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!

Honeymoon is over!

september 29, 2008

They say that time flies when you are busy – well, in Port Harcourt time is supersonic…
I promised to walk you thru a day at work; why not start at the major source of work? On our daily bike-spotting on route to Teme we yesterday spotted a bike with six passengers – a single bike accident here can render more victims than an average bus accident at home!

We arrive at the hospital around eight and immediately start rounds. We are eight medical expats (five doctors, three nurses, and one physiotherapist) and we join forces at the hospital with national doctors and nurses. First the emergency room (ER) to see what has happened during the night; sometimes nothing (once!) but usually quite a lot. Next is the Intensive Care Unit (ICU), which is a little different from the ICU at home. To be honest, I don’t quite understand what is so “IC” about it, but there are more nurses around and they do their best to regularly take the vital signs of the patients. Sometimes corrective measures are initiated, but sometimes those actions are slightly suboptimal.
We next proceed to the wards; there are around 75 beds in three wards, separated by level of infection (green, blue and red). I do my best to assess pain and to adjust pain medications, but the work is sometimes just overwhelming. Besides, we have the current operating list to attend to (usually more than ten cases each day), and I must prepare and check the two operating theatres (OT).

For almost a week I was blessed by the company of dr Albert (we all go by first name here; I don’t even know his surname), a Canadian anesthetist whom I was replacing. The work didn’t seem so bad at the time, but when he left, and Paulinus (a local anesthetist nurse) was off duty for three days, I got thrown into reality. Please see the picture for the daily operating list; twelve patients of which four gunshot wounds (GSW) and the rest road traffic accidents (RTA). The fractures are typically quite complicated and many/most are open (with bone penetrating the skin). I won’t shock you with nasty pictures, but instead show a typical X-ray (maybe equally nasty…) of the lower leg after a gunshot. There have been a few days when we have not had any traumatic amputations…

Operating list

Gunshot wound

Most of the cases are done in a spinal (injection of local anesthetic in the back to anesthetize the lower part of the body), or sedation (which here is actually full blown anesthesia but with ketamine and thus (almost always…) preserving airway control). Complete anesthesia with intubation (airway control) is rarely needed (maybe once daily). Ketamine takes some getting used to (about half a day with the workload here…); the patients are in a dissociative state and can look up and sometimes talk (incomprehensible), but there is no pain or awareness, and the airway is relatively intact.

Well folks, that’s all for now! Next time I think I’ll tell you about my first laparotomy (abdominal operation) and how the OT is like.