MAR-A-2
THE FIRST OF MARCH IN MALAWI:
A FRIDAY FULL OF THE KINDS OF
DAILY EVENTS
THAT A TROPICAL RAINY SEASON DAY CAN PRODUCE,
WITH A FEW CASES THROWN IN
ONE CASE AT NIGHT WITH A CHANGED STORY BY DAWN,
ONE VERY SLICK TOTAL ABDOMINAL HYSTERECTOMY WELL TAUGHT,
AND ONE INTENSE DRAMA WITH AN 18-YEAR OLD 3 WEEK MOTHER
IN EXTREMIS WITH AN UNKNOWN ABDOMINAL DISTENSION
Mar. 1, 2002
A NIGHTIME EMERGENCY—REQUIRING ME TO BE AN OPHTHALMOLOGIST FIRST AND A
DETECTIVE SECOND
The day began with a
run—although I had to push myself out of bed to do so, even though it was not
raining this morning in contrast to the previous run of the same course. And, I ran
the first part, but probably fell down to the shuffle I had never wanted a s a
designation for what I do—a Jog.
One of the reasons I may have been running low on gas was the night before after return from the Maternity Nurse Mercy’s “birthday party” I got called at the door for the “Surgeon, not the Doctor.” I woke up with what seemed like the middle of the night, since I had turned in about 8:30 PM but it was more like about 9:15 PM. I heard only that there was a patient in Casualty, but the nature of the patient was not described further, since the night nurse from Male Ward named Jerdie was burbling about how he knew my name as Geelhoed, and he wanted to say how sad he was “So sorry, Sorry” for the attacks of the bad man Osama Bin Laden on the World trade Center and the Washington DC where, he had been given to understand, I had been at the time of the attack. “What is the nature of the patient and the problem we are going to see?”
“He ran into a pail.”
When I got to Casualty, I was dressed in a tee shirt and Ishmael was already there dressed in a jacket—it must be cold here relatively speaking. The story, which I had to have spelled out several times, was that this young man had tried to walk into his hut in the dark and had struck his head on a hanging bucket which had a wire bail for the pail which caught his eyelid. I then removed the dressing and saw the patient’s eye looking back at me without an eyelid at all. The upper lid had been avulsed with the fractures tarsal plate looking back at me on the undersurface of the lid which was lying over on the side of the face, with a couple of stellate lacerations on the skin surface. “Are you sure this wasn’t barbed wire that caught him in the face?” I asked. There was a bit more translation, and then it came back to me in more detail, that he was coming through the dark in his hut and hit his hanging pail and caught his eyelid on the wire handle of the pail and jerked away from it, causing the damage I encountered here. Well, OK, I can understand a freak accident, and that there are no predictable patterns to such an incident unique in all the hazards that surround us all here, but it surely looked like a barbed wire injury if you were to ask my best untutored guess.
The lid was dangling by attachment to a very big and boggy hemorrhagic conjunctiva with foreign matter in it, and we began by cutting away the ragged skin on the outer lid, and the most of the conjunctiva, which was devitalized. It was early in the evening, and I was comfortable, pulling up a footstool, getting a chair for Ishmael, which he did not use, and telling him I would help him reassemble the eyelid and the whole avulsed lid apparatus. He was surprised, since he was uncertain how to approach it, and thought I might take it and fix it with him looking on (he must have had such contacts with the characteristic UK “consultants.”) But, I checked to see that the patient had vision in that eye, and that the medial canthus lachrymal apparatus was uninvolved. We drew point to point correction, including the lash line on either side of the tear and did a mucosal repair on the everted lid and a couple of sutures through the cartilage tarsal plate, and then a plastic repair of the lid. It was all over in an hour, with Ishmael’s confidence growing at each new stitch showing the coming result. He had to use a very big and clumsy forceps, and I had promised I would get him the fine instruments of the plastic surgical kit I had carried but left in my room. I delivered them to Tembo today at the final chapel appearance and farewell to the Kennedy’s as they posed for the final pictures with the staff, leaving in the morning to Lilongwe with Elizabeth.
