Shocking

I stand at the foot of her bed. Kristin and Augustin are the nurses on duty and the three nursing students, Ndilbe, Honoré and Innocent are gathered around, white coats spotless, notebooks and charts in hand.

The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?

I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.

Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.

I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.


She's gotten a couple liters of fluid and the magnesium and now the potassium comes back normal. She seems stable enough so I leave the monitor hooked up but turn it off to save battery and move on to the next patient. Maybe she'll come out of it on her own.

It's 9:30am.

After finishing rounds and seeing the first batch of ER patients I perform a hernia operation with mosquito net mesh and repair to my office for some ultrasounds.

Augustin knocks on the door.

"Ca ne va pas," he says "Bed 10 is in respiratory distress."

I hurry over to the ward, worried that she's already dead (which is what "ca ne va pas" usually means coming out of a nurse's mouth). Fortunately, not only is she still alive, but she's consious and not really in respiratory distress. However, as I turn on the monitor, I see that her heart beat is still 150-160 and irregular. I feel I should do something but it's been a long time since I've had to deal with cardiac patients and I'm not exactly in the best equipped place to deal with it.

I hurry back my office to look up my little "cheat sheet" on electrical cardioversion. It tells me I should sedate the patient first if possible, put the defibrillator on "sync" and start with 100J. Ok, I feel a little better, it's starting to come back.

I hook up the defibrillator pads, give her some Valium IV, turn on "sync" and see the little dots appear over the QRS complexes on the EKG, turn the knob to 100J and hit charge. I hear the whirring of the charge and then it's ready. But now, I don't know how to make it decharge. I look all over and see nothing. Great.

I turn everything off, take off the pads and return to the OR where I find the paddles with their large, curly-cue phone cable like cords. I hook it into the defibrillator, check out the little buttons and place one over her sternum and the other on her left side under her armpit.

"Everyone back," I announce. "Don't touch the bed or anything!"

She's still staring up at me wondering what the heck I'm doing (as do I). I see that everything is well sync'ed. I hit the charge button and then the two "shock" buttons. Just like in the movies or on TV she bounces a little off the bed, her head thrown back, and then flops back down. The EKG makes a big wave, a brief flat-line and then a normal rhythm of 110 beats per minute starts to play across the little green screen.

I almost can't believe it. I know it's supposed to work according to all I've read and been told in my ACLS courses, but come to think of it, even in the US I don't think I've ever been present for a synchronized cardioversion.

My heart is full with thanks to God for bringing everything together to make it possible for us to save this woman's life first with the operation and then with what I had considered mostly useless defibrillator monitors.

Shocking!

Insomnia

I've had a nice relaxing day. I slept in, thanks to a sleeping pill, did an
appendectomy, came home and watched The Gospel of John on DVD, played the
guitar, cooked some beans and rice, fed the horses, went to evening prayer
and read "Le Comte de Monte Cristo" until 10pm when my eyes were so heavy I
knew I'd fall asleep immediately.

Boy, was I wrong.

At first, the earplugs seem to drown out all noise and the bed is so
comfortable. It's not even too hot. I feel myself sinking into the bed and
a deep sleep. But then, slowly, the ear plugs un plug a little and the
sounds of children's squeals and shouts breaks through. The drum beats waft
over the full-moon lit night. I start to feel a little cold. I pull on the
sheets. Then my muscles feel a little stiff. I stretch them out. I start
to toss and turn. Then I feel hot and take the sheets off. My thoughts
start to pour in on themselves.

Maybe I should've taken out that inflamed Cecum instead of just draining the
peri-appendiceal abscess. I'll probably have to operate tomorrow and it'll
be complicated and who knows what will happen.

Is that a knock on the door? I pull out my earplugs. Nothing. Then a
faint, "tap, tap, tap" of knuckles on sheet metal. I pull off the eye shade
and the other ear plug. I fumble for some shorts and stumble out to the
door, the way lit by the incandescent blue of the bug lamp. It's Samedi.

