Wednesday, September 2, 2015

Rwanda part 2


Case 2

I couldn’t believe it. We haven’t even been here a week and we’ve already set up two procedures! I was really worried that we had brought all these supplies and by the time anyone found out about what we could do, it would be time to go.

However, yesterday morning a pediatric surgeon from the states had come into the reading room to review a possible surgical case. It was a 2-year-old girl presenting with a distended abdomen, vomiting, and weight loss for 2 months, along with intermittent fevers. Laboratory tests up until this point, including those for hepatitis and HIV have been unremarkable. The pediatric team had asked for a CT yesterday which demonstrated a large fluid collection that was intimately associated with the pancreas - concerning for a pancreatic pseudocyst.

Wait, but why would a 2-year-old have pancreatitis? Scorpion bite, I thought excitedly. Both Dr. Rosman, the radiologist we were working with, and the surgeon almost in unison, said ‘trauma.’ Apparently, as I was to find out over my time here, that next to infection, trauma is the etiology of almost everything else. Nonetheless, the patient’s mother apparently denied any trauma. I brought up the idea of catheter drainage, especially given that we had just had a conversation about horrendous post-operative care a couple days ago. The surgeon, almost immediately said, ‘it’s all yours.’

We found ourselves in the middle of the oncology ward, with twenty people observing, about to perform a catheter drainage on a 2-year-old. We had learned a few important lessons from our first procedure about improvising, using the towel that came with the surgical gown as a sterile drape, using a sterile glove as a ultrasound prove transducer cover, and removing flies from the sterile field. I had performed that first case, so it was my co-resident’s turn to perform this one and I was his assistant. We sedated with the help of an expatriate pediatric emergency attending (Dr. Rosman’s wife), prepped, draped, and without difficulty placed the catheter into the collection.

We then realized two things. For one that we didn’t have a syringe larger than 20cc to aspirate all the fluid, and two, we had completely forgotten to bring catheter drainage bags. As far as the syringe was concerned, there was no choice but to aspirate and dump into a bin. About fifteen minutes later, we had removed almost 1000mL of fluid and could aspirate no more. We confirmed with ultrasound that the collection had collapsed and turned our attention to the problem of a bag. Improvising again, we took a Foley catheter bag and inserted it into a 3cc syringe with the plunger removed. The syringe end of was then hooked up to the catheter and fluid freely flowed from the catheter into the bag. We then sent the aspirated fluid to the lab to evaluate for presence of amylase and lipase and congratulated ourselves on a job well done.

Then the real problems started. For one, we had not anticipated the nursing challenges. The nurses were unfamiliar with how to manage a catheter and many of them did not want to touch it. In addition, saline flushes were not available and we had not brought any, and so the catheter was not flushed. Also, while physicians routinely ordered the recording of ‘I&Os’, like vital signs they were rarely accurately documented and hence our catheter output measurements were approximates as some of the nurses did arbitrarily discard the fluid.

The next morning we rounded on our patient and found that she appeared very listless and had apparently a low-grade fever overnight. We asked that gram-stain and blood cultures be drawn and in consultation with the pediatric team added empiric antibiotic coverage. Confused about what may have happened, we conjectured that while we “sterilized” the skin with chlorhexidine, that patients in the developing world are often malnourished and their ability to mount a response to otherwise innocuous bacteria may be compromised.

On post procedure days two and three, she looked no better and catheter output had dropped off as far as we could tell. Now we were anxious about other possibilities. Did we perforate a viscous? Does she have a large hematoma? We asked for a repeat CT to look for any of these possibilities as well as how well the collection was drained. Unfortunately, we found that patient’s family was unable to afford the copay for a second CT scan and would have to consider selling a portion of the family’s farm in order to do so – a not uncommon situation apparently. Having encountered these types of situations before, Dr. Rosman and his wife had set up an emergency fund and the CT was paid through the fund. Ultimately, the fluid collection was found to be partially drained and the remaining collection was multiloculated with thick septations and so the catheter was removed. Much to our relief, the patient clinically improved a couple of days after catheter removal.

Despite the practical lessons learned during the course of this patient’s care, we also learned an important lesson about our limitations as providers, and that in the developed world we often take for granted the presence of our colleagues in other specialties. Unbeknownst to us, during our treatment course, the only pediatric surgeon in the country, the one who had referred us this patient, had completed his term here and left for the United States. And it turned out that another one would not be available for at least 6 months. While the patient ended up doing well during our time there, the partially drained collection could be an issue for her down the road as it could become secondarily infected or reaccumulate and now a surgeon may not be available for definitive treatment.

It is becoming crystal clear from the get-go that providing high-level care, in a country with limited human and physical resources is a challenge.

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