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Travels and Travails

"Nemaste" from the Top of the World

Here are a couple of excerpts form my journal, written during my Interplast, Nepal 1991 trip. Things don't always go the way you plan them when you are far away from home. I hope you enjoy the drama. For the full text log onto the SPA website, and go to Travels and Travails, where you'll find this story and others chronicling the work of your friends and colleagues as they give of themselves, and receive much in return.

(Names were changed to prevent embarrassment)

Monday, November 18, 1991

…I thought we would get an early start because everything was set up last night, but Chiquita (the missionary anesthesiologist) came in and switched anesthesia machines, giving me another unusual, old machine to learn to use. After some problems with leaks, I managed to learn (well, mostly), how the darn thing worked and even set up a scavenge system. Its a good thing, because I was going to really "rough it" and set up Interplast's vaporizer and regulator. Unfortunately, the regulator did not fit the Nepalese tanks. (Mr. Mavrey Ulrich, the Australian engineer whose wife, Estelle, is head nurse here, makes his own oxygen, but the process is slow. The electricity went out for a while, so neither the Nelcor nor the Propac would function. Both batteries are down. When the electricity came back up, the transformer would not work, so it was back to basics. Blood pressure by the bounce method, precordial stethoscope, and my hand on the bag. Because of the delay, the first case was a local scar revision. Then came time to test the "new" system.

Case 1: A 7 month-old boy, with Hg 9.3, here for bilateral complete cleft lip repair - Easy mask induction and one handed 24 g. I.V. (thank goodness that went well). This was the baby whose mother answered my "Does the baby breast feed" question with "only buffalo milk and breast milk." My response, of course was, "no buffalo milk after midnight." (A line that would become the trip's inside joke). Everything went well.

Case 2: A 4 month-old, 4 kg girl Hg 10.8 for repair of incomplete cleft lip. Induction started out smoothly, although Maggie, our OR nurse complained of feeling a little sick. A strange Nepalese man wandered into the room to watch us. He was a visiting medical assistant. As I was trying to start another back-handed IV, Maggie complained of feeling faint. I had the visitor push a stool under her and told her to concentrate on the IV, hoping this would keep her awake. Just after the stool went under her legs, her head slumped forward, her eyes went glassy and then she slipped off the stool and hit the floor, butt first. Then, her head went back and hit the bottom of the stool before the floor. At first she was breathing and I started screaming for help. The baby was breathing spontaneously but with an oral airway and still on 3% halothane. I screamed through the window for J.D. (the surgeon), but he had gone out to lunch. I told the visitor to get help. At first he didn't understand, then he ran out and came back with two young OR assistants. They looked around and were puzzled. I yelled, "get JD." and they disappeared. Then Maggie's airway obstructed and she was not moving much air, and what did move was noisy. The visitor did a jaw thrust. The baby seemed stable and I left him for an instant and banged on her chest. This made her cough. I also tried prying her mouth open and she bit my finger. Then she began to breath and after about three minutes her eyes opened and she looked hellish but wanted to get up and work. We made her lay on a stretcher for a while. (JD had sauntered in to discover this scene with Maggie on the floor. He thought the girls came to get him because we were ready to start the case.) The patient got light as we were deciding whether to proceed (which we finally did) and after a crying mask induction, we were operating. The rest went smoothly. (Murphy was hard at work here today!) …

Wednesday, November 20, 1991

As we sat in the OR yesterday, rumors spread that the hospital was jammed with patients. What I saw as we left was nothing short of astounding. Our patient was placed on a stretcher mattress outside the OR door, ON THE FLOOR. Patients were everywhere; hallways, outdoors, and many on the floor. The wards
were packed with beds six inches apart and in the middle of the room. There were at least two people in every bed. I assume many were relatives of patients. It was very cold. Quite a remarkable scene.

Case 1: A 4 year old girl for repair of a complete cleft palate. During the induction I passed a syringe to Maggie and asked her to give 0.3 cc atropine. She injected, then asked, "is SDC some sort of nickname for atropine?" I was able to disconnect the IV at the hand and flush the line. Everything went well...

Case 3: A 9 year-old boy who was scheduled for surgery and did not get a preop physical, as most of the kids were scheduled for surgery while I was giving anesthesia. Since I am the only anesthesiologist and there is no pediatrician on this trip, the proper preop did not get done. When I placed my precordial stethoscope on his chest, I heard a loud 4/6 murmur radiating to the axilla. The pulses were strong. There was a pre-cordial thrill. When I hooked up the pulse oximeter, it read 78% (checked and rechecked). I then recalled that I had seen the child behind the hospital, naked and squatting on the dirt. Since many Nepalese relieve themselves this way, I thought nothing of it at the time, but it just occurred to me that he may have been squatting as a relief of a tetralogy of Fallot spell. He obviously has a large mixing lesion, without signs of heart failure (no rales, no hepatomegaly or edema, no cough). Looking back at his clinic notes, J.D. recalled that this child could not keep up with his siblings when running. It was my impression that he had a large mixing lesion. Whatever the lesion, a problem with the anesthetic might make things worse, and put him at risk. I decided it was best to postpone this elective surgery until he had a workup. The only thing we were able to do here was a CXR. The cardiac echo machine in Kathmandu was out of service for a couple of months, so he will have to wait. Murphy's at work again…

