Call (medical)

Here is a typical night of call at Tenwek:

Thursday night started around 4:30 with a simple case of an older gentleman with hematuria. He was doing OK other than that, so we set him up for cystoscopy. The differential here is a little broader than in the States. Think stones, infection, or tumor, right? This could definitely be bladder cancer, and partly due to the overwhelming amount of pathology here, I find myself starting to assume the worst condition possible in my differential. But, don't forget schisto!

I've actually gotten to pick up a lot of urology here recently, because we've had a visiting urologist here for the past 2 weeks, as well as Dr. Okorie, a Nigerian urologist serving at a mission hospital in Kenya, who has been teaching me a lot for the past month. So besides the general abdominal cases, wound debridements, skin grafts, I&Ds, I've gotten to do several urology cases. I say "I", but several of these cases were so specialized, it took the two urologists to accomplish, and I just helped hold things out of the way.

For example, one patient in particular has been with us for awhile now, and has been the recipient of several of the cooler urology cases. "E.L." came in with blood in his urine about two weeks ago. I did the cystoscopy, until we came across a tumor in his urethra that was probably extending down from his bladder. It got so bloody, we couldn't see anything. We were going to do a suprapubic cath, but his bladder was shrunken down, so we did an open cystostomy. He was in obvious renal failure, and we saw hydronephrosis in an ultrasound, so we went back and did an open nephrostomy. His renal failure cleared very quickly after that. In the meantime, his pathology came back from the biopsy we took of his bladder: high-grade urothelial carcinoma. This is not good news for the patient. We then did a radical cystectomy and created an ilioconduit (this is where I held things out of the way). The visiting urologist said this is the urological equivelent of a Whipple's procedure. The good news is, this man knows the Lord, and knows where he is headed after his life on this earth is over, no matter how long that is.

But I have digressed. Back to call.

We had two radius/ulna fractures that came in almost together, which we reduced and splinted. Another guy fell off his motorcycle and fractured his leg, which we just splinted. Then a couple RTAs (road traffic accidents) came in, also simultaneously. After putting in a chest tube, several FAST exams, and closing up some minor lacerations, it was well after midnight. As I daydreamed about making the walk back down the hill for a few hours sleep, two more came in leaving a bloody trail from their wounds as they wandered around Casualty. The night had definitely saved the best for last.

Apparently, these two brothers had been drinking, and gotten into a fight with their other brother, who was holding a panga (think Kenyan machete). He cracked one brother across the skull -- well, "across" isn't entirely accurate, more like "through". The other brother had time to raise his hands in defense as he received a chop on his mid-forearm that went down to his ulna.

They both needed to be taken to the theatre for a washing out of their wounds and to see what could be salvaged. Then the dilemma of limited-resources rears its head: there are two urgent cases, and only enough staff overnight for one operating room.

The brain was the higher priority, and needed to be rushed to the theatre. A 3rd year general surgery resident serving here for a year was going to tackle that. "You think you can sew this arm up here in casualty?" he asked me as we looked at this man's gaping arm drip-drip-dripping on the floor.

"...Sure!"

With little light, I leaned over this arm and began. I washed the wound out and explored it, but everytime I removed the gauze from the wound, it filled back up with blood. I couldn't see a vessel. I thought, this guy is going to need a transfusion, if he doesn't bleed to death. In my inadequacy, God's glory was made manifest. I'm reminded of the childhood poem:

Little one's to Him belong
they are weak, but He is strong.

Yes, Jesus loves me. And as I started sewing, practically blindly, the bleeding just stopped. I could wash it out better now, and see very clear bundles of fascia that wrapped around his extensors. I was able sew them very easily, and after that initial feeling of fear and helplessness, he went back together very nicely.

The next day, I got to talk to him about Jesus, and about forgiving a brother that has sinned against you. He said he had no animosity against his brother and wasn't plotting any revenge.

Please continue to pray for me to be as weak as is needed for the Lord to be glorified here.