SMART

Smart Uruakpa is a registered nurse. He graduated from the School of Nursing in Amachara, Umuahia. He first came to my attention in 2008 when he asked me to get him transferred to the Operating Room. Over the past 3 years he has become a fantastic operating room nurse and surgical assistant. He is so good that I don't even like to do a case without him. He hands me instruments before I ask and always knows what we need. He can close a wound better than I can and has started to  begin surgeries on his own, 

His dream is to go to medical school or nurse anesthesia school. He will excel at either but I would hate to lose him.

WHAT IS THE DIAGNOSIS?

Splenomegally! A normal spleen is the size of your fist. For various reasons, including malaria, some patients in the tropics get grossly enlarged spleens. A large spleen can cause pain and abdominal fullness.  

MAGGOTS!

We excised a necrotic skin cancer from an albino about 1 week ago and have been dressing the wound. Today we found maggots! (see 11 o'clock). There were many more but, unfortunately,  the nurse brushed most away. I decided to leave the remaining in the wound since they will gobble up all the dead tissue. Yummy!

HOW DO WE SHOWER

Despite rumors to the contrary, we shower often. Water is pumped into this tank when there is electricity allowing us to have running water-a luxury in Nigeria. We also have a water heater so the showers are not cold!

NEWEST TEAM MEMBERS

Wilson and the puppies

MALARIA

Headache, myalgia, weakness, fever, etc-you have malaria! If you have no immunity, you will be plenty sick. If you have some acquired immunity, it will feel like the flu. I have been feeling weak and have a headache for about 24 hours. I suspect malaria despite prophylaxis so I am starting the drug below, made in China.

WHAT IS THE DIAGNOSIS?

This man has had an ulcer on the medial aspect of his ankle for years. Occasionally it will partially heal then the wound breaks down. He has venous stasis disease with ulceration.

ANOTHER BAD BREAST CANCER

This unfortunate lady has an advanced breast cancer in the axillary tail of the breast. We will start her on chemotherapy.

CASES, CASES, CASES

Over the last 3 days we have done 21 cases for a total of 116 cases. The cases include 1 mastectomy, 3 goiters, 1 large skin cancer, 1vein stripping/Linton Procedure, 1 wound debridement, 1 orchiopexy, 2 lymph node biopsies, 1 inguinal hernia, 3 ventral hernias, 1 c-section, 2 laparotomies, 1 splenectomy, 1 syndactally, 1 excision of a bladder tumor and 1 prostatectomy. A diverse group!

Many are leaving to return to their work. The only surgeon besides myself is Professor. Dabs left today but was stopped by the mobile police. They accused him of having a stolen vehicle. Dr. Kelechi and I immediately went to the police stop and sorted things out. It was clear the mobile police were looking for a dash (AKA bribe). They should pray that they don't get appendicitis anytime soon.

SECURITY

Here is the NCH Security Team. They are a motley crew but we sleep better knowing they are patrolling the hospital and sleeping grounds.

WHAT IS THE DIAGNOSIS?

This X-ray is from a young man with a large pleural effusion which was drained with a chest tube. Most of the fluid is gone but the lung is still unexpanded and the mediastinum is shifted to the right due to volume loss. He has a trapped lung.

MOTHER OF ALL GOITERS 2

Today Dr. Mike came to assist me on a young girl with a giant goiter. You may remember that Dr. Mike trained in Nigeria and has worked extensively with Dr. Farrar and myself. Nine months of the year he is the best surgeon in Nigeria.We removed the goiter without difficulty. It was a record weight-900 gm or 2 lb. Now she will be able to rise her head up proudly.

15 year-old with a giant goiter

100

Yesterday we completed our 100th surgery in just 12 days! We feel like the 300 Spartans at the Battle of Thermopylae. The national power has been out and the big generator has been broken. We have been using the small generator that cannot power the ACs so the OR has been hot and humid. Working has difficult. Fortunately, the power is back today.

We operated on the young man with a shoulder sarcoma. The tumor was very bad. We tried to save the arm but the tumor involved the subclavian vessels so we had to perform a forequarter amputation-which entails surgical removal of the entire upper extremity, scapula, and clavicle. He is doing well-mentally and physically.

Forequarter amputation

Surgical specimen-shocking to look at on the table

WHAT IS THE DIAGNOSIS?

Peau d'orange is the dimpling of the skin that resembles the skin of an orange. It is usually seen in advanced breast cancer where there is stromal infiltration and lymphatic obstruction. This unfortunate lady had a left lumpectomy at another hospital. She has a recurrence on the left as well as a cancer on the right. She will receive chemotherapy.

