I shouldn't have tried to do three surgeries at once. Of course, it's always easy to look back and see what we should've or shouldn't have done.
It all started off so routine.
I enter surgery, the old arab man is sitting upright on the table ready for his spinal anesthesia. He has two bulges sticking out of each side of his lower abdomen. He bends as far as his arthritic back will let him. Miracoulously, the needle goes straight in despite his twisted, calcified spine and I inject the marcaine plus adrenaline.
We lay him down quickly and tilt the head of the table down. Odei has already scrubbed and is putting his sterile gloves on. I scrub and join him. After draping him with the sterile towels we pause and pray as usual.
I start on the right side. It's a hernia all right but not the traditional one. Half his intestines have come through his abdominal wall through the hole where the spermatic cord comes out, but instead of going down the canal into the scrotum it has wormed it's way under the skin of the belly.
It's fairly easy to dissect out since it's not attached to the cord. I bury the sac inside with a purse string suture and close the weak area with mesh so there's no tension. I repeat the same thing on the left side. A little over an hour has passed and the patient is doing well.
I then go for operation number three. I make a small midline incision over the distended bladder and enter the bladder easily. Urine gushes out. I suction rapidly and ask them to unclamp the foley catheter. Nothing comes out below but urine continues to pour out from above. When I've finally sucked up all the urine I ask Abel if it was difficult to get the foley in. He says, yes, he had to force it.
Great. I look in the bladder. I see the bulging prostate but there's no catheter. I stick my finger into the middle of the prostate and start scooping it out in a circular motion starting at the left around to the back and then to the right. It comes out cleanly and easily.
I then ask Simeon to reinsert the large bore three way foley. It won't enter the bladder. I feel down in the mush of blood clots that used to house the prostate and I can't feel the urethral opening for anything.
Abel's created a false track that the foley prefers to the real one.
We try and try as the blood continues to well out of the bladder. Nothing.
We try passing a urethral dilator. Nothing.
I try passing one from above but still can't find the urethral opening. I'm not sure how much time passes, but it seems like forever. Finally, I'm able to find the urethra with a dilator and it comes out the penis. I then have Simeon attach a large suture which I pull back into the bladder and detach from the dilator. Simeon then threads the suture through the opening in the foley and inserts it while I pull from above. Finally, the catheter enters the bladder.
By this time, the spinal has worn off and we have to give him Ketamine. He starts to react by contracting all his muscles making it impossible to continue the operation. Finally, with Diazepam and Chlorpromazine, he relaxes.
I close up the bladder in two layers, the balloon on the foley is blown up and pulled into the prostatic fossa, and irrigation of the bladder is started.
I close the fascia and skin and take off the gown.
I look at the monitor: blood pressure is normal, pulse is a little elevated but not much considering the effect of Ketamine and surgery, oxygen saturation is normal, he is breathing easily on his own. Nothing concerning, nothing to prepare me for half an hour later when...
"James, come quick, the patient's not breathing."
I run over to the surgical ward where I find a crowd of arabs around a cold body with no pulse or respitory effort. I am about to give my condolances and walk away but something pushes me in the opposite direction.
"Bring the gurney" I shout as I start chest compressions.
The nurses arrive shortly, but not after my vigorous CPR hasn't let to a few cracks of breaking ribs.
I continue the compressions as we race to the OR.
In the OR, Abel takes over compressions as I whip out the intubation kit and place an endotracheal tube. Deuhibe does CPR while Abel attaches the cardiac monitor.
Flatline, Oxygen sat 28%, no pulse.
We continue. Electrical activity starts to come and go on the monitor.
We try adrenaline and atropine.
There seems to be electrical activity (QRS complexes) but the rate is slow. Still no pulse. Abel and Deuhibe haven't done much CPR but with my encouragement they are really pumping vigorously as I bag to breath for the patient (we have no ventilator).
Suddenly, there is good electrical activity. I ask them to stop the chest compressions, sure enough, there's a booming carotid pulse. His O2 sat is up to 90%. We keep bagging. I add some IV glucose. Abel makes sure the bladder irrigation isn't blocked.
Still no neurologic response.
