This blog post began a week ago and then got pushed aside in the busy-ness of the past week. I will try to finish something to share this weekend. There is a lot on my heart, and I confess that writing it is not in small part about catharsis. There will be some medical items at the end. And I will warn those who don’t like it that there are some graphic pictures. In honor of my mother-in-law, there is a ‘bunny buffer’ for those who don’t want to see it. When you see the bunnies, beware. Blood is coming.

Part I – Spirituality

God gave us a really encouraging morning yesterday. It was a strong reminder of our strong and sovereign God’s activities, even when we’re unaware of them.

We have a patient who has been with us for a long time named M. M is from a rough area and showed up with a seven-day-old AK-47 wound to the shoulder and jaw. It seems the bullet punched through the top of shoulder from the back, exited the shoulder, and then caught him under his left jaw, exiting out his mouth near his chin. It had completely blown away a segment of his left mandible, including teeth and the soft tissues around it. After a week of no care, it was an infected mess with a huge, gaping hole between the floor of his mouth and the hole in his neck below his jawbone. The then unstable mandible was just sort of hanging there, and he was leaned on his side in bed, drooling out of it.

He has been with us for a long time. We initially took him to the operating room to try to clean out his wounds and figure out some way to stabilize his airway. It took a couple of iterations of attempts, but we were finally able to put an external fixator on his mandible. Like much of the medical descriptions in this post, it reminded me of a mad scientist’s experiment. But it worked and we were able to stabilize the situation and give wound care to clean up the infections. Because the floor of his mouth was pretty well ripped off from the front, he has some difficulty swallowing. But we were able to use some suction tubing as a straw so that he was able to eat porridge and build his nutrition.

We have been blessed to have a plastic surgeon with us for the last week and a half, Joe Woods. We had been waiting for him to come to tackle M’s reconstruction – creativity was needed. By the time Joe arrived, the infection was under control and the communication between his mouth and neck had scarred shut. The trick now was putting him back together. In addition to reconstructing his jawbone, we had to put some good soft tissue in there to fill in what was lost. We ultimately took him for a full-day operation and opened everything up again. We used reconstruction bars to span the bony defect and placed bone graft from his hip. We then borrowed some muscle, fat and skin from his chest (pectoralis major myocutaneous flap) and tunneled it up his neck to drape it over the bars and reconstruct the floor of his mouth. It really went well, in a mad scientist sort of way.

The spiritual issue is that M. holds to a different religion than us and none of our hospital people, residents included, can speak his language. Our only communication with him was through his son, also an attendant of the same religion. We had another patient at the same time from the same region, involved in the same fighting and a member of the same religion. After treating his chest injury and putting his arm back together, we tried to talk with him about Christ, but were firmly rebuffed. I confess that I had little hope of success with M, between his age and the fact that we would have to share the good news of Jesus through an interpreter completely disinterested in doing so.

Yesterday, it was finally time to send M. home. Additionally, we had another young man who was ready to go home. This other man was involved in a fight and, as the on-call resident described it, was “hit on the head with a metallic object”. He had a neat circular fracture in his skull and bone was shoved down into his brain. We had opened him up and removed the brain fragments. He was doing well and also ready to go home.

I felt conviction in my heart to share the gospel with both of them, despite my frank lack of faith. Compounding the problem was the huge gaggle of people we now have on morning rounds, between nurses, residents, staff, and emergency surgery students. It is awfully hard to have a meaningful spiritual discussion with so many people. So we decided to split off. After finishing in that ward, Dave Hardin stayed behind with two of our residents, a more experienced senior resident and one of the junior guys. They were going to try to initiate a spiritual discussion with both of these men. The rest of us moved on to complete rounds and get the day going.

It was later, as I was starting the big case for that day, that Dave came in to share the good news. Apparently M. had been thinking a lot about Christianity during his stay with us. He said that someone in their area had been sharing with them about Jesus for a while now. As the guys were talking with him, it was evident that he had already decided to become a Christian! They prayed together and shared further. Apparently there was a church in the area that he could attend to grow as a believer. The translator son was not quite ready to profess faith, but wanted to talk further with the believer in their hometown about it. He was definitely considering.

