Two weeks in one! I took a vacation from writing last week as I took my turn at not feeling well. Last week I decided to see what a week in the life of surgery entails. Dr. Rhodes just arrived back, so the number of surgery cases increased dramatically. (Within a day, patients knew Daktari Rhodes was back, and were coming in search of him!) The first day was mostly burn contractures examined under anesthesia. In the afternoon we excised a ginormous hip mass, and ended up chipping away part of the head of the femur. The next day there was an equally large mass protruding from the shoulder. With the shoulder, the bone just melted away with the mass, and no chipping was needed! It is amazing these masses get so big. We also did several laceration repairs and incised and drained multiple abscesses (many of which were TB). Unfortunately the pathology of the hip mass and shoulder mass are still pending.
One early morning I was called in to assist with a cesarean section. We opted for the emergency method of opening, and for a first time section (ie no prior scar or scar tissue, I don’t know why we do anything else! Into baby in 3 minutes or less! Mom and baby did well, but my night of night sweats caught up to me and sweat was beading off of me as if it was pouring outside. I filled out the post op documents while Kyle closed the skin subcuticularly, and I didn’t mind the chance to get out of the gown and gloves and try to dry up. The rest of the week was pretty much a blur of cool, clammy sweats and feeling dizzy and extremely weak.
This week I started Medicine and have been in charge of the women’s ward and seeing more outpatients. Some of the highlight patients: a 40 year old severe asthmatic who requires 5 L and despite neb treatments, steroids, antibiotics and aminophylline, we can’t get her chest cleared up; and the 70 something year old lady who is also an asthmatic and saturates 60-90% on 5 L of oxygen (the maximum possible) who one day had absolutely no air movement bilaterally, who is also on aminophylline and every possible medication for asthma available! One patient came in with “conversive disorder” a misspelling/misunderstanding likely of conversion disorder – a physical manifestation of some emotional pain or distress, who upon further investigation has had 12 episodes of passing out after experiencing palpitations, who has an amazing murmur and I suspect all of her passing out is not due to a psychologic illness rather, aortic stenosis! She will go into the next major town 2 hours a way for an echo for further evaluation. The patient I did the LP on, who was found to have cryptococcal meningitis had a clear LP 2 weeks later, and Amphoterecin finally arrived. After writing a page of precautionary orders, the patient was started, and tolerated the test dose, ands subsequent doses. I had to laugh – the medication is sensitive to the sun, so the nurses wrapped the IV fluids, and all the tubing leading down to the patient, in black plastic bags! Managing diabetes with insulin, but without any way to check daily, or 4 time daily blood sugars is definitely a new experience!
One sad story, a young woman came in after a self inflicted ingestion of an insecticide. We set up gastric lavage and believed it was a relatively recent ingestion given the thick yellow substance that was pumped out. Charcoal was given even though the time of ingestion was not known. The patient was identified only by, Unknown African Female, and even her neighbors who brought her in couldn’t give us her name. She was never alert, but after seeing a few kinds recover from such poisonings within a week I had hope for her recovery. She was receiving atropine every 5 minutes! I returned the next day, and the bed was empty. She had died within 4 hours of arrival. More bad news, she was reportedly 30 some weeks pregnant. By the time the doctor was called that she was doing poorly, he couldn’t find heart tones and so there was no need for a stat c-section. According to local custom, the baby would need to be removed, and so we did a post-mortem c-section to retrieve the baby. After making the initial incision, the intestines, now full of air came pushing through the incision. After fishing around for a bit, Kyle was able to locate the uterus, less than fist sized and in its non-gravid location. If the woman was pregnant, she was in the first month or two of pregnancy! That was the end. The pathologists were left to close the incision, and we went to talk to the family members gathered outside. Very sad. I am thankful there was not the tragic death of a viable baby, in addition to this young woman’s untimely death.
Managing outpatients is often a challenge in terms of requiring a translator, but, so refreshing in that sometimes all that is required is an rx for Tylenol or ibuprofen!
Mature audiences only:
I asked to borrow a book on female circumcision, aka, female genital mutilation due to the severity. This book is written about the Marakwet people who are the people that live here, and Kapsowar, this community, is even mentioned. It is supposed to be accurate, but I have my doubts. Supposedly, women asked for the procedure! According to this book I’m reading, written by a local man who studied divinity in the US, and then returned back to Kenya, who interviewed many women and compiled this research, those who are uncircumcised, both men and women, are considered childish. Circumcised men would have parties and slaughter goats, and not bring any of the meat back to the “children”/uncircumcised. So, the women got together and came up with the idea of female circumcision. I don’t buy it. He goes on to say that young girls have to make the decision themselves and get the approval of “instructors.” If the stars are aligned, the crops are plentiful, and the instructors approve, the process can continue. There is a night of getting drunk, and the girls are asked many times if they are going to go through with it, and the gorey details are not spared. On the day of the process, sometimes stinging nettles are used to help anesthetize the area. Sometimes the clitoris is cut out, but as with many of the patients I’ve seen here, the mons pubis and labia minor and majora are removed too! The girls are instructed to be stoic and not to show any emotion. It reflects poorly on their family, community, nation…if they cry, and they are ridiculed for it. They are called cry-babies and can only marry the boys who cry at their circumcisions. For the first two weeks, the girls are spoon fed as they recover. After that, they start to learn about how to be good mothers, care for babies, clean, satisfy men, etc. They are at a seclusion house for 4-5 months, before returning to their families, and as their can only be one circumcised women in a household (ie, the girl’s mom), usually given in marriage quite soon after returning. Really – how does cutting off some foreskin compare to dismembering a female? As of now, the Christian church and doctors and others have announced their opposition, but it is still carried out. Most of the young pregnant females have had it done. It is awkward to talk about even among female nurses and students because some have had it done, and so many have varying opinions of it.
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