Unexpected death

Yeah, I was tired, but I certainly didn't expect this one. I'm still trying to figure it out. But, with our deplorable working conditions and lack of staff and equipment, I'm afraid it's doomed to remain a mystery. I just hope we can do something to change conditions so it doesn't happen again.

It started yesterday. We have been even busier than usual, especially in surgery. We did our 50th surgery in January yesterday...and the day wasn't even finished yet and there's still a week to go in the month.

And to think, I thought yesterday would be relatively easy. I thought I'd only scheduled a couple of orchiectomies (taking out the testicle) and the excision of an abdominal wall mass. But when I finally got to the OR at around 11:30am I found that the first case was a hernia and we had one other one scheduled as well. I've been trying to schedule as many surgeries as possible for next week when a visiting surgeon, Dr. Dekraay, will give me a little break.

I was already tired having done 7 ultrasounds, consulted outpatients and had a meeting with our HIV patients under anti-retroviral therapy. Not to mention the fact that I was up till midnight the night before operating on a ruptured ectopic pregnancy.

I quickly did the hernia and two orchiectomies. In between, I followed up lab results and saw more outpatients. Then, things got a little out of control. This woman had a huge, lumpy abdominal mass that was mobile and apparently not fixed to the muscles or anything. There was kind of a peak to it with a little ulceration through the skin. I cut in and popped out 6 firm fibromas...then she started bleeding like crazy. She had high blood pressure and every little skin artery was shooting a geyser out spraying everything in sight. I compressed as best I could as I called for more hemostat clamps. The cavity was so big and deep I had to excise more skin and open it more to get to the depths and clamp off bleeders. By the time we were done the whole floor, bed, drapes and our scrubs were covered with the sticky red stuff.

Now it's 3pm, I should be going home but a nomad man has just brought in his wife. She was operated on (a c-section they say) at another hospital four months ago and now for two days she hasn't passed gas or stool and vomits all the time. Her belly is distended with absent bowel sounds. She has a bowel obstruction. I send her husband off to pay for the surgery. Meanwhile, the evening nursing team comes to tell me there's a young lad who fell out of a tree and has an open fracture.

Oh, yeah, there's also a patient we operated on 8 days ago for a hernia who's referred from the Bao health center for a strangulated hernia from an "operation badly practiced" at the "Bere BAPTIST Hospital". Interesting, I didn't know there was another hospital here in Bere! I go to examine him and find he has a pretty impressive scrotal hematoma but no hernia. The hernia wound is healing well. When we enter he starts writhing in exaggerated agony. Unfortunately, he'll have to wait.

I go see the boy. His elbow has somehow dislocated and come through the skin of the inside of his elbow without fracturing. The nerve is stretched tense over the exposed joint surface of the humerus. His circulation is intact. He also has a closed distal radio-ulnar fracture dislocation. I take him to surgery as first priority. What I don't do, I'll regret later...I don't do a full physical examination (which I know I would've if I hadn't been so overwhelmed already) nor do I check his vital signs.

In surgery I flush out the wound with 3 liters of irrigation fluid while our medical student, Jamie, and Israel pull the arm in opposite directions. It slowly starts to reduce. With a bend of the arm and a push with my thumb, the humerus enters back into its joint. The elbow bends normally. I rinse out the wound some more and close it up in two layers. I then reduce the wrist and place a cast from hand to above the elbow. The boy does fine with just a minimal dose of diazepam and Ketamine. Nothing concerning, although Israel does note later that he was perspiring profusely and his heart rate was elevated (not uncommon with pain and/or Ketamine).

Since we have no post-op recovery room nor enough nurses to staff one, we wheel the boy directly off to pediatrics. I will regret that as well.

We then bring in the nomad woman who ends up having a small bowel obstruction due to two strictures from adhesions caused by her previous surgery. Those two almost closed off scarred pieces of bowel along with a nick of the bowel on entering the abdomen require a resection and anastamosis. As I'm half way through the suturing of the intestine, Clarice enters. I am shocked by what she says.

"The boy is dead"

"Which one?"

"The one with the fracture you just operated on..."

I can't believe it. On further reflection, though, it was inevitable that something like this happen. In fact, it's a simple miracle that we haven't had more complications or deaths following surgery.

We have become a reference center for people from hundreds of miles around yet our facilities are pathetically inadequate. We have no cardiac monitor. Our pulse oximeter has been broken for over 6 months. Our large autoclave caught on fire months ago. Our two small autoclaves were fried last week. Now we are sending our instruments an hour away to Kélo to be sterilized. We only have one OR which is crammed packed with all our supplies since we have no supply room leaving it difficult to clean properly. We have to walk through the instrument sterilization room to get to the OR. We have one prep room also stocked from floor to ceiling with supplies. We have no real prep room (for bathing patients, etc.) which means a lot of filth gets tracked into the OR. We have no post-op recovery room (as mentioned above) which means patients get dumped on the wards along with all the other patients to wake up from anesthesia. Often, there is only one nurse for all the hospitalized patients who can't possibly give the attention needed to the post-op patients which means we depend on family members to alert us of problems. This time, it was too late.

What was the cause of death? Impossible to determine now...but the real cause is an overworked under-equipped staff and hospital. We need at least another physician and some more nurses. Then, we really need a new operating block with at least two operating rooms, a prep room, a post-op recovery room, a dressing room, an instrument/sterilization room, and a supply room. Of course God always helps us in our weaknesses, which is why we've been able to operate successfully on so many with almost never any complications. However, if we have the means to improve things and don't, I think God also will hold us accountable for that one day.

Unfortunately, one young boy will not have another chance in this life...

James