Day um, 24 I think?

Bless me father for I have sinned. It has been almost two weeks since my last confession...

So I have been negligent when it comes to this blog. And I apologize. Not last Sunday but the Sunday before, I moved into a new place. Previously I was staying in a hotel, which was great because clean room, hot shower, free breakfast and good Internet. Bad because the price, while as expensive as your average Motel 6 in the States, was still above my budget. So moved into the house of a couple of US docs here. No hot showers,  not as close to the hospital, and my excuse for being negligent: the Internet is much worse. 

But this is the view:

And we have a housekeeper named Monique. Monique makes crepes. Monique also does laundry. And irons my underwear, even though I tell her not to. Casey could learn a lot from Monique. 

Not much different to say about CHUK. Still ridiculous wait time for patients to get care. I have been learning to multitask and operate while performing anesthesia. Often I will look I over and try to tell the anesthetist the the blood pressure or O2 sat is too low and how to fix it. Little crazy. 

My operating room. The black stuff on the ceiling is, um, smoke. Yeah, smoke. Not mold, that would be crazy...

Crazy things I have seen lately:

Yes that's a femur in an above the knee amputation. And yes it is supposed to be on the inside. 

The rare scalp urinary catheter. For the patient who pees out their blowhole. 

A little bit of free air and fluid. Perforated gastric ulcer that had been hanging out for about a week. He did fine after we repaired him. Oh, and I got to treat his gonnorhea too. BONUS!

Will be more diligent about posting. Off to get lost in Kigali. 

Day 9: Goats gave their lives for this.

So pretty slow on Saturdays here. Just a skeleton crew to do all the work, no "consultant surgeons" -- or in Americanese: "attendings" -- show up for work, usually. I came on in to figure out how things work on the weekend and to see if I could help. The only thing really going on was a simulation lab on thoracic surgery that was being put on by Dr. Tom Daniels from UVa. He has been involved in the thoracic surgery boot camp, so he put the surgical residents through the paces. They performed five procedures on the viscera from some freshly-killed goat from the local abattoir.

Here two residents are practicing performing a Nissen fundoplication. This is made a little more difficult  by the fact that the residents also need to pick the correct stomach fundus; goats have four of them. Usually Dr. Daniels does these sims with pigs in the United States, but pork is hard to come by here and thus is expensive.

Plus: goat brochettes afterward.

Day 8: Okay, fine, medical stuff too.

So fairly uneventful day. Salvador, the senior resident on the service I am on is post call and looked a little dead. Long hard night. Just before I left the night before there was a guy in the A&E (accident and emergency department; quite British and sophisticated) who looked to be in the late stages of brain herniation after sitting around for about a day. Salvador and the on call neurosurgeon took him back, did a craniectomy and evacuated 500 cc's of clot, and sent him to the icu, where he went into cardiac arrest and died. Dammit, stop that...

So Salvador is tired. Salvador also looks a little like Eddie Murphy. Salvador is secretly the crown prince of Zamunda. "Bark like a dog..."

Had a plastic surgeon come here for the day from another local hospital. Looked at some cases with him that we wanted input on: melanoma of the foot, facial burns, and a 5 month old child with a large sarcoma on his left forearm. Should be resectable, is the good news. He may have some deficits in extending his fingers, but his tendons could come out of this just fine. 

I know, it's a little graphic, so sorry. But think it is important for people to see what people are living with and how some good can be done here by just getting people to the doctor faster. 

To make up for that, here is a random picture of a kitten:

Happy Friday everyone. And impressive showing by Peyton Manning yesterday: seven touchdowns in a game has not been done since 1969. 

Day 6: Get used to the feeling.

Barring an organ procurement where it is obviously expected, I have never had a patient die on the table in the operating room before yesterday. I was told to get used to the feeling.

A man in his mid-twenties was involved in a motorcycle accident. Not sure what time, not totally sure of the mechanism. Some reports said that he was hit by a car. Came into the Emergency Room, and the General Practitioners there gave him about 1.5 liters of fluid. Think he got blood as well, but not sure. When I came into the ED at 7am, an American ER physician was just taking over his care. They were trying to intubate. No blood pressure, had a carotid pulse, but no others, and couldn't get an O2 saturation. He had a massive injury to his perineum that he was exsanguinating from. No other large injuries. The ED docs got him intubated, and soon after we lost pulses, and had to start CPR. Pushed epinephrine, the only drug we have in a code, it seems. Worked though, we got him back that time. We took him to the OR as fast as we could.

