I’ve just completed day one of surgery on this mission. We are scheduled to have four full days of surgery and then a half day on Saturday. There are seven tables, two are for teaching and therefore will go a bit more slowly, and the last table is for cases that can be done under local anesthetic. All the surgeons rotate doing the “local” table; some love it and others would much rather have the patient asleep. The “half day” on Friday may be more like a 2/3 day as there are lots of patients, many of whom have traveled great distances to get here. We’ve seen quite a few patients from Togo, the small African country, not the island. Its border is only about 8 hours from Ho, and there are no cleft surgeons in Togo.
On Monday, Kathy, a pre-op nurse and I went to the hospital at 5:50 am - about 45 minutes ahead of the rest of the team - so that we could get the first two rows of patients ready for the surgeons. The night nurses had done a great job with hydration, waking the patients every two hours to give them dilute juice. Many parents don’t want to wake their babies for fluids and then deal with getting them back to sleep, (never wake a sleeping baby.) It takes a skilled, determined nurse to get 37 babies, toddlers, kids and adults awake enough to drink dilute juice three times between midnight and 6:00 am and remain cheerful about it. If you don’t maintain hydration in this heat, especially in the babies, the anesthesiologist may not be able to start an IV and the surgery will be cancelled. That was exactly what happened today to a one year old who is here to have her palate closed. Ella, the local pediatrician who is a second-year pediatrics resident in her real life - and I were called to the OR with the message that they “needed help.” We ran over, fearing the worst. A call to come to the OR usually means some catastrophe – cardiac arrest, massive hemorrhage or allergic reaction – where additional experienced hands are needed. When we arrived, we found six people surrounding a baby who was asleep on the OR table. The anesthesiologist was keeping her just under with inhaled anesthetic while two surgeons, two other anesthesiologists and the pediatric intensivist tried to get an IV going. Ella and I joined in, each grabbing a limb while one of the surgeons started swabbing the groin and eight of us searched for veins, poked in IV catheters and tried to advance them, for another 40 minutes. Someone shaved a patch of hair looking for a scalp vein and the surgeon tried to get into the femoral vein, a big vein in the groin. We looked at her external jugular veins, but even they were not obvious enough to stab her there. In the end, her surgery was cancelled. If possible, we’ll try to get her on the Wednesday or Thursday schedule. There were 39 patients on the schedule for Monday, including those on the “local” table. Having this extra table where older kids and adults with lip clefts can have surgery with just local anesthetic, without added sedation, means that about 35-40 more patients will have surgery this week. If we had to tie up an anesthesiologist and allow for time for the patients to be “put to sleep, awakened and “recovered” in the recovery room, the number would be cut in half. The fact that these patients are willing to undergo this surgery with just shots of lidocaine into their faces shows how desperate they are.
The first day is always long because both the OR and the ward staff run a “mock code” so everyone knows what to do if a child had a serious event – respiratory or cardiac arrest, severe bleeding, serious allergic reaction. It’s my job to do this for the ward, and it includes going over the “crash box” that has all the emergency drugs, making sure they’re all there, and reviewing the roles of the team members. In an emergency, the child is moved to the “crash bed” by the nurses station where oxygen, the crash box, defibrillator and all other necessary items for disaster are kept. A child can also go to this bed just for close observation for breathing difficulty or more than mild bleeding after surgery. Because of these “last details for the first day of surgery,” the surgeries on the first patients usually don’t begin until around 9:00, an hour and a half later than on subsequent days. This, of course means the day will end later. The last patient arrived on the ward at 10:30 tonight and we were back at the hotel at 11:30. Hans and Ella and I decided to divide up the late nights – an amazing luxury that I’ve never before experienced. I took the first night, Ella will stay on Tuesday and Hans on Wednesday. On Thursday, I’ll stay again.
One of the early kids to come to post-op this morning was an 18 month old palate patient. His oxygen level was slightly low at 85%. As soon as his mother put him down on the bed, his oxygen dropped to 70%, he woke up and began thrashing about, kicking and screaming. In one of those unfortunate coincidences, his Mom was not calm and helpful in a crisis but instead became an adult version of her child. He, of course, followed her lead and was soon hysterical with an oxygen level of 60%. We took him to our crash bed and opened the crash box and tried to get oxygen on him. It was like trying to put a mask on an octopus. He kept grabbing for his mother who would snatch him off the bed, wrap him in her arms and loudly plead with him not to die. Soon a crowd of parents and kids gathered around the bed calling out advice, encouragement and exhortations against death. With the boy’s oxygen at 58%, I asked one of our burly male nurses to snatch him back from his mother and we ran him to the OR, handing him off to the intensivist to deal with. A little sedation and lots of oxygen got him to 85%, and six hours later, he was back on the ward, breathing comfortably, but still only at 85%. His O2 saturation dropped to 70% if we put him on his left side, though he had no change in respiratory rate or work. A chest X-ray showed a marked difference in the circulation of the two lungs with decreased blood flow to the left lung, an abnormality of right cardiac border, (you can tell I’m not a cardiologist,) and increased vasculature in the upper lobe, I think. I don’t know what he has, but he needs an echocardiogram. That makes nine patients I’ve seen in four days with major congenital heart disease. The good news is that there are two excellent pediatric cardiologists in Ghana and we can refer the kids to them. The bad news is that the echo machine at this hospital is broken and won’t be working while we are here. Although the radiologists don’t usually read the films in Ghana, we asked for readings on these eight incredibly abnormal X-rays, hoping to get some clues. Alas, I fear the lack of reading practice has taken its toll. All the readings were the same: “enlarged heart, needs echocardiogram.” The one we put on a diuretic for congestive heart failure had an addendum: “congestive heart failure.”
