Saturday, March 29, 2014

Interesting Cases - an account by Warren Cooper

I am officially sick of interesting cases. It seems like we have had nothing but, in the last week or so. I wouldn't mind a couple of straightforward hernias. It keeps me from getting bored, I guess, but sometimes it's a little much. A few examples...

Bed 2 came into the hospital nearly dead. Not like the cute "Princess Bride" version, but the real thing. He had been vomiting massive quantities of blood for the previous day. He was in shock, with a barely perceptible blood pressure. By my estimation he had one or two red blood cells left in his blood vessels and they were working overtime. I put in a femoral line and we started pouring in fluids. This is a reasonable thing to do, but it really solves nothing. What he needed was red cells, and to stop the bleeding. A quick ultrasound confirmed the diagnosis: liver disease, probably resulting from schistosomiasis (a parasitic disease that you really don't want). We rushed him to the endoscopy suite, where we saved his life with...a couple of tiny rubber bands!  No kidding, that's all it took.  Actually getting them in the right place is little bit tricky.  He was bleeding from what is called esophageal varices.  These are dilated blood vessels in the esophagus which result from scarring in the liver.  I loaded the little rubber bands on a little tube that fits over the scope.  I sucked up the bleeding vessels into the scope and fired off the rubber bands using a nifty system involving tiny strings and beads, if you can believe that.  This whole procedure was complicated by blood which was literally pouring out like an open faucet.  Also the patient had by this time received enough fluids and blood to become agitated and combative.  Imagine the goriest bloodfest movie you've seen, multiply by two and you've got a pretty good idea of how things were.  It was not pretty, but we saved his life!  ...only to have him promptly lapse into a coma.  It was probably the big protein load which pushed him over the edge into hepatic encephalopathy.  Folks with liver disease do not tolerate lots of protein and this guy was essential drinking his own blood (a very high protein beverage!)  Anyway, that's where we stand now.  It may have been something of a Pyrrhic victory, but you have to try.  Maybe he'll wake up.  What a tragic disease!  This guy is in his early 30's and this disease is going to kill him.  If not this time around, then probably the next one.  Solution?  Don't bathe in contaminated water.  

Bed 3 is a man in his 60's who came in with jaundice.  He had something obstructing his bile ducts and pancreatic duct.  This is most commonly a malignant tumor in the head of the pancreas.  We discussed the options and scheduled him for surgery.  What commonly occurs is what (in the surgical realm) we call a "peek and shriek".  You open, you find a tumor that has spread, and you close.  The best I was hoping for was a biliary bypass, in which the bile duct is sewn to the bowel to treat the jaundice.  I opened him up and discovered a small tumor in the head of the pancreas, as predicted.  What I did not expect was that...that was it.  No appreciable lymph nodes, no spread to adjacent organs, no signs of liver metastasis.  In the scenario, the appropriate operation is what is known as a Whipple.  This is a huge operation which consists of removing the head of the pancreas and the duodenum.  In the US, this operation is generally performed in designated "centers of excellence."  Well, I saw one of these operations in my residency.  That doesn't exactly make us a center of excellence.  Anyway, we got started and things went fairly well.  I asked someone to open up a copy of Zollinger's Surgical Atlas to help refresh my memory on the general steps of the operation.  We got the tumor out, completed the necessary anastomoses (pancreas, common bile duct and stomach), and closed.  All things considered, it went fairly well.  We finished in about 4 hours.  This is a long operation for me, as I generally lose interest after about 2 hours.  One hesitates to talk of a "cure" when dealing with pancreatic cancer...but this may well be.  We're still not out of the woods.  Recovery can be a bit of a rocky road, but so far so good.

Bed 5 was injured in a vehicle accident.  It was the usual Congo scenario: a truck full of cement which was also carrying a bunch of people on top.  I'm not sure what happened, but it was bad.  Supposedly the driver fled the scene and hasn't been seen since.  There were one or two killed at the scene.  Four patients arrived at the hospital and it was up to us to figure out who was really injured.  Bed 5 had an obvious fracture of the humerus (no, it's not funny!) and a pelvic fracture.  He was also very, very drunk.  This gave me a little insight into how people tolerate the abysmal conditions of travel in Congo.  You get liquored up and the whole trip seems like fun!  Anyway, over the next couple of days this guy went nuts, probably from alcohol withdrawal.  He was getting up, harassing the nurses, flailing his broken arm in an alarming fashion and wetting the bed.  We gave everything we had to keep him down; valium, thorazine, haldol.  Nothing seemed to do much good.  Eventually we operated on his arm, and it was mess.  I pieced it together as best I could with screws and a plate.  It was an exercise in creative orthopedic surgery, but it actually came our looking pretty good.  After the operation, he kind of woke up and appeared "clothed and in his right mind" (as the Biblical passage relates).  Since that time he's been quite pleasant.  He has been talking with the chaplains and is keen to start reading the Bible.  

Bed 6 was in an altercation and got his hand sliced.  We had a couple of busy days and I was looking forward to a slow day in the OR.  When I saw this guy, I realized it was not going to be the case.  He had a deep gash over the palm of his right hand and his fingers (3,4,5) were extended.  He could not flex them.  Flexor tendon injuries to Zone 3 of the right hand do not make for an easy day.  I was informed by one of our trainees that they generally approached these injuries by simply sewing the skin back together.  That is well and good, but it means your fingers will never work again.  I did an ultrasound-guided block of the median and ulnar nerves, put on my surgical loupes and prepared myself for a tedious operation and a splitting headache.      The patient had a moment of panic when I instructed the team to cut off a black rubber bracelet he was wearing.  He misunderstood and thought I was telling them to cut his hand off at the wrist.  It may have something to do with my reputation.  My local name is "Chinjachinja".  This means something like "The Cutter" or "The Slasher".  Anyway, it was a tedious and difficult operation, which did indeed result in a splitting headache.  The tendons in this area, as it turns out are a very complicated mechanism.  There is both a deep and superficial flexor tendon.  Unfortunately this guy had been closing his hand when he was slashed (grabbing the attackers blade?) and the severed tendons had retracted way up into their sheathes.  It took a long time to find them and get them sutured back together.  It went fairly well, I think, but it's a nitpicking operation, and a region of complicated anatomy, if you're not used to being there.

Anyway, I could go on.  I could tell you about the lady with a nonunion of the tibia, the man with a tumor causing his eye to pop out, the kid who cant stop vomiting, the lady who cannot swallow, the boy whose hips have both died, the man who thrombosed both femoral arteries resulting in bilateral above-knee amputations, the lady whose placenta grew into the uterus, the lady with a huge recurrent tumor of her chest wall........but I won't.  It would take too much time and no one is really that interested to read it all.  

That is my life and my burden to bear.  Too many interesting cases!  In a way it is good.  It means that the hospital is known for taking care of difficult cases.  It means that people are coming here for training and they're seeing techniques that may help them as they serve in other places.  It also means that I come home exhausted and wondering what it would be like to have a "normal job."  I'd probably be bored.  

To anyone who actually made it this far in this gruesome account, congratulations.  Thanks to everyone for your support and your belief that God is doing a wonderful work here at Nyankunde Hospital.

Warren Cooper