Saturday, September 24, 2011

Twelfth Chapter

Twelfth Chapter
In which we see how hands are restored and what our cast thinks of TV doctors
   The patient is asleep and draped on the OR table. He is a 42 year old male, right hand dominate, married, father of two, a computer and electronics repair man who works in his own wood working shop on weekends. He is here in the OR because he had an unfortunate encounter with a table saw and his right hand. Table saws are responsible for more hand injuries than any other power tool. In the music industry, the annual award is the Grammy, a miniature gold gramophone. If there was an annual award for hand surgery, it would be a miniature gold table saw. The patients right arm is extended out at a right angle to his body on an attachment to the OR table just for hand surgery. It is about two feet wide and three feet long. Seated around the hand table on stools are: Dr. Lamb, hand surgeon, Dr. Oriel, a hand fellow (a fellow is a fully qualified surgeon, who has completed a residency and passed his board exams, and is doing an additional year of training in a sub-specialty), and Debs, an OR Tech. Anne is the circulating nurse. Behind the sterile sheet raised to separate the patients head from the sterile field is Dr. Spiro, anesthesiologist. This raised sheet is referred to as the “ether screen”, the term an anachronism from the days when ether was used as an anesthetic agent. Lamb and Oriel are wearing loupes, glasses that have magnifying telescopes sticking out of the lenses, giving them highly magnified views of the field, while allowing them to look around the telescopes for an unmagnified view.

Lamb: OK, I think you have done a good job of exploring the injury, tell me what you have found, and what you plan to do next.
Oriel: Well, there are fractures in the proximal phalanges (the first bone outward from the knuckle) in the index and long fingers. There are injuries in the vascular and nerves as well as severance of the flexor tendons. The ring and small fingers seem to be just superficially injured, maybe a flexor tendon in the ring finger. I want to first get the fractures reduced and stabilized, then repair the veins arteries and nerves in the first and second digits. The tendons can be last. The ring and small fingers can wait until the others are finished. The core of the problem here is that the most important fingers for strength and precision are compromised, and this patient needs both to do his work. The ring and small fingers are not nearly as important, but have minor injuries.
Lamb: That’s exactly how I see it. The fractures are clean cuts, so pinning them with K-wires should be sufficient, no need for plates and screws.
Debs had already reached this conclusion herself and had prepared the pin driver with an .045 K-wire, and now extended it to Dr. Oriel. He begins to drive the pin.
Spiro: Anybody see “House” last night? It drives me crazy the way they always start a patient on some drug before they confirm a diagnosis, and big surprise, the patient gets worse!
Anne: He brings in a patient, makes at least three wild guesses at a diagnosis, orders treatments for each wild guess, the treatments nearly kill the patient, then gets inspired by some random visual cue to make the correct diagnosis! And as many professionals have noted: “It’s never Lupus!”
Debs: And House and his team seem to be the only people working in their hospital. No nurses, no lab techs, no radiology techs. No Radiologists, Pathologists either. They do it all themselves!
Lamb: As if any of us would know how to run the lab equipment or what reagents to use for a given test! And where do they find the time to do all that? It must be great to only have to deal with one patient at a time.
Oriel: And what hospital would ever put up with the way that House treats everyone, patients and staff? No way.
Anne: Not like the old TV medical shows. Remember Marcus Welby, Ben Casey, and Dr. Kildare? They were these saints who not only cured your illness, buy reconciled your dysfunctional family, took care of your bankruptcy, and helped you to find God, even.
Debs: I could swear that the AMA had control of the scripts back then.
Oriel: OK, bring in the C-arm.
A C-arm is a fluoroscopic device that lets you see an x-ray image as a still or video picture. It has an emitter on the top of a “C” shaped steel rail, and a drum shaped collector on the bottom. The “C” is attached to a console with a TV monitor on top where the Image is viewed. The “C” shaped part is draped with a large clear sterile plastic bag.  The hand is placed on top of the collector and a foot pedal activated by the surgeon produces an image on the monitor.
Lamb: Looks good. Turn it over. You won’t get approximation better than that. (Approximation is the lining up and joining the two ends).
Oriel: just need a second K-wire to stabilize it.
Spiro: I used to laugh at Ben Casey. Old Dr. Jaffe would always watch his procedure from way up in this gallery, where you couldn’t possibly make out the small delicate things that go on in brain surgery. Then after the procedure he always without fail tells Dr. Casey “Your technique is excellent”.
Debs: Anyone here ever actually see one of those galleries in an OR? They are such a staple on TV.
Unanimous answer: No!
Lamb: I’ve been in many, many hospitals and I have never seen one. I never could see the point. You can’t see anything that would matter from such a place.
Oriel: I always wanted to hear Dr. Jaffe say to Casey “Your diagnosis is mistaken and your technique is faulty”.
Everyone laughs.

