first stop

Saturday morning rounds are rough. Its not just because it is Saturday and I don't want to be working. Or that I know I am on call for two more days. Its more than that. Its discouraging. It can be frustrating. Its sad. Its a lot of patients.

First stop, first ICU patient. He is a tiny baby with a tube down his nose. An oxygen monitor is hooked up to a sensor on his hand, but it is adult-sized and isn't picking up a signal.

The resident tells me that the patient is three week old baby transferred from another hospital with a tracheoesophageal fistula. As he continues, the story doesn't make sense. "Yes, he has been breast-feeding."  "No, he hasn't eaten anything since birth."  "He is having stools." "We could get an x-ray." "They transferred him here for pyloric stenosis."  "We did get an x-ray, it showed the esophagus is just a pouch."

Me: "Ok, so he has been in our hospital for three days with a tracheoesophageal fistula and is unable to eat. What is the plan?! Babies can't live very long without eating."

Resident:  "Well, we talked about it with [a different attending] yesterday, and he was going to read and think about it and decide what to do."

[I fiddle with the oxygen monitor, still can't get a reading. So, I walk down the hall to the surgical office and find a pediatric oxygen monitor. I hook it up to the machine. Still can't get it to work.]

Me: "What are we going to do about his nutrition?"

Resident: "If we put in a feeding tube in his stomach milk would reflux back into his lungs."

Me: "So, what is your plan?"

Residents:   [No real answer, I conclude that the residents don't have a plan.]

The story doesn't add up.The baby has been in the hospital for three days. I suspect that a plan may have been made, but perhaps hasn't been communicated or the residents didn't understand it.

It is a very difficult problem. But there are some very simple conclusions we can come to. Mainly, if you do nothing for a newborn baby that can't eat, he will eventually die of starvation. Yes, sometimes there is nothing we can do, but we have to consider all the options before doing nothing and allowing the baby to die.

We move on to the next bed because we have already spent 20 minutes on that discussion and its not going anywhere. I need to think about it. And we have 50 more patients to see.

After rounds and an urgent C-section, I took a look a the baby's x-ray.

Contrast filling the first part of his esophagus, which then stops. Lots of air in his stomach and intestines. Yep, looks like a tracheoesophageal fistula. 

Type C tracheoesophageal fistula. The first part of the  esophagus ends in a blind pouch. The second part of the esophagus attaches to the windpipe then goes to the stomach. 

I called the other attending and he was able to explain the story to me. He was planning to take the baby to the operating room yesterday and at least put a feeding tube into his stomach/small intestine. But, the baby became very sick yesterday afternoon and he didn't look like he would survive a procedure or even live through the night.

We decided that if the baby is looking better today, it would be reasonable for me to put in a feeding tube. After taking care of a few more emergencies, I went back to the ICU to check on the baby and decide if he was well enough for a procedure. His bed was empty.

I don't have a nice wrap-up for this one. The baby died, likely from fluid that went into his lungs from the connection to his esophagus. In America, a pediatric surgeon would have taken this baby to the operating room, likely within the first 24 hours of birth, to re-connect the esophagus. Most of the time, babies recover well and go on to live normal lives. This baby didn't make it to us right away. Perhaps we could have done the operation if the baby had come in earlier. There isn't a pediatric surgeon available in this country to send patients to for emergency operations. We are the pediatric surgeons. We do a lot of pediatric surgery but it is still daunting to do major operations on newborn babies here.

In happier news, we have two newborn babies with congenital anal malformations that are doing well after we gave them colostomies this week.

Also, did you know that healthy newborns can survive for a week without food or water? Apparently we know that out from the 1985 Mexico earthquake when several "miracle babies" were buried alive for a week and survived! (Miracle Babies Survive Quake- Chicago Tribune, 1985).

Hearts

In honor of Valentine's Day, I played heart surgeon.  When I was on call last night a young man came in with abdominal pain. My intern evaluated him in the ER, noted his abdominal tenderness and some difficulty breathing. Then he did an ultrasound and reported to me, "His abdomen is tender and. I think he has a pericardial effusion ["fluid around the heart"]...but I can't be sure."  I'm proud of him for doing the ultrasound and looking at the heart- its not something a surgeon always looks at when consulted for abdominal pain!

I took the ultrasound to the ER to evaluate the patient. He couldn't breathe well while lying down, his liver was enlarged and tender...then on ultrasound I saw a HUGE pericardial effusion. Biggest I've ever seen  It was like the heart was a tiny, quivering ball surrounded with fluid.

