My first night on call...in Africa

WARNING PARENTAL GUIDANCE SUGGESTED. THIS IS A PG 13 STORY. I had been in the hospital for 4 days now and was slowly learning the ropes. I knew where the bathrooms were, where the "operating theaters" were and I was making good progress on people's names. I still didn't know where the cafeteria was but that is another story in itself.

It was winter Fri. afternoon in July and I made sure everyone who was on call the weekend knew to call me if they had something interesting, needed help or just anything. This was all volunteered by me. I was a volunteer after all. But I did want to see how the system worked on weekends, what went on, and also I wanted everyone to know that I was "into it".....which I definitely was.

Dr Akim Tampale was on the weekend. She had struck me as a pretty serious women from the get go. This was no piece of cake 9 to 5 bank job she was into. Her schedule is heavy. The hospital doctors are on night call for a week at a time. The doesn't mean you have the days off. Your there just like everybody else during the day, then you go home if its quiet but you're responsible for everything that goes on at night....it's all yours. And just like a 4th of July fireworks display your week ends with a grand finale....the weekend. If you weren't tired by Friday you you will be dead by Monday morning when your friends rescue you. This creates great teamwork. You really do love your colleagues, especially on a Monday morning.

Technology advances in odd and erratic ways throughout the world. Communication at Biharamulo Hospital is almost exclusively by cell phone. Everyone has one..everyone including me. This is a big advancement from MMC in Portland, Me. where we are still in the" beeper age".....so primative. Having left my cell phone # everywhere and given it to Dr Tampale I went home Fri. afternoon to begin our first weekend in Biharamulo.

I woke up about 5:00AM with that inner smile you have when you know you got a full nights sleep with no interuptions. Its like you dodged a bullet, no phone calls, lucked out again, hopefully Tampale had a quiet night too. I closed my eyes and the phone rang not 5 mins. later. It was Tampale, she was in the "minor operating theater with a bad accident ...come quickly.."

I was out of bed, out of the mosquito netting , dressed and walking to the hospital in the pitch dark in a flash.

I walked into the "minor theater" which serves as a procedure room and just about anything else room and all the lights were on and every one was home. On the stretcher was an 18 yo male covered with blood and dirt. One of the anesthetist was putting in a perih IV, nurses were getting bandages and Tampale had his right foot in her hands. Well almost. The only that stopped her from walking away with his foot was the remnants of his achilles tendon. He was awake and still breathing but had lost a lot of blood and was still bleeding actively. After a quick good morning Tampale tells me in English the kid is from a clinic maybe an hour away, MVA (motor vehicle accident), blood is on the way, we need to stabilize and splint. I feel the kids skin, he's cold, trembling, and not saying anything despite her moving his degloved, almost auto amputated compound fractured leg. He's in shock and about to stop breathing. I ask the anesthetist if I can put a central line in to help and he intubate the patient. He looks at me and keeps trying to get a IV in the kids arm. Does he understand English? I ask Tampale do we have a CVP (central IV line thats big and feeds fluid right into your heart) tray or kit? She tells me we don't do that here. !!!! OK, I have to remember where I am and try not to piss off too many in my first week.

The anesthetist has scored with a 16 G IV, if we get one more 14 G or 16 G IV we might have a chance. Tampale is checking the BP. It's 80. The nurse yells the 1st unit of blood is here. I lookup, its a huge bag of blood . I ask Tampale what is that and she says "its whole blood" I keep asking myself "where am I??". In this situation whole blood is a blessing. By now this kid is at risk to have coagulation problems and the whole blood is full of clotting factors..its a gift.

I talk with Tampale on the side. We are in big trouble. We need to go to the Operating Theater(OR) now. There's at least one arterial bleeder in his calf, possibly three, and he's running on empty. We need to forget washing his wounds and try to save his life. We need to stop the hemorrhage and amputate his leg.....which he's already done...mostly.

I put a tourneget on his right thigh and Tampale tells everybody in Swahili we are going to the major theater.

Before we wheel out to the OR we have another "learning moment" The kid is covered with blood and dirt and gravel. His whole body is road rashed with little pebbles in his skin. It's as if he was run over 3 times and dragged thru a gravel pit. He can't go into the OR with his clothes on and nobody seems to know how to get his pants off around his fractures. I keep asking someone, anyone, for a big pair of scissors. Finally a heavy pair of shears appears and I cut off all his clothes. I can't fixate on this but shouldn't this be done when you first arrive at the hospital? We will talk about this on Monday.