Oriel: C-arm again. Looks good. Now the long finger.
Debs: Also known as the “flip” finger.
Anne: I think Grey’s Anatomy is probably the worst offender of all. Such an incredible bunch of sex crazed drama queens.
Lamb: C-arm again. Good.
Oriel: Bring in the micro scope. How are we doing for tourniquet time?
Spiro: Twenty-eight minutes.
Oriel: Let us know when we get to an hour.
Anne moves the C-arm out from the hand table and moves in the microscope, a binocular Zeiss with three sets of eyepieces. It also is draped with a clear plastic sterile drape. Anne removes the foot pedal for the C-arm and places the foot control for the microscope. Anne removes the loupes from Lamb and Oriel. The microscope affords them even more magnification than the loupes, but an un magnified view of the field is not available.
Lamb: They get so far-fetched on Grey’s. I get patients all the time with the most incredible ideas they get from that show. Very misleading.

Anne: The doctors are so caught up in their own dramas that they totally lose sight of the patients.
Debs: Those old shows with the saintly doctors stayed away from the doctors lives entirely. The focus was always on the patients, one good point for them.
Anne: Don’t even get me started on how they have portrayed nurses.
Oriel: Give me a double small vein approximator. (Two small clips attached to a small rod on which they can be slid back and forth. By use of the approximator the ends of the vessel can be brought together and held in place for suturing.) (Veins are almost always repaired before arteries in hand surgery. It sees counter intuitive, but the real problem is getting blood out of the injured finger, not into it. Like when you put a rubber band tight around your finger, it swells and gets purple colored and throbs in time with your pulse. There is pressure behind the arterial blood so it still gets in, but the venous blood can’t get out, causing the purple color, the swelling and the throbbing.)
Oriel: 9-0 nylon.
Debs: Here you go.
Debs places the Castro-Viejo micro needle holder with the suture loaded into Oriel’s right hand in the position it will be used, then guides his hand under the microscope until it is in his field of view. This is so that he will not have to look away from the eyepieces of the microscope. She places a jeweler’s forcept into his left hand. She then places jeweler’s forcepts and a micro scissors into Lambs hands, guiding thm into the field of view. Then she looks into her own set of eyepieces. She has a syringe filled with a solution of Heparin at the ready. Heparin is an anti-coagulent, and will prevent clotting until after the repairs are complete.
Oriel starts suturing the vein. Debs spreads a white towel out on the field. The 9-0 suture and needle are so fine, that if it should be dropped it could only be found with great difficulty on the blue sterile drapes. They show up well against white however.
Spiro: Yeah, always standing at the nursing station with perfect hair and makeup, holding a chart. Meanwhile, the doctors are doing all the things that nurses do. And they are always the ones that find when something is going wrong, not the nurses who are the ones who are actually with the patients.
Anne: Or else they are saintly paragons of virtue and self sacrifice, except when they are mentally deficient sexpots. I remember an episode of Trapper John, MD that had a nurse who was a stripper on the side.
Lamb: The classic naughty nurse fantasy. White thigh length high heel boots with spurs.
Oriel: (looking away from the microscope and making an exaggerated wink) You thinking of taking up a side job Anne?
Anne: You wish, you pervert!(Her eyes sparkling with mirth)
Debs: I forget which show, but they had a nurse that was a dominatrix.
Anne: Honestly, that’s about as likely as a physician doing those things on the side.
Spiro: Remember “ER” with George Clooney? I gave up on that one after they had the nurses stealing the resident’s coffee. In my experience it’s always the other way around.
Anne: Amen to that!
Oriel: I will give “ER” and “St. Elsewhere” credit for showing gritty inner city hospitals and taking on some tough story lines like AIDS. But again, too much on the doctors weird personal lives. But at least there was this thing that the exaggerations were just that, exaggerations for comedic effect. They were not presented as if they were serious. That show “Scrubs” is like that. They punctuate with sound effects to make the absurdities plain. Although a lot of the time when they use medical sounding dialog, it's just gibberish.
Lamb: That looks good. Let’s go for the money shot. How are we on tourniquet time?
Spiro: Fifty eight minutes
Oriel: Let’s let it down for five.
Spiro: OK. Tourniquet down.
Oriel: See the artery here? No leaks. And I don’t see it in the long finger. Looks like we got lucky with that one.
Debs: Doppler?
She extends the Doppler probe towards Dr. Oriel. The Doppler picks up and magnifies the sound of blood moving through a vessel. By the quality or absence of the sound, the presence and quality of blood supply can be established.
Oriel: Good idea, thanks.
He takes the Doppler probe, and extends the end with the contact plugs to Anne over the patient’s chest. Anne plugs the leads into the Doppler box and switches it on. Debs extends a small plastic cup filled with a clear jell to Oriel who dips the end of the Doppler probe into the jell. The jell increases the contact of the probe providing a better signal, just like the jell used for ultrasound examination of fetuses in a pregnant woman. He then applies it to the index finger.  No sound is heard, as expected. He then applies the probe to the end of the long finger. Aloud pulsing, whooshing sound comes from the box Anne is holding. A swishing sound would indicate diminished flow. No sound would mean no flow.
Lamb: good pulse there.
Oriel applies the Doppler probe to the ring and small fingers, resulting in more of the pulsing whooshing sounds.
Oriel: All the rest are good.
Spiro: I really hate the way they portray ERs. Like every person coming in has some big life threatening situation. Reality is that 99.9% of ER admissions are just routine stuff from people with no other access to health care providers, so they turn to the ER.
Anne: And doctors hanging out at the ER doors just waiting for an emergency to come along! As if!
Spiro: Time up. Tourniquet back up?
Oriel: OK, tourniquet up.
Lamb: Now let’s get that artery.
Debs extends an arterial approximator to Oriel. The difference between the vein approximator and the arterial one is in the strength of the clips. Arteries have thicker walls and a muscle layer so that they can constrict and dilate according to the bodies reflexes. The arterial clips must exert more pressure. Oriel applies the approximator and lines up the ends of the artery. Debs hands him a Weck spear, a small triangular cellulose sponge on the end of a toothpick size stick. Oriel uses it to clear the small quantity of blood on the ends of the artery so that he can see better under the microscope. She hands him another 9/0 suture, and jeweler’s forceps. She passes the forceps and scissors to Lamb. She readies a neuro patty (a ¼ by ¼ cotton felt pad) soaked in 2% Lidocaine solution. Because of the muscle layer in arteries, they often go into spasm. The Lidocaine will relax the spasm.
Spiro: I, of course, take offense at the portrayal of anesthesiologists on TV. Most of the time they just sit there doing nothing, just being another part of the furniture. On Grey’s they had one who fell asleep during a procedure, and they started calling him McSleepy.
Anne: You guys are the only ones who get even less respect than nurses.
Lamb: Give us the Lidocaine patty.
Debs: What kills me is how they do CPR on TV. Too slow, with elbows flexing, so that the compressions are worthless.
Anne: And the monitor alarms when it goes flat line, (asystole) instead of a wavy line that would indicate ventricular fibrillation. Monitors only actually alarm when there is a malfunction. Then they proceed to defibrillate even though the patient is in asystole, not a shockable rhythm.
Spiro: I remember an episode of “Medical Center” where Chad Everet, Dr. Gannon, defibs a guy in a parking lot with jumper cables from a car battery. Hah!
Oriel: And on “Gray’s” I even saw them defib a guy that was conscious and talking!
Lamb: How about how they do a surgical scrub? With no mask up, and talking to someone in street clothes!
Anne: They go into OR’s all the time in street clothes. But it drives me crazy how they are talking about all their deep personal tribulations while they are doing all of this.
Debs: And I have never seen them get gowned and gloved in any way that was actually sterile.
Oriel: OK, I think that does it for the artery. Let’s bring down the tourniquet again and get everything freshly perfused.
Spiro: Tourniquet down now.
Debs passes the Doppler probe and jell. A satisfactory whooshing sound is produced. The artery doe not leak. She has prepared the items that will be needed next for repair of the tendons. While they are waiting, they dab the wound with sponges and inspect their handiwork.