And now the “thick plottens.” I heard at morning report after Ishmael reported the case and the instructive repair of the lid in blepharoplasty what Tembo had learned from his listening post out in front of the hospital, where he has the concession to sell warm cokes and little candies. He said, “Yes, there were four boys who were breaking into a house with intent to steal when they were startled. Three of the m got away, but this fourth one ran into a barbed wire fence, and got caught in it and tried to fight his way out of it, getting injured seriously in the attempt.”
So much for my forensic evidentiary gathering, at least the repair was good no matter what the mechanism of its being sustained.
After making brief rounds, which looked as though all the patients were doing well, I helped John Sutter in his one-week follow-up of the first skin graft he had ever seen performed, on the young rejected bride with epilepsy who fell in a fire during her fits. Carefully lifting off the Vaseline gauze dressing (a phenomenon George Poehlman had said was usually accompanied by the lifting off of the graft as well) we irrigated with saline and used the back of the forceps to hold the graft down and remove the dressing. To everyone’s satisfaction, the graft is a 100% take. With that encouragement, we will plan to do her other leg on Tuesday, since we just learned at Morning Report that Monday is a “bank holiday.”
I once learned in South Africa, that –lucky me—I was just in time to celebrate the first ever national holiday “Human Rights Day,” on the anniversary of the Sharpsville Massacre. It was convenient for me, since that was the day of the Benoni Marathon, the first of my South African Marathons and perfectly timed to get trained up for the first of my Boston Marathons a month later. I did not know of the holiday that was new, but they seemed to be proliferating holidays as fast as they had in Labor Party Britain when almost every other summertime Monday was a “Bank Holiday, as I had found to my inconvenience during my James IV tour of the UK.” Now, here was a new one on me, the “Martyrs Day.” I asked what had happened on this day to commemorate it, and they said to me after report, that it wasn’t really on this day that anything happened, although in 1958 there had been some deaths that were allegedly the martyrs referred to, but it made a good four day weekend possible if we started celebrating today on Friday.
So, this “Martyrs’ Day Monday” moves our elective list of the skin grafts and third prostatectomy back on the schedule to Tuesday, my last regular operating day. I am scheduled to give the “Educational Rounds next Wednesday morning just before I leave of Lilongwe. Today, since Elizabeth is leaving tomorrow with the Kennedys, there was a presentation that the two of them, John and Elizabeth, gave on comparing and contrasting HIV and AIDS in the USA and in Malawi. I will show them pictures of the African pathology I had encountered in my first term of experience in Africa when I was exactly at the same stage as John and Elizabeth are now, although only John will hear it from my two GWU students, but the Malawi staff at Embangweni will have a great deal of fun comparing and contrasting Nigeria in 1968 with Malawi in 2002.
I went to theatre with both Ishmael, the clinical officer who had showed such technical skill potential the night before, and with Tembo, the master Theatre Technician who seems to have seen it all before even if he has not done it all, but can tell what he had seen. We were scheduled to do the hysterectomy that neither Ishmael nor Tembo had seen before done electively and completely, but Ishmael had said that he had once got involved in one as a “team.” “Who were the team and who taught you?” I asked. “It was Tembo and we just did it together.” The circumstances are somewhat different, since the occasion was a ruptured uterus following a crash laparotomy for C-section and they both realized that the only way to get out of there without bleeding to death was to take out the uterus. They left the cervix, since they had no idea how to get it out, but the patient survived, even though one ureter had been tied. Now this was the first “Total Abdominal Hysterectomy and Bilateral Salpingo Oophorectomy” they would not only see, but would do, and I would be sure that each one of these non-physicians, but cautious and competent operators would see and feel comfortable with each step since they may be able to carry it on their won later if carefully done.
It was slick. Both ureters were recognized and avoided, the use of the specific Heine clamps and the kind of suture ligature the broad ligament requires were well placed, the vaginal cuff oversewn and left open as a draining since there was a little evidence of salpingitis, and it was done with each of them feeling ownership of the operation and pride in the slick completion of it. It took an hour and had less than 100 cc of blood loss. The specimen was very photogenic, and was presented to the husband.
