Monday, January 25, 2010

Monday, Working at CHUK

Actually enjoyed working in Rwanda today, I think for the first time.
I am getting used to the pace, and beginning to accept that sh*t happens.
Our driver was ten minutes late, so we came into the middle of the morning case presentations. When the presenter speaks loud enough I can follow his French. I think I made a few useful points (in English, I'm afraid). Had a decent discussion with one of the senior residents about a couple of cases. Got to the OR and there was no-one there. Looked over one of the old anesthesia machines and tried to figure how it worked. Went to the tea room and did some reading.
Eventually the first case arrived, but there was no endotracheal tube of the correct size. I made a big fuss about this. This is the University Hospital of the capital city, where they do a lot of paediatric cases. There is no reason why they should not be able to keep a supply of paediatric sized tubes in stock. After much prolonged discussion I cancelled the case. I talked tot he only staff anesthesiologist around, whio was in the ICU, and he eventaully found the rightr size tube in ICU and the case was un-cancelled and done in a different room by a nurse anesthetist, who decided not to use the tube I had found but the smaller one I had said was too small. Odd.

I was getting very frustrated working with one of the weaker residents, who seems not to remember anything I tell him, so I decide to go for an early lunch. As I headed out I saw a trail of fresh blood leading into one of the other ORs. This is never a good sign,,,,,

I wnt in to find one of the final year residents dealing with a patient who had a massive burn . A gas explosion had burnt his face, chest, both arms and upper thighs, about 30% of his body in all. He also had a depressed skull fracture and was bleeding from a skull laceration. At this time he was talking but not co-operative with examination. Two IVs had been started and the resident was working on a third. I put on the monitors and oxygen. No BP was obtainable. He has a slight tachycardia and a saturation of 90%.

Clearly he needed intubation, And clearly it would be a challenge.....
In the end I was able to topicalise the airway, and with a little sedation and two people holding him down we decided we could see enough to intubate. So we did a modified rapid sequence induction with a small dose of propofol, checking we could ventilate with cricoid pressure in place, then sux and a 7 tube with stylet. That all went well.

The surgeon did a debridement and we gave fluids according to the Parkland formula. Originally the BP was around 90 but then it shoyt up to 220/110 for no good reason, In the end I moved the cuff to the other leg and the BP returned to normal.

Had as sensible discussion about a variety of issues:
Should we trach him now? I thought doing a tracheostomy through the burn was a bad idea, especially as hopefully in a week or so the swelling would go down.
What do we do about his head injury? The surgeon could palpate a depressed fracture. Obviously he should have a CT scan, but this would require a transfer to King Faisal Hospital, about 30 mins away. In the end we decided to monitor him clinically and hyperventilate him, and cross our fingers we are not missing a surgically correctable problem.

At the end of the day I called Joseph, who is in charge of the drivers, and asked for a lift back to the apartment. He decided to drive me himself, in Landrover Ambulance. When we got to the roadworks, they let down the barrier for us. When we got to the actual working area, we just drove up onto the pile of dirt and drove straight over it. Very cool.

Stopped at the gas station across the road for yoghurt and juice, then went home. The houseboy (yes, that's what people call him) knocked onthe door with my washing, all neatly dried and folded. I paid him 3000 RwF, less than $6. Sweet deal!

Did some work preparing for the academic day on Wednesday - anticholinergics, anticholinesterases, patient positioning, and anesthesia for ENT surgery - then took the bus into town (20 cents). Doing this blog then out for the expatriate Pizza and Quiz night. Not a bad day....

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