05-AUG-B-8
STILL MORE
AMAZING CASES
AND “OR DOOR
CONSULT CASES”
POSTED FOR OUR CONTINUING EFFORTS IN A
STUNNING SERIES OF OPERATIVE ADVENTURES
AT
DR. HEGIRU
AT ANOTHER CHINESE RESTAURANT
IN
August 12,
2005
Each day, it would seem, could not pull yet another rabbit out of a hat to impress and teach the team I have around me in my own “small private hospital” of wonderfully motivated team. I have a hand-picked team who had been very discouraged about the possibility of ever raising themselves up again to the status they had enjoyed before, when they had a functioning autoclave which has subsequently broken down, even thought the rest of the team is not only up to standards, but is better than we could hope for. Not only do we have running water and electricity, and almost anything we might want in terms of essential supplies, but the team is more than willing to learn and adapt to the Professor’s wishes, and I have a perfect “Chief Resident” and students who are nearly overwhelmed with the opportunity that has fallen to them. I also have very gratifying and challenging patients with problems I have been so far able to resolve, with a great show of their gratitude and their effusive praise.
We
had an interesting night last night after I had prepared a few of these notes
and waited patiently for what I had hoped would be the arrival of Dr. Haregu,
our local surgeon from
I hope to celebrate this and many more “firsts” with the team tonight at the Chinese Restaurant we were trying to get to last night, this time with a clear signal for a rendezvous with Dr. Herigu. Huda Ayas was with us part of the after noon and this time actually entered the operating room to see what was going on---the first time she has been in an operating room since she was the one lying down in Cleveland Clinic getting her mitral valve prolapse fixed. She was at first squeamish and then interested. Amy had emailed her parents telling them she was actually cutting the sutures that Dr. Geelhoed had put in, and her parents had replied “But, you are not a doctor!” She did much more than that today—she put those sutures in, and in the patient that she and Sherri had most closely identified with—the young woman the same age as they whom they had seen with me at the Halibet Hospital on the first day we were here, along with a lot of others whom we had scheduled for operation, and they have all found their way to me here at Hazhaz Hospital along with quite a few others, the next one even more fascinating than the previous one, with an even more grateful responsiveness. So, it is a dream for the students, the answer to all the hopes for Dr. Haregu and her operating team of now very busy and quite useful staff and to me. We are working our hearts out. If only the administrative team could see the results as Huda has today, including the Dean of the medical school whom I am supposed to see on Monday (if I am not busy operating) and the Ministries of Health on Tuesday (whom I will drop out of operating to see in any event to formalize an on-going relationship between the institutions here and the sponsoring kinds of institutions I represent.
I had an unusual wake-up call this morning, since John Sampson and I had planned to go running, so he tapped on my door; I agreed saying I would be ready in ten minutes. He went to make a phone call, and then realized he was in the dark, since he had figured it was 6:15 AM, but it was actually 3:15 AM. I was puzzled as to why he would want to run in the dead of night, but I got the running togs on and waited. I waited until 7:00 AM, and then realizing there was no way I could now run and be back to stand in the queue to shower after a run and still be ready for a group photo and a full operating day. So, I jumped the queue, and got ready for the day and posed for the group photo, almost all of the rest of the team are at different hospitals than “Cosa Nostra”—our thing, in Hazhaz Hospital (the name means “Hugging, or Holding.”
I had learned of other things as to
their naming. Orrotto Hospital is named
for a place at which one of the early battles for independence was fought where
a field hospital was set up to help the wounded. It is now the new and unused medical school
for the country, with a lot of fancy new facilities and a spectacular layout,
but not much in skill and coordination in the services not yet fully
offered. We would have all been in this
new facility if it were fully functional.
As it is now, this facility is the place where we have dumped off
supplies, including the several bags full from my basement, and the instruments
I have brought, and where the sterile packs are run through their autoclave and
then bussed over to us as Hazhaz—the “Peter Bent Brigham” premier hospital with
my one well functioning OR run to high standards by a very good team of OR
personnel. By the way, Nakfa is also the
name of a battle site of independence, and the name of a main road here in the
capital as well as the name of the currency.
They are fiercely proud of their impendent status having won it in a
long series of battles from a population of four million people against a fifty
five million population of an
OUR CLINICAL
DAY OF WONDERS
IN
I began on the wards making rounds, with the same gratifying response of our patients. I had come equipped this time, since I had seen the pediatric ward yesterday with all the kids and their feeding tubes. This time I had carried a bag of toys and beanie babies and miscellaneous small junk for kids. I went in to the same group and gave a toy or two to a few of the kids, who hardly knew what to do with them. But they learned fast. Even faster were the staff who descend on me in s feeding frenzy, and grabbed the bag which was torn apart as each of them grabbed toys for their kids and the bag floated away in pieces. I had one pair of women in head to toe chadors and abayas, who had even joined in the fray as they cradled their babies in one arm and pursued the flying toys with the other as they were unobserved as to their emotions because of their veils obscuring their faces.
