He was born this morning. He has six toes on each foot, six fingers on each hand. Short stubby ears, and a wrinkled forehead. He weighs 1.6kg (3.5 lbs). His parents said he was term but that’s not likely. His heart and lungs sounded normal. He was crying and had a cleft lip and palate. But the biggest problem lies at his umbilicus. There was a 3cm wide hole with all of his bowels laying on the table beside him (gastroschisis). [It is an abdominal wall defect that has 14% associated jejunaland ileal malformations, 4% have other malformations, 60% are premature, and there seems to be no associated genetic factors.] Only the grandfather and some other relatives were there. The mother was to weak to come to the hospital they said. The father was away in another village, and didn’t know he had a new baby. I explained to the grandfather that survival was unlikely but that surgery was his only option. We took the child to the operating room. He was making stool, which made me slightly hopeful. Our student missionary and I were able to take all of the edematous bowl and put it back inside. We sweated profuselyas we attempted to do the repair without air-conditioning because the child was already cold. It was 107deg F outside, and just as hot inside, with our gowns on. We have no warming apparatus in the OR. During the surgery the child vomited and desaturated (dropped his oxygen) and I had to unscrub to help the nurse bag the patient. He was not able to raise the saturation. After 30 minutes he was stable enough on max oxygen for me to reenter the operation. We finished the operation and he wasbreathing on the maximum oxygen that we could give (5L NC). We put him in the incubator donated by Parkveiw hospital and warmed him up. He would periodically stop breathing and we would have to bag him up again. We started another operation, a hysterectomy for uterine prolapse, and observed the baby in the OR while we did it. A few hours later after seeing clinic patients a man came in who was stabbed in his left upper abdomen and had omentum hanging out. Blood oozed from his side and he was drunk and talking profusely. He referred to me as a priest and explained he was stabbed with his own knife he was carrying. As we went to start his operation the baby desaturated again and I had to go between roomsto help him. Then the power cut off. We operated in the dark by headlamp donated by the head of surgery at the end of my residency. I could hear the monitor going off because of the low oxygen but could do nothing about it. They went to find someone to start the generator. Finally the generator was started about 5 minutes later and the oxygen for the baby was in single digits (normal is >92%). I was concerned then about brain death for the child. We found a spleen laceration in the stab victim,through and through stomach perforation and a liver laceration. We repaired the stomach laceration and repaired his cut rib at the entry site. The baby was being bagged more often with less success, he was wearing out. He needed to be on a ventilator, but that’s not available here. Finally I decided to stop and turn off the generator. It is often very difficult decisions that physicians have to make on a daily basis. Unfortunately many are life and death decisions. I pray daily at the beginning of each rounds, that God gives me the wisdom to treat each patient that I see, and not harm more than help. It is frustrating not to be able to diagnose problems and even more frustrating to know the problem and not have the equipment or staff to do something about it. Another along those lines is that we are having a measles outbreak now as Audrey wrote recently. We are up to 8 cases now. Children that were apparently already vaccinated against it, for the most part. Very contagious and preventable. We are thankful for our health that is holding up in spite of our surroundings. Thanks for all your prayers and emails. They are very encouraging.
Greg