Peau d'orange

Recurrent breast cancer

BLOG 1/24/12 CANCELLED DUE TO EXHAUSTION

Author recovering from exhaustion

OLD FRIENDS

This young lady came for a check-up. She had a thyroidectomy 6 months ago. She is very happy!

This lady also came for a check-up. She had a left hemimandibulectmoy for ameloblastoma 6 months ago. She has a good result with nice symmetry despite removal of half her mandible.

Xray showing resected hemimandible

WHO DOES ANESTHESIA?

People often ask me "Who does your anesthesia"? Wilson, Prince and Eric! (left to right). These three are our great nurse anesthetists. Wilson went to school at the University of Nigeria Teaching Hospital. Prince went to school at the Federal Medical Center at Umouhia. Eric is the Chief and has been at NCH for 12 years-taking call 24/7/365!  He  went to at the University of Benin. I have never met a better nurse anesthetist anywhere. Eric is at NCH full-time, Wilson and Prince work elsewhere but come to help out when I come to Nigeria. 

PROFESSOR IS HERE

Professor arrived yesterday. He is a urologist.  I nicknamed him Professor because he knows more urology than me. He has been a great help to the team for many years and comes to spend time with me every visit. Without him we would not know what to do with the urinary problems.

ANOTHER DAY IN THE OR

Yesterday we did 9 cases. We started with a 2 year old with an abdominal mass about 20 cm in diameter. We could tell it was a kidney tumor-probably a nephroblastoma or Wilms' Tumor. We did a nephrectomy. 

Next we operated on an unfortunate woman with a giant breast mass. The tumor was necrotic and foul smelling. I think it is a cystosarcoma phyllodes tumor, which occurs in the breast but is not a breast cancer but a sarcoma. We did a radical mastectomy. She will need a muscle flap and skin graft to close the wound.

Necrotic breast mass

Chest wall after removal of tumor (head to the right)

The next case was a young girl with a recurrent keloid of the face. She was quite disheartened. We removed the mass and injected the wound with corticosteroids to hopefully prevent a recurrence.

We did several other cases, including 2 thyroidectomies, fulguration of skin cancers in an albino, a giant inguinal hernia, a ventral hernia, and excision of a thyroglossal duct cyst. We have done a total of 68 in 8 days. Tomorrow we will operate on a difficult case of a young man with a recurrent sarcoma of the shoulder.

WHAT IS THE DIAGNOSIS?

This beautiful young girl has a facial lesion since birth. It is soft on the side and cystic feeling near the eye. It is neurofibromatosis. We will excise it soon and make her even more beautiful!

SKIN GRAFT

This arm belongs to a young man trhat was ill and wet to a clinic where he was given an IV infusion in the hand. An infection and resuted with a compartment syndrome. Ultimately, he necrosed all the skin of his forearm! We performed a skin graft from his thigh using a donated Corbett Skin Grafting Knife (Integra LifeSciences and Mesher (Zimmer).

Donated Integra LifeSciences Grafting Knife

Donated Zimmer Mesher

BUSY DAY

Dr. Dabs-Cardiothoracic Resident

Yesterday we did 13 cases including 2 inguinal hernias, a recurrent dernatofibrosarcoma protuberans of the face, a skin graft of the forearm, a total thyroidectomy, a parotidectomy, a giant ovarian tumor, an orchiectomy, an excision of an endometrioma of the groin, multiple dental extraction for ectopic teeth, a caesarian section, a biopsy of a neck mass and a partial uvulectomy. We have done 59 cases in 7 days. There are 23 patients in the hospital waiting for surgery. We now have Drs. Uche, Dabs and Emem helping and Dr. Ifeanyi (urologist) is coming today.

WHAT IS THE DIAGNOSIS?

This poor boy came to clinic yesterday. The nasal mass has been growing since birth. It is an Encephalocoele. We referred this patient to a neurosurgeon.

SISYPHUS

Yesterday,  we did 11 cases again, including 2 goiters, a thyroglossal duct cyst, a lymph node biopsy, an orchiectomy, 2 giant lipomas, an I&D of an abscess, a scalp lesion, a pyelolithotomy (opening the kidney and removing a stone) and a gastrectomy for perforated duodenal ulcer. The pyelolithotomy was especially interesting to Charles, our urologist. Unfortunately, the patient with the perforated ulcer died during the night. We have done 46 cases in 6 days. 

Despite all the cases, new patients are pouring in and we still have 29 patients in the hospital waiting for surgery. It is a Sisyphean Task. It is like the Hydra, for every surgery we complete, 2 more patients appear!

