Final post on Haiti Adventist Hospital

Thursday was an operating day. We brought Pierre, the gentleman who fell off a roof on December 2, to surgery to examine his wound from Friday and put an external fixator on his wrist fracture. He also had a pelvic fracture so we had to bring him to the operating room in his bed. The door jamb had been freshly painted so I felt bad about scraping it as I wiggled the bed through, but it would have happened some time. When I got him into the operating room I gave him some Valium and ketamine to facilitate transfer to the operating table. There was a delay so I blocked his brachial plexus while he was still in bed. The nerve stimulator wasn't entirely to my liking but the block worked well just the same.

 While we were in the operating room a lady came in with a fungating growth on her thigh. The tumor is a malignant complication of neurofibromatosis. She came in because of odor and infestation with maggots. The surgery for this is bound to be pretty extreme and she will need blood, so we weren't able to operate on her that week.

 The high point of my day came when Mlle. Bonham came in for the 3-11 shift. She is the most cheerful and helpful nurse on the Adventist staff.

There was no surgery scheduled for Friday so Jen and I went to the Bernard Mevs/Project Medishare hospital in downtown Port au Prince. Surgery didn't start for a while after we arrived, but I got to visit with Judith, Francia and Dorothy; the anesthesiologists on the Bernard Mevs staff. I worked with Francia and Dorothy when I was there in May.

I finally got to do a case by myself! While Jen was giving the anesthesia for a hysterectomy,  I put a lady to sleep to drain a huge (I am in no way exaggerating) abscess in her buttock.  She had reportedly gotten an injection of iron dextran a couple of weeks prior to admission. Her hemoglobin was 7 g/dl when she came in, so the iron didn't seem to do her much good. I graduated medical school in 1980 and this is the worst I've seen. Here's a link to the video: http://youtu.be/PiYCX53HQ_I

I'd like to close out this chapter by thanking Hugh and Kathleen MacMenamin. Hugh is an orthopedic surgeon, Kathleen a developmental pediatrician. I was lucky to have the chance to work with them.

They came from outer space

Today was pretty quiet. I had a mosquito bite on my arm this morning, so I was offered and accepted a doxycycline tablet.  I found out that it is a very bad idea to take doxy on an empty stomach. I felt better after I threw up but had to lie low for a couple of hours as well. In the afternoon Jen and I organized supplies in the operating room. I went to the Deli-Mart and bought a couple of bottles of lemonade that sat well on my stomach. Just before dinner Greg, the bio-med technician, showed me a YouTube video of an alien spacecraft that has been sighted next to Mercury. It is cloaked and only became visible when a solar flare engulfed it.  Greg thinks it could have been there, observing us, for millennia.

He may be right. I’ve always thought that if I were going to invade Earth, I would set up a base camp on Mercury, landing when the sun was interposed between it and Earth. I’d build my camp somewhere in the terminator, the zone between light and dark that would not be so extreme in temperature. I’d use my solar powered equipment (us little green men are green, you see) to build the rest of my fleet and launch my assault when Mercury and Earth are closest.  That way I’d have the sun at my back and conserve the most important element in the universe: the element of surprise.

I expect that Rosanne (the scientist) and I (the visionary) will be called upon to help defend the planet. Fear not, the enemy will never penetrate our troposphere.

Haitan Adventist Hospital: A busy day in and out of the operating room

After dinner Monday night one of the staff asked me to start an IV on the gentleman, Pierre, who fell off a roof last Friday.  He needed blood before we operated on him on Tuesday. Jen and I tried peripheral IVs for half an hour to no avail. The blood was in his room, in a thermos, so I didn’t want to wait until morning.  I went down to the OR, found one of our few central line kits and brought it up to the ward. I was fortunate in that the light was good in his room. It was very hot and I had two of his relatives holding on to him, but even so he nearly contaminated the field. I got an external jugular catheter to thread centrally and flushed all lumina after the transfusion. We’ll see if the line stays in over night.

I slept poorly Monday night. It’s noisy and not very dark. Tuesday morning I found out I’ve been washing my hair with conditioner (vs. shampoo).  This may explain why my hair doesn’t feel too clean.  I’ve never been clear on what the difference is between the two, but it is noticeable after a day or so. I checked on Pierre before conference. His breathing seemed a bit better than Monday and His SaO2 was improved. The dressing on his CV line had come off but the catheter was still in place. I showed the nurse, who was not at all happy about the central line, how to dress it and asked one of the permanent staff who speaks Creole to give them an in-service.