I notice his blood pressure is hanging on the very low end of normal. As Sarah takes over bagging I start to leaf through an anesthesia book. Look, a chapter on the elderly. Interesting, their adrenal function is diminished (duh). I look up onto the anesthesia cart and my eyes light on the hydrocortisone that I secretly wondered why the Romanian orthopedists had brought and left for us (duh).
I quickly give our Arab man 100mg and, shockingly, 5 minutes later his blood pressure is up to normal.
We had brought him to the OR as he was on his Persian rug with his prayer shawl, little skull cap and two sets of Muslim prayer beads. Oh, and his covering, a piece of cloth with a picture of Jesus on it surrounded by the words "Je suis le chemin, la verite et la vie" (I am the Way, the Truth and the Life).
The family wants to know what's going on. We've been inside with the patient for three hours now. I invite the brother in and tell him that his bro has been resurrected by the power of Isa Al-Masih he is the way the truth and the LIFE.
"Al hamdullilah" the brother states with a smile as he is escorted out.
30 minutes later he has started to breath on his own. I pull out his breathing tube and leave him on the oxygen extractor for several minutes. I slowly turn the oxygen down. He continues to breath spontaneously. I turn the oxygen off. I watch him for 15 minutes and he breathes fine with a normal O2 sat. He's still not awake though. Since we don't have oxygen tanks, an ICU or ventilators, we are forced to finally just take the risk and send him back to the ward.
I call in all the family members. Over 20 robed arab men and veiled arab women crowd around. I explain how to keep his airway open and to how to watch his breathing and how to notify the nurse. Then I explain that they've all witnessed a miracle. He was dead, but now he's alive thanks to Isa Al-Masih.
I ask Odei to pray in Arabic. Wisely he turns to them with outstretched palms open towards heaven and says, "Al Fatiha".
Over 20 pairs of hands come up and heads are raised as each one individually repeats his prayer of thanks to Allah. At the end, there are smiles all around with mumbled "Al hamdulillahs" and "Mashallahs" and "Barakas".
At 3 am, I am called to see him. He is barely breathing. We repeat the same thing until 7am next morning. He is back alive but this time, from the rib fractures he has a tension pneumothorax. As I slice open the side of his chest and poke a hemostat into his lung a long hiss of pressurized air comes out. He also has anemia which we transfuse. We keep him in a corner of the OR to breath for him while I take out a 10cm ovarian cyst trapped in the broad ligament all the time trying to avoid the rolls of fat pouring into the operating field.
Then, I do a hernia and take out a small lipoma.
Our Arab is still alive but not breathing on his own. His face, neck and chest are swollen from subcutaneous air from the pneumothorax.
We turn the breathing over to the family members.
He makes it until 2am the next morning, when he dies.
I'm so exhausted that I can't really do my work right the next two days basically neglecting the other hospitalized patients. Was it a waste? Did I poorly use the resource of myself? I may never know...and I don't know what I'll do next time...only God knows...
Pray for us.
Sunday, July 22, 2007
Report 2006
Mes amis,
Just to give you an idea of what finances are like at the Bere Hospital and also send out the report for 2006 from our newly opened Chaplain's office (since June 2006).
Here goes:
Revenues
Hospitalizations $3238.15
Labor & Delivery $227.00
Surgery $8670.40
Lab $6877.45
Radiologie/Ultrasound $556.00
Clinic Visits $5469.25
Pharmacy $46,617.78
Other $311.90
TOTAL $70,565.95
Misc.
Cash on hand $2605.81
Patient loans $2527.66
Staff loans $1270.58
TOTAL $6404.05
Expenses
Salaries $18,827.93
Social Security $1409.81
Medical expenses-Staff $1098.89
Bonuses-Staff $1633.40
Pharmacy $29,644.76
Diesel & other $25,527.47
TOTAL $78,142.26
DEFICIT $7576.31
Note: In reality, the deficit is bigger because some of the Pharmacy revenue is from the sale of medications left over from the PASS project (which finished in 2005) and from donated meds and supplies from a variety of sources. The patient loans are for when patients don't have cash on hand we take a bicycle or a push cart or a large cooking pot or something else as collateral until they can find the money by selling a sack of millet, a goat, etc. The diesel expenses are for running the generator for surgeries and for 1.5-2 hours at night. The generator consumes 5L/hour and costs $1.25-$1.50 per liter. Expenses do not include infrastructure and equipment upgrades and education and training which has been financed through Adventist Health International.
