26 February 2019

Sometimes patients are the most grateful when we provide treatment for the most simple problems. Today a family carried their 3-year old into our outpatient consultation area. She started crying as soon as she saw nasaras in scrubs from across the room. She had a seed in her nose, the family explained in Arabic. Our operating room nurse extracted a few more details, and I learned a new word in French. She had stuck an "arachide," a peanut, into her right nostril, and the family couldn't get it out. Our OR nurse tried positive pressure techniques without success. The patient had already been upset just looking at us, and she was even less tolerant of being examined. We decided to extract the peanut under moderate sedation with ketamine. An 8 French foley catheter was too big to sneak around the peanut, but a small curved hemostat was just right. I slipped the narrow tip of the clamp through a gap next to the peanut and around behind it. The now-calm patient watched as I slowly drew the "arachide" out of her nostril. Her grandmother picked up and examined the peanut, then took the piece of gauze that had been used to swab the ketamine injection site, and she gently wrapped up the peanut to show the rest of the family. As the ketamine gradually wore off, many visitors from her family came one by one to congratulate her on being cured of the offending peanut. They were so grateful to have the problem solved and their little girl doing well. They thanked us over and over in Arabic and in French. Prompted by her enthusiastic family, the previously-terrified little girl even shook my hand just before they carried her back outside.

A couple of weeks ago, a patient's family member was so grateful for another simple procedure. He had been stuck with a Foley catheter, a catheter for draining his bladder. Nurses here often remove urinary catheters by cutting the end of the tube where a syringe is usually attached to fill the empty balloon that rests within the bladder to hold the catheter in place. I had never seen a catheter removed this way in medical school or residency, and I am now even less of a fan of this method. Usually it works, and the fluid in the balloon drips freely from the cut end, allowing the balloon to collapse and the catheter to be pulled out easily. Occasionally, though, no fluid comes out, and with the end of the tube cut, a syringe may no longer be effective at removing the fluid by negative pressure. For this patient, we tried removing the fluid with a syringe anyway, then, when that failed we tried drawing out the fluid more proximally, like trying to draw blood from a latex vein. Nothing. We searched for the catheter balloon on ultrasound and confirmed that it was still full within the bladder. Under ultrasound guidance we pushed a needle into the balloon to draw out the fluid. Finally the catheter balloon collapsed, and the catheter slid out easily.

"If it weren't for you, he never would have been able to remove this catheter," his brother kept repeating, thanking us over and over in Arabic.

We treat many people at this hospital who are close to dying from advanced illness by the time they arrive--severe malaria, hemorrhage from a poisonous snakebite during pregnancy, or severe dehydration from prolonged diarrhea. Often the families of critically ill patients have already started to resign themselves to the fact that their family member might die, or sometimes they don't realize how grave the prognosis is. For whatever reason, sometimes the patients pulled back from the edge of death seem more ambivalent. But remove a peanut from a nose or a Foley catheter from a bladder, and the family pours out their gratitude with as much enthusiasm as if you'd just saved a life.