It’s been an interesting day. It’s been sad. It’s been weird. It’s been stressful. It’s been terrifying. It’s been satisfying. It’s what I both love and hate about surgery. Actually, for a guy who likes his days to be predictable and “under control”, it’s downright comical. How strange that God has led me to this place to do this work. In the end, it’s God that gets all the credit because I’m just a scared guy who is trying his best but is sorely outmatched. It’s late at night and I’m dog tired but I want to put the day in writing. I’m still trying to get used to always being on-call.

The young boy I wrote about in the last two posts took a horrible turn for the worse a day or so after I wrote the last post. I thought we were winning the battle with nutrition, but then his abdominal wound fell apart. His intestines were exposed to the air. Because of all the inflammation, they weren’t “hanging out” but they were exposed. Unfortunately, he looked way worse clinically and would not tolerate another operation at that time. We started wound care but disaster struck the next day when a hole opened up in his small intestines and intestinal juice began pouring out of his wound. This is called a fistula and, without intravenous nutrition, is very deadly. In his debilitated state, he had no chance short of a miracle. The miracle did not come. He worsened over the week and died this afternoon. My heart aches. It’s so hard watching people die but I know God is in control. Though I don’t understand, I must trust Him.

My first operation of the day was a woman with a massive spleen with a massive cyst associated with it. In this area, when huge cysts are noted either on the liver, spleen or in the lung, it is usually something called hydatid disease. It is caused by a parasite called Ecchinococcus, commonly called dog tape worm. It lives in the gastrointestinal tract of dogs and the worm ovums are passed in the stool where humans then eat it from contaminated food. It can form cysts within various organs with active organisms, called protoscolices, and is most commonly found in the liver, lung and spleen. This woman had been treated with a drug that kills the worm, called albendazole.

My grand total of experience with surgical treatment of the disease was watching one of the other surgeons operate on a man with two cysts in his lung. Apparently that means I’m ready. We opened her abdomen and mobilized her stomach out of the way to expose the wall of the cyst. It and the spleen nearly filled her abdomen. There were enormous, abnormal vessels splayed all over the thing. We used a needle to aspirate it and drew out the typical (2 for 2, that is) clear fluid of hydatid disease. It was quickly apparent that removing the cyst and/or the spleen was likely to kill her, so we decided to do what I had observed on the lung case. We widely opened the thing and sucked it out, including the “daughter” cysts inside. After cleaning it out, we stuffed the cavity with a wonderful organ called the omentum (a fatty apron that hangs off the colon, great for stuffing spaces, stopping bleeding, helping infection and sealing holes) and closed her up. So far so good, we’ll see.

Hydatid cyst in spleen

Hydatid cyst in spleen

 

Removing daughter cysts

Removing daughter cysts

The next operation should have been subtitled “how ignorance made me bold.” This was an anemic little lady who came in with a huge mass in the left side of her abdomen. On ultrasound, it looked like a kidney tumor. As near as we could tell, it did not extend into the renal vein or into the inferior vena cava (the main vein going to the heart from the lower part of the body), which would have made resection really hard. Beyond that, it was hard to get much information from the ultrasound. Since kidney cancers can still have hopeful responses even when huge ones are removed we decided to try it.

 

Now, in America, we don’t even like to put in an IV line without a CT scan so I was really wishing I had one. Here in Ethiopia, I’ve started calling it the Soddo CT scan: Cut the Tummy.  So we opened her abdomen and started exploring. Sure enough, it was a huge kidney tumor. It was difficult to ascertain what was going on around the edges so we started mobilizing and exposing stuff. After a lot of tedious work and anxiety, we were able to get the colon off and we identified the main artery and vein going into the kidney. These were, thankfully, divided safely. Whew, I thought! Now we can hog this thing out. As we started “hogging” we got to the top portion and realized the tumor extended well beyond the kidney. This is where the “Soddo CT scan” really falls behind the real CT scan. There are a lot more ugly surprises this way. Further tedious exploration (made much more painful when you thought you were over the hump) revealed the tumor involved the adrenal gland, the pancreas and the spleen.

I thought about it for a minute and decided we were committed at this point, so we pushed on for the home run. We mobilized the stomach away from the spleen and identified the pancreas. We divided the artery and vein to the spleen and then cut the pancreas in half. Following this, we were able to get around the spleen and the mass and remove it from the abdominal side wall. It left an impressive hole. Again, so far so good, we’ll see.

Kidney tumor

Kidney tumor

 

Kidney, spleen and tail of pancreas

Kidney, spleen and tail of pancreas

God gave me a couple of hours to eat dinner before He delivered the last punch in the gut. The on-call resident called to inform me that a four year old girl had just arrived after breathing in some food and was in the operating room on oxygen. She was having a hard time breathing. Great… something else I’ve never done before.

I hustled up and found the little girl lying on the table struggling for air with an oxygen mask held to her face. I thank God that she was maintaining a good oxygen level, though. I grabbed our bronchoscope to see if I could see anything in her airway. It is an adult size but I was hoping it would fit. I was able to get the scope into her airway and I saw what looked like a pea or something lodged where the trachea splits to go to the two lungs, way down there.

Unfortunately, we don’t have any graspers or forceps that I can pass down the scope to grab stuff. I couldn’t think of any instruments we have that would reach down there. At this point, I polled the audience. The residents informed me that the usual method of dealing with this is to perform a tracheostomy, hang the kid upside down by her feet and slap her back until whatever it is comes out. I stared incredulously for a minute and decided, what the heck, if it has worked before, it’s better than anything I’ve got.

After fervent prayer, we cleaned her neck and injected local anesthetic. We cut down to the trachea and made a hole. One of the residents grabbed her ankles and flipped her upside down and another resident started pounding on her back. We laid her back down and put in a tracheostomy tube to give her some oxygen. She still sounded pretty crummy so I put the bronchoscope down the hole and looked. It was still there, hadn’t moved. We tried several more rounds of furious, inverted beating but to no avail. We then moved on to sticking things down there. We tried several clamps and even tried guiding a suction tube down in hopes if sucking it up. Nothing was working. By God’s grace, she was able to maintain her oxygen level in between our attempts. In desperation and after more prayer, we tried another round of back slapping. At this point, I remembered that in our medical supply container there is a catheter called a Fogerty catheter that is used to pull out blood clots from arteries. The gist is it’s a small catheter that you pass beyond something. You then blow up a balloon beyond it and use it like an anchor to dredge it out. I told everyone I would be right back and ran off to the container.

When I got back she actually looked pretty comfortable. I ran the scope down again with the hopes of guiding the resident visually as he tried to pass the Fogerty beyond the food. To my amazement, the airway was clear! Nothing was there. I asked if anything had come out and they said no. So I passed the scope through the hole in the trachea, now going up, toward the head. Sure enough, it was sitting just below her vocal cords.  About half a second later, she started coughing and vomiting everywhere. As the guys at the head of the bed started sucking furiously, I noticed a green thing come out of her mouth that kind of looked like the offending pea. Once everything calmed down, I put the scope back in saw only her vocal cords. It seemed to be gone. I confirmed that it wasn’t back down below and we thanked God. She’s doing fine, albeit with a tracheostomy tube. Hopefully we can pull the tube soon.

Well, I’m tired and God only knows what is coming up later tonight or tomorrow. I think I’ll go to bed.

Paul

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