Oriel: OK, let’s have the tourniquet back up. Take the microscope away.
Anne pulls the microscope back, then gets the loupes and places them over the surgeon’s heads and in place on their noses. Debs places needle holders in Oriel’s right hand. The needle holder is armed with a 4/0 Dacron suture. She places a pair of DeBakey forceps in his left hand. She places a pair of suture scissors in Lambs right hand. They begin the repair of the tendons in all the fingers.
Anne: Can you believe the miraculous recoveries they have on TV? The patient can have just been defibrillated, and they are talking!
Debs: It’s even worse if they have been in a coma. In reality, they would be demonstrating Aphasia (they inability to retrieve words and generate speech. And they probably would have disphagia (inability to swallow). All that requires a lot of time and therapy to get over.
Spiro: Not to mention that their hair and makeup are in perfect condition.
Oriel: OK! I want to check with the Doppler one more time before we start closing the skin. Then we will need a plaster splint and all the dressings. Debs, great work as usual. You too, Anne.
Spiro: What about me? See? No respect here either. I might as well sleep through this.
Anne: Have any of you seen the new Nurse shows? They are even worse! This “Nurse Jackie” takes the flawed hero/anti-hero, breaking all the rules, up against the establishment, fighting for the patient non-sense that has become the standard for the doctor shows to new heights of depravity. In the show that I saw, she commits three huge felonies; forging a driver’s license, seducing a pharmacist to obtain drugs to feed her addiction that makes House look like a kid on candy, and flushes a patient’s ear down the toilet.

Lamb: Yeah, how do any of these characters keep their licenses let alone stay out of jail?
Debs: Well, at least they aren’t blowing things up, and shooting their way through dens of terrorists, torturing middle easterners on the way to truth like Jack Bauer.
Anne: They are the terrorists.
Oriel: Let me have the Doppler one more time. I think we are going to have a good result here. The fractures did not involve the joints, so there should not be any loss of mobility, we have good circulation. The only problems I see will be connected to the nerve repair. He may have areas of numbness or hypersensitivity; I expect that he will have cold intolerance. But he should have a fully functioning hand.
Lamb: It will take a year or more to see what recovery there is from the nerve damage. All will now depend on good physical therapy. I think he will be a good compliant patient.
Oriel: It is surprising how many patients we get that do not complete therapy, and then complain that they have less than optimum results.