OK, we are in the OR and the changes just keeps on coming! This is going to be a real experience. The anesthetist has 2 good periph. IV's to pump blood and fluid into the patient. He has anesthetized the patient with Ketamine. and still has not intubated him. When I tell him he needs to be intubated Tampale starts a running dialogue in Swahili that turns into an argument. Both of the patients lower extremities have been scrubbed up to his umbilcus.

Its a good thing the OR faces east and has BIG windows because the lighting is not great. Not to worry, the sun is coming up just in time!

Tampale has disappeared. Phone call? Probably change her scrubs. Even with the tourniguet

the bleeding continues. I finish drapping the patient and wrapping his dangling leg in a sterile towel, and am looking at the back table where the all the instruments are. Speaking to the nurse, the tech, the anesthetist or anyone who cares to listen to my English. " Do we have a bovie?...you know electical cautery? I'll need a sucker (suction) and the saw and a rongeur ( bone cutting instrument) I'm getting a lot of blank looks from masked faces. The anesthetist says "lets go". I realize the back table is looking pretty bare and lacking everything I just asked for. OK, so I didn't really need an electric saw to amputate this leg but a bovie, a bovie!! thats pretty mandatory. The tech. hand me the knife. First I want to stop the bleeding by finding that artery or arteries that are out of control. But before that I ask for a big pair of scissors. Two snipes and we are through the achilles tendon and skin remnant and we can hand off his distal leg wrapped in the sterile towel. Somehow that just seems to make things neater. The leg stump is a real mess of exposed and twisted tibia and muscle and tendon. There's no real obvious pulsating squirting bleeder, every thing is just oozing everywhere. There is no cautery so I place hemostats on the biggest bleeders but this is wasting time. The best way to deal with this is start the incision and find the popliteal artery ( the main artery to the lower leg), control that, and take care of the hemorrhage. I start a long tangential incision that starts just below that bump thats 2 fingers below the lower part of your knee cap. The cut goes posteriorly and distally down the leg so you create a long flap that will later be rolled up to create a nice meaty stump, all below his knee. The purpose being to create a solid foundation for a prosthesis. I think, will this kid ever REALLY get a prosthesis so he can walk?? Well, first he's got to get through today.

Tamplale is backand scrubbed in. She is across from me and looks OK but flat. I tell what I was thinking. She's OK with that. In surgery there is a lot of protocol, culture, ownership and just simple "surgical manners" One cardinal rule is you don't ever steal a case from anyone else. I think this is universal...even in Tanzania. I ask her what side of the table she wants to be on (ownership is almost always a right side of the table thing). I tell her its her case and she can take over now. She wants me to continue. We cut through a lot of muscle with the knife which creates more bleeding. We place hemostats on bleeders as we go. I cut into a good sized artery. The field fills with blood.That may sound bad but its actually god. Now we know where we are. We control the arterial bleeding with a hemostat and follow the artery back up the leg and whamo! There it is ! The popliteal artery. If we can control this we will stop the hemorrhage. The rest is simple....well sort of.
After a few more minutes we have controlled bleeding, exposed the tibia( the big bone in the lower leg) and the fibula (the little bone) and we are ready to cut thru them both and create a stump below his knee. This part of the operation takes about a minute, if you have an electric saw...which we don't. It could take 5 minutes if we had a gigley saw...which we don't. It took more then 10 minutes with the amputation knife they handed me. I 'm starting to get the impression now that the real reason I'm here is to grunt through this part. The amputation knife is sharper then a butter knife but duller then the history channel at midnight. After 10 minutes of sawing and 2 pounds of sweat I'm drenched and the rest of the patients leg is off the table. We fold up the flap we have made and it looks like it might be an OK closure. Best of all the patient will live.
I'm relieved and have stopped sweating, Tampale is happy, her night call is over. The patient is stable and not bleeding. Even the anesthetist is happy. We get back to our regular broken English conversation with mixed in Swahili and I promise myself a big breakfast....if I can just find that cafeteria.