I REALLY wanted to get my entire Mission Trip blogging (8 days worth) done by Wednesday 12/13 (my last day in Boca Raton) but even if I get this one done now (at airport) and next on the flight home I don’t see it happening, but maybe by tomorrow…
After another good nights sleep I enjoyed my coffee and Clif bar and then headed to the hospital at 5:50am. I wanted to get there extra early to set up my own room and see the patient and get my nerve blocks done AND get patient into the OR by 7am.
I tried dictating a commentary as I walked the peaceful path to the hospital (easier to write hospital than to keep saying surgery center/clinic). Siri was not as great as expected but here is my edited version…
“Tuesday morning walking notes. I can hear the artillery fire from the military base, it is 1 km from here and we were told that you might hear gunshots but this is more than gunshots, I heard some regular gunshots a few days ago but this is like boom-boom. I just passed a beautiful white horse and wouldāve stopped to pet him and feed him some grass, but had to get to work. I saw a yellow bird and a big blue parrot that I didnāt get very good pictures of because he scampered away each time into the woods. Even 30 feet up he was very cautious of me. It is just a 10 minute walk downhill from the Moscati conference center where we sleep to the surgery center. I slept decently; I did wake up at two and briefly had trouble getting back to sleep but then slept until five again. Yesterday was kind of annoying between cataracts and the local eye surgeon, and not being allowed to do any nerve blocks, but Iām in regular ortho room today and Iām actually Iām working with the guy who is the medical Director here who grew up here on the orphanage, then went to school and became a surgeon, and now is the medical Director. I am at the clinic now, so Iāll dictate more later, I guess on the way home.”ā
The men’s locker room was very nice but HOT after the walk to work, I was always glad to get into the very chilled operating rooms. Each day we signed out a box of meds and then kept track of which patient got how much and returned the box and forms at the end of work. The versed and fentanyl came in industrial-size multi-patient containers. Propofol was the same as at home. I brought a bottle of Celebrex and gave 200mg to a few patients after making sure with Dr. Merlin that it was ok. Patients who got nerve blocks with Exparel (liposomal bupivicaine local anesthetic) didn’t need any Celebrex . All the patients got 1000mg of Tylenol pre-op per clinic protocol.
Our patient was a guy in his 30s who had fallen off a ladder at work a few years ago and sustained a tibial plateau fracture (these are common in the US in car crashes and hard to repair, often referred to trauma or university hospitals if they show up at a community hospital). His was only “stabilized” at the public hospital and he ended up with his leg completely stiff in the straight position, they measured just 3 degrees of flexion.
I did an adductor canal block to his femoral nerve in the mid-thigh and then had Theresa watch me do a popliteal nerve block behind the knee to get the branches of the sciatic nerve (it had been a long time since I did a popliteal block since I never really see any ankle fractures or fusions in my current part-time job and I wanted her expertise to make sure I did it perfectly).
Dr. Merlin had told me it would be a long complex case and I was glad they placed a Foley catheter. ***** Here is the Alert that a few surgical photos are coming up soon*****.
Nothing “gory” really. And uploaded from the web as not supposed to post any ābloodyā patient parts. Although there was a surgical “plan” for a tibial osteotomy and releasing the knee to improve range of motion (with a hope for a total knee replacement in a year if it healed well), with such a deformed limb it would depend on what they discovered once they saw inside. Of course, it was worse than they expected. The nerve blocks worked great and I didn’t give the patient any narcotics for the whole case. There was a tourniquet on the thigh above the nerve blocks and that caused pain while the patient was under general anesthesia but I used a higher concentration of gas for that as it was temporary. It was only after the patient was asleep that the surgeons mentioned they would be harvesting a bone graft from the iliac crest (we could have done a nerve block for that area as well). I prepared some local anesthetic with epinephrine for them to inject at that site (I had already used the maximal allowable dose of Exparel). The first part of the surgery was opening up the knee and tibia, they released a lot of tissues, took out overgrown mishealed bone, and figured out a plan. The tourniquet was up almost 2 hours for this portion and then it was let down while they harvested a graft from the iliac crest. It was HUGE, about 2 X 3 inches, the biggest one I have ever seen taken. Because there was now a huge gap there they then put two screws into the edges they had cut off and put a piece of bone cement (like used for total joints) into the gap and shaped it so that at the end the iliac crest looked normal, and I assume would be structurally sound.
They inserted the graft in the tibia (the tourniquet was up for another 2 hours) and did a reconstruction of the MCL that they had discovered was gone.
At the end the patient could flex the knee over 100 degrees and they hoped that eventually he could get a total knee replacement.
The patient went in the operating room at 7am and got to the recovery room at 3:30pm. Despite the lengthy surgery he woke up very nicely having received no narcotics and reported zero pain.
At the start of surgery I had asked Dr. Merlin if the patient was going to go home or stay overnight (they had the ability to keep patients overnight for observation in the clinic area with a nurse paid to stay with them) and he said it would depend on pain control. Despite the pain control being perfect I told Dr. Merlin that because the surgery was so huge and the tourniquets had been up for some many hours there was a risk of compartment syndrome and he should stay to be monitored. With the initial signs of compression syndrome, pain, numbness not going to occur with the nerve block one of the US surgeons suggested putting a pulse oximeter on the patients toe so that if blood flow become compromised there would be a warning sign. All the official translators were gone by the time I was going to leave and it seemed as if the overnight RN did not quite understand the situation as explained by a close to fluent Spanish speaking volunteer; so I went to Medscape on my phone. I pulled up an article about Compression Syndrome and hit “translate” on the iPhone and he was able to read the entire three page article.
I spoke with Dr. Merlin before I left and he said that luckily he was joining us for dinner that night and would check on the patient before he headed home. The patient did great though and when I visited the next morning had zero pain in the leg and could move his toes well, he had “mild” pain in his hip that was well controlled with Tylenol and Motrin. People in 3rd world countries of course have MUCH higher pain tolerances than in the USA, women having childbirths with no meds, men having work, motorcycle, etc. injuries with no oral narcotics ever available.
Somebody else got the great Rainbow photo during the day (I don’t think it even barely drizzled but somehow it was there). It certainly reflected my mood after this rewarding day versus the various issues on Monday.
A much happier smile on my walk home. I heard Latin music through the forest as I walked and wondered where it was from but then saw some teens rehearsing a dance in the pavilion at the school. I would have watched or shot a longer video but I knew I had to hurry if I wanted to exercise before dinner.
I knew I would only get in a short run before it got dark but was fine with sneaking in just 2 miles before it got TOTALLY dark at 5:30pm and I did some Yoga to finish up. I still got to see a cute dog and cat though!
Nice spot for a Yoga selfie, has that Mayan palace vibe. I always try to send one to my Yoga teacher April from my more exciting vacations. Warrior 2 is my go-to for photos because it requires neither flexibility nor balance to look good š
After dinner, Dr. Redler gave a talk on the child sponsorship program which he has participated in for many years. As his sponsored child and some other kids were there we couldn’t have alcohol with dinner but afterward when they left I tried the Honduran beer.
