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Disaster Response B #11  

            I’ve been called in the past two nights to operate emergently on someone.  The night before last I went to bed.  About 1 hour later I awake to a flashlight in my eyes.  I didn’t know whether to go towards the light or away… I realized eventually someone was waking me up.  Eventually I got up and headed in to the ER.  There was a lady who was about 5ft 2in weighting approximately 350lbs with a painful mass in her mid abdomen.  The ER doc had given her sedation with Versed and tried to reduce the hernia- without success.  So I tried- unsuccessfully.  So we called the OR crew in and headed back once everything was ready.  After the anesthetist put her to sleep I made a midline incision.  I was able to dissect out the hernia sac fairly quickly, but it wouldn’t reduce.  So I opened into the area of the intestines and slowly divided the tissue up to the small “neck” of the hernia.  Eventually it was open and still it wouldn’t go into the area of the intestines.  So I slowly opened the sac.  I was now able to see that it contained omentum (the fatty layer inside) and not small intestine like I expected.  So I took off the sac with it’s omentum inside.  The intestine I could see looked good so I didn’t think any intestines were damaged too.   I closed up her abdomen, and since I didn’t have any large piece of mesh, I closed it with sutures.  Her recurrence rate will be higher, both from the size of the hernia and her size.

            Last night I went out with about 15 people they were willing to take to the ocean at around sunset.  This late hour was because the day nurses and staff don’t get to go out if they go any earlier.  I discussed with the ER docs if they minded if I was gone for a little while.  They figured they could deal with whatever till I got back.  It was a very nice evening.  I hadn’t been off the tent campus since I came a few weeks ago.    As we drove about 10 minutes away, we passed lots of houses.  All of them had a pile of furniture, dressers, cabinets, mattresses and random other things sitting in a huge pile on the side of the road.  These were the destroyed items to be picked up by the garbage service.  (as an aside- I talked to a man this evening that said he lives a little way from a town of 300.  He said that they know of 17 of that town that died and that all the houses- you can stand at the front and see through to the back yard.)  Back to our trip.  We passed some apartment buildings about 4 stories tall, that the front wall of the apartments had been blown in to the rooms.  The roof of the apartments were partially gone.  Stuff lay strewn all over the ground.  We went past the KFC and past a bank and other important looking buildings that didn’t appear to have much damage.  We got to the beach about sunset.  I walked out on the sand and the water was very calm, the reef is far out and there was no wind.  I waded out into the water about 100 feet, and it was still about 3 feed deep.  I sank into the water and just enjoyed the last minutes of sunset in the sky.  A while after the milky way was out, we went back to the bus and headed back to the hospital campus.

            As I arrived I was told I was needed in the ER.  Someone with a suspected perforation (hole in the intestine) was there and I needed to operate.  I found two of the local surgeons there, and they said a patient with free air (air outside the intestines- from a hole) was across the street having gotten a CT scan, and would be on their way to us.  It seemed like it took forever.  And in a way it was, because two hours later the patient arrived by ambulance from ACROSS THE STREET-literally!  So the three of us surgeons took him to the OR.  I lead out since I’m the one to be operating here.  He was about 27 and had had epigastric pain and had been taking a lot of ibuprofen.  So I suspected a perforation from a stomach or small intestine ulcer.  In the operating room I cut open the upper abdomen.  The peritoneum was distended with air.  Opening further I found a lot of cloudy fluid.  Looking around through the intestines and stomach, I found a small hole on the front side of the stomach.  The edges of this have poor tissue to fix, so I cut back further around the hole.  This made it larger but got to good tissue to close.  Then I sewed the hole shut.  Next I took a piece of omentum (fatty layer in the belly) and put it up over the hole and sewed it in place.  I consider this a double or reinforced repair.  We got done in the OR about 2 AM.  I slept fitfully for about 3.5 hours till everyone in the 30 persons’ tent, alarms started going off and they started rustling around and turning on the lights.  

            I went in to check on him and the first thing he says to me is “Doc, I’m hungry!”  He was adamant that he be able to drink and eat.  I explained to him that he would not be eating for days.  He didn’t care for that at all, but I think over the day he’s become resigned to the fact._______________________________________________

Disaster Response B #10

             Again we meet a variety of people here.  Today I sewed up a guy who is from New Orleans who was working with a wrench and the nut let go and he hit himself with the wrench.  As I sewed up his chin, he told me how they are trying to raise 2 barges that were sunk by the storm.  He does underwater welding.  He also mentioned that they can cut 4 inches of steel underwater when oxygen is used.  He said to weld underwater you have to coat welding electrode with bees wax to make it waterproof so that it can be done.

            I have two kids that were admitted with head injuries.  One 11 year old boy was found having a seizure in the bathroom.  We were able to get a CT of his head and he had an epidural bleed that was small.  He did well overnight and a repeat CT was the same.  When I checked in on him in the evening he was playing on his phone, and when I checked on him this morning- he was playing on it again.  So today he went home.

