Tag Archives: global surgery

The girl who stumbled while playing outside

Delayed access to surgery is one of the main reasons leading to complications and possibly death when working as a surgeon in conflict areas. The story below is from Yemen in 2012:

It was late afternoon and I was standing on the roof of the brand-new MSF hospital in the outskirts of Aden, the main city in the south of Yemen. It was the beginning of May and already around 30 °C while the muezzin called to prayer in a nearby mosque. Due to the tense security situation we were not allowed to leave the hospital at any time and the entire team was installed in rooms on the 2nd floor. If you needed a breath of fresh air you had to go to the roof. Only brief roof visits were allowed though, due to the risk of shelling.

The medical team leader came up and told me he had received a call from another hospital 4-5 hours away, a smaller facility where surgery was not available: They had received an 11-year old girl who had fallen down from a 1 meter high rock while playing outside. She was not doing well, they said, there was nothing to see on her body, but she had severe stomach pain and could not move. Could we receive her? Yes of course.

The MSF hospital in Aden

5 hours later the girl arrived and upon examining her it was immediately apparent  that she had peritonitis as she presented with a classic peritoneal reaction upon palpation of the abdomen. Blood tests, apart from hemoglobin, were not available, no imaging was possible, but none was really needed: She required immediate surgery. 15 minutes after she arrived, she was prepared and intubated and the surgery began. I had talked to her father via an interpreter and explained the situation, told him that I did not know what was wrong but adviced that she may need a stoma.
Immediately after opening the abdomen I noticed the 2*2 mm perforation on the surface of the small intestine approximately 40 cm from the ligament of Treitz. I remember telling the anesthetist that this was good news, the surgery would be completed in less than 30 minutes. I hope so, she said. Accordingly, I sutured the perforation and closed the abdomen. The anesthetist, trained in pediatric anesthesia and intensive care was responsible for the management in the recovery room. When I woke up the next morning I went downstairs to the recovery room, where the girl was sleeping. She was lucky, it went well, I remember saying. The anesthetist looked at me with an odd expression on her face: She is dying. She has acute renal failure. And there is no access to advance therapeutics such as dialysis, the only possibility to save her life.

The almost 24 hours it took for her to gain access a hospital with surgical facilities turned out to be too long. She died later that afternoon. Had she been operated earlier her life would almost certainly have been saved.

The young bleeding pregnant woman

Lack of access to prenatal care is one of the main reasons behind the high incidence of pregnancy complications in developing countries. But what does that mean in practical terms? The story below is from Cote d´Ivoire in 2012:

At around 10 am the midwife came to the operating theatre where we had just started todays list after completing the morning patient rounds: Mostly minor cases, incision of abscesses, dressing changes. Now, a 19-year old pregnant woman had presented with continuous heavy vaginal bleeding. According to the midwife there was no fetal heart activity and according to the woman, she was in week 33. We did not have access to ultrasound. She needed a Cesarean section. With no obstetrician employed, this is the job of the surgeon.

10 minutes later the woman was in the operating theatre and we prepared for the Cesarean section. Probably a placenta previa I thought.  I opened the uterus ,and I still remember the subsequent moments of  confusion and disbelief when I removed handful after handful of what looked like small white eggs. There was no child inside. Instead this was a molar pregnancy, which the woman had carried undetected into the 33rd week  due to the lack of access to pre-natal counseling in the remote are where she lived. I removed the mola and closed the uterus. She was 19. She would be able to have more children.

Duekoue, Ivory Coast

However, the postoperative course was complicated, she kept bleeding. Was this perhaps an invasive mola?  We will never know exactly. In the end we had to perform an emergency hysterectomy, but the vaginal bleeding persisted, however slowly diminishing. Was there perhaps also an element of coagulopathy? Possibly, but without adequate testing modalities, no way to know for certain and in any case no treatment would be available. After a few more days on the ward she was ready for discharge.

How does the future look, in this relatively remote part of the country, for a 19-year old woman, just married and  not able to have kids? Not necessarily bad, I was told. In many such cases a childless couple would raise the children of other family members, such as her sister, as their own.

Obviously with access to appropriate prenatal care, the condition would have been detected far earlier and she would most likely have been able to have biological children of her own.