Life goes on

oktober 24, 2008

Greetings!

It’s Sunday again and I actually have the day off! I’m spending the day at the house and just enjoy doing absolutely nothing for a change. Strange feeling! The house is in the nicer quarters of the City and I’ve only heard gunfire in the vicinity a couple of times… I have my own room and the ground service is fabulous; housekeeping, laundry and food are all taken care of by the logistic side of the Organisation. They have the explicit orders to do everything possible to enable us in the medical team to do our work as efficiently as possible – I wish the administration at my hospital at home had the same instructions and goal! The food is exceptional and delivered to the Hospital every day. The mission does not offer any hope of losing weight and I have to get the recipe for that homemade pizza!

The mission has tight security rules, but we are allowed to leave the house during daytime as long as we clearly indicate our association with the Organisation with T-shirts and logos. Kidnapping is a major source of income for some elements of society, so all movements and whereabouts must be declared and approved ahead of time, and we shall always be reachable

In the busy city of Port Harcourt, there is no social security and no one but us will take care of you if you don’t have the money. So when receiving a case it was never  an option not to treat the patient.

Preparing for a case I decided on a battle plan based on our airway algorithm from home. I prepared the equipment at hand and told nurse P what was happening in case I needed help. Anyhow, I was confident that I could open her mouth once she was asleep and muscle relaxed.

I was wrong… Her jaw remained locked rigid, but on the positive side was that she indeed was easy to ventilate and somehow I managed the airway with the help of a bougie – again, I don’t know if I did right or wrong and in retrospect I wouldn’t do it again, at least not without prior discussion, more equipment and, most of all, a red button…

Since my last post I have been joined by a French nurse anesthetist, and that has really changed things. We take turns for calls and just to have someone to discuss with makes all the difference. It’s only a couple of weeks left of my mission, but now I can for the first time relax a little and even get some administrative work done! Just like home reports have to be written, statistics compiled, and inventories made. Life goes on…

In my next post I’ll try to wrap things up and answer all your questions. Keep ‘em coming!

Starting to settle in

oktober 13, 2008

Hello again!

Last week’s description of the OT is not at all the weekday daily routine. It’s actually quite organized and not too unlike home. We finalize the operating list in the morning (and then modify it endlessly during the day…) and then set off to the OT. On a normal day it’s me and Paulinus and we take one theatre each, and do the cases as they come. The patients are delivered to the corridor outside the theaters on stretchers by an army of stretcher carriers; no trolleys or elevators at Teme!

For many cases I opt for a spinal and then try my best to explain to them what is going to happen. I now found out that my efforts at informed consent were largely in vain, and I’m better off pointing to my own back saying “injection” and then to their legs saying “no pain”. That seems to do the trick and they are all without exception extremely cooperative and even relaxed – I don’t know if I would be equally relaxed if I were in their place; badly wounded and with strangers that don’t talk your language to trust with your life. Anyhow, once the spinal is in place and the pain is relieved, most immediately fall asleep. The surgeons then do their thing; mostly external fixations and debridements (from minor to beyond major!), but we also do internal fixations and general surgery. When working on the upper extremities a ketamine sedation/anesthesia will often work, but in some cases intubation and airway control is of course inevitable.

At home there is a red button on the wall. If I’m in trouble I’d press the button and then take cover as within seconds a steady stream of world class anesthesiologists would pour into the room from every available door. At Teme in Port Harcourt there is no button. I use my skills and knowledge. We work as a team and finally we do a good, safe standard of work for a population tha would otherwise have no-where to go!

PS. I attach a picture of the wall of the OT; which emergency tool (the fly swatter or airway bougie) do you think is most frequently needed?

OT emergency tools

OT emergency tools

PSS. In my next post I think it’s time to describe our excellent living conditions (really!) and equally exceptional food!

PSS. It seems my mission is extended four weeks – great!