...Just as I was dropping off my patient in our little recovery area, Sister Grace started yelling for help. Of course, I didn't know she was calling for help, so I just looked around when she started yelling for Dr. Vigna (the missionary surgeon). She was calling from the "dirty surgery" room, a small room where abscesses are drained, usually under sedation with ketamine. Sister Grace is an Indian nurse anes
thetist, who came here ten years ago to serve at the Seventh Day Adventist Hospital. She hasn't done much anesthesia lately, restricting herself to cleaning ORs and helping everyone with everything. Today, however, she was doing anesthesia again. This elderly diabetic was waiting for debridement of some awful, gangrenous toes. With nobody else in the room, she administered 125 mg of pentothal. He immediately became apneic. This became obvious to me when Leo (Vigna) yelled for the Ambu bag, which wasn't in the room. There were no monitors, so I checked a quick carotid pulse, and determined that the pulse and pressure were acceptable. Then I flipped up my mask (after deciding that direct mouth-to-mouth was out of the question), placed a breathing mask over his face, lifted his jaw, and did artificial ventilation until the bag arrived. He regained spontaneous ventilation in about five minutes. All in a day's work. As he was recovering, he lost the front of his foot very quickly. Unfortunately, he is missing the other foot (BKA), and will be quite crippled, a very bad asset in this hilly, rocky, territory, where walking is the only way of getting around…

Well, you see, things don't always follow the rules. But overall, we managed to help many people on this trip, with very little morbidity. We did forty general anesthetics, around eight ditzlectomies, plus a few local lip repairs. For the forty cases we used: six 30 cc bottles of 1% lidocaine with epinephrine; two bottles of 0.5% bupivacaine; two bottles of halothane; 20 mg of morphine, ten vials of atropine (1 mg); 20 vials of antibiotics; 14 cylinders of oxygen. Only two out of forty patients had postop emesis - perhaps because we used regional analgesia instead of narcotics. We worked about 120 hours at the hospital. Not bad for a short "vacation" in Nepal.

Alan S. Klein, MD
Pediatric Anesthesia Consultants, Denver, CO

Santo Domingo, Dominican Republic

I recently returned from a two-week trip with Heart Care International (HCI) to Santo Domingo, Dominican Republic. Heart Care International was founded by Dr. Robert Michler and over the past 7-8 years has been providing cardiac surgical services to children in Central America. They recently completed a 5-year project in Guatemala which involved not only providing direct patient care, but also education of local physicians and healthcare providers to eventually provide these services themselves.

HCI has now focused their attention on the Dominican Republic. The January-February trip to the DR, covered a period of 4 to 5 weeks and involved over a 100 health care workers from all over the United States including cardiac surgeons, anesthesiologists, cardiologists, ICU physicians, perfusionists, administrators, ICU nurses, and respiratory therapists. Despite the wide diversity of experiences and geographic locale of the team members, there was an incredible amount of teamwork and cooperation with everyone focusing on the primary objective of the trip. The team provided all aspects of pediatric cardiac care including evaluation by the cardiologists, interventional cardiac catheterization, and cardiac surgery. Cardiac surgery was performed for a total of 8 days, utilizing 3 operating rooms. Over the course of 8 days, over 70 cardiac surgical cases were performed.

As usual, I saw things that we never see in this country including patients with various cyanotic lesions, who were well into their teenage years, including a 20 year-old with tetralogy of Fallot. Many of the children that we anesthetized were severely compromised from their cyanotic congenital heart disease with room air oxygen saturations of less than 50% including one young man with a saturation of 23%.

Our hosts were incredibly gracious and extremely interested in working with us in the hopes of one day being able to provide these services independently. The Dominican Republic provided a beautiful setting in which to work and offered sunshine most of the days with temperatures varying from 60-80oC. As it is a common site for tourists from all over, the environment was safe and hospitable and the people gracious and friendly. Our freetime, albeit limited, was spent touring the city, learning more about their culture and history including a tour of Christopher Columbus's house. I was somewhat ashamed to admit that my knowledge of history was so poor, that I did not know that the DR was Christopher Columbus's original landing site in the New World. Additionally, there were several beautiful beaches within a 20-30 minute drive of our hotel in Santo Domingo. Without a doubt, the DR was one of my more memorable trips.

Joseph D. Tobias, MD
Director, Pediatric Critical Care/Pediatric Anesthesiology
Professor of Pediatrics and Anesthesiology
The University of Missouri
Department of Child Health
M658 Health Sciences Center
Columbia, MO
FAX: (573) 882-2742
Phone: (573) 882-6544
E-mail: Tobiasj@health.missouri.edu

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