fixed and he heads to the postop/preop area. They have the old man with the IV catheter in his abdomen and a urethral stricture there in the preop area. He is refusing to have the surgery as his family hasn’t arrived yet and he is adamant about having the IV catheter out of his abdomen saying he can pee just fine now. I don’t believe his AT ALL, but as I don’t feel like fighting in an old man who can make his own decisions, I pull it out. Had it been a woman or a child, I would have fought the husband or father for the good of the underdog. But this guy- no. They take him back to the surgical ward. It’s mid afternoon and the water is gone again. This time it’s the well pump. They have to take it to a town 3-4 hours away to try to get fixed. So now I have this emergent surgery and another one that just arrived with an ectopic pregnancy. Both HAVE to be done today. I ask the staff to get some water from a hand drawn well in the village, add bleach to it and use it to wash our hands and postop instruments. They put it in a bottle and dump it over our hands and arms as Dr. Sarah and I scrub for this guy. She opens up his abdomen along the middle from top to bottom. Im initially suspecting a gastric perforation as he has upper abdominal pain to begin with. But his intestine is really distended. As soon as we open the abdomen the intestines “jump” out, released from the confines of the abdominal wall. I see some of them in the lower abdomen are purple. (not great blood supply). I look around and realize that there is a volvulus. The intestines have twisted on themselves, blocking off their own blood supply. I untwist it and they look better within a few minutes. The large intestine fills with fluid as it continues on as well. At the end of surgery there is poop all over the operating room table as it was released. What a mess without much water. They have brought in more water and they clean up well.
The 22 year old woman is there in the preop area, lying under a sheet and with her head scarf on. She is obviously uncomfortable. I touch her abdomen and she winces in pain. Dr. Sarah does an ultrasound and confirms what appears to be a pregnancy outside the uterus with fluid (blood) in the abdomen. The generator has now quit as we take her into the operating room. They restart it and it runs for 10 seconds and shuts off. I hear that it is to “hot”. To me that means out of water for the radiator or out of oil. It runs in the hot season when it is 125 deg, so now when it’s 90, it should run just fine! Eventually the anesthetist comes in and says that we should proceed, as it won’t get fixed. So I run back home to get extra batteries for my headlamp and other lights that I happened to bring with me. I see Gabriel and he rounds up some more headlamps for us to use. It is very hot and still in the OR now. I figure it will be my sweat that will cool me now. We use cloth gowns here as they are reusable. As I open one of the gowns, I get a little odor of rotten flesh. OH NO, I hope these were cleaned and sterilized well after the leg amputation the other day. I ask if anyone else can smell something. They can’t, and my nose doesn’t work well anyway. So I hope I’m imagining things. I don’t see anything unusual, and the marking tape on this pack seems to have reached the temperature needed. Or at least black marks on the tape. I sure wish I KNEW that these were sterile. I wish we had a real, functional, electric autoclave!!! As we open this woman’s abdomen dark blood comes flowing out all over me. It quickly saturates through to my skin! And no water for a shower tonight. I wish I had thought to fill some buckets with water earlier in the day or when I arrived here! We find a small tubal pregnancy that has ruptured. We remove it and as we’re mid-surgery the electricity comes back on. Guess the generator is working again. The generator runs this hospital 24/7/365 days a year. It is one of the major expenses of running this hospital. More than all the salaries of the staff. In the end, I head home and find a washcloth that I saturate with water left in a cup that I had sitting out, and wipe the dried blood off me. I feel better, but not clean. I guess 9pm isn’t a time to try to find water in the village, it’s nice to sit under a fan though. I head back into the hospital to tell them I’m on call again and see a young student that is jaundiced and vomiting in the ER. I order some things and hope we can figure out something for him.
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