"The young man with the snake bite. His dad wants to take him home. I told
him I can't release him without the doctor's orders. I tried to explain to
him to wait until the morning, but he says that everyone in the neighborhood
is saying that his son is dead, so he wants to take him home."

"What kind of excuse is that?" I think to myself then reply to Samedi,
"have him sign the form that he's leaving against medical advice. We're not
a prison, we can't force anyone to stay. The dad doesn't even care that his
son is better and if he was going to die he would've done it the first day
or two?"

"I've tried to reason with him," Samedi replies. "Even Pierre and the lab
guy tried to talk to him. He's totally beyond reason."

"Ok, bon travail!"

I try to return and hope that now I'll be able to sleep.

At first, I think it'll work. But then the thoughts start to come in,
unwanted worries crowd my head. The kid's voices keep penetrating the
silence of the ear plugs. Medical and surgical cases keep parading through
my subconscious along with preoccupations that I should have done things
differently or maybe I should've done this and not done that. Then, I start
thinking about the projects I want to do, all the preventative measures that
could be taken. What are we going to do about malaria? Will DDT spraying
ever happen? What about the TB and AIDS patients? Will I ever get time to
train the village health care workers like I want to? What about the
Moundou project? How are the volunteers going to work out? Am I giving
them enough direction? Am I being too controlling?

As I fitfully fall into a light slumber, the tossing and turning continues
as I continually wake up, my heart beating fast having dreamt once again
that I'm having to flee something...that I need to escape something that is
chasing me and almost finds me except miraculously, they somehow overlook my
obvious hiding place. It's a recurrent nightmare.

Thoughts in French wander in about the Count of Monte Christo and what I've
just read. Is that a knock on the door? I pull out the right earplug.

"Oui?" I ask. I look out the small bedroom window onto the porch. The
moon illuminates the door. There's no one there.

I'm cold again. Now I'm hot. Oh, it's so comfortable on my back as I
stretch my legs out. Now it's uncomfortable. Maybe on my side. I
should've taken a sleeping pill.

I pull out my earplugs. The dancing and singing and playing has stopped.
The crickets and frogs are blasting a cacophony around the house. Somewhere
a rooster crows. His friends answer from all over the neighborhood. A tint
of red lights up the windows. Dawn is on it's way. I get up, turn on the
computer and write this email...

Fixin da bone

Considering I'd only done it once before in my life, it's hard to believe that this is the third time this month I'm slicing open a thigh. This one should be the hardest one to date.

Abel helps me stretch a sticky, yellow plastic covering over the thigh where we'll cut to try and get to the unhealed femur. As I poise with the scalpel over the now yellow window of thigh in the surgical field the first two cases flash through my mind.

The first was a large man hit by a motorcycle two years ago. His twin brother came to our hospital for some other reason and then asked me if I could do anything for his brother whose leg had healed badly leaving him crippled hobbling around with the aid of a crutch thanks to his now shortened right leg. Surprisingly, the traditional method of bone setting hadn't worked leaving him only with a circomferential scar where they had attached a cord too tightly.

Maybe it was the twin angle, but I told him to have his brother see me when I'd be in N'Djamena next. Sure enough he showed up with several sets of xrays showing his femur shortened by 4 cm and angled at about 25 degrees. It was well healed though. When he came to Bere I was able to break the two fragments apart and then put him in traction to pull it out to length. He's been here for a month now.

The second was an 8 year old girl referred by the first patient. In fact, she was his niece or something, also with a right femur fracture 3 months old due to a motorcycle hitting her. Basically the same procedure and she's been here for a couple weeks now. She also ended up with malaria needing a blood transfusion. She is stoic and looks me directly in the eyes every time I do rounds lifting out her hand solemnly for the obligatory greeting and exchange of "Ca va's". I look forward to seeing her every day.

As I slice through the yellow plastic, the black skin and the light yellow fat turning quickly red with blood, I think again that this one won't be as easy...

Again another call came to me while I was in N'Djamena last week saying he also had heard that we'd operated successfully on two of his relatives with right femur fractures and he hoped we could do the same for him who had the same problem. Yep, the right femur broken by a motorcycle hitting him while he was riding a bicycle.

