COTW: Appendectomy

By Jason

This is not a typical "Case of the Week" (COTW).  It is also not a case that occurred in Kenya.  I have been working here in Michigan for the last few months at a local hospital and this "case" has happened over and over again, which is one reason it is so remarkable. I will contrast it to an analogous situation in the developing world to give a sense for why it is so amazing.

It usually starts with a page from the ER - a patient has early appendicitis based on the CT findings.  Antibiotics are given.  The ER then transfers the call to the nurse in charge who calls in the Operating Room team - An anesthesiologist, a scrub nurse, a circulating nurse and a recovery room nurse.  While the patient is being transferred upstairs by a transporter person, I log in to the hospital computer system from my couch at home and look at the CT scan (which has usually already been read and reported on by a radiologist) and review the patient's medical record.  As I drive into the hospital, my preference card is pulled by a nurse in the operating room, which lists the sutures, staplers, scalpels, drapes, laparoscopes, needles, medication, ports, and even steristrips that I prefer.  These items are all obtained from the supply room and the room is set up.  I see the patient and dictate a note into the phone, which is typed up and can be reviewed within 30 minutes.  After the anesthesiologist and nurse do their assessments of the patient, we go back to the clean, well-lit, 68-degree operating room.  The patient is put to sleep flawlessly, and I make my incisions.  All of this - from the initial page to incision - routinely takes about 1 hour.  The operation goes well and all the equipment functions perfectly.  The patient goes to the recovery room and will usually be discharged home about 90 minutes after the operation ends. 

How would this go in Burundi, if the same patient showed up to Kibuye Hospital?  The patient probably wouldn't even come to the hospital until a few days later, so the appendix will likely be ruptured.  No CT scan for diagnosis...there is not even an x-ray machine at this point.  Hopefully the phone lines are working, otherwise someone is sent to our house with a note to request me to come.  The single room ER is staffed by a medical student and a nursing student, who are seeing a couple other patients concurrently.  Through them translating, I would get the patient's story and decide how to proceed.  I might try to do an ultrasound, but I am certainly  no radiologist.  We would transport the patient to the Operating Room ourselves and prepare the patient.  I would try and find some suitable suture among some expired donated supplies or low-cost substitutes from India and find a sub-optimal set of instruments which have been sterilized in a pressure cooker over an open fire.  A nurse with no formal anesthesia training would give the patient Ketamine - an anesthesia drug which is primarily relegated to veterinary use in the US.  The patient might be given oxygen through the only machine that can provide it in the whole hospital.  The electricity may or may not be on.  It went out 12 times one recent afternoon.  If it goes out, we will operate by flashlight until someone can power up the 40-year-old generator.  He will be transferred to the ward, where 1 nurse is taking care of 15 or more patients.  The patient will probably do OK, but will remain in the hospital for about 5 days for further antibiotics. 

The differences are astonishing.  No doubt the mortality of such a procedure is 10 or 100 fold different between the two settings...that is, if the Burundian patient manages to get to see one of the 9 surgeons in the country.  May God continue to allow us to play a small role in rectifying this situation through training quality doctors and nurses.
Sutures at hospital in Michigan

Sutures at Kibuye


Nachiket Mor said...

I was very touched by this email. I want to applaud all of you for your willingness to serve in such difficult circumstances.

I am from India and such situations are not uncommon even in my country. My work has tried to focus on primary care -- a place where I feel, even given our limited resources, we can make a very big difference. We now have a model which can provide comprehensive primary care (including for dental, eye, and chronic disease related care) for about $40 per family (of four) per year. Using an insurance mechanism for an additional $20 per family per year we think we can give them access to good quality secondary and tertiary care as well.

We would be eager to have you visit with us. We are not far from Africa and could use all the guidance and inspiration that we can get.

Anonymous said...

My eyes filled with tears as I read your story. Oh how true for most of the developing world. May God grant all of you wisdom and skills above your human experience as you serve HIM in difficult situations. God bless ALL of you. Linda S.

Sarah said...

J, thanks for posting. Comparing the differences side by side like this is truly astonishing! We continue to pray for you guys and all the work you have ahead. Hopefully we will get to join you eventually, for a short time at least!

susan said...

I agree with Linda S and Sarah. The conditions you are going to enter are unthinkable. May God bless you in the preparations, and give you endurance for the task, and joy in the performance of it. YOu are in our prayers

Jen said...

I so enjoy reading this blog! Todd and I are getting married in July and plan to leave for Tenwek sometime soon after Christmas. Your posts help me envision what we're heading to, encourage me that we've made the right decision, but as an MK it also stirs up all the MK emotions as you write about your kids and their transitions. Thank you for sharing so many different stories and perspectives on your time in Kenya and also this transition time.

Steve Doane said...

Ha! That hospital in Michigan is much more efficient than our urban hospital in Philadelphia... :)
Thanks to everyone for the updates. I am praying for your growth together as a team, your deepened passion for God's glory in Burundi, and many opportunities to bless folks you meet along the way in the coming year.