Letter #4 from Malawi

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So I wake up this morning at 5:30 to a call from the clinical officer. I feel good having gotten 7 hours of sleep. the patient I took out a GIGANTIC prostate from yesterday, was having abdominal pain. He had figured the catheter had plugged and his bladder was being filled with the irrigation solution to feel like bursting. He irrigated it and the pain subsided. I figured I was about to get up at six and knew I couldn’t sleep that quick so I got up. I made some toast and slathered it with peanut butter, then put on a thin layer of some fruit sauce. It tasted great. I drank extra water as I knew that since I came here I haven’t had time for lunch, thus meaning no water either (of course I don’t want to carry a water bottle all day!).

I headed in to the hospital at 7AM for the morning worship and sign out of admitted patients overnight. After that I went and started seeing patients till they had my first patient ready.

Manchiru had received spinal anesthesia and lay on the operating room table, her short thin frame exposed to all in the room. I placed a foley catheter as the circulating nurse is off on Fridays. I scrubbed and the scrub tech helped me don my cloth surgical gown and gloves. Fortunately before I came they discovered some size 8 gloves, so my fingers are not falling asleep by using small gloves! I then prepped her abdomen with betadine. I cut through her lower abdomen along the middle. Below black skin the white flesh and yellow fat opened behind the blade. Next fascia (gristle) and muscle, and lastly the peritoneum. There was yellow fluid in the abdomen. I swept the intestines towards the stomach to get them out of the way and took a look at her uterus. The ultrasound had demonstrated correctly that there were huge fibroids of the uterus. They introduced me yesterday to a uterine clamp. It looks like a giant, heavy duty, tongs with forked teeth that bend to curl towards each other. this is clamped onto the apex of the uterus in a savage way to use it as the force of retraction. The fibroid was so large it took two hands to force the handles together enough so it would lock into a closed position. The intestines were stuck to the back of the uterus, and a large fibroid protruded forwards toward the bladder. Everything was so stuck that the uterus could barely be moved with the medieval clamp I had placed on it. some intestines were stuck to each other as well. These adhesions could be spread easily and then cut with scissors. The ones behind the uterus, where the colon lay, were really difficult. Snip, feel, worry, snip, feel, worry…repeated again and again. I could free up one side but not the other. I started on the sides and when it became difficult I changed to another side. This cycle repeated over and over. Eventually the sides were freed down to near the cervix but the back of the uterus remained difficult. I decided to amputate the uterus midway so that I could have space to work easier behind in the area that was difficult. I started and got even more bleeding. We had lost 1.5 Liters of blood! The anesthetist left the room to call for blood from the lab. I decided the only way to get through this surgery was to cut through the thick adhesion between the colon and the uterus. I felt like I needed a machete as I hacked my way through the scar. This is likely the result of a pelvic infection in the past. I clamped either side where the uterine vessels lie. I had reached the bottom of the area that was accessible from any direction. I wasn’t really yet where I wanted to be, but decided that if I continued that disaster was sure to follow. I took the scalpel and amputated the uterus above the cervix. I quickly controlled the bleeding. I examined the colon and had not injured it in the process. I thanked God internally. I closed the opening and washed out the abdomen. I sutured the fascia and washed again. The skin was sutured closed and I went to the next OR.

I had a 50 year old guy that had dropped his hemoglobin to 7 (normal 14). So I did a scope to evaluate his stomach then his colon. The colon showed some polyps that they did not have any devices to biopsy them. But no obvious area of bleeding.

Then there was another 18 year old guy that had pain whenever he swallowed. So I did an upper scope to evaluate his stomach. He had ulcers and gastritis. So I started treatment.