Chaplain's report June-December 2006
Special prayer with patients 441
Exorcisms 3
Spiritual healing 90
Conversion to Christianity 46
Bible studies 17
Baptisms 12
Seminars 1
Funeral services 2
Visits to local authorities 4
Baptismal candidates 9
Meaningful Muslim contacts 11
Muslims accepting Isa as savior 3
Cell groups organized 1
Churches planted 0
Contact avec AIDS patients 6
Difficulties encountered: prevelance of Tuberculosis and HIV/AIDS, lack of time and staff for followup after patient discharge, behavior of certain staff members, lack of literature (Bibles)
Hope this gives a different perspective on the work here in Tchad at the Bere Adventist Hospital.
Just to give you an idea of what finances are like at the Bere Hospital and also send out the report for 2006 from our newly opened Chaplain's office (since June 2006).
Here goes:
Revenues
Hospitalizations $3238.15
Labor & Delivery $227.00
Surgery $8670.40
Lab $6877.45
Radiologie/Ultrasound $556.00
Clinic Visits $5469.25
Pharmacy $46,617.78
Other $311.90
TOTAL $70,565.95
Misc.
Cash on hand $2605.81
Patient loans $2527.66
Staff loans $1270.58
TOTAL $6404.05
Expenses
Salaries $18,827.93
Social Security $1409.81
Medical expenses-Staff $1098.89
Bonuses-Staff $1633.40
Pharmacy $29,644.76
Diesel & other $25,527.47
TOTAL $78,142.26
DEFICIT $7576.31
Note: In reality, the deficit is bigger because some of the Pharmacy revenue is from the sale of medications left over from the PASS project (which finished in 2005) and from donated meds and supplies from a variety of sources. The patient loans are for when patients don't have cash on hand we take a bicycle or a push cart or a large cooking pot or something else as collateral until they can find the money by selling a sack of millet, a goat, etc. The diesel expenses are for running the generator for surgeries and for 1.5-2 hours at night. The generator consumes 5L/hour and costs $1.25-$1.50 per liter. Expenses do not include infrastructure and equipment upgrades and education and training which has been financed through Adventist Health International.
Chaplain's report June-December 2006
Special prayer with patients 441
Exorcisms 3
Spiritual healing 90
Conversion to Christianity 46
Bible studies 17
Baptisms 12
Seminars 1
Funeral services 2
Visits to local authorities 4
Baptismal candidates 9
Meaningful Muslim contacts 11
Muslims accepting Isa as savior 3
Cell groups organized 1
Churches planted 0
Contact avec AIDS patients 6
Difficulties encountered: prevelance of Tuberculosis and HIV/AIDS, lack of time and staff for followup after patient discharge, behavior of certain staff members, lack of literature (Bibles)
Hope this gives a different perspective on the work here in Tchad at the Bere Adventist Hospital.
Sunday, July 8, 2007
Mistakes
I'm in way over my head and it's all I can do to not panic. I'm not a surgeon after all and the mistakes I've just made prove it. Now, can I save this lady's leg and kidney?
I had opened the belly of a woman with a large lower abdominal mass. A huge smooth lumpy, solid but not hard mass fills her entire pelvis. I identify the right ovary and tube with what appears to be a fibroma sticking out behind and a huge fibroma filling the rest of the belly.
I start to remove the uterus but it's difficult because there's no room to manouver to get down the side to the base. I do most of the right side and then move over to the left. That's where I start to make mistakes because I misdiagnosed the problem.
It's already taken an hour and a half with no muscle relaxation and trying to keep all the intestines out of the already cramped pelvis. I'm moving down the uterus staying close to it like I've been trained to avoid the ureters when I cut through...the ureter.
Mistake number two...the first one I won't discover till later.
I realize I'll have to repair it later so I tag it and keep moving. Finally, I get low enough where it's time to separate the bladder from the cervix.
It's stuck. As I try to free it, I enter the bladder which is weird because their doesn't seem to be really any uterus behind it.
Mistake number three.