A picture of a small pericardial effusion from the internet. Probably measuring about a centimeter.  Now imagine the fluid space to be wider than the heart...that's what I saw

I measured the distance from the heart muscle to the sac: over 9 cm! Usually pericardial effusions are graded as small (less than 1cm), moderate (1-2 cm), and large (>2cm). This effusion was off the charts. We also got a chest x-ray:

a normal chest x-ray (thanks Wikipedia)

His chest x-ray...his heart shadow took up half of his chest!

Amazingly, his heart rate was only a little bit fast and his blood pressure was normal. Obviously he had had the fluid for a very long time. Months probably (likely from tuberculosis). His liver had been hurting for three weeks because of the pressure build-up. After seeing an effusion that big, I wanted to rush him straight to the operating room to get the fluid off.   But it was the middle of the night, he was stable, and the effusion had been there a long time. So, we took him this morning. I opened the heart sac, put a drain in it, and got over 1 1/2 liters of fluid out! It was a pretty satisfying operation and I got to literally touch someone's heart on Valentine's Day. :)

Yesterday, we got a package from my mom with some amazing Valentine's treats (just in time!). She included some heart-shaped sprinkles. I happened to have a box of cake mix and some frosting and was inspired to make a last-minute Valentine's cake to bring for the OR staff.

The power went out, so I ended up baking the cake mostly in the dark ...but it still turned out.

When I gave it to the OR supervisor, he was a confused when I said "Happy Valentine's Day." It took a few minutes to explain why I brought a cake because I didn't know the French word for Valentine's Day and its not really celebrated holiday around here. Most of the OR staff didn't even know it was Valentine's Day, but now they do and they were very happy to eat some cake! :)

I also made some Valentine cookies last weekend...

The cookie press was left here by a missionary several decades ago. Still works fine!

Usually I would make Spritz  wreaths for Christmas....but the Christmas red hots came in January this year. So I made the Valentine version of Spritz...What do you think? Perhaps a new Valentine's tradition has been started.

Happy Valentine's Day!!!

rough

Today was kind of a rough day. This weekend I'm on call which means I work from Friday evening to Monday morning. At 7:30am today, I walked into the surgical ICU to start teaching rounds with the residents. Immediately, I saw the charge nurse doing chest compressions (CPR) on a little boy. It was the little boy I had admitted from clinic yesterday afternoon. He was severely malnourished. We had operated several weeks ago and fixed his typhoid perforation. He was discharged from the hospital last week and had been staying close by in the ambulatory care unit behind the hospital. When he came into clinic he could barely open his eyes. His surgical incision had come apart. I wish I had a picture of the boy to show you. But perhaps you would rather not see it. Just picture one of the starving children you see on the news.

His dad said that he hadn't eaten since he left the hospital (one week ago). His father had been faithfully dissolving the pills in water so he could given them through a syringe and had been giving the child water as well. They had been told to come back in a week after discharge. He did. It was too late. I guess he didn't know to bring the child back as soon as he stopped eating. He obviously cared and was trying to help his son.

But now the boy was too weak to breathe.  We helped him breathe for a while...but we don't have any ventilators here so we were unable to keep breathing for him. There was nothing more we could do.

After taking a few slow, agonal breaths he stopped breathing. Then, his heart stopped beating. I said, "I'm sorry, he is dead." The charge nurse translated for the father who was standing by his bedside. The father let out soft, heart-wrenching, sorrowful cries as he covered his son and wrapped him in a mat to be buried.

It is only the second time I've seen a man cry here. Not a good start to the day. But, unfortunately, it was not the end of the sadness.

its on

Typhoid season seems to be in full swing again now that rainy season has come to an end. My first patient of my first call weekend after vacation was a nine-year-old boy with high fevers and severe abdominal pain. He was very sick. In fact, he had been very sick for over a week before finally coming to the hospital. His story was typical for a typhoid perforation

We gave antibiotics and fluids and got him stabilized before taking him to the operating room. As soon as I opened his belly, pus and stool poured out. Often that release of abdominal pressure helps with breathing. But this time, he stopped breathing and his heart stopped beating. A surgeon's worst nightmare...

We fought for his life. We breathed for him. We gave medicine. We did chest compressions. He pulse came back. A few seconds later we found the hole in his intestine...typhoid perforation. But before we could fix it, his heart stopped again. For many agonizing minutes we fought to revive him. We couldn't. He was gone. We closed his abdomen, covered him with a sheet, and went to find his father.

