BAH Continued

And now, back to our story!

When we last saw our hero, he was in Blantyre, Malawi where he continues to stamp out disease, and save lives (though, not all the time).

The first full day that I spent at the hospital, the business administrator started taking me around around to give me a tour of the facility. As we walked down the hall to the double doors that entered into the operating rooms, a doorway to my right burst open and the medical director grabbed my arm saying, "Come quickly Dr. Cobos we have an emergency!!"

Dr. Verona is a pediatrician, and she and the two anesthetists were struggling to save a preterm baby who had JUST been born at 33 weeks gestational age (no prenatal care, mom had had vaginal bleeding for the past month, ruptured her membranes yesterday. It was her 4th child). The parents were waiting down the hall to hear of the outcome. I saw the child had a club left foot, and was beginning to have that ominous gray dusky appearance the newborn black children have when they don't get enough oxygen. This, despite the fact that the child was intubated and being ventilated with 100% oxygen. There was no blood pressure cuff. There was no EKG machine. There was no pulse oximeter that we could get to function on those tee-tiny fingers. Of course, even if it had worked it's not like we could have given any more oxygen. My immediate guess was that this child was going to live about 10 more minutes, at best. I listened to the heart and chest with a stethoscope. The heart rate was aproximately 100, and the lungs were not being ventilated very well. This did not surprise me, since the child's lungs were not designed to even function until after at least another month's develpment in utero. If we saved the child, there was no ventilator which could be used for respiratory support.

We decided to continue resuscitative efforts for approximately 30 minutes, after which time we all agreed that further efforts were futile. We stopped, and I drew down the little eyelids for the last time, never having had the chance for light or vision to spark her imagination. Dr. Verona went to explain to the parents what had just happened. I stayed behind.

Later that day, I was able to e-mail my family and friends back home to let them know I was still alive and that my malaria test was negative. It was not my time to die. It had been someone else's.

It had been some time since I had actually had to stand right there and watch someone die. It's hard to explain clearly what all goes through your mind during the experience. And of course, it is different when it's a young child as opposed to an old person, full of years. In the case of the latter, there is consolation in the belief (be it grounded in truth or not) that the dead or dying one had a fulfilling life which is successfully coming to a close. In the case of the former, one is haunted by the fact that this life was barely opened, and an uneasy wonder that had you but acted smarter or sooner an entire world of difference would have been made, and a life full of dreams achieved. These are, as it were, the skeletons in my medical career's closet. Thankfully, they are few and far between. But is it important to acknowledge their presence, if only to crack the door open just wide enough to accept one more silent, small, skeleton.



The next day, much of my time was spent modifying the draw-over vaporizer system they were using. They were using too much cylinder oxygen, and the modifications would allow for them to save money by using less, making up the difference with room air. I have been surprised how much repair work I have needed to do. I've actually spent more time as a repair technician than an anesthesiologist.

The next case was done under spinal rather than general anesthesia. I watched in shock and awe as the anesthetist performed the sterile prep without wearing a mask. Then, he proceeded to place a nonsterile lidocaine jelly on the skin in an attempt to numb it. This was promptly wiped off, as if it could have taken effect in five seconds. Why lidocaine was not injected directly into the skin I have no idea. Before I had a chance to voice my concerns over what I was watching, the announcement was made in English that we were about to pause for a prayer. Given what I had just seen, I felt this was an appropriate intervention, so I just stay quiet.


Things got a little bit busy during the day and I was asked to do minor surgery alone to facilitate completion of the surgical schedule. I removed five Norplant rods from a lady's upper arm, using lidocaine with epinephrine, a scalpel, scissors, forceps, and closed her up with two stitches. I still got a it! I can still cut and sew!

We operated for much of the next day also. I had been scavenging for parts and supplies throughout the OR and nearby storage room, but had not found much useful equipment. The Drager anesthesia machine had three large locked drawers in it, but of course no one had a key to open them. I wonder if anything worthwhile was inside. I pushed the machine away from the wall and looked at the back. There was an opening behind the top drawer which was just large enough for my arm to fit through to reach in behind the drawers. Though the top drawer would open, it would not come out completely (thus, exposing the contents of the drawer beneith). However, there WAS just enough space for me to fit my hand down to the second drawer's locking lever arm. It was held in place with a flathead screw, which was just begging to make friends with my Swiss Army knife. So, with a flashlight strapped my head, the second, and then the third drawer, were opened African style (i.e. they were broken into).