As I held up the xrays in the faint rays of light filtering through the slats of the ER windows I could tell instantly that this was complicated. The two fragments of the femur were separated by about 4-5 cms with a separate fragment also to the side and no evidence of any type of callous or new bone formation anywhere. It was a year already after the accident. His fracture had also been an open fracture with a draining would for 3 months before it closed. As I looked again at the thigh I saw the healed scars from where the bone shard had pierced the skin. As I picked up his leg I found he had an extra joint mid-thigh. I could move his lower leg in all for directions without his hip moving at all. Not good!

I cut through the fascia and the red muscle wells up into the wound as Abel retracts. As I continue down through the muscle, I see the fibers twitch and retract. I hit some nice arteries and scramble to clamp them off. I call for a suture and tie off the bleeders. I can feel the proximal fragment of bone with a muscle spilling over it down into a cavity where the other bone has to be somewhere. I keep digging until I find the distal part of the femur. There is about 2 inches of muscle and a ton of scar tissue all around. I try to free it up with various instruments: scalpel, scissors, periosteal elevators and various others. I get into part of the scar tissue that has walled off some yellow inflammatory liquid like a cyst. It is clear though and happily doesn't look infected. The distal part just doesn't want to free itself.

I'm kind of a little nervous as I know somewhere around the back or medial side of that deep bone are the big arteries and veins that supply the leg. I don't want to have to resort to a Celox miracle again.

I have the scar tissue freed up superiorly, medially and laterally, but behind the bone I just can't seem to get to it. Finally, I find some dangerous looking pincher-like instrument and manage to grasp the fragment and pull it up enough to cut off the scar tissue keeping it from moving.

I then grab some Rongeurs and start ripping and tearing and biting and cracking off pieces of calloused bone over the two unhealed ends. Finally, I'm down to pretty fresh, raw, bleeding bone. Klevin and Gabrielle have been taking turns putting some traction on the foot and now I really have them tug with all they've got. The bones are still overlapped by a centimeter. I wedge in a chisel and with my prying and the boys' pulling the distal part finally slips over the proximal and meshes together with all the sharp edges left after my gnawing at them.

As Klevin and Gabrielle maintain tension on the leg I suture closed the fascias and the skin and place a sterile dressing.

I then take out a sterile, threaded pin about 20cm long and put one end into a very not sterile cordless drill. I make a small incision on the skin over the tibia and pull the trigger. The pin barely moves, the battery is weak. It makes it a few millimeters into the bone before conking out completely. I ask for the other battery. It is even deader since the charger hasn't been plugged in. I try an old rusty hand drill. Doesn't move at all. Finally, I send Gabrielle to my house to get another cordless drill. After a long five minutes he's back and I drill through the bone, nick the skin on the other side and let the pin work it's way halfway through before detaching the drill. I then attach a U-shaped wire onto it so we can attach a bag of sand to work as traction to keep the leg out to length.

After transferring him from the OR to his bed and attaching the sand bag, I do the final manoeuver, I put two empty Ceftriaxone vials over the sharp edges of the pin, make sure the legs are the same length and go home.

Futbol

Why did I choose to wear shoes? I thought it would protect my ankle which had been smashed by Jason last week forming a superficial blood clot leaving my left inner ankle and foot swollen and different shades of purple and green.

Now as I send the ball skimming back across the grass, in the general direction of where I want it to go, I feel some burning pains on the sides of both small toes.

As Bond, Gabriel, Klevin and Stephan continue to play with some of the neighborhood kids I step behind the two broken bricks marking the goal posts and take off my shoes. Sure enough, blisters have already burst leaving raw flesh where the side of the toes should be. I jump back up from the ground and join back in the game. As I look up past the other goal defended so well by Bond things sort of go into movie mode as four well muscled, lean teenage Chadians stroll up slowly from past the end of the fence. I almost feel like things should go in slow motion with sinister music from some gang flick plays in the background. The brief moment is burst, however, as they flash large smiles and I recognize Koumakoy and Frederick's "little" brother along with some of the normal neighborhood soccer thugs.