            The other was in his late teens.  He had been riding a motorcycle and went into a telephone pole.  He was unconscious for a few minutes then was thrashing about by the time he came to the ER.  It took us about 4 hours to get a head CT on him from across the street.  He had a small bleed in his head, a broken rib with a bruised lung, and a small broken bone off the edge of his pelvis.  He required a lot of sedation to keep calm, but he is improving today and responding more appropriately.  His repeat head CT doesn’t show any progression of his bleeding and remains small too.

            I was asked to see another person who had had a stroke.  They had no gag reflex.  This means that if we attempt to feed them they are very likely to aspirate it. (breath it in).  They can’t move the left arm or leg.  So because the esophagus is paralyzed, a feeding tube is needed to keep them alive.  So I was asked to place a gastrostomy tube.  I waited till the family came in around noon and discussed it with them.  At home I would place a PEG tube which is placed using a gastroscope , and puts the tube from the inside out.  Here no gastroscope is available, so I discussed the small incision method of putting one in.  After they agreed we took them to the operating room.

            In the operating room they were put to sleep and a small incision was made in the upper abdomen.  I realize that the liver was bigger than anticipated and comes down to the area of my incision.  I pull it out of the way and find the stomach and choose a site for the tube.  I make a separate hole for the tube and make a hole in the stomach and put the tube in.  I put a purse string suture around it  and start attaching the stomach to the abdominal wall.  I then realize that the liver is going to be putting constant pressure on the tube site.  That would not be good as it may disrupt the connection between the stomach and the abdominal wall.  So it take it all back out and choose a lower skin tube site.  Then I redo the same process.  The lower site puts it in a good position for the liver and I close the abdomen.  Later his family, his pastor and many friends come in.  They gather around his bed and hold hands and pray for healing for him and also sing songs of praise to God.  I am happy to see this outpouring of love for him.

            Another patient works as a police officer.  He has a ulcer on the bottom of his big toe that is infected.  After walking around in the water of the storm it got much worse.  So we take him to the OR to clean it out.  We find that the dead tissue goes all the way to the bone and that the bone is soft and infected.  He will need the big toe removed, once he is mentally prepared for it.  

             I know the ER is getting slammed tonight.  Every few minutes I hear an ambulance come in.  Guess I will see if I get called in tonight or not.

Disaster response B #8

            I am grateful, the next hurricane that is to come this way appears like it will be turning back out to sea before hitting the Bahamas.  These people sure don’t need any more trauma than they’ve been through.  

            I’ve done a few inguinal hernias today and assisted in a hysterectomy for someone who has had vaginal bleeding for many months.  It reminded me of the story in the Bible of a woman being healed because she had faith, and her bleeding stopped with touching Jesus cloths.  I wish Jesus power was in me to stop bleeding or healing at a touch!  That would be much better than the part I play now in the process.

            Tonight I’m asked to see a guy who has a dialysis catheter in his groin that is infected.  One was placed under his left clavicle before the storm but no one took out the infected one.  This is bad, because if there is infection in one part of the blood stream, it will often infect the new catheter as well.  I’m not sure why one wasn’t removed directly after the replacement was put in.  But here we are.  It seems a number of people we are seeing aren’t happy with the care they are getting on the island.  We could be seeing the slice of people unhappy, or the care could be poor.  Either way we are happy to take care of them and demonstrate Jesus love for them.  I decided to take it out.  I numbed up his skin and tried to dissect out the felt cuff along the catheter that holds it in.  I couldn’t seem to do it from the opening that I had, so I made an incision along the catheter.  I dissected it out and it still seemed stuck further on.  So I did the same thing closer to where I expected the entry into the vein.  Gradually it freed up and I pulled it out.  Then I held pressure for about 10 minutes.  He was supposedly on a blood thinner, but didn’t know which one.  He didn’t really seem to bleed a lot, but I wanted to be cautious.  The ER doc agreed to send him home a bit later on so I left to eat. (rice sprinkled with veggies)

            New day.  So a few days ago, after the operation of the person with extensor tendon injuries, I realized their thumb wasn’t working.  Had I missed a tendon repair, or was there a nerve injury that explained that finding.  So today the orthopedic surgeon and I explored the arm again.  I opened up the closed incision.  Next I dissected down to the tendon repairs.  I was able to find the missed tendon and when I pulled on it the thumb straightened out.  We extended our incision and couldn’t find the muscle belly that belonged to it.  We did find the other tendon that ran the thumb and it was intact, so it must be that that one is denervated (cut nerve so it doesn’t work any more)  So finally we attached the tendon end we found, to the extensor tendons that ran some fingers.  So when she opens her fingers her thumb will open as well.  At least this way she can open to grasp a cup or object.

