Shanksteps Bere April #10 with pictures
As you read in my last Shanksteps Ive fretted a lot about wether I should take this old guys nose off for a squamous cell carcinoma, leaving him looking very deformed with a large hole in the middle of his face. I thought a lot about it last night as I was trying to go to sleep and also this morning as soon as I woke up. I do that when I have sick or difficult patients. When I got in there this morning to the OR, the crew told me he had decided against surgery and had gone home. So I was at peace then. I was looking through an Indian textbook of surgery and realize again, that we are not the only ones who see advanced cases of cancer and other diseases. It’s probably indicative of being in a third world country where there is very low income, minimal health care, and inability to get to where there is healthcare.
I examined another woman today between surgeries. She was one of the many medical consults I saw today. She could speak in French quite well. So as I talked to her I got the story that she is about 5 years after her period ended and she noticed about 2 months ago she was having vaginal bleeding. She also has some hematuria (visible blood in her urine). I suspect cervical cancer. So I do a vaginal exam and find that she has a large hard cervix that is attached anteriorly to the bladder. So it must be invading the bladder causing her to bleed with urination. I have to tell her that she has cervical cancer and it is already to advanced to take it out. If she has means, she can go to Cameroon and see if she can find chemotherapy that may help. I think that is only in the capital. I have to give information often to people- and I don’t like having to do it. It makes me sad and uncomfortable and it certainly does for the person who hears it.
First surgery is a prostatectomy on an old guy who can’t pee. The second is on a young boy ?8, who can’t pee either. But his problem is a bladder stone. David wants to intubate with ketamine. I question wether this will work, but figure he must have learned this with Dr. Olen recently so I question him about the dosing. He tells me how many mg he wants to give and it sound correct to me. So he gives some and goes to intubate with me looking over his shoulder. The kid clamps down hard on the laryngoscope and I worry about him breaking his teeth. He gives him more ketamine. Then again, Finally I ask him how much is he planning to give? 7ml. For his weight Im guessing less than two would be way more than enough. He tells me how he calculated it and how many cc’s that is. He calculated correctly but thought there were 50mg/10ml. In reality its 50mg/ml. So he has way overdosed. The kid keeps on breathing and so I decide Ill proceed and Ill ask him for more if the kid really starts moving. We fill his bladder with water and start the surgery. After opening the bladder we find a stone about the size of a pencil eraser- large enough to plug the exit of the bladder. I closed him up and checking on him later he seems to be doing well.
On rounds, I ask the kid with the open neck to try a swig of water. It pours out his neck in a different place. So we will just keep with G-tube feeds for a while before trying again. He is starting to heal, and I’m hopeful that he will survive.
I was called in tonight to see a guy who had had an accident on a motorcycle yesterday in a town about 2 hours away. They left the other hospital to come here. He has been unconscious since the accident. He has a cut on his head that they repaired. As I examine him I find he had normal pupils, hardly reacts to painful stimulus and has a broken clavicle and loose ligaments in his left knee which is also swollen. I don’t find any other abnormalities. His glucose is normal, and his blood count a little low but reasonable. He has a urine catheter in place, but it’s in the wrong place because the bladder is full without it coming out. So the nurse will replace the urine catheter and start IV fluids and we will watch and see if he recovers from his traumatic brain injury. Im called back in because the foley catheter can’t be re-inserted. And he’s bleeding after the last one was removed. Yep, the balloon must have been blown up below the prostate. I hate it when people do that- it makes for a lifetime of urethral strictures- if he survives his brain injury. I go in and there is blood all over coming from his penis. Sure enough, I can’t get a foley in because the urethra was burst with a blood inflation. I try a number of times. Finally I give up and put in a suprapubic IV catheter. This will get him through the night so I can deal with it tomorrow.
PICS- Below are the burn kid post-op leg contracture release, and the old man with squamous cell eaten the inside of his nose.
_______________________________________________
Missionnews mailing list
Missionnews@missiondocs.org
http://missiondocs.org/mailman/listinfo/missionnews_missiondocs.org