skull and neck bones

Its been awhile since I've shared any medical stories...but, never fear, the steady stream of interesting, difficult, and heart-wrenching cases has not stopped (or even slowed down). Here are a few cases from the last month. Check this out:

normal neck x-ray

abnormal

I think almost anyone can see in this x-ray that something is horribly wrong. His upper neck bones are completely separated from the lower ones. When we saw the x-ray, we could not believe he was still alive- talking and breathing, but paralyzed. Unfortunately, we couldn't do much to help other than to make him comfortable.


In happier news, a couple of months ago we had a young man come in with a skull fracture. The story was told like this: he was in a tree and was frightened by seeing three demons, fell out of the tree, and hit his head on a rock.

his x-ray

depressed skull fracture

lateral view

putting the bone back in place after pulling it off the brain

His skull was smashed in on the right side, and he couldn’t move his left arm but everything else was normal. My partner, Dr S, took him to the OR to elevate the fracture and release the pressure on his brain so he could hopefully regain function in his arm. After the operation, the man still couldn’t move his left arm. I was pretty disappointed that the operation hadn’t helped him. We sent him to rehab therapy (another story about that on my our therapist's blog here). Last week when I saw him in clinic I could hardly believe my eyes. I asked him if he could move his left arm. He didn’t just move it, he waved it around- completely normal function!

Brace yourself (or stop reading here). This next story is one of the more disturbing things I have witnessed here. Last week a woman came in one-month after a C-section. We knew something was wrong when she walked into clinic and all the other patients covered their mouths and noses because of the foul smell. Our most experienced obstetrician saw the patient and found a hard object stuck in her birth canal…Then she called me over the see the patient since I was on call for the weekend and would be the one operating the next day. Even though we do several C-sections every day here, she was still able to recall the details of this particular C-section because it was so distubing. The midwife had called to tell her that the baby’s brain was coming out, but the rest of the baby wouldn’t deliver. So, a C-section was done to remove the already dead, mutilated baby. The woman was discharged a few days later doing well, but then started having foul-smelling discharge. Finally, one month later, she came back to be seen. When we took the woman to the OR, and this is what we found:

Yes, that is the top of the baby’s skull that was stuck in the birth canal. She had to cut out piece of it in order to remove it. One of the many examples of why we desperately need to educate and empower women here. 

sharing the load

For the next two weeks we have a head-and-neck surgeon visiting! I'm excited, because I don't even know where to start with patients like this:

It is such a relief and encouragement to have an expert come alongside and help out.

This is  the maternity record for one of the women I did a C-section for recently. Once again, I was shocked. In case you aren't familiar with the obstetric terminology, let me interpret:

Gravida (the number of times she has been pregnant): 15

Para (the number of times she has delivered): 14

Vivant (the number of children she has alive now): 4

D (number of her children who are deceased): 10

I did a C-section to remove her 15th child, a perfectly formed yet dead little baby boy. Most likely her uterus was too tired to push out another baby and she had started labor days before coming to the hospital. She told me that ten of her children died before they could walk. She didn't know why they died. They don't have a hospital near her village. Maternal and child mortality...not just a statistic but a personal tragedy for this woman and many more here in Niger.

made my day (its the small stuff)

I had a small moment of victory in clinic today amid a morning of mysterious and difficult cases. A young man came in with a week of pain in the right abdomen. No fever, no nausea, nothing else. Just pain. On exam he was tender in the exact right spot for appendicitis. McBurney's point. At this stage, many surgeons would feel comfortable going straight to the OR to operate for appendicitis (although in the States we would check the white blood cell count, the urine, and might still get a CT scan or ultrasound).

Well, I tried the "just operate" approach yesterday. First for a man with almost the same story and pain in the same place. But, when I operated I found not appendicitis but typhoid that was almost perforated. I had to make a second incision to fix his intestines. Not only did he get two incisions, but it was a bit frustrating and made the operation last longer.

Next, I operated on a little boy whom I thought had appendicitis, but his story and physical exam weren't as clear. I tried to ultrasound but couldn't see the appendix. Since I didn't want to end up making two incisions again, we just started with the bigger incision (its not that common here to have straightforward appendicitis, anyway). Turns out it was ruptured appendicitis.

