June 12^th (Tuesday)

Today was very eventful and very tiring! Nicole went to some villages with Dorothy visiting some of her chronic patients. She got to have a very African meal of nshima, little dried fish, fried pumpkin leaves, and a large fish (brine?). She was gone all day.

Fiona and I went to Kariba. We were there for ward rounds and Dr. Mwansa only wanted to do a few surgeries during theatre day as she wasn’t feeling well. I observed an ultrasound of a woman who has an ectopic pregnancy. Then in preparation for theatre JR guided me in (attempting) to insert my very first IV cannula (they are much longer here). During this time Fiona scrubbed into theatre and was Dr. Mwansa’s first assistant for a bilateral tubal ligation. It went well but Fiona had to exit and scrub out while the patient was being closed up as she felt a little warm (and close to fainting). But she did well for her first time scrubbing in.

Next up was two other patients who are expected to be fairly easy and quick. However, just then someone on staff came and got JR and told her that a patient in the men’s ward had an abdomen that essentially “exploded”. So JR and I went to investigate immediately and found the patient sitting in a chair with 2 to 3 L of beige liquid that had leaked out of his abdominal incision that had dehisced. A family member lifted the man’s shirt and the discharge bubbled/came out of a small opening in the healed wound. We told Dr. Mwansa, then cancelled the other patients and began to prep him for a laparotomy. He was stable so we had a break for tea. We enjoyed brownies and a hot drink.

After tea, we began the surgery and I scrubbed in as the second assistant standing next to Dr. Mwansa. Fiona helped Kate, Allison, and Tiffany with anesthetics. She got to push a few drugs and was essentially the respirator for most of the five hour surgery by squeezing the ambubag periodically. The surgery was quite difficult. Dr. Mwansa freed up some of the bowel around the easily detected perforation. But most of the bowels adhered to each other and it was very hard to separate. JR and Dr. Mwansa couldn’t tell which part of the bowel was the proximal end and which was the distal, to create a colostomy. We tried some strange methods to try to figure it out (NG tube up from the rectum, NG tube down the bowel to follow it, we thought of using dye but that would take too long). Dr. Mwansa asked quietly for a chair and I looked behind me and couldn’t see one, she asked again a little louder and I started to say “Fiona” – to bring her stool over and Dr. Mwansa was falling (as she fainted) JR grabbed her arms so that all the bowels and instruments stayed inside the patient and sterile. As she was falling Kate and Jack and Allison were quick to come behind and catch her as JR had yelled “Mwansa!”. JR told them to lay her on the ground and take her mask, visor, and gown off. A few seconds later she came around. They were fanning her with a book and laid her on her side. She then sat on the floor to catch her breath. JR said, “I hope you can come back to this, we need you to come back as I can’t finish this yet for you. I wish I could but I really can’t.” Once she was able to catch a breather and cool off and she re-scrubbed in quite quickly, she just said to us, “I told you I wasn’t feeling well, I didn’t want to come in today.” JR said “well, let’s get the patient to the point where I can help you close him up. Let’s save this patient. You are probably the only person in this whole province who can perform this surgery. We will help you as much as we can.” They weren’t entirely sure how to finish for this patient but decided after looking at some textbooks that a loop colostomy may be a good approach (to keep both ends of the bowel open and see which is the proximal by which is active). However, there wasn’t enough free bowel to do it so she just made two stoma’s, to colostomies for the same reason as the loop.

After five hours we successfully closed up the patient. The patient remained stable throughout the surgery. Also the scrub nurse’s instrument count was incorrect, we were apparently missing two forceps. Everyone looked high and low and couldn’t find it. So we decided that we would have to x-ray the patient and make sure they weren’t inside and we determined that the first count was incorrect. There wasn’t any forceps detected on x-ray. As we were finishing up the surgery Joey and Owen brought us all pop bottles. It was very refreshing after five hours in the theater. We were all extremely grateful.//