Trauma; Life in the ER: Soddo Edition

Every evening seems to bring a new adventure.  I'm not complaining, though.  I'm just glad we've gone over 24 hours without a stat C-section (and now I've totally jinxed myself).  The day started out with some new operative challenges.  John and I resected a nephroblastoma (freaking huge kidney tumor for you non-medical types) from a 4 year old.  I think the tumor was half the kid's body weight.  It was stuck to a 4cm segment of his vena cava.  That's God's country because really, only God should know what the back side of someone's vena cava looks like.  Unfortunately, we found out what the inside of his vena cava looked like, but John is a super vascular surgeon and fixed that, so all is well.  The tumor is out and the kid looks great (albeit a bit smaller and less lopsided).  Hopefully, he will be able to get the chemotherapy he will need in Addis Ababa.  I did a few more minor procedures before heading to the surgery clinic for the afternoon.  As expected, I recognized little of what I saw, but at least there are few subtle diagnoses in Soddo.  People live far away and therefore wait until things are REALLY bad before taking the long trek to the hospital.  The tumors are big or the wounds and infections are quite advanced by the time they get to us.  There was also a lot of gyn stuff - my favorite!  Dr. Morad, the OB/Gyn doctor is back, but we're trying to give her the rest of the week off because she is exhausted from her travel and is also moving into a new (not quite completed) house. 

        After clinic, I was hoping to join up with the OR staff for another game of soccer.  I am getting acclimated to the altitude and thought I might make it a whole 30 minutes before requiring intubation.  All this got tabled, however, when a nurse from the OR asked me when I was bringing the "new patient" to the OR.  I wasn't quite sure who the "new patient" was.  She said, "You know, the bleeding skull fracture from the car accident."  Actually, I didn't know, but she showed me to the ICU where there was a very bloody man who wasn't quite conscious.  He had been admitted from the outpatient department/ emergency room with an order to consult surgery to close his scalp lacerations.  He had more urgent issues.  He was bleeding from his mouth and tongue and was struggling to breathe through the blood and around his swollen tongue.  His jaw was obviously broken in at least two places.  He was going in and out of consciousness, his blood pressure was too low, his oxygen saturation was way too low, and who knows what his cervical spine looked like.  He was too combative, however, to tolerate any attempts to secure his airway.  I resorted to the ABC's of trauma - A is for airway, because without that, nothing else is going to matter.  We decided he would need to go to the OR for a tracheostomy before his tongue could swell any further.  I stabilized his cervical spine, lifted his jaw a bit to open his throat up, and tried to examine the rest of his body (with my third hand).  John had arrived to help, and we were able to get some fluid into him and raise his BP above 90.  The we went to the OR, placed a tracheostomy and did an ultrasound of his abdomen to evaluate for any bleeding or injuries to his liver, spleen, or kidneys - everything looked okay, his BP was better, and his oxygen levels were 100% now, even just breathing room air through the tracheostomy.  We sewed up his scalp lacerations and got him back to the unit.  It's at this point (or earlier) that I would normally be CT scanning his head to look for intracranial bleeding, CT scanning his neck to look for fractures, and consult facial plastic surgeons, neurosurgeons, and orthopedic surgeons to assist in managing him.  Apparently, however, there is no CT scanner and I AM the facial plastic surgeon, neurosurgeon, and orthopedic surgeon.  We'll just try to get him through the night, then worry about defining and fixing all his injuries in the coming days and weeks.  I think we've gotten to all the life threatening stuff for now.  I just hope is brain is okay. 

        We eventually made it back to the house - later than usual, but not too late to prevent us from playing a game of Catan.  It's even popular in Ethiopia, and the Foor family is pretty good at it.  Sarah, the eleven year old, is RUTHLESS.  She cleaned my clock AND ate all my beef jerky while doing it.  Oh well.

        This post is getting a bit wordy. I would attach photos, but my hands were too busy to take many today.  Those will come later as patients recover.