Steve Katz, the Norfolk based professional photographer on contract with PFP (Physicians For Peace) to film and get still photos of our experience for publicity had a field day, saying he has already got all the “grateful patient” shots he could handle from the number of people who seem to seek me out around the Hazhaz Hospital. We had fun with the kids, and then saw the lineup outside the O R door. Our patients form yesterday seemed very happy, especially the one who had the goiter wrapped around her trachea with the spastic unrelenting cough. I took out the tumor which was in a plastic bottle and showed it to her. She was curious and gave it back. I insisted that I certainly did not own it, and left it with the family for disposal. Almost as if on signal, she developed a classic finding for the medical students to observe directly. After we had gone through each of the complications of near total thyroidectomy, and they had guessed all about the bleeding under the flap or the recurrent laryngeal nerves, she went into carpo-pedal spasm with a positive Chvostek. She was immediately relived by a slow infusion of Calcium after cautioning them about the incompatibility of calcium infusions with many other products, such as bicarbonate which would produce a precipitate—turning the patient into limestone!
The other patients were all doing well, and the man who had the bowel resection was doing so well he was released
Our first patient was the man we
had seen at the
We did a smooth slick thyroidectomy, showing the students the difference between diffuse hyperplasia and goiter from Multinodular disease. Then Dr, Haregu grasped both my hands and said “That was my first thyrotoxic thyroidectomy!” This follows the triumphant realization she had been helped through her first hysterectomy and several other “firsts”—to be followed a bit later by the next three big “Firsts.” First use of the dermatome for skin grafting, first acquired diaphragmatic hernia and first use of a Pleurovac for chest tube drainage. For the students with me, EVERYTHING was “FIRSTS!” And what better firsts than the most amazing collection of cases for them?
The next operation
was the one they had most closely identified with at the first day when I saw
the patients in screening those that had been selected for me at
Not only that, but I had said to both Amy and Sherri as they stood in awe of their first exposure to not only breast cancer, but the technique of cancer surgery then the surprising utility of skin grafting. With a little help, the Aesculapius dermatome brought over from Orrotto Hospital had been used efficiently to harvest three drums of skin and then I said to the students as Dr. Heregu dropped out, “Now, you will be closing this patient with a bit of help form me.” No longer just cutting sutures but wielding the needle holder and stitching together the skin graft and the defect in the chest wall, they were nervous about the role they suddenly had in their hands on a patient their own age. I believe Dina will be very well followed as to how the graft “takes.”
In the interval
between cases I had dropped out to help them remove the sutures from the
plastic excision of the nose wart from the pretty woman who had a twice
recurrent wart growing on the bridge of her nose. I had done an elliptical excision and fine
sutures of the pesky five-o Prolene which can scarcely be seen when it is being
put in, and it is even harder to see when covered by s scab and needs to be
removed. So we moistened the areas and
painstakingly removed the sutures with the help of my
THE “SIGNATURE CASE” OF THE DAY—
PERHAPS THE WEEK!
A twenty two year
old boy we had seen on our first day to be decided about operating on him was
an engineer in his first year of a job. He
was a pleasant fellow named Johannes who used English well and was very modest
and smiling, and had asked up about several worries he had about not only his
condition but the accompanying scoliosis he had. Eight months before he was riding his bicycle
and was struck by a car with severe injury.
After that he had difficulty breathing and also some symptoms of partial
bowel obstruction. He had a very
“scaphoid abdomen", and his spine curved to the right. He had bowel sounds in his chest. His chest X-Ray revealed a lot of bowel gas
in the left chest and he had a step ladder pattern in hat side, with a
partially collapsed lung. He had a
“diaphragmatic hernia” or more correctly “eventration of the diaphragm.” He was a big case in the making and I
suggested several potential problems.
One was that he had “lost domain” of his gut in the abdomen since he had
it in his chest and it might cause some trouble if returned precipitously. He
may also have some adhesions in the chest and need a thoracotomy to return the
viscera to the abdomen. He might also
have a problem with re-expansion of the lung if there were any cortical peel on
the lung from the long standing association with the gut moving into the
neighborhood. I was sure he might have a
large defect that would require a mesh graft so we had brought some form the
In a real “crowd pleaser” of an operation, for which Huda Ayas from GWU came over to join us for lunch and then even got up the courage to see what we were doing in the operating room—she had heard the students emoting about their experience in returning from the mastectomy and the coverage of the thoracic defect with the skin graft which they had had a hand in suturing to secure the graft---she made her first appearance in scrubs in the OR. Her last visit to an Or was when she was the one lying down as the patient in Cleveland clinic where she went to have her mitral valve prolapse repaired Now she was in cap and gown and watching as this spectacular case showed the continuity between the abdomen and thoracic cavity through a two fisted size diagrammatic gap.
The edges were grasped after the gut was pulled down. A Deaver retractor was inserted directly on the heart to help visualize the edges and the lung was inflated, It could not have been more apparent to all that we were looking at a large hole when the gut was pulled back to the abdomen and we began to suture the edges together. We were able to do this without mesh and accomplish primary closure. We could complete the whole procedure from the abdominal side. I then showed the sucking chest wound that had been porn since the diaphragm was and then stabbed the chest for a chest tube throracostomy. We hooked that chest tube to a water seal through the use of the Pleurovac system that had been part of our kit. He will probably resolve his scoliosis since it was in accommodating his chest full of abdominal viscera that he had bent to the side. He will be a very happy camper—and I hope the pictures of this spectacular lesion will show in adequate detail of this highly instructive case at our ‘Show and Tell.”
So, now, we go off
to the China Star Restaurant to celebrate a good day and a continuing series of
operations which have been added for tomorrow (an unusual Saturday schedule
which will prevent us from leaving for any weekend excursion down to the