We quickly divide into "us" versus "them" as they are intent on preserving the national Chadian football honor on this warm, Friday afternoon. In fact, warm is an understatement as the humidity from last night’s downpour hangs like a suffocating blanket over the ratty field as a cloudless sky lets a merciless African sun slowly broil us alive.

Needless to say, a few minutes into the match and my scrub bottoms are already soaking with sweat from the waist down and the top has long since been discarded. Along with our great Brazilian hope, Klevin, we are the only barefoot ones on our team. Stephan is our version of a gangbanger with his recently shaved-head-except-for-monstrous-sideburns look intimidating the opposition almost as much as his bare bear chest and cleats. Gabriel and Bond also are wearing scrubs and tennis shoes. Our opposition is lean and mean wearing only shirts and the occasional t-shirt along with bare feet and/or flip flops of various sorts.

We score first, a beautiful pass from Klevin after some footwork only a Brazilian could imagine setting up Stephan for a nifty tap in. Second blood is a breakdown in passing on my part setting up an easily intercepted ball across the middle and an easy angle shot off the bricks. From there on out it's back-and-forth with the Chadians controlling the ball the majority of the time before losing it through too much dribbling and not enough passing. We on the other hand make the most of our few opportunities and are soon up 3 to 1.

A loud thunder from the East makes me look up to see angry clouds forming quickly casting a slight shadow over the millet jungle that Bere has become and sending a cool breeze across our sweaty bodies. A perfect rainbow encircles the encroaching storm and as brilliant footwork and sometimes stellar passes continue beneath the now menacing sky, small pellets of water began to drop into the dry dust of the road making up the Western part of our playing field.

I quickly run over and put my Bible and songbook into the open doors of the church just to the Southeast, then grab my shoes and barely get them in before the downpour starts. We have not yet begun to play.

The game goes on.


We are drenched within minutes and passes start to get sloppy and slow down as the earth turns boggy. The rainbow has disappeared but there is still clear sky to the West where the sun is almost changing color into sunset. The rain is coming down almost parallel to the ground drilling into our welcoming flesh from the East.

The western part of the field (formerly the road) is now almost unplayable as any pass hazarding into its slimy clutches is instantly stopped in a puddle of water and muddy sand. The Chadians with flip flops are starting to slip and slide dangerously while the barefooted ones continue with no loss of traction. A huge grin splays across my face as Bond looks on from the eaves of the church having retreated there with the first of the downpour.



I haven't had this much fun in a long time.

Eventually, the Chadians say they are done. Down now 5 to 1 I don't blame them. They rub their tummies and give mournful looks as they say they haven't eaten since the morning...no strength. I mock them comparing our sagging bodies to their chiseled frames but they just laugh and insist. We finally agree to meet again sunday, slap hands all around and I head back over to the church as the torrent continues.

The noise inside the tin-roofed church is deafening. The only people who've made it for Friday evening prayer meeting are Lazare and a few kids who come around me as I sit in front of Lazare and say we should sing or something.

Shouting out loudly as we belt out songs in Nangjere I can tell that the kids are loving it, especially one-armed-boy. Finally after a few rounds of "Ka Ama Kouma Kwani Teri" and "Kela ka dane ma ei kera...dul kang ddi, Jesus, Jesus-Christi". I tell them the story of David and Goliath using Lazare to translate from French into Nangjere.

I end with teaching them "Only a Boy Named David" in Nangjere (Kware kusi ne David) by holding the songbook up to the last rays of light coming in the slit that serves as a window on the church. Then, one of the boys prays, Lazare locks up and I walk back slowly home through the mud and the mist.

