Theater

Today was SO cool! I spent the day in the "theater," which is what they call the operating room. I observed in the first 2 surgeries, and got to assist in the second 2, which is where you are scrubbed in and helping the surgeon. That's what I'll be doing in residency, so it was cool getting a head start. I know not all of you have a stomach for medical pictures, so I'll only post the ones suitable for everyone. Later I'll do a composite post of all the unusual things I've seen here, which you'll have to read at your own risk.
The operating room is much like in the US, and it was surprisingly easy to figure out my role despite being on a different continent. A few things, however, were different. First, the patients are brought wide awake completely naked into the operating room. In the US we pay a lot of attention to patient modesty and comfort, but here you're just naked in the middle of the room for all to see. Our first patient, (who was actually pretty sick), lays down at the table, and the doctor actually says to her "you are fat, you've been eating too much." She just laughs, and doesn't seem offended. Perhaps it's just a cultural thing, because no one batted an eyelash, but I think my jaw was on the floor. This woman maybe weighed 170lbs and was 5'5". And she was pregnant. Tough crowd! Anesthesia is also do different here! Everyone gets spinal or epidural anesthesia, which means they're awake for surgery but numb from the abdomen down. There is no local anesthesia to numb them before they get the epidural. The doctor just tells them to bend over and hold still and shoves a huge needle into the patient's spine. These people are so tough, it looks incredibly painful. After the surgery is over, the patient (now numb and paralyzed from the waist down), gets dragged by their limbs onto a recovery cot. They turn them on their side, I think because it's easiest to move them that way (they call this the "recovery position"...it looks very uncomfortable), and push the cot into the hallway and leave the patient for the ward nurses to come pick them up. No recovery room, just the hallway.
The first surgery of the day was the woman with the ectopic pregnancy. In the US this is a laparoscopic surgery, but because they don't have that equipment here, they did it through an open incision, which was cool for me because I could see everything! The ectopic pregnancy was in the tube, and was as big as the uterus itself! The doctors thought it was days from rupturing, which has a high maternal mortality rate. This is the natural consequence of an ectopic pregnancy, because a tube cannot sustain the pregnancy, so eventually the tube ruptures and the mom goes into shock from blood loss. Thankfully this was diagnosed before that happened! We took out the tube on the right side, but she will still be able to have future pregnancies from the other side. She is doing very well now!
The second 2 patients had hydroceles, which I had also never seen. A hydrocele is where fluid from the abdomen can leak into the scrotum through a small hole in the abdominal wall, kind of like a hernia. The Besotho don't seek medical care for small problems, so needless to say both hydroceles were impressive. Both procedures went well, and I actually got to assist with the second one!
The fourth surgery was both exciting and overwhelming. It was a C-Section and tubal ligation. This was the woman's third C-Section, so it was a challenging surgery due to lots of scarring from her prior surgeries. The baby came out and it was pretty small, and blue and not breathing. In the US, there would be a neonatologist to assess the baby. But, in Lesotho, it's just us. And the anesthesiologist, but he has left the room at that point...something that also doesn't happen in the US. So, I do the only thing I can think of, stick my suction tube in the baby's mouth and start rubbing it and smacking it's bottom trying to stimulate it to wake up. That's all I could think of from my pediatrics rotation. Eventually a midwife comes in and takes the baby and resuscitates it. Once I hear it crying I am relieved. I look back down just in time for the doc to say, "there's another one!" Oh, a surprise twin you say? Now, with twins, after one baby comes out the uterus starts to clamp down, so it's important to get baby #2 out quickly. The second baby is bigger and appears to be stuck. The doctor yells for me to push (which it takes me a minute to understand because she speaks broken English with a thick French accent). I push with all my might, and at one point am laying on top of this woman's abdomen trying to push the baby out from above. I did this wearing 3 layers of clothing in a room that must've already been 90 degrees. By the time the baby came out I was sweating and shaking. I was so relieved to hear its strong cry. Mom and babies survived the operation relatively unscathed, which I consider a personal victory. I was very excited about the twins and congratulated the mother afterward, who was equally surprised. She already had 2 boys at home and was really hoping for a girl. Instead she got 2 boys, so I don't think she was very happy with us. After my first c-section was a third surgery in an HIV positive woman with surprise twins, I should be ready for anything in residency, right?!
I think I am adjusting well to the Lesotho culture, but am receiving quite a culture shock in the hospital! Things are so extreme here, and literally anything could walk in the door, and the doctors here, who call themselves General Practitioners, take care of it. Anything from surgical emergencies, to poisoning, to pregnancy, to tuberculosis. I know I've pointed out the many ways that we do things differently in the US, but I have great respect for these doctors and the vast knowledge they must have to practice here. It's much more than I could ever handle. Seeing the severity of disease and lack of resources here makes me thankful to have the chance to train in a place with such wonderful resources. In the meantime Im going to learn as much as I can here...they seem very willing to help me get hands on experience. Enjoy the pics!
H