We got the operating room going in a very timely fashion, under the circumstances. I helped Jen in the operating room while going back and forth with the Haitian nursing and medical staff about Pierre.  They were anxious about the central line and worried about taking him back to surgery.  I explained several times about the need to examine the wound from Friday to look for any sign of infection and that placing an external fixator on his wrist fracture would not pose any risk of further blood loss. I thought we’d come to an agreement to operate on him that day, but an hour later when I asked one of the aides to help me fetch him he told me that the case was on hold, pending consultation with ophthalmologist and neurosurgeon. At that point I decided to stop trying to get him to surgery that day. We’ll hope to work on him on Wednesday or Thursday.

There was a power failure in our common room/sleeping quarters after work. Greg and Randy were champions, tracking down the problem and putting in a fix to get us through the night. They’d both put in a full day prior to this but seemed happy as larks to have another problem to solve.

We are a little short of spinal drugs. This vial is labelled "Bupivacaine 0.5%" and I think it is in a hyperbaric solution of dextrose. I sent photos to Young Kim, the anesthetist from Columbia-Presbyterian, with whom I worked in Egypt, to ask for a translation before I shoot it into someone's back.

Haitian Adventist Hospital

We had our first plowable snow fall on Saturday night in St. Paul. It was a good warm-up for the road crew as it was only a couple of inches of fluffy snow and there was not so much morning traffic, being Sunday. 

My first good news was from the American clerk, telling me I better get my passport replaced as it's becoming unacceptably worn. I spent about $90 on adding pages a year ago, so this was not happy news. The only other notable event was a two-hour delay on the tarmac in Miami. Seems they overloaded the aircraft with fuel and had to take some off. This involved two fuel trucks: one that didn't work and one that did. Traffic was light leaving the airport. The presidential palace is still in ruins but the streets seemed cleaner than August 2010.

Monday morning we made rounds with Hugh. The most interesting patient is a gentleman who fell of a roof on Friday. He had seven hours of surgery to place a sign nail in his L humerus and repair an olecranon fracture. He also has a pelvic fracture that has not been treated surgically. Post-op he had fluid problems and his hemoglobin was 7.5 on Sunday. This morning he still has rales but the edema is better. He had a SaO2 of 86% that increased to 89% after moving him around in bed. We plan to put an external fixator on his wrist fracture and examine the wound tomorrow. He can't see out of his right eye and the pupil responds poorly to light. I suspect it's a post-op optic neuropathy, as he was lying on his left side during surgery, his systolic blood pressure ran in the 60s-70s and he got between five and ten liters of isotonic fluid. Not much to do on that but wait and hope.

After rounds Kathleen, Jen and I went to visit an orphanage run by the family of one of the HAH staff members. The place seemed pretty full to me, but the only students there were the boarders. The children in the neighborhood who attend the school were excused because today is a holiday. Jen shared the Sinter Klaus candy that her boyfriend Erik gave her. The paper and colored pencils that Kathleen bought were a big hit, too. 
After lunch Jen and I worked in the operating room, checking out the anesthesia machines and organizing our supplies. They have nice new monitors since I was here in August 2010. We have six cases booked for tomorrow.

Hotel Windsor

I can't leave the visit to Cairo without mentioning the Hotel Windsor. The building has been a private residence and later a British officers' club. It was bought by SwissAir in the late sixties and is now privately owned. The building and its furbishings are pretty old, but everything works well. Seeing the switchboard is well worth the price of admission. The breakfast was tasty and the staff friendly. My room was clean but a bit musty. The water was hot and the toilet flushed. I had a little problem with no-see-ums getting in through the screens.

This is the telephone in my room. I didn't make or receive any calls, but I had a chance to practice my Arabic numerals. The hotel is in the downtown area, away from the tourist hotels and the Egyptian Museum. It was about one-fourth the cost of the Four Seasons. I'd stay there again if the opportunity came up.

And here is my policy on hotel recommendations. If you haven't started reading xkcd, you should.

Hotels

Vacationing in Cairo

We had a free day on Thursday, a holiday celebrating Egypt reclaiming the Suez canal. I went to see the Citadel of Cairo and looked around two of the mosques. Compared to a church a mosque seems very open and airy, probably because there are no pews, statues, altars or paintings. The buildings themselves were very impressive.

Stop me if you've heard this one. A Buddhist, an atheist and a Jew walk into the mosque one morning...

Thursday evening the plastic surgery department treated us to a cruise on the Nile. We left the dock about half an hour before sunset. Here's a picture of Dr. Jihan Mohasseb, an Egyptian plastic surgeon living in Germany, in front of the Cairo Tower. The tower was built in the late fifties and is lit up at night.