Thursday, September 15, 2011

Eleventh Chapter


In which Molly travels to Africa as a volunteer, and writes up her experiences in a blog:


September 1st: I have completed many preparations for the trip. I started my anti-malarial meds today. Reading the list of possible side effects had scared me somewhat, and I had wanted Ed to be around in case I started hallucinating. I’d rather not have to see Gene Kelly in miniature dancing around in the kitchen sink tap dancing “Singing in the Rain” if I can help it. At least Ed could slap me back to reality before I try to flush Gene down the drain with the sprayhose.

Ed has assembled a kit for me: Swiss Army knife, insecticide impregnated mosquito netting, industrial strength insect repellent in sticks, wipes and sprays, bottles of water purification tablets, small maglight, spare batteries, army surplus rain poncho, a capacious rucksack with frame and padded compartment for my laptop, and a nifty small digital camera that uses the same size batteries as my maglight.

I will be busy the next couple of days, so I might not get to blogging again until after my departure.

September 5th: I arrived in the Republic of West Africa (hereafter RWA) after 26 hours of travel, New York to Amsterdam, then Amsterdam to Nairobi, Nairobi to Capitol City, RWA. I am staying in a guest house tonight, very nice, the family that runs it very friendly, they have six rooms here, furnished with very basic furniture, but all of it sparkling clean. My single bed has a mattress that has seen better days, but it is brightened up with Star Wars sheets. There is a convenient hook over the bed for my mosquito net.

I had my first sample of RWA food: some form of meat in thick gravy, served over a starchy paste that had a yellow color to it, very, very spicy hot! It really cleared out my sinuses and brought tears to my eyes. Later I had another version of this, but with rice instead of the starchy paste, and if possible, even hotter!

Water comes in little plastic bags instead of bottles; you nip off a corner and drink.

Cell phones are huge here, probably because there is no need for the infrastructure of poles and lines. There are little kiosks and stores everywhere that sell top off minutes, as prepaid service is the only game in town. Minutes of time are surprisingly cheap. Service is a variable thing, you often get cut off in the middle of a call.

September 6th: People here are very religious: All the taxis have “God Bless”, or “Jesus Saves” painted on them. Stores and businesses have titles such as “Fear God Cell Phones”, “God Is Good Fashions”, “With God All Things Are Possible Tire Repair”. Repair shops are common, unlike back in the States, it is more economical to repair things than buy new. Repairs are often marvels of ingenuity and improvisation, as spare parts are scarce, and when available are often cannibalized from the unrepairable. There is almost no litter here, as cans, bottles, cardboard, etc are all looked at as materials to be used. I bought a model helicopter for Ed made from scavenged wire. There is a lever on the side, and if you push and pull on it, the main and tail rotors spin. Aluminum cans are prized for the parts that can be made from them to repair things, and for all the things that can be made from them. I also bought a beautiful candle lantern made from a soda can. A popular toy here is a car made from soda cans that is about the size of a shoe box. It has a stiff wire that sticks out the top to about two and a half feet, with a circle of wire at the top making a steering wheel. When you turn the steering wheel, the front wheels of the car actually turn. The children “drive” these beautifully made cars all over town.

It is hard to say who is more influential here, Jesus or Bob Marley. Pictures of both are everywhere. Reggae music is the soundtrack to everything. It often seems to me that the whole country is bopping along to “One Love”, the music perfectly in tune to the laid back life style. I have to explain about RWA time, or it is more probably just African time. Among westerners, there are many jokes about this. If someone says “five minutes” they really mean “an Hour”. I had to wait two hours for food at a restaurant. But on the other hand, you do not have to rush for anything, there are no deadlines, and your lunch break is a s long as you want.

September 7th: People here are warm and friendly. English is theoretically the official language, but many other local dialects and languages are spoken. Everybody has some English, although individual words have novel meanings. It was an amazing experience to ask directions and then be led for fifteen or twenty minutes through a maze of narrow streets to the tro-tro station, then to exactly the right tro-tro for my destination, and then my offer of a small cash reward refused. I have to explain about tro-tros.

A tro-tro is a van outfitted with seats. They are uniformly in deplorable condition, rusted and paint peeling. They are the main conveyance for people and packages, all crammed in to fullest capacity. Private ownership of cars is rare here, so tro-tros are the way to go.

The roads here are another thing, with as many holes as a Swiss cheese, and that’s the paved ones! The drivers of the tro-tros must dodge and weave to avoid the largest ones, often into the face of oncoming traffic. After about twenty minutes of sheer terror, your adrenaline level comes down to just higher than normal. At every stop a crowd of people swarm to the windows of the tro-tros hissing at you (the way you get someone’s attention here) selling a bewildering array of things, bags of water, plaintain chips, toothpaste, batteries and other food products.