So, with my patient today I was determined to try to find the appendix on ultrasound again. Third times the charm, right?! After just a few minutes with the probe on his belly, I almost couldn't believe my eyes. There it was!  So clearly! A thickened, inflamed appendix.  I could even see the hardened stool ball (fecalith) blocking the appendix and causing his appendicitis. Look!:

see the appendix?! It measured 1.2 cm in diameter.

I sent him over to the operating room to have his appendix removed. There was a lot more to be seen in clinic, but nothing a straightforward as the appendicitis. Here are a few pics:

For seven years this man has had a growing mass dangling off the first part of his arm. What is it? I do not know, but we will take it off and see. 

This man showed me these stones that had come out in his urine six years ago. (He saved them a long time!)

Unfortunately, he now has more stones. (those bright round things).

Mouth tumor...I'm so happy that we have a head and neck surgeon coming to visit us in just a few weeks!!!

large, fixed chest wall mass, there for two years and growing...should we try to take it off?

another one for the urologist...a narrowing of the urethra (stricture) so this man has to urinate from a tube in his bladder

"Suspicion du stenose du pylore." I read the referral paper then looked at the tiny two week old baby in front of me.  The mom says he's been vomiting for a week.

I ask "What has he been vomiting?" 

Which gets translated into, "He has been vomiting milk, right?" 

Mom says, "Yes."

I ask, "Does he vomit bile? Green vomit?"

Which gets translated into, "He vomits green stuff, right?"

Mom says, "Yes, its green."

Me, "Is it milk or is it green?"

Mom, "He vomits after I feed him."

And so it went...now this "run-around" may not seem like a big deal, but one of the most important things to know in vomiting babies is, "Is the vomit bilious (green) or not?"  Green vomit is often a big emergency. Milk, not an emergency. Despite multiple questioning attempts, I just couldn't get a clear answer but it seemed most likely he had projectile vomiting of milk.  

I decided to move on to physical exam. Of course, a two week old baby isn't going to tell you if it hurts. He just cried. His abdomen felt pretty normal, although I thought I could see his stomach contracting under his skin.

I  briefly recalled my three months of pediatric surgery training at Seattle Children's hospital. I knew the next step for this vomiting baby: ultrasound. In Seattle, I would just order the ultrasound and wait for a report from the pediatric radiologist. It came back with numbers, measurements, and an interpretation: pyloric stenosis- yes, no, or maybe. Those were the days.

But now, it was just me, the antiquated ultrasound machine, and the baby. I laid the baby on the exam table and grabbed the ultrasound probe.  I've never done an ultrasound for pyloric stenosis...but there wasn't anybody else to do it.  I started scanning and eventually I found something that I thought (hoped) looked like an enlarged pylorus.

I found something that looked kind of like this...fuzz and all

I measured it all the while thinking "Hope this is right....what I wouldn't give for a ultrasonographer right now." I admitted him to the hospital to prepare him for the operation and put him on the list for the first case Saturday morning. 

Saturday morning OR list

The next morning, as we put him on the OR table,  I felt the full weight of my decision to operate. What if I was wrong?  What if his pylorus is normal? Then what? What if he doesn't need an operation? What if I am putting him through the risk of an operation for nothing? 

We prayed and I cut. I found his little stomach and followed it down to the pylorus and...breathed a sigh of relief. It was clearly abnormal.  In just a few minutes, I taught my intern how to fix a little baby's hypertrophied pylorus so the milk can once again empty out of the stomach. 

Within twenty-four hours he was breastfeeding without any problem and two days later he is on his way home!   

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).

It's textbook...

Sometimes, I look at a patient in clinic and think, "This patient belongs in a textbook...in fact, I think I saw a picture like this in a textbook in medical school. If only I could remember what it is..."

This girl was one of those patients who looked like her picture belonged in a book. You can't tell as much from the picture, but she was short/stout.

She is an adolescent with a goiter that had been growing since she was a child. Her parents said that she used to speak as a child but for the past eight years she hasn't made much sense. Although, she understood when I asked her to come and could say her name. But she didn't say much else, she just looked at me with a somewhat vacant, sad stare.

huge goiter

We checked her thyroid function and her TSH was 26. (very high, which means her thyroid isn't working). All of her symptoms (mental deficiency, goiter, stunted physical growth) seem to be from congenital hypothyroidism, which causes cretinism. 

