I can feel my heart start to beat a little faster in anticipation. My mouth starts to water and I hope I don't drool. The suspense is killing me! Every time I see someone with some kind of rag draped over a body part or waddling in like a sore cowboy after a long ride wearing nothing but a wrap draped around the waist, I can't help but wonder, what gross thing am I going to get to cut open or take out next?
Friday, it's an eight-year-old boy from Kélo. The father brings him in his arms. The right leg is draped in an army green rag that was probably a shirt at one point. The air gets a little thicker and I'm glad for my cold that dampens the odors. I quickly pull out the strip of paper to cover the exam table. The rag is hanging wet and limp. As soon as the boy is put down I regret having brought him into my office as the paper is starting to soak up whatever foul liquid is oozing from whatever it is under that "bandage." I hurriedly pick him back up myself and take him outside to the gurney where I gingerly lift up the cloth to reveal...
Saturday night, it's a quiet shake from my wife. Sarah's on night duty and I am feeling drugged from fatigue. The last two weeks we've been doing 2-3 surgeries a day and it's taking it out of me. She's saying something about a teenager who has no lung sounds on one side. I seriously can't wake up. I'm trying but it's like I took a sleeping pill. I mumble something about sticking a needle in over the rib and seeing if there's liquid or air making the lung collapse. I tell her if there's air to come get me, if liquid than I'll see him in the morning. I wake up early Sunday morning wondering what I'll find as I walk over to the hospital in the coolness and stillness of an early African morning...
Monday, two guys waddle into my office wearing only skirts. They've both come from far away. I can hardly contain my excitement as I ask them to lie down on the exam table and fumble with the knot attaching the cloth skirt to their waist. As I slowly un-wrap it to look I find just what I was expecting...
Tuesday, I operate on a woman who'd come in the Thursday before. She had a cloth wrapped around her mid-abdomen. She'd been sick for a month with pus draining from a small hole (fistula) in her belly button. As I am poised with my scalpel after the pre-op prayer, I wonder what I'll find inside. I quickly slice down from her belly button to her pelvis. To my surprise, I find...
Wednesday, Sarah comes running up to me with an amazed grin on her face. "James, you have to see this guy's arm. It's three times the usual size." I walk into the clinic and see an elderly man with whitening hair and beard on his rugged face lying moaning on a stretcher on the floor. His left arm is wrapped in a rag that at one time ages ago was probably white. From finger tips to mid upper arm I can see nothing. The upper arm to the shoulder is swollen to three times the size of the other arm. As I grab some gloves and bend over to unwrap it and take a look I have a feeling I might find... sure enough, as I snap off the gloves and order him to surgery...
One of the glorious benefits of working in a bush hospital is the phenomenon of pus surprise. No matter how often I see it. No matter how often I suspect it. No matter how often I have to really search for it... I always find it. Seek and ye shall find is my motto for tropical pus explorers. It is usually deeper than you think... but it's always there. But why this rush when I suspect it or the anticipation when I suspect it's there hidden under some rag? Maybe I'm weird, but few things bring instant gratification like liberating some imprisoned pus.
The boy's leg is a fungating, purulent mass surrounding his entire lower leg with the exception of his foot which is swollen and edematous. I take him to surgery, wrap a blood pressure cuff around his upper thigh and slice down to his tibia. I then cut up his tibia taking off his patellar tendon from the bone. That opens up his knee joint where I cut through the ligaments and menisci exposing his patellar space. There is barely a drop of blood anywhere thanks to the tourniquet. I divide and tie his vessels and cut through his sciatic nerve. I then slice down leaving some muscle for the flap. Israel lifts off the leg under the drape while I attach the patellar tendon to the posterior cruciate ligament. I then suture the flap closed and put a dressing and ace wrap on. While I didn't get to directly liberate pus, I did get to cut it off.
