No Choice

I think it was when the 4 year old's oxygenation dropped below 60% (normal being above 90%) when the panic started to grip me. Her pulse was dangerously high and erratic...I recognized the impending cardiac shock as her body fought for oxygen. Today I came face to face with my worst fear and my heart rate still hasn't settled...

I expected chaos when we arrived at the hospital, only two of us along with our two occupational therapists (who make splints and manage the patients physiotherapy) were present, the other two surgeons divided our efforts and went to CoRSU hospital, a private, NGO funded facility about an hour away. A lot can happen in any hospital over the two days while we were gone, and Mulago is no exception. Surprisingly there were no major admissions over the weekend. I guess all the broken legs and half amputated arms were at home getting traditional medicine for now. You have to take your breathers where you can get them. I can't say we were well rested after the weekend of hiking and long car travel but we were determined to make the most of this last week. We met with our plastics team, a volunteer general surgery resident from Boston, living off her savings with a strong interest in burns and two Ugandan interns, doctors in their 1st year general practice residency. The more senior local staff were rarely present, typically relegating morning rounds to their juniors, which is common practice in most hospitals. Unfortunately their involvement throughout the day was not always much different.

A common flyer posted throughout the hospital, these on a piece of plywood blocking a open elevator shaft. I'm not sure which is worse, having to pay to have a nurse care for you in hospital or the parasitic loan sharks that prey on the employees when they are short on cash.

Our post ops from the previous week were doing well. Some had been discharged home over the weekend, others remained, usually because of the long distance they had to travel or concerns about wound care. Our lower lip/face recon was doing well and embarrassingly grateful. She was still quite swollen but I expected a fantastic result over the next few weeks. Her fevers had settled but the malaria medication would continue and she could go home today. Many people in the region suffer from malaria and certain forms of this disease can flare up and resolve and then flare up again months or even years later as the relatively impervious cysts in their blood stream hatch and reestablish themselves. This makes curing the disease extremely challenging and is why Malaria accounts for a significant chunk of the morbidity and mortality of the African population.

This burn scar had not only caused contracture of the knee, preventing flexion but also developed into a form of cancer, a known but rare condition called a Marjolin's ulcer. Complete and immediate excision is critical to prevent metastasis. Unfortunately large blood vessels and nerves travel along this course in the leg turning the surgical site into a minefield.

5 days post op, the bubbling scar and cancer is gone, note the "Z-plasty" styled incision which takes tension off this new incision as it heals.

Hand to crotch guy was doing well (yup, that's his name now), the dressing teaching I had done previously was clearly well heeded. His neighbor, also in the same crash, suffered crush and amputation of 2 fingers and a thumb. We discussed the possibility of doing a toe to thumb transfer, transplanting the big toe to the hand as a new thumb, to give this hand more function, but it would have to wait until next year after his current wounds healed fully.

Our gunshot victim was showing signs of improvement and sensation was slowly returning to her arm and hand. It remained to be seen if motor function would return but as long as improvement was happening we would hold off on any invasive surgery.

The rest of the patients had similar updates with a few exceptions. A young child, about one and a half years old, who had suffered superficial but extensive burns long before our arrival had deteriorated over the past week due to an unknown infection. Barely able to lift his head, we had tinkered with various antibiotic and antifungal combinations. The blood cultures we ordered to elucidate this bug, originally returned as negative (meaning no infection) but today it was revealed those culture bottles had been expired, making our results worthless and left us flying blind. Over the weekend the child had become less responsive with a fixed gaze, where the eyes don't move normally, indicating a possible brain dysfunction. I suggested an infarct, or stroke, rare in a healthy child but a potential complication of one so sick. It was then the nurses whispered that the mother had in fact dropped the child on its head, twice, over the weekend. The team looked at each other and then the mother. A quick inspection showed no obvious contusion or swelling on the head. I encouraged caution to jumping to conclusions, but it was not unheard of for parents to attempt to speed along a sick child's demise. Ultimately it was decided to leave the child in the care of the mother, what choice did we really have? I hope I don't regret this.


Monday was clinic day. We still had a handful of patients from the previous week that needed surgery but more were needed to fill our OR space from Tuesday to Friday. The Ugandan plastic surgeon informed us that he had some administration to take care of for an hour and asked if we could run the clinic ourselves for this period. It wasn't appropriate to have foreign visitors leading a clinic but we agreed. Again, what choice did we have. The bastard didn't come back until the afternoon, about 30 seconds after we finished. Word must have gotten out quickly that the Muzungos (white people) were in charge. There was very little order and there was no semblance of a line or patient list. The calm and serenity of last week's clinic gave way to frenzy. I clearly had no appreciation for the control the local doctors maintained over these clinics. Patients and parents would push their way past each other to the door, displaying their or their children's injury, arguing with the nurse if she wouldn't let them in. Often patients wouldn't wait and charge in while we were still seeing the previous person, hovering over them menacingly to get them out. Charts appeared and disappeared. Nurses scolded patients for complaining about pain, or anything for that matter, which we could seriously use back home. It was madness. Benign presentations were ejected on sight and we focused our time on pediatric congenital defects or acute hand, face or other soft tissue injuries.