Got him on the OR table, and he coded again. More chest compressions, more epinephrine, more volume given. We now have blood available, and he gets it. Get his legs up in stirrups so we could access this perineal injury. Trauma ex-lap found only a large retroperitoneal hematoma that was extending from his pelvis all the way to the SMA. Turned our attention to the still-bleeding large hole in the man's perineum. It is approximately 5 inches, right next to the anus, and a steady stream of blood is pouring out despite the packs we put in there and my hand holding pressure. Rectal wall has been sheared off to the mucosa, but not fully penetrated. The hole extends into the pelvic retroperitoneum and the sacral plexus of vessels is bleeding. Try to cauterize what we can, try to tie off what we can, decide to pack and get out of there as quick as possible. We intraperitoneally pack the pelvis, pack the wound, and close skin on both sites.

Anesthesia can't find pulses. PEA arrest. Two rounds of chest compressions, epinephrine. Nothing. We keep going. Nothing. Twenty minutes later we call it.

Oh, and a two-year old kid with 50% of his body surface area burned who is on our service died the night before. Probably pneumonia.

Went to bed fairly early last night. Got to get up now and get back in the game. It's 4:30 am.

I've decided to not let myself get used to that particular feeling.

Day 5: CHUK hospital

So I was right: there was as much confusion as I thought there would be yesterday. Got up early, walked into CHUK. Hospital is made up of what are essentially one story barracks. The grounds are meticulously maintained by a hive of workers that are constantly grooming and cleaning. 

Every patient is helped by a "caretaker," a family member  that stays with the patient, cleans them, makes food for them, everything. What is amazing is how all the caretakers will take care of not only their family, but also the person in the bed beside the patient they are here to see. But not only that, the caretaker must go and buy many of the supplies, like exam gloves, for their family member. You learn not to waste even the littlest things very quickly, when you realize how it really is coming out of the pocket of the patient and their family. Caretakers also are responsible for getting tests done. The machine that does a test known as a "complete blood count," a test we get in the USA at least once a day, is not functioning. So to get this test done, a patient's caregiver must get the blood and the proper paperwork, get on a bus or the ever-present motorcycle taxi, and then drive across town to another hospital with a working machine and deliver the sample. Then they must get the results and come back to CHUK. This process can break down in any of a number of places, literally. 

The emergency room is mass chaos. One, its not really an emergency room: it's a hive of wards, each with about 20 patients crammed into a space the size of my living room. Patients are being moved constantly. Work ups are non-existent. Nothing is acute, even traumatic injuries have been there for days before they are seen by surgeons. GPs run the ED, and they are overwhelmed with no resources. Most patients are first seen at a district hospital before being sent to Kigali, so there is usually a delay of days to weeks before they arrive here. 

You constantly are saying to yourself, he sat around for how long with that? How has he not been to the OR yet? For example, today my Rwandan-speaking colleague was stopped by a patient about an iv that was backing up. As he was talking to this guy, I noticed clear fluid dripping from his right ear--he had been in a mototaxi accident, and had had cerebrospinal fluid dripping from a basilar skull fracture for days ("for the first two days, blood was coming out, now this fluid is leaking out." Unbelievable.) No head CT. No neurosurgeon consult. 

Things seen yesterday: open dislocated thumb joint from two weeks ago that now was draining massive amounts of pus. A 90 year old lady with a displaced hip fracture who comes in with huge decubitus ulcers. 75% total body surface area burns. Dead foot needing amputation. A huge tumor of the liver that was able to be diagnosed by palpating of the abdomen alone. 

Today: guy after an accident two days ago with this cervical spine x-ray: 

That's a C4 on C5 subluxation with complete spinal cord transection. Couldn't move anything below the neck except his shoulders. More dead feet. An eight month old boy with 50% TBSA burns that were three months old. Chronic malaria infection resulting in a spleen that fills half the abdomen. 

This all can create a sense of hopelessness in the situation. What can I do in the face of this burden of disease that has remained untreated for so long? The Americans here are not trying to teach diagnosis, or better surgical skills; these guys already have those things. They can do more in the operating room with much less than we can. The Americans are trying to implement a culture change, an attitude that says it is not acceptable for these patients to sit around for so long. Organization. Breaking down the roadblocks that prevent care from occurring. 

Let's see if this change can be done on a faster time scale than geologic.