Tuesday, July 7, 2009

A Day at Peltier

Monday was a day of anticlimax - a good thing in Anesthesia, perhaps less so in life's other aspects. As I'd said, we were off to assist our colleagues at the Djiboutian hospital with a sort of challenging case. If you study the neck film on the top you'll see a picture of a very lucky unlucky guy. The bright spot to the viewer's right is the way a bullet appears on x-ray. Many people with a bullet in that location - near some prime real estate in the human body - will not have survived to seek medical care. This chap did make it, still walking and talking, but developed a communication (that's a hole) between his carotid artery and his jugular vein on his wounded side. This turns out to be a bad deal - even if better then the other potential outcomes - as the high pressure blood in the carotid would much rather take a u-turn and head back down the low pressure jugular vein then take much more tortuous and wearisome route to its original destination, the brain. Brains though are pretty particular about getting all the blood they want, and this fellow had many symptoms of low perfusion of his cerebrum. Not to mention the constant hum (we call it a bruit) of the blood gushing from high pressure to low through the small rents in the vessels, which the patient complained about being too loud to sleep through. Finally of course, this type of post-factory modification of the Designer's original plan voids all warranties, and the abnormal junction between the vessels is likely to fail in time, with catastrophic results.

Our mission then was to assist the Djiboutian surgeon and anesthesia team with a fairly complex case, combining such skill as we had and resources as we could spare with those of the good folks at Hopital Generale Peltier. We brought along one of our monitors, some materials for pressure monitoring, and a few drugs that we knew we would want if things went wrong. In the team were a couple of our OR techs, our OR nurse, Bill our surgeon, and Herman and me to provide anesthesia support. We probably didn't both need to go - but heck we've only got one surgeon so anyone who stayed back at camp wasn't going to be doing much. I was going to say that nobody ever comes by for just an anesthetic, but events surrounding Michael Jackson's passing may yet prove me wrong.

Well, although I could talk anesthesia and surgery all day, I'll spare you the details. Our set-up went well despite the failure of our expired carbon dioxide monitor to work as desired. As it turned out, the answer would have been to turn it off then turn it on. Try to find that in the instruction manual though. Anesthesia was uneventful (anticlimactic) and Bill and Dr. Elias quite skillfully found, isolated and repaired the injuries and closed the patient's incision back up. Our wake up was a little slower than we could have hoped. In Djibouti the anesthesia machines use halothane, an older volatile gas that tends to hang around longer than the more modern agents used in more well resourced areas (heck, we don't even teach halothane to our residents anymore). Wake up our patient did though, apparently doing well and with a normal neurologic exam. It was a long day - about 8 hours from our arrival to departure - but a good one. I don't mean to imply by the way that the Djiboutian team couldn't have done the case without us - they are excellent folks and would have done fine I'm sure. As it was it was nice for both sets of folks to have a chance to work together through a case that was a little unusual for everybody concerned.

In any event, the picture on the right is of Herman, Dr. Mustafa and me right before we got started. I'm in the middle. :-)

The next part of the day was to have been the party at the US Embassy celebrating Independence Day. It was to be in summer whites for officers and "business casual" for civilians. I was feeling just the least bit smug for thinking to have Donna send my whites against just such an occasion. As you can imagine, a bright white uniform with white shoes, is an awful potential burden here in the land of blowing dirt, so most folks leave them at home. When you need your whites though, it is nice to have 'em handy. As I started to get dressed, however, I realized with dismay that I had omitted to ask Donna to send along my name tag - it goes over the right breast pocket - and would thus have an incomplete uniform. Argh! As Proverbs 16:18 doesn't quite say "Pride goeth before the fall". (What it actually says is "Pride goeth before destruction and a haughty spirit before a fall". Nobody ever quotes that though - the other being a bit more compact and pithy). I thought about it for a while, and decided that although it was a small omission, I didn't want to be out in a uniform that was less then perfect, not at the Embassy and not on that occasion. I called my ride and begged off. I felt like Cinderella on the night of the ball.

As it turned out, the folks who attended had a fine, if hot and sticky time as the affair was held outdoors. I'm sorry I didn't get to meet the embassy folks, but I've met a few as it is and will hope to have other chances. As for me, I went to my CLU, watched the last of season 1 of The Wire, and had a grand night's sleep. Anticlimax again.

And that wraps it up. After some thought, and some advice from my very thoughtful correspondents, I've decided to stay with the blog format. This seems to suit me just fine, and I can't help the suspicion that I'm just not cool enough for Facebook.

Nothing big on the horizon, but rest assured that your faithful Djibouti Djournalist will keep his eyes open and his trusty Mac at the ready. Take care, gentle readers, until next time.

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