CARING FOR THE VERY SICK

In East Africa tuberculosis is widespread and a master of mimicry.  It can affect any organ in the body, and has a variety of manifestations. For that reason a high index of clinical suspicion is required. Presentation can occur in the lungs, the central nervous system (CNS), the lymphatic system, the bones and joints (septic knee, osteomyelitis of the spine, etc), as peritonitis or as skin ulcerations.

Several weeks ago I had the opportunity to help care for a young man who came to the OR for thoracic surgery.  He had severe pulmonary tuberculosis, which included scarring in the left upper lobe of his lung and significant entrapment of the entire right lung.  TB had created a thick rind around the right lung that was preventing normal expansion and function. The patient had been started on appropriate medications for treatment of TB - but required surgery to free his trapped lung.

The needed surgery involved opening the right chest cavity and stripping off the material surrounding and constricting his lung.  In order to accomplish this safely the left lung needed to be ventilated with a high oxygen concentration, while the right lung was allowed to collapse - thus giving the surgeons the access necessary to perform the operation.

This is not a difficult anesthetic in the US - but there were challenges to performing it in Kijabe. We did not have all of the device options usually available for intra-operative lung isolation, we did not use invasive monitoring, and Kijabe hospital does not have an OR stat lab that provides rapid and repetitive arterial blood gas analysis.

We always pray for our patients after the entire team is assembled and prior to beginning the procedure.  Following prayer and induction of general anesthesia, we placed a 39 Fr left-sided double-lumen endotracheal tube under direct laryngoscopy, which permitted independent ventilation of each lung and specifically allowed right lung isolation.

Though the current standard of care is to confirm correct placement of this type of endotracheal tube with a fiberoptic scope, I trained prior to that technology being widely available - and so we confirmed placement using older techniques; a stethoscope and our physical senses.

The surgery was long but went extremely well and the young man is on his way to recovery.


This is the young man in the ICU the day after surgery. He was extubated, breathing without distress and smiling. His father was thrilled to see his son breathing comfortably and healing well.

It is a privilege to work with a team of professionals who can work together to accomplish excellent outcomes in spite of limited resources.