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