I decide to open up the uterus and take out the myomas to free up some space and try to identify things better. I open it up and find thick, jelly like contents.
It's a huge mucinous ovarian cyst that has attached to the uterus and ovaries making it seem like fibromas.
I shell it out and suddenly, the normal sized, half taken out uterus appears in the right pelvis. I then look back at what I thought were the enlarged uterine vessels and realize I've probably cut the femoral vessels.
I ask Simeon to feel the left leg. He's says it's a lot colder than the right.
I'm getting desperate. In my ignorance I've probably cost this lady her leg and kidney. We're already two hours into the surgery, the leg is without blood for 30 minutes already and I still have to take out the uterus and the rest of the ovary before clearing up room to try and do something about the artery and vein and ureter and bladder.
I'm fighting off panic. I want to rush. I have to make myself turn on autopilot.
Do I have what it takes?
I've been praying almost continuously that God won't make my stupidity or ignorance or whatever you call it be the cause of such a catastrophe.
Somehow, while the panic rests under the surface, I feel somehow that I'm not alone in this. That I have a mentor, an attending physician with me but who says, I'm not going to take over, I've given you what you need and I'll walk you through it.
I suture up the bladder in two layers.
I search for the femoral vein first. I find both ends of a large severed vein in the right place (now the anatomy is clear) and clamp them with vascular clamps before cutting off the sutures and trimming the ends. I find the proximal end of the artery but can't really find the distal end.
I take some very fine suture and painstakingly put in the sutures starting from the back side and working around to the front. Odei and Taiana, my assistants are fighting a neverending battle to help me against the intestines and the oozing blood and fluids and the vein itself that doesn't want to stay close enough to suture.
In the meantime, Simeon has done a hemoglobin and it's 6 so he's ordered a blood transfusion.
I release the clamps and a huge clot bursts out followed by dark blood rapidly filling the operating field. We suction and mop up desperately as I reattach the clamp. I suture a bit more where the leaking was and try again.
The same thing. I'm trying hard not to get desperate and just quit.
Finally, we release the clamps again and there's no bleeding.
I start the search for the distal part of the artery. I just can't seem to find it. What I thought was the artery turns out to be the vein as I release the clamp I thought was holding the artery to try and attach it better. I know it's the vein because dark blood immediately begins to gush out again.
We repeat the same process until it's definitely stopped. I hunt and hunt for the artery. It has to be here.
Finally, I find and clamp it and start the slow process of suturing with fine suture.
We are four hours into the sugery, two hours without blood to the leg.
I release the clamps on the artery. There is no bleeding, but no real pulsation either. It's probably clotted up. I don't know what else to do so I head to the ureter.
I always wondered what we were going to do with all those ureteral stints that someone put in the container of supplies we got two years ago, but I'm glad for them now. I open one up, slide it into both ends of the severed ureter making sure it goes all the way into the bladder, and suture up the ureter around it.
Finally, we close up the abdomen and I check her leg.
Is it my imagination, or does she have a faint pulse in her foot? The leg is still cool. Only time will tell.
We put her on some Heparin and Diclofenac, the only blood thinners we have and pray for the best.
I don't know how to explain it, but as I walk out, instead of feeling stressed and annoyed, I almost feel refreshed, at least spiritually, even though my body is tired, it has been a time when I knew God was with me. He didn't say, well, you caused the problem so you're on your own.
Rather, he encouraged me, kept me from giving up and led me through.
(Today, two days later, her leg is a little swollen, but not bad and she has a good pulse and can move her leg normally. Her urine is clear, her intestinal function has returned and she's starting to take liquids...Al hamdullilah)
I had opened the belly of a woman with a large lower abdominal mass. A huge smooth lumpy, solid but not hard mass fills her entire pelvis. I identify the right ovary and tube with what appears to be a fibroma sticking out behind and a huge fibroma filling the rest of the belly.
I start to remove the uterus but it's difficult because there's no room to manouver to get down the side to the base. I do most of the right side and then move over to the left. That's where I start to make mistakes because I misdiagnosed the problem.
It's already taken an hour and a half with no muscle relaxation and trying to keep all the intestines out of the already cramped pelvis. I'm moving down the uterus staying close to it like I've been trained to avoid the ureters when I cut through...the ureter.