Dr. Pierce, part of the group here with SIMS from Loma Linda Univ., asked me to see an old gentleman with COPD that had strider (an expiratory sound in the back of this throat. It had happened for few weeks and he wanted it evaluated. We put liquid lidocaine in the back of his throat and he gargled it. once his throat was numb the sound went away. I was very surprised. I look at his vocal cords with a laryngosope. Then one of the staff thought of looking with a gastroscope, so we looked with that. It gave a very good view and all appeared normal. Afterwards I realized he was probably “auto peeping”. Meaning that he had bad COPD/Emphysema and it was his natural way to pressurize his lungs to breath well.

There was another teenager that had a swollen hand for the past month. A few days before it had started draining pus. I helped the clinical officer numb up his finger. Once numb I directed her how to hold the knife and open his finger in a Z fashion. Pus poured out. We followed it and it went into his hand. So we opened on to the palm of his hand. We placed a dressing and hope the tendon that was at the bottom of the pocket of pus will heal over as well.

As I was finishing there was a woman who they were afraid of uterine rupture that had been given a local herb that makes extensive contractions happen during the labor. They started a C-section with a clinical officer. I have not helped with any C-sections because they apparently do them all here. Mid way through the anesthetist was available to do the second room at the same time. He left some random worker to watch the vitals and headed into my room. We had an older woman who had a femoral neck fracture. I prepped her leg for a traction pin to be put in her tibia. So I chose the pin site and made a nick in her skin. Then I got out the Dewalt drill and attached the pin. I drilled it through her leg from side to side, then we dressed the edges and sent her to the ward.

Then there was a couple patients for me to see. One had had upper abdominal pain for about a month who I scheduled for an EGD (upper scope) and the other was a 1.5 year old boy with a cleft lip. I scheduled him for next week.

The SIMS group was heading to a tea plantation for afternoon “high tea and croquet” and then a fancy dinner. It was an old huge home converted into a hotel by the family. We had missed high tea but headed out there for dinner. We drove out from the hospital compound and headed back towards town then veered off on another dirt road. Through field after field of tea. Eventually we went through the gate then for a couple miles further in the plantation. It was owned by an Italian family that had lived in Malawi for 4 generations. We arrived at the hotel that used to be the old house. It had huge rooms that were very ornately decorated and cost about $120/person per night. We met the grandfather that owned the plantation. He was a very energetic guy with white hair and a white goatee. We had a awesome meal at $20/person. It did NOT feel like I was in Africa. After much talk we headed home, checked on my patients and headed to bed, to sleep till 4AM. Then I received a call about someone who had been drunk and was gashed in the head with a broken bottle. I advised the clinical officer of how to close it over the phone. She felt comfortable with doing it so I went back to sleep until at 7AM when the children were outside playing.

Shanksteps Malawi #3

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Third Shanksteps from Malawi

Today, Wednesday, is the day I go to Blantyre and have a surgical clinic in the morning. the hospital vehicle leaves at 7:30 so I was in the hospital making rounds at 6:30. I started in the male surgical room. Saw one patient then saw a commotion in the furthest bed near the wall. Siti and I walked over to the patient where two nursing students where holding the tip of the penis of the man I had done the elbow reduction on yesterday. Blood was pouring past their finger and there was a large pool between his legs and on either side of him. I grabbed some gloves and held pressure between his legs where the prostate is. With pressure the bleeding stopped. I held for five minutes as I figured out what had happened. One of the nursing students came to evaluate the patient this morning and the patient complained that he couldn’t urinate and his bladder was full. This student went and go the student that had placed the catheter yesterday. the two noticed there was no urine in the bag and decided to take it out. They deflated the balloon and pulled it out, with the ensuing fountain of blood that wouldn’t stop. A nurse had decided the man needed a urine catheter yesterday in preparation for his elbow reduction (which had not been ordered), and told the student to go do it without supervising it. The patient had “just urinated” so when he inserted the catheter and no urine came out, he inflated the balloon. The patient had much pain, but the student told him that that is the way it is! Thus the balloon was blown up in the urethra and not in the bladder like it should have been. So removing the pressure let loose all the vessels that had been damaged causing significant bleeding. The bladder was now full and I asked them to try and see if he could urinate while I visited with my other patients. At about 7:25 I got done and went back to check on him. NO URINE had come out, but the bleeding was fairly well controlled. I ran to tell Cristy what had happened and asked her to do a bladder puncture to let the urine out, so he could bide time till I came back in the afternoon after clinic.