After that, I just wanted to go home. To process. Looking back, there was nothing more we could have done.  I told myself we had done everything we could. That didn't make covering my patient with a white sheet any easier. It didn't make telling the father easier. It certainly didn't make preparing to operate on my next patient, another little girl with exactly the same diagnosis, any easier. She was so sick that the anesthesiologist insisted that I go tell her family again that she was very sick and could die. I did.

As I made the incision, I thought, "Dear God, please don't let this little girl die too. Please don't let her die."

Thankfully, she didn't die. She made it through.  So far, so have my other six patients with typhoid perforations this week. Many of them just barely. None of them without a fight. It has been emotionally exhausting, hoping with each incision that the child will live through the operation. Knowing that tomorrow morning when I go to the hospital, there may be an empty bed from a child who didn't make it through the night.

One hundred and twenty years ago, the typhoid fever mortality rate in Chicago averaged about 65 per 100,000 people per year. Now it is perhaps 5 per 1,000,000.  I hope someday we'll have the same progress here.

when it won't stop

I used to be able to count on two hands the number of times I had taken patients to the operating room for abdominal exploration without having a pretty clear pre-operative diagnosis confirmed by CT scan. Now I have lost count of the number of abdominal explorations I have done here without knowing what I would find. I'm frequently surprised. Yes, it makes life interesting...but I miss being able to anticipate and plan before finding myself in the operating room faced with trouble. Sometimes big trouble. Which brings us to Saturday afternoon, operation number four...exploratory laparotomy (abdominal exploration).

this was my weekend...plus another couple C-sections and several non-operative consults

He said he had been having abdominal pain for awhile- since Ramadan (a couple of months). He had well-healed scarification (traditional medicine) markings visible on his upper abdomen and had been treated with various medications at various dispensaries and wasn't getting better. Four days before he came to our clinic he developed severe pain. His family told him to just keep taking medicine, but he insisted on coming to the hospital.  I saw him in clinic and he was clearly very ill with peritonitis (severe abdominal tenderness). 

His story was pretty typical for a perforated stomach ulcer...but something seemed a little off. He didn't have fevers and his stomach wasn't quite as rigid/distended as most perforated ulcers I've seen here. But, he had severe abdominal pain and I could see free abdominal fluid on the ultrasound.  So, after resuscitation, I took him to the operating room for exploration.I made my incision and found blood. Several cups of old mixed with new blood. That was a surprise. Then I felt the mass. A large mass coming from the whole right side of his liver. Oh no. I looked at the liver and saw nodules and scarring: cirrhosis. Bad, very bad. I looked back at the mass...it had burst open and was bleeding, bleeding, bleeding. My heart sank. Defeat. I knew it was a losing battle. I couldn't take out the mass. It was too big. His liver was too diseased. Trying to suture the tumor to stop the bleeding would be impossible, like trying to sew oatmeal. It was mush. So I packed the tumor to slow down the bleeding and closed. He survived a few more hours in the ICU, just enough time to say goodbye to his family. 

We bring our years to an end like a sigh. The years of our life are seventy, or even by reason of strength eighty; yet their span is but toil and trouble; they are soon gone and we fly away. So teach us to number our days that we may get a heart of wisdom.

Psalm 90:9b, 10

I welcomed eleven new babies into the world this weekend. Another young man died from severe burns. The extremes of joy and sorrow can be exhausting and heart-breaking. But, there is something about the seeing the daily realities of birth and death that reminds me that life is short and this world is not my home. And that's a ok with me...I think 70 years is plenty of time to spend here.

He will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning, nor crying, nor pain anymore, for the former things have passed away.

Friday Clinic

Have I told you that I do NOT like Friday clinic? We alternate Friday clinics so that the surgeon that is taking weekend call also does clinic on Friday. Well, Friday clinic overwhelms me. First of all, all of the orthopedic patients are told to come to clinic on Friday (remember, I am a general surgeon...bones are not my thing). In addition, most of the inguinal hernia patients are told to come to clinic on Friday and there always seem to be plenty of emergencies. It's can be a lot for one person to manage.

This Friday's clinic was no exception. I left conference early to get started. I spent the first 20 minutes trying to decipher charts to figure out who needed follow-up x-rays so I could send them all to radiology first thing. After sending about ten people to radiology, I started with a couple of inguinal hernia patients.

