A rapid introduction

Surgeon David blogs about his first 30 hours in Paoua in the Central African Republic.

It’s Friday evening in Paoua and I have just finished in the OR (operating room). I arrived here just 30 hours ago on a small plane from the capital Bangui. After two stops, we landed in Paoua just before lunch. I was met at the landing strip by an MSF Landrover and taken to the local office and then the residential compound where my orientation and introductions began. They were cut short within the first hour by a woman in labor who needed emergency surgery, a Caesarean section. With a history of three previous c-sections she was at risk for rupture of her uterus during labor. If the uterus ruptures during labor, there is a high likelihood of the mother and baby dying, therefore the need for an urgent c-section.

Thus began a busy introduction to the hospital in Paoua, with six emergency surgeries in the first day-and-a-half plus a number of consults and follow-up visits and dressing changes with surgical patients operated on by my predecessor. I am reassured by other team members that this is busier than usual though the anesthesiologist who has been here almost a month isn’t as convincing as the others.

Our last operation today was on an eight-month-old boy for suspected intussusception, a condition where the small intestine invaginates itself into the large intestine, resulting in a mechanical blockage. Though uncommon, it’s a well known problem in children this age and slightly older. Left untreated, the blood supply to the small intestine will eventually be cut off completely and peritonitis follows. We had planned to operate on him earlier in the day but were interrupted by an emergency surgery for a more common problem; a 27 year old woman was bleeding into her abdomen from a ruptured ectopic pregnancy

The hospital in Paoua is the only inpatient hospital in a region roughly twice the size of Massachusetts. Transportation barriers abound with limited access to motor vehicles and variable road conditions during the nine month rainy season. Patients may travel for days once their symptoms begin, often coming by foot to the hospital or an outlying clinic. Our patient with the ectopic pregnancy had been having pain for two days prior to being able to reach the hospital. Our eight-month-old patient had been brought by his mother on foot the day after his vomiting began. In the United States, where people have easy access to doctors, hospitals and a panoply of lab and x-ray tests, ectopic pregnancy is a problem that is recognized and treated early, often before there is rupture and any bleeding in the abdomen. Although intussussception is uncommon, when a child under the age of three is brought to a pediatrician or emergency room with signs of intestinal blockage the diagnosis can easily be made with a CAT scan, a test that is readily available in almost every community in the US (maybe even too readily available for our own good) and treated by a radiologist with a barium enema. The pressure from the barium will usually undo the invagination and cure the problem. Early intussussception is almost always correctable this way without the need for surgery and sometimes even without the need of hospitalization.

After we finished tonight, one of the local medical doctors, a CAR national, asked me what my first impressions of the hospital were. I replied with care, as the CAR is a French speaking country and my French is nowhere good enough to be certain that I am not missing the subtleties of a loaded question on his part or a rude answer on mine. The fact is that my first impression is a very good one and I tell him so. The hospital staff had made the diagnosis of ruptured ectopic pregnancy in the first patient expeditiously including the use of a bedside ultrasound. Our patient had come to the operating room with adequate IV access and IV fluids. The OR team, all national staff except for myself and the anesthesiologist who is from Benin and has been in Paoua for three weeks (this is his first MSF mission also), moved efficiently. Operating somewhere new is always an adjustment but they had all the instruments I needed and then some. After finishing the first operation, the time it took to clean the room, set up for the next operation and bring the eight-month-old patient over from the pediatric ward (“turnover time” in surgeon lingo) was good and fast. Once again for the second operation we had everything we needed to perform surgery, including support from the MSF pharmacist on the dose of drugs for this tiny patient.

So how did our patients do? By the time the first patient got to the OR, she had bled well over a liter from the rupture. We were able to stop any further bleeding without much difficulty. I expect her to  recover quickly and go home in a few days. In our second patient, the diagnosis of intussussception had been made based only on his history, physical exam and a plain X-ray without the benefit of a CAT scan. For a surgeon there is always the concern that you might do an unnecessary operation for an incorrect diagnosis. But tonight we were correct about the intussussception. One third of his small intestine, including the appendix, was trapped in the large intestine, the blood supply very congested but not yet cut off. I was able to “reduce” the small intestine by hand. Given the length of time his intestines were blocked, I anticipate he will need three to five days of bowel rest before eating. But after that he should go home and have a normal life expectancy (for the CAR), a far better chance than he would have had with no surgery tonight and peritonitis* by Monday.

It’s getting late and I’m tired, still adjusting to Paoua time. I’m outside on the patio of the residential compound and can see lightening in the distance from an approaching storm. Hopefully it’s just the end of the rainy season and not a metaphor for an emergency operation headed our way tonight. Either way, I had better go get some sleep.

*Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.