March 2014 - Week Two - Rebecca Maine

Rebecca Maine Week 2

It’s hard to believe how quickly my time here is going.  I feel like in 4 weeks I will only begin to learn about the challenges that the physicians here face in trying to provide care for their patients, especially the sickest patients. 

Unfortunately, we had many more complications in this past week.  Including the loss of two young, new mothers from post-partum abdominal sepsis.  In both cases after laparotomy they reminded septic.  However, intubation was not an option with limited numbers of vents.  When the physicians wanted to broaden antibiotic coverage to meropenem, they chose partial treatment (daily instead TID dosing) because of the high cost of the medications to the family.  In fact, I was told by a medicine colleague that meropenem resistance is on the rise here, as this partial dosing practice due to cost is not uncommon.  One of these patient became very hypotensive, and we wanted to give fluids rapidly.  However, central lines are too expensive for many patients and are not available in the hospital, so not that helpful in an emergency. 

 As one patient started to code, there was nothing we could do, as no ACLS drugs were available, in fact, oxygen was not even available in the block at that time, despite it being the “mini-ICU”.  Both patients might have benefitted from full ICU care, more availability of appropriate antibiotics and perhaps the ability to return to the theater more quickly to have a second look and further washout.  But all of these things that I have taken for granted in the hospitals at home are not easily done here.

 It is hard for the residents and specialists here who must fight against these limitations constantly.  Last week we did a damage control laparotomy for a patient very ill from a perforated transverse colon tumor.  (One of 3 emergency laparotomies we did that call!) After resection, we left the bowel in discontinuity with the plan to return the next day to look again and do the formal anastomosis.  While the team knew about the idea of damage control, it is not an approach that is used here often.  One reason is that the very sick trauma patients that we often give these laparotomies to, are not making it to the hospital for care in Tanzania.  However, the delayed presentation of many patients means their peritonitis is fairly severe, making it an option to consider. It became obvious the next afternoon, however, that the OR space and anesthesia availability is another factor that limits the number of damage control surgeries.  The surgical residents spent 2.5 hours begging and cajoling to get the patient back into the theater the next day.   There is a protocol for how emergency surgeries are booked (airway, ectopics, pediatrics, ruptured viscera – all come first).  As we were talking with anesthesia – even though we had added the patient to the add-on board at 8am- 2 visceral injuries were booked.  The resident, however, was able to convince the team to get the patient to the OR. The case went well and the patient is recovering, slowly in the ICU.  Until things change in terms of access to OR time, it’s hard to think that damage control operations will be widely practiced here.

 

In addition to the emergency laparotomies I have had the opportunity to see a variety of very interesting cases.  This week the team performed gastrectomies, colectomies and cystjejunostomies (all for probable malignancies), all potentially palliative.  The cystjejunostomy was very interesting as it was diagnosed by imaging pre-operatively as a post-traumatic pancreatic pseudocyst.  However, as it was explored and drained intra-operatively we become very concerned that it was malignant.   Unfortunately the lesion was unresectable. The woman had been having pain from the large cystic lesion and it had been opened, so we did a drainage procedure and sent biopsies.  We did a finger amputation, giving me the chance to learn about radial, medians and ulnar blocks.  On call there were 5 emergency laparotomies (for duodenal perforation, gastric perforation, transverse colon perforation, post-septic abortion peritonitis and post partum peritonitis).  Observing and participating in the theater continues to be a great learning opportunity and I feel lucky to get to participate in the care of these patients, even with all of the challenges.

More updates next week. 

Rebecca

Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change, Harvard Medical School
Boston Children's Hospital
PGY5 UCSF General Surgery Residency