Clinical Digest5

If, by now, you are starting to expect some clinical stories from my new front, you’re right. For I’ve been in Ntcheu for 3 weeks already and have not sent any reports yet. That is partly because I was busy assimilating it all, and working on the contrast there exists between here and Lilongwe, sorely aware of the extreme contrast even this state-of-the-art centre presents next to the UK.
However it has not felt like a gloomy debut at all. There are so many facets of working in this environment that would make Lilongwe blush with envious shame, let alone the UK. For one the people working here are all approachable, all eager to help and all extremely welcoming. Despite there being a significant deficit in knowledge and skills, largely attributable to the resource-stretched training reality here, the affinity to learn on the job is remarkable in so many clinicians. The latter group comprises in order of seniority student medical assistants, student clinical officers, medical assistants, clinical officers, specialist clinical officer, medical interns and doctors.
The clinical highlight of my first week was really ward rounds and clinics, with little theatre work, besides assisting (mostly C-sections and a hernia). Orthopaedically, we did do one knee arthrotomy and washout for the management of a septic knee joint. I also saw some interesting cases of gross mal-union [a harsh reality of ORIF (metal implant)-deprived settings] and deep burns turned necrotic.
The second week saw me finally getting to the knife, performing salvage operations mostly. First of all, I did a below knee amputation (BKA) on a 3yr old for a necrotic snake bite wound on an ankle which had turned completely septic. My main concern about her management came intra-operatively when I discovered some suspicious looking fatty tissue as far up as the knee. I was not prepared to escalate to my first through-knee amputation though, with no guarantee that even that level would be adequate. So a careful decision was made to wait and see how the BKA alone would fare. By the day 10 mark post-op, I have to admit that, to my surprise, encouraging signs of healing were showing. The next operation came in the form of multiple disarticulations required on a man with severe septic eschars on his dominant hand from a burn injury. I did it under a wrist block (my first ever), which was somewhat helped by his HIV associated peripheral neuropathy anyway. In the end, after more tissue had to be resected than originally intended, he was left the best semblance of a hand that he will ever get. Time will only tell if that will survive or he will end up losing even that rudimentary pincer grip we have tried to preserve.
The second week also saw some colourful moments in minor theatre, which is essentially a treatment area, where most wound management is done. Most of it by junior clinicians, often unsupervised. The result of this state of affairs revealed itself to me in a pretty hairy manner, as I unintentionally found myself taking over a few times (at lunchtime as it typically happens) from struggling clinicians, completely out of depths. Firstly there was an excision of a dorsal wrist ganglion misdiagnosed as the universal lipoma! An unmounted blade was the instrument of choice for plane dissection and a big question mark on the clinician’s face, the method of choice to dissecting it out! Another case was the excision of an actual lipoma (correct diagnosis for once, even though they were unable to distinguish it clinically from a pseudo-aneurysm), over the radial artery territory. It came out very satisfactorily as a whole and so was the ultimate state of the radial artery. Finally, the scariest bail out of all was for a “lipoma” dangerously close to the femoral artery which the clinician was blindly pecking away at. This is a case I would of course have chosen to do under GA/Spinal in majors. But here I was using a tiny incision, to limit the damage done and resect as much of a pus filled lymph node (?TB) as was actually possible. The femoral lived on... by a very close margin!
Week two ended on an especially convened clinical meeting, at my request (excepting the timing), on the Saturday morning. This is a quality control exercise which is very laudable in its concept, the effectiveness of which remains to be seen. It should normally be conducted monthly but often months can go by without one. Most pertinently, it is a hospital-wide clinician reunion, where issues are raised by everyone on their own or their department’s behalf. The size of the institution in Ntcheu is really what allows for such an exceptionally democratic and wide-ranging meeting to take place. We discussed myriad issues relating to hospital organisation and the dichotomy between volunteers and locals was again starkly drawn out. Whereas we were banging on about issues of accountability, initiative and quality control, many of the points raised by the locals pertained to remuneration, satellite TV subscriptions and free diagnostic kits! Thankfully, the chair, a local Malawian doctor, was very impartial and did pick out priority issues for the main agenda and left “social” ones to be discussed as AOBs (any other business). I left with an overall satisfied feeling and a great urge to put our resolutions into practice.
Last week (week3), was when things really started to come together a bit more neatly. This was in part helped by competing operators being away at a training (ETAT- emergency triage assessment and treatment of under-5s). I therefore managed to get into theatre a bit more and to get to grips with the booking process and how to expedite work. My two main operations were both on hands for, you guessed it, necrotic wounds. With a slight difference, the first one was not a burn wound but a infection secondary to a foreign body. It’s worth remembering that tetanus is a real danger here and can kill pretty quickly too. This patient was not such a case but his middle finger needed amputating. With poorly functioning tourniquets and less-than-optimal lighting, ligation of tiny bleeders can be one serious challenge here. We had to leave the stump to heal by secondary intention and it will be quite a new experience to see the natural progression of such management on the ward in days to come. The second operation was almost a carbon-copy of the previous multiple disarticulation mentioned. This guy was not as lucky though and was left with only his thumb, which itself is unlikely to survive. We’ll be preparing for a definite below elbow amputation next week, rather than allow the infection to spread more proximally. The wards meanwhile, were being populated with an increasing number of people on traction for a number of different diagnoses. We had tibial skeletal traction for a couple of femoral shaft fractures (treated with skin traction in children), skin traction for femoral neck fractures and an amazing case of 900/900 traction through the tibia in a 60 yr old man with a femoral fracture but bilateral knee and hip contractures and shortening, secondary to multiple bony epiphysiodeses. What I particularly enjoyed was giving instructions to the elderly patients in skin traction regarding, regular exercises to avoid DVTs, as low molecular weight heparins are something of a distant dream in Ntcheu. The week was concluded by an educational visit to CURE hospital in Blantyre, which proved to be so useful and insightful that I’m going to be making of this a regular occurrence, with huge benefits for my patients.