Roughing it

Roughing it

1/21/12

Sorry to take such a break from posting. Settling in often means becoming busier and more immersed in the work and people at hand. Though unique experiences abound, they become more numerous, and for some reason I felt less compelled to immediately blog about them. I am also enjoying hearing the experiences from our clinic team who have been out and about at increasingly remote and destitute locations. Stories of train-cart rides through the jungle to grass-hut villages replete with Dengue, anacondas, naked children, even a leper. Considering having one of that team write a guest-post as they are seeing and experiencing parts of Bolivia I have not seen (and might not get to anytime soon).

From a surgical standpoint, we have become busier and thus more efficient with each day. Dr. Henry got to do a number of orthopedic cases, especially on Weds thru Fri. Katie (his daughter) got to observe a femur nailing on a day off from her work in the clinic. I have been a hernia fixing machine, but have had a few different cases mixed in. Got to take out a suspiciously ovary that wound up being a teratoma (complete with hair and teeth... pretty cool). Had to do a hemorrhoid (I told him not to tell anyone, lest a reputation be built).

The most memorable case to date has been an appendectomy on a very sick 5 year old. While I was in working on a hernia, Dr. Pendse was called to the ER to evaluate him. He was listless. Had been sick for at least 2 weeks according to what we could make of the chart. He was barely conscious, heart racing, blood pressure too low, feverish, and his labs demonstrated an anemia shocking for a 5 year old. Dr. Pendse made the diagnosis of ruptured appendicitis based on the history he got from the kid's mom. He admitted him and hit him hard with fluids and antibiotics, trying to get him to make urine and to stabilize his blood pressure before we took him to surgery.

In the States, he would be at a specialized pediatric hospital, admitted to the ICU, and descended upon by a team of specialists (surgery, critical care, ID, hematology), would get a CT scan and likely an attempt to drain the abscess with a CT guided needle. He would get blood transfusions. He would get everything. None of these are options here. It is surgery or nothing, and surgery on a child in this condition is risky. We seldom see kids so sick.

We got him somewhat stabilized and brought him to the OR, offering the family what assurances we could. They would pray and so would we. We started. He bled tremendously from places that should not bleed. With limited lighting, limited retraction, and weak suction equipment, it was nearly impossible to tell where it was coming from. The infection was severe, but contained and we were able to clear it out and remove the appendix without too much difficulty. But the bleeding continued and seemingly from everywhere. We estimated it at about 20% of his already anemic blood volume. Jon (anesthesia) tried to keep up by pushing more and more fluid through his little IV. We extended our incision, but still could not find the source. We packed him tightly with gauze sponges, a maneuver from damage-control trauma surgery intended to slow the bleeding enough to give the blood time to clot on its own. But would it? We packed and we prayed. Each of us, silently, even as our hands worked.

It stopped. All of it.

We will never know where it came from or why. We washed him out and removed the gauze. We looked everywhere for bleeding and could find none. His heart slowed a bit and his pressure remained steady, no longer dropping. We closed and moved him to the ward, alive. At home, we would keep him asleep on a respirator in the PICU and do the breathing for him. At home, we would give him blood. My translator, Sandra, is a match and tried to donate, but it was late and the lab was not even open to run the necessary tests on the blood. He would have to make it through the night on his own, though his blood count was only a third of what it should be.

He was still listless in the morning, but he was alive. He will likely receive blood from a family member today if the tests are able to be run. He is most certainly not out of the woods yet. There is much infection and inflammation to fight and limited resources with which he can do that. God must sustain him.

Returned to see him later and he was actually standing up with the help of his mother. Though small, it is a sign of strength and we pray he will find more of it. Will try to keep everyone updated as to his progress.