Chad #15 2019
I’ve operated on a few very young children in Africa. They always seem to die. So when I saw this child with an omphalocele, I think should I try or let the infection take him? An omphalocele is where the umbilicus hasn’t completely closed and there are intestines covered with some tissue but not skin. This is a defect in development somewhere around the 12th week of fetal life. I feel I need to try again. I wonder why they always seem to die. I read about it again and see something new, a silo. When we do a long trauma operation and sometimes the intestines are edematous and cant be fit back in the belly, we sometimes have to make a temporary closure of the abdomen with a large plastic IV bag, sewn over the top of the open abdomen to keep things in place. Once the edema has gone down, and the bag has been rolled down, the bag can be removed at another surgery and the abdomen closed. So this is thought to be the way to close omphaloceles from my reading (if there are any pediatric surgeons on this email list- please comment back to me your thoughts). This makes the pressure of putting all the intestines back in the abdomen occur more gradually and doesn’t collapse the inferior vena cava (big vein in the abdomen), or cause respiratory compromise.
So I take this baby to the OR. I ask Dr. Olen to help with anesthesia as Phillipe says he doesn’t give ketamine to babies who “don’t have an age yet”. I questioned further, and I think he said less than one year. I guess on the carnet they are bebe ..moms name. After they are 1, then that number is put on the carnet as it’s a spot for years not earlier. I prep his belly and the edematous sac over the intestines with a dead short segment of cord attached with string around the end. I cut off the dead cord to prep better. I then dilute the only lidocaine they have, add adrenaline, and calculate the dose that’s the maximum, to avoid cardiac arrhythmias… Then I inject all the way around. He cries and squirms. Dr. Olen gives him a drip of ketamine and I begin. I cut in at the bottom of the sac and enter the abdomen. Then with scissors I cut off the sac and free up the intestines that are stuck. There is some pus between the sac and the intestines. The IVs here are bottles, but we find an IV sac that’s residual in the OR and I cut off a corner to make a plastic silo. I suture this all the way around. The baby does well and he is taken out to the preop/postop area and his mom is let back in. She has been in and out of that area many times during the surgery, concerned over her baby. Later that night I was called back to see the baby that was breathing poorly. Fortunately it just required that I extend the babies head and he breathed better. In the morning he was still alive and had taken a little mild that the mom expressed for him. He wasn’t breast feeding yet.
I open the carnet of a consult to see between surgeries. A lady has had tooth pain and swelling of her cheek for about 2 weeks. I ask one of the nursing students to call her in. She walks in and makes a slight groan with every breath. Her left cheek is hugely swollen and taught. I don’t see any drainage point on the outside. I ask her to open her mouth and she gets her teeth about ¼ inch apart. She cant open any more. I try to push her teeth apart- no budging, and she winces more as I do this. I see a dead tooth, pushed up in the mass effect of the infection, I can rock it but cant pull it without more space. I feel around on the skin and find a soft area in all the hardness. She definitely has pus in that cheek. I numb her up as best I can (abscess are impossible to numb adequately). I incise over the numbed area and molasses thick pus flows out. I put a finger in to sweep around, and break up any loculations. The pus cavity goes to the mandible, and up to the zygomatic arch. This is a huge pocket to be in a cheek. I flush it out with the hospital “dakins” solution (dilute bleach water) and put a gauze soaked with the stuff up in to fill the pocket. As she had before, she continues a soft groan with every breath. I order IV antibiotics and send her out to be admitted to the surgical ward.
That evening I head to bed about 10PM. At about midnight, Dr. Stacey calls me to help in a C-section. The mother had presented with an arm sticking out and a live baby. As I mentioned in a previous story, when an arm is the first thing out in a delivery, then this means that the head and body are shaped in a U and the arm is at the bottom of that U. And babies don’t come out shaped like a U but more shaped like an I. Meaning that they should be head or butt first, not folded in a U. She received IV fluids, then the spinal. We went through the abdominal layers, took the bladder off the front of the uterus and then incised the uterus. Meconium flowed out. We grabbed the head of the baby and pulled her out. No crying. I suctioned her nose and mouth and got a short gasp, then nothing. I did it some more and ruffed up the kid and started drying her. Finally she started breathing and crying. I grabbed her slimy body, covered in vernix, and passed her off to Phillipe (the anesthetist nurse) to dry and keep the kid breathing. We sewed up the uterus then closed the abdomen. I was about to have diarrhea again so, I left before skin was closed.
I fell asleep about 3 and was called at 4. As you probably can tell now, whoever is on call for maternity ward is very busy day and night, and the surgeon is too. Dr. Stacey wanted to know if I can do a suction delivery or use forceps. Yes, so I head in. There are two women on 2 of the 5 delivery tables present. The one that needs help is on her 9th vaginal delivery, but she started pushing to early and it seems has run out of steam to push any more. She is fully dilated, and when she gets a contraction the head comes down, but when the contraction stops, the head rises back up. Is the baby to big? I feel around and there seems to be space, there is definitely a hematoma or edema on the top of the head from being stuck there a while. It doesn’t seem like suction would work and attach to this form of head, so I choose forceps. They are still in the OR, so I go back to the OR, unlock it, get them, and relock it. I’m able to slide each half in without difficulty and lock them together. I wait with one hand on the forceps handle and one on her abdomen, feeling for the next contraction. One comes, so I start pulling, gentle, constant, traction. The babies head comes down and then starts coming to fast. I stop pulling and put my hand on the kids head as it crowns at the opening. Slowly lets tissues stretch, and there is less likely to be a tear. Finally the babies head is out and the forceps are off. We clamp the cord and Sr. Stacey gets the baby breathing and crying. I massage the uterus through the abdomen and try to get the placenta to deliver. Gentle traction on the umbilical cord and eventually it delivers. It seems like there is a piece missing, so Dr. Stacey reaches inside the uterus and scoops out some more. Her hands are much smaller than mine, and it is easier for her to do this maneuver. We look around and there doesn’t seem to be any cervical tear and only a very small skin tear. I head to bed.
A couple hours later on rounds Dr. Stacey finds the woman is pale, short of breath and has bled, and the nurse didn’t notice the clots in the cloth she was wearing between her legs. We take her for a curretage and scrape out residual pieces of placenta. Im concerned about the amount of bleeding she is having even thought she has gotten 2 unites of blood and a 3rd is going in. I decide we should stop, give her more blood and if she continues bleeding to, curretage again. She does continue bleeding, and after we’ve caught up on blood a little longer, Dr. Denae does a curregate, fills her uterus with 4 foley balloons and does a vaginal pack. Apparently there is a nice large balloon made for this in the US, but of course, not available here. She finally stops bleeding!