Today was my last full day at L'Hopital de L'Esperance. Leaving will be bittersweet - over the time here I've developed a heart for the people of Northern Togo.
It's late right now and (12:30AM) and I need to pack and be up for rounds tomorrow morning at 7:30.
Answered Prayers
1.
Dr. Bob Cropsey has a reputation for causing plans to change - my case was no exception. My original plans for leaving were to head south to Lome on Sunday in a 10 hour van ride, spend time there with Todd DeKryger and his family, fly back to Kenya via Addis on Wednesday afternoon, have a 17 hour layover in the Nairobi airport, fly to Amsterdam on Thursday night, have an 8 hour layover, and then finally take the 8 hour flight home on Friday. All of this was done as a part of my efforts to be thrifty with my airline tickets: buying round trip is significantly cheaper than buying multi city or one-way trips.
After hearing about my nutty travel plans, Dr. Cropsey presented the idea that I could just leave from Accra, Ghana; Delta (with whom I flew to Kenya) also leaves from Accra. All that it took was one phone call and my ticket was switched.
Later that night I realized that I did not have a visa to enter into Ghana. Normally people get a visa more than a month in advance. I had on my hands a big problem.
What resulted was a car ride to the Ghana border on Sunday (Mom and Dad - I should have mentioned this to you earlier...sorry) to see if I could get a transit visa to allow me to travel through the country. People who have been at Mango for some time thought that my chances were slim, but after sitting with the border guards for 20 minutes, talking about the Hospital of Hope, and explaining my travel plans, they said that I was "family" and agreed to get me a travel visa. (It helped that Dr. Cropsey, who knows everyone it seems, had traveled through the border 2 months earlier.) The entire way down to the border I was praying that things would go well - if they didn't, I would have to venture south to Lome, pay more money for a flight from Lome to Accra, and potentially wait for a significant amount of time in the Accra airport.
In order to get to Accra, I have to fly south from Tamale. There are a number of flights leaving each day and the one that would be optimal is leaving at 2:55PM with Antrak Air. Normally, one has to buy the tickets at the gate and the flights sometimes fill. As I am currently in Mango I am not able to purchase the ticket at the gate. After another short phone call to the airline all was arranged such that I can purchase the ticket when I check in and my seat will be reserved.
Getting to the border from Mango is another issue. I have to have one car drive me the hour to the border and another waiting to pick me up. Thus far I have someone who will be driving me to the border from Mango and the man who will be picking me up we will hear from tomorrow.
2.
I was in clinic on Monday and Dr. Cropsey stopped by my room: "John, have you ever put an umbilical line in?" Not having done a PICU rotation or having been involved in the care of neonates, I responded, "No, why?"
A 26 week old premature infant weighting 650 g (slightly more than 1 pound) had come to the hospital and needed a line for resuscitation. Nurses had looked for veins and there weren't any available. All of the staff with experience putting in umbilical lines weren't at the hospital and the doctor on call, Dr. Moslee, wanted some help putting in the line. Dr. Cropsey didn't have any experience and I replied that I would do my best to help. This was the very, very young man's best chance for intravenous access.
After looking at a book and texting Dr. Kelly Faber, the pediatrician extraordinaire, we decided to proceed. 2 arteries, 1 vein; how difficult could it be?
The baby was tiny - he could easily fit in the palm of my hand. I could see how the nursing staff couldn't see any cutaneous veins - there just weren't any that were visible. I cut down from the edge of the umbilical stalk to fresh tissue and identified the vein and tried to insert the catheter, which had been flushed with sterile saline: no progress. So, I cut down again and tried to insert the catheter: no progress. Dr. Moslee took the catheter while I had each side of the cord with a hemostat. I said a prayer: "Jesus, let us get this line". Sure enough, the catheter was inserted.
Fluids went easily into the catheter and the baby had IV access, critical for delivering fluids and antibiotics. I placed a pursestring suture around the catheter and secured it down with a tegaderm. When I checked today it was still providing fluids to the infant.
He still has a very uphill battle - 26 week old infants have a poor chance of survival, even in the USA.
3.
Just this morning we took back the child with the large chondrosarcoma filling the entirety of the L hemithorax.
The beginning of the case went well - we were able to take all of the muscle off of the tumor without too much bleeding. This was critical as we needed that muscle to cover the large defect that we would create by removing such a large tumor. As we proceeded along the tumor alternating on different sides - tedious, meticulous work - we were retracting it towards the middle and towards the lateral edge to have better exposure while working. During this time the tumor was retracted to far laterally and made a small rip at the vessels of the lung at the hilum, which was densely adhered to the tumor - slow bleeding, controllable with towels, started. While the towels were in place stopping the bleeding, we retracted the tumor medially, freeing it up from the side walls. The tumor was so big that it compressed the heart.
At this point, with all of the blood loss and compression on the heart, the patient went into cardiac arrest. Dr. Yee was pumping the heart manually with his hand, saturating the blood with oxygen, keeping the patient alive. Anesthesia was rapidly giving blood to the patient as well as epinephrine. Cardiac activity again started - we were relieved. This process occurred 4 more times. Arrest, manual circulation, more drugs, return of tenuous cardiac function. I left to go and get Dr. Kelly Faber, pediatric intensivist extraordinaire, for help on the best vasopressors to use during the case.
We returned to the room and the situation was still very tenuous. The initial goal at the beginning of the case, oncologic resection, was scrapped in favor of just getting the patient to the recovery room so that the parents could see the child without the tumor.
The patient was still exceptionally unstable and went into ventricular fibrillation, a type of heart arrhythmia that usually cannot be reversed with drugs. What is needed to reverse this type of arrhythmia is an electric shock. Unfortunately, we did not have the usual equipment used during these cases, in which paddles are directly placed on the heart and shocks it back into rhythm. Dr. Yee
had the idea of putting warm saline in the chest (saltwater which would warm the patient as well as conduct electricity) and shocking the skin with normal paddles. A 50 joule shock was delivered - nothing happened. Kelly suggested turning it up to 70 joules; a shock was delivered. Normal cardiac function miraculously returned. Throughout the rest of the case the heart did not cause any problems.
We ended up having to take out the entire left lung as it was so stuck to the tumor. But the chest wall was able to be closed with mesh, and the mesh was able to be covered with muscle, and the muscle was able to be closed with skin.
With only one lung functional, the patient was able to have the breathing tube removed (extubated) and was transported to the recovery room conscious and able to say hello to his parents. When I saw him this evening before going home (10PM) he was looking decent: a fast heart rate, decreasing oxygen requirements, making enough urine.
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Thank you to everyone who prayed for us today - there was a peace present in the OR, despite all of the chaotic happenings of the case. And thank you to everyone who prayed for me during my 2 months overseas. My entire time here has been filled with blessing upon blessing and many answered prayers.
It is currently 1:10 and I still need to pack.
My word, 2 months has gone by quickly; alas, such is life.
L'Éternel te bénisse et te garde!
L'Éternel fasse luire sa face sur toi et te fasse grâce!
L'Éternel tourne sa face vers toi et te donne la paix!
Blessings,
John
PS: Many of the people here at HOH are too poor to pay for their hospital bill. If you are feeling moved, I would really encourage you to donate to the Hope Patient Care fund to help with the expenses of their medical care: http://hospitalofhopemango.org/hope-patient-care-fund/
