Yesterday morning Abba, my consultation nurse, called me into his office to see a young woman. Abscess from a cavity in one of her teeth was his working diagnosis. My nurses know that these are serious cases and need to be seen right away, so he had appropriately had me come in to see her, instead of just adding her to the stack of carnets (health-care booklets) on my desk. That would mean I would see her, oh, around 5 or 6 pm.
I agreed with his diagnosis, hard swelling around the neck, can’t open her mouth, in a lot of pain, been sick for a week. Yep pretty much a standard neck abscess from a cavity. It is truly amazing how much suffering can be caused from a very simple minor problem, not treated in a timely fashion. And as I have said before, it is not because Tchadiens are stupid, they are very smart. It is a matter of not knowing where to go to get help, and also not having the money to get there if you knew where help could be found.
I went back to my office, which is just next door to Abba’s, our doors are probably all of 5 feet apart, sat down and began writing out the orders, including her Operating Room sheet (fiche operatoire). We started her immediately on fluids and all the big gun antibiotics I had, and started preparing her for surgery, I wanted to get the pus out of her neck before the swelling blocked off her airway.
Three hours later we had her in the bloc (OR). She was given the usual ketamine/diazepam “anesthesia” that we use. We do cases like these 2 or 3, maybe even 4 or 5 times a month. Dental abscess, necrotizing fasciitis (flesh eating bacteria for the grocery store checkout magazine readers), fractured jaws, all these cases that prudent doctors uses general endotracheal anesthesia for. In other words, standard of care is to control the airway with a breathing tube. We control the airway by hoping the patient or family was truthful in telling us when they last ate, and by having a semi-functioning sucker handy if they seem to be vomiting or acting like they are aspirating. If things get really dicey we have an oxygen concentrator so we can give supplemental oxygen at 5 liters per minute. And we have the patient fully monitored, automatic blood pressure every 5 minutes, and continuous, mostly functioning pulse oximetry to monitor how well oxygenated the patient is. Then of course we stay observant to make sure the patient is breathing, although that can be lost sight of when we are busy trying to stop bleeding. I think you get the picture.
There is not one time I have headed into one of these cases without being scared spitless, wondering if this will be “The One”, “The Disaster”, that will end up in a blog. There are more things that can wrong, lethally wrong, than you can count, and there is precious little I can do if they do go wrong.
Things started out OK, Jeremie gave her enough meds to put her to sleep, her sats were good, she was breathing, we had prayer as we always do before each case, and then things started to fall apart. After prayer I opened her mouth and found pus, the abscess had obviously eroded into her mouth and drained there. We suctioned her out. I identified the most likely spot to open up her neck and found a pocket of pus. I put my finger in and broke into a much larger pocket, that covered most of her neck and under her chin. I could feel the mandible (jaw bone), the muscles, the salivary glands, but not a lot of pus came out, certainly not as much as I expected, and certainly not enough to remotely fill the cavity. She had obviously drained a lot of it into her mouth.
About that time the beep from the sat monitor started to drop. Unfortunately to compound things she was one of the rare large (read fat) Tchadiens. So her neck was short and fat, and very swollen. I immediately did a chin lift/jaw thrust which was quite easy because her neck was open so I could just hook my finger around the chin part of her jaw bone. That usually does the trick, as most commonly the problem is just a bit of airway obstruction due to a relaxed tongue and jaw. And it worked, sats started to climb. All the way to 85%. It should have gone to 99%. By now we had her on oxygen, we got an oral airway in, and a nasal trumpet. She was breathing, moving her chest, moving air in and out.
Then her sats started to drop again. Then they went back up, but not as high, then they dropped, and up. We gave steroids, kept up the jaw thrust, made sure the oxygen concentrator was actually working. She started to wake up and cough, so we sat her up, and tried to help her cough. Got the sat monitor working again. With her sitting up and coughing we got a good consistent reading of 99% for…not long.
My med student asked, “Is she breathing still?”
No as a matter of fact she wasn’t. We laid her back down. No pulse either. Started CPR, threw our whole ACLS pharmacy at her, adrenaline, made sure her airway was open, it was. Once she coded I tried to intubate her. The light was weak, the whole posterior pharynx was swollen and there was only one place the tube was going to go, into her esophagus.
I had been watching for the last 15 minutes as we had tried to avert this. I had seen her oxygen saturation keep going up and down, but never going as high as it had been. Mostly around 50-70%. I had watched her pulse rise, 120, 140, 150. I knew that once she arrested it would be over. I figured she had to have aspirated, probably was all the pus that wasn’t in her abscess cavity. What else would make her be hypoxic with an open airway?
We did the CPR anyway, my nurses were frantic, they found the bag valve mask and tried ventilating her. I learned that they had not a clue how to do chest compressions, and not a clue how to bag someone. That was probably the best thing that happened, because I have two western nurses and a western medical student, all who speak French who are going to do CPR and first aid training on Monday morning for our students and staff.
I finally stopped them, her pupils were fixed and dilated, even if by some miracle we pulled her back she would at best be brain damaged if not brain dead. I tried my best to break the news to her mother gently. I thought she might have a clue that things had not gone well when I brought her into my office with another nurse. But it didn’t work, she was not prepared when I got to the part about, “she died”. We tried to be as caring and compassionate as possible, but what can you say? No one, not even in Africa expect that their loved one will die in the OR, on the table. They were fine when they went in, what do you mean they are dead? Diana took the family and the body home in the ambulance, it was the least we could do.
Many of you who are reading this are medical people, doctors, nurses, physical therapists, and so on. I know what you are thinking, especially the surgeons and anesthesiologists, and OR and recovery room nurses, “What the h…l are you doing? Where is the code cart? What do you mean you are going to do CPR training on Monday, why haven’t you done it before? Why didn’t you intubate and secure the airway before you started?”
And you are exactly right, those are the questions, the right questions. I have sat on quality assurance, peer review committees for years in the US. If a case like this came to that committee, I would lose privileges faster than the time it takes to read this sentence. If you really want the answers to those questions I invite you to come and work with us for a while, I think you will find the answers you are looking for.
This young woman died because the quality of care didn’t come anywhere close to the standard of care found in most of the rest of the world, not even in much of Africa. But the sad reality is that as bad as it is, we have the best reputation for quality of care in the city. And it is a deserved reputation. When I look back at how far we have come in the last 2 years I am so proud of my staff. They are the best healthcare team in Tchad. Unfortunately that is not as much a commendation for us as much as it a glimpse of the reality of life and death in a country so far
behind most of the rest of the world we can’t see the taillights anymore.
It’s sad really, but I wasn’t surprised she died, I was surprised that in 24 months she was the first one.
For those of you new to our blog please look around at the other pages, the “About” page tells a bit of who we are and our background, the “Definitions” page explains some terms that are used that some of you may not be familiar with, such as GC or AHI. The “Timeline” gives an idea of where we will be throughout the year, and the “Video” page has a video Bekki made of Koza Hospital as well as the videos she has made of Moundou. There is also the Surgical Pictures Page, but be forewarned, it has some very graphic pictures, so if you don’t like blood and guts, stay away from that page. You will also find links to other missionary blogs such as Olen and Danae Netteburg and others. Finally, if you like our blog and want to receive each new post directly to your e-mail, please sign up with your e-mail in the subscribe box. It doesn’t cost anything, there is no commitment, it just makes it easier to follow us.
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