My seatmate is George, a medical student from England, on the way to the same provincial hospital as me. He has been here the past two summers and has picked up some of the local language called Twili. At a stop just outside the city, a man dressed in a black suit climbed aboard. As the tro-tro moves off, he gets up and starts speaking rapidly in Twili. I asked George who he thought the man was. I had guessed a preacher by his black suit, and the general level of religiousness I had seen in the country. George said he was a patent medicine salesman, and did his best to translate and summarize the pitch. He described the miracle spices in the tin he was holding up. He passed out little cards, like business cards, that listed all the things his medicine would cure. Diabetes, hypertension, stroke, headache, malaria, dementia, heartburn and indigestion to name a few. He was very entertaining and I was reminded of the TV infomercials back home (But Wait! There’s More…..). Next he pulled out a box of toothpaste with a picture of a pack of cigarettes on it. It was supposed to make your teeth shiny white. I hope it didn’t taste like cigarettes.

September 9th: We encountered heavy rains part of the way to the provincial capital, our destination. I had not considered that: dirt roads + heavy rain = mud. Our driver chooses to drive through a large puddle rather than around it and we get stuck. The water is so deep it begins to flood into the tro-tro. We all get out and after about twenty minutes of pushing, manage to free the tro-tro. Of course, it then refuses to start. And no bother about the mud and dirty water we were covered with, the rain washes it off. The sun comes back out and we wait in the shade of some trees for about an hour while the driver summons a mechanic on his cell phone. Thank god that was working! The mechanic arrives, does something under the hood, the tro-tro starts, we all pile in and we are off.

I am staying with a host family. The husband has a business manufacturing cement blocks, and selling lumber and other building supplies. She is a school teacher. They have two children who are away at a boarding school, which is the norm here for the wealthy. Their house is one of the more upscale in the town, made of stucco and cider block with a tile roof. The interior is very nice, well furnished with a modern western kitchen and electric ceiling fans in every room. Unlike in the west, there is no separate neighborhood for the more affluent. Next door is a mud walled shack with a thatched roof and no electricity. I am given a very comfortable room. My hosts speak very good English, the King’s version, as both have been to university in England.

September 12th: About technology: Africa capriciously decides when it will work, and when it will not. In a town you may have electricity to run technology, such as the internet café I am sitting in right now, the only internet access for this whole provincial capital. Like most of Africa, the power only works when it wants to. Half the time the power is out, so you get by with candlelight , and you don’t buy more food that needs refrigeration than you can eat in a day or so. This is also true of the water as well, so when you get in the shower, you fill a bucket with water first, so if it goes off before you finish, you can still rinse off. I was in surgery at the hospital this morning, a myomectomy (removal of uterine fibroids) when the power went out. The procedure had to be finished by flashlight, and suctioning had to be done with a foot powered pump. The hospital does have a generator for back up, but it steadfastly refused to start. They are used to things like that here

The hospital is a cluster of small buildings made of cement block with corrugated metal roofs and covered verandas on the side that faces into the yard that the buildings enclose. Everything is whitewashed, but the rains have given the lower portions of the walls a red-brown color from splashed up dirt. Patients see a clerk in one building, a doctor in another, get their prescriptions in a third, and then go to a fourth to get a bed. There are three buildings that serve as wards. One for men, one for women and one for children. If you do not have family or friends, you are out of luck, as the hospital does not provide food or linens. Family members provide the everyday care. Everything is done to conserve supplies. For example, gloves are very scarce, so they are only worn when absolutely necessary.

There is a secretary who does all the typing and filing of records, with a meticulous efficiency. The typewriter is missing the type bits on the end of the type arms for the letters “h”, ‘’e” and “s”. When she finishes typing a document, she goes back and fills in these letters with a fine point pen. Her draftsmanship is so good that her hand written letters are indistinguishable from typed ones. The documents are very easily smudged however. This is because the typewriter ribbons are re-inked with soot from the kerosene lamp chimneys.

September 18th: I have been so busy that I have a lot of catching up to do. As I expected, there is a very high incidence of malaria here, it is the leading cause of childhood mortality. Hypertension, cardiovascular disease and diabetes are also high here, even more so than in the states, the diet (high in salt, low in vegetables and a low level of exercise) is most likely to blame, but there appear to be genetic factors as well. Typhoid and tetanus are common as well, things almost never seen back home. There are cases of HIV as well, but due to the huge stigma attached, testing is mostly not done. As a rule, people do not seek attention until there is no other alternative, so most cases that come to the hospital are in advanced stages. I have seen some very advanced cases of anemia and malnutrition, especially among the children.

Clinical tests, like technology, are a sometimes thing. Maybe there are no testing reagents at the moment, or the equipment is broken down. Despite malaria tests coming back negative, doctors still prescribe anti-malarials on the basis that the symptoms are there, and the test results may be unreliable. As a result there are problems with drug resistance here.

