Day 12

I think this will be our last day of operating, as we hope to go to an art market tomorrow before we leave.

Colleen and I started this morning with the 4 year old boy who had a large lipoma on his back. It was a 10+ cm mass which we removed through a 5 cm incision, so that was cool. Kinda like delivering a baby ! He was moving some during the surgery, but then afterwards he didn’t wake up for nearly an hour. Finally, he did, but it brought to the fore once again my concerns about anesthesia, and the anesthesia providers, here. I think they do an ok job, but it seems like supervision of the student nurse anesthetists is quite lax. They monitor O2 saturation, but not end-tidal CO2. There are also no CO2 absorbers that I can see; I will have to ask about that when I get home.

The next case was a young woman who had a criminal abortion in January, in which they perforated her uterus in 3 places as well as her sigmoid colon, so she had a hysterectomy at the MSF Hospital, and then was transferred here where she had a Hartmann’s by Dr. Konneh. When he heard that we had brought 2 EEA staplers with us, he was begging us to do this woman, and so we agreed. Dr. Konneh is an interesting fellow who is very enthusiastic and perhaps more aggressive than warranted, but he has been quite helpful to us. So Robert was doing a lipoma in the other room, and he and I did this woman. I was surprised and pleased with his abilities ! We did the whole case, and I let him go down below to do the stapling; I think and hope it all worked well!

My experience with him today has reaffirmed an idea I had last night, which I talked to Adaman about and he liked the idea. I want to come back here in the fall maybe, with no residents, and just work with the house staff here. I think they have done a remarkably good job of learning surgery under the circumstances they find themselves in, but they really need to work with someone to improve their technique and give them some stimulation. I think that would be an interesting 2 weeks for me, and I think it would be useful for them. Dr. Konneh thought it was a great idea!

Robert was doing bilateral inguinal hernias next, so Colleen and I did a takedown of a colostomy and handsewn reanastomosis in a 26 year old woman. She had been through 3 days of obstructed labor, delivered a dead baby, and was then found to have a rectovaginal fistula. So She had 2 attempts at repair: the first without a colostomy, and the second after a colostomy. The second one worked. SO now she was ready to be decommissioned. It went well, but they could certainly use more and better instruments. Their bowel clamps are what we put rubber shods on; they don’t have any actual bowel clamps as we know them. They also don’t have retractors, though in honesty we have done ok with them, probably because the people are thin.

While we were doing that, Robert came in to tell us that his hernia patient had coded, but had been resuscitated. He then developed what appeared to be flash pulmonary edema. Right now they have him in the ICU, and apparently they were able to find the guy who has the key for the ventilator, so he is on it. Once again, my concerns about anesthesia at JFK. They either don’t know, or don’t think it is important to know, what level of anesthesia their patients are under. Waking up and bucking during a case is more the rule than the exception. I know that can happen anywhere, but it seems that too often I look up to announce to the head of the table that a patient is bucking, and it is a student who seems to have little clue what to do.

We just heard that Robert’s patient died. It is terribly frustrating that we really have no idea what happened, and I have the feeling that no one will ever know. It will not be discussed among the participants, and no one will learn anything from it. Very sad.

We have a 4 year old with an acute abdomen to do, but his mother just fed him, and now we have to wait till 9 PM tonight. Oh well.