It was a beautiful day to be driving through the tall slender stands of eucalyptus, little groves of pine, and huge fields of green tea plant. The road was mostly paved and had shallow pot holes all over. Most had been filled with dirt to make them smoother. Women were walking along the road with large loads wrapped in a cloth on their heads. Mini vans passed by constantly taking 18 people to and from town. A rare 125cc motorcycle whizzed by with a couple guys with helmets on. A few large trucks traveled this road, traveling slow to save gas and tires from the potholes. We passed small villages with a small market area. Houses are built of clay bricks and most are topped with a tin roof, some are thatched. There were 7 of us in the land rover, and we arrived to the clinic.

The midday was slow for me. I diagnosed a fluid collection around a man’s testicle, a woman who had colitis (inflammation of the colon), a man with a keloid in the central portion of his chest (this I injected with long acting steroids), a man with a peri-anal fistulae, a woman with severe reflux in spite of medication, and a late teen who was after surgery and had a ostomy and bowl leakage coming through his incision, and a woman with a urine infection after having a hysterectomy.

At noon the patients for me were done. The car would not come to get us till 4PM. So I sat in the office and waited for Dr. Chipolka to finish so we could go eat together. During my wait an Indian man named Adam, came into my office for a dressing change. We was a fourth generation Indian to live in Malawi. He said he new Cristy and invited me to his house to spend the afternoon with his family since he found out I had nothing really planned. I left with him and another gentleman in his Toyota Corolla. we wandered through various streets of town and ended up at his 15 year old daughters school, “where I used to go to school”. They both spoke perfect English and the local dialect, chechewa. We went to their house. He showed me their store and their house with a huge fence around it across the street. inside were tile floors, three fish aquariums, an african grey parrot. I met the rest of the family then we sat down and ate. There were about 10 different dishes of food in small quantities. We all took a small amount of each, filling our plates. then we dug in with our right hands! (the clean one, as the left is traditionally used for wiping yourself). It was very tasty. Afterwards we sat around and discussed fishing, family, work, and a little about the new female president of malawi. At 4PM he took me back to the clinic.

As I waited I read a book. Dr. Chipolka invited me to go get local transport and go into the market area as the car would not be ready for about 2 hours. They were trying to pick up blood from the blood bank. We walked around and saw the supermarket, the clothing stores, the random item shops, and a shop strictly for kids about 0-4 years. was very interesting to see the things that are available for the one who looks around.

At 6;30 the land cruiser picked us up. We drove back just after the sun had set. Arriving back at the hospital. I found Cristy and asked how the guy had done that couldn’t urinate in the morning. She and then a clinical officer had put a needle into his bladder from his belly whenever he was in pain from to much urine. I decided that I needed to take him to the operating room. I planned on opening his bladder, placing a foley catheter backwards through the penis then connect another catheter to it and pull it in the correct direction.

We took him to the OR, he got a spinal, then I attempted placement of a large catheter before performing the surgery. Thank God, it went right in. We were all happy to go home around 9PM.

At 10:30PM I got a call from the clinical officer on duty and the covering general doctor. There was a 22 year old guy who had been in the market in the afternoon, had a problem with someone over 100Kwacha ($0.45) owed to someone that had escalated when the guy tried to collect his money and was stabbed in the inner bicep. They had put a bunch of clamps into the wound and the bleeding had slowed. They wanted help taking care of it. I threw on some shoes and headed in. The wind was blowing, everything was black except for the brilliant milky way and the southern cross. The guy, Precious, is laying on the exam room bed with blood all over him. Blood is covering the sheets that on him. A random appearance of surgical towels around his right upper arm identify the area of bleeding. Clamp handles are sticking out of an open wound on the inner side of his bicep. Precious seems to be going in and out of consciousness. and IV is running in his left arm. Female family members wait in the waiting room just outside and there are two young men in the room with him. Dr. Chipoka and Amie show me the area. The bleeding is currently stopped but nothing had been used to clean the skin in all the commotion.

