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"Nemaste" from the Top of the World
Here are a couple of excerpts form my journal, written during my Interplast,
Nepal 1991 trip. Things don't always go the way you plan them when you
are far away from home. I hope you enjoy the drama. For the full text
log onto the SPA website, and go to Travels and Travails, where you'll
find this story and others chronicling the work of your friends and colleagues
as they give of themselves, and receive much in return.
(Names were changed to prevent embarrassment)
Monday, November 18, 1991
…I thought we would get an early start because everything was set
up last night, but Chiquita (the missionary anesthesiologist) came in
and switched anesthesia machines, giving me another unusual, old machine
to learn to use. After some problems with leaks, I managed to learn (well,
mostly), how the darn thing worked and even set up a scavenge system.
Its a good thing, because I was going to really "rough it" and
set up Interplast's vaporizer and regulator. Unfortunately, the regulator
did not fit the Nepalese tanks. (Mr. Mavrey Ulrich, the Australian engineer
whose wife, Estelle, is head nurse here, makes his own oxygen, but the
process is slow. The electricity went out for a while, so neither the
Nelcor nor the Propac would function. Both batteries are down. When the
electricity came back up, the transformer would not work, so it was back
to basics. Blood pressure by the bounce method, precordial stethoscope,
and my hand on the bag. Because of the delay, the first case was a local
scar revision. Then came time to test the "new" system.
Case 1: A 7 month-old boy, with Hg 9.3, here for bilateral complete
cleft lip repair - Easy mask induction and one handed 24 g. I.V. (thank
goodness that went well). This was the baby whose mother answered my "Does
the baby breast feed" question with "only buffalo milk and breast
milk." My response, of course was, "no buffalo milk after midnight."
(A line that would become the trip's inside joke). Everything went well.
Case 2: A 4 month-old, 4 kg girl Hg 10.8 for repair of incomplete
cleft lip. Induction started out smoothly, although Maggie, our OR nurse
complained of feeling a little sick. A strange Nepalese man wandered into
the room to watch us. He was a visiting medical assistant. As I was trying
to start another back-handed IV, Maggie complained of feeling faint. I
had the visitor push a stool under her and told her to concentrate on
the IV, hoping this would keep her awake. Just after the stool went under
her legs, her head slumped forward, her eyes went glassy and then she
slipped off the stool and hit the floor, butt first. Then, her head went
back and hit the bottom of the stool before the floor. At first she was
breathing and I started screaming for help. The baby was breathing spontaneously
but with an oral airway and still on 3% halothane. I screamed through
the window for J.D. (the surgeon), but he had gone out to lunch. I told
the visitor to get help. At first he didn't understand, then he ran out
and came back with two young OR assistants. They looked around and were
puzzled. I yelled, "get JD." and they disappeared. Then Maggie's
airway obstructed and she was not moving much air, and what did move was
noisy. The visitor did a jaw thrust. The baby seemed stable and I left
him for an instant and banged on her chest. This made her cough. I also
tried prying her mouth open and she bit my finger. Then she began to breath
and after about three minutes her eyes opened and she looked hellish but
wanted to get up and work. We made her lay on a stretcher for a while.
(JD had sauntered in to discover this scene with Maggie on the floor.
He thought the girls came to get him because we were ready to start the
case.) The patient got light as we were deciding whether to proceed (which
we finally did) and after a crying mask induction, we were operating.
The rest went smoothly. (Murphy was hard at work here today!) …
Wednesday, November 20, 1991
As we sat in the OR yesterday, rumors spread that the hospital was jammed
with patients. What I saw as we left was nothing short of astounding.
Our patient was placed on a stretcher mattress outside the OR door, ON
THE FLOOR. Patients were everywhere; hallways, outdoors, and many on the
floor. The wards
were packed with beds six inches apart and in the middle of the room.
There were at least two people in every bed. I assume many were relatives
of patients. It was very cold. Quite a remarkable scene.
Case 1: A 4 year old girl for repair of a complete cleft palate.
During the induction I passed a syringe to Maggie and asked her to give
0.3 cc atropine. She injected, then asked, "is SDC some sort of nickname
for atropine?" I was able to disconnect the IV at the hand and flush
the line. Everything went well...
Case 3: A 9 year-old boy who was scheduled for surgery and did
not get a preop physical, as most of the kids were scheduled for surgery
while I was giving anesthesia. Since I am the only anesthesiologist and
there is no pediatrician on this trip, the proper preop did not get done.
