Wednesday, July 23, 2014

Operating Theatre- Morgan Olson


As I am a pre-med student with an interest in psychiatry, my service learning has taken place with Ghana Health Service. Going into my first day in the operating room, or "theatre", at Winneba Municipal Hospital, I really had no set expectations or preconceived notions of what might ensue after crossing the red line to the operating room floor. I had seen multiple operating rooms when orienting at a variety of Ghanaian hospitals, public and private, therefore I was aware of the disparity of technology and equipment among them. However, I was unaware of how staff were utilized, any policies and procedures they may follow, and even what types of cases I should expect to see. I had no basis of comparison to American theatres so that is why you will not find a compare and contrast analysis here in this reflection of my experience.

I arrived promptly with two other students from our group that were also scheduled to shadow in the theatre that day and the surgeon we were to follow was not in yet. I want to be clear that we were there only to observe the surgery and not participate in any way. The Ghana National Health Service gave us permission to observe after a background check was performed, and after meeting and speaking with all of us. The total number of students observing the surgery was five; two of the students were from an organization called Projects Abroad and the other three students included myself and two other students from our group. After about an hour of waiting around (one of many the opportunities to exercise patience with “Ghana time”) we were told to prep ourselves to observe another surgeon’s operation in the meantime. This included putting on a scrub cap that was provided to cover our hair, change into scrubs, tie on a facemask and switch into surgical shoes (they are basically white crocs).

Side note: Ghana time refers to how slowly things happen here. People will schedule a meeting with you and they may show up two hours early or two hours late and that is completely acceptable here. I have found this especially interesting in my work in mental health here as compared to my work experience in mental health in the states. In the U.S. many anxiety disorders are in some ways a result of the fast paced high pressure culture we have whereas in Ghana anxiety disorders are most often a result of poverty and hunger. 

This first procedure was a cesarean section. We observed the patient get transferred from “pre-op,” which is the lobby of the theatre, to the major theatre (the larger of the two theatres). Once situated on the operating table the patient prepared to receive a spinal anesthesia to ensure she cannot feel anything from that point of her back and below. Next the patient laid back and the nurses washed the patient with a sanitizing solution while the surgeon and scrub nurse scrubbed in. All of this occurred while the patient was completely naked and up to five students as well as multiple nurses were observing or assisting. My education certainly did not prepare me for that situation. I couldn’t imagine how that woman was feeling, and couldn’t help but feel guilty being there as I was benefiting from her uncomfortable and vulnerable experience while I didn’t contribute anything to her in return. When I become a physician later in life, I will take those moments with me and remember to be incredibly sensitive to the patients’ feelings and needs. These situations have illuminated why teaching hospitals are necessary because while education is necessary, the patients’ needs must come first and they should have a choice as to who should be in the room, etc.  

I was surprised to see that after the first incision, only two minutes or less passed before the patient’s baby was introduced to the world. The surgeon quickly instructed his scrub nurse to cut the umbilical cord and he handed the baby off to another nurse. The child was cleaned, weighed, and then wrapped up in a blanket and set aside. The surgery in total took no more than thirty minutes and the vast majority of that time is spent suturing the various layers of muscle in the uterus, abdomen, and finally the skin. I was surprised to not hear the doctors immediately announce the gender of the child or quickly hand the child to the mother after birth. I have found it is increasingly common to not give the child to the mother here until the mother is able to breast feed. This was one of the many situations where I have had to remind myself that just because I have learned something to be the best or most appropriate process that does not make everyone else’s process wrong. It clearly has been working for them for hundreds of years. Open mindedness and other critical thinking skills have certainly helped me process and analyze the many things I have seen all over Ghana thus far.

At this point, while I was surprised at how much blood was lost during surgery and to learn that it is normal for there to be pools of blood on the operating room floor, I did not get nauseous or feel like fainting. This realization made me feel a bit better about my consideration of surgery as a specialty in case I change my mind about psychiatry. 

Next, we waited for a little longer for the surgeon who specializes in obstetrics and gynecology to arrive so we could receive and prepare the next patient for a myomectomy, in which he would excise her fibroids. Fibroids are noncancerous growths that often develop during child bearing years and come from the muscle layers of the uterine wall. The same process ensued and I was stunned that this patient also only received a spinal anesthesia and not a general anesthetic. I could not imagine myself having fibroids cut out of my uterus and hearing everything going on in the room. I recognized myself empathizing with patients and reflected on when this empathy would be healthy and helpful in medicine and in what types of medicine it could be potentially harmful to you or to the patient.

After having witnessed the previous procedure, things become more familiar: the process of preparing the operating room, the patient, the initial incisions, and the muscles that must be cut in order to gain access to the uterus.  However, I was not mentally prepared to see the size of the most of these fibroids. After this procedure, we observed two more myomectomies and saw fibroids varying in size from a lime up to a grapefruit; patients most commonly had multiple fibroids excised and therefore the total amount of tissue removed in many cases was shocking. I had a hard time seeing how much blind cutting these surgeons are forced to do as a result of Ghana lacking access to the technology, such as a laparoscope, that is so accessible in the United States. After the surgery that day we asked the surgeon what effect the myomectomy might have on these women’s fertility as they lost significant amounts of their uterus in the process. I was so pleased to learn that their fertility will only increase now that the blockage has been removed, but more importantly, the size of the uterus was reduced to its normal size; the fibroid forces the uterus to stretch to three times its original size or even more in some cases, so we simply change it back to its original size.

I was in the theatre again on Tuesday and saw several C-sections and a bilateral tubal ligation. The first surgery that day was a surprise twin C-section and that was a very exciting experience! The patient was losing a significant amount of blood and the amniotic fluid was going everywhere. Shortly after retrieving the baby (which takes a significant amount of force on the surgeon’s behalf) the surgeon recognized something was wrong: there was another baby. The surgeon started shouting at the scrub nurse to hurry up and cut the cord as there was another. It took all of the nurses a few moments before they realized he meant another baby; she was carrying twins. Among all of the shouting and nurses scurrying about the mother was awake and hearing all of this, not knowing she was having twins prior to this moment. Within five minutes of that first incision two small newborns were on the table getting cleaned up by another nurse, then hurried off to be weighed and measured.

While I do not know if I could ever be an OB/GYN surgeon, I did learn that I have the stomach and passion for surgery. I learned that it takes a significant amount of body strength to be an OB/GYN surgeon and to do surgery in general, so I may want to start hitting the weights now! I feel that if there is any way we can get a used laparoscope and endoscope donated to the Ghana National Health Service it would change the health outcomes of so many women. The amount of complications that could be avoided if they had technology to perform less invasive surgeries would be profound. I also feel strongly that Ghana is in need of smaller needles for IV lines as they currently are using needles that are comparable to blood donation needles in the states. This has also created avoidable complications for patients. I just hope people become engaged with the Ghana National Health Service as we have with Challenging Heights in the past by donating any medical supplies possible or through considering ways to fundraise for Holy Cross Hospital and others. This has made me contemplate whether I want to do work with nongovernmental organizations in the future to support healthcare for those that cannot afford it, as well as contemplate the idea of international medicine.

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