I lay awake last night. Is it still jet lag, or is it that I’m thinking about the 10 year old girl with the mouth mass, or am I still amped up after the difficult ostomy reversal I did till 9 last night with the hand sewn anastomosis? I don’t know but i was tired and couldn’t sleep. Sometime about 1AM I drifted off and didn’t want to wake when I when my alarm went off in the AM.
My first patient to operate on is the 10 year old with the mouth mass. It took a while for Phillip to put her to sleep and then when he intubated her, he got the tube in pretty quickly- that was great. Then she was prepped and drapped and I started. Just prepping it caused it to bleed. If her mouth had been open all the way it would have filled the opening, but it was a little off to the side. The mass was dark pink and her tongue light pink. It seems to be coming from the area of her teeth. So I attempted to put a suture around the base of it and amputate it so that I could see what to do next. The tie didn’t help much as it got stuck on her teeth and not really tight like I wanted. So I just held pressure on either side of the gums and cut it off. I cut away all the tumor down to the mandibular bone pulling the two involved teeth. Then I used a rongour to nibble away at the bone to get all of it off I could find. Then cautery and packing to get the bleeding to stop. There was a large lymph node under her mandible on the same side. I’m sure that was involved too. So I cut through the skin, fat, platysma, and then shelled out the node and stopped the oozing afterwards. After closing this one, the tooth area was relatively dry so I left the packing in place. She was extubated and seemed to be awake and doing well when they wheeled her back to her room.
Another one was the 14 year old girl who I had seen with the breast cancer and B cell lymphoma that I talked about in the last shank steps (of faith). Every time I see this girl she is only wearing a skirt and no top- which is usual here. However the unusual part is she always has one or two hands up cradling the breast and when I ask she says it hurts a lot. So she’s on the operating table and going to sleep. Philleep can’t seem to intubate her and as I look over his shoulder he is traumatizing the area and it’s bleeding a little. I ask if he wants me to try and he does. So, thank God, I was able to get the tube in an we started. Her breast was huge on the one side compared to the other. I slowly excised the whole breast taking the surface of the pectoral muscle with it and in some areas that were hard with tumor, went deep in to the muscle. I feel some enlarged lymph nodes in her axilla, so I take them out as well. One just falls apart into goo as I try to gently grab it. That one definitely had the cancer. Now I have a very large open chest wall where the breast used to be. So i had planned on doing a skin graft. they have a large blade with a guard on it and I try to use it on her leg for the graft and make a mess of a few inches of her upper leg. Then Daveed volunteers that they have a dermatome (cuts off half the layer of skin like the other was suppose to. This allows the skinned area to grow back and helps new skin to start on the recipient area.) This dermatome is put briefly into the autoclave to warm but not to sterilize like other instruments, as it would ruin it. I’m pretty sure warming didn’t help but that is what he does. There are blades with it and I pick one that both of us think is new. He says old (reused) and new are mixed together. I pick one I think is new and use it. The dermatome works great but the blade only half works, meaning it cuts on one side only. So I make a number of small strips of skin to use. Then there is suppose to be a machine that cuts small slits in to the graft to make a small piece of skin cover a larger area when it is stretched out. That isn’t available here so I just use a scalpel and make slits all over. it works pretty well and then the FP resident with me, Ted, does some and takes time and his looks much better. We then put all these pieces over where the breast used to be and with a lot of sutures, and time, they are sutured in place.
There is an old guy with a penile stricture that wants a repair. It’s been a few years since I did one of these so I look up the post operative care and find that they need repeat urethral dilations every few weeks for life. He lives a few hours away and though he says he will do it, I decide that it’s not best for him and that he should keep his suprapubic catheter. He accepts this and I tell him there will be a Kenyan surgeon here in about a month if he wanted to talk to someone else about it and get another opinion. He says he’ll come back in a month to find out.
As I’m about ready to leave the OR one of the other doctors says there’s a guy who she thinks needs a chest tube. We look at him together and do a bedside ultrasound with my pocket ultrasound. Its not as good as a larger model, but it’s portable! I can see that there is fluid about half way up the lung. This ?20 year old guy was stabbed by a cow horn about a month ago and has gotten gradually a bit of pain and a little shortness of breath when he walks. We put a needle into his chest and get out pus. So I take him back to the operating room and walk Ted through the technique of putting in a chest tube. After the tube is put in, there is no pleuravac, so we connect it to a urine bag which immediately fills to 1500ml of pus then some blood at the end. WOW, that’s a lot of pus in the chest. No wonder he was a bit short of breath!
Each day is a variety that is interesting. Many advanced stages of diseases are seen here! God help us help these people, give us wisdom to know what to do and how to do it! Guide our minds and hands!
