CATASTROPHE

10 October 2013

I'm deep in the belly when the catastrophe starts.  I've already started
dissecting the descending colon off the grossly enlarged and inflamed left
kidney when suddenly I can't see anything.  The man's stomach comes popping out
of the abdominal wound and his abs tense up so that all the rest of the
intestines and the enlarged spleen block off any view I used to have of the
diseased kidney.  The man is retching and dry heaving.

"Can't see or do anything here, can't you give him something?" I shout at
Patrice, our nurse doing anesthesia.  Thus starts a long, labored process of me
trying to hold in guts on one end while trying to verbally direct anesthesia on
the other.  Finally, I have to break scrub and tend to the man as his oxygen
saturation has plummeted.

His jaw is rigid and his whole body tense and he's refusing to breathe.  This is
why Ketamine isn't used often in the developed world.  Alcoholics just don't do
well on it.  We're pounding him with Valium, Thorazine, Promethazine, Ketamine,
trying to get his body to relax so he'll take a breath.  But now he has vomit
spilling out of his oral airway and nose.

"Suction!" I scream as I try in vain to tilt his head back and open his mouth
against his strong muscular contractions.  Finally, I get a suction tip into his
mouth and aspirate the yellow, bilious liquid out.  I can barely get in a
laryngoscope but fortunately it's enough as I see the vocal cords wide open.  I
slip in an ET tube and start bagging.  His sats finally come up to decent, but
not ideal as yellow froth bubbles up in the tube.  I suction out the tube  and
lungs but it keeps coming.  He's aspirated and this is not good.

And I still have an open belly and most of a difficult surgery ahead of me.  I
scrub back in.  The abdomen is still rigid.  Finally, after 5 doses of Valium,
one each of Thorazine and Promethazine and two bottles of Ketamine, things are
relaxed enough to operate but his sats are still not good and I'm afraid he'll
die on the table.  There is lots of oozing in the operating field so I decide
that careful dissection just won't do in this situation.  I reach in my hand and
peel off the kidney all around it's lateral and posterior aspects and pop it up
into the wound.  I pack the kidney bed and put three clamps across the pedicle
where I know the major vessels and ureter are.  I cut out the kidney and toss it
onto the mayo stand.  I stick tie the pedicles, irrigate the abdomen, place a
drain and close up.

As I scrub out to check on the anesthesia part, the man is now completely
relaxed and his sats are normal.  He has a bag of blood running and has used up
over 10L of Ringer's Lactate. We wait about 30 minutes until he starts to make
some movements with his mouth.  I take out the NG tube and then extubate him.
He does fairly well on just oxygen so we take him out to post-op recovery.

There, the woman with the thyroid mass who is intubated now needs the oxygen so
we are forced to switch back and forth between the two patients since we have
only one oxygen concentrator.  When one patient's sats go down we give them
oxygen for a few minutes until it comes up and by then the other's sats are
dropping so we switch.

The next day, Roger comes to see me about a patient who has an intestinal
obstruction that was hospitalized yesterday.  The man is gaunt with a swollen,
air filled tender belly.  I go see Juliette who hospitalized him with Malaria
and constipation yesterday.   He hasn't had a stool or gas in 10 days.  When I
ask her why she didn't tell me about this patient she says it is because I was
so busy with the complicated case yesterday and then she forgot to tell me
afterwards.



They have no money and are obviously poor so we just take him to the OR bloc
even though he hasn't paid. When I open the peritoneum, gas and a foul odor
escapes.  THere is over 3 liters of putrid pus in the abdomen.  His cecum is
necrotic with a hole oozing brown, gritty stool.  The appendix is normal.  I
dissect out the cecum, ascending colon and terminal ileum and remove them.  I
then reattach the ileum to the rest of the ascending colon, wash out the abdomen
with liters and liters of tap water, place three drains and close up.

Fortunately, his anesthesia went without any catastrophes.