Sometimes I wonder why I even bother. I stand in the semidarkness of the early evening with my hand over the heart of an 11 year old girl feeling the life ebb out of her. I've detached the ambu-bag from the tracheostomy tube in her neck and she's not breathing. Her pupils are fixed and dilated and I'm now getting to experience for the first time in a raw way the process of life leaving a broken body.
She came in four days ago. She was by the side of the road drawing water from the lake that has now all but flooded the road in between Bere and Kelo. A truck was trying to plow and rev it's way through the water logged mud and slid over towards the girl. She was knocked over and the truck turned on it's side crushing her legs beneath. The passengers frantically unloaded the barrels off the truck and were able to lift the truck up enough to pull her mangled body out from under it.
She arrived at the hospital conscious with her right leg twisted out at an impossible angle and her left leg wrapped in a bloody, mud-splotched t-shirt. She had no apparent head, chest or abdominal injuries, just her two legs.
I unwrap the shirt.
Her left lower leg is sliced open from just below the knee to just above the ankle as with a butcher knife. There is another 6 inch long cut on the side, a 2 inch long cut on the back of the calf and an inch long wound over her outside ankle.
The large lower leg bone is broken and the pieces sticking out at weird angles with much of the rest of the bone exposed.
Her right femur is also fractured, but not open.
We start an IV, give antibiotics and put her under anesthesia. We scrub out the wounds and rinse with liters and liters of antimicrobial fluids. I set the bones which have cracked in a V-shape making the reduction fairly stable. Liz holds the reduction at the foot and I suture the wounds closed.
I put casts around her ankle and knee with a broken broom stick on each side to act as an external fixator. The fracture is stabilized and we have room to clean and dress the wounds.
I then drill a pin through the bone on her other leg and we move her to her hospital bed where I attache a sand-filled shirt to the pin with a rope to act as traction for the femur fracture.
She is breathing well and is otherwise stable.
A few hours later I go to check on her and she is in respiratory distress. She has what is every anesthesiologist's worst nightmare: micrognathia. In other words, her lower jaw never developed well and is so tiny that her mouth won't really open, her tongue is too big for her throat and her airway is small.
She has too many secretions and now her neck has started to swell. She probably had head trauma as well. She is struggling to breath sucking desperately with her chest. I run and get the pulse oximeter and her oxygen is already going down. I yell for the family members to grab her bed and bring her to the OR (it has no wheels so has to be carried...with the traction it'll be impossible to move her quickly otherwise).
I run ahead to open up and go back to find they haven't really moved. I notice she has stopped breathing. I yell again and this time they come running. We somehow manage to get the bed out of the ward, across the courtyard and into the OR.
No breathing, no pulse.
I grab a scalpel and slice her throat. I poke aside the muscles with a clamp and expose her trachea. I cut into it with a scalpel and widen the hole with the clamp and grasp each side with clamps. I insert an endotracheal tube into the hole and attach an ambu bag while Anatole starts chest compressions.
Miraculously, she comes back to life. After a few minutes she is breathing on her own through the tube in her neck and after waiting a while to make sure she's stable we take her back to the ward.
She stays in a coma, however, and we realize she has brain swelling from the accident. For two days we keep the swelling down enough with medicines that she breathes on her own. Her pupils still react normally. On the third day, we have to start breathing for her. The family members take turns "bagging" her to force air into her lungs.
The fourth day, today, the pupils are fixed and dilated.
I'm amazed at how long it can take to try and save a life and how quickly one can remove those life saving devices. Surgery took two hours. The tracheostomy and resuscitation took another hour. Not to mention all the other time spent adjusting meds, explaining to family members, suctioning her tracheostomy tube, etc.
Now in 10 minutes her IV is out, the urinary catheter has been removed, the tracheostomie was pulled, the traction pin drilled out, and the cast cut off. Nothing remains but the sutures and the slightly twisted, un-stabilized legs.
As I sit to write this, I'm sobbing deep down with no tears. How much have I prayed for this girl over the last four days? How much of my own time, strength and energy have I put into her despite having Malaria myself? Why do I bother?
Why does God seem to never intervene? Why does it seem I'm on my own in this?
I need to make sense of it or I'll lose my faith.
Maybe it's not God's fault at all...maybe it's ours. Maybe if this girl had a clean well or running water she wouldn't have been forced to draw from the side of the road. Maybe if the road had been paved with appropriate bridges and drainage systems the truck wouldn't have slid into her. Maybe if the hospital had better lab facilities we could've intervened to prevent any of the number of things that could be unknown contributing factors to her death.
Maybe we in the West can't go out to buy the latest Energy drink or expensive gourmet coffee without using up the resources that could have gone to furnishing clean water sources in the Third World.
Maybe we can't buy bigger and fancier gas-guzzling SUVs without wasting the money that could've gone to provide simple improved infrastructure in developing nations.
Maybe we can't spend millions of dollars on boob jobs and face lifts and lipo suction without depriving bush hospitals of basic laboratory and x-ray equipment.
Maybe we can't live our comfortable lives and sit back and expect God to do the work that he has given us adequate resources, abilities, talents and time to do ourselves. Maybe God's saying, I haven't refused to save that girl's life...
You have.
Saturday, September 22, 2007
Wednesday, September 19, 2007
Dragonflies
I live in a world of incredible suffering and stunning beauty.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
Sunday, September 2, 2007
Dabegue
It's pouring down rain soaking through my jeans and fogging up my glasses. Sarah and I have saddled up the horses, packed the medicines in the saddlebags and are on our way to Noel's.
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
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