Three days later he's already up on crutches moving around on his own. Sarah has been giving him books to read and crayons to draw and he is quite smart and a talented artist. He talks almost nonstop without fear. The only time he expressed any reserve was after I took the dressing off and was going to replace the bandage. In a tiny, timid voice he begged "please, not too tight, it hurts."
As I enter the OR, Sarah has already prepared the young man for his chest tube. I infiltrate around the ribs between his nipple and his armpit. I slice down to muscle and then poke up and over the rib with a curved clamp. I feel the pop. I see the stream of liquid pus squirt up. Most severely, I am almost floored by the pungent force of the odor that escapes with the pus geyser. I smell plenty of body fluids and odors in my work but this one I can barely take. It's not that I feel nauseated, I just feel like I really don't want to breathe that one more second. I try to hold my breath as I grab the large bore chest tube with the clamp and push it in over the rib and into the pleural space. I then attach the drainage chamber and suture the tube in place. The damage has been done, though, and I think I have never attached and wrapped a chest tube in place faster in my life before bursting out for a breath of fresh air. The block isn't the same for days, despite our best efforts at deodorizing.
Tuesday, I operate on the two skirt-wearing gentlemen. Out of the first, I take a newborn-baby-sized hydrocele with his testicule and cord ensemble. It's the only way for a man to really experience the joys of childbirth as we push the hydrocele out of the incision into the air I almost expect to hear a baby's cry. The joy is about the same for either. The second, I cut into his scrotum, expecting the same pleasurable result only to realize it's actually an extremely large hernia. Changing strategy mid-operation, I open up his inguinal canal but with the size of the defect and sac I'm obligated to take out his testicule and cord as well. Well, it's almost as good as pus!
Unfortunately, as I follow the fistula down from the woman's umbilicus I find it leads to the bladder which is filled with friable tumor which I scrape out as much as I can. I know that this is a very advanced cancer that I can do nothing about so I'm forced to close up and give the family the bad news. Sometimes the surprise is a bad surprise...especially when there's something besides pus. If you find pus, you can usually do something about it. If you find cancer...
I lift off the rags from the man's arm. The whole arm is three times the usual size. The skin on the back of his hand is like the bladder from a basketball that is half-filled with water. It pokes in and bounces out as if there's nothing but liquid inside. His skin is peeling off in many places and in others is like wet cornmeal that crumbles off when rubbed. He has blisters in spots and holes leaking pus in a few spots. We inject Diazepam and Ketamine to put him under and I incise down the back of his wrist. Yellow and red liquid seeps out. I extend the incision towards his shoulder with scissors. The skin is thin and like rubber with nothing attached underneath all the way to the elbow. There is just a little yellow jello like substance that melts away with pressure like a jellyfish caught on the beach on a hot summer day. I find what used to be muscle or fat but is now just a fibrous mass the consistency of sponge cake which dissolves into pus when my fingers dig into it searching for the limits of the infection. I pull up mats of this spongy pus leaving anatomy I haven't seen since cadaver lab in Gross Anatomy my first year of med school. All the superficial veins are intact and thrombosed. A fine net of superficial nerves remains draped over the veins. All the tendons and aponeuroses are exposed on the back of the hand leaving skin covering the fingers like an inverted weight lifter's glove. When I finish debriding the wound it extends from the base of the fingers to above the elbow and half way around the circumference of the arm on both sides. The other side of the arm, while swollen, doesn't appear to be necrotic or pus-filled.
We wrap up the arm in diluted bleach soaked lap sponges and wrap it tightly with an ACE wrap before letting off the blood pressure cuff tourniquet. There is some brisk bleeding near the elbow that I compress while sending Siméon to get a sand bag. A family member soon comes with a piece of cloth filled with a few kilos of sand that I place over the bleeding part to compress it and we take him out to his bed.
I'll never forget the pleasant sensation of feeling my fingers dig into that mass of necrotic fat and muscle squeezing out the pus along the length of the man's arm. To get all that nastiness out is a source of great satisfaction. I pray that with dressing changes and powerful antibiotics we'll be able to save his arm by liberating his pus surprise!
James
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