Cretinism. Thats the textbook diagnosis I was looking for. Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones. Its a condition that has been all but eliminated in developed countries due to the introduction of iodised salt and other iodine supplementation. It was so effectively eliminated that I had only seen it in the black-and-white pictures of my medical school textbooks...until now.

typical textbook cretinism photo

I did a little reading and found some quite interesting information:

• According to the World Health Organization, "Iodine deficiency is the single greatest preventable cause of mental retardation."  The Lancet, Iodine deficiency- way to go yet. 
• When iodized salt was introduced and became widely used in the USA in 1924, there was a gradual increase in average intelligence of one standard deviation. IQ increased up to 15 points in iodine deficient areas!  (fascinating article here)
• Millet (one of the staple foods here) decreases iodine absorption (cabbage, corn, and radishes can also).
• We are on the UNICEF list of sixteen "Make-or-Break" countries with high numbers of unprotected newborns, low levels of salt iodization, and a need for a high level of support in attaining universal salt iodization. (UNICEF report here).

The same report shows that from 1995 to 2005 iodine intake has increased from 7% to 46% of households here. Perhaps that is partly due to the ubiquitous, iodine-containing Maggi chicken bullion cube used in cooking here.

Don't forget the iodised salt and MSG!  

by the numbers

This week marks one year (!) since I started operating as an attending surgeon in Africa. Wow. And what a wild ride it has been. In the spirit of the annual report I sat down and tallied my cases for the past year.  Here are some numbers I found particularly interesting:

• I've done over 750 major cases. Compared  to an average of 200 major primary cases a year during my five years of residency that is a 375% increase in case load.
• 169 of those cases were C-sections...which I didn't do at all in training.  
• 106 were inguinal hernias...without mesh. I only fixed three without mesh during training.  
• 82 laparotomies to repair intestinal perforation from typhoid  (you guessed it...never operated for typhoid in training)
• 17 Graham patches for perforated stomach ulcers.

I've also removed 11 bladder stones, 11 uteri, 9 [huge] thyroids, 13 hydroceles, 3 esophageal foreign bodies, one worm...and only 6 gallbladders. No laparoscopic surgery. Lots of pediatric surgery. 

One thing is certain...there is no lack of work to do and no lack of variety!  I am so grateful for all of you that follow this blog, leave encouraging comments, and otherwise support the work that is happening here. We couldn't be here without you. 

conversations in the OR

One of my favorite things about my day is the sometimes random conversations that happen in the operating rooms.  When you put a female American surgeon in the middle of  an operating room full of Hausa men, interesting conversations are inevitable. As my Hausa has progressed, the conversations have become less frustrating and more enjoyable because with my Hausenglish and their Frenchausaenglish we can usually figure out what is being said.

The following conversation transpired while I was tediously cleaning spinach, pus, and inflammatory tissue out of the abdomen of  a patient who waited 5 days after his stomach ulcer perforated before coming to the hospital.

Me: "Why do Hausa people wait so long with severe pain before coming into the hospital??? It would be so much easier to fix if they came right away. And fewer people would die."

A (Anesthesia): "Hausa people consider it a weakness to complain about pain. So they don't, even if it is really painful."

Me: "But we have pain for a reason. It tells us when something is wrong. Pain from a perforated ulcer is SEVERE, I don't understand how you could ignore it.  People view pain differently in America. Americans think they should almost never have to feel pain."

A (as if revealing some very interesting news):  "I read the other day that in Europe they give women pain medicine and even anesthesia for childbirth!! Do you know about that?!"

Me: "Yep, epidurals are a wonderful thing."

A: "But, that's crazy, women are supposed to have pain during childbirth. It is part of the curse of childbirth. You shouldn't take the pain away. And who gives the anesthesia? The obstetrician?"

Me: "The anesthesiologist does."

A: "Oh."

The conversation went on about whether Eve caused Adam to sin because he loved her and if women should have pain during childbirth. The conversation quickly became way too complicated for my Hausa.  I wanted to tell him how many of my patients had epidurals during and after their operations when I was a resident...and that more than half of women who give birth in hospitals in America have an epidural.  Even if I knew how to say that in Hausa, I'm not sure he would have believed me!

day "off"

It must have been something I ate or some contaminated water. Just after I was starting to get over a week of cold/flu symptoms,  I was up sick most of Wednesday night vomiting, etc. I felt a little bit better in the morning, so I went in to the hospital at 6:30am to do teaching rounds. I almost lost it again on rounds a few times when the odor of dirty wounds or other bodily fluids arose...but I didn't.