WHAT IS THE DIAGNOSIS?

Empyema (infection in the chest), post drainage via an extended Eloesser Flap. This man came in 3 months ago near death from an empyema. We drained the chest by removing 2 ribs and packing the chest with gauze daily. This allowed the pus to drain. If you look in the hole you can see the inside of the chest. The cavity has shrunk 50% in the last 3 months and the patient has gained about 15 pounds. This simple procedure (rather than a decortication), can be life-saving.

BREAST CANCER

Patients with advanced breast cancer continue to appear at the hospital. We give neoadjuvant chemotherapy then surgery. Males also suffer from this disease although not as commonly as males.

WHAT IS THE DIAGNOSIS?

Thyrotoxicosis with Exophthalmos. Once we get this man's disease medically controlled we will perform a total thyroidectomy. His eyes will probably not improve, however.

GETTING GOING

Yesterday, we did 11 surgeries including 2 orchiectomies (for prostate cancer), 2 thyroidectomies, a gastrectomy (for gastric outlet obstruction),  a fistula in ano, an inguinal hernia, a recurrent ureterocutaneous fistula,  2 pediatric hernias, and a bone biopsy. We have done a total of 35 surgeries in 5 days. There are 30 patients waiting for surgery. The hospital is full and patients are sleeping on mattresses on the floor. We are just warming up!

MOTHER OF ALL GOITERS 1

This lady has had a growing thyroid mass for 10 years. Today we removed it. The gland  weighed 850 grams-almost 2 pounds. The piece on the right was substernal, lying on top of the aortic arch.

Dr. Mike and I operated on their lady yesterday. She has a large parotid tumor. We were able to find the 7th nerve and save it. These are some of our most difficult and tedious cases but can be much easier with a great assistant like Mike.

WHAT IS YOUR DIAGNOSIS?

This young man came in with nausea and vomitting. He is holding a film from his upper GI series.

He has a gastric outlet obstruction. We operated today and did a subtotal gastrectomy with a Billroth l anastomosis. His stomach was quite distended with barium from the previous day.

MONDAY, MONDAY

Yesterday was so busy that I didn't get to the blog. It was the first Monday since my arrival and the word had gotten out that I was around. Patients pored in to the hospital. Between the 9 surgeries, I saw about 50 patients with all types of horrendous problems.

We are glad that Eric, the chief nurse anesthetist, is feeling better. He has chicken pox!!! He and his children are all recovering. Nonetheless, he came to work and helped us. We now have 3 anesthetists-Wison, Prince and Eric. All 3 are experts. With their help we were able to do nine surgeries today including a splenectomy, a goiter, a LN biopsy, fuguration of skin cancers, a breast lumpectomy, bilateral salpingoophorectomy rectopexy, excision of an abdominal wall mass and an incarcerated, strangulated ovary in a  pediatric hernia.The last case was very interesting from an anesthesia viewpoint. I saw the patient in clinic and decided to operate. Eric had the 3 month-old baby asleep within 15 minutes. A record for any part of the world.

We had a great surprise. Ngozi, our patient from last trip with advanced dermatofibosarcoma protuberans, came for a check up. You may remember that we did a radical resection of her shoulder area including her pectorals muscle, deltoid muscle, upper trapezius muscle, upper breast and clavicle. We transposed her lower breast for tissue coverage over the shoulder joint. She later had a skin graft. She is doing great!!!

This little girl came in with a thyroglossal duct cyst. I was surprised when I asked her to open her mouth. She has several accessory teeth.

Our patient, Chinaka, from last trip came for a check-up. We performed a left hemimandibulectomy for an ameloblastoma. He is doing great and gaining weight despite the loss of most of his right mandible.

We have 21 patients waiting for surgery and many more are still coming.

THYROIDS AND SPLEENS

The first case of the day was a very difficult thyroidectomy. The goiter was substernal and very vascular. We got it out but it was a struggle. Fortunately. the recurrent laryngeal nerves and parathyroids are intact. 

We followed with a giant spleen. The patient was somewhat unhealthy. When we entered the abdomen, we found a hemoperitoneum! I think this was caused by small areas of infarct in the spleen due to its size.

The team is growing. Dr. Bock left but Uche arrived. We also have Drs. Eze, Charles, Kelechi, John, as well as Wilson, our nurse anesthetist (far right), and Smart, our surgical technician (3rd from left). Tomorrow will be a big day. Patients will pour into the hospital joining the 15 we already have waiting.