The team has two coordinators who help us with all the schedule and administrative tasks, translate our English into French if needed, bring the patients back for us from the ward, and any other tasks left undone. Chuck is from Belgium and is a powerhouse of energy and organization. Manon is a lovely woman from Canada, and we could not do this without them. Manon brought me my first patient.
As with any other day, there were some surprises. Earlier in the week our team leader Steve and Deb (both anesthesiologists) went to consult on a patient elsewhere in the hospital. He had been scheduled for a procedure but had to be canceled because the local anesthesia personnel could not intubate him. Steve and Deb scouted the patient out, and found him to indeed look like he would be difficult to tube. He had large teeth, large tongue, small mouth opening, stiff neck (elderly), and a large mass on his cheek the surgeons were planning to remove. All red flags to us that the tube we slide around the corner behind the tongue and between the vocal cords into the trachea would not pass as easily as usual. Plus, attempts had been made and failed.
The plan was for the local team to pick a day later in the week or next week, schedule the case based upon our availability, and check with us when this could happen. As is usual on these trips, we got a surprise this morning. The patient was already in surgery and the surgeon was waiting for us to get the tube in. Luckily it fit well between some cases we were doing and we agreed to come over and give it a try.
One of the surgeons walked us across the courtyard into another building. We were taken back to a fairly dark room with sparse contents. There was an anesthesia machine with isoflurane, a monitor of an unknown make, an old black OR bed with manual cranks, and a wire rack with some packs and a few other items. I was struck with how empty if felt; it was nice to not have to climb over and around various electronic toys, cords, and bags.
Steve and I brought a bag of various equipment items and settled in for our procedure. There were about eight people in the room - no idea who or why - who were all interested in what we were doing. One anesthesia person dived right in and started giving drugs, and we had to stop him so we had time to set up our equipment and give the drugs we normally use. They actually had some very familiar drugs, but we use a slightly different recipe when tip-toeing around a difficult airway. There is a time during intubation when the patient can no longer breathe for himself and we take over, but we want to be sure we can do this. It is very scary to suddenly realize one cannot breathe for a patient who has stopped breathing!
Steve did a great job of setting up - made his plan, laid out what he wanted to use, took control of the room, and proceeded. Monitors checked, IV checked, tools checked. Meds in, bag and oxygen working, patient paralyzed after confirming ability to breathe for patient. Just like a cock-pit check list. Luckily we had our new video Glidescope, and when the time came to look at the airway, the scope slid in, we could see the vocal cords and trachea right away, and in went the tube. Pretty slick, Steve!
Back with all our tools to our OR, clean up and set up, and more cases on the way. Next one was also a difficult airway case - a large keloid of the neck. One of the surgeons described it nicely - when a scar heaps up within the boundaries of the original injury, it is a hypertrophic scar (overgrown). When it grows over almost like tumors of the scar, larger than the injury borders, it is a keloid. It is like a cancer of scar, except cutting it all out often results in regrowth. All the skin does the same thing. It is difficult to avoid, and for this young man, could well return. But he is seventeen, cannot button his shirt over this eggplant-sized mass, and wanted to give it a try.
Holding the mask over his face was difficult. His chin and jaw line could not be felt, so the mass was held as part of the face to make a seal. We put out video scope to work again, got a good view, and got the tube in. Hurray! Another good result when the surgeons were done, with a neck collar to compress the graft down on the skin.
There is one very sweet sixteen year old patient that the nurse educator has been working with the week before we came to get his wounds cleaned up. He is tall and skinny like a gazelle. He grabbed a live wire and got a bad electrocution injury, leaving both legs without skin, almost like a bad burn. One leg even appeared to have the calf muscle pulled loose and pulled down around the Achilles tendon. He has been battling with the pain and misery for months.
I had gone earlier to try to get an intravenous in him, and he was so cheerful and helpful, smiling even as a tear made its way down his cheek when I had to poke him. It was all I could do not to cry! He was even handing me things and holding now and then to help me. Very nice young man. He got some skin grafts and dressing changes done in the OR today. His mother and baby sister were waiting for him when he came out.
Another interesting patient was a three year old with an abscess on her leg. When it was cleaned up by the local doctors, they found it was down to bone. She came to surgery, and our artists fashioned a cover for it from the calf muscle of the same leg. The muscle was tunneled and placed over the wound as a flap, which will allow the defect to heal and fight infection.
I don't know if you remember the Grand Pooh-Bah from Happy Days, but his brother works here...
Lots of good teaching going on. More people coming each day. Not all the people coming are exactly up to speed on sterile technique the way our surgeons like to see it, but each day is
getting better and the students are doing more.
One of Deb's patients today surprised us all as we got him ready for his surgery. Sometimes patients will write little notes or do silly things that make us laugh, but this patient quite innocently wore his Obama underwear. We were all delighted.
Poor Oumar was the next one to be found asleep. He is trying to get ready for his wedding Saturday, seeing patients, helping us with surgery, translating, bringing blood, and generally making the impossible happen. No wonder he is totally exhausted!
Come to think of it, so am it. Off to bed, and more tomorrow.