The first patient had had a successful left inguinal hernia repair here, then last year he went to have his right inguinal hernia fixed at another hospital. Only, he told me, they just "made an incision, looked, and closed without fixing it." Huh? I took a look. Yep, there was a nice incision and an obvious, reducible hernia. I don't know what they did at the other hospital. As usual, we don't have any records. But, he has a hernia and I know how to fix that.

After that, I continued on with the usual smattering of neck masses, mastitis,  non-specific abdominal pain, and spina bifida. After seeing about 10 non-orthopedic cases, I finally started in on the bones. X-rays, X-rays, X-rays. Keep the cast, take it off...not too bad. And then there was this: 

I wish..Proceed with caution: stop here if you don't want to see some slightly disturbing medical stuff.

A bent leg, an x-ray with a metal rod and a loose screw...its been three years since the operation and he is here for follow-up. I guess I should take the dressing off to see what's underneath.

As I unwrapped, suddenly some white things fell out of his ankle and onto the floor. White, wriggling things. Worms. Gross. Gross. Gross. Yep, his wound was full of worms...on the bright side it was otherwise pretty clean because they had been eating all the dead tissue. Once, while I was in training,  I put "sterile" maggots on a wound  to help with healing. Its not always a bad thing.

Fully unwrapped...exposed bone, exposed metal, and a pile of worms. Just when I think, "that's the worst... I've ever seen" I'm wrong again. He needs an amputation, but he refused to have the leg amputated.

the ocean

"For the needy shall not always be forgotten,

and the hope of the poor shall not perish forever." 

Psalm 9:18

Perspective.

Yesterday morning I did teaching rounds with the residents. We saw every surgical patient in the hospital. There were 46. It took almost three hours to see them all. Seven patients with typhoid perforations. Two with peritonitis scheduled for exploratory laparotomy after rounds. Seven patients with neglected infections that will lose or have lost an arm or leg.The little boy who lost his arm because he came to the hospital several weeks too late. The girl with epilepsy who burned both of her hands and needs multiple finger amputations, but refuses as her fingers become more black and shriveled every day.

Healthy, straightforward patients seem few and far between- there is the man who can pee now because we took out his prostate, the child with the hernia repair, the thyroid removal. Despite all of the suffering, almost every patient responds with a huge smile when I greet them. Even the kids smile with just a little coaxing and a piece of candy. They are amazing, resilient people. I'm not so strong. By the end of rounds I just want to go home and forget about the suffering somehow.

I find myself thinking...Why does being a doctor here seem so hard? Why does it feel like there is a never-ending ocean of patients needing help?  

Because there is . 

It feels hard because it is hard. 

Turns out, its a big adjustment to move from practicing medicine in a country ranked number three on the UN Human Development Index to the country on the bottom of the list.  Last week, I read an article that was recently published in the Lancet, Malaria and Malnutrition: Niger's Twin Crises. Somehow, it helps me mentally to have a bigger perspective of the health care situation here.

"According to the UN Human Development Index, there is no country worse off than Niger. The landlocked West African nation, which is mostly desert, lingers at the bottom of the index: 186th of 186. Its government, heavily dependent on foreign donations, spends a paltry US$10 per person on health care every year. Vast swathes of the country are effectively wild: without schools, roads, or security. There are fewer than two health-care workers per 10 000 population (23 is considered the minimum number for provision of essential care) and more than 2 million people live in chronic food insecurity, of a population of 16 million." 

Life is hard. But there is hope. So I didn't go home after rounds and hide in my house. I did what little I could. I stayed and repaired a typhoid perforation and a stomach ulcer. Yes, its only a drop in the ocean, but I think I'm ok with that. I'm not here to save the world.

Friday night sunset

comic relief

It was a routine Saturday afternoon laparotomy for probable typhoid perforation. He had the typical story... a week of fevers, a few days of severe abdominal pain, diffuse peritonitis, and abdominal distension.  So, we opened him up and found a liter or so of foul-smelling pus and mucus-like stuff in his abdomen and a 1/2 inch hole in his small intestine.  We got to work cleaning the pus and junk out of his belly. Here is where it got weird.  As I was blindly reaching up into the dark recess behind his spleen to scoop out the pus, I felt a tube. What?! I was confused. Did this guy have an old drain tube floating around in his belly? He said he had never had an operation before. Then, I saw the tube, grabbed it with my glove, and as I brought it into the light I saw it for what it truly was. A long, live, squiggly worm. GROSS!!! I gasped, jumped back a bit and quickly dropped it on the drapes. 