I grabbed some betadine and swab everything on the arm including the instruments. I don sterile gloves that are quite small and check out the area. It appears to me that one of the clamps is on the median nerve. The brachial artery is clamped as well. Before donning gloves the entire arm and hand were very cold, so this confirms my findings. Apparently when he arrived from a nearby clinic, he had had a tourniquet placed about 5 hours before. I unclamped the one on the nerve and immediate bleeding ensued. Then I was attempting to stop it just as they had. I realized this was not something that would be able to be fixed easily so asked them to call the operating team. I probe the depth of the wound and my whole finger disappears to where I suspect skin is on the opposite side. He has received multiple bags of IV fluid and I ask them to find the lab tech and order blood. Fortunately when I was in clinic in town yesterday they had picked up blood from the blood bank. they never have much but had some. They attempted to call the lab techs, then the other ones not on call. None answered for the subsequent two hours! Finally a hand carried note to their door produced one unit of blood, in stead of three, right at the end of surgery.

We lay Precious on the operating room table, and stripped all the bloody cloths off him. His arm was prepped while I scrubbed my hands and arms with the local liquid soap that’s available. The scrub brush is the same I’ve used ever since I got here. I extended the stab wound in each direction. This helped to show the vessels and nerve better. The vein was a labyrinth around the artery. It was cut in numerous areas and the artery was severed in a strange shape. It was quite tedious trying to figure out the anatomy. I eventually deciphered what everything was and anastomosed the artery back together. I questioned the arms viability as I did not have any catheters that are used to pull the clot out of the artery the had been held shut with a tourniquet then a clamp. The vein was irreparable and I tied it off. The nerve I sutured back together in hopes that it will grow and he would have function again. At the end of the surgery just as the anesthetist was going to remove the breathing tube he started vomiting. A thick paste of whatever he had eaten flowed out of his nose and mouth. he was not yet conscious and thrashed back and forth on the bed. It took 4 of us to hold him on the OR table while he vomited repeatedly. We wiped vigorously each time as the suction was to small for the size of the things coming up. After about 15 minutes of retching there appeared to be no more to come up so we were able to extubate (remove the breathing tube) and take him to the ward. His arm remained very cold and had no palpable pulses. I made my way past the numerous hospital buildings, through the trees to Cristy’s house. I took a warm shower but still was to wound to sleep so I wrote part of this that night. “God, please help Precious arm to live and be functional” I prayed as I drifted off to sleep for 2.5 hours before they called at 5:30AM for anther patient.

Shanksteps Malawi #2

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Hello again from Malawi, second day:
After the late night last night, I still start at 7AM. After worship I started to make rounds with Siti. She is a clinical officer that has had three months of rotation on the surgical service. As we made rounds she had gloves ready, charts at the bedside, x-ray films set out by the appropriate patients… She was very organized compared to the person I rounded with yesterday. Like yesterday, the rounds were interrupted multiple times. Some to see patients in clinic and others to do a gastroscopy on a 14 year old Pakistani girl that had significant reflux in spite of treatment.

Next was the woman with a femeral head fracture for traction. I had asked the OR staff to sterilize the pin that is used to go through the tibia bone for the traction. It had not been sterilized. When questioning them as to why, they said that they don’t have enough packs to sterilize it. Apparently they wait a few days till there are a number of surgical packs ready to be sterilized, then they build a fire under something that produces steam that runs the autoclave to sterilize the equipment. The process takes a number of hours, so it was being done today. Tomorrow is a clinic day at an outside clinic, so it will have to wait to be added to the things I have planned for Thursday.

