Flies in the Operating Room

It's already been a month in Soddo, but it seems I'm still finding things that surprise me. The first few weeks I was trying so hard to be as "un-American" as possible - to not naively ask questions or make assumptions that would give away my western upbringing. To mask my bewildered look when fly swatters (hanging in each of the 4 ORs) are pulled out to swat the buzzing creatures that do not honor sterile field and seem to find amusement in flying near or into open body cavities.

One of the patients I've been following is a precious 2yo boy named Tedi (though age isn't traditionally kept here because of the 13 month calendar) with an incredibly large mass revealed to be adjacent to his right kidney on Ultrasound. The surgeons assumed it was a Wilms tumor (the most common solid tumor in children under 5yo) and brought him in for surgery. After the long preparation ritual for anesthesia, he was put under Ketamine. He was then hooked up to the just-functioning vitals monitor. BP of 165/122 (dangerously high in a child). Did someone take his blood pressure this morning? No, there wasn't a pediatric cuff available in the surgical ward. Surgery cancelled, patient transferred to the ICU/Recovery ward next door. No verbal transfer summary, just wheeled in and left alone. I followed him in and tried to interpret the chaos around me, whether his family needed to be notified of what had happened (again, not a traditional practice here), whether there was something to do for this now-moaning child. In turning to ask the anesthesist why they hadn't given him an anti-hypertensive, I was promptly notified that no IV drugs (which he needed because he couldn't take an oral drug in his semi-conscious state) were available in the hospital.  We'd just have to watch and wait.

I watched closely, securing a pediatric BP cuff from the pediatric ward and chiding off numbers to a ward nurse who barely understood my English. What a silly sight I must have been, this foreigner marching in and demanding resources in short supply for a patient I adopted as my own. Pestering the on-call surgical resident all night when Tedi spiked a fever, or when he spit out the now-supplied 10mg tablet of Propranolol (can you imagine an American 2yo being forced to swallow a pill?).

He waited in the hospital for over a week for his blood pressure to lower enough for surgery. There is a CT scanner here, but it isn't licensed for use by the government yet. No lab tests for the cause of his high blood pressure (possibly catecholamines/adrenaline secreted from the tumor). Just the assumption that the tumor near his kidney was causing his previously undiagnosed hypertension. And a lot of waiting. The surgery itself was complicated by low oxygen levels for over 20 minutes (I was worried about brain damage) and tumor invading a large vein (IVC) with blood pooling into the tumor cavity. Jesus worked a miracle in that OR, a fact the lead surgeon was not shy to point out, and he was able to go home after a few days of recovery.

Despite my efforts to adapt to the level of available care in Soddo and assimilate my western ideas with those of the culture; to avoid taking on the "White Man's Burden" (William Easterly) and to uncover the "pathologies of power contributing to structural violence" (Paul Farmer), I'm still learning. Most importantly, I'm learning that a little shock is productive, that it exposes the gaps that should be addressed, where advocacy is needed, which shouldn't exist at all in a world with a gross imbalance of resources and skills.