Clinical Digest3

Clinical Digest: 8/3/10
I have been at the Kamuzu Central Hospital for just over two weeks now, doing my orientation, so I don’t feel that I’m being thrown in at the deep end once I start fending for myself in Ntcheu. It’s remarkable what spectrum of surgery I have covered in such a short time. I feel strangely like being a medical student again, learning many things for the first time. That is mostly true for my stint in Obstetrics and Gynaecology. This actually made up the bulk of my last week, where I split myself between two hospitals to try and maximise my exposure. The experiences worthy of making it on my blog include:
1. My first clinic in gynaecology, where from being a mere observer trying to gain familiarity in the typical casemix for Malawi, I found myself performing all manners of gynaecological examinations. It felt really strange at first and I was completely clueless as to what I was feeling. However, given the reality on the grounds, and the fact that I was being taught by a clinical officer (a non-doctor), I had no choice but to embark on a steep learning curve- which has become a daily feature of my orientation.
2. The gynae list in Kamuzu, where I saw some pretty revolting stuff- a powerful reminder of why I choose to do Orthopaedics instead. I even saw the mightily feared “Teratoma” twice here (complete with hair and teeth). This is a condition the very mention of which used to send nauseating shivers down my spine in medschool.
I made the approach in the second case and closed in both of the cases. It’s really rewarding being able to expand my skills so widely in so little time.
3. Unfortunately, such has not been my luck as far as Caesarean sections are concerned, that being one of my main objectives here. Even though I assisted in at least 4, they were all either complicated emergencies or the first one with a particular instructor. As a general rule of thumb, one has to see one (with a given instructor) before being allowed to do one (by that instructor), and ultimately teach one (to others). So goes the dictum.
One of the C-sections I assisted in stood out though. Indeed, it brought out a number of fundamental differences in the way doctors operate and that in which clinical officers do. Respect for the soft tissues and neurovascular structures appears not to rest on the same level between the two groups. Maybe this sentence will illustrate what I mean- Clinical officers are happy to chop and repair, whereas doctors spend a lot of time avoid the chop in the first place, so it does not need repair... since the success of the repair is indeed far from 100%... as that case I am referring to served to prove very convincingly. That was compounded by unorthodox approaches and surgical skills, which seem to get passed on from one generation of COs to the other without ever being corrected. One example is the transfixion stitch, which instead of being secured tightly once it has gone round the stalk, is, for some reason, taken round and round and round it, without ever having a solid 3throe knot to secure it!
Also, never mention a transverse C-section incision around here, because that might challenge some well anchored myths: that the one and only incision for C-sections is the laparotomy!
4. My next and most startling observation concerns the anaesthetic side of things in a resource-limited setting. Whereas one’s heart would sink, with the knowledge of a delayed list, at the mention of a spinal over a general anaesthetic, here one tends to be rather elated at the news. In fact, so far they have had a fairly good record, with the exception of the said C-section above, where the patient started ‘feeling’ us close the wound as the spinal was wearing out! General anaesthetics are generally a hit and miss business here, where I think Thiopentone is the drug of choice. This is often combined with Halothane, for the one main reason that patients are often already awake before the end of the operation, and sometimes even seek to indicate it to you through hemiballistic arm swings! I’m yet to come across the ubiquitous milky suspension (propofol) I know from England. A very prominent detail regarding the delivery of the GA is that mechanical ventilation tends to require a permanently assigned attendant, whose job is to continually press and release the oxygen reservoir bag.

Today I went back to general surgery, which isn’t a field that I would call myself entirely proficient in either, Orthopaedics being where I belong. I was set on learning how to do an inguinal hernia repair. Overjoyed was I to see that there were three on offer today. So I tagged along for the first one, which proved to be an extremely difficult one to reduce, hence limiting any chance of me learning some vital steps in a cool manner. The second one got robbed by the theatre next door and the third one, well, was a hydrocoele. That was in fact beneficial for me as I also wanted to learn how to tackle this condition. The slight drawback was that the instructor was a clinical officer and, as such, I stood little chance of learning any detailed anatomy.
My net of experience got widened further in the afternoon, as I was involved in a breast mass excision, which I had to complete, my colleague having stabbed himself during the op. The cherry on the cake was a debridement of some escharified septic burn wounds, which had to be done “on the rocks” as we had run out of gowns and drapes! What a joy! They had sterile gloves.

Disclaimer: Please do not interpret my humour as sneer that’s being poured onto the department I am presently working in. If anything, I am very impressed with what is actually possible here and, above all, with the hard work from everyone. Yet without some form of satyr at least, I could not begin to establish the contrast that exists between our over-resourced setting back home and the one here. [If you don’t laugh about it, you’ll cry about it!] The ability for the people of Malawi to cope with so little, the unconditional gratitude they express for it all (as exemplified by the numerous gifts of corn cobs our staff receive from the poorest villagers) and the warmth and overall happiness they seem to maintain through it all, is none but awe-inspiring. It beggars the question, to me, why one would ever want to complain so much about futilities, when they do have a system which entitles them to so much for free.