I was called to see an older gentleman who was found to have a urinary stricture after a prostatectomy and had a urine catheter in his lower abdomen. He wanted surgery to address this, and has tried each surgeon covering this hospital. Dilation has been tried here and elsewhere to no avail. So I assured him that if multiple surgeons have been unable to pass a dilator that I also would be unsuccessful and told him he would have to live with the cathater.

I was then called to see the lady who I had done the below knee amputation on yesterday. The nurse said she was breathing poorly. So I went up to see her. Her saturation had been 70-80% all night (normal >92%). She was breathing poorly and had wet sounding lungs. I ordered lasix, and headed to the OR for the other patient they were putting to sleep.

“Mike” was a 18 year old guy who had been in the hospital for 5 days with a dislocated elbow. His arm was hanging from his hand from the bed frame. The weight of his arm had NOT replaced it for days. I had seen him the night before, and decided that since his elbow had been out of so long waiting overnight to sedate him, wouldn’t hurt him anymore than the damage already done. So on the OR table he lay. Ketamine was given for sedation, then I started. I pulled and manipulated his elbow and finally heard a pop, it was in place. I moved it and realized it was out again. this happened a few times. then I decided to place a cast on his arm to help hold it in place.

I went to recheck on the woman who had an amputation and found a better oxygen level. I went back to Cristy’s house and had a nice evening with her and friends.

Malawi #1 Shanksteps

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Hello Friends and Family,
It has been quite some time since I sent out a letter. I have now traveled to Malawi to visit my sister for a few weeks and cover for a surgeon who is on vacation. So the next group will be from my time in Malawi.

Everyones question was, how long does it take to get to Malawi? Where is Malawi? Well I left, driving to Portland at 11 AM Friday. I arrived in Malamulo Malawi at 10PM Sunday night. So all the intervening time was travel or wait to travel (layover). My longest flight was from Washington DC to Addis Ababa, Ethiopia- 13hrs. Cristy picked me up for the last hour trip. It is great to see her!

My first day was today, Monday. It was to be a slow day as they had not planned any surgeries for me thinking that I would be jetlagged! They had worship at 7AM, then a quick review of what happened with certain patients at 8AM. Next I started rounds with a clinical officer, Leventhani. We would see one patient, translating english into Chechewa. then back again. It was a slow process, as he didn’t know any of my patients, and we had to repeat many questions. This one had been beaten by a stranger another by a husband. dressings needed to be replaces. the dried bloody gauze was pulled from the wound and stitches and then there was no gauze to replace it. So he went searching for gauze. After about 5 minutes I couldn’t wait any longer so went looking for him. He was called to see another patient on his way and was sidetracked repeatedly. They pullled us out to check someones prostate that they felt has prostatic hypertrophy. They had prostatitis, so I treated and sent home. Another prostate exam- hypertrophy. Female bleeding for 3 years in a post menopausal woman who is HIV positive- cervical CA ?resectable? Then back to the female surgical ward. This all finished around 1PM when it was “time to eat”. I ran and grabbed a bite with the SIMS group visiting from Loma Linda, then went back. There was no one to round with so I waited.

I had seen a gentleman with a lipoma on his head so I went to the operating room and we removed that. Then there was the woman with large femeral head decubati. One side had pus draining from a large black area on her left hip. As expected, when we removed all the dead tissue the femur was exposed, with pus around the femur head. (the upper leg bone head at your hip). She has not walked for 4 months and Im quite sure she will do poorly.

After that I was asked to see a 13 year old girl that had been admitted over the weekend with abdominal peritonitis. A typhoid test had been done this morning that was normal, she had a little elevation in her white blood count and had had nausea and vomiting but no longer. I tapped on her little belly and she cried out in pain. I bumped the bed and she cried. Her abdomen was very firm. She had signs of peritonitis. I recommended to the family that we operate TODAY! They agreed so we arranged for that next, 4PM. Then there was a new admission that they wanted me to see because she had a “dead foot”.