Furthermore, the young man with the brain injury was a similar story. He was of the same faith but also wanted to follow Jesus. He was fearful of how his community would respond to the change, so our resident exchanged phone numbers with him and tried to set up some time to stay in touch to help disciple him. The young man accepted a Bible and discretely wrapped it up in a newspaper to take it home.

Amazing! All the while I’m feeling doubtful about any chance of success, and God has already brought the fruit to such ripeness that it’s about to fall off on its own accord. All we had to do was reach out and take it. It was very fitting that my Bible reading this morning included this passage from the book of John:

(Jesus) “Look, I tell you, lift up your eyes, and see that the fields are white for harvest. Already the one who reaps is receiving wages and gathering fruit for eternal life, so that the sower and reaper may rejoice together. For here the saying holds true, ‘One sows and another reaps.’ I sent you to reap that for which you did not labor. Others have labored, and you have entered into their labor.” John 4:35-38.

Part II – My family is awesome

God has deeply blessed me with an incredible family. I love them so much. I just want to brag a little. Becca is an amazing woman. I can’t believe how much she accomplishes, all while being a fantastic mother and dear wife. To a “T”, she is the so-called Proverbs 31 woman. There are so many areas where she is taking care of business that I can’t get to. In addition to being a lover and friend, she is a heck of a partner. God willing, our residents will have a great new apartment building to move into in a month or so. And it will be in no small part to Becca’s work.

We had a fun date night last weekend. The Hardin’s graciously took the kids and we went to the best eating establishment in town – our house! We locked the door and turned off the porch light. I actually drew up a great sign that said “Go Away” in both English and Amharic, including a reasonable drawing of an upturned hand blocking the way. Becca, always the wise one, wouldn’t let me actually post it outside the door. We used the money we saved by not going anywhere to buy a new album on iTunes and enjoyed the music while cooking/eating dinner together. Very yummy and great atmosphere!

I am also awfully proud of my kids. Lydia has such a vibrant personality. I have so enjoyed getting to play with her, having “tea” together and playing “Sweetie”. Sweetie is when she and usually Nathan pretend they are the mom and dad at home. Lydia assigns the roles and off they go. When we play together, it is precious, albeit a little odd. Usually, I get assigned the role of dad while she and Nathan are assigned the roles of sister and brother… I’m still trying to figure out which part is “pretend” but they get very strict if I stray off role – such as to become “Scottish accent dad” or some other fun accent. “No, daddy! Talk like you normally do!”

And with Nathan, I’ve nearly become a bone fide crack dealer. I have my boy firmly hooked on Minecraft, the video game. But we have so much fun playing together in the evenings before he goes to bed. We also like to occasionally watch a YouTube Minecraft tutorial from a guy who drives Becca crazy. This past weekend, I also introduced him to a new drug when I gathered Nathan and Lydia together for a late Saturday night showing of Star Wars, A New Hope. Ah, Star Wars is truly timeless. Especially with all the new kids on campus who are already hooked on Star Wars, I felt it was important for his social development to understand the storyline. He’s hooked.

Part III – Creativity Required (written last week)

It never ceases to amaze me how much happens in any given amount of time here. Previously I shared about a six-year-old little girl we operated on for a skull fracture and herniated brain.  She survived her hospitalization and has since been discharged from the hospital. Like a lot of severe head trauma, I’m not sure how she is actually going to do; but she is alive. It took a few days but she woke up and began feeding. But she still isn’t moving the affected side of her body much and she isn’t able to communicate or engage her environment. Dave and I received advice from one the neurosurgeons at Baylor and we will plan to reoperate on her in three months (assuming she returns). We will need to reconstruct her dura (tough lining around the brain) and perform a cranioplasty (give her something hard where there is currently no bone). He gave us a few options since we don’t have titanium mesh. The most creative was to harvest rib bone and weave it together like a piecrust. I’ll never look at apple pie the same again…