After rounds, I decided that rather than spending a miserable day in clinic several hundred feet from the nearest toilet, I should probably just take rest of the day off to recover. This was kind of a big deal. I don't think I have ever taken a day off work for being sick.  In fact,  I felt pretty guilty all day for not working. That's what surgical residency does to you, I guess. Or, more likely, the type of people who decide to endure surgical residency are the same type of people who feel guilty for taking legitimate sick day.  I know I'm not the only one.

In other news...I removed an even bigger ovarian cyst this week. So gratifying...in less than an hour she went from looking 42 weeks pregnant to having a flat belly and a scar.

for scale, the scalpel is approximately 6 inches long

you have a knot in your stomach...

About once a week (sometimes daily) I cut into someone and find something that mystifies me. Monday we had three exploratory abdominal operations for patients with peritonitis (severe abdominal pain).  Most of the time we find a typhoid perforation, a perforated stomach ulcer, or ruptured appendicitis. Sometimes its another surprise...The first laparotomy (done by one of my partners) was a sigmoid volvulus (the sigmoid colon twisted around itself).  Sigmoid volvulus is also relatively common around here- seems like we operate for one every few weeks.

Removing the redundant sigmoid colon. 

When I opened the second patient's abdomen, I found some gangrenous small intestine and large intestine. The weird thing was, the small and large intestine and their blood supplies were all twisted around each other. I couldn't figure out how to get them untwisted, no matter which way I turned them. They were just all wrapped too tightly together and the intestine was very fragile because its blood supply had been cut off for at least a day.

The intestine  looked kind of like this, except this ileosigmoid knot has been untwisted

I've operated on twisted bowel (called a volvulus) many times...but I'd never seen (or heard) about the small and large bowel getting twisted around each other. Well, guess what? Its a real thing, your intestines can literally tie themselves in a knot. I searched Google for answers after the operation and discovered that what I found is called a ileosigmoid knot or double volvulus. It is more common in African countries- for some reason (likely related to genetics and/or diet) many African's have longer colons that twist on themselves more easily.

When bowel twists on itself, the blood supply gets cut off and the intestine dies if you don't untwist it soon enough.His twisted bowel was dead, so I cut out both sections and dead bowel and made new connections. When I finished, I tried to draw out what I had found so I could understand it better. This is what had happened:

The shaded part represents the dead bowel. 

another view

The few articles I read said that the mortality rate after operating on an ileosigmoid knot is very high. Forty to fifty percent of people die soon after the operation, especially when the bowel is dead (this man's bowel was very dead). Happily, he is doing very well and has started drinking liquids 3 days after the operation!

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!!!

on a good day...

Not gonna lie. Its been a bit rough around here lately. There hasn't been just one major tragedy, but multiple tragedies (big and small) and the every day struggle has been wearing me down. Patients dying, difficult operations, barriers to good patient care...the list could go on. I could write a blog post every day about the continual frustrations of trying to provide good medical care in a resource-limited setting. But then, no one wants to hear about that every day any more than I want to write about it every day. :)

Instead I will write about today. It was a good day. A really good day. Nothing earth-shattering happened...but it was just one of those days that things went well. Here is how it went...

I woke up before my alarm and actually felt rested. While making some tea, I checked online and learned that the Seahawks won the Superbowl. I don't get too excited about football...but I did grow up in Seahawk territory and I'm happy they won. :)  AND...it was cold enough this morning that on my walk to work that I wore my sweatshirt (it got all the way down to 75F last night)!

During morning report, I got a few words of encouragement (its nice to have some positive reinforcement sometimes).

Then, I rushed off to the OR for an emergency C-section for fetal distress. When I opened the abdomen, I saw an amniotic sac with a baby in it...but it wasn't in the uterus. My heart sank. Another dead baby. I took the limp, blue baby out and then... he moved!!! He was alive and started crying! What a happy surprise! A live baby is very rare after uterine rupture.

Between cases, one of the residents asked for help exchanging a gastrostomy (stomach) tube. The patient was a little six year old that had accidentally swallowed some of her mom's cleaning chemicals a couple months ago. The chemical caused her esophagus to scar shut so she can't swallow anything (even her own spit). She was very thin and dehydrated when she was referred to me for placement of a stomach tube.

Little F....she looked like she had gained about 10 pounds! She wouldn't smile or look at me because she was still upset that I had exchanged her tube. 

