I'm poised over the body, scalpel in hand. It's hard to believe that this will be the third major surgery on this poor woman in a month. I've been torn inside as to whether this is the right thing to do, but now as I stand ready to cut, I feel peace.
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
Sunday, August 19, 2007
Tuesday, August 14, 2007
Baby Hernia
Friday. The end of a long week. I'm set to travel Sunday to N'Djamena to pick up some volunteers. The day is almost over. It's been pretty quiet...
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
Monday, August 6, 2007
Chantal
I only get to know, really know, two classes of patients: ones hospitalized with chronic wounds or osteomyelitis and AIDS patients. There are really no other chronic diseases here...people don't live long enough (life expectancy = 49 years for men and 47 years for women).
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
Sunday, July 22, 2007
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.
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.
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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