I sit in the cold of a Cameroonian morning here in the mountains of Koza. The sunlight is beginning to stream through the dust covered windows, seeming to sift slowly to the floor with the ever present dust in the start of the dry season.
I wait. The lab guy should be coming any time. My body is weary and my back aches. Will I have to give blood or not? The result of the hematocrit will tell me. My mind wanders. Did yesterday really happen? It's kind of all blurred together. In my head, I'm back in the OR yesterday...
We're getting started late. I'm a little frustrated as I try to occupy my time straightening up the counter that serves as the anesthetist's work station. I'm alone with the patient stretched out on the bed barely covered with a skimpy hospital gown. This is going to be a long, tough surgery and it's already approaching noon. The system here is archaic. The patient's family must pay for the surgery, then go to the pharmacy and get all the supplies needed for the surgery since the OR has almost nothing there. Then they have to go to the lab to get tested and give blood. All this could've and should've been done yesterday or at least early this morning. Finally, the nurse himself had to go get the supplies because no one oriented the family members where to go and what to do.
Finally, I stand with scalpel poised in hand, flanked by two congolese doctors, Roger and Solomon. I start the incision in the old, midline c-section scar. I decide to repair the vesico-vaginal fistula first. Urine has been leaking from a hole in her bladder through her vagina for over a year since she was operated on in Maiduguri, Nigeria. Sometimes, after a difficult delivery or as a result of a surgery on the uterus, the bladder can be damaged creating what's called a fistula, or a hole so that the woman has no control over her urination, but leaks pee constantly.
I open the bladder and spot the fistula. I cut out the mucosa and free up the tissues and then close the deep vaginal layer, the bladder wall muscle and finally the mucosa of the bladder in three separate layers. I suture up the bladder and extend the abdominal incision all the way to her chest. My back is already starting to hurt as the ancient operating table will only raise itself so high, not nearly enough for a scrawny, six-foot-five man. I have to lean way in as I dissect the colon off the enlarged, non-functioning left kidney. It must have been chronically infected as well since there is a lot of inflammation that makes dissecting and identifying the ureter and the large blood vessels difficult.
After hours, I've finally mostly freed it up, but the blood vessels remains in a mass of inflammatory tissue. I've just damaged the kidney and it starts to bleed dark blood. A lot. I hold pressure and tell the staff to get the blood transfusion running. Ganava calmly tells me there's been a mistake, the family never actually gave blood, that was for the next patient. I'm incredulous. I would've never operated on such a big case without having blood available. I send Elissa running to the lab to check this patient's blood type and see if there's any blood from other surgeries left in the fridge.
After what seems like an eternity, Elissa comes back with the blood typing reagents and a bag of O + blood. Sure enough the woman is O + as well so we get one bag running. I release the compression on the kidney and dark blood wells up again. I send up a quick prayer and go for broke. I sweep my fingers behind the kidney and tear it loose from the adhesions holding it in until just a stalk remains attaching it to the circulatory system of the body. In that stalk is the vein and artery. I put a clamp across the whole mess and then a second one almost on the kidney and cut the kidney off and lift it out. The bleeding has stopped. I then leisurely double tie the blood vessels under the clamp, pull out all the gauze holding the intestines at bay, making sure to get them all and close up.
I do a hernia next and then we all eat for the first time since breakfast as Caitlin and Elissa have brought back some beans, rice, eggplant and dinner rolls from the house. They also have a case of Fanta and Coke. Since there's not bottle opener I try something I saw someone do once. I place the cap over a metal edge and hit the top of the bottle several times until I break off the glass. I gingerly drink from the now sharp edged bottle the renewing sugary mix.
The final case is a young 30 year-old-woman with advanced cervical cancer. I feel it's worth a shot at least in opening her up to see if the cancer is resectable. Since we don't have CAT scans or other ways to see the extent of the spread, an exploratory surgery is the only way. Unfortunately, I soon realize that the cancer has surrounded the ureters and blood vessels and started to erode into the bladder and rectum. By this time, she is oozing dark blood from many small wounds in the uterus that are two friable to suture. I hold pressure for a long time, but in some surgicel and a drain and close up. Fortunately, she has three bags of blood: two B+ corresponding with her blood type and one O+ that is also compatible. We get the first bag in quickly and get the second one running as we take her out to the hospital ward.
I go to see the first woman we operated on and she really needs more blood but there's none available except the one bag of O+ for the woman with the cancer. I make a tough decision. Both need the blood, but the woman with the cancer has an incurable disease. I go in to see the family. I explain that her cancer is inoperable and she has a few months to live at best. After some translation from French into Mafa they understand and express their thanks that we at least tried. I offer to pray for them and the nurse prays in Mafa. They all warmly shake my hand. I then explain that we are going to take the last bag of blood and give it to someone else. At first they resist, but finally agree after much time spent explaining.
I give the bag to the nurse and head home, weary, walking gingerly because of my back pain and ready for some Ibuprofen and a hard cold floor to stretch my back out on.
After a wonderful, but too short night's sleep I hear a knock on the door. The nurse needs my on the surgery ward. It's the woman with the cervical cancer. Her blood pressure is 90/50. That doesn't worry me to much. She is awake and alert, but her heartbeat is fast. Her conjunctiva are a little pale. The drain has put out over 200cc of blood overnight but her abdomen is soft. I prescribe IV fluids and tell them to call the lab guy for a hematocrit. I told him to come give me the results directly at home. If she needs blood, my B- blood will be the first bag she gets.
So I wait, in the cold, bare feet and short-sleeved to know my fate early this Saturday morning in the mountains of the Extreme North of Cameroon...
11 December 2010
Posted by jj at 2:32 PM