Dave and I have had several difficult situations where we have had to rely on God for grace and creativity. A few weeks ago we had a man come to clinic with a long history of right upper quadrant abdominal pain and jaundice. His bilirubin was elevated and it appeared that he had stones in the area of his gallbladder. Additionally, the biliary ducts in his liver were dilated. It looked like his gallstones had fallen into the main bile duct coming from his liver and had blocked the system, usually near the duct’s entrance into the small intestines. This represents a problem that has seen a huge evolution in the United States. These days, gastroenterologists are usually able to fish these stones out with a scope and it is quite uncommon to have to do it surgically. As it turns out, I never saw a single common bile duct exploration as a resident, with exception of a few times where we flushed some tiny stones out during laparoscopy. But I was certainly never involved in some of the cases like I’ve seen here.

This one turned out to be one for the books. We knew we were going to have to use the C-arm (x-ray in the OR), so we talked with orthopedics about using the room with the x-ray. Dave got the case started and found a very angry abdomen. The man had a long-standing, chronic state of inflammation in the area, with dense and difficult adhesions. His pancreas had also been made chronically ill from this as well. It was abnormally firm and had further contributed to the difficult inflammation, complicating the dissection. It took a long time to just whittle the gallbladder down until we could find the main bile duct. Even then, the anatomy was shot. We finally were able to remove the gallbladder and open the bile duct. He was full of various sized stones, and we were able to milk several out of the common bile duct. There were some large, palpable stones down behind the pancreas and near the intestines. And we were able to extract the ones we could feel. It took a combination of milking and gentle use of stone forceps. Finally, we were able to pass a urine catheter down the duct and into the intestines. As far as we could tell, it was clear.

So we went with the x-ray. The only type of x-ray dye available here that is safe in this setting is a type of dye normally used for urology tests. But it works. The patient’s family had to purchase the vial from the pharmacy before surgery – and we only had one vial. We just don’t have anyone who really knows how to operate a C-arm so this procedure (and anything else like it) is always a beating. We also don’t have the proper catheters, three-way stopcocks, etc., to do it easily. So after what felt like an extended Abbott and Costello skit, we finally felt sure there was a big stone still down there. But we were almost out of dye. And when we sent someone off to the pharmacy for another, we were informed that the hospital was all out.

At this point, Duane came into the room to heckle us since we had been at it for such a long time. He mentioned that it would be helpful to have a scope to look down there. Too bad we don’t have a choledochoscope. But, we do have a reasonable quality flexible laryngoscope…. Dr. Wayne Koch, ENT surgeon, had sent it to us. I think he would be mortified to realize that our first real use of it was to stick in some guy’s bile duct. But, we were desperate. I broke out and fetched the scope. The problem is the scope doesn’t have any working channel. If you just stick a scope by itself down there, you’re not going to see anything without some irrigation, and there is nothing on the scope to allow irrigation. So we decided to go side-by-side. We wiped the scope down with a disinfectant and I handed it to Dave. We took some sterile IV tubing and asked anesthesia to plug in a bag of saline. Through the hole in the bile duct we slipped in the scope and the IV tubing, running fluid in. Amazingly, it worked. Dave was able to guide the scope down and into the bowel. As he backed out, he finally saw the stone. Now we had to get it out.

We tried unsuccessfully to milk it out, grab it with forceps, or dredge it out with a catheter balloon. Nothing was working. Finally, I walked down the hall with a scrub nurse to fetch a stone basket normally used for urinary stones. It is a small wire-looking thing that, when deployed, extends a four-wire little hoop basket that will grab a stone. Again, the challenge was how to safely get the thing down where we needed. Normally you would guide it down a channel in the scope, but no doing. We first tried to gently feed the basket beside the IV tubing and scope. But it was too sharp and we were afraid of perforating something. Finally, we took a needle and jabbed a hole in the side of the IV tubing and were able to feed the stone basked inside the IV tubing. With Dave guiding through the scope, we fed the IV catheter down and deployed the basket. It grabbed the stone and we were able to pull it out, albeit with a fearful tug to deliver the beast through our hole. Dave confirmed via the scope that we were clear. The guy did well and we will see him back, hopefully in a week or so, to pull the drainage tube from his bile duct. 