Mistake number two...the first one I won't discover till later.
I realize I'll have to repair it later so I tag it and keep moving. Finally, I get low enough where it's time to separate the bladder from the cervix.
It's stuck. As I try to free it, I enter the bladder which is weird because their doesn't seem to be really any uterus behind it.
Mistake number three.
I decide to open up the uterus and take out the myomas to free up some space and try to identify things better. I open it up and find thick, jelly like contents.
It's a huge mucinous ovarian cyst that has attached to the uterus and ovaries making it seem like fibromas.
I shell it out and suddenly, the normal sized, half taken out uterus appears in the right pelvis. I then look back at what I thought were the enlarged uterine vessels and realize I've probably cut the femoral vessels.
I ask Simeon to feel the left leg. He's says it's a lot colder than the right.
I'm getting desperate. In my ignorance I've probably cost this lady her leg and kidney. We're already two hours into the surgery, the leg is without blood for 30 minutes already and I still have to take out the uterus and the rest of the ovary before clearing up room to try and do something about the artery and vein and ureter and bladder.
I'm fighting off panic. I want to rush. I have to make myself turn on autopilot.
Do I have what it takes?
I've been praying almost continuously that God won't make my stupidity or ignorance or whatever you call it be the cause of such a catastrophe.
Somehow, while the panic rests under the surface, I feel somehow that I'm not alone in this. That I have a mentor, an attending physician with me but who says, I'm not going to take over, I've given you what you need and I'll walk you through it.
I suture up the bladder in two layers.
I search for the femoral vein first. I find both ends of a large severed vein in the right place (now the anatomy is clear) and clamp them with vascular clamps before cutting off the sutures and trimming the ends. I find the proximal end of the artery but can't really find the distal end.
I take some very fine suture and painstakingly put in the sutures starting from the back side and working around to the front. Odei and Taiana, my assistants are fighting a neverending battle to help me against the intestines and the oozing blood and fluids and the vein itself that doesn't want to stay close enough to suture.
In the meantime, Simeon has done a hemoglobin and it's 6 so he's ordered a blood transfusion.
I release the clamps and a huge clot bursts out followed by dark blood rapidly filling the operating field. We suction and mop up desperately as I reattach the clamp. I suture a bit more where the leaking was and try again.
The same thing. I'm trying hard not to get desperate and just quit.
Finally, we release the clamps again and there's no bleeding.
I start the search for the distal part of the artery. I just can't seem to find it. What I thought was the artery turns out to be the vein as I release the clamp I thought was holding the artery to try and attach it better. I know it's the vein because dark blood immediately begins to gush out again.
We repeat the same process until it's definitely stopped. I hunt and hunt for the artery. It has to be here.
Finally, I find and clamp it and start the slow process of suturing with fine suture.
We are four hours into the sugery, two hours without blood to the leg.
I release the clamps on the artery. There is no bleeding, but no real pulsation either. It's probably clotted up. I don't know what else to do so I head to the ureter.
I always wondered what we were going to do with all those ureteral stints that someone put in the container of supplies we got two years ago, but I'm glad for them now. I open one up, slide it into both ends of the severed ureter making sure it goes all the way into the bladder, and suture up the ureter around it.
Finally, we close up the abdomen and I check her leg.
Is it my imagination, or does she have a faint pulse in her foot? The leg is still cool. Only time will tell.
We put her on some Heparin and Diclofenac, the only blood thinners we have and pray for the best.
I don't know how to explain it, but as I walk out, instead of feeling stressed and annoyed, I almost feel refreshed, at least spiritually, even though my body is tired, it has been a time when I knew God was with me. He didn't say, well, you caused the problem so you're on your own.
Rather, he encouraged me, kept me from giving up and led me through.
(Today, two days later, her leg is a little swollen, but not bad and she has a good pulse and can move her leg normally. Her urine is clear, her intestinal function has returned and she's starting to take liquids...Al hamdullilah)
Death Encore
I'm not even sure what time it is as I stumble like a drunk man trying to walk the line over to the hospital. It has to be after midnight and there is no moon leaving us in cave like blackness. Only my dim head lamp briefly lights up the grass on either side of the path like the headlamps of a car going in slow motion.
