Day 9: OR

Morning Meeting

We began our discussion on the issue of staging surgeries, or correcting a patient in multiple successive procedures. Many of the patients here have staged surgeries to avoid extreme stress, but improperly staging operations can create further damage too. Prof said that it is ideal to have the second surgery one to three days after the first, though in certain cases (like one that will soon be discussed) that time period isn’t possible. When the surgeon waits over three days to perform the second operation, the patient is weak because they haven’t had an appetite post-operatively. Their body is also in stress, which is apparent in their hemoglobin levels and other factors. In the United States, a patient requiring two consecutive procedures avoids this dilemma by receiving total parenteral nutrition (TPN), or intravenous nutrition, in between surgeries. If this is not done, the patient waits six weeks for their final procedure, which is not realistic with the cases and resources at FOCOS. Esther, a post-op patient that I’ve been discussing, is waiting two weeks to have her second surgery because of the conditions of both her recovering body  and her deformity. In the mean time, she is on increased nutritional supplements, aggressively using an incentive spirometer to improve her respiratory function, and having a total protein profile performed to ensure that she is healthy enough. Despite her progress, she has fluid consolidating in one of her lungs and needs to attend chest physical therapy and use her spirometer more. Her first procedure was an anterior (from the side of the body through the ribs) release to increase flexibility in her spine, and her upcoming procedure will be a posterior (from the back) spinal fusion.

We then reviewed two patients who I was fortunate enough to observe the surgeries of in the OR later on. The first was Eshetu, a nineteen-year-old Ethiopian female with congenital kyphosis so severe that she has high risk spinal cord compression, or myelopathy. This has caused a partial loss of motor function, so she walks with a stick. Pre-op, Eshetu’s kyphosis measured 93 degrees and her lordosis 73 degrees. Her lungs are very compromised and she needs room in the front of her spine for her spinal cord. This is a lot more difficult than patients who need room in the back of their spine for the cord, as that can be corrected by a laminectomy and is fitting to the posterior approach; surgeons open from the back of the spine, so it’s a lot easier for them to make room for the cord there than it is from the front where there’s no incision. It is unclear if she’ll regain motor function and if so how much.

The second patient was Mengistu, a delightful nine-year-old Ethiopian boy that I spent a lot of time with on Monday. He is constantly smiling and very intelligent. He was one of the first to finish his drawings with his name well-printed and politely asked if he could color some more. Mengistu had two previous operations: one to correct his curvature and another later to remove an infected, exposed implant from that procedure. This complication resulted from his small size and stubborn spine, which I touched on in yesterday’s blog. Mengistu is short and very underweight, with a BMI of 13 with his arm span (more accurate) and 14.9 with his height. He has been on the antibiotic augmentin for some time, and will continue on his six week course post-operatively. His procedure will be re-instrumenting his spine from his T2 to L4 vertebrae to prevent deformity where the old hardware was removed. Prof noted that he will have to be mindful of the patient’s small size and weak skin and soft tissue.

Operating Room

It was such an incredible opportunity to shadow Prof in the OR. The rules, conduct, and timeline of each procedure were very similar to what I have observed in the US. However, the procedures were much longer and more high risk. Eshetu’s procedure was around five hours. Due to her compromised motor function, her MEPs and SSEPs were abnormal. I will go into greater detail about this when we formally review her post-op case. Secondly, the forward nature of her spinal cord compression required operating on the front of the spine to make room (the part of the spine you’d first encounter if you cut through the patient’s chest area, which is not possible). This required Prof to maneuver from his posterior incision in her back essentially around and under the spine to manipulate the front of it. This is extremely dangerous, but her operation went as planned without further complications. Mengistu’s procedure was much shorter and offered more visibility, though spinal surgery is difficult to see and is aided by cameras hooked up to screens. Both cases were fascinating and I look forward to telling you more about them when their details are discussed at the next morning meeting. Thursday will be filled with more patient interactions, and I hope to go in depth about certain children that I’ve formed special bonds with.