Dawn Masai Mara

Dawn Masai Mara

Saturday, July 1, 2017

I was called to Casualty (emergency room) late one Saturday evening to evaluate a patient with a huge left-sided neck abscess. The patient was a young Somali man who spoke no English or Swahili and was obviously in great discomfort. He was lying with his left side down, drooling because he was unable to swallow, and could only open his mouth 1.5 cm. On exam I noted that his trachea was deviated dramatically to the right side of his neck.

He needed to go to the OR urgently to have the neck abscess opened and drained, but the question was how to control his airway (place a breathing tube in his trachea) and induce anesthesia safely for the procedure.

This is the type of clinical dilemma that anesthesiologists face on a regular basis – and like most clinical judgments, you often make a decision without knowing with absolute certainty that it is the correct one.

Ordinarily with this type of situation an awake nasal endotracheal intubation under fiberoptic guidance (placing a breathing tube through a nostril and into the trachea using a fiberoptic scope to visualize the trachea, while the patient is conscious and breathing) would be the preferred technique. But that technique requires a cooperative patient with whom you can communicate. And this patient was not cooperative, and did not understand the 2 commonest languages spoken in Kenya.

So Peter Bird (our chief of surgery at Kijabe) and I agreed that I would attempt to intubate the patient using a video-laryngoscope (a fiberoptic device that is placed in the patient's mouth and allows visualization of the pharynx and hopefully the vocal cords) and that he would be present to perform an urgent tracheotomy should I be unsuccessful.

We prayed with our patient - as we always do prior to surgery. And then had him breath 100% oxygen for 3 minutes (called pre-oxygenating the patient) in order to ensure that his functional residual capacity (the volume of gas remaining in the lungs at the end of a normal exhalation) was completely full of oxygen. This would allow him to maintain a normal blood oxygen content for about 5 minutes after he stopped breathing, and would give me the maximum possible time to intubate his trachea if I could not ventilate him by mask after induction of anesthesia.

While this was taking place Dr. Bird was prepping his neck and ensuring he had all the necessary equipment should he need to perform a tracheotomy.

We then rapidly induced anesthesia and I attempted to visualize his vocal cords using an old Glidescope (a type of video-laryngoscope).  It was difficult to visualize his glottic opening due to the distorted anatomy caused by the abscess. Fortunately, we were able to ventilate him by mask between intubation attempts – and on the third attempt I successfully intubated his trachea. 

Dr. Bird was then able to perform an I & D (incision and drainage) of the abscess and obtain a biopsy of the tongue.

We transferred the patient to the ICU as we did not think it safe to extubate him until the swelling in his neck had further resolved.

As is the case in many patients we see at Kijabe, this patient did not present until his disease process prevented him from carrying out the normal activities of life. He sought medical care only when he could no longer eat or drink. 

The biopsy that was taken in the OR revealed that this young man had squamous cell cancer. He was referred to an ENT physician for specialty care, but died several weeks later of complications related to his cancer.   

This is one of the hard realities of practicing medicine in East Africa. Many patients present late in their disease process, and we cannot offer them all of the options available in high-resource countries. 

But we are called to "walk by faith, not by sight". And walking by faith in this setting means offering the best care possible to those who need it. Not knowing if we will be successful in our attempts to promote healing, but trusting in the fact that we have a sovereign God; who calls us to persevere and to keep our eyes fixed on Jesus - the author and perfecter of our faith

Part of walking with these patients is not just helping them recover their health, but in the event that nothing can be done, it is to help the family process their grief. Please pray for this family, that their time at Kijabe softened their hearts to the gospel, and that God would bring other Christians into their lives.

1 comment:

  1. What a challenging reality to live with. Thank you for telling this small story. Grateful for your work in Kijabe