Mama Chima, the only one of the nursing staff who is not the characteristic four standard deviations off the weight norms, has a problem. This wizened and tough maternity clinician has a right trapezius spasm that has been “paining her.” She insisted at6h I must have knowledge of medicine that would make it go away. I said that what she needed was a course of physical therapy, stretching the muscle and deep massage. So, I started on her, and she said: “Oh, that pains me too much!” I replied “Oh come now, you useless woman, it does to hurt any more than labor, delivery, episiotomies and their repair—all without anesthesia!” I gave her my own supply of Vioxx that has been so helpful after marathons and ultra marathons, so she has got the top of the line in post-massage comfort, perhaps getting the better end of the treatment that Humphrey got. She had a good chuckle over that, and along came Kathryn the Matron, our hostess for the local dinner later this evening.
I said to the Matron, “We have run short of patients so that we have started treating the staff, and I have one here who is more trouble than all the patients combined in Mama Chima.” The Matron looked perfectly deadpan and then said without missing a beat: “Remove her heart.” These folk have been working together a long time and know what each can do and trust each other. I have confidence in the theater staff to do the right thing in a cautious conservatism as they have been trained in the business of daily clinical and emergency work, without a lot of direction and are very grateful for what they do receive in education from visitors, some of whom do no t appreciate how limited in equipment and resources they are and may make requests for nearly extravagant use of some things they are used to back home. That is why I try to be instructive and helpful as a “Bush Surgeon” not as a Visiting Professor from the First World “raising standards that are unaffordable –even there.
SO THAT I CAN ENCOURAGE THEM BY CHEERING ON THEIR
BELL RINGING CHOIR—
JUST AS A VERY SICK YOUNG WOMAN COMES IN
As I had come out of the hysterectomy, completing the theatre list, George Poehlman came over to say that there was a young woman who would be coming to see me with an abdominal problem, but we could see her right after we had given her some fluids. We had lunch which Betty Poehlman had early since she was going over to the Deaf School to help them with their practicing the bell ringing for a special presentation along with the keyboard, which they could not hear, but they knew from reactions of audiences that it made good music. I promised to come on by just before going over to se the patient who would be scheduled for a D & C, based on the fact that she had just given birth three weeks ago to a small, cute girl, who was sitting alone in her mother’s bed when Elizabeth and I came by to examine her. I said to Elizabeth after I photographed her holding the little baby, “Now, if you don’t take good care of her mother, you will inherit this baby and you will be hit up for the school fees and the whole of the events through her wedding day when you can collect her lobola.”
What I did not know until I examined the young mother, is how close this would come to being true, since I believe I saw here a few hours before she would be leaving an orphan behind.
I walked over to the Deaf School, and arrived just as the bell ringers were following the color coded notes to their colored bells of different notes which they have never heard, as their teacher signed to them, and Betty pointed with a stick to the notes as a conductor might. “How Great Thou Art,” was one of their songs, and one of the other special numbers for which they were delighted to present to “Dr. Geelhoed, before he has to run back to Theatre....” was “Twinkle Twinkle Little Star.” This was a new song for them and was done in tune with the keyboard, so they were eager to “hear” how well they had done. I quickly learned that you do not applaud a deaf concert, but raise both hands and wag them back and forth, since it is the visual cuing that counts. They babble joyfully as I had to take leave. Along the way back, I met a head master and a teacher in the public school seven kilometers down the road, who insist that I go to visit them tomorrow, when I believe we have to be out in that direction anyway to attend the Nkosa’s command performance, as his 83-year5-old immanence will put on a dance and fest for us.
