Chad #10 2019
I’ve taken a shower with nice smelling soap, scrubbed everywhere, and my hands still smell like pus and stool. I guess the gloves are thin enough that they must let fluid through or I got it in the sleeves. It’s hard to say, because my hands are wet early on in the case from sweat. The OR air conditioner didn’t work for a month apparently before I came but they’ve fixed it and it runs constantly during the day.
I saw a guy yesterday that had what the carnet said was a strangulated hernia. It was after I had finished my last case. He was a little distended in his abdomen and had a right inguinal hernia. I was able to reduce it, and gave him an order for surgery. The total for the surgery and the meds after came to 58000CFA, that’s about $120. I see that he’s paid and on the list this morning. After a couple hernias, and a tubal ligation and a washout on the guy I did a few days ago with a perforated appendicitis and lots of pus, eventually we got to him.
He was about 55 years old and walked into the OR with a stick as a cane. I took a feel of the hernia which was visible and he got his spinal and we started. Dr. Stacey wanted to do it with me as she is feeling a little better after dysentery. We did the usual entry in the groin at an oblique angle and down through the layers to the inguinal structures. We dissected out what looked like a hernia sac with stuff in it. It seemed thick. I squeezed it to empty it and if felt like I was just pushing out air.
No I believe the Holy Spirit prompts me to do things some times and if I follow it, things turn out better than when I don’t. I felt a prompting to tap his abdomen. I put one hand on the hernia sac and one on the abdomen and tapped the abdomen. It seemed to pulse in the hernia sac. I deduced that the hernia sac was full of air, meaning there was a hole in the intestines. But the sac still felt thick like there was intestine in it. And to thick to see through. I decided I had to progress one way or another, so I cut it open. Air and liquid stool flowed out! OH NO! I must have just cut into the colon. I put my finger in and felt the usual sac with an entrance into the abdomen and I could feel intestines in their normal position inside. I was relieved that I hadn’t hurt the man and worried about what I was to find next. I made an additional incision down the middle starting at his umbilicus and extending down to the pubis. When I entered the abdomen, more air and stool came flowing out. The room wreaked of stool. Every area of the abdomen that I started separating the stuck intestines, more pus and stool would flow out. It saturated both sides of the bed and ran to a large puddle on the floor in spite of us sucking up liters of it with the suction. My whole front felt wet through the cloth gowns, which is a disgusting feeling considering where it was coming from. The whole small intestine appeared like it had typhoid and I expected to find a typhoid perforation and found none. I identified the appendix and it didn’t appear inflamed. Liquid was up around the liver and spleen after opening up higher in the abdomen. On initial view the colon that I could see seemed fine. I looked at the anterior stomach, no hole. The posterior stomach was so stuck that I couldn’t see it nor seem to get to it. Eventually I discovered a hole about an inch in diameter in the sigmoid colon. There was some thickening there, so I assume it was a perforated colon cancer. It could be a diverticular perforation, but I’ve not seen diverticula here before. I assume I haven’t seen it because of their generally high fiber diet. I resected the segment and decided to close the distal end and bring out the proximal end as an ostomy. I hate giving people ostomies here, a there are no supplies for ostomy care. But with all the contamination, he needed to be diverted, and not re-anastomosed. About this time Dr. Stacey was didn’t look well. She’s been suffering from dysentery so I asked how she was feeling. “Not good”, so I asked her to scrub out and ask Abouna to come in to help me. Once he scrubbed in, I sewed off the distal colon end in two layers, then I brought out an ostomy of the upper cut end of colon. The intestines were to swollen to get back in the abdomen. I had Phillipe put in a nasogastric (NG) tube to evacuate his stomach, and then milked all the fluid that I could, in the small intestines, back towards the stomach so it could be sucked out the NG tube. Then I looked at the closed end again. It was dusky and didn’t appear good. So I cut off a couple more inches, and reclosed it again in two layers. I brought out the proximal cut end through the rectus muscle as an ostomy. There seemed to be insufficient length so I freed up a bit more of the descending colon to give more length to the ostomy and brought it back through the rectus and through the skin. With quite a bit of effort the intestines were crammed back into the abdomen and the fascia was closed. Before closing the abdomen I had to finish my inguinal hernia repair. I resected the thick hernia sac and oversewed the end. I did a suture repair, then felt it from the inside. It seemed secure. We closed the rest of the layers in the groin. Then back to the open abdomen for closure there. After getting the midline closed with loose sutures I “matured” the ostomy. That is that I sutured it to the skin in a way that makes it stick out, kind of rolled out on itself making a somewhat mushroom appearance. Dr. Stacey was back in the room and found an ostomy bag for us and we placed that as well as a bulb on the drain I had left in the pelvis.
I’m called in the night because the family is refusing to get meds for him. I tell the nurse he needs meds as he has a huge infection and will die without them. He goes back and apparently the family came up with a little money to buy meds for the night. A nock at the door again at 4 AM, and the nurse says that the patient is demanding water and pulled out his NG tube. I’m sure he needs more IV fluid and is dry. I don’t think it will make any difference for me to go talk to the patient and think that administration should consider whether he needs meds for free? So I tell the nurse the complications again and ask them to address it with administration- which I’m sure won’t happen till morning.
During rounds this morning I discuss how crucial the antibiotics are for the man to the 4 younger men with him- likely his sons. I get on their case about not doing what is necessary for him. At the end of rounds they have gone and bought his medicines, so after 12 hours without antibiotics in a perf sigmoid, finally he has antibiotics. Unfortunately, I am still jaded from my time in Cameroon, where everyone claims to have no money. Even the Koza chief who drove an old mersades, and had 4 wives and numerous children, claimed to not have money. Obviously I could help financially, and it is hard to know when to and when to push the family to fork it over. So is still struggle with it. I think hospitals should have a good Samaritan fund that is run by an honest local who can differentiate who really needs the help and who is not wanting to contribute to their care.