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.