SOAP Notes

A contribution from Dr. Rajdev (general surgery resident) and Dr. Sullivan (anesthesiologist):
Tonight, we'll be focusing on our patients—that is, the reason we are here in the first place. To recap, last Friday, our team was involved with a patient who presented to the ER after a several hundred-pound tree branch hit him over the right side of his face and neck. He underwent an emergent tracheostomy with ligation of a branch of the external carotid artery. Since that time, his facial swelling has greatly improved, one of his drains (intraoral) has been removed, and his tracheostomy balloon has been comfortably deflated. This morning, we walked into his room and to find him sitting up, wide awake, ready to get on with life! Tomorrow’s a big day for our patient: we will be downsizing his trach and performing a swallow study (in the OR, for safety). We will keep you posted on his progress.

​Yesterday, we performed a palliative mastectomy on an elderly patient with an exquisitely tender, firm breast mass with clear axillary lymphadenopathy. In the US, our treatment plan might look a little different: palliative surgery may come sometime after palliative radiation or chemotherapy. But symptom relief is our top priority here, so we performed a “toilet” mastectomy, excising gross disease for pain control and to prevent the development of a fungating mass that could become superinfected. Our patient has done well post-operatively, with good pain control and minimal output from her drain. 

​Our third patient is a young woman with chronic lower abdominal pain and dysfunctional uterine bleeding. She was actually a patient of the HBP’s OB/GYN, Dr. Etienne. He allowed us to assist him in the case in order to utilize laparoscopic methods of diagnosis and treatment. A preoperative ultrasound had revealed a large ovarian cyst, with what appeared to be “simple” fluid (foreshadowing…). We began the case laparoscopically, which takes some advanced planning down here in Haiti. Indeed, our eventual goal is to have enough in-country surgeons trained to use the laparoscopic equipment for diagnostic procedures in lieu of having a CT scanner or ready access to other cross-sectional imaging. Diagnostic laparoscopy is particularly well-suited for unclear pelvic pathology (think ovarian cysts, endometriosis, torsion) as well as for other abdominal pathology of unclear etiology (small bowel obstructions, mesenteric masses, etc). Our case today was particularly interesting: we started out with an open Hasson technique, placed two 5 mm ports in the LLQ as we might for a lap appy, and focused on our pathology of interest, which was a large ovarian cyst that engulfed all normal ovarian tissue. We tried to drain the cyst, which again appeared to be “simple” on ultrasound, but quickly found that it was filled with very viscous material and debris, including, wait for it, hair! Yes, it was a teratoma. After making this diagnosis, we converted to open, making a small Pfannenstiel incision to deliver and resect the right ovary. It was an interesting and unique case for every single one of us in the room. 

We also continued last week's teaching sessions with a lecture on the Trauma Registry, a project pioneered by four prior Emory medical students (two of whom are current PGY2 residents). The session was both informative and engaging. Our in-country colleagues were able to draw on their experiences with last Friday's trauma to correlate the ABCs of ATLS to real-world action. See below for a great, short video of the Q&A session.

We'll round out tonight's post with another missive from Dr. Sullivan--

​Notes from the Ether
Dear Lord! Don’t look at the pictures. Why didn’t anyone tell me I had gotten old? I mean, you come down here for 10 years with the same people and you’d think someone would at least recommend I put on something like lipstick, or mascara, or rouge. (Purposeful use of the word “rouge”)

If you insist on glancing at the pictures, I want to point out that this year the integration of daily teaching for med students and Haitian personnel has continued to grow. Dr. Srinivasan performed an abdominal ultrasound on a liver failure patient with Dr. Wagner, Internist. That was after we did a diagnostic laparoscopy to remove an ovarian teratoma- teeth, hair, and all. Gross, but satisfying.
One of my sneaky goals is to take all these great med students and make them Anesthesiology converts. My plan includes letting them all do spinals, intubations, and leaving to go to the bathroom at any time during the case--crowd pleasers in the medical community.

This is not a long diatribe, but who wants to listen to me wax rhapsodic when there’s cool pictures to look at?