When I placed my precordial stethoscope on his chest, I heard a loud 4/6
murmur radiating to the axilla. The pulses were strong. There was a pre-cordial
thrill. When I hooked up the pulse oximeter, it read 78% (checked and
rechecked). I then recalled that I had seen the child behind the hospital,
naked and squatting on the dirt. Since many Nepalese relieve themselves
this way, I thought nothing of it at the time, but it just occurred to
me that he may have been squatting as a relief of a tetralogy of Fallot
spell. He obviously has a large mixing lesion, without signs of heart
failure (no rales, no hepatomegaly or edema, no cough). Looking back at
his clinic notes, J.D. recalled that this child could not keep up with
his siblings when running. It was my impression that he had a large mixing
lesion. Whatever the lesion, a problem with the anesthetic might make
things worse, and put him at risk. I decided it was best to postpone this
elective surgery until he had a workup. The only thing we were able to
do here was a CXR. The cardiac echo machine in Kathmandu was out of service
for a couple of months, so he will have to wait. Murphy's at work again…
...Just as I was dropping off my patient in our little recovery area,
Sister Grace started yelling for help. Of course, I didn't know she was
calling for help, so I just looked around when she started yelling for
Dr. Vigna (the missionary surgeon). She was calling from the "dirty
surgery" room, a small room where abscesses are drained, usually
under sedation with ketamine. Sister Grace is an Indian nurse anes
thetist, who came here ten years ago to serve at the Seventh Day Adventist
Hospital. She hasn't done much anesthesia lately, restricting herself
to cleaning ORs and helping everyone with everything. Today, however,
she was doing anesthesia again. This elderly diabetic was waiting for
debridement of some awful, gangrenous toes. With nobody else in the room,
she administered 125 mg of pentothal. He immediately became apneic. This
became obvious to me when Leo (Vigna) yelled for the Ambu bag, which wasn't
in the room. There were no monitors, so I checked a quick carotid pulse,
and determined that the pulse and pressure were acceptable. Then I flipped
up my mask (after deciding that direct mouth-to-mouth was out of the question),
placed a breathing mask over his face, lifted his jaw, and did artificial
ventilation until the bag arrived. He regained spontaneous ventilation
in about five minutes. All in a day's work. As he was recovering, he lost
the front of his foot very quickly. Unfortunately, he is missing the other
foot (BKA), and will be quite crippled, a very bad asset in this hilly,
rocky, territory, where walking is the only way of getting around…
Well, you see, things don't always follow the rules. But overall, we
managed to help many people on this trip, with very little morbidity.
We did forty general anesthetics, around eight ditzlectomies, plus a few
local lip repairs. For the forty cases we used: six 30 cc bottles of 1%
lidocaine with epinephrine; two bottles of 0.5% bupivacaine; two bottles
of halothane; 20 mg of morphine, ten vials of atropine (1 mg); 20 vials
of antibiotics; 14 cylinders of oxygen. Only two out of forty patients
had postop emesis - perhaps because we used regional analgesia instead
of narcotics. We worked about 120 hours at the hospital. Not bad for a
short "vacation" in Nepal.
Alan S. Klein, MD
Pediatric Anesthesia Consultants, Denver, CO
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Santo Domingo, Dominican Republic
I recently returned from a two-week trip with Heart Care International
(HCI) to Santo Domingo, Dominican Republic. Heart Care International was
founded by Dr. Robert Michler and over the past 7-8 years has been providing
cardiac surgical services to children in Central America. They recently
completed a 5-year project in Guatemala which involved not only providing
direct patient care, but also education of local physicians and healthcare
providers to eventually provide these services themselves.
HCI has now focused their attention on the Dominican Republic. The January-February
trip to the DR, covered a period of 4 to 5 weeks and involved over a 100
health care workers from all over the United States including cardiac
surgeons, anesthesiologists, cardiologists, ICU physicians, perfusionists,
administrators, ICU nurses, and respiratory therapists. Despite the wide
diversity of experiences and geographic locale of the team members, there
was an incredible amount of teamwork and cooperation with everyone focusing
on the primary objective of the trip. The team provided all aspects of
pediatric cardiac care including evaluation by the cardiologists, interventional
cardiac catheterization, and cardiac surgery. Cardiac surgery was performed
for a total of 8 days, utilizing 3 operating rooms. Over the course of
8 days, over 70 cardiac surgical cases were performed.
As usual, I saw things that we never see in this country including patients
with various cyanotic lesions, who were well into their teenage years,
including a 20 year-old with tetralogy of Fallot. Many of the children
that we anesthetized were severely compromised from their cyanotic congenital
heart disease with room air oxygen saturations of less than 50% including
one young man with a saturation of 23%.
Our hosts were incredibly gracious and extremely interested in working
with us in the hopes of one day being able to provide these services independently.
The Dominican Republic provided a beautiful setting in which to work and
offered sunshine most of the days with temperatures varying from 60-80oC.
As it is a common site for tourists from all over, the environment was
safe and hospitable and the people gracious and friendly. Our freetime,
albeit limited, was spent touring the city, learning more about their
culture and history including a tour of Christopher Columbus's house.
I was somewhat ashamed to admit that my knowledge of history was so poor,
that I did not know that the DR was Christopher Columbus's original landing
site in the New World. Additionally, there were several beautiful beaches
within a 20-30 minute drive of our hotel in Santo Domingo. Without a doubt,
the DR was one of my more memorable trips.
Joseph D. Tobias, MD
Director, Pediatric Critical Care/Pediatric Anesthesiology
Professor of Pediatrics and Anesthesiology
The University of Missouri
Department of Child Health
M658 Health Sciences Center
Columbia, MO
FAX: (573) 882-2742
Phone: (573) 882-6544
E-mail: Tobiasj@health.missouri.edu
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