September 22nd: Yesterday we went on a community outreach to a nearby village. It was obviously a much poorer place than the provincial capital in which we have been staying. There is very little car or truck traffic here, but there are bicycles. Goats and chickens forage everywhere. There is almost no western style clothing here, most are dressed in traditional clothing, brightly colored long skirts and full sleeved blouses for the women, trousers and brightly colored shirts for the men. Mothers carry their babies in shawls on their backs, the babies fast asleep. I almost never heard babies crying. The women and a few of the men carry large loads on their heads, sometimes heavy and bulky items. I even saw a heavy foot powered Singer Sewing machine carried in this manner.

There are many stalls in the market place, most made of plywood and brightly painted, the names of the stalls reflecting the religious nature of the culture, such as God’s Bounty Vegetables. Almost everyone seemed to be engaged in some sort of business in order to bring income for their families. No one was idle or just sitting around under the trees.

First we went to the school. Under the direction of the teachers, the children raced to set up tables and chairs in the courtyard of the school. We were directed to chairs and were not permitted to help. The children obviously knew from prior visits how to arrange the tables and chairs and seemed very happy and excited. The teacher then got the children lined up, and things got started with a triage at the first table. The other tables were set up for vaccinations, wound care and the last table for screening for TB, Sickle Cell, Malaria, etc. I got the wound and skin care. Many of the children have infections of simple cuts and scrapes because a common folk remedy here is to rub mud into wounds to stop bleeding. So I clean the wounds and dress them as needed, and try to teach them not to put mud in the wounds. The kids love bandaids, especially the colored ones, and will ask for a “plaster” as they call them even if they do not need one. There were one or two that I referred to our doctor for antibiotics, as they had more advanced infections. Everything is done without gloves as there are none to spare, but we had lots of soap and water to wash between patients.

After we finished at the school, we went back to the market area and by this time, our crew had set up a couple of tents and a canvas awning, and we had a clinic for prenatal, mother and baby care. I dispensed oral polio vaccine drops. Because of the lack of gloves, I was instructed not to touch the babies, just get the mothers to get the babies mouths open to receive the drops. One must not use the left hand. It has some connotation of insult; even beggars will refuse money offered with the left hand. Another volunteer entered the vaccination in the patient record carried by the mothers. One or two of these were very tattered, and these were sent to our clerk for replacement. Most however had been carefully folded and then placed inside a piece newspaper or other salvaged paper to keep them clean and intact. There was also screening for hypertension and diabetes, and appointments were made for follow up as needed.

A district Nurse then conducted a class where she covered a whole variety of subjects from breast feeding to basic baby care. She used stories and songs, humor and repetition, much in keeping with the traditions of oral history and culture. I couldn’t help but think of this as the African version of the pamphlets and flyers that are passed out at clinics back home. Though we were tired from a long day of it, we loaded up our van and boarded in good spirits for the trip home.

September 24th: I am writing from The Tall Horse Café. “Tall Horse” refers to a giraffe. This is the one place in town where there is some western style food (pizza, french fries and coca-cola). It is also a place of refuge from being the major side show in town. Western white people really stand out here, and everything we do is of great interest and a subject of much conversation, a major source of entertainment. There are a couple of things I want to write about before we leave in a few days, as this will probably be my last chance to post.

The Brain Drain. The Republic of West Africa loses a lot of the nurses and doctors they train to other countries, especially England. There are a couple of reasons for this. A nurse can go to England for two years and come back with enough money to buy a house, set up a business for herself and/or her family. Secondly, many nurses are assigned to positions by the government with little regard for or choice of location. Because of the brain drain, the government closely watches nursing students and graduates, and they may be refused visas for foreign travel.

Politics. Political influence peddling and maneuvering results in a far less than optimum allocation of the available resources. Some is also lost to bribery and corruption, although the RWA is reckoned to be one of the least corrupt in this area of Africa. The government tries to keep as many people as possible employed in the public sector, albeit at very small wages. This is part political patronage, part works program.

Ed, I have used everything in your kit many, many times, especially the Swiss Army Knife and the water purification tablets. You should market the kits to those traveling to Africa.

The people here are really lovely, and I will always remember them with great fondness. I hope I can come back again next year, and maybe bring some of you with me. See you soon!

Thursday, September 1, 2011

Tenth Chapter

Tenth Chapter
In which our neophyte reaches competence, and we learn about trauma

   University Hospital, the employer of our subjects, is a Level I trauma center. Trauma is the leading cause of death for people ages 1 – 44. The leading causes of trauma in rank order are MVA’s (motor vehicle accidents), falls and assaults. Trauma is a surgical condition by definition. Trauma Centers vary in their capabilities, and are rated level I,II and III, with level I being the most capable. To be a level I center, a hospital must have highly trained and specialized surgeons, nurses and technicians on duty 24/7, as well as the equipment and facilities. It is very, very expensive. The metropolitan area served by University Hospital originally had three Level I centers, after two years only University Hospital had the resources to maintain Level I status. For the trauma victim, being treated at a Level I facility can raise the chances of survival by 25% or more. For those that reach a Level I center within an hour of injury, the odds go up even further.

