You can’t save them all

Whilst you can’t save them all, its probably better not to try and kill them before you start….

With the mesh autoclave still out of action, our operations were limited to a paediatric hernia and an exploratory laparotomy. Unlike yesterday’s challenging recurrent paediatric hernia (who today is doing very well I am pleased to report), todays 1 ½ year old was a joy to operate on. The anatomy was fantastic, and I was able to demonstrate beautifully the V of the cord structures when completing the herniotomy. This was a fantastic case to consolidate a lot of what we have been talking about. Furthermore, the newly revamped paediatric set is almost what you might have back home. So overall a pleasure.

The second case however, was far removed from this joy. It was the case of an older lady in her late 70s who had been unwell for some time. Having been admitted to hospital 5 days ago, she was slowly declining. I had been asked to see her two days ago and was not completely sure what to make of things. She certainly had some abdominal signs, but with an otherwise confusing clinical picture. It is the classic case where I would have not hesitated in getting a CT back home. But that option is not available here. Despite employing the maximal medical treatment available here, she was worse yesterday. With no other option to attempt to understand or reverse this decline, I recommended a laparotomy. If we didn’t do something, it looked like she would die, and there was certainly a reasonable chance of finding something we could ‘fix’ given her signs. However, yesterday, the family needed more time to consider. This is a very African way of doing things and not being completely sure what we would encounter, I didn’t feel I could push things. Today however (predictably perhaps), she was worse and this time they asked for surgery. So we went to theatre. I carried with me that burden of uncertainty that what we were doing might kill her. It is one of those times that you actually hope to find something to justify your decision.

However, I did not anticipate that we might actually nearly kill her before I got anywhere near the abdomen. Avid followers of my blogs (if there are any!?!) might consider the account that follows “take two” of a previous post ‘complicated, complications’. Today we had a plethora of staff including 3 nurse anaesthetists, two experienced and one in training. From barely having one when I arrived in November, we now seem to have five on the books in some capacity? (Something else I have given up trying to understand). Anyway, today I think ‘too many cooks’ might have spoiled the ‘broth’ so to speak, almost catastrophically.

Things seemed to be going well at the head end, preparations as usual taking place whilst we surgeons got scrubbed. Gowned up and now sitting on stools, we patiently waited for the green light to prep (for more explanation of this culture see previous blogs). I was mulling over my decision to operate and was vaguely aware of a bit of ‘faff’ at the head end. I have always been very supportive of training and clearly with some teaching going on, I just zoned out. Except the faff seemed to be going on a bit longer than normal, with lots of changes in roles and positions between the three ‘gasmen’ (two were ladies I hasten to add, so forgive this slang terminology).

I started to pay a bit more attention. Things were not going well. There were some dubious attempts at intubation and in between times, support of the airway was poor. Saturations were dipping significantly and not recovering. What this means in layman terms is that we were sequentially asphyxiating her. Not wanting to undermine staff I knew were very good, I held my tongue. But when things weren’t being corrected (the trainee was barely supporting the airway) I spoke up. Correction was made but performance was still suboptimal. I let things run. Saturations were poor (my concern levels rose, my attention now very clearly held by events at the top end). There was another ‘change of guard’ and I relaxed. Intubation was made. However, it was very clear to me that this had intubated the oesophagus (the wrong tube) and the stomach was now being blown up. I gently made the observation. However, the stomach continued to be ventilated. I made the observation more assertively, pointing out the issue, the rapidly distending abdomen, the now unrecordable saturations, the rising tachycardia. Action required now… but there was a distinct lack of leadership between the three and now the patient was becoming bradycardic. This means that their heart rate was slowing down, a sure sign that they were very soon about to have a cardiac arrest. I could not watch any longer. The tube had been taken out, but airway management was poor. The patient had also clearly regurgitated. 

An 'oh shit' momen

This was a very shit situation. Gastric acid was now drowning the patient. Later it would likely cause a pneumonitis (behaves like a bad pneumonia). My worst fears were being realised in front of my eyes, we were killing this lady and she might not have even needed the operation (this demonstrates quite starkly, the ‘stakes’ that surgeons have to play when making such decisions). 

Intubating the patient. You can see the worrying sats.

I gently offered to help which was readily accepted. Genuinely, I think that of the three anaesthetists present, my airway skills were probably only better than one. But what I offered was some leadership. In my surgical gown, I managed the airway and now working as a team, we did some simple things to improve the situation. Although it was still not great. Saturations up to mid 80s only (bad). The patient clearly needed a controllable airway and making sure all the kit required was present, I intubated. This time it was fairly straight forward (although I make this statement from a position with a fairly low denominator), the cords seen, no faffing, bougie in, tube safely down, cuff up, bilateral ventilation, CO₂ trace, airway suctioned, saturations improved. Phew. And now I only had the laparotomy to do.  

Getting stuck in at the bottom end - note the new hats!

It turned out that my decision to operate was justified, with positive pathology (badness) encountered. I am only sorry to say that it was beyond salvageability. Today I would have greatly valued the option to phone a friend for a second opinion to confirm that what I was seeing was indeed what I was looking at. There was a retroperitoneal necrotic mass, centred over the pancreas and at the root of the SMA (the main blood vessel that supplies the small bowel ‘jiblets’, you can’t live without it), with some strange deposits in the lesser omentum and also in the ascending colon. I was either looking at disseminated malignancy (cancer that has widely spread) of some sort, possibly pancreatic, possibly lymphoma – although it was not completely typical in appearance for either – or something like a bizarre presentation of TB. Regardless, with a heavy heart I was clear that I could not just ‘cut it out’. Even if technically possible (which I don’t believe it was), she would never survive such extensive surgery. We closed her abdomen.

I suspect she will die in the next 24-48hrs. I think it would require something of a miracle for her to get home. In the circumstances, I believe it was the right thing to operate, but unfortunately there will always be limitations to what can be achieved. But then this is true wherever in the world you are.