“These patients can exsanguinate,” explained Dr. Annaliese. “That’s why I’ve followed this technique of ripping everything out quickly and getting the bleeding under control. It works much better than carefully dissecting everything out and having so much blood loss that you can’t control anything. Once you get the mandible out, you can see where the bleeding is coming from and easily control it with pressure and cautery.”
Dr. Annaliese, a medical student, an intern and I are working on removing one half of the jaw bone of a young man who developed a large, deforming and painful mass which pushed the left side of his face outward in a dramatic fashion. Who knows how long this has been causing trouble for him. Dr. Annaliese has carefully split the face in half, cut through the middle of the chin with a Dewalt multitool vibrating saw, and separated all of the muscle and other attachments from the left side of the jawbone all the way to the temporomandibular joint. There is a gaping hole in the inside of his mouth where this growth has collapsed and allowed all manner of debris to enter. His tongue, mouth and teeth are involuting or distorted in some way. Anna, the intern, and Maxim, the student are holding retractors and gauze. I’m holding his head as Annaliese pulls at the stubborn jawbone. “Here,” she says nodding at me. “I’m going to hold pressure down here. You’ve got a better angle. Just grab that thing and yank it out.” I feel my way around the back of the mandible, deep into the recesses of his neck, around to the place where the jawbone creates a joint with the skull, the temporomandibular joint. Then I start pulling. Tissues, muscle, periosteum, vessels all give way as I tear the bone from its moorings. “There,” Annaliese sighs. “You have just performed your first hemi-mandibulectomy.” I ask her if she will write me a letter of recommendation. She nods. I laugh.
She rests for a moment, gloved hands deep in the cavity we have created, pressing on stubborn vessels that just need a moment to adapt to their new role of having nothing to do. She uses the moment to walk us through the procedure we have just witnessed, her treatment plan, her differential diagnosis, the risks of the procedure. She is a gifted surgeon and teacher. I hand off the surgical specimen to the surgical technician. It looks like an alien, unhuman thing. We control the bleeding, then close the gap with layers of suture and a drain in place. I look up at his vitals as we finish cleaning and wrapping the wound. Puls 140. Blood pressure 69/53. I ask Maxim, “are those really his numbers?” “Yup,” she replies. She has already been here in Angola long enough that this is just part of the expected roller coaster of anesthesia care. There is some blood and IV fluids slowly dripping in an IV, but it’s late and slow. His next blood pressure has improved to 88/60. We’re getting closer to where we should be.
Earlier, Sam put a long orthopedic nail down the shaft of a humerus that hadn’t healed for years. The bone looked healthy enough, but perhaps due to the way it had been casted, or perhaps due to nutrition, the bone had never grown back together. By this procedure, he is trying to give the bone a fresh start. It’s a rough procedure in the sense that orthopedics involves a lot of drilling, power tools, hammers, slide hammers and screwdrivers. It’s not like other medical specialties. During the procedure, the oxygen levels keep dropping, but we can’t think of a reason for this. 60’s, 50’s, 40’s. it gets a little dicey, and it’s distracting. I’m observing this procedure, since I came in late to the case. I presented a neonatal resuscitation course in the morning called “Helping Babies Breathe,” (more on this later) so decided I wouldn’t disrupt the case by scrubbing in in the middle, but would simply observe. I stepped out during the excitement of the low oxygen levels to grab my stethoscope and be prepared to help with airway issues should this be necessary. The anesthesia tech was able to straighten things out by reducing the anesthesia, and things settled down so that Sam could finish the case. Everything turns out well.
On the way home, we talk over the day. The surgical cases are wild and difficult. The techniques used are of necessity practical, careful, but without the glitz of every imaging study or material needed. Sam had to make due with the size nail he had on hand, for example. We talk about anesthesia and means that have been tried to improve the consistency of the quality of the care provided. We discuss concerns about supply challenges. Of the ortho cases we have witnessed to date, I asked Sam, “if you had your wishes, what would you need?” “I wish there was a manufacturer in Africa of the antibiotic resin kits for osteomyelitis. Those work really well for chronic osteomyelitis, but the supply is inconsistent because we need to order those in from outside.
At the end of the day we share a wonderful meal of tortillas, falafels, vegetables, cheese and potatoes. We relax together smiles all around. “What did you do in school today?” I ask Bella. “Nothing.” “I learned about bones,” I told her. Sam and Maxim both laugh, knowing the brutal orthopedic procedures we were part of today, and how I was sparing her all of the gory details. Amanda. Maxim and Bella play a game called “Cat Crimes” while I relax for a few minutes and prepare for tomorrow’s trip to Kalukembe, which promises to be remarkable.
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