David thanks me for coming and I mumble something in reply. I just can't clear the cobwebs and I didn't even take a Benadryl or anything. Maybe it was the four hour surgery earlier on top of three previous one's that day capped off by learning that the patient died three hours later. While it wasn't a surprise since he'd had intestinal volvulus for over a week, it still is draining.
I exam the child. He's panting, his eyes are wide with that starting to get vacant stare. His belly is swollen and tender. He hasn't had any bowl function since the morning. He needs an operation.
I manage to scribble out some orders and then weave my way over to where the night watchman has slung out a thin, lumpy cotton mattress on the cement in front of the clinic. I tell the nurses to call the OR team and wake me when the patient is ready.
I collapse. My whole body wants to sink through the mattress and through the cement even. As I drift off, I beg God to somehow give me the strength to do this operation.
Simeon is shaking me awake. "We're ready."
I wearily get up and enter the surgical suite.
A few moments later, as I stare at the 18 month old boy lying naked on the blue plastic covering the OR table I have a hard time imagining that I'm actually going to shortly be taking a very sharp scalpel and slicing open his belly.
But I do and pus comes out in clumps mixed with slippery, inflammatory fluid. We suction and suction all the corners of the abdomen until we've gopped most of it up. We rinse out and then I start looking for the source.
I find nothing. Absolutely nothing.
I stuff the intestines back inside and suture up the midline incision. As I take off the drape, I glance at the urinary catheter and see pus coming out instead of urine.
Of course, a severe kidney infection. We've already given antibiotics so I write to continue him on them.
He has been stable throughout the surgery and we move him out to the ward.
The next morning he is doing a little better but still breathing fast and not really waking up. His urine has cleared up though and his heart rate has decreased.
Half way through the day the nurses call me. I rush over to his bedside but find that he is actually a little improved over the morning.
It seems like he'll make it.
That night, the nurse calls me to see a kid she's hospitalizing. I go over to the Pediatric ward and notice an empty bed.
The little boy died a few hours ago.
I can't wait for the day when "He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away." (Revelation 21:4)
David thanks me for coming and I mumble something in reply. I just can't clear the cobwebs and I didn't even take a Benadryl or anything. Maybe it was the four hour surgery earlier on top of three previous one's that day capped off by learning that the patient died three hours later. While it wasn't a surprise since he'd had intestinal volvulus for over a week, it still is draining.
I exam the child. He's panting, his eyes are wide with that starting to get vacant stare. His belly is swollen and tender. He hasn't had any bowl function since the morning. He needs an operation.
I manage to scribble out some orders and then weave my way over to where the night watchman has slung out a thin, lumpy cotton mattress on the cement in front of the clinic. I tell the nurses to call the OR team and wake me when the patient is ready.
I collapse. My whole body wants to sink through the mattress and through the cement even. As I drift off, I beg God to somehow give me the strength to do this operation.
Simeon is shaking me awake. "We're ready."
I wearily get up and enter the surgical suite.
A few moments later, as I stare at the 18 month old boy lying naked on the blue plastic covering the OR table I have a hard time imagining that I'm actually going to shortly be taking a very sharp scalpel and slicing open his belly.
But I do and pus comes out in clumps mixed with slippery, inflammatory fluid. We suction and suction all the corners of the abdomen until we've gopped most of it up. We rinse out and then I start looking for the source.
I find nothing. Absolutely nothing.
I stuff the intestines back inside and suture up the midline incision. As I take off the drape, I glance at the urinary catheter and see pus coming out instead of urine.
Of course, a severe kidney infection. We've already given antibiotics so I write to continue him on them.
He has been stable throughout the surgery and we move him out to the ward.
The next morning he is doing a little better but still breathing fast and not really waking up. His urine has cleared up though and his heart rate has decreased.
Half way through the day the nurses call me. I rush over to his bedside but find that he is actually a little improved over the morning.
It seems like he'll make it.
That night, the nurse calls me to see a kid she's hospitalizing. I go over to the Pediatric ward and notice an empty bed.
The little boy died a few hours ago.
I can't wait for the day when "He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away." (Revelation 21:4)
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