I returned to the hospital to be shocked at what I saw. Here an 18-year-old girl with a three-week old baby looked about two hours from dying. She had a large distended abdomen, which had almost no superficial tenderness. If pressed on, she could evince deep discomfort, but nothing like abdominal rigidity from peritoneal irritation of the kind that is “an acute abdomen.” She was very dehydrated and barely conscious, but even if anesthetized or brain injured, the acute abdomen is rigid and does not allow the kind of thumping I was doing on it to show its hyper-resonance. Old people can sometimes be very sick with minimal abdominal findings if their bowel is dead from some kind of mesenteric vascular problem. I had suggested to George that she should have a D & C, since she might have endometritis from her recent delivery at home in the village with retained placenta or some reason that would give her some bizarre septic complication of childbirth. So, of we went to the Theatre, where Mister Tembo tried to get the pulse oximeter hooked up, and George put in the speculum with my Petzel headlamp as an illumination of---essentially nothing unusual in the uterus.
Grace had already wheeled in the trolley to carry her back to the female ward. I said to Grace, “This young lady has no hope unless she is fixed, and that within the next hour, so we cannot carry her back until we have done something therapeutic for her. I know we don to have a diagnosis, but she does not need a diagnosis just now, she need s desperately to be FIXED. Before the days of fancy laboratory tests and CT and MRI scans, we used to operate on clinical suspicion and do what is called and “Exploratory Laparotomy,” and I have seen no one here so suspicious, and she needs an operation—right about now!”
To convince the others of this fact, I suggested George put the needle and syringe he had on his D & C tray into the distended belly to see if there were free air from some form of perforation, which we would otherwise not know, since the X-Ray machine has not worked. And a good thing it does not work, too, since that may have delayed what she really needed, and that was an operation. The needle aspiration showed nothing, so an operation is what she got –and quickly.
George Poehlman became the anesthesiologist, as I suggested she might need about eight liters of fluid if we could get another IV started. She was so tipsy (her pre-op status was Class five) that I made the abdominal incision essentially without anesthesia. Tembo assisted me and I had gowned and gloved Elizabeth for her dramatic swan song in surgical care. On entry to the abdomen very dirty looking and foul-smelling fluid gushed out, and the bowel could be seen through out its length—black and lifeless. Dead bowel? In an 18-year-old? She would not have mesenteric vascular problems, so what is the source? I twisted the midgut volvulus around and tried to see if the gut resumed the color of viability. It shifted from black to gray. I tried to se if there were a tether point or an internal hernia that might have obstructed it, and there was none. Remembering where I am, I milked the distended paper-thin bowel to see if there were Ascaris worms
obstructing it. None.
I tried to get the demarcation line of the devitalized bowel and looked all the way back to the jejunum, milking the very distended foul smelling bowel to get the fluid down to the colon. The appendix and the ileocecal valve with the colon appeared to be normal.
Now, what to do? You cannot excise the whole of the ileum or even exteriorize the dying bowel in Africa, where every bit of bowel is needed to extract every single calorie from that poor nutritional nsima source. A resection would not allow a viable anastamosis, and two ends of the bowel would have to be brought out. The abdomen could never be closed with such a distended mid gut. I cut multiple holes in the suction tubing I had brought with me, and made a purse string suture in the bowel wall and threaded the home made “Baker Tube” though it. The fluid inside was sucked down, and I plicated the whole of the small bowel over the tube, all the way to the cecum. Then I did a Stamey enterostomy to the abdominal wall and closed the belly while pouring fluids into her, with, as yet, no urine output.
George drawled: “Well, I believe you made a difference in her day!” Yes, that is probably true—lengthening it beyond the few hours she would have had—which is about the interval that her three-week-old baby can go without being attached to her. Mister Tembo said, “OK! This was a necessary operation!” I added, “If only it can also be sufficient!”
There is no ICU here. We will have to watch her closely and take her back for a second look operation to see that part of the bowel might survive now that it is decompressed. But, if a dramatic case were needed for Elisabeth’s African or surgical swan song, this young woman qualifies. I said, “She has a young heart and lungs and even kidneys, so do not worry about pouring extra fluid into her, and hope for the best!” Stay tuned for further developments here, since several lives are hanging on the outcome of this “necessary operation.”