“Doc, you are needed in the ward immediately, there is a sick patient there.”
They are not subtle around here, he, the nurse, emphasized the immediately part. So I got dressed, grabbed my office key, headlights and stethoscope and headed to the hospital, all of 50 feet away. I made my way through the women’s ward into the men’s ward where I spied the telltale group of people huddled around a bed. I figured that had to be the patient in need.
I found a young man, late teens, early 20’s lying quietly on his side, with a large distended abdomen. I asked the usual questions, when did he come? How long has he been sick? What are his symptoms? The questions are asked in a somewhat hopeful manner, as often the answers make no sense whatsoever. A patient with something that clearly has been going on for some time allegedly became ill just yesterday, or I will get the history that he has been vomiting, two minutes later I am told he never vomited, five minutes after that the story is he vomited a little, take your pick.
Well for this young man the story fit, he was fine until this morning, fairly sudden onset of illness, complaining of abdominal pain, nausea, vomiting and not going to the bathroom.
On physical he looked sick, (a very important sign), was quiet, tachycardic (fast pulse) and his pulse was weak. His abdomen was distended, and very tender. I couldn’t find any hernias. Otherwise he was normal.
My diagnosis was peritonitis, maybe an internal hernia with a bowel obstruction, a torsion of his intestines, or a perforation of something that shouldn’t have a hole in it. Whatever it was, he needed surgery. Soon. Of course after some IV fluids and antibiotics.
So I evaluated my resources.
OR crew, all at home asleep, and I had no way to reach them.
Laparotomy pack, I had looked at it, I could work with it, but hopefully it would not be anything difficult.
OR lights, it is tough enough to do a hernia in the dark, but a laparotomy, on a dark skinned patient? I don’t think so.
OR electricity, non-existent at this time of day, or night, and no way that I know of to get the generator on.
For those of you wondering why I didn’t have many of these things already worked out, for instance knowing how to reach the OR crew, or who to contact to start the generator, the last reason will explain it.
Anesthesia, I a.) don’t know how to get ahold of him and b.) would not dream of trying to do a major elective laparotomy with him with him during the day, let alone an unknown emergency laparotomy during the night.I had already decided that we are not anywhere near ready to do major cases, let alone major emergency cases. I have visited several hospitals out in the provinces here (rural) and they are at a more advanced level than we are. The standard of care here in Sierra Leone is higher than we can achieve in the OR. And that is not a knock on the OR staff or anesthesia nurse. They have never had the opportunity to be trained, and they are working without adequate resources. For instance my anesthetist is a ward nurse who was pulled into the OR and given training by Dr. Koroma who is a General Medical Officer (and a very very good one), which is basically a PA. Thursday I had to teach Ibrahim what a jaw thrust is and how to do it. He faithfully takes vital signs and pushes the ketamine and diazepam as I tell him to, but I really doubt he would recognize a problem or know how to deal with it. Again, not his fault that he has had no opportunity for adequate training. And no knock on Dr. Koroma who has done a fantastic job with nothing (quite literally).
Back to our emergency case. I am not going to do some heroic operation that will probably end up with me slicing my finger with the knife and the patient dead when there are perfectly good hospitals in Freetown an hour and a half away.
I told the family he needed emergency surgery beyond our capabilities and he needed to go to Freetown to the Government Hospital. I asked the nurse if we could call an ambulance to come get the patient and take him into the city. I hear government ambulances going back and forth in front of our hospital all the time after all.
And so started a very African dialogue:
“Sure”, said the nurse, “We can call for a government ambulance.”
“Great”, I said, “Is there anything else, are you OK with it?”
“No problem, Doc.”
“OK”, I said, “I am going home, good-night.”
I had just left the hospital and I heard someone running after me, calling, “Doc, Doc!”
I turned around to see a short stocky man, obviously a patient relative.
“Doc”, he said, “You need to call for the ambulance, if we call or a nurse calls it won’t happen. If you call, you have authority as the doctor and they will listen to you.”
Unfortunately it made sense so I headed back to the ward with him. I asked the nurse if I needed to call the ambulance.
“Yes, it would be best if you called for the ambulance”, he told me.
“OK, where is the government ambulance”, I asked.
“Well, doc, a government hospital (actually just a health center) is right next door, but they don’t have an ambulance we can use”, he replied.
“But we can call for a government ambulance, right?”, I queried.
Again he assured me that we could call. Then I asked the $64,000 question.
“Do you have the number for the government ambulance?”
He smiled, and shook his head, “No”.
Alright, we are getting somewhere, we have now eliminated the possibility of transferring the patient by ambulance.
“So how do we get him to Freetown?”, the American asked.
And again I was given the “They really do send the stupid ones to Africa, don’t they?” look and was told the obvious, “By private car, doc.”
By now I knew to leave nothing to chance. I turned to the short guy who had brought me back.
“Can you get a private car?”
“Yes, I think so, but it will be difficult.”
I stressed the importance of getting the patient to Freetown tonight and told the family we would give him 2 liters of IV fluid, antibiotics and pain medication while waiting for the car.
As I walked toward the exit I heard the rain starting to pelt the roof of the hospital. The tropical shower felt good as I walked home with very conflicted feelings. I knew there was no way I could justify trying to do an operation we had no business doing and putting this boy’s life in jeopardy, but I also knew the stories I had heard of the government hospitals. I knew he might not see a doctor, let alone a surgeon until Monday. He would likely be dead by then.
Since deciding to leave Tchad and come to Sierra Leone I have had a certain amount of guilt. I knew I was needed in Moundou, I knew I could have helped a lot of people that were going to suffer because I was not there. I soothed my conscience with the thought that people needed me in Sierra Leone too. As I crawled into bed, I realized it had not just been a rationalization, it was true. I am desperately needed here. We were not ready for this young man yet, and I am sorry for that, and it will take some months before we are up to speed to be able to handle most surgical cases that come through our door, elective and emergency. But by the grace of God, and with your help dear readers, in time this hospital will be ready for whatever presents itself.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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