   The trauma area is adjacent to the ER. There is an ambulance ramp that goes right up to the doors of the trauma area, and directly across the ramp is a helicopter landing pad.  Inside the doors are four stabilization/evaluation bays, and directly behind the bays are two trauma ORs. There is one trauma team in the center at all times, with a second team available in the hospital. A trauma team is made up of an Anesthesiologist, a Trauma Surgeon, a Trauma Resident, two ER nurses, and two OR nurses.

   A patient arrives, by ambulance or chopper, and enters into one of the bays. The most severely injured go right back to one of the ORs. Lines are placed, blood samples drawn, IV fluids and O negative blood administered as needed, the airway assessed and stabilized. O negative blood is used as it is the Universal Donor, and can be given without the time consuming need to type and cross match the patient’s blood. Even with a medical bracelet or “file of life” with blood type information on a patient, the O negative blood is used, as the teams have learned the hard way not to trust such sources of information.  A Foley catheter is placed into the bladder. These steps are the provenance of the anesthesiologist and the two ER nurses. While this is going on, X-rays are taken as needed. The Trauma surgeon acts as captain of the team, and directs the activities of the team as a whole. The OR nurses assess the patient injuries and prepare the appropriate instruments and equipment on the OR, the patient moves into the OR and surgery begins. In more extreme situations the patient skips the bays, goes right into the OR, and all this happens at once. 

   It has been almost two years since we first heard Cates story as a beginning nurse in the OR. Things have “clicked" for Cate, and she has earned the trust and respect of the other nurses and surgeons. It has not been easy. Dr. Syriani, famed surgeon to the deceased, had been particularly hard on Cate. Syriani was known for his lack of tolerance of beginners, taunting and ridiculing them. He had one day gotten Cate to the point of tears, and then crowed to the assembled team “Look! I made her cry!”, as if he had scored some kind of goal. Cate sucked it in and finished the case. She had learned not to give in to frustration and anger. And Syriani never bothered her again. He zeroed in on the scent of fear. That was the day things started to go better for her in the OR. When you get to the bottom, it all looks like up.

   Cate has just completed sixteen hours of classes and passed an exam so that she can take turns  covering the trauma center for the OR. She has had to learn the ABCDE of trauma. A= airway, B= breathing, C= circulation, D= disability, and E= exposure. Always in that order. B is no good if you do not have A, etc. There are detailed algorithms for each of these letters that Cate has memorized. She has practiced the techniques and interventions for each step. Airway is getting the air to the lungs. This could be by inserting an ET (endotracheal tube), tracheotomy, or cricothyrotomy (A large bore needle placed into the trachea just below the cricoid cartilage, and then air or oxygen blown in under pressure). Breathing is the chest and diaphragm, getting oxygen into the blood. This is done manually by an ambu bag (a cylindrical rubber balloon that attached directly to a mask, ET tube or tracheotomy tube), or mechanically with a ventilator. Circulation is the heart and vasculature, getting the oxygen to the organs of the body. There were several avenues of attack here: 1) Replacing fluids by crystalloids (saline, or other IV fluids) or blood products such as whole blood, plasma, etc. 2) plugging the leaks (control bleeding). 3) Reduce the volume to be filled. This last could be accomplished by the use of MAST (Military Anti-Shock Trousers), inflatable pants with three chambers, one for each leg and one for the lower abdomen.

The pressure of the MAST diverts blood from the legs and lower abdomen to the chest and head. Disability is the level of function of the brain and nervous systems. Exposure is getting the patient exposed and controlling his body temperature. Trauma victims are by definition thermally compromised. Clothing has to be removed quickly, using scissors that look cheaply stamped out of metal, but their serrated edges and large leverage granting handles can cut a copper penny in half easily. The nurses refer to these as “Rambo” scissors after the Sylvester Stallone movie character. Karen once got a complete set of leathers off a motor cyclist in about a minute. There are two basic means of warming the victims, by IV infusion of warmed fluids utilizing the Level 1 warmer/infuser, and the use of a Bear Hugger. The Bear Hugger is a sort of plastic and paper blanket that circulates warm air around a body. The Level 1 is a piece of equipment that can push a liter of fluid or blood into an IV line in less than a minute, and at body temperature to boot. Both were absolute necessities for the trauma rooms.