Fracture update

I feel like an idiot. What was I thinking! Of course, the wound would get infected. I was too optimistic when I wrote that the wound looked great three days later and maybe a miracle would happen. The fracture got infected the next day. I tried to clean it out again and cover the bone with some muscle. That got infected. I tried to cast it in various ways, the bone didn't stay in place and kept pushing out through the wound, seeking the outside air like a drowning man. Nothing seemed to work. I thought maybe we'd have to amputate. Finally, we just left the whole thing open and let diluted bleach dressings do their trick. Slowly the wound cleaned up and granulation tissue formed. We kept asking if anyone could send us an external fixator, no one could find one. Finally, the wound was clean but the fracture was still only partially stabilized and the bone was still exposed.

Luckily, I am temporarily not alone. Dr. Bond and Dr. Jason Shives are with me in Bere. We talk about the open tibia fracture and what to do. Finally, we come up with a brilliant plan straight out of the MacGyver archives. Abel and Simeon prepare the patient while I head over to the house. I find a long piece of two and a half inch pipe that seems pretty strong. I grab a saw from the tool box and we cut two pieces off, roughly the length of a certain man's tibia.

Meanwhile, Jason and Abel have brought out the small generator and the cast saw and have been spewing plaster powder all over the ward in an attempt to take of the full leg cast.

We rejoin Bond in the OR where we try out Bond's regional spinal anesthetic technique by having our patient lie on his left side, the side of the fracture, while we put in the spinal lidocaine and let him sit on that side so only his left leg will be numb. When it's settled in, we turn him back onto his back and I hand the leg off to Gabriel to hold while Abel preps the leg with Betadine.

Jason and I scrub while Bond directs and advises. I first pull out some pieces of infected sequestrum and chip off some of the bone sticking too far out with a rongeur. We twist the leg into a more anatomical position and Gabriel holds it steady. I follow Bond's suggestion and make four tiny incisions, two above the wound and two below. Then I take a regular, unsterile cordless drill with my right hand and insert a sterile, threaded Steinman pin into the drill with my still clean left hand. I insert the still sterile end of the pin in one of the incisions and push it against the bone. I then squeeze the trigger and thread the pin in and through the tibia till it pokes the skin on the other side. Jason makes a small cut with the scalpel over the pin and I drill it the rest of the way through till it's sticking out the same amount on both sides. I repeat the processes for the remaining three pins.

Then, while Jason holds the PVC pipe steady against the pins, I mark where they should go through and then drill holes through the pipe. I then force the pipe over the pins till the pins hit the other side of the pipe. I then try to estimate where I should drill the second holes and mark the pipe again. I drill again and this time get each pin to go through it's second hole with the help of a little hammering. I repeat the process on the other side.

Gabriel lets go his stabilizing hold on the leg and we confirm that the fracture is now stabilized. Jason wraps gauze with Betadine around the pins while I dress the fracture wound with diluted bleach and we take him back out to the ward. It's once again in God's hands.

Eclampsia

Boom! Boom! Boom! The pounding on our cheap, metal front door jolts me out of a deep sleep. I glance quickly at my watch. 4:13am.

"James! Are you awake?!" I hear Dr. Bond's son, Gabriel, calling me, out of breath.

I pull on some shorts and fumble my way through the darkness out the bedroom door, past the bookshelf on the left, through the curtains covering the exit, out the living room door and onto the porch.

"What's up?" I mumble, trying to clear the cobwebs.

"Doudjé's wife just came in with seizures and we need some Magnesium from the pharmacy." I notice the shadowy form of Dr. Bond behind Gabriel in the moonless night.

"I'm coming," I reply and head back in to pull on some scrubs, grab my keys and a head lamp and back outside where I hear the voices of Gabriel and Bond fading around the corner of the container across the yard.

I push through the wet leaves of the bushes forming a hedge between our house and Lazare's little hut just outside the main house and stumble over his wire cooking "gounan". I make my way over to the fence, unlock the gate and head towards the dim light coming from the ER. I hear screams and wails and the sounds of a struggle coming from within that grow louder as I approach at a fast walk.

I push aside the bright green and yellow flowered curtain blocking the entrance to the ER and my eyes are instantly drawn to a group of 8-10 people surrounding on of the beds. Cries and moans are coming from inside the circle of bodies, a bottle of IV fluids hangs from a wooden IV pole and a tube descends into the crowd. Arms and legs shoot out here and there and are instantly seized by several hands and pushed back inside.