            Next there was a lady that returned to have her abdominal hernia repaired.  She was done under spinal and did very well during surgery.  After that was a woman who had fallen and landed on her foot.  This fractured her medial ankle bone and her small leg bone (fibula), and ruptured some tendons.  So I helped the orthopedic surgeon do the operation.  She was put to sleep and then her leg was skin prepped all the way around up to the hip.  Then we put the drapes on.  We made incisions on either side of her leg, starting with the inside part.  Her medial maleolus was fractured and so we were eventually able to turn the foot out to the side and then back and get the bone fragments to line up.  Then we drilled, tapped and placed two screws to fix it.  On the outside, where the fibula was broken we cut down to the bone and found the fracture.  We bent a plate to match the bone and camped it to the bone (think something like a visegrip for the bone)  Then we drilled holes.  Measured each hole.  Tapped each, and then put the appropriate length screw in each one.  It’s like carpentry for the bones.  Then we closed each incision

In the evening I was asked to take fluid off a lady that had a near white out of her right lung field on xray.  So there was fluid around the lung.  She also had a large abdomen, and a thin body.  So she had ascites on exam.  We don’t have a thoracentesis  kit nor a paracentesis kit to drain these.  So I had to improvise.  The problem with that is, that the lung space has negative pressure.  So if there is a needle or a cut in the chest, it will suck air in around the lung and collapse the lung.  I had to place a needle, then remove the needle, leaving an angiocath, and then connect IV tubing, and then pull fluid from the lung space, push it down the tubing and start the gravity flow.  It took about 1:30 minutes to get it drained.  1800 from the lung space, and 300 from the abdomen. 

            I made it to the food tent to find all the food was gone.  Then I heard there were some people at Wendy’s.  So they brought me a salad to eat.  Now Ive showered, eaten, and going to hit the sack. 

Disaster Response B #7

            The patient load is changing.  Over the weekend we had 140 ER visits one day and 130 the next.  Today is less.  It seems that there is a whole lot of congestive heart failure now.  People lost their meds in the storm and can’t see their own doc so they’ve been without meds and now are coming in very short of breath.  Last night someone about 30 was at home and had worsening breathing for a  few days.  Everyone was living in their upstairs rooms because the bottom of the houses had been flooded.  The car had been ruined with the flood, so they went to find a neighbor with a car in the middle of the night.  They tried a number of times to call 911 and couldn’t get out.  The cell phone system was down.   Once they found a neighbor with a car, they had to carry her down 13 stairs to the car.  They piled her five sleepy, young children in the car and headed in to our hospital.  They raced into the parking lot with the horn blaring.  Our nurses ran out to see what was going on, and found a woman barely breathing.  She was brought in and intubated.  She was given medicine to make her urinate off the extra fluid and the staff arranged transfer to the referral town on another island.  A helicopter landed in the parking lot to pick her up.

            One of the people I saw for a surgical consult was a woman with a fungating breast cancer.  She had had it for a long time and when it was small back in 2012 had seen her doctor who had said it was nothing and they didn’t do anything about it.  Later it became huge and ulcerated, necrotic and smelled horrible.  She saw a doctor and was referred to an oncologist.  The oncologist flies in from another island and charges $600 to be seen.  Then chemo the patient said costs $3000 for the first round.  They heard things were cheaper in Cuba, so flew there to be evaluated.  So they’ve been going to Cuba for every round of chemo.  She wanted to be seen to see if we could do anything else.  I looked at her breast and it was all raw, red tissue all over and firm and dimpled out into the armpit (peau d orange).  She was improving some with the chemo.  The local surgeons said that chemo was free by the government, but she said it’s not what she found out.  I advised her to continue the chemo, and referred her to the local surgeons to be seen again here.

            I did a right inguinal hernia repair in the OR and then removed a toenail on an older man with an ingrown toenail.  Then there was a older man with a left inguinal hernia that I repaired.  I saw another man with an inguinal hernia in the ER and set him up to do his tomorrow.

            I was asked to see a 98 year old woman in the ER who’s son was with her.  She had a large pendulous breast with cancer on one side maybe about 8 inches in size and another breast cancer on the other side about 2 inches in size.  Both appeared mobile and I could likely get them off.  At least it would take away the smell of the one breast that was necrotic (dead tissue).  She had been loosing a lot of weight and her son was very attentive and concerned about her weight loss and some pressure ulcers that had developed on her spine in the low back.  She wasn’t eating much for a few weeks because she didn’t want to and it appeared like she couldn’t stay awake to talk to us.  I decided that in her wasting condition that it wouldn’t be wise to do a surgery on her- that it would speed up her demise and she wouldn’t heal in her malnourished state.  The son was fine with that as he was afraid of her having surgery too.

            Tonight’s meal was pasta with veggies.  Different than the other nights- somewhat tasty.

            As I sat there and talked to a few of the other doctors and staff, the ER doc asked me to see a patient in the ER.  This man had had a mass on his tongue a long time.  He is a smoker.  The mass had gotten larger and eventually filled up his whole tongue.  Tonight as I looked at him he appears about 40 with a large mass under his left mandible (jaw bone).  It was about 2 inches long and stuck out about 1 inch from the surface.   This appeared to be one of many metastasis that I could feel in his neck.  There is nothing we could do for him and recommended that he see an oncologist and wrote a referral for him.  The suffering of people is incredible, both from disease and from the hurricane.  God give me continued compassion for each person I see, and give me wisdom to treat each ones physical and spiritual needs.