A day at the Hospital

Yesterday began with ward rounds before morning prayers.  I met several new patients that needed attention, including a 7 year old boy (about half Levi's size, due to the same pervasive malnutrition that seems to affect all children here) with a both-bone forearm fracture on the right.  His arm was held in a home-made, or more likely hospital-made, splint of a torn cardboard box with fabric wrapped around.  Luckily the x-ray showed relatively well-aligned fractures, so a long-arm cast would do the trick.

After repairing an inguinal hernia and removing an intramedullary nail (long metal rod used to stabilize a fracture) from a young man's femur, I was called to the pediatrics ward to see a 10 year old girl who had been brought by her mother the night before.  Her abdominal x-ray showed several areas of dilated bowel, but did not reveal a specific diagnosis.  She was listless, and looked quite anemic.  She had typical signs of malnutrition, weighing in at about 40 lbs (my 6 year old daughter Anna weighs 40-50 lbs).  Her abdomen was bloated and tender.  The mother informed us that this had been going on for 3 days.  

The pediatrician and I made a plan for giving IV fluids and checking a few laboratory values, and I returned to work in the OR and on the surgery ward.  When I returned to see the girl, her abdomen was now even more distended and tender.  The labs showed an elevated white blood cell count and though I couldn't come to an exact diagnosis, I was sure of one thing: this girl belonged in the operating room.  

After she was under general anesthesia, I made an incision down the middle of her abdomen, curving slightly to avoid the belly button.  I had no idea what we would find... a perforation from typhoid?  Intussusception (inside-out telescoping of the intestine)?  Any of a variety of more rare tropical diseases?

What I actually found was more surprising, and disconcerting than I had imagined.  At lease 2/3 of her small intestine was dead.  It had spiraled around its own blood supply and kinked, then clotted the blood vessels.  Working quickly we clamped the blood vessels, then began to untwist the knot.  As we did, both myself and the other surgeon jumped as we came face to face with a crawling Medusa-head of Ascaris (round intestinal worms about the size of earthworms) penetrating the wall of her dead intestine.  Gross, and otherwordly-appearing, yes, but even worse it meant adding insult to injury for this young girl.  We measured-off the remaining healthy small bowel - knowing that a length of about 100cm is necessary for digestion and absorption of nutrients from food (and therefore necessary for life).  Thankfully, just about 100cm remained.  

While sewing her wound closed, I kept thinking of the huge odds she is up against for surviving.  Her chronic malnutrition will now only be compounded by shortened intestinal length, and there is no option for alternative nutrition (i.e. IV nutrition) here.  We lack many of the diagnostic tests that could help identify problems early, so they can be "nipped in the bud."  It will definitely be an uphill battle.  

When surgery was over I explained everything the girl's mother with the Rwandan nurse anesthetist translating.  She stoically accepted the news and warnings of a difficult recovery, likely fraught with complications.  It will truly be a miracle if this little girl survives... but that is just what we're praying for.