I push the people aside and get my first look. It is certainly Doudjés wife (and Koumakoy and Frederic's sister) but she is barely recognizable. I nod to Frederic and his mom who are part of the crowd.

"Lapia ei?"

"Lapie, Jamsuh," responds the mom.

"Ca va" is the reply from Frederic.


Doudjé hasn't arrived yet but his wife is swollen up like a balloon with edema everywhere and is alternately thrashing and lying moaning on the exam table. Just then she makes a violent effort and pulls out her IV causing blood to splatter all over the bed and floor as a nursing student rushes to stop the bleeding with a cotton ball.

She seems to vaguely recognize me as she looks at me, or more like through me, and mumbles "Jamsuh, jamsuh, jamsuh" over and over.

Augustin, the night nurse, informs me that she came in convulsing and with a blood pressure of 140/90. No question about it, it's eclampsia. I had just done an ultrasound on her a few weeks ago and discovered she had twins. There is definitely no time to lose.

"I found both fetal heartbeats" reassures Dr. Bond as I start to bark out orders.

"Augustin, call Simeon and Abel! Gabriel, you and the nursing student go get the gurney and take her to the OR! David, go call Sarah, tell her we need her immediately! Bond, I'll go get the Magnesium from the pharmacy, here's the keys to the OR."

We all split as the family continues to hold her down.

I pull out 6 ampoules of Magnesium and meet the gurney in the OR just in time to see the next seizure.

As she rolls through the door her body stiffens, her eyes roll back in her head and then she starts shaking violently with her teeth clenched. She starts bleeding again from the old IV site. Then, after a few seconds, the seizure stops and she falls unconscious.

"Now's our chance since she's unconscious. Let's get her clothes off, get her in the OR, start an IV and get her ready for surgery."

Sarah and Abel have both arrived now so an IV, a foley catheter and antibiotics are quickly done and she is transferred to the OR table.

I sidle up to Bond and ask him quietly if he minds if I do the surgery. Since I've been following her during her pregnancy and it's a friend of mine and I myself was a twin born by c-section, I request the privilege of doing the life-saving surgery on her. Bond is generous and concedes me the case. We scrub together.

By this time Simeon has arrived and I tell him to prepare one millilter of Ketamine. Doudjé's wife is still somnolent. Bond and I scrub and don gowns and gloves. Abel has prepared the surgical field and we drape the lower abdomen.

We pause for prayer and then I take up the scalpel. Two slices later and I see the uterus. Bond stretches the peritoneal opening wider as I insert the bladder retractor. I make a small transverse incision and poke through with a hemostat. I then insert the index finger of both hands and pull out and up opening the uterine wound. There is the upper back and neck of a tiny baby. I insert my hand down into the uterus till I find the head and lift it up and into the uterine wound. Bond pushes the top of the uterus and the baby slides into the world with a gasp and a scream.

Here's where things go temporarily wrong. Bond has grabbed the clamps for the ombilical cord and tells me to go for the next baby. I see the bulging amniotic sac and try to break it with my fingers with no success. Then, for some strange reason, I do something I never do, I reach again for the scalpel and as I bring it up to the surgical wound, Bond reaches down to grap some scissors to cut the cord and the scalpel collides with his finger. I'm horrified but Bond signals me to keep going as he finishes cutting the cord and handing off the baby. I put the scalpel down, burst the sac with another instrument and deliver the second baby who also comes out with great tone and grimacing and crying. Bond calls for another glove and we suture closed the uterus, the fascia and the skin with no further complications.


By the end of the surgery, her blood pressure has already normalized. Bond goes off to wash out his wound. We call in the lab to do an HIV test which is negative and Bond starts on post-exposure prophylaxis. By the next day, the edemas have started to go down, the twins are breastfeeding and Doudjé is the happiest, proudest man in town giving praise to God for his blessings.

