Waste?

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.