Chad #8 2019
There is fluid between the liver and the kidney, Dr. Sarah told me this afternoon after I had completed a hernia, prostate, and hernia. (By the way, the prostate was the largest I have removed, about an orange in size). There seems to be sediment in the fluid. It may be an abscess. The guy is sitting stone-faced, on the chair in front of me. He shows me his belly, which is distended. I have him lie down on a stretcher. He doesn’t seem to have percussion tenderness nor rebound, but definitely doesn’t like me pushing on his abdomen. He is the usual thin Chadian guy about 5ft, 8in tall. He probably has a BMI (Body mass index) of about 15. I don’t know what he has but I think we should operate on him. So I do a digital CT. (that is cut and touch with a finger). That’s the best diagnostic tool we have! As I examined him lying down, I did have the sense that as I tapped on his belly, there was a slap against the organs- making me feel like there must be free air in the abdomen, even though the rest of the exam didn’t seem like that. We had the nurse start an IV and I operated on a guy with difficulty urinating.
This guy had had a prostatectomy here before and apparently had a small 0.6 cm bladder stone. I had tried to pass a foley a day or two ago and there was a urethral stricture about mid-penis. So I couldn’t even get in the smallest. I had planned on operating on him that day, then after he paid and before I got to him, he urinated “well”. He wanted reimbursed, so I wrote for that. Next I see him the following afternoon, and he’s saying he’s not urinating well, and wants the operation. I send him again to pay for the operation, and I see in the computer Friday afternoon that he’s paid. At the end of our other surgeries Friday, we call his name and he’s no where to be found. So we left. They thought he may be at the mosque for Friday prayers. Finally I see him Sunday and he says its’ still hard to urinate. So we schedule him for today guessing that he must be getting some urine out, as he wasn’t in the “ER” for it.
His bladder was distended, which makes the operation easier, as it pushes the intestines up and out of the way to cut down to the bladder. As I cut down to the bladder through his previous scar, I had barely gotten through the muscles when I entered the bladder in the scar tissue. Urine flowed out. I enlarged the opening. I felt around in the bladder and didn’t find a stone. Since I hadn’t been able to pass a foley from the outside I passed one from the inside. It seemed to get hung up in the same place about mid-shaft on the penis. So I used metal dilators and dilated up the urethra. After getting up to a 22F size, I still couldn’t get a 20F foley in(smaller). An 18 wouldn’t go in. so I put a dilator backwards from the bladder out, attached a suture, then pulled the suture through. Then I tied the 18F foley to the suture and pulled from the bladder side, to pull the foley in. This worked. I closed the bladder in two layers and then the fascia then the skin.
Next I thought would be the guy with a broken nose to elevate the pieces, but they had told him to go home and come back tomorrow. So next was the guy with a distended abdomen. He got the usual spinal, then I prayed for his as I do with all my surgeries. Since we thought the fluid was more in the upper abdomen by the ultrasound report I started up there. I asked Phillipe to give ketamine, and after he had I cut along the middle from top down to the umbilicus. As I got in the abdomen there was a rush of air coming out. I didn’t find much else initially, but as I searched around, I got LOTS of pus flowing up. 2 liters of pus came out. As I finished one pocket of foul smelling stuff, I’d find another. I had everyone in the room give their guess as to the source. Abouna- infected ascites, Phillipe- infected ascites, Diana-wouldn’t commit, and I chose a perforated stomach ulcer. I should’ve known better just by the smell. But I figured upper abdomen, either that or perf typhoid. I kept getting more pus the more I searched. I kept on opening down, further and further, till eventually he was open from xyphoid to pubis. There seemed to be a little fullness in the right lower quadrant. I looked for the appendix and then felt like I got a different smell, and worried that I had pushed a finger into the colon. As I explored the spot more, and gradually identified structures from all the inflamed tissues, I eventually realized that this was below the cecum and not the small intestine. I identified the ureter and then followed it down, protecting it. Then I discovered it was a rotten appendix that had perforated. I did and appendectomy and we washed and washed the abdomen. I decided that I would plan on another washout in about 24-48 hours. I closed the fascia and left the skin open. My cloths smelled like the other day- stink! I have blood and pus on me! I wish there were impervious gowns here! After surgical cases like these- my soap and shampoo always smell especially wonderful!