Surgery on steroids

Thursday we did two mastectomies, two hernias, a hydrocele, a lipoma, drained a neck abscess and I don't remember what else. Today we did a prostatectomy, two hernias, a tube ligation, sutured an eyelid, saw a kid eviscerated by a bycicle (seriously!) and put it back together, and sutured an arm that was hacked to pieces in a machette fight. Not to mention the consults. And rounds. 

I get to practice my subcutaneous sutures on every patient, my LPs while doing the spinal anaesthesia, and generally have a great time sticking my hands inside patients, looking for a prostate here, a fallopian tube there. To me, this is kinda like Disneyland: you stand around for hours but you have fun anyway. My legs and back are always killing me at the end of the day, I'm basically standing up from 8am-6pm straight.* No pause, no lunch, no bathroom break. And I love every second of it. I don't even remember I'm hungry until we finish the last case. Then my stomach wakes up and screams at me, demanding to be filled. 😂😂😂

We saw a baby with a meningocele on the lower back and hydrocephalus. He already had trouble opening his eyes. And there's nothing we can do. We sent them home. The baby will get worse and worse, without any way to relieve the pressure on his brain, and he'll die. There's no neurosurgeon here. No imaging (beyond ultrasound). No instruments or materials to insert a shunt. 

Neurosurgery is not an easy specialty to practice in Africa. At least, it seems impossible in Chad. Hence why Danae is trying to convince me to do OB just like Dr. Scott tried to convince me to do general surgery. But just touching that baby's soft spot, knowing his brain was right there, gave me a chill. I really don't think I'm gonna change my mind (although the only thing that could possibly do it, is cardio). 

We also saw a little one with a hemangioma on the left hand. We're going to operate on Monday. Should go well, but we might lose the little finger. Hopefully we can save it though. 

Anyway: lots and lots of work, every day, from morning 'till night. I'm not complaining. 😊😊😊

*I guess surgery rotations in the US are worse, you have to be there at 4-5am. We start rounds at 8am here and OR after that, usually around 10am, until 6pm and doing consults in between surgeries.

Mastectomy for advanced breast cancer. Non-curative, her lymph nodes were already involved, but hopefully this will give her more time.

Loosening a prostate with my fingers. There's no way to do transurethral prostatectomies here, so it's still done old school, through the bladder.

That was only the first half of the prostate!! 

Concentrating on my sutures! :) 

Children

(Surgical pictures at the end of the post, scroll slowly if you don't want to see them.) 

It's a recurring theme in Tchad that nobody seeks medical attention until they're about to die, or whatever ails them becomes unbearable. And since they are extremely resilient, sometimes that means years.

Today we had 3 surgeries, the first of which was a 4 year old with an exposed femur fracture for 1 year. The exposed bone was dead, of course, but surprisingly, he had no infection.

So Dr. Scott cut off the dead bone and put the 2 ends together, put them on an external fixator and closed. The hope is that the bone will actually grow enough to compensate for the loss and he will have legs of equal length. In any case, he will definitely get to walk. Again, something that isn't possible with an exposed femur fracture...

Then another little kid, from yet another motorcycle accident. That one was 10 days ago, but the arm had gotten stuck on something and almost completely ripped from the torso. Almost, but not completely. Except the nerves, ligaments and blood supply was part of what got ripped... and the result is a child attached to a completely dead, cold, putrefying arm. I'll let you imagine the smell. So it was an amputation, leaving the wound open because of the infection.

The third was a woman with a large, hard mass on her thigh. It looked like a giant mole. It was deep into her sub-cutaneous fat, but had not reached her muscles. Besides a little bleeding, it was removed without complications. Of course, we have no way of knowing if it spread somewhere else, and that thing was massive. 7cm by 5cm at least.

Anyway, I had been craving surgeries, and it felt great to scrub in again, but that little kid who lost his arm made me really sad.

Things that happen in Tchad that you have to get used to but probably never will...

All good things...

Irene got discharged today. Finally. She gave me a huge hug, her mom smiled and shook my hand, and we took a picture together before they left. I told her I was going to print it out and when she came back for her check up, she could pick it up. Something to remember me by.

It's been exactly 8 weeks since I first saw her. Since her amputation. 

She left, and so will I. 

The decision is made. There will always be more patients. I will come back. But it seems that the cycle has ended. Two of my other patients were discharged todayas well. Blaise is officially free of infection and not taking antibiotics anymore. Gombo also seems to be doing better and no more pus is pouring out of his leg. Tahir (the 11 year old boy) went from dressings to steri-strips. He's almost ready to go home too. 

I don't know if my patients will miss me. They have missed me during the week I was gone, but once they leave the hospital, I guess they'll want to forget everything about their stay. 

I will miss them. And I will miss all the blood and guts part of it, the right to walk into the OR and scrub in any time I want, having the keys to the entire hospital and actually knowing exactly what to do and when. 

This has been an incredible adventure. It has been harder than anything I've ever done, but I have also learned more than I could have ever imagined possible in 2 months. 