Dr. Riham El-dasouki, the lady below with the big smile, is one of the plastic surgery residents at Aim Shans. She was charged with making our visit comfortable and she did a marvelous job. From the very first day she anticipated our needs and made sure that anything we wanted would appear. The Nile cruise was her last  function and she made it memorable.

The buffet included lamb, turkey, eggplant and a variety of side dishes. The hospitality in Egypt was the best I've encountered in the middle east.

 We didn't talk much about the revolution but I got the sense that it was very much on people's minds. One of the students from Mansoura went to Tahrir square early on and was attacked by the police. He came home with a broken arm, and his father didn't speak to him for three days. He felt terrible about this when he realized how frightened and angry his father felt, but he didn't regret participating. Another guy told me how his friends would organize a demonstration by telephone when the internet was shut down. I think the mood was generally hopeful about the future of a representative government in Egypt. Everyone that I talked to made it clear they were in favor of a secular state, but some of the Coptic students were worried about the possibility of an Islamist government. I think their concerns were justified by the violence that broke out on the day I left.

Wrapping it up at Aim Shans

 One major difference between Egypt and the West Bank is the number of women in medicine in Egypt. Yasmina, who is looking to see if her IV will run, is a senior resident in the anesthesia department at Aim Shans. She is far and away the handiest registrar anesthetist I met and was a pleasure to work with. I've been to Palestine four times and haven't seen any women in the anesthesia or surgical departments.

 Another cute baby!! This little girl has a unilateral cleft that will make intubation difficult. If you put the laryngoscope blade in in the midline, you'll be able to see the larynx but it will be hard to pass the endotracheal tube because the premaxilla, the part of her lip that sticks out in front, will hang down in your way. What you need to do is put the blade in from way over on the left and expose the vocal cords. That way you'll have plenty of room to intubate, passing the tube beneath the gap in the baby's upper lip.

 Young Kim, CRNA from Columbia-Presbyterian, is a great teacher and a skillful anesthetist. Here she's working with one of the female anesthesia residents. She was very well prepared and well-stocked, with a supply of endotracheal tubes and IV accessories that made me green with envy.

The anesthesia equipment at Aim Shans was pretty good. One of the three machines we used didn't have a CO2 absorber so an open system, where the fresh gas comes to the patient close to the mask and the pressure release and rebreathing bag are at the far end of a length of corrugated tubing. The problem was that we didn't have a real pressure relief valve. One way around this is to cut a small hole in the end of the rebreathing bag. This works fine so long as you have the dexterity to control the pressure in the system by partially or completely closing off that hole. I've never been good at that, so I used something I saw in Gaza last spring. I made a slit in the barrel of a 3 ml syringe and then stretched the opening in the bag around the business end of the syringe. With this I could vary the release pressure by moving the plunger. It made it easier for me to concentrate on managing the airway, and gave me a chance to show off my Leatherman!

Treating vs. Teaching

Give a man a fish, feed him for a day. Teach a man to fish, feed him for a lifetime. Every mission has a tension between sharing experience and operating time with the local doctors and doing as many cases as we can while we are in town. Teaching is a vital part of our mission in Egypt, with the medical students in Mansoura and the registrars and junior lecturers very interested in observing and participating in the surgery. Here, Dr. Jihan Mohasseb (at the head of the table) talks one of the Ain Shams plastic surgery residents through the closure on a lip repair.

In the recovery room, the patient's mother is very happy with her son's new lip. And check out the embroidery on her sleeve!

Now we are in Cairo

For the second week of the mission we moved to Ain Shams University Hospital in Cairo. Our first day was spent screening patients: out of the many children who presented, we had to decide who would benefit from surgery now vs. later, and who was healthy enough for surgery now. It's a complicated process and made for a long, but interesting, day. Here's a photo of Carole Hart, the team pediatrician, discussing a plan with house staff, patient and parents.

This plaque used to say that the clinic was a gift from Suzanne Mubarak.

We finished clinic fairly early, time for a quick trip to the pyramids. We were too late to go out on the desert and get close to them, but I had a nice Turkish coffee and took a picture.

Third and last day in Mansoura

30 September 2011

Lorena (above) just plain ran out of gas last night, had to be helped back to her room, and (predictably) insisted on working today. She did let me put an IV in her and said the additional fluid helped.

The medical students in Mansoura were hard-working, helpful and interested in the surgery and anesthesia.

Pink is popular with girls all over the world. One of the fellows bought a bag like she is carrying for Katie.