As I finished with in my last post, I got brutally thrown into reality when dr Albert left and Paulinus was off for the weekend. The surgical team (general surgeon, orthopedic surgeon, and I as anesthetist) work all days of the week and we’re always on call; so far relieved only approximately one night every two weeks. We’re supposed to have Sundays off, but today it’s Sunday and I just spent my 17:th consecutive day at work…

This particular Saturday we were doing a laparotomy on a ruptured spleen (great call dr Wiji!). I had my week of learning so I felt pretty relaxed and started the work enthusiastically.

Let me describe the setting:

We were called to the ER for a traffic accident. Due to the prevalence of malaria an enlarged spleen is quite common and prone to traumatic damage. Dr Wiji (the general surgeon) examined the patient and determined the correct diagnosis without any X-rays or lab tests; just the history, examination and the vitals – I’m still amazed at that. The patient seemed quite stable with a pulse around 80 and normal blood pressure and as almost all patients, young and fit. I had to do a preoperative assessment and investigation. The history and examination was done in a couple of minutes and I then had to pick what laboratory tests I wanted! That was quite easy as the lab only offer Hb (blood value), blood group and screen for safe transfusion, blood sugar, and malaria. The lab-tech was off for the weekend so I had to do the tests I wanted myself. I took some blood, found the keys to the lab and did the Hb (96 g/l) and blood group. I had never done it myself before, but it’s not rocket science: take three drops of blood on a white kitchen tile, add reagents, mix and see what antigens the patient carries. Open the fridge and see what the blood bank has to offer. Take your pick of compatible blood and do a cross check on the actual bag you choose and you’re ready to transfuse!

I did as we do at home and prepared the patient with two large bore IV-lines, checked my airway equipment (a laryngoscope, tubes, oropharyngeal airways, masks and bougie), prepared my drugs, made an action plan and backup plans, and put the tea-kettle on (that is, to get a bucket of warm water for the blood and IV-fluids). We were four people in the OT: myself, dr Wiji, an OT-nurse and an OT-assistant. Just then I suddenly realized that now I’m all alone as the only anaesthetist; no one to help or assist me, no one to fetch and find things or to set up and check the OT and equipment, no one to back me up or relieve me, no one to think for me when needed. I had trouble even reaching my cupboard with the stock of drugs and equipment as I had to manually and continuously ventilate the patient (the OT isn’t equipped with a ventilator).

The induction (with ketamine) was uneventful (dr Wiji injected and kept the cricoid pressure; it’s mandatory); but soon thereafter I got busy. The diagnosis was of course correct and there was roughly 2 liters of blood in the abdomen. I had from the ER given about 2 to 3 liters of fluid, but I reckoned it was time for another Hb: 59 g/l (low bloodcount)! The patient was still not so tachycardic (far less than 100 beats/min) and I still don’t understand why! Maybe his normal blood value was the original 96 g/l due to malaria and that I successfully transfused him to a normal volume but in so doing diluted him? He should still be tachycardic though!?

As you may well understand (and as I also suddenly understood): here I was aggressively transfusing, warming fluids, doing Hb checks, mixing and administrating drugs, maintaining anesthesia (with halothane using an OMV; thanks EDA-exam! (for the anesthetists of you)), checking vitals, taking notes of everything, and continuously ventilating the patient. As if that was not enough, I had to once set off to hunt down a mosquito!

Everything worked out and the patient woke up after the operation; he was a little (well, eh, actually quite extremely) tired and cold… The first I blame on me, my drugs (especially the halothane) and the temperature, the second was inevitable and I saw it coming; despite my efforts to keep him warm he had a temperature of (close your eyes at home!) 34.3 degrees! The next morning he was warm, stable and after another day ambulatory and eating.

After all that I have said its important to note that despite the basic standards and equipment the results are mostly like this case. Positive. For the patients who reach Teme alive nearly all stay that way and receive a standard of care not available elsewhere in the region, free of charge. Next week I think I’ll walk you thru the normal working conditions as they really are quite different from the laparotomy above.