While hardly life threatening, the stigma of duplicate digits is high. Simple deformities such as this can prevent an individual from getting work, or being accepted by their partner's family.

This procedure was done last week: The duplicate thumb is removed, the errant neurovascular  bundle resected to avoid chronic pain and the thumb joint reconstructed to correct the laxity that arises on the duplicate thumb side. No, it isn't just a matter of snipping it off. No one will ever know this girl even had this condition.

A number of post ops were present as well. Our cleft  foot was healing well and could now fit into normal shoes. A child with a volkman contracture, leaving his hand in a tight claw, was treated with tendon lengthening and transfer and now was extending his fingers for the first time in months. The young man with the disfiguring leg growth the size of a melon was walking after the excision and able to sit without pain and wear normal pants. It was pretty satisfying and most importantly no major complications had occurred. My less harm than good plan was working. So far.

With clinic finished, the team was asked to reassess our young four year old electrical injury we had treated the previous week (and discussed in a previous post). She had a fever and her vitals had been soft and suggested the possibility of early sepsis, blood poisoning, likely from necrotic tissue in her arm wound seeding bacteria into her bloodstream. Though her wounds had looked reasonable at the last dressing change on Friday, clearly something had  changed. The special antimicrobial silver dressing I had placed on the open wound had been taken off on Saturday for no clear reason (families would sometimes do this randomly). Operative exploration and further debridement of the dead and toxic tissue was the only option to prevent the child from getting sicker. Just one problem: We had no anesthetists. One of the anesthetist's children had died on the weekend. The funeral was today and EVERY anesthetist in Mulago hospital took the day off to attend. The Orthopedics had already suffered complete cancellation of their OR slate as a result but our patient couldn't wait for tomorrow.

A quick discussion and it was decided to perform a conscious sedation, which is the use of oral or intravenous drugs to make a patient dopey enough to do minor procedures but awake enough that they breath well on their own. It takes some skill to manage but the Ugandan team felt up for it. I recommended oral midazolam. They pointed to the halothane. I must have looked concerned, maybe horrified, because they quickly informed me they use it all the time. Halothane is an ancient anesthetic gas that NO ONE uses anymore but remains popular in the developing world . We don't even use it on rats in the laboratory. Though less of an issue with children, it can induce a form of hepatitis, with high mortality rates and has some unpleasant respiratory side effects. It was also meant for general anesthetics, not the much less involved conscious sedation and a quick scan showed no anesthetists in the room, just a trainee in anesthesia, not even a resident yet having just graduated medical school. I deferred to their judgement, trying to avoid being judgmental about practices that are outside the boundary of our own. Maybe I should have stopped things then and there but the child needed treatment, what choice did I have?

The majority of the case went smoothly. The arm and its fasciotomy site, where we had previously released the swollen muscle, tendons and nerves, was exposed revealing a large patch of necrotic muscle that would have to go. Several tendons were already frail and failing as well as the median nerve being exposed. We did our best to partially close the wound without subjecting the contents of the forearm to high compressive pressures.

Myself controlling unexpected bleeding during the case with an electrocautery tool.

It was as we put the dressings on that I could hear the oxygenation monitor signal slow in pace and drop in pitch. I glanced over at the O2 sat monitor, which measures the amount of oxygen in the blood via a small scanning device on a finger tip. Anesthesiology is a bit like flying a plane. Usually it is pretty easy and runs on auto pilot but can turn into a compete nightmare if something goes wrong. The oxygen levels fell quickly from 98% (good) to 82% (not good, but not too worried). The pitch dropped further, now to 73% (uh oh) and then to 65% (officially worried). I stopped everyone and focused on the respiratory issues. The trainee struggled with the face mask trying to get a good seal, as they dropped the halothane concentration and pushed up the oxygen. Again, like flying a plane, when something is going wrong in anesthesia, you need to run a check list in your mind to ensure you aren't missing something critical. Is the oxygen tank running? Are any of the connections loose or disconnected? What does the chest sound like, has a lung collapsed? Now 50% (sweat forming),  the trainee wasn't coping, so I stepped in. Turning the oxygen to 100%, I asked for suction to clear the airway. People started to yell instructions before I quickly ask everyone to be quiet and let one person speak (me). 42% (underwear is now wet). 35% (make that wet and brown). We were losing this child. At these low levels, brain damage would soon occur and the heart would go into arrhythmia. I wont lie, as worried as I was for this patient, my thoughts focused on a doctor who was charged and sentenced in abstentia in the middle east for an OR case where a patient died, through no direct fault of his own. He didn't even realize he had even been charged and sentenced until a year or two later when he was pulled off a plane connecting through Dubai and imprisoned.  The heart rate was severely rapid and irregular. I asked the team to recheck the ventilator and repositioned the patient to maximize his airway. We fired a dose of epinephrine in to treat what could have been a spasm in the lung. I got ready to begin chest compressions and called for the crash cart. 29% (Doom). 34% (what?) 41% (I'm keeping my license!) and steadily up to 98%.

The child woke up after the gases had fully cleared form her system. She was well. I  said very little as we placed the dressing over the arm. I must have been white as a sheet because the staff surgeon I was with saw me later and asked what happened. I said we had had a rough case. We were coming back tomorrow. What choice did we have?

I'll be in touch.