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Tuesday morning Arusha, Tanzania "No Theatre today." "What do you mean? We have six cases scheduled." I was standing in front of the scheduling board with Farada Ali, the intern who would be operating with me that day. Samuel, our anaesthetist, had just joined us. "No Theatre today." Samuel pointed to the pole that held the power lines to the small building that housed the operating rooms. The pole had fallen over during the night--its complete collapse prevented by the water tower. There were two men busily digging around the base of the power pole, and I was assured they should have the problem solved by the next morning. The next task for me was to determine how to reschedule the two semi-urgent operations and the four outpatient procedures we had planned for the day. I was most concerned about a nine year old boy who had been admitted during the night with appendicitis. He looked rather ill, and I feared he would be far worse by morning. As we puzzled over the particulars and possibilities, Husnity, the intern assigned to Casualty for the day, came running up to us. "Dr. Tracy, you must come to Casualty immediately!" Casualty is what we in the U.S. would call the Emergency Department. We all followed him at a jog across the courtyard, through the crowd of roughly sixty people who had queued up in hopes of seeing a doctor that day. Casualty was a ten-by-twelve foot room equipped with a rickety stretcher covered with a torn sheet, a small metal table on which sat a half box of gauze and a stethoscope missing an earpiece, and a wooden chair. The nurse on duty was standing over the stretcher where a nine month old baby girl lay. She was semi-conscious, covered in dirt and scrapes. Her mother stood nearby, wringing her hands. She explained they had been on a motorcycle taxi and there was an accident on the main road just outside the hospital. The infant's left foot had been amputated completely at the ankle. The resourceful intern had tied a latex glove around the baby's calf as a tourniquet to prevent blood loss, and in doing so probably saved her life. There was nothing more he could do then but come find me, as she would certainly require surgery. Though barely conscious, the baby's heart rate and breathing were normal, so I was a bit reassured. I examined the wound, complimented the intern on his quick thinking and actions, and turned to Samuel. "I'm going to need to tie off the vessels, debride the wound, and apply a dressing", I told him. "No power to the Theatre." "Yes, I am aware. But I can do this without power. It will take less than ten minutes. Can you give her a sedative and we'll just get it done? She'll need a formal amputation and wound closure, but that can wait until tomorrow." "OK", he conceded. Samuel started an IV, and we took her to the operating room. I removed the tourniquet, ligated the major veins and arteries, trimmed away some dirt and damaged tissue, cleansed the wound, and applied a dressing. The next morning, I was delighted to learn that power was restored, and we could proceed with surgery as planned for the day. My first priority was the nine year old boy with appendicitis. He had indeed worsened overnight, with high fever, chills, vomiting, and severe abdominal pain. I was sure his appendix had ruptured and that he was developing peritonitis and sepsis. He needed surgery right away. As the nurses prepped him, I went to see the baby girl from the day before and was pleased to find her actin more like a normal baby and nursing from her mother. As the intern interpreted for me in Swahili, I explained to the mother that more surgery would be needed. I would amputate higher up on the leg in order to provide good closure of muscle and skin over the end of the bone. We agreed to do that the next day, as the present day was already full of cases we'd postponed from the day before. Some of the outpatients had walked for hours to the hospital the previous day, only to be turned away due to the power outage. They had been instructed to return today. We performed the appendectomy, and as expected there was widespread infection in the abdomen. With several days of antibiotics, the boy recovered and was able to return home. The following day, we returned to surgery for amputation of the infant's leg. It's customary to immobilize the leg after surgery, so I asked for plaster to make a splint. None was available. I was told by the intern that such materials must be purchased by the patient or their family from a pharmacy, and he assured me he would write the prescription for the mother to take to the pharmacy. I instructed him to apply the splint as soon as the plaster arrived. When we made rounds the next day, there was no splint. The baby's mother explained to me that she had no money for the plaster, the cost of which amounted to less than $2 US. I later gave the money to the intern, he went to the pharmacy and purchased the plaster, and we applied a splint. The next day, the child went home with her mother. 
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The pain began suddenly last night, woke her from sleep. It wasn't the first time, but was worse than before. The ER physician diagnosed a gallbladder attack, and that's where I came in. Surgery is often indicated for recurrent gallstone problems.
"L" was surprised to hear the diagnosis. She had assumed it was yet another pelvic infection caused by an STD, just like last time. As as we talk, I notice the pasty texture and pallor of her skin. Her eyes are bleary and bloodshot. Innumerable scars and scabs cover her body. Her sparse, greasy hair is pulled into a messy ponytail. "I need a cigarette." I've seen the medical chart: opiate overdose, methamphetamine use, anxiety disorder, history of sexual abuse, migraines. I glimpse broken, discolored teeth through cracked lips as she tells me she's feeling better now and wants to go home. I explain the nature of gallbladder disease, my recommendation for surgery, potential complications and likelihood of recurrence. "I don't want those scars on my belly. And I'm fine. Just let me go." It's her choice, her decision. I feel hopeless. Her gallbladder was the only thing I could fix. I take her hand and wish her well. Her father is waiting by the door. He thanks me for my help. I write the order: Discharge to Home. All I can think of is what "home" is for her. She's twenty-eight years old. She looks fifty. I doubt she'll make it that far. |
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