Cat on a Hot Tin Roof

It was bound to happen. I mean, I was expecting it…eventually. Today we finally got a case that was going to be hard to do with the little supplies I had to work with. I just hadn’t spent much time thinking about what specifically I’d do for workarounds given I didn’t have inhaled anesthesia.

James called me into to look at an abdominal ultrasound he was performing on a man with complaints of right upper quadrant pain. It seemed obvious, even to an anesthesiologist, that the guy had some junk in his gallbladder, and probably needed it removed. Thing was, he was otherwise doing pretty well, and happened to be the chief of the area. You hate to do something for a VIP and things go wrong, you know? But, it seemed as though this guy’s time had come. So, that left me to figure out how best to do the anesthesia.

Ketamine and spinals was all I had, though after using nothing but for over 2 weeks, I had gotten used to it. On the other hand, we’d not had to operate this high in the abdomen yet, so a spinal would probably not reach high enough to cover the operative area. Then again, ketamine, while entirely adequate to keep the patient pain free and unaware of what was going on, would likely leave James a very difficult operation to perform, high up near the diaphragm, with no abdominal relaxation. What to do?

I chose an unorthodox approach. I planned to place a spinal anesthetic, then tilt the table to get it to rise higher in the abdomen than usual. It would be a bit of a trick, I’d have to watch out for hypotension and maybe a dangerously slow heart rate, but if it worked… it’d be just what the doctors ordered. The patient paid his bill (all services here are prepaid, even the pills you take), and we went to the OR to take care of business.

The spinal went in easily, and I put him at about 5 degrees head down for 10 minutes while the spinal medication set in. His blood pressure and heart rate seemed to be doing fine, so we started the case. He didn’t flinch at all as James cut him open and started moving in toward the liver and gallbladder. So far so good.

Well, it took a while, but he did indeed get hypotensive… to the tune of about 60/35. Gulp. OK, not a problem. I had some epinephrine set aside just for the occasion. I had jealously guarded it since my arrival because it was the only vial in the whole hospital. And I was about to need it.

I got the sense that things weren’t going to go as planned right after I cracked opened the vial. See, over there, most meds come in breakable glass ampoules. No big deal, many in the States do to. Just crack the top off the vial… I’ve done it hundreds of times. Well, this time was a DIFFERENT glass vial. This was a brittle, brown glass that shattered between my thumb and forefinger as I opened it, cutting my thumb and spilling out the precious fluid like perfume out of an alabaster box.

It’s hard to stay calm in a situation like this. I mean, how much worse could it get? And the fact that I was the one who had essentially wasted the very drug that was desperately needed only made things worse. I muttered under my breath as I looked at the crumbled glass in my hands, but noticed one larger piece of glass that had a *small* puddle of epinephrine still in it. Looked to be about 1/20 of what came in the vial. Well, I thought… it’s all I’ve got. And, it may just be enough. After all, I didn’t need the whole vial. At least, not just yet.

So I sucked it up and diluted it into a 10 ml syringe, all the while hoping I wasn’t inadvertently mixing in either tiny broken shards of glass or trace amounts of my own blood. The next blood pressure was enough to convince me that there was no error being measured… he truly was hypotensive, and he wasn’t responding quite the same to me as he was before (even though we didn’t speak the same language). It took a few doses, but I was able to get him back up closer to 100/60 mmHg.

By now, James was convinced his gallbladder was fine. This was good news for me. It meant that we’d finish quicker than I’d thought, and that the spinal would not likely wear off before we were on our way to the medical ward with this patient.

The odd thing though, was that as he was wondering how he could have thought things were so bad on the US, when in reality the anatomy was pretty much well fine, he noticed a dark spot that seemed out of place. It was a little past the stomach, on the small intestine. Closer inspection revealed a duodenal ulceration that was probably the source of his upper abdominal pain. AND… it perforated WHILE James was looking at it! We were stunned. We had operated for the wrong reasons, using an incision and anesthetic plan that would’ve been completely different had we actually known what we were in for. Yet, providentially, it worked out perfectly. Amazing. Just amazing.

I try to do other stuff to help out around the hospital when we aren’t actually operating. Today was the day I planned to solve one aspect of the water supply. See, there’s a water tank, mounted above the garage, that is fed from a 300 ft well. It’s a very important feature of the hospital’s operations. The water comes from below the bedrock, so there is no runoff contamination. It’s pure, no need to boil it or anything. The tank supply is used for nearly everything from scrubbing in for an operation operation, (important), to patient’s laundry and cooking (less important). It’d be nice if surface well water (only about 10 feet deep) were used for the later since cooking always entails boiling, and giardia on your clothes is really no big deal (especially since it’s going to get cooked in the sun as it dries on the clothes line anyway). But people would rather turn a spigot instead of draw from a well. So, we run out of tank water relatively often, and often it’s at an inconvenient time (time to scrub for surgery).

The problem is that you never know how much water is in the tank, and you don’t know if it’s time to turn off the generator before wasting fuel as the overflow valve lets excess water spill out of the tank after it’s been filled by the pump. So I designed a gauge for the tank… MacGyver style (modified from a similar design seen in season #1). I tied some fishing line to a plastic soda bottle with about 50 ml of water in it and floated it inside the water tank. I fed the free end out a small hole in the top of the tank, near the edge that faced the hospital, and covered the edge of the hole with scrap plastic and epoxy putty I’d brought from the States. This way, the heat and friction would not cut or melt the line. From there, I ran the line down the side of the tank, back up again, and down once more, weighting it down with small lead sinkers on the free end. I had cut off several of the plastic rings from which the IV fluid bottles hang to make a pulley system, again, sealed onto the side of the water tank with epoxy putty. The down, up, down arrangement of the line made it so that the middle third of the fishing line rose and fell with the bottle floating inside the water tank. And for the finishing touch, I used a piece of Duct tape acted as a marker, reflecting where the water level was inside the tank.

At least… that was the theory. See, when I actually climbed up on top of the garage to install this contraption, things got a little dicey. I took off my sandals (shoes were stolen, remember?) to make it up the round rung ladder that led up the side of the water tower. As I stepped off the ladder and onto the top edge of the water tower, my feet were scorched by the intense heat accumulated by the hot metal tank under the blistering Sahara sun. I instinctively lunged away from the edge, hopping around toward the middle of the tower, in case I lost my balance and fell over (at which point I fully expected to get 2nd degree burns on my hands and forearms). I quickly realized I was NOT going to be able to do this indefinitely. It must have looked like I was doing the Samba or something while dancing around on top of what felt like the trap door to hell itself. Then I had a another one of my brilliant ideas… I’d just sit down. I mean, I had scrubs on covering my legs, right?! I’d have a little insulation, a bit of a reprieve… just what the doctor ordered!

I quickly sat down and flopped my legs over the side of the tank… only to become acutely aware of the need to turn the other cheek. Buns burning, I maneuvered as best I could to relieve the somewhat diminished pain and heat coming off the top of the tank so recently felt on my feet. CLEARLY, I had made the right decision that morning to wear underwear instead of going commando (fortunately for me, I’d done laundry the day before). In the end (HA, funny!), that little extra bit of insulation saved me from developing what I imagined in the moment to be lifelong disfiguring scars all up my thighs and buttocks.

I somehow managed to “walk” my way over to the ladder without giving myself the wedgie of a lifetime, scamper down to the cool, shaded underside of the tank and put my sandals back on. I hobbled away with a stout resolve to return only AFTER the sun had set to complete my best laid plans (which, it turned out… worked perfectly).


Things you don't want to hear in the mission field: "Yes. It’s rice again."