Hospital_edit The day started simply enough, four or five patients referred for "the Professor's" opinion. (I love that - makes me feel like one of those old time European guys). We scheduled some resonable cases for the next few days and then went off to do the first of two scheduled for today. The first was an 80 year old man with a large mass attached to one testicle. It was not possible to determine pre operatively if it was benign or malignant but it was hurting him. Given the option of living without the pain and one testicle he enthusiastically chose the surgery. The anesthetist gave a super smooth spinal and the surgery went off without a hitch - almost. Near the end of the case our overhead surgical light died. It wasn't a big deal because the room was well lit from other sources and we were working at skin level when it happened. The next case was to start soon after but without the light - no way. Four hours later we finally got our light working and began the case around two thirty in the afternoon. This was a 24 year old male patient who had evidently been suffering with a partial intestinal obstruction for four years. He was almost emaciated looking with a hugely distended abdomen - not unlike the pictures you see of starving children. But this abdomen was filled with blocked gas in the intestine. Lacking any facilities for making an accurate anatomical diagnosis and going on history and physical examination and a poor quality abdominal x-ray we opened tha abdomen to find not the three foot large intestine dilated as I had expected but rather the entire 20 feet of small intestine. Normally the diameter of an ordinary household candle, these loops were the size of dryer vents, Once out of the abdomen there was no way they were going back until they were decompressed. The obstruction turned out to be a twisted loop that had been ignored for four years with the patient having spent the last month in the hospital undiagnosed. This is unacceptable by any standard. Emptying the small bowel is a difficult, dangerous process the details of which I will spare you. Midway through this process all lights in the OR went out leaving us with the window light of early dusk. We then found out that the person responsible for turning on the generator in such instances was nowhere to be found. No flashlights were available. We continued until most of the fluid and gas had been removed and then closed the intestine. Fortunately I had brought a modern bowel stapling device with me so I didn't have to waste a lot of time sewing it. We were rapidly heading toward darkness. There was one more thing that had to be attended to and that was placing a drain tube in the stomach. Otherwise the gas could re-accumulate before the intestine regained its function. The easiest way to do that is to pass a tube into the patient's nose and down to the stomach and tape it in place. These tubes cost about a buck and a half and are standard equipment in every OR and ward. Not here. The anesthesiologist seriously suggested that we send a family member out to a medical supply place to buy one. I declined and went for the other approach - a tube directly through the abdominal wall into the stomach using a baloon urinary catheter that was available. The problem now was that I could barely see under the incision to place the tube into the stomach and suture it securely. It was only because I have done this maneuver hundreds of times that I was able to pull it off, practically by Braille, without spilling stomach contents all over the abdomen which would have been a disaster. I quickly closed the deep layers of the abdomen and then in near darkness my assistant closed the skin while I fixed the stomach tube in place. Elapsed time - two and one half hours. The whole thing should have taken less than an hour and been finished before lunch.
The sad part is that I don't have any of the fluids or equipment to provide the concentrated intravenous nutrition that his patient needs and he could just starve to death before he regains intestinal function. Catherine asked me what the patient's chances were and I told her at home you could count on him walking out of the hospital. Here and now the chances are under twenty five percent.
This one case points up so much of what's wrong here. The equipment problem has gotten worse. Things like NG tubes , suction equipment and functioning, reliable lights should be available. They don't cost that much but nobody cares enough to see that they are on hand. It's easy to blame the administrative personnel but I accuse the doctors. The same physicians who let this boy languish with an obstruction all that time can't get it together to make sure they have basic equipment. There is one cardiogram machine in the hospital and it is in the office of the physician/administrator who never sees a patient. The excuse you hear over and over is "Well, this is Africa. Things will get better poli-poli (little by little.)" Well, people, poli-poli isn't cutting it. I've been away from here over a year and from what I see things have gotten worse. They've gone from an occasional power outage to four or five a day with no improvement or even deterioration of back-up capacity. The conditions in the wards are dreadful. Most even lack a place to wash your hands. Some improvement is noted in the availbility of pharmaceuticals but most of this is through donations. The medical record system is atrocious with almost no ability to trace a patient's history. Pathology services are non existant and lab and xray are rudimentary when available at all. They have allocated a fortune to build a new surgical unit which will be beautiful but how can they use it when they lack the ability to supply the unit they already have? When built it will be a showplace to display to visitng dignitaries who have no idea that it is an empty shell providing the same crappy care as the old one.
OK, enough ranting for one post. What's my role in all of this? For now I'll just continue trying to provide for one patient at a time as best I can. But before I leave I'm going to make sure someone high up who just may care knows exactly what I've seen and how I feel. Maybe that someone will get that it doesn't have to be this way.
Do you have any sterile iv fluids to give? There is some reasonable data that gum chewing causes vagal stimulation and helps to resolve ileus postop. Might be a low-budget fix. Maybe he can tough it out without opiates (anything to spare motility) and ambulate early... Good luck.
Posted by: Ara | June 25, 2008 at 03:48 PM