Friday, January 7, 2011

#12 If I Had Balls Like These

So Olen told you about the little baby boy who can barely breath because of a right neck abscess.  Both of us have been nervous to do an I&D (incision and drainage) on his tiny little neck.  What if we kill him on the spot?  The only time he has gotten a little bit better was when Olen drained 10cc of yellow-greenish pus from the slightly swollen area the day before.  You can hear him breathing when you are in the same room as him.  He rests with his neck extended.  It must be easier to breath that way.  

What do I know about the neck?  I’m an OB/GYN!!!
Olen says....”What are you worried about?  There’s only the Jugular and the Carotid sitting there.  He may bleed out, but he’ll die eventually from sepsis or respiratory failure if we don’t do this.”  
So we bring him into the room next to the OR after finishing our cases for the day.  The room for minor little surgeries, like I&D’s and lumpectomies from various parts of the body (really ALL places).  You know, since this is just a minor little thing!  Not really!
We don’t intubate here.  We don’t have oxygen here.  Ketamine is really (as James has said before) God’s gift to the third world countries.  We do spinals a lot also (well the nurse does).  I haven’t learned that yet.  We are afraid to give ketamine because this little baby has never really breathed that well since he came to us.  So, I inject a few cc’s of lidocaine under the skin.  
We say a prayer.  I cut down very carefully and make about a 1cm incision, hoping to find the pus right there.  Nope.  I extend the incision some.  I try to dissect bluntly through the muscle.  
I can’t find the abscess.  I grab the syringe again.  I am able to aspirate 1cc of pus a little bit deeper.  So I need to go deeper!  I am not very comfortable with this case already.  
Samedi (the VERY experienced nurse who IS really a surgeon here) says to just stab where I think the pus is.  That’s a good idea I think.  Ya, right where I aspirated.  But somehow, I just can’t seem to stab deep enough.
I tell him to do it.  He says...”No, it’s not I who can help you, but God.  He is the Great Physician.”  I say I know, and continue with the dissection.  I try to puncture where I think the abscess may be...  Then, I get the Jugular.  It's dark and fast, but it's not bright and pumping. It's not the carotid. If it was the carotid, the muscular wall of the vessel would spasm and tamponade the bleeding spontaneously. The jugular has no musculature in the vessel wall. It will bleed until death. Olen and Samedi hold pressure while I run into the OR to grab some suture.  Samedi helps me clamp the 2 sides of bleeding and I put 2 figure of 8 stitches in this tiny little neck.  The bleeding stops.  
I search a little more, but can’t find the abscess.  We decide to suture a little of the skin, but leave the middle open for the abscess to hopefully drain.  Maybe there wasn’t any more pus for left today.  
I told Olen that I needed to grow some balls.  We explain the english saying in French to Samedi.  “Quand on dit en anglais, ‘vous avez les testicules,’ c’est a dire, ‘vous etes courageau.’” He laughs.  
“Vous avez les testicules!” (You have testicles) he reassures me.
Later that afternoon a man walks in for a surgery consultation.  Samedi shows him to me.  It was a little bit humorous that we had just spoke about me needing “balls.”  
If I only had balls like this patient.  4000 grams (nine pounds!) worth of left-sided ball that is!   This elderly man has been walking around with his scrotum close to his knees for many years.  (Elderly here in africa is in the 40’s, maybe 50’s, you never can tell most of the time......Nobody knows their age here it seems.)  Anyways, he has white hair.  The arabic men here also wear these cool long robes, so probably only his wife (or 2 or 3 wives) knew.  
Samedi is teaching me surgery.  I will write more about him later.  But I am VERY thankful he is here!  He is cool, calm and collected.  He is a nurse, and makes nursing salary. (He actually makes more than any other nurse, about $5,000/year.)  It doesn’t seem quite right since he is basically the general surgeon here.  
Today he did an inguinal hernia while I was rounding, and then we did 3 hydroceles together.  Hydroceles are so fun!  They are easy for me now.  If it is hard and infected we take out everything including the testicle.  For all of you OB/GYN’s out there, this is probably more fun than shelling out a fibroid or a large ovarian cyst without it breaking!  
The third hydrocele case was this guy with his testicle close to his knees.  It really did weigh 4000 grams!  
If I DID have balls like this, maybe I wouldn’t flinch when I walk into the consultation room and Olen says....”Oh, here is my wife now, she is a specialist with women.  A gynecologist.”  Also a specialist in breast surgery (according to him).  Um, NOT true!
“Hi nice to meet you”, I say in French, of course not showing my adoration for my husband when he has already told them I can do this difficult surgery that I have NEVER done before.  
 The young lady pulls up her shirt.  Her left breast is large, nodular, and rock-hard.  It’s even extended into her axillary nodes.  I know this can’t be good.  In the States I would refer her, of course, to a general surgeon who specializes in breasts!  
Thankfully God put Samedi here.  He says he knows this surgery well.  That will be for another day.  Probably next week if the family can find the money.  I can’t imagine this case NOT being difficult.  
Also, I need some pessaries while I grow some courage to do vaginal surgery here.  I love vaginal surgery, but I haven’t done any in over 6 months now (since residency).  Vaginal surgery is all about the right set up.  I need some time to put together the right kits to use.  So I hope eventually I will start.  
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