Today I helped put a humerus back into place, in an arm that was pretty much torn apart in a car accident. 

I have had my hands inside various body cavities, seen intestines, bladders, prostates, hernias, hydroceles, etc. etc. etc. 

That's Dr. Scott's hand this morning, nuckle deep in Gombo's thigh. I did that dressing change twice a day for a month. To reach inside someone's thigh far enough to touch their femur--that's pretty incredible... 

I'm going to miss all of that. Sticking needles into people's veins or muscles, putting on gloves and snapping them off, the smell of alcohol and waving my hands in the air so they dry faster between patients, so I can put on a fresh pair of gloves. 

Might seem silly, but I will miss all of that. 

In a few months though, I will be thrown back into the world of medicine, and I will be the best freaking med student this world has ever seen! 

So I am leaving. In 48hrs I will be in a plane to Paris, and after 12hrs of eating stinky cheese and taking the longest, hottest shower of my life, I will be on another flight to Nepal. 

I have another day in the OR tomorrow though. I'll enjoy every last second of it. :) 

A day of firsts...

**WARNING** Graphic pictures, not for the faint of heart!!!

Today, in the middle of rounds, they bring a man in carrying him in a very awkward position, sort of vertical... When they passed by where I was standing, his eyes were rolling backwards and he seemed to have no muscle tone. Apparently he had fainted when he went to the bathroom... They put him on the bed as I finished the bandages on another patient. I immediately went over there, and the Samedi, our Chadian doctor had just stopped looking for a pulse. He was gone. I grabbed his wrist, nothing. Looked for his carotid pulse, nothing. He was still warm. 

The daughter let out a scream, almost fainted herself, and walked out crying, accompanied by another family member. The wife stayed there, wailing and touching him, and covering him, and touching his face... 

It was heart wrenching... 

It was the first time I actually saw someone die. Not even my own family members, (my dad!), I had not seen them after they were dead. 

I have seen dead bodies, cadavers in Anatomy Lab, but it is **really** not the same thing. They're cold, bloodless, and feel like rubber. It's hard to think of them as humans.

He was warm. It's hot here, so he was a little sweaty. He had come in for a hydrocele and had seemingly nothing else wrong with him... 

There are no autopsies here. He just died. I'll never know why. Maybe he had a stroke, or a pulmonary embolism... who knows...

People here seem to have coagulopathies, either they clot all the time, or they bleed and bleed and bleed. Probably a product of their poor diet... 

They also have cancer. Giant cancers. They let it go on for too long, and usually come in when they have giant fungating masses that smell awful and look even worse... 

That's supposed to be a knee. There's nothing that can be done, except amputate above the knee, but at this point, it's certain that it's in his lymph nodes and has spread to who knows where. There are no CT scans or MRIs here. He's going to die. We just don't know how soon. 

The surgery was gruesome. I had only seen a big toe amputation (diabetic foot) and the last part of an arm amputation, but I was scrubbed in and holding his leg from beginning to end. 

Separate the muscle from the bone 25cm below the hip joint, pull back the flesh to expose the bone, bring on the electric saw...

Those are my hands holding his stump.

Did I mention he was moving? He had a spinal block and ketamine, but apparently it was not blocking his motor functions. Thankfully, it *was* blocking his pain receptors, so he couldn't feel a thing.

It was the saddest surgery I've ever seen... 

I had to leave and go make myself some coffee... It was a really rough morning. 

In the afternoon, there was a hernia repair, no complications, a simple operation... So I scrubbed in as the first assist! 

That was awesome. I had my fingers inside this lady and pushed her intestines back into place. It made me realize that in the OR, when you're focused on what you're doing, you forget everything else. For a little while, I forgot about the man who died, and the other man who lost his leg... 

I guess I understand why some surgeons say the OR is their sanctuary... I think it might be mine too... 

Balls the size of Texas...

WARNING: if you're a boy, you might want to stop reading right now... 

I have been in Chad for a week. So far, I have seen 2 prostatectomies, 2 hernia repairs (one bi-lateral), a femur fracture repair, an amputation and a really cool patela (knee) reconstruction that I actually scrubbed in and assisted on (awesome!!)

That's a lot of surgeries for one week. I am LOVING IT! 

But today, I walked into the OR to ask a question, and this is the first thing I saw: 

They weren't lifting it quite that high, so for a moment, I wasn't sure what I was looking at. So I asked what was the surgery, and they explained it was a http://en.m.wikipedia.org/wiki/Hydrocele_testis

A recurring theme in Chad, is that they don't come looking for a doctor until whatever it is that ails them, becomes unbearable. And they are very resistant to pain and discomfort. 

So this particular man didn't come in until... you guessed it. He had balls the size of Texas. Actually, it was just one testicle. The surgeon, table, floor, drapes, were all drenched, and they still suctioned almost 600cc out of his testicle. 

Honestly, I did not even know that existed, but that was pretty impressive. I wish I had seen it before it was drained! 

So the next time I hear someone say that expression, I'll just chuckle, think back on this patient, and say "naaah... not even close!" 

:)