April 19th, 2018 by Daniel Boron-Brenner

After a frustrating few days at work, I finally had a good day. In fact, today might have been the best day I’ve had at the hospital so far. I saw enough patients to keep it interesting without feeling overwhelmed, I did a procedure, and I went to the operating theater. All in all, everything I’ve wanted out of this trip.

Jamie and I started the day on the men’s ward, which had three new admissions overnight. One was for a man with organophosphate poisoning (organophosphates are commonly used in insecticide and cause your parasympathetic nervous system to go into overdrive. You essentially drown in your own secretions). He had received the antidote on admission and looked fine, watching us as we walked by. The other two were much sicker. One was a fifteen year old boy with a history of cerebral malaria. I had actually seen him a few days prior and sent him home after consulting with one of the Zambian doctors. To my regret, he came back in an ambulance and we were treating him for another bout of the disease.

The last patient we almost didn’t see. Without a Zambian doctor present, we typically stop by the wards in the morning to check on any new lab results or to see patients that the nurses are particularly concerned about. That’s about it. The nurse thought this patient has an upper respiratory tract infection and wasn’t worried about him. We only checked on him because one of the clerks we work with stopped us in the hallway and asked us to take a look (they are related.) When we arrived at his bed, we found a circle of concerned family members and an emaciated, unconscious man lying under a pile of blankets. It turns out he has HIV and a history of tuberculosis. He was brought to our hospital after he stopped walking and then stopped speaking. We ordered a full work up on him, including a lumbar puncture to rule out meningitis, which I later performed. It wasn’t a “champagne tap” (just cerebrospinal fluid and no blood) but it was my first and I won’t forget it.

The rest of the day passed smoothly. We checked back in on the men’s ward to see if the results of the LP had come back and I saw the fifteen year old with malaria sitting up and eating. Small victory, he still has a long way to go, but it was a country mile from what he looked like in the morning. Then we went to the outpatient clinic and there were several Zambian doctors working (this is a far cry from the norm, where there may be one, sometimes two.) It was crowded, and between the patients sitting down or standing up in every corner of the room to talk to a provider, a little bit busy but we churned through the waiting room and then left for lunch. When we came back, the LP results were back, showing us that something was brewing but nothing conclusive. Then we were invited to theater.

We had been told that an emergency came in and we found a man prostrate on the surgical table, his abdomen grossly distended and tight like a drum. The doctors suspected he had a sigmoid volvulus, when the distant portion of your large intestine twists on itself and begins to die. Three Zambian doctors, Dr. Mulangi, Dr. Munga, and Mr. Hachobe (“Mr.” being the preferred nomenclature for a surgeon trained in the British system) were prepping him for surgery. Soon, they began. They dissected his abdomen and began making a path towards the colon. What they found confirmed their suspicions. Normal bowel is flush with blood, a healthy, almost velveteen red. This man’s bowel was enormous and black, so tightly expansive that it looked like a balloon ready to pop. It was dead, and they began running backwards to find the nearest viable tissue. When they found it, they began cutting the dead part away. They were going to create an anastomosis, a connection between the two ends of still-living intestine that bordered the dead section. Soon, they were cutting and sewing, cutting and sewing, creating a junction out of what remained.

For a while, things proceeded smoothly. The surgeons operated and made jokes, and the rest of the room joined in. People were still laughing when something, perhaps a suture or a scissor, slipped and nicked an artery. The man’s open abdomen began filling with blood. The pulse monitor, normally sedately pinging along, began sounding an alarm as his blood pressure dropped and his heart rate shot up to 150 beats per minute. The room grew quiet and the surgeons quickly started suctioning the blood and working feverishly to find the bleed. Mr. Hachobe (having deferred operating for anesthesia) secured a second line and we began pouring liter after liter of saline into the patient, trying to prop his blood pressure up until we could stabilize him. Seconds passed like minutes. Eventually, the surgeons found the source, staunching the flow with sutures, and the patient leveled off. We gave the patient a unit of blood (all that we had available) and the surgeons finished the operation without further incident.

The patient was wheeled out to the front of the theater, awaiting transfer back to the surgical ward. I went to change out of my scrubs. As I left the dressing room, I noticed it was dark. Mr. Hachobe was calmly speaking to the man’s family, a cluster of heads peering out of the night at us. I didn’t understand him, he was speaking Tonga, but I got the sense he was telling them everything would be fine. I slipped around him and we went back to the wards to add final orders for the night. As Jamie and I walked back to the guesthouse, the stars came out, shining brilliantly. The moon was brighter still, a silvery arc set against a blazing nighttime sky.