Clinical Digest2

Clinical Digest: Monday 22/1/10
Today I spent my first day in Kamuzu Central Hospital, Malawi’s 2nd leading government hospital, after Queen’s in Blantyre. However, from my previous experience of the Orthopaedic service at least at the latter 2 years ago, there are certainly some developments I’ve seen here which would have been looked at as luxuries there.
I saw three operations today, all of which were performed by expats, who appear to be the only surgeons in the department. Most of them are unfortunately ‘de passage’ and bring about a short burst in activity (and hope) that soon subsides. In a way, this is what VSO tries to avoid, by laying the greater emphasis on the sustainability (not environmental in this case, issue which I will take up with them) of our work over service provision. Two surgeons have been here for many years though. One, the godfather really of this department, is an American-trained Filipino surgeon, who literally will take on (almost) anything! He has been here for 25years now and has the coolest demeanour about him. Not one to moan about such and such kit not being available (Oh what a contrast with the cliché from home) and really one to just approach things in a slow thought out manner. That really reminded me of the importance of such an approach today, where overenthusiasm and hastiness, could really result in you falling way behind your starting point. I’m referring to the epidemic of AIDS of course here, the prevalence in hospitalised adults being much higher than in the overall population. I saw him train another (clinical officer) to do a tracheostomy today. I guess that is the start of my training in this procedure too, as I’ll probably be called upon to do some in Ntcheu.
The second surgeon, a Tanzanian national who’s been here about 6years, is again a remarkably well composed operator. He performed a modified radical gastrectomy with splenectomy. This was for a gastric antral tumour, which was originally thought to be a hypertrophied pylorus from a chronic duodenal ulcer. In fact the original operative plan was that of a vagotomy and pyloroplasty. I was actually dead psyched up to see an operation that’s almost historical in the UK now. Maybe another time...
The case that stole the show however was the one orthopaedic case I assisted in today. A mammoth of a case it was- a retrograde femoral nailing combined with external fixation of the most comminuted pilon ankle I can remember seeing, the lot not helped by a set of really blunt instruments. The surgeons were a pair of Norwegian guys, again really relaxed and affable, who are here on short-medium term placements. One of them comes to Kamuzu on a regular basis for varying lengths of time. They used a SIGN nailing system, which is a charitable venture set up by a Vietnam war surgeon. His main motivation for this project was the injustice he felt in treating only the fallen American soldiers while leaving the others to die. Thus came about his scheme, in which free nails are provided to third world hospitals, with one minor condition: that the operating surgeon fills in an audit form after each nail used and sends it back. The SIGN nail, originally designed for the tibia, worked quite well as a femoral nail too. The jig is used for both the proximal and distal locking screws, which actually are designed so the proximal end is expanded and sits in quite tight. Of course, with natural error and bend, the distal locking screw doesn’t always slot in as expected and a few tries at least are needed. But given the absence of target drills and reliable image intensifiers, I think they are an excellent alternative- which brings me to one of the improvements I was really not expecting to see here in Lilongwe: a functioning image intensifier. It might have been wonky and tricky to operate at times, but it worked and the results are the same. The final reduction and quality of the fixation was, in short, commendable (better than some I’ve seen with state of the art equipment). Isn’t Orthopaedics simply fantastic?!