Perforation

>
> It must be bad. They only call me out of church for real
> emergencies. I gather my books and walk out on the dusty dirt floor
> to a bright late Tchadian morning. Noel and Pierre are waiting for
> me. I don't see a nurse anywhere. What's going on?
>
> "Abel's in-laws have just informed him that his fiancee will come to
> him tonight to become his wife. He has nothing to prepare a wedding
> with but wonders if we'll do a dedication for him in church."
>
> After much discussion it is decided that the women of the church
> will prepare a goat that I will provide and we'll do a wedding
> ceremony at his house tomorrow evening. He has no family here, so
> we will be his family.
>
> That afternoon, I'm too tired to go to the river. It's a good
> thing. Tchibtchang comes calling with the traditional "clap-clap"
> at my door.
>
> "There's a father who brought his son in for a blood transfusion for
> severe anemia and malaria. After we drew his blood to give to his
> child, he told us his hernia popped out in route on the motorcycle.
> We can't get it back in."
>
> I accompany him to the hospital and see Simeon and Abel already
> waiting.
>
> "Aren't you supposed to be preparing to receive your bride tonight?"
>
> Abel chuckles loudly with a huge, toothy grin. "No, tonight she
> comes to my house but I'm not supposed to be there until tomorrow
> night...so here I am!"
>
> A quick look reveals that this hernia is not going to be reduced
> without surgery.
>
> Just then Augustin One comes in. "There's a guy who's been gored in
> the butt by a bull."
>
> "Ok, bring him over." I take a look and fortunately the gore wound
> is to the side and back of the anus missing the intestines. It's
> pretty deep though so I order antibiotics and we prepare for the
> hernia.
>
> Simeon gives the spinal anesthetic while Abel scrubs. I prepare the
> surgical field with Betadine and then scrub. Abel puts my gown on
> and snaps my gloves into place. A few scalpel strokes later and we
> see a dark mass of intestines. I open the sack and there is already
> some dark, coagulated blood in the mesentery but the intestines
> still look viable. I push the squishy, slippery mass of bowel back
> into the abdomen and close the sack. He also has a hydrocele and
> since his left nut is good I take out the hydrocele, testicle and
> all. I sew a piece of mosquito net over the weak spot in the muscle
> and close the skin.
>
> The man with the anal wound is stoic. I give him local anesthesia
> and close the wound in four layers leaving the skin loosely
> approximated. I tell him to soak in salt baths four times a day and
> go home.
>
> Later that evening, Augustin One asks me to see a little girl who
> was treated here a month ago for malaria. She now has abdominal
> swelling. I approach the bed in pediatrics and see a thin little
> six year old with bright eyes who looks tired but not too acutely
> ill. Her belly seems slightly swollen but is soft and non-tender.
> She has diarrhea so I put her on Chloramphenicol and Metronidazole
> and go home.
>
> The next day, Sunday, I lazily do rounds around noon. Melodie asks
> me to see a girl on pediatrics she feels isn't doing well. Her
> glucose is a little low but she's awake. She just doesn't want to
> eat. It's the same girl I saw last night. She is alert but refuses
> to eat. The diarrhea has all but stopped but her belly seems more
> swollen. I examine her and the belly is soft and she doesn't flinch
> or anything when I touch her. I look in her face and something in
> her gaze tells me there's something serious going on. I feel a
> strong impression that I should operate on her. I feel bad because
> this means I'll probably miss Abel's wedding. I tell the father and
> he agrees. Koumabas calls in Simeon and Samedi.
>
> In the OR, Samedi has already scrubbed and the little girl is lying
> resignedly on the operating table. I feel a sudden panic. Why am I
> operating on her? Maybe she has abdominal TB. I run to my office
> and bring in the portable ultrasound. The images reveal a full
> bladder and a lot of stool but no intra-abdominal fluid. Well at
> least it's not abdominal TB. I'm still uncertain but feel committed
> now to the operation. I scrub and join Samedi at the surgical field.
>
> We all bow our heads and I pray in French "God, we're not sure
> what's going on with this girl. We just pray we are doing the right
> thing. Help this operation to be a success and this little girl to
> recover her health completely afterwards."
>
> I cut through the skin and fascia below the belly button. The
> peritoneum seems thickened and I'm not sure if the intestine is
> stuck. I enlarge the incision to above the belly button and make it
> into the abdominal cavity. A gush of liquid stool spurts out under
> pressure as we try to suck it up. I'm at first afraid I've
> punctured the bowel but as the stool spills everywhere over the
> surgical drapes I soon see that she must have had a perforated
> intestine. I can't believe she didn't have pain but am relieved we
> decided to operate. Samedi sucks out the stool as we irrigate and
> search for the damaged section. My finger digs into an inflammatory
> mass and a clump of green, peat moss looking stool slithers out.
> We've found the hole. I pull out the mass, clamp and cut it out.
> It's in the distal ileum. I then suture the two parts of good
> intestine back together, rinse out the belly with liters of fluid,
> put in two drains and close the fascia and partially close the skin.
>