We’ve had several other “bush league” shenanigans here at Soddo. Last Tuesday morning, Dave called me at 0330 about an 18-month-old girl who was in respiratory distress with an aspirated bean. Apparently she had aspirated the bean almost a week ago, but had been languishing in another hospital while be unsuccessfully treated for bronchitis. The kid was now nearly obtunded and struggling to breathe in the ICU. We rushed her over the OR with the video scope equipment and pulled out our rigid pediatric bronchoscope. Actually, come to think of it, Wayne Koch donated this as well. That guy has saved a lot of people here! This thing is a true lifesaver. Basically, it is a metal tube that can be placed in the child’s trachea through which a scope somewhat like that used in laparoscopy can be passed. Additionally, you can attach a ventilator to the tube as well to deliver oxygen and anesthesia. There is also a grasping forceps that slides over the scope and can be passed down the tube and used to grab offending items for removal.

We gave some light anesthesia to the child, but allowed her to keep breathing for herself. Using the same technique to intubate someone, we placed the bronchoscope into the child’s trachea. It was challenging due to the voluminous pus in her throat and gasping, but it slipped in, thank God. I’ve had some babies that are so small the tube almost didn’t fit. Inside, we had to suction out a lot more pus and were finally able to slip the scope down the tube. It was a mess and hard to see, but we finally saw what looked like a bean in the bronchus heading to the right lung. Unfortunately, for reasons we still haven’t ferretted out, the scope wasn’t working well and the vision was really foggy – couldn’t fix it. It took several near-blind grabs, but we finally pulled out most of the bean and the husk. But the bean had been there long enough that it was falling apart. A small little piece was still down there, now in the bronchus heading to the right lower lung. The bronchus was just too small to admit the forceps. We weren’t sure how to get it out.

In a similar desperate grab, we decided to try the stone basket thing again. Except now, there was no room for the IV tubing gig. And we were afraid that the same type of basket was just too big for this space. So we found another stone basket that worked a little different. When deployed, this one extended four little tines that spread away from each other and had tiny little hooks on the end. With it open, you could hug it up next to a stone and, as you close it, pulling the tines back in, it grabs the stone. It might work. Getting it down there was, again, the problem. So we took some suture and tied it onto the scope, so that the stone basket would go down right next to the scope. Unfortunately, the dang thing was so foggy, we couldn’t see.

So Dave suggested our old friend, the laryngoscope. He ran off and brought it in. We lashed it up with the stone basket, the two things tied together, and we attached a camera head to the eyepiece, letting us watch on a monitor. It worked like a charm. I’m telling you, this thing is golden. With a nice, clear picture, we were able to get down there next to the chunk of bean and carefully deploy the stone basket tines under direct vision. One of the little hooks managed to beautifully snare the fragment (which was actually three little bits barely held together by vegetable fibers), and we pulled everything out together. The little girl had a roaring pneumonia, but she responded great to antibiotics and went home about four days later. God was so gracious.

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Here’s your bunny buffer warning. Venture forward at your own risk.

Part IV – Wild and crazy operations

We have had some challenging operations lately. Most are related to having a visiting plastic surgeon and tackling things I wouldn’t normally do.

First is a young woman who came to the hospital with a terrible tumor involving her entire right cheek, half of her upper lip, and most of her lower lip. It was terrible and disfiguring. With Joe’s help, we were able to remove the tumor, including several teeth and a rim of bone from her mandible. The real challenge was putting her back together. Again, we took skin, fat and muscle from her chest (pec flap) and brought it up to her face. This time, we flipped the skin inwards and used it to recreate the lining of her mouth/cheek. We were also able to fold part of the chest skin outwards and somewhat recreate the corner of her mouth. I won’t pretend she looks great (still think mad scientist), but it is a lot better than before. We initially planned to bring up a flap from her shoulder to reconstruct the outside skin of her cheek. But in the OR, it was evident that it wasn’t going to work. With the pec flap in place, the outside of her cheek was now the underside meat of her chest flap. So we harvested a full-thickness skin graft and put that in place. We took the dressing down the day before yesterday and it looks good. Again, not good per se, but better than before. 

