The end is near

november 5, 2008

Hello again!

Yes, the end is near and inevitable – in fact, after 10 weeks in the City I’m now on my way home! It’s been an extreme challenge with many and lasting impressions – actually way more than I had anticipated. I’ve learned and been exposed to so much that I don’t know where to start now that I have to summarize it all – in many aspects it far outweighs my previous 4 years of experience from home. Let me give you some numbers to put things into perspective:

During my 68 days in the city, I’ve worked 67 days (of which 51 consecutive) and 12 nights. I’ve done 122 cases under general anaesthesia (47 with intubation), 119 spinals, 23 laparotomies (11 during night), 1 thoracotomy, and each and every day except Sundays I’ve done pain rounds on approximately 65 pre- and postoperative patients. The EU law on working hours is as you understand not implemented here… BTW, did I say in my last post that I had the Sunday off? Well, that turned out to be not entirely true. At 00.10 the phone rang; the local anesthetist (out of approximately 10 to 15 in the whole City with a population of about of 2 million!) could not be on call and we had to go in and do a laparotomy on a pelvic gunshot wound. The patient was relative stable, but the blood bank fridge had little to offer – at the end of surgery he had an Hb of 42 g/l! Well, he made it, and a week later he got discharged home. I guess though that we won’t accept him as a blood donor for months to come…

Now for your questions that I promised to answer; first come first serve!

Rik: Yes! Let’s get wet when I come home – I can use some serious R&R! I’ll call you and you better stand up to your offer!

John: Well, now I’m on my way home as you can see and I also hope your food question has been answered. Yesterday it was Thursday and thus time for my weekly dose of mefloquine against malaria. Doxycycline is an alternative as some people have psychiatric side effects to mefloquine. However, I haven’t jonglerarnoticed anything; I’m completely normal, anybody saying the contrary has joined the conspiracy, nobody saw me, I’ve got an alibi, my friends made me, and does the voices in my head bother you?

Steffo: I think I have fully succeeded in one of my original goals, but the other goal has been a complete and utter catastrophe. I’ve rarely made it home before dark and it’s mostly been raining anyhow. However, indoors I have been able to perfect my 5 ball act somewhat, outdoor juggling has been impossible on all but a few occasions (see picture; and notice the Swiss leader on the top; thank you PPD-gang!). I guess my dream of 7 will be one that I won’t fulfill; and definitely not during this mission.

MJ: My previous experience with ketamine was extremely limited. I had the textbook knowledge, and I can remember using it twice: once on a ruptured aorta, and once on the field at the scene of a motorbike accident. I know it’s more widely used in other places, but by tradition (?) not so at my hospital at home. I definitely think I’ll now use it more frequently on severe traumas; I can in retrospect remember several cases that probably had been better off with ketamine. But one must remember that our resources are infinite at home; we have blood and fluid delivery systems that can keep up with virtually any blood loss, and our human resources and infrastructure is all but limitless. I know you folks at home might not agree with me on that; but trust me, we are extremely privileged.

Uffe: Yes, a bougie is same same as the blue thingy on the wall. It’s used to guide the breathing tube between the vocal cords when it’s tricky to get it down in the right place. It’s my favorite airway tool and I use it frequently, maybe too frequently as I should probably fiddle around a little more to get the perfect view without any additional tool. But, I’ve got a lifelong learning curve, so in a couple of years I might find myself using it less frequently. Thank you also for your warm and generous support to me and the Médecins Sans Frontières – you’ve probably already have more lives on your conscience (in a positive sense) than most!

Well, that concludes my story from my first mission with Médecins Sans Frontières! It seems like I’m off to my second mission in two weeks; this time to a country plagued by civil war and harsh weather. It’s not yet finalized and many changes might come down the road. I’ll continue this blog and add new posts; check in again in a couple of weeks to find out what’s happening!

Finally and again: thanks for all your support; I now understand just how much it means. Keep it up and I’ll try to do the same!

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.