Wednesday in Labo
The rain stopped yesterday afternoon and this morning it seemed like everyone was in brighter spirits. We had a group photo before boarding for the hospital. I looked in on the three pediatric cases from yesterday. Everyone looked good, including the one month-old who had the apnea problem in PACU.
The first patient for OR today was a fifty-ish lady with a lipoma the size and shape of an eggplant arising between her scapula and distal clavicle. I say fifty-ish because she is an Ito, or Negrito, one of the indigenous people of the Philippines. She spoke no English and I'm not sure how much the Filipino nurses could talk to her, either.
We couldn't get the cautery to work, so I asked to put the second case, a lady with a tumor on her occiput and upper c-spine, on hold.
I had case #4, a gent with a tumor of some kind between the first and second metacarpals of his left hand come to pre-op. Leila, one of the nurses who works part-time in a pain clinic, helped me put in an axillary block. I had no nerve stimulator but I got a paresthesia and used 50 ml of 0.25% bupivacaine. Still no cautery, so we went on to case three, a 21 year-old lady with a thyroglossal duct cyst. That case went well.
At lunch the surgeon told me he thought he could do the neck mass without cautery. In my view, her hemoglobin is 10g/do, we have no blood bank and she isn't going to bleed less than usual just because she's in the Philippines. So I held firm on the cautery. We had a break while they rigged up a tourniquet for the hand case. We had no way to measure the pressure but by keeping it pumped up as high as it would go we got a bloodless field and completed the surgery in 64 minutes.
Well and good, but after the dressing was on and the tourniquet released he started bleeding through the dressing. Holding pressure didn't help so we had to open the wound and ligate a couple of bleeders.
It turned out that when one of the nurses told the lady with the neck mass she wouldn't have her surgery she started crying. The new plan is to operate on her on Thursday, planning to back out if bleeding becomes problem. There are a couple of logical faults here, but I hate to have people crying. So she is first case Thursday morning, because if you are going to do something that may lead to problems, it's best to do it early in the day.
I was going to do a hernia repair but we were put on hold for a possible C-section. A lady came in laboring. She delivered a 1.5 kg vertex girl, but there was an undiagnosed second breech baby. I set up to do a general and brought our last spinal tray into the room. When the lady came in to operating room no one could tell me how much blood she'd lost or how urgent was the section. Her color was good, her systolic blood pressure was over 130, so I went ahead with a spinal. The baby was pretty floppy and they had no means of suctioning her. I'll check on her tomorrow. The change in schedule led to a conference, the upshot of which was that I would stay to do two more cases with the local surgeon. I had to wait for a while but we got #5, an inguinal hernia and #6, incision and drainage of a sacral mass that was cystic that will most likely turn out to be TB, done by nine pm.
I got back to the hotel about ten, had supper and went to bed.
The rain stopped yesterday afternoon and this morning it seemed like everyone was in brighter spirits. We had a group photo before boarding for the hospital. I looked in on the three pediatric cases from yesterday. Everyone looked good, including the one month-old who had the apnea problem in PACU.
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| She has a good surgical result, but if we hadn't had good care in PACU it might have been a disaster. |
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| Ito lady positioned for removal of lipoma. Note patio chair supporting arm board. |
I had case #4, a gent with a tumor of some kind between the first and second metacarpals of his left hand come to pre-op. Leila, one of the nurses who works part-time in a pain clinic, helped me put in an axillary block. I had no nerve stimulator but I got a paresthesia and used 50 ml of 0.25% bupivacaine. Still no cautery, so we went on to case three, a 21 year-old lady with a thyroglossal duct cyst. That case went well.
At lunch the surgeon told me he thought he could do the neck mass without cautery. In my view, her hemoglobin is 10g/do, we have no blood bank and she isn't going to bleed less than usual just because she's in the Philippines. So I held firm on the cautery. We had a break while they rigged up a tourniquet for the hand case. We had no way to measure the pressure but by keeping it pumped up as high as it would go we got a bloodless field and completed the surgery in 64 minutes.
Well and good, but after the dressing was on and the tourniquet released he started bleeding through the dressing. Holding pressure didn't help so we had to open the wound and ligate a couple of bleeders.
It turned out that when one of the nurses told the lady with the neck mass she wouldn't have her surgery she started crying. The new plan is to operate on her on Thursday, planning to back out if bleeding becomes problem. There are a couple of logical faults here, but I hate to have people crying. So she is first case Thursday morning, because if you are going to do something that may lead to problems, it's best to do it early in the day.
I was going to do a hernia repair but we were put on hold for a possible C-section. A lady came in laboring. She delivered a 1.5 kg vertex girl, but there was an undiagnosed second breech baby. I set up to do a general and brought our last spinal tray into the room. When the lady came in to operating room no one could tell me how much blood she'd lost or how urgent was the section. Her color was good, her systolic blood pressure was over 130, so I went ahead with a spinal. The baby was pretty floppy and they had no means of suctioning her. I'll check on her tomorrow. The change in schedule led to a conference, the upshot of which was that I would stay to do two more cases with the local surgeon. I had to wait for a while but we got #5, an inguinal hernia and #6, incision and drainage of a sacral mass that was cystic that will most likely turn out to be TB, done by nine pm.
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| Abscess with caseating material arising from the sacrum. |
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