Saturday, July 14, 2012

Heat + creamy cheesy discharge = not good

Dear friend,

Today marks the end of my first full work week here at Kalene. It’s hard to believe I have only been here a week, as the memories of home already feel far and foreign while my life here feels like the norm.

Physically it has been taking its toll on me. Don’t worry, I’m not sick, it’s just that I have found it harder than expected, adjusting to full-time work in this heat! Even on days when I may not work as many hours compared to back home, I feel absolutely shattered here.

All of which culminated in my near fainting episode in surgery on Thursday. I have never fainted in my life but twice I have come very close, both times as a medical student when I scrubbed up for surgeries after skipping a meal. Since then I make it a point to have a decent breakfast on days when I know I will be in theatre…


Day 5, Case 3

On Thursday, knowing it was our theatre day, I had a good breakfast before heading to the hospital. We had two relatively straightforward cases listed, one of which was an excision of what we thought was a lipoma (=small fatty mass) in a young, otherwise well woman. The mass was quite large, at least 15cm wide, at the bottom of the neck on the left hand side. The history given was that the patient had had a similar mass as a child, which someone back in the Congo had excised but that over her adult lifetime it had slowly recurred.

On feeling the mass it felt like a typical lipoma albeit ever so slightly more fluid-like than fat. Having limited imaging available the decision was made to proceed to surgery for excision. 


Unbeknownst to me the air conditioning had not been turned on in theatre that morning. (You can see where this is heading.)

Initially only Dr M and I were scrubbed. Our every experienced scrub nurse, JP, remained unscrubbed and manned the anaesthetic side of things (which these nurses also do…?). Most surgical procedures here are done under ketamine.

Slowly dissecting around the mass there was quite a lot of bleeding, unusual for lipomas, and it had grown into the tissues around it, again unusual for lipomas. With these unexpected difficulties JP decided to scrub in to lend an extra pair of hands.

At this point we would have been about forty minutes into the procedure and it was at around this time that the patient started to groan and move and struggle while being under ketamine. Of course she was given some more, etc, but I am told that generally this is not too uncommon (for all the procedures they do under ketamine here) and that the patients don’t remember any of it once the anaesthetic has worn off.

Yet being a newbie I found it seriously unnerving.

Then, all of a sudden, Dr M let out a frustrated moan as he inadvertently nicked the mass and out of nowhere this creamy cheese-y fluid began to gush out. It was obvious this was not a simple fat mass -- it gushed and it gushed and it gushed.

With the surgical drapes usually not being taped down onto the skin here, the creamy fluid managed to gush down the patient’s neck. This combined with the patient’s intermittent groaning and moving under the ketamine meant some of it was getting on her face and mouth.

It looked like vomitus.

I don’t get queasy easily but this was not a pleasant sight.

In the next few minutes I started to feel increasingly hot and… not right. Hoping to “fight” it off I tried ignoring it, shifting my weight, changing position as much as I could whilst assisting, etc, etc. And then that inevitable point came at which I knew I would faint if I didn’t do something soon. I felt a deluge of cold sweats, nausea, and weakness so I set down my instruments, moved away from the operating table and took a seat across the room.

It’s always hard when this happens as it feels like a failing. Especially as a female doctor pursuing a surgical career it’s hard not to take it personally and to admit, to accept, that this has happened. Much like the Swiss cheese model of multiple circumstances lining up just right to result in an error, all the events of the day lined up to get me to that point – sitting on the ground, gloves off but scrubs still on, feeling horrid.

The other theatre assistant brought a fan over to where I was sitting on the ground; Dr M and JP asked if I were okay, but they remained focused on the operation (as they should). Luckily I had some food in my bag next to me, which I started to munch on slowly. When I was feeling a bit better about five minutes later I headed home. Hayley immediately knew something was wrong when she saw me – apparently all colour had left my face. After a good lunch I went back to the hospital for another hour to tie up some loose ends on the wards, then came straight back and took a nap (which I never do normally!) and that night I went to bed before nine, for ten hours straight.


The heat with the work has needed some adjustment. I’m getting there slowly, I think. The most important thing is to cut myself some slack while I adjust. 

On the plus side, I am definitely getting more confident with the medical side of things and by the end of the week Dr M and I seemed to have found our groove. I even had my first full day of Outpatients Clinic (=primary care/Accidents & Emergencies) yesterday, seeing patients for myself with the help of an interpreter.

The kiwi surgeon, Dr J, (de factor clinical head of the hospital) returned yesterday from South Africa and is on the mend. Still recovering from his illness he will most likely leave the day-to-day running of the wards to Dr M and I, reserving his time for surgical opinions and theatre days.

We had our first proper team ward round this morning, reviewing all the patients who have been awaiting Dr J’s surgical opinion. It was clear everyone was very happy to have him back.

With a Saturday Clinic after the ward round I didn’t get home until 2pm, so a full day off tomorrow will be most welcomed.


‘Till next time,
-A


Medical P.S. For the medics, that mass we excised was most likely a lymphangioma (aka: cystic hygroma) and that creamy cheesy fluid lymphatic fluid! Take a few minutes to read about it on Medscape, it’s quite interesting.

1 comment:

Hazel said...

Anna I'm feeling queasy just reading your blog!!