My hope had been that the drawer would hold the power cord for the oxygen/halothane analyzer, or at least a spare set of cables for the EKG machine or pulse ox. All I found were some US 110v power cords, precordial stethoscope heads, paper clips, and some laryngoscope blades that fit none of the handles we had. Well, it was worth a try.

By the end of the day the power cord for the gas analyzer was found by one of the anesthetists. This allowed me to test the oxygen concentrator's performance and evaluate the modifications I had made in their draw over anesthesia system. It was only then that I knew they would be able to save tank oxygen, use the oxygen concentrator instead, and save money without compromising patient safety.

They also brought me the cable for the EKG machine which they said wasn't working. The reason was now obvious. The cable appeared to be 30 to 40 years old, with cracked, broken off plastic insulation around each of the leads. The leads had been forming short cicuits, and after I wrapped each cable (what was left of them) with cellophane tape the EKG machine worked fine. :)

Two pulse oximeters were not functioning, and the rumor was that all they needed were batteries. ("Why do they need batteries? They run off the outlet in the wall! Whatever.") The surgeon brought me one battery which he said was supposed to work in them, but that no one knew how to install it. If I could figure it out, I would save the hospital money that was the equivalent of one month's salary for a nurse. Nobody could bring meat tools that were helpful, so I was thankful my Swiss Army knife at all the screws I needed to undo. The inside of the pulse-ox appeared free of physical damage, with only two wires (one red, one black) dangling free. ("Ah, so there's a break in the power circuit. No wonder it "needs" a battery. I wonder if a dead battery would work?") Obviously, this is where the battery was supposed to go. I looked at the battery and quickly saw that the wire connections were designed to fit a different battery. The wires had connectors with two small holes, whereas the battery had connectors that were flat, flush to the plastic housing, with one hole screwed in the middle. Now what? I looked around the room and began to hear the theme from MacGyver playing in my head.

I went back to the Drager machine I had just Africanized and looked in the bottom drawer. I wondered if maybe I could rig a connection using the power cables I had just seen. But, that would require a soldering iron, which they told me they didn't have. So much for that idea. Well, I thought... who says you actually need to solder the thing? I grabbed a couple of the paper clips out of the drawer. These were small and round, I thought. Just what I needed for the wire connectors. I bent the other half of the paperclip flat to match the shape of the battery's connectors. Then, since I didn't have duct tape, I used the cellophane tape left over from the EKG cable repair job to hold the home-made paperclip jumper cables tight against the flat metal posts of the battery. I screwed the whole thing back together again, cliped the pulse ox on the finger of one of the anesthetists, and turned on the power. Viola! The most rewarding thing I'd done in weeks!

Not a bad day's work. It ended with two functional EKG machines, one additional pulse ox, and one gas analyzer. None of which were working before I arrived. People at the hospital thought it was like Christmas!

In the afternoon I went to the maintenance building, where I had been told donated supplies from the US had been stored. The room was steaming hot, filthy, dusty dirty, with stacked cardboard boxes up to my shoulders, all unlabeled, some with cockroaches, others chewed by rats/mice, and filled with donated equipment and supplies (obviously, some no longer sterile). Amongst other things that I found within a few hours were an EKG machine, a new manual suction device (great for when there is no electricity), Ambu bags, carbon dioxide sample lines for the gas analyzer, one-way respiratory valves, tons of masks, airways, and ET tubes, small adult and adolescent blood pressure cuffs, and a brand-new laryngoscope with replacement light bulbs. They were sitting on a gold mine, and they weren't even using it! It reminded me of the stories I heard about rice and other food being donated to starving Africa, only to be left to rot on the docks where the shipments arrived. There is such a lack of organization and lack of personal responsibility that multiple people become the weakest link in a failing supply chain meant to provide equipment and supplies for those in need.

I spent one hour trying to connect to the Internet that night. Eventually the power went out, and the hospital's emergency generator kicked in a little while later. I still couldn't get connected. I decided to walk home and go to bed. The guest house where I was staying with only a one to two minute walk away. It was quite dark outside the hospital, where no generators were running to provide power. Halfway to the apartment the power surged back on and a large cluster of sparks flew from a transformer atop a nearby telephone pole, lighting up the night.