Working with two other pediatricians makes a huge difference. This mission is very big and complex, which makes for lots of time-consuming extra work. In addition to managing the surgical patients, every day there are children and adults who need to be seen for illness. Most are parents or siblings of the patients, and they are staying at the shelter, a motel-like residence where they are housed for the duration of the mission. As one might expect, gastrointestinal illness has broken out, and in this heat, dehydration occurs rapidly, especially in malnourished babies. We have rehydration packets and water to give them, but have run out and had to re-order three times now. I’ve also seen seven patients with malaria and have started to be able to recognize the symptoms. Ella, the pediatric resident, knows it well. She does a rapid screen and then gives the patient the medication from our stash. The people here treat it like a bad cold and usually have had it in the past.
Hans, the pediatrician from Sweden is on his first mission. He is one of those very kind, thoughtful, “old school” doctors that everyone would like to have for their own. He’s had a bit of an adjustment to make to the shortcuts required by the pace on the mission. For instance, when a child comes back to the ward from the OR, unless the child is unstable, the pediatrician takes the chart and writes orders for ibuprofen and acetaminophen before doing an exam. This is done so the nurse can go get the medication and give it right away. All patients get an acetaminophen suppository in the OR at the start of surgery, and local anesthetic nerve blocks toward the end of surgery. However, as those are wearing off, the pain will kick in. I’ve found, and have been taught by other Op Smile pediatricians, that a dose of ibuprofen on admission to the ward goes a long way toward providing pain coverage. Hans, as a careful, thoughtful physician, would normally review the chart and examine the child and then determine what medications are needed. Prescribing formulaically goes against his medical principles. Another time saving device I use is that once I’ve admitted a post-op patient, I partially fill out the discharge papers, leaving the discharge exam and signature line blank. I fill in pain medication doses, time and place for the follow-up appointment, and I check off the pre-printed boxes for lip or palate care and diet instructions. When the surgeon discharges the patient, I fill in the exam and sign the page. This saves time when all 39 kids are discharged at the same time the pediatrician is trying to finish up the pre-op exams and round on the post-op patients with the surgeons. The patients need to leave so we can ready the ward for the patients who will be arriving from the OR. Hans is now following this protocol, but in the beginning, it felt very foreign to him to write anything on the discharge summary until the surgeon had officially discharged the child. He looked at me after I explained the “partial fill-in,” and said, “but it says, “discharge” on the form right here!” To his credit, he has quickly become comfortable with the shortcuts, realizing that they don’t involve falsifying records or recording exam results 24 hours before the exam. I clearly remember my own discomfort the first few missions. I had to find a balance and a way to provide excellent pediatric care in a much more efficient and time-constrained manner than I was used to.
The actual surgeries went well today but finished very late. The next to the last patient had his palate repaired and had been on the ward only half an hour when he started bleeding heavily. For minor bleeding, the nurses or pediatrician can put pressure on the palate with gauze or have the child rinse with ice water. We occasionally put various clot enhancing substances on the bleeding spot as well. This child, however, was beyond all that. We called the surgeon down and after clearing out a bunch of clots, he soaked a piece of gauze in lidocaine with epinephrine (constricts the blood vessels,) and held it against the palate for 15 minutes. The child started out protesting but finally fell asleep with the surgeon’s finger in this mouth. The surgeon seemed surprised that the bleeding stopped as he was thinking he would be taking the child back to the OR.
A final anecdote before bed. As I was walking down the outside corridor this morning on my way to the storeroom, I passed by a group of kids, age about 8-10 who were siblings of our patients. They were playing dodge ball with two 8” diameter beach balls brought by the Child Life specialist. As the days's discharged patients filed by, the boys stopped their game, the 10 year old tucking one of the balls under his arm to give high fives to the departing kids. One of the departing mothers who had a baby on her back, grabbed the ball out of the boy’s hands and said to him, “I need this ball more than you do,” and walked off to the bus with it. I was appalled but not actually surprised. The people here have so little that putting kids first doesn’t always happen. That’s it for today. Tomorrow we’ll come early again and Hans will join us.
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