Oxygen, anyone?

Patient monitor minus oxmetry and blood pressure.

Had a great few days at the Central Hospital of Kigali (CHK) this week working with the residents and nurses in anesthesia department. Obviously the OR runs a bit differently here in Rwanda than at John Muir Medical center back in Walnut Creek. And the practice of anesthesia is no exception.

Oximetry is an extremely useful and relatively inexpensive monitoring device to give a real-time measurement of a patient’s oxygen saturation. Most of you walk around with oxygen saturations of near 100%. Climbers on Mount Everest would be at 80% or less without supplemental oxygen. Most people will go unconscious and their skin turn a shade of blue below 75%. And irreversible brain damage will occur if oxygen saturation levels fall to critical levels (say, less than 40%) for greater than 10-15 minutes. The near 100-fold increase in the safety of general anesthesia over the past 40 years is in no small part due to the invention and widespread distribution of oximetry monitors. No anesthesiologist in the US or Europe would anesthetize a patient without one. I’m doing it here, in Rwanda.

Most of the monitors in the operating room here are equipped with oximeters. The reason they are not being used is because they are missing the readily available, plug-in cord to attach the monitor to the patient. Apparently the original cord broke, and they are waiting for it’s replacement to arrive. When a cord breaks at John Muir Medical Center, someone merely walks to the stock-room and grabs another from the inventory. For whatever reason, be it financial, lack of assigned responsibilities, or failure to realize the importance of backing up critical equipment, rarely does something get done here until there’s a problem. And until enough people scream about it, the problem remains. C’est la vie en Kigali.

Lecture with the anesthesia residents

Gave a lecture to the anesthesia residents yesterday afternoon at CHK. I had about 10 people in attendance for a talk on the management of acute pain. My voice was cracking due to a recent case of laryngitis, so I could hardly speak English, let alone French. At first everyone was very quiet, and it what looking like I was going to spend the whole 2 hours listening to myself talk while everyone else dozed. Fortunately, bribing them with Civco ink pens got the questions going, and pretty soon, I was having to moderate some heated discussions. It was a smashing success! And since this is same the group I’ll be lecturing every week for the next 4, things should go well.

They are very bright and asked some tough questions (I’m supposed to know the difference between an ‘enkephalin’ and a ‘dynorphin!?’). Every resident, including some on their very first week of anesthesia, seemed very engaged in the topic and excited about their training. I just hope the funding keeps coming.

Watched a 2 month old baby’s heart squeeze it’s final beats in the OR today. The poor kid was already pretty ill with an intestinal disorder that would have made long-term survival very difficult. And he had already survived 2 abdominal surgeries. There are no incubators in the entire hospital, save the one in the Intensive Care Unit (ICU). This kid would have been an obvious ICU case in any hospital I know. He arrived from the general pediatric ward, no more than 3kg in weight, and already hypothermic.

I have no way to know what his core body temp was upon arrival, because I wasn’t involved until later. Since the scheduled surgery was not an emergency, the proper thing to do would have been to cancel the case, and send the kid back to the ward until his temperature was normal and his circulatory status assured. I don’t know why they forged ahead. Perhaps because it may have been the only day this week when the pediatric surgeon was available.

When I arrived to the OR room after being alerted of trouble, the baby was already on death’s door. Her extremities were white and cold from extremely poor circulation due to a failing heart and profound hypothermia. When I couldn’t palpate a pulse, I grabbed the ultrasound unit and did a quick scan of the heart. It was only beating 40 times per minute, and poorly at best. I knew the child wouldn’t survive, but we went through the requisite resuscitation with CPR and potent drugs anyway. On the ultrasound screen, I watched the weakened heart make one final, gasping attempt to squeeze, and then silence.

Checking out the anatomy courtesy of the trusty laptop.

This is where the needle goes...