Shanksteps Bere April #6 with pictures
BEWARE_ The attached picture some may consider gruesome. That is the reality here!
I’m adjusting a little to the heat but sleeping is still the hard part. I go in and see my surgical patients while I wait for the first surgery to be ready. I round on the ward that has about 20 people. Here is a brief summary: There is the teen girl with bladder extrophy, multiple vessico-vaginal fistulae repairs, guy with a hippo bite to his arm with tendon repair, bladder stone boys, Achilles tendon repair boy after bicycle accident, osteomyelitis on the foot boy which is granulating. repeat repeat bladder repair after stone extraction. above knee amputation infection, and open neck teen. Im called back to the OR as Olen has intubated my first baby.
The baby is about 1 year old and has a retinoblastoma. That is cancer of his eye. His eye looks very abnormal and appears to be growing out of his face. I can’t remember if Ive taken out a retinoblastoma before in Cameroon or not. I know Ive seen them before. Either way I think of the possibility of a lot of bleeding deep in a hole I have difficulty of controlling. I pray over each patient before operating and do the same for this baby. (I don’t like operating on babies!! here they die to often of unknown problems) After prayer I start by prepping the face and I scrub my hands with the bar soap that is available. No normal surgical soaps available here. I probe around the eye and realize the lower lid is invaded by the cancer but the upper lid isn’t. So I save as much of each eyelid as possible to be able to put those into the cavity that’s left so that less granulation will be needed. to close up the space. I gradually cut and dissect around the eye, initially its fairly easy but as it gets further deep in the hole of the eye socket it becomes more challenging. Finally I’m back to where I imagine the optic nerve and vessels to be. I place a right angle clamp and work it around the eyeball down to the base and clamp. I hope I have whatever bleeder is there as I have to now cut off the eyeball to seee what I’m doing behind it. I cut and there is no bleeding. I realize as far back as I can go there is cancer or at least it looks like that to me. I reclamp as deep as I can and take off a little extra cancer. I see it also appears to have invaded towards the nose side. I knew this was palliative not curative- but it’s still sad! i suture in the eyelids as much as I can and pack the rest of the space.
Next one is a 7 year old boy who was burned down the back of his leg a couple years ago and has a large contracture from his buttocks down to his ankle. It creates a large web of tissue going down that pulled his heal towards his buttocks. His knee he cannot straighten beyond 90deg because of it. So he stands perched on one leg like a flamingo. I plan on a Z-plasty, which takes the forces of contraction and changes their direction so as to not make the same contracture again. I finish my rounds on the surgical ward as Olen intubates him teaching David while he does it. Since it is hard to find surgeons and anesthetists to come here they are teaching local nurses to do anesthesia and surgery. If you want to help in this way please contact me and I’ll put you in contact with Dr. Davenport. I’m called after he’s intubated. We turn him mostly prone and prep his legs. I prep the second for a skin graft if I need it.
First I cut the cord on the back of his leg the part that is really contracted up and firm. Then I gradually mobilize a flap of skin on each side. I start making my cuts in these flaps and then have a hard time figuring out how to create the Z-plasty with them. I ask Olen to open a book for me and my incisions are correct but I still can’t figure out how to make it look good. Eventually i find an acceptable way but it seems to have areas of tension and areas of laxity. So I have probably chosen a poor location to do a Z-plasty. I free up everything that feels tight and still the knee doesn’t go straight, even with a lot of pressure there is still about a 20deg bend. I guess it must be his knee then. so I continue closing, which takes me a long time and a bunch of suturing to get this closed. There is a small open area left at the top so I fashion a piece of skin I cut off into a skin graft and suture it in place. I put his leg in a splint after placing a large dressing.
There is a guy waiting in the consultation area that Olen says needs a chest tube. While my next patient is being gotten ready I take this guy into the other OR and place a chest tube. As soon as I get it in he takes a huge breath and coughs. Pus from his lung space spews out the hole and all over me and shoots out the chest tube hitting boxes and the floor about 10 feet away. This is disgusting!!! I suture it in place and he continues to cough but now I’m ready. I’ve had coughing later as the lung expands but not at the beginning like this. I put a dressing and hook up the reused reused pleuravac. I put him to suction and it appears to be working. I attack the little foot pump suction I brought here last time and show the family how to pump it to create suction. Later that evening he has put out 1500ml of pus into the pleuravac.
The last guy of the evening is the teen with the open neck that I wrote about a few shanksteps back. The one who necroses the front of his neck with infection from a tooth abscess and when he eats it comes out his neck. He his for a feeding gastrostomy tube. He is given spinal anesthesia and sedated a little unintentionally. The nurse didn’t realize that one of the IV bottles had Ketamine- even thought it was written on it, and gave it quickly. So he was out of it too. Fortunately he didn’t stop breathing and didn’t need to be intubated as that would be disastrous, as he can barely open his mouth. And a tracheostomy in the open pus field would be awful. The G-tube part of it went well and he went back to his room.
It was a long day. A cool shower was awesome!