Jugular

The dark blood suddenly gushes out of the neck wound like a hot spring bubbling up from the ground. I had hardly slept the night before anticipating the complexities of operating on this man's neck. He had a mass bulging out under his right mandible which looked like a bunch of large grapes with bearded skin stretched tightly over them. The mass was smooth and lumpy and about the size of a large grapefruit.


He'd been to many other hospitals who'd told him there's nothing that can be done.

The surgery started off bad with a difficult intubation. I put the laryngoscope into his mouth only to find myself faced with a looming open esophagus and no vocal cords in sight. I pulled up with all my strength, tried repositioning the head, had someone try and push his voice box down, all to no avail. Finally, I blindly inserted the tube above where I could see the esophagus and pulled out the guide wire. As my cousin Jenny filled up the cuff with air and my cousin John attached the ambu-bag I looked for the telltale signs of vapor on the tube. Then, Jenny verified that there were breath sounds.

Unfortunately, at this time his oxygen saturation started to fall as his pulse jumped up to 172 beats per minute. I listened to his lungs and they were clamped down like a severe asthma attack. I quickly asked Simeon to give him some IV steroids and Chelsey to run to the pharmacy for some bronchodilators. It was about this time he started to grunt and clench his jaw and hands while straining like he was going to burst through some invisible barrier like the Incredible Hulk transforming himself into the Green Monster. I shouted at Simeon who quickly gave him more Diazepam on top of the Ketamine.

Finally, after about 30 minutes, we had him sedated enough, airways open enough and heart rate down enough to start the hard part of the case.

I had dissected the skin off the mass and was working my way around the lateral side underneath the tumor when I got into the jugular vein.

As the blood gurgles into the wound I quickly put my finger over it with a gauze pad between me and the large vein carrying most of the blood from the head. I pause for a moment. What do I do now? I'm definitely in uncharted territory. I calmly ask Johnny to put on some sterile gloves and hold pressure on the wound. As he holds the man's lifeblood from escaping under his finger I continue to methodically and painstakingly dissect the rest of the mass off the mandible, the voice box, the trachea and the carotid artery and other deep muscular neck structures. An hour later, the mass is out.

Johnny's fingers are paralyzed in position and totally numb.

I ask him to gently take off pressure. Blood surges into the surgical field. He quickly presses back down.


It's then I remember my old friend, Erling Oksenholt pulling me into his office in Oregon in May and showing me a short video. In the video, a gloved hand is poised over a pig's groin. A sharp scalpel suddenly lunges down slicing through the porker's femoral artery. As blood spews from the wound the gloved hand quickly piles on gauze and holds down fiercely. Then, just as quickly, the gauze is withdrawn and a white powder is poured into the wound and the gauze and pressure is quickly reapplied. A note on the bottom of the screen says "five minutes later" as the scene shifts slightly. The gloved hand releases pressure and gently pulls up the gauze. There is no bleeding.

I also remember that Erling gave me some packets of this miracle powder (Celox) that I had left with my cousin John to bring with him when he came three days ago.

I yell to Brian to run over and check the bags that he and John brought and see if he couldn't find any. Meanwhile, John and I continue to wait and hold pressure. Brian comes back at first to say he didn't find any. Jenny and Chelsey go to help him look. Finally, Brian comes back with a small, white plastic bag with Celox in big red letters. Brian opens the sack and I say, "ready" and lift off the gauze as he quickly pours in the powder and I reapply pressure. Five minutes later I lift off the guaze and see white powder in the wound but no bleeding.

Johnny has been reading the instructions and says that now I should irrigate the powder out of the wound which I do. At the end I am trying to wipe out the last fragments and the blood gushes forth again. We repeat the process and the second time I'm a little gentler.

It holds and I close the muscles and skin, wrap his head and neck in a loose ace wrap and then send him off to ICU attached to a ventilator (whoops, dreaming again). Instead, I take out his endotracheal tube and send him out to the hot, sticky wards where his family will fan him with homemade woven fans and we'll hope he wakes up and his throat doesn't swell up too much so that he can't breathe.

Two days later he's complaining of a sore throat but sitting up, breathing normally and taking liquids. His neck has virtually no swelling at all.