April 8th, 2018 by Daniel Boron-Brenner

During one of my previous posts, I mentioned that I participated in a bilateral tubal ligation where the patient was anesthetized with a spinal anesthetic. Which means she was effectively awake as we operated. The idea of a patient watching me as I helped operate is disconcerting to say the least, as much as for the existential creep I imagined the patient experiencing as they saw me pull here or press there (“here” and “there” being their exposed internal organs) as for the notion that they were conscious to begin with.

But this post isn’t really about operating on patients who are awake (and just to clarify, the patient wasn’t watching while everything was exposed. She was covered by a thick, sterile, canvas sheet with a small field, so that she could see me and the surgeon but that was about it.) This post is more about what led to the spinal anesthetic, and other forms of pain control at Macha. Analgesia, the ability to modify the body’s response to painful stimuli, is in short supply at the hospital here. Thus, while a spinal anesthetic is routinely used for C-sections in Zambia (as it is in the US), other operations utilize it when they can, or else a mixture of ketamine (a dissociative) and diazepam (a long-acting benzodiazepine.) That’s it for anesthetic agents. It’s not uncommon to see minor (“minor”) procedures performed with a local anesthetic like lidocaine and a pinch of ketamine if things start to get out of hand.

For patients on the wards, we have paracetamol (the international name for tylenol), ibuprofen, diclofenac, and diclofenac gel. Both ibuprofen and diclofenac are NSAIDs, good at treating pain and reducing inflammation, and paracetamol is good at treating pain and reducing fever. But, again, that’s it for analgesia in the rest of the hospital. There are no narcotic agents, even in cases where the patient requires stronger pain control (such as a fracture.) Patients are frequently left to sit with their pain, utilizing what we have but essentially taking our help, at least in this regard, at a loss.

I am not blaming Macha for the lack of pain control. There are much, much larger forces at work responsible for the paucity of resources. Poverty is the primary culprit. Ketamine and diazepam are cheap drugs to produce and in ready supply. Other drugs that I am used to in the United States, such as any opioid, are just not as easy to come by and so the doctors here use what they can to get the job done.

Still, it gives me room for pause. On one level, it’s difficult to acknowledge a patient’s pain and give them what we can while understanding there are more effective agents to be utilized. On another, it is, like the patient watching me as they are being operated on, a bit unsettling to help the providers. I know the patients are in pain, yet my hands are tied when it comes to offering more effective medicine. I can only continue the course, doing what I can to help and offering condolences when I can’t.