April 7th, 2018 by jamiefelzer

So much has happened since I last updated here! But let’s start with today… Friday is theatre day (OR day for those of you not used to the British terminology). It was a fascinating day filled with many surprises and learning, as well as incredible respect for these doctors here who truly do it all. The doctors I’ve been working with in clinic and on the wards operate and do anesthesia like it’s no big deal. Now I know that’s the epitome of a true general practitioner, but being able to do skin grafts, c-sections, tubal ligations as well as think through the medicine side of things is pretty impressive. The doctors here work 6 days a week, every week, and sometimes will also come in on Sunday or in the evenings if there is an emergency. Now granted, their hours are a little different than mine when working 6 days a week, they typically work from 8-5 with a 1-2 hour break for lunch depending on the patient load. We sometimes get frustrated because they do not show up when they say they will for rounds or theatre clinic and I am left to run clinic on my own, but they do work an incredible amount, are quite intelligent in every field of medicine and take care of quite a lot of patients, so I have a great amount of respect for them.

The beautiful road to MRT

Now back to theatre, so I showed up after rounding on my patients and waited for the real docs to show up. Once they did we got straight to work. Theatre comprises of a separate building, and much like at home you cannot cross the red line without proper attire on. They have their own (mismatched and even dress) scrubs and shoes that must be worn when entering. There is a major theatre and 2 minor rooms, each of which have their own air con. There is a central scrub area, which although slightly different in practice (we scrubbed with a bar of soap and a touch of chlorhexidine rinse), the concepts were the same and everyone was very careful about sterility. Another interesting difference was that most of their sterile drapes and gowns were reusable in that they were cloth and could theoretically be sterilized.

First up was a bilateral tubal ligation for a 35-year-old woman who was in a polygamy marriage where there were 3 wives and 32 children between them, 10 of which were hers. It seemed like they did a lot of BTLs here so I asked if men ever got vasectomies and everyone at the room stared at me in shock. I gave her spinal anesthesia for this procedure with one of the doctors who had done training in anesthesia prior to his general practioner training. After this in rapid succession because the docs split into their own rooms was: a lady with genital warts that hadn’t responded to medical treatment so after a battle trying to get the stirrups in place (that took quite a while!), we were able to cauterize all the lesions off. Next was a 2 month old boy with a frankly purulent abscess that was drained from his neck, dressing changes that I actually did on my own for horrific wounds. The first dressing change was a 9-year-old boy who had a septic knee now status post multiple wash-out for pyomyositis with 3 massive wounds that were packed. I irrigated all the wounds very carefully as I didn’t want to spray anything and then just dressed it so we could start to allow for healing. It almost looked like there was gauze still in there initially, but I quickly realized that was just muscle and tissues that had the imprint of gauze. His procedure was done under ketamine (as all general anesthesia is done here) so he was saying some funny things in Tonga the whole time. At the last dressing change he kept repeating “white man” to my colleague. The next dressing change I did was on an HIV positive woman who had what was presumed to be a venous ulcer that turned gangrenous and by the time she made it here had ulcerated the entire medial portion of her leg and there was absolutely no skin left. She will eventually need a skin graft.

The next case was an emergent c-section for a lady I had admitted from clinic the day prior. She was having failure of labour progression, which we found out was due to a cord being wrapped around the baby’s neck. They decided just to go with GA (Ketamine) instead of a spinal and we were able to get the baby out pretty quickly. Took the baby a little long to really start crying but he did well. Suction was certainly not great and they don’t have cautery, but we were able to stop all the bleeding by tying everything off. We then received a call about a lady who came in from a rural clinic after an abortion at 4 months (which was spontaneous miscarriage) who was hemorrhaging from retained products of conception. She was hypotensive and confused so we bloused her with fluids in both arms and took her in for a D&C. We scrapped out all the products but yet she continued to hemorrhage. It was scary that we couldn’t get her to stop bleeding. She was clearly in pain despite being on Ketamine, so we just kept giving her more. They called in another doc and despite being able to feel the fundus of the uterus without any retained products of conception, the bleeding wouldn’t stop. We ended up putting a condom on the tip of a foley catheter and tying it off twice to obscure it. The first time we inflated it she pushed it out thinking it was a baby so we ended up suturing her cervix closed most of the way so that we could insert the balloon to tamponade the uterus. After that stayed in, we gave her two units of blood and her blood pressure started improving. There were definitely some times during this procedure where I worried we were going to lose her.

It was definitely an exciting day in theatre, where I was able to see these doctors work a lot of magic, but also often felt disappointed that we weren’t able to help with things like using cautery, eye shields, peri-procedural imaging to find objects or even modern stirrups or suction that actually worked well. I was reminded of how I do enjoy aspects of surgery such as fixing things and reminding myself of the important anatomy of the human body. After not urinating or eating for 12 hours, and remaining on my feet for much of it however, I was very much reminded of why I clearly chose not to go into surgery.

Can’t believe my first week here is already done! So far, we’ve already made some positive improvements at the hospital; using my public health training by encouraging all of the nurses to put our TB rule-out (and active disease) in “isolation” which means on the outside veranda or a side room, as they were previously all in the same big room with everyone. I will continue to work on this and am trying to find ways to make this sustainable, such as finding an extension cord so that they can have oxygen in the “isolation” areas, as there are only plugs in the main ward which is why they are all in the same room. Additionally, I’ve started rounding with the medical students on the men’s and women’s wards every day to ensure that any sick patients, new patients, or patients with updated labs are seen every day instead of every 3 days as they were previously seen. Next week I’m headed to an orphanage in the bush for three days while I will be doing some public health and medicine, so am quite excited about this exciting opportunity.