Amputation

I ran into more internet problems between uploading this and the previous entry.  With that said, this is part 2 describing Thursday’s adventures at CHUK (a day late and two dollars short?).  I can’t really complain… I’m using the internet in sub-Saharan Africa.

While the morning took on more of an uplifting tone, the afternoon shot that down a fair amount. The Alliance for Smiles group had finished checking in patients for the day (some girls in the group helped with that earlier in the day), and we figured it would be worth finding something else to observe within the local system.  With the addition of a French speaking student, we decided to try our hand in the surgery department again.  This time around we spoke with a nurse in the preparation area who told us we could talk to a surgeon in a staff room… but we couldn’t enter the main portion of the surgery building, which was a “sterile area.” I then pulled out some stuff I had saved from the smile group (hair net, shoe covers, mask), asked if those would work, and we were in.  The situation served as an example of the kind of interesting approach to sterility and sanitation that I’ve seen in the country.  The doctors that I’ve seen have generally been trying to move closer toward what we would recognize as proper precautions, but I’ve also seen a nurse in the OR put on gloves just to pick up her phone when it rang… and then hand something to the surgeon (just one example).  It’s progress, but it still wouldn’t fly stateside.  

Once in, we walked in on an orthopedic surgery involving a shattered femur.  We didn’t stay terribly long since the surgeon we initially talked to said he would be performing an amputation soon, but it was a sight to behold.  The patient’s thigh had been opened wide with a ~12 inch incision, and the broken pieces were in plain sight.  We were shown X-rays of the leg, but it really wasn’t necessary at that point in the procedure.  Besides walking in to see a leg hanging open, the most surprising aspect of the surgery was that the patient was still awake, staring at us.  I’ve heard that there are limited anesthesia options here, and our amputation patient was awake throughout the procedure as well…

The patient being prepped for the amputation above the ankle was a woman about my age, whose foot had failed to heal properly after a mid-foot amputation a few years ago.  The surgeon performing the amputation came across as rather young, but he took more of an interest in pointing things out as he went along.  Given that he needed to cut through the entire lower leg, it became an anatomy refresher course with more wincing and more squirting (he could at least cauterize arteries, but we still observed a number of spurts).  As for the procedure itself, it turned out to be a bumpy ride.  If there’s one thing to be taken away from my time in Rwanda, it’s that they work with what they have (like using an NG tube for a catheter), but limited resources can really be problematic on occasion.  The surgeon seemed to do fine getting through skin and muscle, but getting through bone naturally required some sort of saw.  He started with what was comparable to a Dremel with a relatively dull blade.  This actually worked adequately on the first time through, but he realized that not enough tissue had been left to close the wound after removing the foot.  After failing to cut off more bone with blades meant for single use (not sure how many times they had already been used and autoclaved), he told us we would be going “back to the stone age.”  Out came the bone saw.  He seemed to get through most of the fibula, and he broke off the rest with some twisting.  The tibia, however, proved more difficult.  Out came a chisel.  After failing with the chisel, we went back to the bone saw.  Now, keep in mind that the patient was awake through all of this.  Not only that, but the nurse assisting on the surgery had placed the severed foot in view of the patient after removal (another student in the OR with me said he saw the patient’s heart rate jump from 60 bpm to 90 bpm).  The patient eventually pointed it out to another nurse in the room who had the first assistant cover it up, but it was likely half an hour later at that point. (Another student and I had initially tried to slide the table holding the foot out of the line of site, but it was a sterile table which prevented much movement.  We were also attempting to limit the amount of attention drawn to the missing appendage.)  After noticing the surgeon’s frustration building due to difficulty closing the wound, among everything else, we thanked him for his time and told him that our ride had arrived. 

While this was certainly a less than stellar procedure to sit in on, it’s hard to blame the surgeon or the system.  He probably could have left some more tissue to work with in his initial incisions; but he couldn’t control the issue with supplies, and he didn’t know the patient would have some sort of pathology that toughened the tissue around the bones (either due to inflammation from complications from the previous amputation or impaired circulation from a gunshot to the buttock in ’94).  It was a tough situation that just seems more likely to happen in a system making do with what they have. 

-Scott

Once again, since I didn't take any pictures today, here's a picture of the Rwandan flag.