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Pre-operative

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Post-operative

We also tackled a poor lady with a huge, fungating tumor on her scalp, in the back right of her head. It was a horrible thing to live with. By God’s grace, it was not invading her skull and we were able to remove it without too much trouble. Again, the challenge was putting her back together. Joe performed a complicated set of flap rotations developed by a guy named Orticochea and was able to get things closed with appropriate coverage. She is doing so well and it is humbling and heart-rending to see how happy she is.

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Pre-operative

 

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After resection and a few days of wound care. Must have coverage of exposed bone.

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Scalp flaps raised to reconstruct defect

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After suturing in flaps and skin grafts

The last I will mention was an absolute beast of a case. This poor woman came with a huge abdominal mass, and was malnourished and miserable. She couldn’t afford to go for a CT scan so all we had for pre-op imaging was the portable ultrasound in our office. All I could ascertain was that it was… well, huge. It didn’t seem to be liver or kidney. But other than that, all bets were off. We explained that we probably weren’t going to be able to remove it safely and that in all likelihood all we could do is biopsy it. But she was desperate and wanted to try.

This is a tough area where I admittedly go back and forth. I don’t want to give up on people too early, but I don’t want to just hurt people either. Sometimes, especially with such poor pre-op work-ups, it is hard to know where to draw the line. But I felt like a biopsy wouldn’t be unreasonable.

We took her to the operating room the day before yesterday and started with a small incision. The mass seemed to be in the retroperitoneum on the left side (back part of the abdomen, behind all the bowel). Feeling around, it was evident that it hadn’t spread throughout the abdomen and seemed somewhat mobile. It felt kind of fatty and there were several other smaller fatty tumors. My initial hunch was that it was a malignant fat tumor. If we could get it out, it probably wouldn’t cure her, but it would certainly palliate her due to its large size. The question was whether or not we could safely get it out. There are lots of dangerous things back there in the back part of the abdomen. I called Dave out of the other room where he was working with Joe on a child with burn contractures to get his advice. Sometimes courage needs a little help. Dave encouraged me to just try, so long as it came easily.

So we started dancing around the edge of it. We started by rotating the left colon and its blood supply off. It took close attention, but it gave way easily enough. Bit by bit, we kept working at it, slowly circling around the thing when one area became tough. Dave eventually came over and scrubbed in to help. At one point, it was dicey that the blood supply to the small bowel was involved, but we were able to clear it off. Eventually, we found what looked like the left renal vein going into it – a very big, very fat, very short renal vein. We moved back over to the outside and felt the kidney. I tried to find a plane between the tumor and the kidney – but it wasn’t happening. Further work revealed that the kidney was definitely abnormal and it felt like hard cancer. So much for my so-called ultrasound skills.

At this point, we felt like full disclosure was needed. Something we could probably never do in the U.S., we asked one of the nurses to go get the family. A few minutes later, one of the family members came into the room wearing OR clothes, hat and mask. We showed him the huge thing sticking out of her open abdomen and explained that we were nearing a crossroads. We felt like we had a chance to get it out, but it was about to get really dangerous. There was a real chance we could get into something terrible and she could die on the table. He affirmed that she did not want to go home with that tumor, even if it killed her. He asked us to try.

I have to be honest with you. Even when you have permission to murder someone, it doesn’t make it any easier to do so. I haven’t been as scared as I was in that operation for a long, long time. And lest anyone think I’m being melodramatic, this stuff happens. I am still haunted by the death of our house worker’s sister after a complication at my hands while trying to remove a huge tumor of her carotid artery.

But God was very gracious. We were able to safely take the renal vessels and avoid other dangerous things. In the end there was gaping cavity where her tumor and kidney used to be and she was missing a fist-sized chunk of muscle in the back, with exposed ribs and spinal column. It took seven hours, but the beast was out. She is doing well so far. Please remember her in your prayers.

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Tumor held by scrub nurse

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Tumor with scalpel handle on top for size comparison

As ever, thank you all for your love and support. God bless you and may Jesus return speedily.

Paul

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