   Cate was in a state of adrenaline infused impatience, as this was her first solo in the trauma room, without a preceptor to back her up. Mercifully, the phone rang and Dr. Murphy, the trauma surgeon for the shift picked up the phone and listened. He hung up the phone and announced to the team, “We have a penetrating injury to the neck, an older male, John Doe, trauma scale 4 coming in. He was found unconscious on the sidewalk, no witnesses.The EMT's scooped him up and are coming straight here.” Trauma scale 4 meant unresponsive, very low blood pressure, low respiratory rate, very low pulse. The key thing here was the very low pulse. This told the team that the victim was in the last stages of shock. In the early to middle stages of shock the pulse becomes very rapid, the body’s attempt to make up for loss of circulating volume and pressure. As shock progressed, this compensatory mechanism also fails.  A score of 4 was the worst score in the scale, an indication that the chances of survival were poor. John Doe meant that his identity was unknown. This one was obviously a problem to be addressed in the first of the ABCDE, airway. The team leaped up and prepared the A list items, for placement of ET tube (also known as a breathing tube, to be inserted through the mouth), tracheotomy, or cricothyrotomy,(means of making openings into the windpipe) as well as peripheral and central lines, O negative blood and Normal Saline IV fluid. The other thought that occurred to everyone on the team was that the score of 4 plus a penetrating neck injury probably also meant hemorrhage of a significant portion of the victims blood, so Cate grabbed and opened the tray with vascular instruments, as well as the tray of basic instruments. Once an airway was established and ventilation accomplished, the next likely thing was going to be control of bleeding. 

   With a screech of brakes, the ambulance arrived at the door. The doors of the ambulance flew open and the EMT’s ran the stretcher into the trauma area. Murph waved them past the stabilization bays directly into the trauma OR. Cate took in the MAST trousers, and the victim covered in blood from the eyes all the way down the chest. One of the EMT’s was pressing a wad of towels against the victim's neck. The towels were saturated with blood and the EMT was covered in blood. Several things happened simultaneously: Kurt, the anesthesiologist, got a laryngoscope in the victim’s mouth and was suctioning large amounts of blood, saying “I can’t see a damn thing!” Chloe, one of the ER nurses was hooking the Level 1 to the IV line the EMT’s had placed. She cursed in turn as she saw that the line was running Lactated Ringer’s solution. This meant that blood could not be pushed through the line as it would instantly coagulate, the coagulation triggered by the calcium in the Lactated Ringer’s deactivating the anti coagulant in the bank blood. Only Saline should have been used. Blood would have been the best thing that could be given at the moment, because it could also carry oxygen as well as increase circulating volume. Crystalloids such as Saline and Lactated Ringer’s expanded volume but could not carry oxygen. She started the Level 1 pumping with saline.  Nan, the Other ER nurse was struggling to place another IV line in the other arm, hindered by the omnipresent blood which obscured visualization of the veins, and which also made everything slippery. Cate was mopping at the neck trying to clear the blood, so that she could see the wound and prep it with iodine solution. She couldn’t find a wound. Murph joined her in wiping at the neck with an artery clamp in hand, ready to clip a vessel. The blood was all dark, indicating a venous source as opposed to an arterial one. There was no wound!

   The monitors at the foot of the stretcher alarmed and flatlined. Kurt rammed the ET tube home, suctioned more blood out of it and attempted to ventilate with an ambu bag. The chest rose and fell. The monitor showed no heart activity at all, a condition called asystole. This is not a shockable rhythm, so the use of the defibrillator was out. Cate began cardiac compressions. Chloe took over ventilations with the ambu, synchronizing to Cate’s compressions. Kurt began injection of epinephrine (also called adrenaline) through the chest directly into the heart. A shockable rythm had to be established before the defibrilator could be used. Nan continued to struggle with the IV placement, finally getting it into the antecubital fossa in the inner aspect of the victim’s elbow. She attached it to the Level 1 and started it pumping O negative blood. Murph explored the neck, still finding no wound.

   The team continued their efforts for one minute, the held compressions and ventilation so that it could be determined if a shockable rhythm had been restored. None. The team continued its efforts. After ten minutes Murph called it. Every one backed away from the table looking at each other, their breathing and pulses returning to normal. Kurt ventured an opinion: “The bleeding must be internal, there being no wound. And from the volume of venous blood I suctioned out of the airway, I suspect that what we have here is a case of esophageal varices that eroded and bled.” Esophageal varices are varicose veins of the esophagus, a condition caused by a back up of venous blood from the liver, which in turn is caused by liver disease such as cancer or advanced cirrhosis. He continued, “The victim was expelling all that blood out of his mouth, and the EMT’s could not see that there was no wound, but from the volume of blood expected a vascular injury to the neck.”

   The team turned to removing the clothing from the corpse. Each item was inventoried and recorded. Nan was the one who found his wallet, a few cards and eight dollars in it. There was an ID card. Nan announced " This is no longer John Doe, his name was Harold Morgan. Could we please have a moment of silence in respect for Harold Morgan." Everyone stopped what they were doing for that minute.Then Nan, Chloe and Cate Washed the body and the corpse was respectfully placed in a shroud. An orderly transported the body to the morgue with a bundle of clothing and his meager belongings in a paper bag on top. Paper was used so that the clothing and belongings would dry out and not molder. Then they turned to restoring the OR to a state of readiness. Murph made phone calls; to the police, to the medical examiner, to the 911 dispatcher. He made an attempt to call the number found in Harold's wallet, but there was no answer. Then he began his paper work. To Cate fell the responsibility of filling out the rest of the rest of the records. Murph told them that they had done a fine job, that he could not have expected any better from the team. Everyone looked to the clock willing the hands to speed to the end of the shift. The autopsy report two days later confirmed Kurt's opinion.