My second day in Mansoura

29 September 2011

I didn't think this young man could get any cuter until we put the plastic shoe-cover on his head (in an effort to keep him warm during his lip repair).

I was the float anesthesia person on my second day. I circulated between three operating tables: starting IVs, cleaning equipment in between cases, giving breaks and checking patients in pre-op and PACU. Not a glamorous job but I had a good time explaining what pipe cleaners are while I was using them to clean the endotracheal tubes that are special-made for oral surgery. I also got to do some emergency plumbing when I dropped a small laryngoscope blade while cleaning it and it went down the drain in the scrub sink. I had the panel covering the bottom of the sink off in thirty seconds and the drainpipe taken apart in another minute. The nurse watching me thought I was crazy (good for a first approximation) but was reassured when I pulled the hardware out of the pipe.

Hans Kesper is our pediatrician, from Germany. He worked in the clinic during screening and took care of the children post-op.

Tom Flood is our team leader. His motto: "If you're not five minutes early, you're late!"

First day of work in Mansoura

28 September 2011

Laparoscopic surgery is routine at this hospital, but not on children this age.

We left for the hospital promptly at 7:30. I was assigned a slower room with the general surgeon. We did a rectal dissection via laparoscope and an anoplasty on a child with imperforate anus. It was a long but uneventful procedure. We finished about two-thirty. I gave a couple of lunch breaks and was then told that we had an added case, an 11 month-old boy with a diaphragmatic hernia. It was more along the lines of a hiatal hernia, but he had so much guts stuck up in his chest that the breath sounds were diminished on the left. A little bit disconcerting but I finally convinced myself that the tube position was okay and we proceeded. It was another long but uneventful operation.

During the course of the day I was called over to the other room where they were doing plastic surgery, two tables in one room. One of the children for a cleft palate repair was difficult to intubate, but they put the tube in just as I got there. Later, during a break, I helped manage this kid’s airway in the PACU. That was when I noted that he had a very small mandible. I later found that the child started to bleed in PACU and had to be returned to OR. He had a very rocky course after that and was ultimately transferred to the CCU for ventilation and pressor support. So no complaints from me about long, boring surgery.

When we returned to the hotel a wedding party was arriving for their reception. It seems the Hotel Marshal is quite the chi-chi reception venue. The bride was gorgeous; my picture doesn’t do her justice.

Flight into Egypt

26 September 2011

I arrived in Cairo at 6:30 pm yesterday, about thirty minutes late. It seemed like it took forever to go through immigration. I waited in line for twenty minutes only to be told I first needed to buy a visa. So off I went to another kiosk where the guy took my $15 and gave me a piece of paper with a shiny sticker. Fortunately the immigration officer let me jump the line to get my passport stamped. Customs was no problem and I met Ahmed and Mansoura as soon as I left the customs area.  I sent a photo of myself to Ahmed and that made it easy to recognize me. My first task: Mansoura handed me a $100 and told me to pick up four bottles of wine and a bottle of whiskey at the duty free shop.

 This is the hospital where we work. The operating rooms are good, with adequate light and plentiful soap and water. The anesthesia machines were unremarkable with piped in oxygen and functional ventilators.

 Here's a view from the balcony outside our room. We also got a ring-side seat for the fireworks display during a wedding reception. Smog is a big problem in urban Egypt.

The drive from Cairo to Mansoura was long and uncomfortable but the hotel is comfy. They had WiFi in the lobby so I was able to send a note to Rosanne. Ahmed and I met Betsy and Young in the restaurant. Betsy is a peds CCU nurse and Young is a CRNA from Columbia; both seemed very nice.

On the way to Cairo

26 September 2011

Charles de Gaulle Airport

Paris France

0905

The flight from MSP to O’Hare was delayed so I was squeezed to make my connection to Air France. The good news is I got an upgrade to first class. No big deal on such a short flight, but I disembarked in a timely fashion. I had to leave the terminal and go through security once more, but fortunately the line wasn’t long. The flight from O’Hare to Paris was pretty boring. I had a funny seat with no TV screen so I read and napped. With the seven-hour time difference we rolled up to the gate about 7:45. I took another bus to terminal F5, went through security again and now I have to wait until 1335.

Conversations: None

Overheard: Two guys talking about mistresses vs. wives. Didn’t understand everything. In general, if you expect a property to increase in value, buy. Otherwise rent.

I like the lines of the roof in the terminal.

Duty-free shops are much the same from place to place. There are differences: Foie gras in Paris,  smoked eel in Amsterdam. Shipol in Amsterdam is a more comfortable place to hang out.