I looked down on an 80 year old woman with two men at her bedside. This was the “Annex” or more wealthy person ward with only two patients per room and a toilet and shower in the room. She was “not talking” since morning. She withdrew to pain, I wondered if she was having a stroke from her high blood pressure 180 or septic from her dead foot. I examined the feet. pealing back the three blankets that covered her, I gazed down at a blackened foot that had open areas where her three middle toes used to be. She had been seen at a clinic and they had amputated black toes. When she looked worse they referred her to the government hospital a hour away, but they preferred to travel here. This hospital was built more than 50 years ago. And it’s reputation as a good hospital is still carried on from years past. I recommended that we remove the leg today. They agreed so I went to the theatre (operating room) for the 13 year old girl.

Judith’s young slender frame lay on the bed. She winced at every movement, and cried out when someone pulled out the gown from under her. Soon she was intubated and asleep. A urine cathater was placed with my guidance of how to keep it sterile, it had appeared the nurse was just going to insert it without cleaning at all! We covered her with some throw away paper drapes after prepping the abdomen with betadine. It is nice to operate on extremely thin people again. No excess, just skin ,then fascia, then your inside. Clear fluid came pouring out. Ascites! The small intestines were huge. She had a blockage. I felt around inside and felt the area that was large on one side and small calibar intestine on the other. A firm white mass lay between the two diameters. Cancer? Tuberculosis? “Is this patient HIV positive?” It hadn’t been done. It seems about 50% of the hospital patients are HIV positive. I decided to resect the obstructed area. I slowly made my way through the vessels feeding this part of intestine in the mid transverse colon. The pancreas near by, duodenum to the right, there’s the right kidney and ureter. I point out structures to the clinical officer who is helping me. This is his first day of assisting in surgery. I take out her large appendix which is hiding behind the cecum (beginning of large intestine). I take out the “bad” section and reconnect the two open ends with silk sutures. I put in nearly 100 sutures taking 1.5 hours. The diameter was quite large because of the dilation. At the end all looks healthy. I wrap it in her pitiful omentum (the hanging fat layer in the abdomen). I notice a small white spot of the same thing sitting on her tiny uterus. I’m suspicious of cancer, but she’s so young! I will try to convince the family to take the mass to a pathologist in Blantyre to have it evaluated so I can know in a week or two what this was. Hopefully they will agree.

After cleaning the operating room we are ready for our last surgery, the woman with a dead foot. She was wheeled in on the gurney. Transferred over to the operating room table. The anesthetist attempted to intubate (put the breathing tube) her four times. Finally they held a mask to her face and let the ventilator do it’s work. I put a tight elastic bandage on her upper thigh to make a tourniquet. Chose the area to cut then cut, deeply cut. Down to bone, tibia then fibula. They handed me the small saw, and with a back and forth motion, I cut the tibia in two. Next the fibula was snipped in two. Vessels were tied, and nerves were divided. Eventually the two edges came together covering the bone. I asked for a drain and there weren’t any. So I took a sterile glove, cut it, using it as a drain. A tight elastic bandage was placed over the stump.

After writing the one sentence surgical note, and the orderes, I looked for the clinical officer. He had already split. I realized I still had to make rounds on the male surgical ward-10 patients. I went there and found the nurse. She helped me make rounds at 10:00PM. One with head trauma after a beating, one with broken ribs after falling out of a truck while riding in the back. Another a displaced elbow for the past five days- wow that should have been reduced days ago. Another with a broken male appendage (yes that can happen when stiff). And another diagnosed with appendicitis, treated with antibiotics since there was no surgeon last week. Fortunately, today his pain is much better than it has been for the past 6 days. I make it “home” about 10:45PM. I scarf down some wonderful soup Cristy had made, shower, then lay here in bed. It’s 1AM and my brain thinks it’s 4PM. I suspect sleep with come soon, when I attempt to shut off my brain again. It’s been a good, busy day. Lord, help my patients heal!