The woman was gored by a bull. Not just any bull, a Chadian bull with 3 foot long horns. And she was gored in the mouth, straight through her palate into her nasal cavity. But that was months ago. Now, she's just a wizened old lady who'd like to swallow her porridge without it coming out her nose. I have her open her mouth and I shine in a light. There's a small hole, slightly smaller than one centimeter right in the center of the roof of her mouth. I poke around with a clamp. There's some green stuff; looks like bean leaf sauce for lunch.
We prepare her for surgery. She has high blood pressure. Three days and three medications later her blood pressure is mostly controlled. We wheel her into surgery.
There are four medications God has reserved as gifts for the third world. One of those is Ketamine. It is dirt cheap, can be given through an IV or into a muscle, dissociates the person from their conscious brain yet doesn't hinder breathing, swallow or gag reflexes. It also increases heart rate and blood pressure (both generally good things during surgery) and dilates bronchioles in the lung increasing oxygenation. It allows us to do most major surgical procedures without intubation, ventilators, or other complicated anesthesia equipment. Too good to be true? Well, there are a few drawbacks...
Simeon gives the woman some atropine to dry up her secretions since Ketamine tends to make one salivate and shed a lot of tears. He also gives her Valium since people on Ketamine can have vivid dreams, visions or even nightmares. This is especially true on emergence from anesthesia. Valium should blunt that. So far so good.
I have put on sterile gloves and arranged the instruments on the tray. I'm ready for the patient to be knocked out. Simeon slowly injects one milliliter of Ketamine. I watch as her eyes start to twitch and then she goes out. Then she contracts her abdomen, chest and neck in a huge grunt and stops breathing. I can hear the beep beep of the pulse oximeter in the background as her oxygen saturation goes slowly but surely down. This happens sometimes with Ketamine for a few seconds. I sit tight. She still doesn't breathe. I start doing some chest compressions to move a little air in and out of her lungs. Simeon is keeping her airway open. Her sats come up a little, but are still very low. Usually, the person starts breathing right about now, or rather a few seconds (or is it minutes) ago.
I decide to intubate. Simeon opens the drawer filled with about 10 different laryngoscope handles and light sources and over 20 different lighted blades. I grab the one I want, it doesn't light up. I try changing blades. Nothing. I'm starting to panic as I go through all the handles and blades and not a single one works. We have the endotracheal tubes ready, but no way to see the vocal cords to put them in. Meanwhile the patient isn't breathing because she's all tensed up from a reaction to the Ketamine. Her sats are going way down in the background with that annoying little beep.
I see in the bottom of the drawer a laryngoscope I've never seen before. It's made of green plastic and the blade is rigidly attached to the handle which is hollow with no top. It's just a long tube attached to the blade. On the side is written, use laryngoscope light source (or something like that). Inspiration (or desperation) comes. I yell to James (the medical student/EMT from the states).
"Get me that headlamp over there on the wall. Turn it on and shine it down this handle!"
It works, a little light at the tip of the blade lights up. I quickly jam it into her mouth and see her vocal cords! I grab the ET tube. I try to put it in but her mouth is tense and the tube bends. I forgot the guide wire. I quickly fumble in the drawer and bend the wire back into shape and jam it down the ET tube.
"James, put your hand right here and push her cricoid down and to her right!" I can't see the cords. Finally, a swollen, tight little hole with two white flaps opening and closing pathetically shift into view. I thrust in the tube and it passes into the trachea.
"Blow up the cuff with that syringe!" I yell to the other medical student, Jonathan. I attache the bag to the tube and start pumping air into the patient's lungs. I see a reassuring vapor in the tube with each exhalation and an even more reassuring increase in the tone of the pulse ox which says she is now being well oxygenated.
I give the bag to James while I put on fresh gloves and make two incisions about half a centimeter from the hole in the woman's palate. Jonathan and Abel retract and Abel suctions while I free up the tissue from the bone and then move the two flaps to the center and suture them over the hole made by the bull horn.
Fifteen minutes after the surgery is over I'm able to extubate the woman and she soon breathes normally with normal oxygen saturation.
Note: No supplemental oxygen was used in the filming of this nightmare due to unavailability.
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