She will need esophageal replacement surgery, which we cannot do safely here. Hopefully we can find a way to get her to another country to have the operation performed.


Next, I did a washout and closure in a patient who had had a perforated stomach ulcer. Then, my next operation was for a girl in her late teens with a huge abdominal mass (she looked like she was 7 months pregnant). When I saw her in clinic, I couldn't quite tell where the mass was coming from on ultrasound. It definitely wasn't her uterus. Probably not her liver. At the start of the case, I told the team that the case would take one hour or six hours...turned out it took less than thirty minutes! It was a huge ovarian mass that almost literally popped right out. All I had to do was divide the vessels and tubes that attached it to the uterus.

the mass

checking it out

trying to explain where the mass came from in Hausa. its quite difficult since there is no word for "ovary" in Hausa!

When I cut it open I found clumps of hair, chunks of bone, lots of fluid and creamy white sebaceous material. This is good news because it means it was a benign dermoid cyst.

Last case of the day: an inguinal hernia. I am becoming much more proficient at performing inguinal hernia repairs without mesh (not something we do often in America). Now, the tissue based inguinal hernia repair is among my favorite operations here. It was a good way to end the day.


.

back logged

When I looked at the OR board Friday morning I had to laugh. It was a are-you-kidding-me-that's-not-going-to happen kind of laugh. You see, we had planned to have all three of us surgeons here this week so we booked about 4-5 elective cases for each day. Then, Dr. S. had to leave unexpectedly for a few days and we were down to two surgeons. As per usual, this week we've had enough emergency operations every day to keep at least one surgeon busy, enough clinic patients for two surgeons, and enough elective operations for another couple of surgeons!  This is what I saw scheduled for the day:

1. Reprise (a typhoid patient scheduled for a second look operation)

2. Hysterectomy

3. Another reprise 

4. Left inguinal hernia

5. Epigastric hernia

6. Fistula-in-ano

7. Inguinal lymph node dissection for cancer

8. Right hydrocele

9. Left inguinal hernia

10. Urgent laparotomy for peritonitis

11. Laparotomy for cystic abdominal mass

12. Below knee amputation

13. Prostatectomy

14. Thyroidectomy

15. Sequestrectomy

16. Reprise (another typhoid patient scheduled for a second look operation)

17. Skin graft

18. Epigastric hernia

Those 18 cases would usually take at least 25 hours of operating. Many of the patient's operations had already been delayed several days. To make matters worse, what you don't see on the board is the emergency C-section, D&C, two more emergency laparotomies, and multiple day cases that were added on throughout the day.

I knew it was impossible. There is an impossible amount of work to be done here every day. So we just do what we can. We did all of the emergency cases, a few of the elective cases. Then we learned that the washing machine was broken again and we were running low on surgical drapes and gowns. By then it was the end of the day so we finished up the last two urgent operations and everyone else will have to wait. Sai hankuri (have patience) as they say around here.

what typhoid can do to the bowel...

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.

since you asked... :)

Click on photo to enlarge. This picture is before cutting the mass open. Abby, no colon was harmed  in the taking out of this mass. :) The mass had two different colors probably because she had bled into the red-colored part.

Cut open...

guess that mass

The uterus...its an organ that I didn't operate on much during general surgery residency. It fell under the realm of the gynecologists. In fact, the gynecologists usually took care of anything involving the "female organs" (and, in turn, they would call us for almost anything involving the bowel).

Right now, there are no gynecologists here. Hence, I now operate on the uterus, tubes, and ovaries.  Turns out, as long as you know the anatomy and have an experienced surgeon to consult when things are unusual (as they often are here), its not that complicated.

In addition to the 105 (!) C-sections  I've done so far, I've also removed a few uteri and ovaries. Here are a couple pics:

this was the second elective hysterectomy I've done here (uterus is on bottom right). For reference, the scalpel is 14 cm long (about 5 1/2 inches). I'm not sure what this mass is...but it was big.

This is the inside of a 15cm ovarian cyst that had twisted on itself (torsed). After removing it, I cut it open and found a tooth inside!  Although it seems bizarre, having a tooth growing inside an ovarian mass is a kind of a good thing because it means it was a benign tumor called a dermoid cyst. Those cysts can have anything from hair, teeth, eyes, bone, etc. in them. Fascinating, huh?