Another 3 weeks gone in the hospital and so many new surgical adventures to recount. The nature of operating has not exactly changed, in that it is still mostly salvage surgery, but a few items have been added to the repertory. One of them is split skin grafting. Since I got to Ntcheu I kept hearing that we had the kit for it but I was yet to put it to the test. I judiciously chose a small case to be my first one. The surgery was uneventful, although remarkably slow, owing to some issues with positioning and kit. The knife in question is a donation from a very enterprising Dutch doctor who pioneered this new model based on its resemblance to the “Schick” razor and even uses the blades for it. Only drawback is that it only allows you to harvest tiny grafts which you then knit together on the wound. As it is, the wound on our patient in question was right over his Tendo Achilles and the anaesthetist was not happy doing him prone. So I kind of got him supine with a figure of 4 crossleg, which made the actual job of the final stitching tediously slow. It’s a question of time now to find out if it takes or not.
My level of amputation has also progressed and I now count a below elbow amputation in my logbook. One must wonder whether all this is really necessary or whether we could just debride radically and wait. Well that’s precisely what we were doing at first and discovered we were being too conservative and had to take patients back. Just to contradict this pattern, then came a case of a grossly septic leg which we were very close to performing a through knee amputation on but had to hold back as the patient refused surgery at the last minute. What ensued was rather enlightening. To my consternation, this leg which I had, by now, consigned to an irrevocably doomed fate, started to get better with stringent wound care alone. That threw me back to the original question of “to chop or not to chop”. I guess that there will always be cases, especially here, which behave differently from the norm. The actual protocol of practice however, should, I believe, be based on the average (which time and experience will aid my clinical judgement of) rather than special cases. And indeed, that below elbow amputation was another special case, which I thought was amputated high enough. Yet it gave me reason to worry that it was still infected, ie I hadn’t gone high enough. Thankfully, aggressive wound care sufficed.
By the way, you will have also noticed that we are consenting our patients, but the process is a far cry from our 4 pages of carbon-copy material plus all the other forms in England. The form here resembles more like an 8th of an A4 page with the following signed statement: “ I hereby consent to have an operation on any part of my body as deemed necessary by the surgeon,” or something similar!
The degree of sepsis encountered here is something of a completely different order to that found in the UK. Whether this is explained by the virulence of the pathogens or toxins (as in the few snakebites I’ve already dealt with) or by the time it takes to get to the hospital, or even by the time it takes from admission to get to theatre, or by the stubborn stoicity of the people who have faith it will get better by itself, if not with the assistance of the greatly revered witch doctor (whose involvement is often recognised by the tell-tale abrasion scars on the skin), I can’t really tell for sure, but it is likely to be a combination of many if not all of the above. The management of such sepsis is a real challenge and necessitates intervention on a number of different levels.
My latest case in theatre was a surprise last minute one I only picked up the day before and planned for the end of the 3rd week: an index finger drop. The patient had been severely panga-knifed, sustaining bilateral Tendo Achilles divisions as well as multiple scalp and bilateral forearm wounds. Poor chap (19yr), he looked like he’d just come out of a sarcophagus, with all the bandages around his body! (He was approached by some ruffians who wanted a mobile phone from him, which he didn’t have. So he ended up paying for it in the form of these unwarranted lacerations). The hand on the non-operated hand was afflicted by an ulnar nerve palsy beyond repair. The other hand needed an extensor tendon exploration and repair, which I had only ever assisted in them in the UK but never done one alone. Technically though, there was no reason why I shouldn’t be able to do it. So I approached this case, made more complex from the fact that he had two potential wounds on the dorsum of his hand/wrist where the tendon could have been divided, not to mention the fact that he was almost a week from the time of injury (hence starting to retract). I was quite pleased when I finally freed both lacerated ends of the tendon, although I only had a flimsy silk suture to reapproximate it. My first independent case of reconstructive surgery, provided the best booster at the end of this 3 week stretch I could ever wish for. And now also, my interest in hands has been properly rekindled.
Besides operating in the main theatre, minor theatre has also provided its fair share of excitement in the recent weeks. I embarked upon a poster teaching session forced by some of the practices I had witnessed earlier by the student staff. Hence we drew posters on safe administration of local anaesthetic and the differences between common lumps and bumps (a description which caused hours on end of giggling here). The rules behind the dosing of LA and its limits were completely alien to this staff group who had been administering them liberally for months if not years already. Being low resourced is not an excuse for letting your standards down on such an easy-to-implement concept. As for the lumps and bumps question, we now have a readily accessible chart to differentiate between them. This is been a welcome addition to the trauma room, where hopefully lipomas will now be diagnosed only when they are actually lipomas and not cysts or nodes or pseudoaneurysms anymore! As a real coincidence, that same day, we received a serendipitous casemix to examine in our clinical area: a real lipoma (which was enormous and I only just managed to excise under LA), a ganglion, a scalp sebaceous cyst, a skin tag, a histiocytoma and a pyogenic granuloma! What were the chances of that? What I found with the style of the teaching is that it is very participatory and depending on how it works, I can surely see myself exploring a wealth of topics during the year to come. Next one is already lined up- aseptic handling and sterility. The microbiologist in me, not to mention the one attached to me, could faint at the way some instruments and specimens are handled here!!
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