Near Death, by Dr. James Appel, from Moundou Surgical Clinic in Chad

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Things do not start off well.  The old man lying on the gurney is a giant.  But he can’t pee and he’s got a fever and is throwing up.  I stick a gloved finger in his anus and confirm a huge prostate.  I pass a urinary catheter into the bladder releasing the pent up piss and start him on IV quinine.  He does not look operable.  Besides, the family seems more concerned about his leg which they say hasn’t worked right since a motorcycle accident several weeks ago.

Three days later, I see him on rounds and he looks 100% better.  He’s eating well, sitting up, looks normal.  I schedule him for surgery.  We check his hemoglobin which is a respectable 11 and take two pints of blood from his family members.

The day of surgery, things start off well.  The spinal anesthetic goes in easily, his blood pressure is normal (these old men often have hypertension which complicates things) and I quickly enter the bladder.  That prostate is by far the biggest I’ve ever seen.  It’s baseball size and I have to take it out in 6 pieces, each about the size of a golf ball.

Then things get ugly.  I try to pack the prostate cavity with a lap sponge but no matter how much I compress it blood continues to well up into the wound.  I place a large three way foley and inflate it with 50cc, pulling the balloon in to the wound and repack.  Still bleeding profusely.  The suction can’t keep up.  The small canister is filled.  Yola goes to change it and now the suction doesn’t work.  I’m panicking.  The guy is bleeding out and I can’t even begin to see to try and suture something.  Not only do I not have suction but the retractors are too small for the man’s chronically distended, floppy bladder.

Yola finally gets the suction working but it’s weak.  I’ve been going through the lap sponges and I’m filling up another canister with blood.  I call for Anatole to put on gloves and try to help retract.  We have two large bore IVs going and I tell Yola to start giving blood in both IVs.  I continue to struggle with trying to get both Abel and Anatole into position with the retractors so I can see the prostatic cavity but we can’t get a good visual and blood continues to well up despite packing.  I’m sweating profusely.

I glance over and his blood pressure is almost nil.  He stops breathing.  I start doing chest compressions.

“Get some adrenaline!”  Yola can’t find it.  I continue pounding his chest feeling the futility of this attempt at resuscitation as no one else really seems to know what to do.  I can’t stop to intubate.  I feel ribs cracking under my vigorous compressions.  Finally, Yola finds a vial of Epinephrine that is made for IV tubing with an IV port.  It’s a US model made for safety and preventing law suits I’m sure.  It does us no good since our IV tubing has no ports.  Finally I find a way to inject the medication and continue CPR.  The blood continues to flow in the IVs but with the low blood pressure and cardiac arrest, at least he’s not bleeding from his bladder wound which is still packed.

Amazingly, the pulse oximeter starts to pick up a saturation and it slowly climbs to low normal.  I listen with a stethoscope and he has a heart beat.  Then his blood pressure comes back.  I take out the bladder packing and there is minimal bleeding.  Everything is contaminated so I just close up the bladder and pack the rest of the wound with gauze soaked in diluted bleach.  I start the bladder irrigation and very bloody fluid comes out into the urine bag.  We’ve given 6 units of blood by now.  I place a 7th and we take the patient out to recovery room still on 5L of oxygen barely sating in the high 80’s on the pulse ox.  I doubt he’ll live, but I want him to come out of the OR alive so the family can see him.

Out in recovery, his foley keeps blocking up with blood clots.  I place a suprapubic catheter in to help with drainage.  He’s still not oxygenating well and is awake but looks punky.  I listen to his lungs.  Almost absent breath sounds on the left.  I’m sure I’ve broken his ribs with CPR and caused a pneumothorax.  He needs a chest tube, but will he tolerate it?  He’s already been through so much.  I decide to keep going as long as he’s still alive.  I rush out to the storeroom and find a chest tube.  I collect a scalpel and large curved clamp and some gloves.  I can’t risk giving him more anesthetic so I just infiltrate the skin with local anesthetic around the ribs where I’m going to place the drain.  I slice down to the rib, undermine up to the top and poke the clamp into the chest cavity.

Pus squirts out all over my shirt.  He has an empyema.  Probably from the accident weeks ago.  Would’ve been nice to have a pre-op xray or at least done a more thorough physical exam.  He went the entire surgery and losing most of his blood volume using only one lung!  I insert the chest tube, suture it in place and attach it to the drainage apparatus and suction.  His oxygenation improves quickly after almost a liter of purulent fluid escapes his thorax.

Fluid is leaking into both urinary catheters and from his abdominal wound.  I continuously have to strip the clots out of the foleys and the bed and floor are soaked with bloody fluid from the bladder irrigation.  He’s getting cold.  I bring in the infant warming light from labor and delivery.  Family members are refilling the irrigation bottle with tap water as quickly as they can.  The suction is overheating so I leave the chest tube to water seal.  He’s off oxygen now and his O2 sats are normal.  I prescribe antibiotics, check that the urine drains are working one last time and walk out into the cool Tchadian evening.

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