Sunday, 24th June. Time check, 7:45pm. My colleague had a social event to attend and hence the onus fell on me to take over his duty for the night. As a usual thing I do, right after stepping out of my room, I once again put the tiny buds into my external auditory meatus to buzzle some rhythm into my spirit and furthered it off with a prayer for a calm night. Personally I don’t like night duties though comparable to an akin 12-hour duty, they seem shorter, not spending a night in the comfort of my bed is one wrecking encounter. Even if there are no bothering cases, sleeping with an internal alarm of being woken up at any time to the arrival of an emergency can be quite demoralizing.
After the prayer, I kept throwing my fingers into the air with a heightened spirit. I was high on a recent track I had fallen in love with – “good life”. I knew in my spirit my last emergency night duty was going to be friendly.
“Obed! Are you for night? Maro has a case for you”. That was what Dr. Davis met me with. Well… That wasn’t much alarm. We always hand over cases so what’s there to worry about? I continued with my earpiece in my ears as I walked through the emergency sniffing through the cubicles to possibly have an idea of what case it could possibly be. With nothing found, I made for the doctors’ room to change over. I kept my calm, as it wasn’t my greatest fear that had ensued – mass casualty, I could still enjoy some breather. Entering the treatment room of the emergency, I realized what Dr. Davis was talking about. Indeed, there was a case for me to handle overnight. I looked around and almost everyone was in that small chamber. My calmest glance fell on my boss. I knew all was well then. In this ocean of blood stood a bed having a near disoriented lad sunken in his own blood. My eyes zoomed in on those loops of bowel that had eviscerated. Two guys at the head end of the bed each squeezed a bag of intravenous fluid, forcing it down this man’s veins. He really needed some fluids to build up in his vessels. The sort of hemorrhagic shock he had gotten into was apparent from the enduring quest for water to drink. My boss requested that we alert the theatre that there is an emergency coming in.
That order automatically fell on me. “Hello, this is Dr. Benyin-Mensah, A&E, we have a patient with eviscerated bowel secondary to RTA. We are bringing to theatre for exploratory laparotomy, is there any anesthetist around?”. The exact words I used. “No please. Let me check and get back to you” – the theatre recovery nurse replied. The next time I realized, I was on phone with the anesthetist on duty who had for that moment stepped out to town to get something. He gave his approval that the case should be sent to theatre immediately and that he was on his way.
I knew I had some good news to break at the emergency. At least the patient could be pushed to the theatre. My words couldn’t come out as in the heat of the moment, what the eyes in my socket saw what was a bit too much for me to keep talking. Earlier I had only seen loops of intestines occupying their own space alongside the patient. Little did I know that majority of the bleed was from them. With artery forceps and surgical scissors, some intestines oozing out blood had to be clamped and resected right in the open of the treatment room of the emergency ward. Had he really started the surgery right in the treatment room?
Boss wanted to be sure the theatre was ready for the emergency so I had to rush to the place again. The scrub nurse available gave the heads-up they were ready. In my mind, my work on this case was done. At the gate I saw my boss coming. “Are they ready?” “Yes boss, they are” – responded. “Okay! You, tell them to rush the case here in 30s and join us in theatre”. I looked around and I was the only one there. Surely I was the one he was referring to. Well. The night duty was now going to be at the theatre.
“Is the patient in shock” the anesthetist who had arrived in the changing room right on time asked. My response: “I can’t really tell but he has really bled a lot”.
Clock tics, 9:00 pm, patient pushed to theatre, handing over done and intravenous fluids running through the usual two wide bore cannula. Group O-negative blood on the run. General anesthesia initiated, BP check, 78/38mmhg and there I found myself in a theatre gown ready to assist. Externalized bowel had some devitalized and gangrenous parts that needed more resection. Bleeding from the bowel was immensely copious. How easy can it be searching for a drop of water in an ocean? Enough hemostasis was secured and then gangrenous part of bowel were resected and bowel returned to the abdominal cavity ready for anastomosis (joining of two ends).
“Boss, there is a call from Kpando, they say they want to refer a case of a stabbed injury to the abdomen with stable vitals”. That was enough bad news for me but complaining wasn’t what I could do at the time. “Tell them to refer tomorrow morning if the case is stable” – my boss replied.
Even before anastomosis could be done, a new area of the abdomen was noted to be bleeding but its source couldn’t be identified. Adequate pressure packing with gauze was done and bleeding seemed to have moderated. After about an hour and 30 mins into the surgery, anastomosis of two segments of small bowel was complete. Inspection of bowel revealed two perforations on the ileum each about 2cm in diameter and repairs had to be done for them as well. Thinking all intraabdominal work was done, my boss wanted to find out what was causing the bleeding that was not initially identified only to find the very unfortunate.
“Do we still have enough time?” He asked the anesthetist. “Why? What’s the issue?” he replied. “I just found something and I hope it’s not the caecum. Too bad. It is the caecum. It is perforated and at several points.” My boss answered. This was 3 hours into the surgery. A bit down in spirit, a decision had to be made on the best possible handling of the current issue we were met with. To go the way of an ileostomy (a stump of the small intestines to the outside of the abdomen to allow intestinal content to pass out) or thread the path of a hemi-colectomy with ileocolic anastomosis. A blood pressure of 86/50 wasn’t going to be able to support the amount of fluid to be lost from the ileostomy. And an anastomosis in the presence of another anastomosis and two repair of perforations with the sort of edema on-going was a though choice to make. After a brief period of intellectual exchange, a decision to do a limited right hemi-colectomy (resection or cutting away of part of the ascending large intestines together with the caecum) was decided on.
“I am about to start the transfusion of the O-positive blood. Should you realize any change in the colour of the blood please notify me so I take necessary action” – the anesthetist explained to keep as on the alert as all the available O-negative blood available at the hospitals blood bank had been consumed by the same client. Meanwhile, an ileocolic anastomosis had to be done and damage to the anterior abdominal wall repaired. Attempt at repair of anterior abdominal led to the finding of two penetrating injuries to the groin directly at the femoral triangle.
“Check the feet. What’s the colour of the right foot? Does it feel colder?” Dr. Affram requested. “Boss, the pulse is here.” “Have you felt it? Thank you Jesus.” He sighed off after palpating the femoral pulse too. How the penetrating force missed the femoral artery still remains a mystery.
The major abdominal injuries had been dealt with. Now was time to do a thorough visual body scanning to identify other injuries to other parts of the body. Avulsion (peeling away of a tuft of skin and subcutaneous tissue) injuries to the left thigh and leg had to be explored and sutured accordingly.
2:45am, BP check, 105/65mmHg, a smile on all our faces. We have made good headway. Other multiple scalp and facial lacerations were sutured. Urine bag inspected with adequate urine production and nor hematuria (blood in urine). A count of the number of sutures used. Your guess might be as good. An even 34 sutures were holding the man whose intraabdominal findings suggested it had not been long after he eat that the unfortunate swept him of his norm.
3:00am, client was off theatre table and was sent to Intensive Care Unit for continuous monitoring and to be put on some high level antibiotics.
I bid my boss goodnight at 3:30am as we both dozed intermittently whiles writing the operation notes. It was then that I remembered the duty for the night was still pending. I had to return to hoping that there were no more cases waiting for me at the emergency.
Fast forward three days, after, I pass by the male surgical ward and here my guy is on the ward. Stable and talking.
A life had been saved from perishing. Congrats to the team of Doctors, Nurses, Anesthetist who played their resounding parts in keeping this man alive.
Benyin-Mensah, Obed (July 2018)