Gross, right?!

Of course, the rest of the OR staff found my reaction to be HILARIOUS.  The chuckled and laughed and teased me saying stuff like,  "You're a doctor, why are you afraid?"   To which I replied,  "I'm not afraid...but that was unexpected, gross, and, well, downright, disgusting."  I mean, he had a big worm free-floating around in his belly. I wasn't expecting it to be there.  It was the first time I've pulled a worm out of a human's belly. I'm allowed to be a little surprised and grossed out.

the worm- Ascaris

  
Just goes to show...there are no boring days at this hospital!  After a few rough days, everyone needed a good laugh and the story of the worm that escaped out of the hole in this man's intestine and then hid under the spleen until it could give the white lady doctor a fright...perhaps it was just what God intended to give us a bit of comic relief! 

 

A few fun facts about the Ascaris worm from Wikipedia:

• Ascaris lumbricoides is the largest and most common parasitic worm in humans
• One study indicated that the prevalence of ascariasis in the United States at about 4 million (but I've never seen it in the US...not sure that it is that common nowadays)
• Perhaps as many as one quarter of the world's population are infected, with a prevalence of 45% in Latin America and 95% in parts of Africa.

 Check out more from the National History Museum website. 

2 am in the OR

Last week was...crazy. busy. weird. wild.  That describes every week here, but this week seemed busier  with one surgeon still away and a full weekend of call.  In seven days, I did 25 major cases and 22 (!) of them were emergencies including 12 C-sections, 4 typhoid perforations, gangrenous cholecystitis, perforated duodenal ulcer, and a perforated marginal ulcer. Even with a national holiday on Wednesday and no elective cases, I ended up spending the entire day operating.

And, lest you think, 12 C-sections...those are nice, easy, happy, short cases. Ya, sometimes. But here, more often than not, they are difficult, sad, and, occasionally, long cases. Let me illustrate with a series I'll call:

"True (Disturbing) Stories from 2am in the OR" 

WARNING: Graphic medical descriptions. 

2am Friday- Emergency C-section for a baby with hydrocephalus (enlarged head from a congenital abnormality). The head was too big for the mom to deliver. We got the baby out,  barely alive and obviously deformed with a very large, misshapen head. Per standard procedure, I handed the baby to the midwife. She took one look, gasped, shrieked, and quickly tried to hand him back to me. I'm not sure why...Did she want me to put him back?! Sadly, there is not much we can do for children with hydrocephalus here because we don't have the resources/surgical equipment and most of the patients cannot afford to travel to the capital city for treatment. Sad.

2 am Saturday- I'm elbow deep in one of the most horrendous "C-sections" ever. Its not really a C-section. She needed a C-section several days ago...now she needs a miracle. The teenage mother had been in labor for days. I was called to do a C-section because she hadn't delivered yet. As soon as I opened the abdomen foul-smelling, purulent, bloody fluid gushed out. At first I couldn't find the uterus because it was all the way up by her spleen and had shrunk to the size of a grapefruit. There was no baby in the uterus...just a gaping hole. I turned my attention back to the pelvis...her bladder was stretched up to her belly button and part of it was dead. Behind the bladder I found the tiny, blue hand of a decomposing infant who had clearly died several days prior. Extracting that baby was the most gruesome, disturbing thing I have done. Ever. I can't imagine being that mother. Why didn't she come to the hospital sooner? Maybe it took her several days to travel. Or she didn't understand. Or they didn't have money. It was probably a combination of factors...all of which are much too common here. Now, she can never have children of her own and will need major reconstructive surgery...both huge challenges for her to overcome in this society. Unfortunately, this is an all too common scenario here.

2 am Sunday- As I was falling asleep at midnight after returning home from a C-section, I heard an ambulance and thought “there comes another C-section…but I sure hope not.”  Sure enough, just after I had fallen into a deep sleep I was awakened by the phone call… “C-section, rupture utérine" (at least I could understand that much of the midwife's French). So I trudged back in. Opened the abdomen. First thing: blood. Second thing: a little hand. An infant, floating free in the abdomen. Not alive. Then, placenta, also free floating…and a ruptured uterus. I closed it as best as I could and did a tubal ligation. 3 am. Time to go home...after fixing this:

2am orthopedics
 

that doesn't look right

"There is a fracture" "Where?" "In the ER"  (if that doesn't make you laugh...check out the link for some doctor humor)